Evidence-Based Reviews

Alcohol dependence in women: Comorbidities can complicate treatment

Current Psychiatry. 2009 June;8(6):52-59

References

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In a study of >1,200 adolescents, girls age 13 With age, drinking for social and enhancement motives increases more among male than female adolescents. Drinking to reduce or manage negative affect is associated with an increased risk of heavy drinking (particularly for adolescent girls), more frequent intoxication, and alcohol dependence.¹⁴ These findings suggest:

Clinical Point

When developing a woman’s treatment plan, consider the addiction status and drinking patterns of her partner as well

Young women with alcohol use problems may benefit from learning strategies to regulate negative emotions and alleviate depression or anxiety symptoms that may be contributing to their drinking.
Young men with alcohol use problems may benefit from learning to manage peer pressure and from finding alternate sources of pleasure enhancement.⁵

CASE CONTINUED: Depressed and anxious

Ms. F admits to depressed mood, crying episodes, isolation from others, anhedonia, feelings of guilt, low motivation, difficulty concentrating at work, restless sleep, and weight loss. These symptoms recurred soon after she and her husband separated 4 years ago. She denies suicidal thoughts or suicide attempts.

She suffered similar episodes in the past, including when she was breastfeeding and abstinent from alcohol after the birth of her daughter. Her obstetrician treated her depression with fluoxetine. Problems with anxiety began in high school, especially associated with parties and dating. In college, she often would drink beer before class presentations.

You diagnose alcohol dependence, major depressive disorder, and social phobia. You also ask Ms. F about a history of trauma. She reports that her father was “real harsh” when he was drinking and often hit her and her sister. She also relates being struck by her ex-husband during arguments. Screening with the Clinician-Administered PTSD Scale is negative for posttraumatic stress disorder (PTSD), however.

Comorbid psychiatric disorders

Gender differences in reasons for alcohol use may be related to women’s higher rate of medical and psychiatric comorbidity (Table 2).^6,8,15,16 Vital signs, physical examination, and lab work are helpful for diagnosis and monitoring of medical comorbidities and complications. The gamma-glutamyl transferase (GGT) test for liver disease and carbohydrate deficient transferrin (CDT) test for chronic heavy alcohol consumption are less sensitive and specific in women than in men.¹⁷ Even so, monitoring GGT and CDT results over time may serve as a valuable marker of continued drinking by women.

Mood and anxiety disorders are significantly more common in women than in men among individuals with alcohol use disorders.^15,16 This pattern is not unique to alcohol-dependent persons, however. In the general population:

women are more likely than men to meet diagnostic criteria for anxiety, depression, bulimia nervosa, and borderline personality disorder
men are more likely than women to meet diagnostic criteria for antisocial personality disorder.¹⁸

Table 2

Comorbid disorders in women with alcohol dependence

Psychiatric Posttraumatic stress disorder Other anxiety disorders (such as panic disorder without agoraphobia, simple phobia, or social phobia) Major depressive disorder Cognitive impairment
Medical Hypertension Fatty liver disease Gastrointestinal hemorrhage Brain atrophy Reproductive system irregularities
Source: References 6,8,15,16

Mood and anxiety disorders are more likely to precede the onset of alcohol use disorders in women than in men. In a longitudinal study,¹⁹ women with major depression at baseline were 7 times more likely to have alcohol dependence at 2-year follow-up than women without major depression. Men with major depression at baseline did not show an increased risk for developing alcohol dependence over time. This finding suggests a different etiologic relationship between depression and alcohol use disorders for women than for men.

Suicide risk. A recent study by Connor et al²⁰ examined suicidal ideation, planning, and attempts in 3,729 alcohol dependent subjects (35% female) and found an association between female gender and both planned (odds ratio [OR] = 3.4) and unplanned suicide attempts (OR = 3.8). Further research is needed to clarify the relationship between female gender, alcohol dependence, and suicide risk, behaviors, and attempts.

Anxiety disorders are the most common psychiatric disorders in women,²¹ and social anxiety and social phobia may play a predisposing role in alcohol dependence.²² Individuals with social anxiety may self-medicate with alcohol as a social lubricant. Some research suggests that anxiety disorders are more severe in alcohol-dependent women than in men with similarly severe alcohol dependence.²²

Clinical Point

Mood and anxiety disorders are more likely to precede the onset of alcohol use disorders in women than in men

Posttraumatic stress. Childhood physical and sexual abuse and subsequent PTSD are important risk factors for alcohol abuse or dependence in women. Past physical or sexual abuse can complicate treatment and recovery in women because abuse is associated with increased psychiatric symptoms, more complex treatment needs, and poorer treatment outcomes.