Hearing the word “alcoholic” may cause a particular image to spring to one’s mind. This is natural because stereotypes of alcoholics are found in all cultures and throughout the books, movies, and television shows these cultures consume. The reality, of course, is that there is no one type of alcoholic. A functioning alcoholic, for example, can mask his chemical dependency from the outside world while holding down jobs, maintaining relationships, and handling their daily responsibilities despite their substance abuse issues. But for physicians and scientists whose job it is to understand and treat the disease of chronic alcoholism, there is a genuine need – to be able to identify even such a high functioning alcoholic and differentiate them from non-problem drinkers. The question many of these professionals have been asking for the last few decades has been, “Are there different types of alcoholics?”
This article provides some of the historical attempts about the classification of alcoholics and explains the five different types of alcoholics as they are currently understood.
A few family members, friends, or co-workers may suspect the truth, but for the most part, others are not aware of how serious the person’s drinking problem is.
A History of Identifying the Different Types of Alcoholics
Early attempts to define and define the classification of alcoholics – those who suffer from AUD – tended to classify alcohol abusers into four broad categories:
- Problem drinkers – those who often drink to the point of intoxication and the resulting impairment of faculties and decision-making.
- Binge drinkers – those who drink vast quantities of alcohol frequently.
- Alcohol abusers – those who drink regularly, with a consistent increase in the amount consumed and the frequency of consumption.
- Alcoholics – those who have developed a physical and psychological dependence on alcohol.
In 1987, Swedish doctor C. Robert Cloninger attempted to categorize the last category –alcoholics – into two subtypes. His distinctions between the two types primarily dealt with genetics (whether there was an inherited family history of alcoholism) and the onset of the disease, together with other qualities such as personality traits and dependence:
- Type 1 Alcoholic – not as influenced by genetics as Type 2; onset tends to occur in adulthood as the result of setbacks, losses, and outside circumstances; personality traits include anxiety, shyness, rigidity, pessimism; dependence level involves drinking to reduce one’s anxiety level.
- Type 2 Alcoholic – much more influenced by genetics than Type 1; onset tends to occur before the age of 25, and they drink regardless of outside circumstances; personality traits include impulsiveness, risk-taking, being quick-tempered, optimistic, and excitable; dependence level is high and often involves other drugs.
The problem with this analysis was that Cloninger’s two subtypes were based on a study of 360 male patients being treated for alcoholism in Veteran’s Administration hospitals. Thus the data was therefore not a representative sample of men and women, and it also ignored the 25% of alcoholics who never seek or receive treatment. So in 2007, a more thorough study, one based on a more representative sample of people with AUD, was undertaken by the National Institute on Alcohol Abuse and Alcoholism (NIAAA), a unit of the National Institutes of Health (NIH), about the classification of alcoholics.
The NIAAA Study and Their Definition of the 5 Types of Alcoholics
The NIAAA study was based on the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a nationally representative study of alcohol, drug, and mental disorders in the United States. It focused on 1,484 NESARC respondents who met all diagnostic criteria for alcohol dependence and included people who were in treatment for their AUD as well as people who were not.
This broader sampling enabled the researchers to pinpoint five different types of alcoholics, based on the respondents’ family history of alcoholism, their age at the onset of alcohol problems, their symptoms of alcohol dependence and abuse, and the presence or non-presence of other substance abuse or mental disorders.
These five NIAAA subtypes are briefly described below, and then in more depth in the following section:
- Young Adult Alcoholic – constituting 31.5% percent of US alcoholics, this subtype of young adult drinkers is characterized by low rates of both family alcoholism and co-occurring substance abuse and mental disorders. This subtype rarely seeks or receives help to treat their alcoholism.
- Young Antisocial Alcoholic – constituting 21% percent of US alcoholics, this subtype tends to be in their mid-twenties and is characterized by an early onset of regular drinking and alcohol problems. Over 50% of the members of this subtype come from alcoholic families and have been diagnosed as having an antisocial personality disorder. Over 75% smoke both marijuana and cigarettes, and many have co-occurring cocaine or opiate addictions. In contrast to the Young Adult subtype, about a third of these alcoholics seek help for their drinking problems.
- Functional alcoholic – constituting 19.5% percent of US alcoholics, this subtype is well-educated, middle-aged, and with a stable job and family. A third have a multi-generational family history of alcoholism, and a quarter has had episodes of depression sometime during their lives, and half of this subtype smoke cigarettes.
- Intermediate Familial Alcoholic – constituting 19% percent of US alcoholics, this subtype is middle-aged, and over half come from families with a multi-generational history of alcoholism. Most of this subtype smoke cigarettes, and 20% had problems with cocaine and marijuana. Only one in four of this group seeks or receives any kind of help to treat their alcoholism.
- Chronic Severe Alcoholic – constituting 9% percent of US alcoholics, this subtype is typically composed of middle-aged adults who had early-onset drinking problems. High percentages of them suffer from Antisocial Personality Disorder or display criminal behavior, and almost 80% come from families with a history of multi-generational alcoholism. This subtype also has the highest rates of co-occurring psychiatric problems, commonly including depression, bipolar disorder, and anxiety, and has the highest percentage of smokers and users of marijuana, cocaine, and opiates. On the other hand, this type has the highest rate (66%) of seeking help for their drinking problems despite chronic alcoholism, so is the most prevalent type of alcoholic found in the treatment.
In the next section, we provide more detailed traits of each of the five types.
What Is A Functioning Alcoholic Condition?
A functioning alcoholic is someone who abuses alcohol regularly but is still able to work, go to school, handle parenting or marital responsibilities, maintain their appearance, and manage an assortment of daily tasks. A few family members, friends, or co-workers may suspect the truth, but for the most part, others are not aware of how serious the person’s drinking problem is.
According to research sponsored by the National Council on Alcohol and Drug Dependence (NCADD), approximately 14 million American adults—or one out of every 13—suffer from an alcohol use disorder. Out of this total, as many as 20 percent may be functional alcoholics.
Identifying a Functional Alcoholic
It takes courage to ask oneself this question and even more courage to answer it honestly.
Unfortunately, most functional alcoholics live in denial, too ashamed or too proud to admit the truth to themselves or others.
The Telltale Signs of High-Functioning Alcoholism
Is someone a functioning alcoholic? Here’s how to tell:
- When they wake up in the morning, alcohol is the first thing on their minds.
- They often feel shaky when they first get up and are not above “calming the nerves” by sneaking a quick drink.
- They plan to have only one or two drinks, but they end up having twice that amount or more (and this happens in a variety of circumstances).
- They experience blackouts or memory problems related to their drinking on at least a semi-frequent basis.
- They feel compelled to hide their alcohol consumption from others, especially loved ones.
- They’re uninterested in attending social events where alcohol isn’t served.
- They drink to help cope with emotions (stress, anxiety, boredom, anger, frustration, and so on).
- Hangovers are a common side effect of their drinking.
- They drink every single day—and miss alcohol dearly if, for some reason, they can’t.
In 2013, NY Times published a story: A ‘Perfect Mother,’ a Vodka Bottle and 8 Lives Lost, about a 39-year old mother named Diane Shuler, who died in an accident when she was under the influence of alcohol. She was a high-functioning alcoholic.
Too often, the loved ones of a so-called high-functioning alcoholic end up as collateral damage, and that was the case with Diane Shuler. In this sad incident, her son and three nieces also lost their lives, casualties of a disorder that selects its victims mercilessly and without discrimination.
Functional alcoholism is a silent epidemic, and far more people are suffering from its hidden symptoms than most would ever imagine.
Can High-Functioning Alcoholism Be Controlled?
The answer to this question might surprise one, but it is no, such people cannot, at least not all on their own. Functional alcoholism can be overcome with time and treatment, but one cannot wish it away or take command of it through willpower alone. According to this study, even in highly-educated and high-functioning groups of men, alcohol abuse and dependence predicted the onset and cessation of alcohol-related problems.
Alcoholism undoubtedly schnucks up, as an individual began drinking more in response to stress, relationship troubles, workplace disappointments, or the loss of a loved one. A person probably didn’t notice the way alcohol was taking over life, but with time the body’s tolerance for alcohol increased, and one needed to drink more and more to achieve the same effects. The individual didn’t realize it, but ethanol was slowly gaining control, and its mastery over their life has only been gaining in strength.
A person may be functional now. But if they continue down this path without seeking professional help, their performance and health will gradually deteriorate as profound alcohol dependence develops.
Living with a Functioning Alcoholic
In the privacy of their own homes, functioning alcoholic are not the confident, self-assured achievers they usually pretend to be when they’re hiding behind their facade. While family members may not be sure of what’s going on (although they often do have strong suspicions), they know the functioning alcoholic is dealing with a plethora of problems. Their anxiety and depression may be obvious, and their moodiness and secretiveness impact spouses, children, and other loved ones who are puzzled by their inconsistent behavior.
Functional Alcoholism and its Long-Term Impact
A functioning alcoholic who tries to quit drinking may be derailed by the strength of their cravings and withdrawal symptoms, and they may retreat into rationalization and denial once again as they slide back into chronic substance abuse. With functioning alcoholism, the drinking frequently escalates, and the eventual deterioration in home life, working life, and overall well-being are inevitable.
Functioning Alcoholics in the Workplace
Alcoholics in the workplace can be a danger to themselves and others. They can be reckless and unreliable, either drinking on the job (as their condition intensifies) or showing up for work hungover and unprepared to perform.
Many employees don’t realize it, but federal law guarantees them time off for work for substance abuse treatment, and their employers must keep their jobs open for them until they return.
Functional Alcoholism Treatment and Recovery
Outpatient treatment programs are usually the best course of treatment for a high-functioning alcoholic, likely supplemented by an initial period of medical detox.
The latter procedure usually takes place in a treatment facility or clinic and will allow patients to be carefully monitored as medications, vitamin supplements, diet plans, and therapy are offered to help them pass through the withdrawal process with a minimum of difficulty and discomfort.
Government websites are an excellent source of information for people with alcohol use disorders. The National Council on Alcoholism and Drug Dependence provides vital support and assistance to men and women with drinking problems and their families.
Young Adult Alcoholics
These drinkers tend to be young and often are associated with the college and young professional “party scene.” That is, they drink heavily in the company of friends on weekends, but rarely during the week. As a group, they have low rates of mental illness and low rates of family alcoholism. According to NIAAA publication, the largest percentage of alcoholics, i.e., 31.5% of all alcoholics in the US, fall in this category.
Interestingly, while this group drinks less often than other alcoholics, they tend to “binge drink” more often and consume more alcohol during those binges. For example, on “binge days,” members of this group often consume up to 14 drinks. Although the average age of this group is 24, most have spent at least the last four years as an alcoholic.
According to this CDC report, underage drinkers between the ages of 12 and 20 consume more alcohol at one time, and 90% of them binge drink.
Fewer than 9% of the members of this group seek help for recovery; when they do, they tend to prefer 12 Step programs over rehab clinics or private, professional practices.
Young Antisocial Alcoholics
This group is primarily in their mid-20s and has the earliest age of onset of drinking (16). They tend to come from families with alcohol addiction problems, start drinking early, and also abuse other substances. NIAAA researchers found a definite link in this group to antisocial personality disorder (ASPD), which is not surprising because another study in the Archives of General Psychiatry found that one particular serotonin receptor in the nervous system is associated with both antisocial behavior and alcoholism. This is of interest because people in this group may be using alcohol as a form of rebellion, drinking heavily because it is not socially acceptable. Given the high incidence of mental illnesses in this group, they may also drink to “self-medicate” to help control these disorders.
The traits of antisocial personality disorder include regular fighting and assaults, criminal activity, impulsiveness, deceitfulness, a lack of remorse, and an inability to accept responsibility for one’s own actions. This may contribute to the group’s binge drinking behavior, the highest of the five groups, with people consuming up to 17 drinks at a sitting. Studies have shown that people with ASPD are 21 times more likely than usual to develop an alcohol dependency in their lifetimes.
Over three-quarters of this group are male, and less than 8% received a college degree. About half are employed full-time, and their median family income is the lowest of the five subtypes.
About a third of the members of this group seeks help; when they do, they prefer self-help groups and detox programs.
Young Adult and Young Antisocial Alcoholics presently account for about half of the alcoholism in the United States.
Intermediate Familial Alcoholism
The name chosen for this group seems odd but was selected because the majority of its members are middle-aged and come from families with a history of alcoholism. The latter statistic is not surprising, because according to the Collaborative Study on the Genetics of Alcoholism, the child of an alcoholic parent is four to nine times more likely to become an alcoholic than a child without an alcoholic parent. It is unclear, however, whether this statistic is accurate because they watched alcoholic behavior growing up or whether they have a genetic disposition to inherit the disorder.
Members of this group began drinking at an average age of 17 and developed a dependence on alcohol at age 32. Of the five NIAAA alcoholic subtypes, this group has the highest employment rate, with 68% working in full-time jobs.
Nearly half of the members of this group struggle with clinical depression and other mental health disorders. Alcoholism may become a method of self-medication to fight depression and other emotional symptoms.
About a third of the members of this group seek help for recovery; when they do, they prefer private treatment programs, detox programs, and self-help groups.
Chronic Severe Alcoholics
Although this is the smallest group (9%), it is one of the most detrimental. This is because people in this group often have mental health issues that are difficult to resolve or deal with, such as anxiety, depression, bipolar disorder, and antisocial personality disorder, and also have addictions to other substances and drug addiction. They have the highest percentages of drinking more than they intended, alcohol-related work problems, withdrawal symptoms, and alcohol-related emergency room visits. They also experience severe life problems such as homelessness, joblessness, relationship issues, legal issues, and other social and behavioral issues as a result of their chronic alcoholism.
Around 80% of these alcoholics have a genetic link to alcoholism, with members of their immediate family has struggled with or still struggling with alcoholism.
While these facts may paint a less than hopeful portrait of this group, the NIAAA researchers also found that they are the most likely of any of their five subtypes to seek treatment. When they do, they prefer specialty rehab, detox programs, self-help groups, and inpatient treatment for recovery from chronic alcoholism.
Getting Treatment Before It Is Too Late
Identifying oneself or a loved one with an alcohol problem and categorizing them in one of the five categories based on the classification of alcoholics can help recognize what kind of treatment will be suitable for the patient. Professional rehabilitation and treatment facilities can help patients determine what form of treatment is optimal for them based on their specific circumstances and conditions. The sooner chronic alcoholism is identified, the better it could be treated and managed. Such severe consequences could be avoided, and alcoholics can start their lives in recovery.
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