Clinical Textbook of Addictive Disorders 3rd ed - R. Frances, S. Miller, A. Mack (Guilford, 2005) WW

5. Alcohol 97Female breast cancer shows a dose-dependent increased risk with alcoholconsumption (e.g., RR = 1.3 with use of two drinks per day) but anincreased RR of 2.7 if alcohol consumption averages over eight drinks per day(Bagnardi et al., 2001). The mechanism of alcohol’s interaction with breastcancer is most likely related to increased estrogen levels associated withdrinking. The increased risk of breast cancer with alcohol use may be limitedto women with a family history of breast cancer (Vachon, Cerhan, Vierkant,& Sellers, 2001).Fetal EffectsFetal alcohol syndrome (FAS) is the leading known preventable cause of mentalretardation. FAS is defined by maternal drinking during pregnancy, growthretardation, a pattern of facial abnormalities, and brain damage characterizedby intellectual difficulties or behavioral problems (Stratton, Howe, & Battaglia,1996). The fetus is most vulnerable to alcohol during the first trimester. Facialabnormalities are characterized by a thin upper lip, absence of a philtrum,midfacial hypoplasia, and short palpetral fissures. Behavioral and intellectualproblems include difficulty in shifting attention, slower reaction time, poorermemory, language problems, and deficits in executive functions such as planningand organization (Olson, Feldman, Streissguth, Sampson, & Bookstein,1998).No safe limit of alcohol use has been determined, but infants born towomen who drink more than 150 grams of alcohol per day during pregnancyhave a 33% chance of having FAS (Greenfield, Weiss, & Mirin, 1997). About3.1 per 1,000 first-grade students may show evidence of FAS in the UnitedStates (Clarren, Randels, Sanderson, & Fineman, 2001).TREATMENT PRIORITIESEstablishing a trusting therapeutic relationship is integral to treating the alcoholicpatient. A psychiatrist is in a strong position to develop a nonjudgmental,empathic relationship with alcoholic patients but, in addition, must be preparedto challenge denial and confront pathological behavior or regression. Thephysician’s awareness of the continuing incentive to drink, mediated bychronic stimulation of dopamine-rich pathways in the mesocortical system, willassist him or her in tolerating relapses and encouraging the patient to learnfrom relapses rather than either the patient or the clinician succumbing to asense of defeat. Alcoholism leads to impaired impulse control and an impairedpriority system; that is, the salience or importance of alcohol has become dominantfor the alcoholic patient, and the reversal of this priority is a slow, steady,day-by-day process.