Is Alcoholism a Mental Illness?

As the old saying goes, “First you take a drink, then the drink takes a drink, then the drink takes you.” 

Incidentally, the saying is sometimes attributed to American writer F. Scott Fitzgerald. And while he almost certainly didn’t make it up, it’s worth noting that “the drink” really did take “the man” in his case. Caught in the grip of alcohol misuse for much of his adult life, the writer achieved a year of sobriety before his untimely death at age 44. Unfortunately, it seems that years of drinking and the health problems that came with it had already taken their toll.

But how did he get there? How does anyone, for that matter, get to the point where the drink “takes them”? Is alcoholism a mental illness that makes it impossible to untangle ourselves from its grip once it has a hold on us? The answer is a bit more complicated than we might think.

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Nobody thinks it will happen to them. It starts out innocently enough: the first taste of alcohol, then regular drinks with friends on the weekend. Then the weekend starts on Thursday (or Wednesday, especially when the bar is having a two for one special or it’s been a rough week). Then it becomes a nightly thing. Eventually, we find ourselves too shaky to brush our teeth before tossing back a drink in the morning, or we wake up with our mind racing at 3 a.m. and quiet it with booze just so we can get a few hours of rest.

Whether or not we want to define ourselves as an “alcoholic,” there’s clearly a problem. And it’s getting worse at record speed.

Searching for Definitions

But is alcoholism considered a disease? In many ways, this is the question of the century. 

The short answer is yes, it is. But that wasn’t always the case. In the past, alcohol addiction has been seen as everything from a moral failing to a curse or demonic possession. Throughout the 19th century and at the cusp of the 20th, the scientific community recognized the physical “disease-like” nature of the problem. However, modern disease theory was still in its infancy and pre-Darwinian notions of “degenerationism” — a belief that moral failings were passed down from one generation to the next, leading to eventual extinction of entire family lines — loomed large. 

As a result, those who found themselves in the grips of alcohol misuse were in a frustrating double bind: their problem was seen as a moral one, but they were “doomed” to succumb to it no matter what. Depressing indeed. (But don’t worry, as we move through the century, things start looking up.)

As the 20th century brought about improvements in the scientific understanding of the brain, the medical community increasingly looked at “alcoholism” as a disease. However, the lines between personal choice, habit, and compulsion remained blurry.

In fact, even the word “alcoholism” is a bit confusing. Someone who is an “alcoholic” is obviously suffering, but how much of their trouble is of their own doing? There’s an undeniable dose of judgment in the term. 

In 1994, the American Psychiatric Association (APA) threw out the term “alcoholism” in favor of “alcohol abuse” and “alcohol dependence.” The difference is subtle, yet important: it’s not “us,” it’s “it” (or, more precisely, the way we’re using it).

Alcoholism and Mental Illness

In 2013, the definitions changed again — this time to “alcohol use disorder” (AUD). According to the National Institute on Alcohol Abuse and Alcoholism (NIAAA), “Alcohol use disorder (AUD) is a medical condition characterized by an impaired ability to stop or control alcohol use despite adverse social, occupational, or health consequences. It encompasses the conditions that some people refer to as alcohol abuse, alcohol dependence, alcohol addiction, and the colloquial term, alcoholism. Considered a brain disorder, AUD can be mild, moderate, or severe.” 

The current Diagnostic and Statistical Manual of Mental Disorders (DSM) defines AUD as a psychiatric disorder. And in the sense that psychiatric disorders and mental illnesses are synonymous, we can say that yes, AUD is a “mental illness.”

But when exactly does the “disease” or “illness” start? The line between what starts out as a habit but progresses into physical dependence is, by definition, a blurry one. Nobody starts out planning to develop AUD, and yet most people drink socially for a good part of their adult lives. So how does a socially acceptable behavior morph into one we find on the pages of the DSM?

To clarify this situation, let’s start by looking at alcohol’s effect on the brain, since that’s what sets the process that eventually leads to AUD in motion. Then we’ll see how that effect changes as we continue to drink in excess.

The Starting Lineup: Booze and the Brain

It’s no secret that alcohol has a powerful effect on the brain. Here’s the gist:

• Alcohol boosts dopamine. That uplifted “all is well with the world for these 20 minutes” feeling we get after a few sips? It’s dopamine at work. Alcohol floods our brain with this “reward” neurotransmitter that plays a key role in habit formation. The problem? The system is primitive and can’t distinguish between good and bad habits, so truly rewarding things (meaningful conversations, exercise, or nutritious food) get the same neurological “gold star” as booze.
• The depressant effects make us groggy. In addition to flooding the brain with dopamine, alcohol acts as a depressant, boosting the levels of GABA (an inhibitory neurotransmitter) while suppressing glutamate (its excitatory counterpart). The result? We feel relaxed for a bit, until the relaxation morphs into drowsiness. While we might even fall asleep, that slumber is unlikely to be restful, however. Alcohol disrupts our natural sleep cycle, robbing us of the restorative REM phase. Moreover, in an attempt to balance things out, the brain releases dynorphin — a chemical that leads to rebound anxiety after drinking.
• Drinking inhibits the prefrontal cortex. The decision-making part of our brain — the prefrontal cortex — takes a temporary vacation when booze is in the picture. The result? We say, do, text, post, buy, lose, and maybe break things we later regret.

For a deeper look, check out “How Alcohol Affects the Brain.” But for now, let’s turn our attention to the timeline of what happens as alcohol turns from a casual presence to a constant in our lives.

Game On: Moving Through the Stages

While alcohol has the same effect on everyone’s brain, the question of alcohol and mental health — specifically whether or not there’s a mental illness at play — is a bit more complicated. Let’s look at the stages through which the problem typically progresses: how casual use gets heavier and turns into misuse and dependence.

• Casual use. At this point, we might fall into the category of “social drinkers” who have a glass of wine with dinner now and then or a beer with friends on the weekend. Alcohol is still a “take it or leave it” matter, and it doesn’t interfere with our daily activities or jeopardize our health. At least not yet. (But watch out! It’s easy for casual use to turn into misuse if we’re not careful.)
• Heavy drinking. At this point, alcohol is a regular presence, and we’re exceeding the recommended limit, starting to put our health in danger.
• Misuse. We’re relying on alcohol,and it’s interfering with our relationships, work, and home responsibilities. We might be drinking too much at one time, also known as binge drinking. Alcohol misuse isn’t necessarily about the amount we drink (though it’s most certainly over the recommended amount), but more about the impact it has on our life and health.
• Dependence. Once dependence sets in, we’re no longer in control. We find that if we do stop, we experience withdrawal symptoms. On the milder side, these include headaches, fatigue, nausea, shakiness, and an overall “blah” feeling — kind of like a bad hangover. However, if we’ve been dependent for a long time, withdrawal from alcohol can be dangerous, bringing on seizures or delirium tremens (DTs).

In This Naked Mind, Annie Grace describes dependence in this way: 

“You drink to end the distress. The drink itself does not provide enjoyment, but you sincerely enjoy ending the nuisance of wanting a drink. The relief is so strong you feel happy, even giddy. You drink to get the feeling of peace that someone who is not dependent on alcohol always feels.”

At this point, we’re clearly in dangerous waters. The drink has “taken us.”

A Vicious Cycle

Once we reach dependence, a three-step cycle is set in motion. The NIAAA defines it as a repeating cycle with three stages. Each stage feeds into the next, and each person might go through it over the course of many weeks or even months. As our problem gets worse, however, we might find ourselves spinning through the stages several times a day, trapped in a roller coaster that leaves us more nauseous, disoriented, and exhausted with each turn. Here’s the pattern.

1. Binge/intoxication stage. At this stage, we give in to the craving to get the “reward” (such as alcohol). As a result, the cycle is set in motion. 

2. Negative emotions/withdrawal stage. We feel bad about falling back into old patterns and might try to stop, only to suffer from withdrawal symptoms and stress that comes with them. 

3. Preoccupation/anticipation stage. We start feeling better, but face cravings and eventually give in to impulsive actions, unable to exercise executive function. 

Each of the stages in the cycle involves a different part of the brain. The basal ganglia is involved in the reward pathway activated by drinking; the extended amygdala is involved in the emotional turmoil that follows; and the prefrontal cortex (its inhibition, to be exact) comes into play in the inability to control our impulses. We’re stuck in one of the most frustrating types of prisons — one that locks us inside our own mind.

Adding Other Players: Co–occurring Disorders

As if the situation weren’t challenging enough, there’s another complicating factor: AUD often comes with other disorders, some of which might be easier to categorize as “mental illnesses.” Here are the most common ones that tend to go in tandem with AUD.

• Anxiety. More than just feeling temporarily anxious or nervous, anxiety disorders involve repeated episodes of sudden feelings of intense fear or terror that reach a peak within minutes, giving rise to panic attacks. According to NCBI, 20% to 30% of those with anxiety disorder go on to develop AUD.
• Bipolar disorder. This mental health condition is characterized by extreme mood swings, including emotional highs (mania or hypomania) and lows (depression). These swings can affect our sleep, energy levels, behavior, and the ability to think clearly. NCBI reports that a fourth to just under half of people with bipolar disorder struggle with AUD at some point in their lives.
• Schizophrenia. This mental disorder might cause us to interpret reality abnormally. It may result in some combination of hallucinations, delusions, and extremely disordered thinking and behavior that impairs daily functioning. A little under a quarter of those with schizophrenia meet the criteria for AUD.
• Post-traumatic stress disorder (PTSD) and complex trauma. PTSD can happen after experiencing or witnessing a traumatic event. Symptoms may include flashbacks, nightmares, severe anxiety, and uncontrollable thoughts about the event. Alcohol frequently becomes the go-to way to cope, leading a third to half of those affected to develop AUD.
• Depression. Depression engulfs our life much the way AUD can, causing severe symptoms that affect how we feel, think, and handle daily activities, such as sleeping, eating, or working. We might feel persistently sad or lose interest in activities we once enjoyed.

While some of these disorders fall into the classic “mental illness” definition more easily, it’s often difficult to untangle their trajectory from that of AUD. For one thing, there’s a classic chicken-and-egg dilemma at play: it’s not always clear which condition comes first. Moreover, the symptoms — mood instability, impulsive behaviors, insomnia, and isolation, to name a few — tend to be similar. The conditions also affect one another in complex ways, taking turns at the wheel of what feels like a runaway train as we desperately try to hold on. (But don’t despair! We have good news ahead.)

Settling the Score: Recovery Is Possible

A major source of hope that comes with defining a condition as an “illness” is that illnesses have cures (or, at least, treatments). Thankfully, AUD — as well as the co-occurring disorders that might come with it — are no exception.

AUD recovery is possible, and today there are more resources than ever available to help you along the way. Here’s an overview:

• Clear the field. First things first: we need alcohol to get off the field. For some, the initial detoxification process can be done at home, but others might require hospitalization. If that’s you, don’t be discouraged — what’s a few days compared to the rest of your life? Alcohol withdrawal can be dangerous, so if you’ve been drinking heavily for a long time, it’s best to err on the side of safety.
• Choose your strategy. There are many approaches to take once the initial stage is over and booze is out of your body. Some find talk therapy helpful, others benefit from more practical approaches, such as cognitive behavioral therapy that helps you restructure your thinking around alcohol.
• Pick your team. Recovering from AUD is no small task, and we need a solid team around us. In addition to doctors and mental health professionals, we need a support team of peers to rely on when things get rough. Ask trusted friends and family members for help, and let them know exactly how they can support you. And check out the Reframe 24/7 Forum — a thriving global community of folks just like you who are eager to share their stories and advice!
• Look at the whole picture. Remember how we talked about co-occurring disorders? Unfortunately, conditions that affect our mental health often team up — a tendency that can make them harder to tackle. Whatever course of treatment or recovery approach you choose, make sure all the issues are addressed.
• Watch out for sneak attacks. Cravings and urges can hit when we least expect them to, especially at the beginning. First and foremost — don’t be surprised! Even if you’ve made a conscious decision to quit or cut back, the habit-forming part of the brain might automatically slip back into old thought patterns. The most helpful thing to do here is to get to know your triggers and observe them without judgment when they come up. Have a plan in place to avoid falling back into old patterns. For example, if you know that a certain work event will have booze and you’ll have a hard time saying no, bring a trusted member of your support team along.

With these tips, you can set yourself up for success on the journey. We wish you the best of luck and are here to support you every step of the way! (For more information on AUD treatment approaches, check out “Understanding the Stages of Alcohol Use Disorder: Causes and Treatment” and “Types of Therapy for Alcohol Misuse.”)

Summing Up

In the end, instead of wondering whether AUD is a mental illness, we might be better off asking a different question: how do we get past it? And, just as importantly, how can we keep casual alcohol use from sliding into heavy use, misuse, and dependence? At Reframe, we’re here to help you tackle the problem head-on and support you every step of the way. Check out our vibrant community and science-backed program that makes quitting or cutting back easy, achievable, and fun!