Alcoholism and Clinical Psychiatry Alcoholism and Clinical Psychiatry

Alcoholism and Clinical Psychiatry Alcoholism and Clinical Psychiatry Edited by Joel Solomon Downstate Medical Center Brooklyn, New YorK Plenum Medical Book Company New York and London Library of Congress Cataloging in Publication Data Main entry under title: Alcoholism and clinical psychiatry. Bibliography: p. Includes index. 1. Alcoholism-Addresses, essays, lectures. 2. Psychiatry-Addresses, essays, lectures. 3. Psychology, Pathological-Addresses, essays, lectures. I. Solomon, Joel. (DNLM: 1. Alcoholism-Complications. 2. Alcoholism-Therapy. 3. Mental disorders - Complications. WM 274 A3S48] RC56S.A44S33 616.86'1 81-22701 ISBN-13: 978-1-4684-4030-0 e-ISBN-13: 978-1-4684-4028-7 AACR2 001: 10.1007/978-1-4684-4028-7 © 1982 Plenum Publishing Corporation Softcover reprint of the hardcover 1st edition 1982 233 Spring Street, New York, N.Y. 10013 Plenum Medical Book Company is an imprint of Plenum Publishing Corporation All rights reserved No part of this book may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the Publisher Contributors Malcolm Beaudett, BS Third-Year Medical Student, State University of New York, Downstate Medical Center, Brooklyn, New York Sheila B. Blume, MD Director, New York State Division of Alcoholism and Alcohol Abuse, Clinical Associate Professor, Department of Psychi atry, Albany Medical College, Albany, New York Marc Galanter, MD Director, Division of Alcoholism and Drug Abuse, Associate Professor, Department of Psychiatry, Albert Einstein College of Medicine, Bronx, New York Donald M. Gallant, MD Professor, Department of Psychiatry, Adjunct Professor of Pharmacology, Tulane University School of Medicine, New Orleans, Louisiana Donald W. Goodwin, MD Professor and Chairman, Department of Psychiatry, University of Kansas Medical Center, Kansas City, Kansas Meredith Hanson, MSW Clinical Instructor, Division of Alcoholism, State University of New York, Downstate Medical Center, Brooklyn, New York Martin S. Kesselman, MD Professor, Department of Clinical Psychiatry, State University of New York, Downstate Medical Center, Director of Psychiatry, Kings County Hospital Center, Brooklyn, New York Elizabeth T. Khuri, MD Clinical Associate Professor of Public Health, Cornell University Medical College, New York, New York Benjamin Kissin, MD Associate Chairman and Professor, Department of y vi ContributoR Psychiatry, State University of New York, Downstate Medical Center, Brooklyn, New York Gerald L. Klerman, MD Professor of Psychiatry, Psychiatric Service, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts Robert B. Millman, MD Clinical Professor of Public Health, Associate Professor of Clinical Psychiatry, Cornell University Medical College, New York, New York Frederic M. Quitkin, MD Director, Depression Evaluation Service, New York State Psychiatric Institute; Associate Professor of Clinical Psy chiatry, Columbia University College of Physicians and Surgeons, New York, New York Judith G. Rabkin, PhD Research Scientist, New York State Psychiatric Institute; Adjunct Assistant Professor of Public Health in Psychiatry, Columbia University College of Physicians and Surgeons, New York, New York Austin Silber, MD Clinical Professor of Psychiatry, Training and Super vising Analyst, The Psychoanalytic Institute at the New York University Medical Center, New York, New York Joel Solomon, MD Clinical Associate Professor, Director, Division of Alcoholism and Drug Dependence, Department of Psychiatry, State University of New York, Downstate Medical Center, Brooklyn, New York Barbara Thornton, RN Unit Chief, Kingsboro Psychiatric Center, Clinical Instructor, State University of New York, Downstate Medical Center, Brooklyn, New York Joseph Westermeyer, MD, PhD Professor, Department of Psychiatry, University of Minnesota, Minneapolis, Minnesota Sheldon Zimberg, MD Director of Psychiatry, Joint Diseases, North General Hospital, New York, New York Foreword It is well known that alcoholism continues to be one of this country's major public health problems. This issue is carefully documented by Dr. Gerald Klerman, Chief of ADAMHA, in the second chapter ofthis volume. In spite of the major role that alcohol plays in the health care issues of internal medicine, neurology, and psychiatry, the subject continues to fall between the cracks of the various disciplines. For this reason, it has become almost a discipline of its own; yet there are no academic departments of alcoholism because academic departments are unidisciplinary and alcoholism is clearly a multidisciplinary field within medicine. In spite of the many disciplines involved in the study and treatment of alcoholism, psychiatry continues to have a special, albeit often neglected, relationship to alcoholism, and it is the articulation ofthat relationship which prompted the Department of Psychiatry at the Downstate Medical Center to organize the conference upon which many chapters in this volume are based. Particular emphasis in selecting the topics to be covered was placed on the interface between alcoholism and clinical psychiatry, including affective disorders, schizophrenia, suicide, adolescence, the special problems of women, and psychotherapy, to mention only some of them. The realization that psychiatric disorders cause as well as result from alcoholism has prompted the Residency Review Committee of the American Psychiatric Association to call increasing attention to the need for more training in alcoholism in psychiatric training programs. We hope that this volume will serve as a resource for trainees, clinicians, and other students of this area of medicine and health care. EUGENE FEIGELSON, MD State University of New York Chairman, Department of Psychiatry Downstate Medical Center Brooklyn, New York vii Preface This book is composed largely of papers delivered at a conference held on October 24 and 25, 1980 at the New York Academy of Medicine. The decision to develop this conference and subsequent book was based on several events presently occurring in the fields of alcoholism and psychiatry. Alcoholism or alcohol dependence is now generally accepted as a psychiatric disorder and during the acute phase, alcoholism can manifest a wide range of psychiatric symptomatology. The course of alcoholism is acknowledged to be progressive and varied and psychiatric factors may be present at all points along the alcoholic pathway. Psychiatric symptoms may preexist the alcoholism and playa role in its development, may arise as a complication of chronic alcoholism, may be part of any phase of acute alcoholism, or may occur as an independent event in an alcoholic. Until recently, psychiatrists generally ignored the alcoholic or viewed him as morally weak, with a bad habit symptomatic of severe underlying psycho pathology which was substantiated by labeling it with psychoanalytic terminology. From the other perspective, the alcoholic community has been wary of psychiatry and its labels as well as the ability of psychiatrists to treat this popUlation. Medication was often inappropriately prescribed, groups such as AA were perceived as threatening, and patients spent years on the couch drinking their way through interpretations of preoedipal conflicts rather than directly addressing the problem. The rapprochement has been slow, but has been taking place neverthe less. There seems to be general agreement that psychiatric impairment is not the same in all alcoholics. Many, perhaps even most alcoholics can be treated without psychiatric involvement because their primary problem is alcohol and the medical and social complications which arise as a result. Other alcoholics clearly need the assistance of psychiatric intervention and withholding it may be ignoring a factor which perpetuates the alcoholism. Ix x Preface The relationships between the various psychiatric disorders and alco holism need clear delineation. It is hoped that this volume is of assistance in developing a better understanding of both conditions and, most important, their effective treatment. JOEL SOLOMON, MD Contents Foreword vii Eugene Feigelson 1. The Bio-psycho-social Perspective in Alcoholism 1 Benjamin Kissin and Meredith Hanson 2. Prevention of Alcoholism 21 Gerald L. Klerman 3. Alcoholism and Psychiatry: A Cross-cultural Perspective 35 Joseph Westermeyer 4. Altered Use of Social Intoxicants After Religious Conversion 49 Marc Galanter 5. Alcoholism and Clinical Psychiatry 57 Joel Solomon 6. Alcoholism and Schizophrenia 69 Martin S. Kesselman, Joel Solomon, Malcolm Beaudelt, and Barbara Thornton 7 A. Alcoholism and Affective Disorders: Methodological Considerations 81 Joel Solomon xl xII Contents 7B. Alcoholism and Affective Disorders: The Basic Questions 87 Donald W. Goodwin 8. Alcoholism and Suicide 97 Joel Solomon 9. Alcoholism and Sociopathy 111 Joel Solomon and Meredith Hanson 10. Hidden Psychiatric Diagnosis in the Alcoholic 129 Frederic M. Quitkin and Judith G. Rabkin 11. Psychiatric Aspects of Alcohol Intoxication, Withdrawal, and Organic Brain Syndromes 141 Donald M. Gallant 12. Alcohol and Adolescent Psychopathology 163 Robert B. Millman and Elizabeth T. Khuri 13. Psychiatric Problems of Alcoholic Women 179 Sheila B. Blume 14. The Contribution of Psychoanalysis to the Treatment of Alcoholism 195 Austin Silber 15. Office Psychotherapy of Alcoholism 213 Sheldon Zimberg Index 231 CHAPTER 1 The Bio-psycho-social Perspective

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