The 5 Different Types of Alcoholics & How to Deal With Them

Different Types of Alcoholics

Alcohol Use Disorder is a medical disorder defined by the inability to stop or control the use of alcohol despite adverse consequences. Alcohol use and misuse occur along a spectrum ranging from non-problematic use of alcohol to conditions such as alcohol abuse, dependence, addiction, and the common term, alcoholism. While these descriptors explain the progression of the disease, they lack some demographic factors and differing presentations that better inform identification and treatment protocols.

The National Institutes of Health conducted an epidemiological study to identify and understand the major subtypes of sufferers of alcohol use disorder to understand differences in identification and treatment response.¹ While an estimated 11.3% of adults and 3.4% of youth suffer from some form of AUD, many fewer receive treatment.² The NIH reviewed 1484 responses to the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Using the results of this representative sample of people in and out of treatment in the United States, researchers identified the subtypes based on family history, age of onset of use and misuse, symptom patterns, and the presence of additional substance abuse and mental disorders.

Young Adult Subtype

Young adults comprise about 31.5 percent of people with Alcohol Use Disorder in the United States¹ and are among the most under-treated subtypes. Individuals who fall into this subtype have low rates of co-occurring mental health or other substance abuse disorders, low familial alcoholism, and are rarely identified as needing treatment. The risk of developing alcohol use disorder is higher for females who begin drinking at a young age.

Behaviors of Young Adult Alcoholics

Young adult alcoholics are likely to engage in disproportionate binge drinking. Binge drinking is five drinks on one occasion for men and four for women.³ Young males have a higher prevalence of binge drinking. The likelihood of binge drinking in this subtype leads to greater risk-taking behaviors, resulting in accidents, unplanned pregnancies, sexually transmitted illnesses, and legal issues. Long-term binge drinking is associated with a higher incidence of memory issues, mental health concerns, and other poor health outcomes such as cancer.

Among young adult alcoholics, males are more likely to suffer from the condition and are likely to suffer from physical dependence. Young adult alcoholics have lower identification and treatment rates.

Young Antisocial Subtype

Some young sufferers of alcohol use disorder (about 21%) also suffer from antisocial characteristics.¹ Examples are irresponsibility, aggressiveness, disregard for social conventions, lack of remorse, and the tendency to lie. They are more likely to be male. About half of this subtype meets the criteria for Antisocial Personality Disorder.¹ Unlike the young adult subtype, this group is likely to engage in poly-substance use or abuse and have a significant family history of addiction. They are also more likely to seek help for their alcohol use disorder; about one-third of this group seeks treatment.¹

Young Antisocial Alcoholics and Co-Occurring Disorders

Over half of young antisocial alcoholics have an antisocial personality disorder (ASPD). Individuals with an antisocial personality disorder diagnosis are likely to engage in alcohol use at an earlier age which is a risk factor for alcohol use disorder. The tendency to disregard social norms, spend time in high-risk contexts, and suffer from co-occurring disorders also correlates with treatment resistance in this sub-type. ”Continued substance involvement exhibited by youths with an antisocial personality disorder may serve to limit future opportunities for acquisition of skills and is likely to create new problems, the consequences of which may further promote substance involvement and restrict opportunities for emerging from an antisocial lifestyle.”⁴

Young antisocial alcoholics may also experience other psychiatric disorders:

• 37% have a major depressive disorder
• 33% have bipolar disorder
• 20% have ADHD⁵
• 6% have Opioid Use Disorder⁶

Functional Subtype

About 19.5 percent of U.S. alcoholics have a disordered relationship with alcohol yet can function in key life domains.¹ A typical profile of a functional alcoholic is well-educated, middle-aged, with stable employment and family life. Many also use tobacco and may have co-morbid depression. About one-third have a multigenerational family history of alcoholism.

A high-functioning alcoholic may confine their drinking to non-work hours and use alcohol to quell anxiety or help them fall asleep at night. Notably, they often drink more than intended or make excuses for excessive use on social occasions. Some functional alcoholics drink alone and have a high tolerance such that they may not appear drunk to outside observation.

Signs of a Functional Alcoholic

It can be harder to identify a functional alcoholic, as they’re better at hiding their drinking habits. There are red flags that could help you identify someone who is at risk and may need help.

Signs of a functional alcoholic include:

• Drinking alone
• Unable to control the frequency or volume of their drinking
• Engage in a few activities without alcohol
• Use alcohol as a sleep aid
• Higher tolerance than others
• Choose activities with alcohol over occasions without alcohol
• “Pre-game” social occasions by drinking beforehand
• May engage in attempts to control alcohol use, e.g., Dry January, Sober October
• Blackouts
• High contrast between sober behavior and that displayed while drinking
• Deny or excuse drinking
• Hide alcohol in water bottles

Intermediate Familial Subtype

About 19% of alcoholics in the US belong to the Intermediate Familial Alcoholic Subtype, characterized by a 50% family history of alcoholism, typically spanning more than one generation.¹ People classified in this subtype have high comorbidity, with about half experiencing clinical depression and 20% experiencing bipolar disorder, cocaine addiction, problem drinking, marijuana use disorder, and also smoking cigarettes.¹ Unfortunately, only one-quarter receive treatment for their disease.

Characteristics of Intermediate Familial Alcoholics

Familial alcoholics suffer from the trauma of carrying family secrets and often neglect or disruption caused by growing up in an environment mediated by a member’s use of alcohol. Growing up in such an environment often results in an earlier age of first alcohol use and the presence of conduct issues as a youth. There is also a tendency to suffer higher symptoms of alcohol use disorder among this sub-type. There is a high likelihood of a genetic tendency toward alcoholism, most likely associated with the genes that mediate alcohol metabolism.⁷

Chronic Severe Subtype

The 9% of individuals who fit the Chronic Severe Alcoholic Subtype are at the highest risk for poor outcomes and treatment resistance.¹ As a progressive illness, this subtype began drinking early, with comorbid conduct issues and high rates of Antisocial Personality Disorder, mostly in their middle years. A large percentage comes from families with multiple members suffering from substance use disorder. The psychiatric co-morbidities are the highest of all sub-types. They are also the sub-type seen most frequently in treatment settings.

Symptoms of Chronic Severe Alcoholics

The Chronic Severe Subtype is suffering from a disease progression that has reached the most dangerous levels with severe emotional and sometimes life-threatening physical dependence. It is not uncommon for the individual to have had multiple efforts at treatment and legal issues relating to the use of alcohol. Other consequences of continued impairment might include significant family or employment disruption.

Chronic severe alcoholics have the most extensive symptoms, including:

• Highest rate of withdrawal symptoms
• Highest rate of emergency room visits
• Highest rate of continued drinking despite consequences
• Comorbid liver disease
• High rates of domestic violence
• Obsession with alcohol
• Damaged relationships
• Underemployment or history of job loss

Why Do the Different Types of Alcoholics Matter?

Understanding the five alcohol use disorder subtypes can help prevent, identify, and treat alcohol use disorder. Knowing the subtypes in primary care facilities, emergency departments, schools, or other community settings can help identify problems early and provide screening and early intervention efforts, such as the Screening, Brief Intervention and Referral to Treatment (SBIRT).² Knowing and treating the likely comorbidities within the subtypes may improve treatment outcomes. It is important to recognize that initial intervention opportunities may not present for alcohol-related concerns for some subtypes. Initial concerns for some subtypes might be related to legal issues in youth, family or marital counseling, or juvenile delinquency. Likewise, knowing the subtypes and considering these factors may influence treatment choices.

Treating Different Types of Alcoholics

Young antisocial and chronic severe alcoholics have a high participation rate in treatment, most likely due to the severity of symptoms and the likelihood that their behaviors have prompted intervention by the healthcare or judicial systems. In contrast, the young adult and functional alcoholic subtypes are less likely to receive treatment and more likely to deny the problem for an extended period.

Younger individuals may be more amenable to group treatment even if they are in earlier contemplation stages. Across all subtypes, people who suffer from comorbid anxiety, trauma, or mood disorders benefit from an integrated approach to treatment. Many later-onset issues with alcohol are related to psychosocial factors that must be a focus of treatment.

The five stages of change are:

• Motivation: Successful treatment of alcohol use disorder depends upon understanding the motivation for change. Motivation to change is best expressed in the words of the person suffering from the addiction.
• Precontemplation: Unawareness of the need to change drinking behaviors. A person at this stage may say, “I can stop whenever I want,” or “All my friends do the same thing.”
• Contemplation: As the person recognizes the need to change, they will demonstrate an understanding of the problem and begin to consider needed changes. People at this stage may ask others about how they manage their alcohol consumption or if they know any good programs or therapists.
• Action: The person in the action stage begins engaging in the effort to change, seeks assistance, and begins to manage setbacks. A person at this stage may try to make changes like reducing consumption of alcohol, trying to only drink on weekends or social occasions, or abstaining altogether and is likely to exhibit more consciousness of their consumption. They are more likely to try Alcoholics Anonymous, therapy, or other treatment options.
• Maintenance: This is where the person begins to sustain positive gains and develop strategies to deal with triggers and relapses.³

Seeking Help for Alcohol Addiction

An integrated health model using individual psychotherapy, group therapy, and rehab programs in inpatient or outpatient rehab settings are the best ways to treat alcoholism. Anyone who feels unable to control or stop drinking and is concerned about rising tolerance or alcohol withdrawal symptoms or how alcohol may have negatively affected their life should consider seeking treatment.

Recommended treatment is based upon assessment by a competent professional in the field and is determined based on ASAM criteria. The six dimensions of the ASAM are: (1) Intoxication or withdrawal, (2) Biomedical conditions or complications, (3) Emotional, behavioral, or cognitive conditions, (4) Readiness to change, (5)Relapse history or propensity, (6) Recovery environment. Once scored, outpatient, intensive outpatient, inpatient treatment, and detox may be recommended.

For those seeking outpatient options, you will want to choose your therapist based on their substance use disorder experience. You can find the right therapist using an online therapist directory. In addition, finding a support group for this specific issue can be helpful, and loved ones may benefit from doing the same.

In My Experience

In my experience, different individuals experience alcohol problems based upon a complex array of family and alcohol use history, the contribution of comorbid physical and emotional concerns, recognition of the problem, and the need for change. Many people in earlier stages of change notice that they do not like how they behave when drinking. I would recommend that anyone with these concerns consider speaking to their primary care doctor or seeking therapy to assess the situation and consider the next steps.