410 Unit 4 NURSINGPRACTICE FORPSYCHIATRICDISORDERSONSET AND CLINICAL COURSE
Much research on substance use has focused on alco-
hol because it is legal and more widely used; thus,
more is known about alcohol’s effects. The prognosis
for alcohol use in general is unclear because usually
only people seeking treatment for problems with alco-
hol are studied.
The early course of alcoholism typically begins
with the first episode of intoxication between the 15
and 17 years of age (Schuckit, 2000); the first evidence
of minor alcohol-related problems is seen in the late
teens. These events do not differ significantly from the
experiences of people who do not go on to develop al-
coholism. A pattern of more severe difficulties for peo-
ple with alcoholism begins to emerge in the middle 20s
to the middle 30s; these difficulties can be the alcohol-
related breakup of a significant relationship, an arrest
for public intoxication or driving while intoxicated,
evidence of alcohol withdrawal, early alcohol-related
health problems, or significant interference with func-
tioning at work or school. During this time, the person
experiences his or her first blackout,which is an
episode during which the person continues to function
but has no conscious awareness of his or her behavior
at the time nor any later memory of the behavior.
As the person continues to drink, he or she often
develops a tolerancefor alcohol; that is, he or she
needs more alcohol to produce the same effect. After
continued heavy drinking, the person experiences a
tolerance break, which means that very small
amounts of alcohol will intoxicate the person.
The later course of alcoholism, when the person’s
functioning definitely is affected, is often character-
ized by periods of abstinence or temporarily con-
trolled drinking. Abstinence may occur after some
legal, social, or interpersonal crisis, and the person
may then set up rules about drinking such as drink-
ing only at certain times or drinking only beer. This
period of temporarily controlled drinking soon leads
to an escalation of alcohol intake, more problems, and
a subsequent crisis. The cycle repeats continuously
(Schuckit, 2000).
For many people, substance use is a chronic ill-
ness characterized by remissions and relapses to for-
mer levels of use (Jaffe, 2000c). The highest rates for
successful recovery are for people who abstain from
substances, are highly motivated to quit, and have a
past history of life success (that is, satisfactory expe-
riences in coping, work, relationships, and so forth).
Although an estimated 60% to 70% of people in alco-
holism treatment remain sober after 1 year (Schuckit,
2000), this estimate may be optimistic because most
relapses occur during the second year after treatment.
Evidence shows that some people with alcohol-
related problems can modify or quit drinking on their
own without a treatment program; this is called spon-
taneous remissionor natural recovery (Cloud &
Granfield, 2001). The abstinence was often in response
to a crisis or a promise to a loved one and was accom-
plished by engaging in alternative activities; relying
on relationships with family and friends; and avoiding
alcohol, alcohol users, and social cues associated with
drinking. Spontaneous remission can occur in as many
as 20% of alcoholics although it is highly unlikely that
people in the late stage of alcoholism can recover with-
out treatment (Schuckit, 2000).
Poor outcomes have been associated with an ear-
lier age of onset, longer periods of substance use, and
the coexistence of a major psychiatric illness. With
extended use, the risk of mental and physical deteri-
oration and infectious disease, such as HIV infection
and AIDS, hepatitis, and tuberculosis, increases es-
pecially for those with a history of intravenous drug
use. In addition, people addicted to alcohol and drugs
have a rate of suicide that is 20% higher than that of
the general population.RELATED DISORDERS
Substance-induced disorders such as anxiety, mood
disorders, and dementia are discussed in other chap-
ters. For instance, Chapter 21 discusses delirium,
which may be seen in severe alcohol withdrawal. A
clinical care plan for a client receiving treatment forDrugs and alcohol can lead to legal problems.