Clinical:Case Study: Keeping Secrets - Women and Alcoholism

Original materials created in May 1999 by Karen Johnson, M.D.

History

MC, 53 yo bright, witty, high-functioning corporate executive is not your typical alcoholic. She is well-groomed and outgoing. She has never missed a day’s work due to drinking. She has never been arrested for driving under the influence.

Few women identify alcohol abuse as their chief complaint. However, it is estimated that there are up to six million female alcoholics in the United States. Almost 10% of women age 30 and younger have alcohol problems, and the proportion may be even higher in women over 30. While men seem to do their heaviest drinking during young adulthood (ages 21 to 34), women’s drinking continues to increase into mid-life (ages 50-64). Even modest drinking can be hazardous for elderly women due to chronic illness, impaired metabolism or diminished excretion.

It is generally believed that denial is the main obstacle that prevents women from seeking help from drinking problems. Certainly this is the case for some women, but for others it may be shame or embarrassment that presents the biggest impediment. Some women will readily express concern about their drinking if a physician asks during a routine history.

While intoxicated, MC fell down her basement stairs carrying a load of laundry. She did not sustain any major injuries, but developed a large bruise on her right buttock. Her gynecologist saw it during a routine pelvic exam, and made a mental note to pay particular attention to MC’s response to the CAGE questions.

The CAGE mnemonic is widely used to evaluate alcohol-related problems. Two or more “yes” answers confirm the diagnosis of alcoholism about 80-90% of the time.

C Have you ever felt you ought to Cut down on your drinking?

A Have people Annoyed you by criticizing your drinking?

G Have you ever felt bad or Guilty about your drinking?

E Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (Eye-opener)?

Some experts who specialize in treating alcoholism in women believe that the diagnosis sometimes can be made with the single question, “Are you concerned about your drinking?” This was the question MC’s gynecologist asked and MC readily admitted that she was concerned.

Drinking alone, which is particularly dangerous, is quite common in women. Also, a major loss may precipitate an increase in alcohol consumption. This was precisely MC’s situation.

MC’s company had recently been bought by a major competitor. Although she had received an impressive severance, she was not offered a position in the merged company. After 11 years of loyal service and as a divorced woman who had two grown children living away from home, when her job ended, MC felt that she had lost her entire identity. In addition, as a midlife woman, she worried about her options in the youthful industry of retail clothing.

Previously a social drinker who enjoyed a glass or two of wine with dinner a few evenings each week, she now consumed a bottle of wine daily. She tried various strategies to cut down, but none worked for long. She continued her regular attendance at church each Sunday, her one day of abstinence, but she did not have enough self-esteem or sense of well-being to look for a new job.

No one in her family or friendship network knew what was happening. Fortunately, her primary care physician recognized the possibility of alcohol abuse and offered help. MC was given information about two self-help groups, Alcoholics Anonymous (AA) and Women for Sobriety (WFS) and a referral to a therapist who specialized in working with women alcoholics.

MC took the referrals. When her Pap test showed a mild abnormality, she returned for a follow-up appointment. The doctor took that opportunity to ask again about MC’s drinking.

The physician was not surprised to learn that MC was still drinking the same amount and that she had not pursued any of the referrals. Fortunately, this physician understood that each intervention needs to be viewed as part of a longterm process. A compassionate, informative, non-judgmental approach at each visit reinforced the message that MC’s alcoholism was a treatable health problem. The treatment was abstinence, and with support, it could be achieved.

Guidelines

• Consider alcohol abuse a possibility in all patients.
• If alcoholism is suspected based on history or clinical observation, discuss health consequences, especially those related to women’s more rapid development of cardiovascular and gastrointestinal diseases.
• Address the “relational context” of alcohol use (e.g., partner with alcohol problems, history of physical abuse, recent significant loss).
• Empathize with and help address practical issues of housing, childcare, employment, physical health, and legal issues.
• Recommend a self-help program. (Women for Sobriety is especially designed for women, although Alcoholics Anonymous may be more accessible.)
• Provide referrals to therapists with expertise in treating women with alcohol problems.

Discussion

Although a predisposition for developing alcoholism does exist for women whose father, mother or sibling has or had a drinking problems, alcohol abuse is not simply a matter of biologic vulnerability. Women use alcohol for many reasons - to relax, to feel sexy, to anesthetize painful feelings, to help themselves sleep at night.

Historically, physicians have been reluctant to ask about alcohol use in women because they have not viewed it as a “women’s health problem.” They have seen alcoholism as untreatable or they have not known what to do about the diagnosis once they have made it. Fortunately, most alcoholics do improve with the care of a knowledgeable and skilled physician and through lay organizations such as AA or WFS. Even if relapses occur, a sensitive and concerned primary care physician can help a woman regain abstinence.

Alcoholism is a life-threatening illness. Fortunately, an accurate diagnosis and effective treatment is life-saving.

Resources

Alcoholism Anonymous 475 Riverside Drive NY, NY 10015

Women for Sobriety P.O. Box 618 Quakertown, PA 18951-0618

References

Brown, Treating the Alcoholic: A Developmental Model of Recovery. Wiley-Interscience Publications, 1985.

Cry and Moulton, The physician’s role in prevention, detection, and treatment of alcohol abuse in women. Psych Annals;23:8, Aug 1993.

Zerbe, Women’s Mental Health in Primary Care. W.B. Saunders, Co. 1999