A lawyer (let’s call him Joe) comes home every day and pours a big drink into a Bobcats cup, goes into his den and closes the door. Because his wife has been complaining about his drinking he has started keeping a bottle in the car, so he had had a couple of long pulls even before he got home. After all his wife is a pain to live with, practicing law is no fun any more because his clients are always complaining, and a couple of his partners are becoming increasingly irritating to him. From Joe’s perspective, life would be fine if all the people around him just did not cause him so many problems.
Joe suffers from a brain disease called alcoholism. Technology is now beginning to allow us to map the interactions among nerve cells in the brain, from the first slug of hot liquor in the car, till Joe closes the den door.
Positron emission tomography (PET), single photon emission computed tomography (SPECT), computed tomography (CT) and magnetic resonance imaging (MRI) are some of the tools that are allowing scientists to observe the brain of the alcoholic more closely, including observations being made while intellectual tasks are being performed and emotions experienced.
What does Joe’s brain look like? First, we know that with a history of long term alcohol consumption his brain is smaller, lighter, more shrunken than the brain of a non alcoholic of the same age and gender. We are able to observe damage to Joe’s brain even though there are not other clinical indicators of severe alcoholism such as chronic liver disease or alcohol induced dementia.
The shrinkage in Joe’s brain is more extensive in the folded outer layer of the frontal lobe (i.e. cortex) which is understood to be the part of the brain that governs higher intellectual function. For a male alcoholic we know that vulnerability to frontal lobe shrinkage increases with age. Current studies are underway to determine if the same is true in women. The rate of shrinkage in the area of Joe’s brain responsible for developing trial strategies and coming up with good legal advice correlates with the amount of alcohol that he consumes. But not only is the “thinking” part of the brain shrinking, other brain structures associated with memory, as well as those associated with coordination and balance, are shrinking also.
When Joe drops into his den easy chair, blood flow decreases in his brain and there is a reduction in the amount of communication between adjacent neurons. There is particularly a decrease of blood flow in Joe’s brain in the area of the brain where the neurotransmitter dopamine is present.
Joe’s wife comes into the den interrupting his reverie to ask him about a bill collector’s call. Joe reacts with rage-full anger that seems to come out of nowhere. When he yells at his wife, the frontal region of Joe’s brain reflects decreased metabolic activity, as compared with the brain of a nonalcoholic, suggesting a diminished capacity for dampening excessive neuronal activity and a weakening of Joe’s ability to inhibit behavior.
In the future scientists expect to use imaging technology to measure alcohol’s effects on mood, emotional states, craving and cognition while simultaneously assessing metabolic, physiologic, and neurochemical function in the brain. In practical terms the scientists will be tracing the neurochemical paths and reactions that cause the alcoholic to feel irritable, restless and discontented. The behavior and feeling states that alcoholism produces are well known. Tracking how these actually work in the brain will probably continue to confirm what scientific studies have shown to date — that for the past sixty years the best treatment for alcoholism is based upon the twelve steps of Alcoholics Anonymous. If past experience is any predictor, research will help show why AA is such an effective treatment. This research is already validating the experience that people find in recovery, where newfound sobriety is often described as being on a pink cloud. That pink cloud may be an apt metaphor to describe what happens when abstinence from alcohol allows there to be more red blood in specific areas of the brain. The good news for Joe is that recovery based on abstinence offers lots of hope. Cognitive function and motor coordination may improve at least partially within three to four weeks of abstinence accompanied by at least partial reversal of brain shrinkage and some recovery of metabolic functions in the frontal lobes and cerebellum. Frontal lobe blood flow continues to increase with abstinence, returning to approximately normal levels within four years. As might be suspected, relapse to drinking leads to resumption of shrinkage, continued decline in metabolism and cognitive function, and damage to brain cells.
Maybe one day research will show why the organ most damaged by the disease of alcoholism, the brain, is also the organ that is most likely not to be of help to the lawyer suffering from the disease. The sick lawyer will rationalize, minimize and find a hundred good reasons why all of his or her problems stem from other causes. The sick brain itself is not able to think itself into perceiving objectively how the illness is affecting the lawyer’s life. For that we are each dependent on some outside help.
Increasingly, good medical help is available, but the prevailing public view about addiction limits its effectiveness. Our attitude is shaped by a perception that drug dependence is primarily a social problem that requires interdiction and law enforcement rather than a health problem that requires prevention and treatment. The difficulty with this perception is that it lumps two vastly different problems into a single analysis. The social problems are all those things that lead up to the possibility of alcoholism and other drug dependence and the medical problem is all those things that ensue once the onset of the disease of chemical dependence has occurred. Most of us don’t mind helping those who have diseases, but we don’t want to coddle social problems. Ironically, it is the social part of the problem, where the opportunity occurs over which we have some control to limit exposure to the disease, where we as a culture are least interested in doing anything. Joe grew up in a culture that encouraged drinking in college and law school. For the most part, marijuana and other recreational drugs were also available and a part of the social scene. A huge amount of the country’s advertising industry encourages people to believe that they have a right to instantaneous relief for any emotional discomfort or assures them that use of addictive chemicals is a way to achieve happiness. The truth is we coddle the social problem, which encourages the opportunity for addictive disease to occur. Then, when the disease does attack a person, we are apt to turn our backs on the opportunity to utilize medical treatment. This occurs because alcoholism and other chemical dependencies are not like an acute infection where an antibiotic can be given and the patient can immediately get well. Rather, alcoholism and other chemical addictions are long term chronic conditions that require ongoing attention. In the October 4, 2000 issue of The Journal of the American Medical Association, drug dependence was compared with three other chronic illnesses: type 2 diabetes mellitus, hypertension and asthma. The authors noted the many similarities among these chronic conditions and concluded that alcoholism and other drug addictions should be insured, treated and evaluated just like other chronic illnesses.
– by Don Carroll
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