Does my loved one drink too much? A new book by well-credentialed writers (Robert Doyle, M.D., of Harvard Medical School, and clinical psychologist Joseph Nowinski, Ph.D.) examines that vexing territory, the land between “normal” drinking and true alcoholism. —Ed.  

I have seen many patients over the years who complain of fatigue, sleep disturbance, mood disorder with volatility, cognitive “fuzziness,” and lowered libido at midlife. Some of these women would like the convenient label “hormonal problems” (I am a gynecologist) when, in fact, my three-hour consultation reveals that their symptoms could be caused by something else.

In an unconscious way, many women in their 40s begin to use alcohol in increasing amounts. They tell me they don’t really drink: “I just have wine.” Or, when they are questioned initially, a common response to “How much do you drink?” is, “I only drink socially.” My response to that answer has always been, “What is your social group?” After some time, patients often report that they “enjoy” a glass of wine when they begin preparing dinner, have another with their partner at dinner, and often a third after the children are in bed.

These women can rightly say that they don’t become intoxicated from three glasses of wine over this three-hour weeknight ritual. The weekend nights often involve a cocktail before dinner and two glasses of wine in the company of friends. And this drinking behavior may have gone on for years. These women do have disrupted sleep, more fatigue, more irritability, and less interest in sex. And it isn’t hormonal.

When a patient’s complaints can be confused with symptoms experienced by women in the menopausal transition, primary care doctors like gynecologists, GPs, or internists should always take a quiet, nonjudgmental history. This takes time, and patients are not always pleased with the questions that must be asked. But the doctor needs to persist until he or she gathers enough information to ask whether alcohol use could be a factor in the symptoms the patient wants to eradicate.

When does a person slide from “drinker” to “alcoholic”? That worrisome question is at the heart of Almost Alcoholic: Is My (or My Loved One’s) Drinking a Problem?, a new book by Joseph Nowinski, Ph.D, a clinical psychologist, and Robert Doyle, M.D., of Harvard Medical School. The book is part of an excellent series, “The Almost Effect,” written by Harvard Medical School faculty and other experts and published by Hazelden Publishing/Harvard Health Publications. These books offer guidance on “common behavioral and physical problems falling in the spectrum between normal health and full blown medical conditions.”

Almost Alcoholic provides a new way of thinking about the large number of people who have a variety of drinking problems that don’t meet the criteria for alcoholism, or even alcohol abuse. I recommend it to all primary care medical professionals and to anyone who may be concerned about personal drinking and its impact on their lives or the behavior of someone they know.

The book’s new terminology for the difference between the true alcoholic and those who lie “below the water line in terms of their drinking” should have an enormous effect on the conversation about drinking. Till now, drinking behavior has been construed as a strictly black-and-white issue: alcoholism, with its set definitions, or not-alcoholism. Alcohol abuse and dependence has been defined as a disease by the American Medical Association only since 1956. Even now, alcoholism is often regarded as a shameful character flaw, not as a disease that can be recognized and treated.

Signs of the “Almost Alcoholic”

The five key signs of the “almost alcoholic” are listed in the book and discussed. Here are two of them: (1) continuing to drink in spite of some negative consequences (bad mood, volatility, poorer performance at work, or disruption of close relationships); and (2) the emotional reasons that “almost alcoholics” have for drinking—social anxiety, boredom, control of negative emotions like anger, anxiety, grief, sadness, or “to unwind.” And these drinkers continue to drink even if their behavior causes suffering or embarrassment for themselves or loved ones.

Patients often tell me that when they were children and a parent had a “drinking problem,” they could not bring friends home from school or for sleepovers because they could not predict the “emotional temperature of the home” in advance of a friend’s visit. Parents’ destructive behavior from alcohol use may never be seen by outsiders at church, at work, or in simple social settings—but can cause suffering in childhood and emotional hurdles that last a lifetime.

Almost Alcoholic provides easy-to-understand questions that substance abuse specialists use. The easy scoring system allows readers to find where their drinking behavior places them on the continuum of no alcohol/moderate drinking/almost alcoholic to alcohol abuse and dependence. Those who are “almost alcoholics” have been drinking too much for long enough to have entered a state where drinking “dulls the senses and sedates the drinker.” This prevents introspection and affects the way they see the world and their place in it.

The author makes it clear that taking a total break from alcohol for some period of time is necessary for the patient to have the cognitive and emotional clarity to answer, “Who am I? Who would I like to be?” as an essential part of recovery and emotional healing.

The chapter on emotional and spiritual evaluation after a sustained period of abstinence will be very useful for any reader, covering topics as diverse as “What is my purpose in life?” to “After I am gone, what would I like those closest to me to think and say about me”?

The common-sense guidelines to changing drinking behaviors in Almost Alcoholic include avoiding people and places where heavy drinking is likely to occur and instead to focus more on social activities and time spent with people where alcohol is not of significant interest. A chapter on changing habits and behavior is helpful in this area as well.

I strongly recommend this book for its information about our epidemic of alcohol overuse and its accessible guide to understanding the continuum of drinking behavior. Women are at increased risk of health consequences from alcohol use—greater chance of liver damage, cognitive change, and an increase in breast cancer risk, among other problems. Both men and women risk more diabetes, hypertension, cancers, obesity, and harm to important personal and professional relationships due to alcohol overuse.

The good news is that recognition of the problem is the start of healing. Almost Alcoholic can trigger this recognition for a reader with an open mind.