- Email: [email protected]
Collaborative investigation of adult children of alcoholics with anxiety
Collaborative Investigation of Adult Children of Alcoholics With Anxiety Mary R. Haack The literature reports an increased Incidence of anxiety disorders in alcoholic families. Whether anxiety is a complication of alcoholism or a precursor to alcohol abuse is not understood. Studies suggest that there are psychological as well as genetic components In substance abuse and anxiety disorders. The purpose of this paper is to describe a collaborative effort designed to explore the complex interaction between the etiologic factors that lead to anxiety and substance abuse. This collaboration brings together the unique perspectives of both
psychiatric medicine and psychiatric nursing. © 1 9 9 0 b y W.B. S a u n d e r s Company.
ROWE AND COLLEAGUES (1980) found an 18% risk factor for anxiety neurosis, a condition that is similar to the current criteria for panic disorder, in relatives of patients with anxiety disorder. More recently, Crowe's group found a far higher incidence (24.7%) of panic disorder in first-degree relatives of patients with panic disorder than in relatives of normal controls (2.3%). Twin studies also suggest a genetic explanation for panic disorder. Torgensen (1983) studied 32 MZ and 53 DZ twins in Norway and found anxiety disorder with panic attacks was five times more frequent in MZ than DZ twins. Twin studies assume that MZ twin pairs are treated by their families in exactly the same manner. Studies after adoption would clarify the influence of environment, but this type of investigation has not been done with panic disorder twins. Other investigators observed that patients with panic disorder often experience anxiety attacks after vigorous physical activity and that their blood lactate levels were higher than controls after exercise (Cohen, Consolazio, and Johnson, 1947). As a result, it was postulated that anxiety attacks were caused by increased levels of blood lactate, the end
C
From the National Institutes of Health, Bethesda, Maryland Address reprint requests to Mary R. Haack, Ph.D,, R.N., National Institutes of Health, Bldg. I0, 3B19, 9000 Rockville Pike, Bethesda, biD 20892. © 1990 by W.B. Saunders Company. 0883-9417190/0401-001053.00/0
6Z
product of glucose metabolism when available oxygen is exhausted. Pitts and McClure (1967) followed up with experiments and infused panic patients with sodium lactate. They found that most of them experienced panic attacks during the 20minute infusion. Further evidence that lactateinduced panic attacks replicate spontaneous attacks is that pharmacotherapy, such as imipramine, that is used to treat panic also blocks lactate-induced attacks (Rifkin, Klein, & Dillon, 1981). Other drugs, such as isoproterenol, have also been used to produce panic attacks. These experiments are based on the hypothesis that patients with panic disorder have abnormally sensitive or hyperactive beta-adrenergic receptors. Many of the symptoms of panic (sweating, tachycardia, tremulousness, and tachypnea) can be produced by stimulating peripheral beta receptors in animal studies (Gorman, Liebowitz, and Klein, 1984). Procaine, which influences the limbic system, a region of the brain involved in emotionality, has also been used to stimulate panic. These studies seek to identify deregulation of specific neurotransmitters that may be responsible for panic attacks. Klein (1981) has formulated a separation anxiety therapy of panic attacks that suggests the mechanism that underlies normal human separation anxiety is deranged in patients with panic disorder. This hypothesis is inconsistent with Bowlby's theory that the attachment of an infant human to its mother is not learned but is genetically pro
Archives of Psychiatric Nursing, VoLIV,No. I (February), 1990."pp. 62-66
63
ADULT CHILDREN OF ALCOHOLICS WITH ANXIETY
grammed and biologically determined (Bowlby, 1976). Other theorists have focused on the environmental stressors that may have occurred in early childhood development. Freud postulated that panic attacks were caused by inadequate repression of memories of past events such as sexual trauma (Breuer and Freud, 1961). Behaviorists hold that spontaneous attacks are learned phenomena subject to the patterns of behavioral learning models. Both psychoanalytic and behavioral theories have provided the underpinnings for treatment approaches to the phenomenon of anxiety disorders. As theories of etiology, they have not been adequately tested. ALCOHOLISM
Evidence for genetic vulnerability to alcoholism continues to grow. Studies of adoptees in Sweden have identified two types of genetic predisposition to alcoholism: milieu-limited and male-limited. Milieu-limited susceptibility occurred in both sexes and required environmental provocation to become expressed as alcoholism. Male-limited susceptibility occurred only in adoptees with biologic alcoholic fathers and gave rise to severe early onset alcoholism accompanied by antisocial and violent behavior (Bohman et al, 1981, 1984; Cloninger, 1981; and Cloninger, 1983). Kaij (1960) studied 174 male twin pairs of which at least one of whom was a known alcoholic and reported a concordance of 54% for MZ twins and of 28% for DZ twins. Adoption studies provide a more rigorous approach to establishing a genetic factor in alcoholism. Goodwin (1973, 1974) studied adoption records in Denmark that included 55 men with alcoholic biologic parents and 55 controls who were adopted away before the age of 6 weeks and had no knowledge of their biologic parentage. Both groups came from similar socioeconomic backgrounds. Twenty percent of the children of alcoholics as compared with 5% of the controls were alcoholic at the mode age of 25 to 29 years. Psychoanalytic and behavioral theories of alcoholism interact in the implication that the need for alcohol is symbolic of narcissistic drives or the need for punishment. In this way, alcohol is a reinforcing agent. The more classic analytic approaches discuss the oral or passive-dependent as-
pects of the personality (Conger, 1956). Although psychoanalytic concepts and behavioral approaches are useful in the treatment of addicted people, it is very difficult to test their contribution to the etiology of alcoholism. Currently, the cause of alcoholism is considered to be a complex interaction between biochemical and environmental factors. SCOPE OF THE PROBLEM
Lifetime prevalence rates for anxiety disorders are between 10.3% and 11. 1% in the general population. Th~ prevalence of panic disorder is much less (1.4%), although many symptoms, specific for the diagnosis of panic disorder, are common in the general population. The lifetime prevalence of alcohol abuse/dependence, however, is between 11.5% and 15.7% in the general population. ADULT CHILDREN OF ALCOHOLICS (ACOA)
Children of alcoholics are one of the most prevalent groups at risk for the development of substance abuse, anxiety and depressive disorders (Russell, Henderson and Blume, 1984). Based on estimates in the general population, there are approximately 22 million ACOAs. These individuals represent an important target group for the development of prevention strategies. Several risk factors are suggested by the clinical literature. ALCOHOLISM AND ANXIETY DISORDERS
Research on the relationship between alcoholism and panic disorders such as panic attacks and agoraphobia has been limited to alcoholics. No studies have been done on offspring of alcoholics. Bibb and Chambless (1986) compared 22 alcoholic agoraphobics and 21 nonalcoholic agoraphobics and found that the identified alcoholics were more depressed, more socially phobic, more fearful of somatic symptoms, and more likely to engage in catastrophic thinking. Use of alcohol to selfmedicate for dysphoria was reported by 91% of the alcoholics and 43% of the nonalcoholics. Kroll, Stock, and James (1985) reviewed the charts of 411 patients hospitalized for alcohol treatment and found that 13% had been abused as children. These individuals demonstrated more legal difficulties, domestic violence, and more suicide attempts, as well as increased levels of pervasive and situational anxiety.
64
A variety of family r61e behaviors seen in ACOAs have been described in the clinical literature (Black, 1981). For example, a high need for control, a characteristic identified in the child who adopts the "responsible" r61e or the "hero" rble, may be a predisposing factor for the development of an anxiety disorder. When control over events is not possible, people with a high need for control tend to devalue problem solving and exaggerate the threat. The resulting anxiety is a manifestation of the person's perception or cognitive processes. Wilson and Orford (1979) noted several factors that explain some of the variability on how parental drinking influences the health of offspring. Among them are degree and type of exposure to parental drinking and variation in its impact, effect of parental drinking on mood and the atmosphere of day-to-day family life, the presence of significant others who may cushion the children from impact of parental drinking, the presence of violence and fear in the home, and the r61e and family task rearrangements that the children may take on due to parental drinking. At least one longitudinal study conducted on children of alcoholics from birth to age 18 reported that males and the offspring of alcoholic mothers had higher rates of psychosocial problems in childhood and adolescence. Moreover, the children of alcoholics who developed serious problems experienced more stressful life events disrupting their family unit in the first 2 years (Werner, 1985). These studies clearly indicate an increased incidence of anxiety and panic disorder in alcoholic patients. Whether anxiety is a complication of alcoholism or a contributor to the need for selfmedication that leads to alcohol abuse is not known. There appear to be psychological as well as biochemical components to alcohol and anxiety disorders. Children of alcoholics with anxiety, who are not alcoholic themselves, represent an interesting population for study. These individuals embody a family history for alcoholism and have the diagnosis of an anxiety disorder that places them at risk for the development of substance abuse. Moreover, patients with panic disorder need not self-medicate if they can be treated with pharmacotherapy and psychotherapy. An increased understanding of this at risk group could lead to the development of prevention and treatment strategies in the practice of psychiatric nursing.
MARY R. HAACK
COLLABORATIVE RESEARCH
The literature cited provided the basis for exploration of the factors involved in the development of anxiety disorders among children of alcoholics. Information about the interaction between biochemical vulnerability and environmental factors is currently being generated through a collaborative effort of Dr. David Theodore George and Dr. Mary Haack in the Laboratory of CJinical Studies, the National Institute on Alcohol Abuse and Alcoholism, on the National Institutes of Health Campus, Bethesda, MD. The process of this collaboration has thus far involved several steps: (1) Development of separate protocols representative of the traditional biomedical paradigm and the psychiatric nursing perspective. Dr. George's work is focused on neurotransmitter deregulation in ACOAs with panic disorder who are not alcohol or drug dependent. Dr. Haack is exploring the role of stressors related to psychosocial development, family of origin environment, and personality characteristics of ACOAs. (2) Development of the protocols which represent the two paradigms. Dr. George's protocols involve infusion of provocative chemicals. Dr. Haack's protocol involves 5 hours of structured interview. (3) Submission of the protocols to institutional review boards of the university where Dr. Haack was employed and the NIH review committee. (4) Development of proposal for funding. In this case, 3-year funding for the nursing perspective was obtained from the National Center for Nursing Research. Funding for Dr. George's protocol was provided by the intramural program of the National Institute on Alcohol Abuse and Alcoholism. (5) Agreement on selection process of possible subjects for the studies, sharing subjects whenever feasible. (6) Conflict resolution on points of disagreement concerning diagnosis of a patient, assignment to specific diagnostic categories, and other day-to-day interactions. (7) Publication of findings. Although it is too soon to report the outcome of this research, agreement has been reached on authorship for two articles. Each step was arduous and time-consuming, necessitating agreement not only between the collaborators involved but the administrations of the institutions employing the collaborators, review boards, as well as the funding agencies. The steps
65
ADULT CHILDREN OF ALCOHOLICS WITH ANXIETY
described took two years. The psychiatric nursing portion of the study has been funded for 3 years and is currently in progress. In all, this project will represent a 5-year effort. The present agenda that exists in psychiatric research emphasizes biomedical paradigms that require skills in the basic sciences that are primarily in the domain of medicine. Yet, a person's biochemical vulnerability, as important as it may be, is only a portion of what makes one become ill or of what enables one to become whole again. Psychiatric nursing has traditionally stressed the importance of family dynamics and early child development in the etiology of psychiatric illness. These constructs are more meaningful if they are integrated with an understanding of the biochemistry of the individual. Interdisciplinary collaboration can and does change the rules of the doctor and nurse game described by Stein in 1968. First, according to Stein (1968), nurses are socialized to believe that doctors are omnipotent and all-knowing, and any suggestion by a lowly nurse would be insulting and expose one to public ridicule. Second, in matters of patient care nurses must somehow disguise their knowledge in a way that won't offend the doctor but at the same time influence the doctor to do what is in the patient's best interest (Richards, 1978). A formal collaborative agreement clearly delineates the unique contribution of medicine and nursing. This is both liberating and intimidating. For nursing research must participate in the same arena with the physician and is, therefore, subject to the same critical process. In addition, it requires patience and the willingness to learn from the opposing perspective. The discovery of genetic markers and new methods of pharmacologic treatment have necessitated a biochemical focus in psychiatry. This situation has cleared the way for nursing to make known its unique contribution to the care of the mentally ill and has rendered the old games between physician and nurses archaic. Ideally, the successful collaboration between psychiatric medicine and psychiatric nursing will ultimately mean better research and better care because it will be more comprehensive in scope. It is hoped that the collaboration described in this article will lead to development of holistic prevention and treatment strategies for children of alcoholics who are vulnerable to debil-
itating anxiety and the development of substance abuse disorders. REFERENCES
Bibb, J.L., & Chambless, D.L. (1986). Alcohol use and abuse among diagnosed agoraphobics. Behavior Research and Theory, 24(1), 49-58. Bowlby, J. (1978). Separation: Anxiety and anger. New York, NY: Basic Books. Breuer, J., & Greud, S. (1981). Studies on hysteria. In J. Stmchey, (Ed.), Standard edition of the complete works of Sigmund Freud. London, England: Hogarth Press, vol. 3., p. 81. Bohman, M.,.Cloninger, C.R., Von Knotting, A.L., & Sigvardsson, S. (1984). An adoption study of somatoform disorders. III. Cross-fostering analysis and genetic relationship to alcoholism and criminality. Archives of General Psychiatry, 41, 872-878. Bohrnan, M., Sigvardsson, S., & Cloninger, C.R. (1981). Maternal inheritance of alcohol abuse. Archives of General Psychiatry, 38, 965-969. Cohen, M.E., Conslazio, F.C., & Johnson, R.E. (1974). Blood lactate response during moderate exercise in neurocirculatury asthenia, anxiety neurosis, or effort syndrome. Journal of Clinical Investigation, 26, 339342. Cloninger, C.R. (1983). Genetic and environmental factor in the development of alcoholism. Journal of Psychlatric Treatment and Evaluation. 5, 487-496. Cloninger, C.R., Bob.man, M., & Sigvardsson, S. (1981). In. heritance of alcohol abuse. Archives of General Psychi. atry, 38, 861-868. Conger, J.J. (1956). Alcoholism: Theory, problem and challenge, II. Reinforcement theory and the dynamics of alcoholism. Quarterly Journal of Alcohol Studies 17, 296-305. Crowe, R.R., Pauls, D.L., & Slymen, D. (1980). A family study of anxiety neurosis. Archives of General Psychi. atry, 37, 77-79. Goodwin, D.W., Schulsinger, F., Hermansen, L., Guze, S.B., & Winokur, G. (1973). Alcohol problems in adoptees raised apart from alcoholic biological parents. Archives of General Psychiatry, 28, 238-243. Goodwin, D.W., Schulsinger, F., Moiler, N., Hermansen, L., Winokur, G., & Guze, S.B. (1974). Drinking problems in adopted and nonadopted sons of alcoholics. Archives of General Psychiatry, 31, 164-169. Gorman, J.M., Liebowitz, M.R., Klein, D.F. (1984). Panic Disorder and Agoraphobia. In Current concepts: A scope publication. Kalamazoo, MI: Upjohn. Kaij, L. (1960). Alcoholism in twins. Stockholm, Sweden: Almquist & Wiksell. Klein, D.F. (1981). Anxiety reconceptualized. In D.F. Klein & J.G. Rabkin (Eds.), Anxiety--New research and changing concepts. New York, NY: Raven Press. Kroll, P.D., Stock, D.F., & James, M.E. (1985). Behavior of adult alcoholic men abused as children. Journal of Nervous and Mental Disease, 173 (11), 689-693. Pitts, F.N., Jr., & McClure, J.N. (1967). Lactate metabolism
MARY R. HAACK
66 in anxiety neurosis. New England Journal of Medicine, 277, 1329-1336. Richards, R.D. (1978). The game professionals play. Supen'isor Nurse, 48-50. Rifkin, A., Klein, D.F., & Dillon, D. (1981). Blockade by imiprimine or desipramine of panic induced by sodium lactate. American Journal of Psychiatry, 138, 676-677. Russell, M., Henderson, C., & Blume, S.B. (1984). Children
of alcoholics: A review of the literature. Buffalo, New York, State Division of Alcoholism and Alcohol Abuse. Stein, L.L. (May 1968). The doctor-nurse game. American Journal of Nursing, 68, 101-105. Torgensen, S. (1983). Genetic factors in anxiety disorders. Archives of General Psychiatry, 40, 1085-1089. Schukit, M.A. (1984). Etiologic theories on alcoholism. In N.J. Estes & M.E. Heineman (Eds.), Alcoholism: Development, Consequences, and lnten.ention. (pp. 15-30).
psychiatric medicine and psychiatric nursing. © 1 9 9 0 b y W.B. S a u n d e r s Company.
ROWE AND COLLEAGUES (1980) found an 18% risk factor for anxiety neurosis, a condition that is similar to the current criteria for panic disorder, in relatives of patients with anxiety disorder. More recently, Crowe's group found a far higher incidence (24.7%) of panic disorder in first-degree relatives of patients with panic disorder than in relatives of normal controls (2.3%). Twin studies also suggest a genetic explanation for panic disorder. Torgensen (1983) studied 32 MZ and 53 DZ twins in Norway and found anxiety disorder with panic attacks was five times more frequent in MZ than DZ twins. Twin studies assume that MZ twin pairs are treated by their families in exactly the same manner. Studies after adoption would clarify the influence of environment, but this type of investigation has not been done with panic disorder twins. Other investigators observed that patients with panic disorder often experience anxiety attacks after vigorous physical activity and that their blood lactate levels were higher than controls after exercise (Cohen, Consolazio, and Johnson, 1947). As a result, it was postulated that anxiety attacks were caused by increased levels of blood lactate, the end
C
From the National Institutes of Health, Bethesda, Maryland Address reprint requests to Mary R. Haack, Ph.D,, R.N., National Institutes of Health, Bldg. I0, 3B19, 9000 Rockville Pike, Bethesda, biD 20892. © 1990 by W.B. Saunders Company. 0883-9417190/0401-001053.00/0
6Z
product of glucose metabolism when available oxygen is exhausted. Pitts and McClure (1967) followed up with experiments and infused panic patients with sodium lactate. They found that most of them experienced panic attacks during the 20minute infusion. Further evidence that lactateinduced panic attacks replicate spontaneous attacks is that pharmacotherapy, such as imipramine, that is used to treat panic also blocks lactate-induced attacks (Rifkin, Klein, & Dillon, 1981). Other drugs, such as isoproterenol, have also been used to produce panic attacks. These experiments are based on the hypothesis that patients with panic disorder have abnormally sensitive or hyperactive beta-adrenergic receptors. Many of the symptoms of panic (sweating, tachycardia, tremulousness, and tachypnea) can be produced by stimulating peripheral beta receptors in animal studies (Gorman, Liebowitz, and Klein, 1984). Procaine, which influences the limbic system, a region of the brain involved in emotionality, has also been used to stimulate panic. These studies seek to identify deregulation of specific neurotransmitters that may be responsible for panic attacks. Klein (1981) has formulated a separation anxiety therapy of panic attacks that suggests the mechanism that underlies normal human separation anxiety is deranged in patients with panic disorder. This hypothesis is inconsistent with Bowlby's theory that the attachment of an infant human to its mother is not learned but is genetically pro
Archives of Psychiatric Nursing, VoLIV,No. I (February), 1990."pp. 62-66
63
ADULT CHILDREN OF ALCOHOLICS WITH ANXIETY
grammed and biologically determined (Bowlby, 1976). Other theorists have focused on the environmental stressors that may have occurred in early childhood development. Freud postulated that panic attacks were caused by inadequate repression of memories of past events such as sexual trauma (Breuer and Freud, 1961). Behaviorists hold that spontaneous attacks are learned phenomena subject to the patterns of behavioral learning models. Both psychoanalytic and behavioral theories have provided the underpinnings for treatment approaches to the phenomenon of anxiety disorders. As theories of etiology, they have not been adequately tested. ALCOHOLISM
Evidence for genetic vulnerability to alcoholism continues to grow. Studies of adoptees in Sweden have identified two types of genetic predisposition to alcoholism: milieu-limited and male-limited. Milieu-limited susceptibility occurred in both sexes and required environmental provocation to become expressed as alcoholism. Male-limited susceptibility occurred only in adoptees with biologic alcoholic fathers and gave rise to severe early onset alcoholism accompanied by antisocial and violent behavior (Bohman et al, 1981, 1984; Cloninger, 1981; and Cloninger, 1983). Kaij (1960) studied 174 male twin pairs of which at least one of whom was a known alcoholic and reported a concordance of 54% for MZ twins and of 28% for DZ twins. Adoption studies provide a more rigorous approach to establishing a genetic factor in alcoholism. Goodwin (1973, 1974) studied adoption records in Denmark that included 55 men with alcoholic biologic parents and 55 controls who were adopted away before the age of 6 weeks and had no knowledge of their biologic parentage. Both groups came from similar socioeconomic backgrounds. Twenty percent of the children of alcoholics as compared with 5% of the controls were alcoholic at the mode age of 25 to 29 years. Psychoanalytic and behavioral theories of alcoholism interact in the implication that the need for alcohol is symbolic of narcissistic drives or the need for punishment. In this way, alcohol is a reinforcing agent. The more classic analytic approaches discuss the oral or passive-dependent as-
pects of the personality (Conger, 1956). Although psychoanalytic concepts and behavioral approaches are useful in the treatment of addicted people, it is very difficult to test their contribution to the etiology of alcoholism. Currently, the cause of alcoholism is considered to be a complex interaction between biochemical and environmental factors. SCOPE OF THE PROBLEM
Lifetime prevalence rates for anxiety disorders are between 10.3% and 11. 1% in the general population. Th~ prevalence of panic disorder is much less (1.4%), although many symptoms, specific for the diagnosis of panic disorder, are common in the general population. The lifetime prevalence of alcohol abuse/dependence, however, is between 11.5% and 15.7% in the general population. ADULT CHILDREN OF ALCOHOLICS (ACOA)
Children of alcoholics are one of the most prevalent groups at risk for the development of substance abuse, anxiety and depressive disorders (Russell, Henderson and Blume, 1984). Based on estimates in the general population, there are approximately 22 million ACOAs. These individuals represent an important target group for the development of prevention strategies. Several risk factors are suggested by the clinical literature. ALCOHOLISM AND ANXIETY DISORDERS
Research on the relationship between alcoholism and panic disorders such as panic attacks and agoraphobia has been limited to alcoholics. No studies have been done on offspring of alcoholics. Bibb and Chambless (1986) compared 22 alcoholic agoraphobics and 21 nonalcoholic agoraphobics and found that the identified alcoholics were more depressed, more socially phobic, more fearful of somatic symptoms, and more likely to engage in catastrophic thinking. Use of alcohol to selfmedicate for dysphoria was reported by 91% of the alcoholics and 43% of the nonalcoholics. Kroll, Stock, and James (1985) reviewed the charts of 411 patients hospitalized for alcohol treatment and found that 13% had been abused as children. These individuals demonstrated more legal difficulties, domestic violence, and more suicide attempts, as well as increased levels of pervasive and situational anxiety.
64
A variety of family r61e behaviors seen in ACOAs have been described in the clinical literature (Black, 1981). For example, a high need for control, a characteristic identified in the child who adopts the "responsible" r61e or the "hero" rble, may be a predisposing factor for the development of an anxiety disorder. When control over events is not possible, people with a high need for control tend to devalue problem solving and exaggerate the threat. The resulting anxiety is a manifestation of the person's perception or cognitive processes. Wilson and Orford (1979) noted several factors that explain some of the variability on how parental drinking influences the health of offspring. Among them are degree and type of exposure to parental drinking and variation in its impact, effect of parental drinking on mood and the atmosphere of day-to-day family life, the presence of significant others who may cushion the children from impact of parental drinking, the presence of violence and fear in the home, and the r61e and family task rearrangements that the children may take on due to parental drinking. At least one longitudinal study conducted on children of alcoholics from birth to age 18 reported that males and the offspring of alcoholic mothers had higher rates of psychosocial problems in childhood and adolescence. Moreover, the children of alcoholics who developed serious problems experienced more stressful life events disrupting their family unit in the first 2 years (Werner, 1985). These studies clearly indicate an increased incidence of anxiety and panic disorder in alcoholic patients. Whether anxiety is a complication of alcoholism or a contributor to the need for selfmedication that leads to alcohol abuse is not known. There appear to be psychological as well as biochemical components to alcohol and anxiety disorders. Children of alcoholics with anxiety, who are not alcoholic themselves, represent an interesting population for study. These individuals embody a family history for alcoholism and have the diagnosis of an anxiety disorder that places them at risk for the development of substance abuse. Moreover, patients with panic disorder need not self-medicate if they can be treated with pharmacotherapy and psychotherapy. An increased understanding of this at risk group could lead to the development of prevention and treatment strategies in the practice of psychiatric nursing.
MARY R. HAACK
COLLABORATIVE RESEARCH
The literature cited provided the basis for exploration of the factors involved in the development of anxiety disorders among children of alcoholics. Information about the interaction between biochemical vulnerability and environmental factors is currently being generated through a collaborative effort of Dr. David Theodore George and Dr. Mary Haack in the Laboratory of CJinical Studies, the National Institute on Alcohol Abuse and Alcoholism, on the National Institutes of Health Campus, Bethesda, MD. The process of this collaboration has thus far involved several steps: (1) Development of separate protocols representative of the traditional biomedical paradigm and the psychiatric nursing perspective. Dr. George's work is focused on neurotransmitter deregulation in ACOAs with panic disorder who are not alcohol or drug dependent. Dr. Haack is exploring the role of stressors related to psychosocial development, family of origin environment, and personality characteristics of ACOAs. (2) Development of the protocols which represent the two paradigms. Dr. George's protocols involve infusion of provocative chemicals. Dr. Haack's protocol involves 5 hours of structured interview. (3) Submission of the protocols to institutional review boards of the university where Dr. Haack was employed and the NIH review committee. (4) Development of proposal for funding. In this case, 3-year funding for the nursing perspective was obtained from the National Center for Nursing Research. Funding for Dr. George's protocol was provided by the intramural program of the National Institute on Alcohol Abuse and Alcoholism. (5) Agreement on selection process of possible subjects for the studies, sharing subjects whenever feasible. (6) Conflict resolution on points of disagreement concerning diagnosis of a patient, assignment to specific diagnostic categories, and other day-to-day interactions. (7) Publication of findings. Although it is too soon to report the outcome of this research, agreement has been reached on authorship for two articles. Each step was arduous and time-consuming, necessitating agreement not only between the collaborators involved but the administrations of the institutions employing the collaborators, review boards, as well as the funding agencies. The steps
65
ADULT CHILDREN OF ALCOHOLICS WITH ANXIETY
described took two years. The psychiatric nursing portion of the study has been funded for 3 years and is currently in progress. In all, this project will represent a 5-year effort. The present agenda that exists in psychiatric research emphasizes biomedical paradigms that require skills in the basic sciences that are primarily in the domain of medicine. Yet, a person's biochemical vulnerability, as important as it may be, is only a portion of what makes one become ill or of what enables one to become whole again. Psychiatric nursing has traditionally stressed the importance of family dynamics and early child development in the etiology of psychiatric illness. These constructs are more meaningful if they are integrated with an understanding of the biochemistry of the individual. Interdisciplinary collaboration can and does change the rules of the doctor and nurse game described by Stein in 1968. First, according to Stein (1968), nurses are socialized to believe that doctors are omnipotent and all-knowing, and any suggestion by a lowly nurse would be insulting and expose one to public ridicule. Second, in matters of patient care nurses must somehow disguise their knowledge in a way that won't offend the doctor but at the same time influence the doctor to do what is in the patient's best interest (Richards, 1978). A formal collaborative agreement clearly delineates the unique contribution of medicine and nursing. This is both liberating and intimidating. For nursing research must participate in the same arena with the physician and is, therefore, subject to the same critical process. In addition, it requires patience and the willingness to learn from the opposing perspective. The discovery of genetic markers and new methods of pharmacologic treatment have necessitated a biochemical focus in psychiatry. This situation has cleared the way for nursing to make known its unique contribution to the care of the mentally ill and has rendered the old games between physician and nurses archaic. Ideally, the successful collaboration between psychiatric medicine and psychiatric nursing will ultimately mean better research and better care because it will be more comprehensive in scope. It is hoped that the collaboration described in this article will lead to development of holistic prevention and treatment strategies for children of alcoholics who are vulnerable to debil-
itating anxiety and the development of substance abuse disorders. REFERENCES
Bibb, J.L., & Chambless, D.L. (1986). Alcohol use and abuse among diagnosed agoraphobics. Behavior Research and Theory, 24(1), 49-58. Bowlby, J. (1978). Separation: Anxiety and anger. New York, NY: Basic Books. Breuer, J., & Greud, S. (1981). Studies on hysteria. In J. Stmchey, (Ed.), Standard edition of the complete works of Sigmund Freud. London, England: Hogarth Press, vol. 3., p. 81. Bohman, M.,.Cloninger, C.R., Von Knotting, A.L., & Sigvardsson, S. (1984). An adoption study of somatoform disorders. III. Cross-fostering analysis and genetic relationship to alcoholism and criminality. Archives of General Psychiatry, 41, 872-878. Bohrnan, M., Sigvardsson, S., & Cloninger, C.R. (1981). Maternal inheritance of alcohol abuse. Archives of General Psychiatry, 38, 965-969. Cohen, M.E., Conslazio, F.C., & Johnson, R.E. (1974). Blood lactate response during moderate exercise in neurocirculatury asthenia, anxiety neurosis, or effort syndrome. Journal of Clinical Investigation, 26, 339342. Cloninger, C.R. (1983). Genetic and environmental factor in the development of alcoholism. Journal of Psychlatric Treatment and Evaluation. 5, 487-496. Cloninger, C.R., Bob.man, M., & Sigvardsson, S. (1981). In. heritance of alcohol abuse. Archives of General Psychi. atry, 38, 861-868. Conger, J.J. (1956). Alcoholism: Theory, problem and challenge, II. Reinforcement theory and the dynamics of alcoholism. Quarterly Journal of Alcohol Studies 17, 296-305. Crowe, R.R., Pauls, D.L., & Slymen, D. (1980). A family study of anxiety neurosis. Archives of General Psychi. atry, 37, 77-79. Goodwin, D.W., Schulsinger, F., Hermansen, L., Guze, S.B., & Winokur, G. (1973). Alcohol problems in adoptees raised apart from alcoholic biological parents. Archives of General Psychiatry, 28, 238-243. Goodwin, D.W., Schulsinger, F., Moiler, N., Hermansen, L., Winokur, G., & Guze, S.B. (1974). Drinking problems in adopted and nonadopted sons of alcoholics. Archives of General Psychiatry, 31, 164-169. Gorman, J.M., Liebowitz, M.R., Klein, D.F. (1984). Panic Disorder and Agoraphobia. In Current concepts: A scope publication. Kalamazoo, MI: Upjohn. Kaij, L. (1960). Alcoholism in twins. Stockholm, Sweden: Almquist & Wiksell. Klein, D.F. (1981). Anxiety reconceptualized. In D.F. Klein & J.G. Rabkin (Eds.), Anxiety--New research and changing concepts. New York, NY: Raven Press. Kroll, P.D., Stock, D.F., & James, M.E. (1985). Behavior of adult alcoholic men abused as children. Journal of Nervous and Mental Disease, 173 (11), 689-693. Pitts, F.N., Jr., & McClure, J.N. (1967). Lactate metabolism
MARY R. HAACK
66 in anxiety neurosis. New England Journal of Medicine, 277, 1329-1336. Richards, R.D. (1978). The game professionals play. Supen'isor Nurse, 48-50. Rifkin, A., Klein, D.F., & Dillon, D. (1981). Blockade by imiprimine or desipramine of panic induced by sodium lactate. American Journal of Psychiatry, 138, 676-677. Russell, M., Henderson, C., & Blume, S.B. (1984). Children
of alcoholics: A review of the literature. Buffalo, New York, State Division of Alcoholism and Alcohol Abuse. Stein, L.L. (May 1968). The doctor-nurse game. American Journal of Nursing, 68, 101-105. Torgensen, S. (1983). Genetic factors in anxiety disorders. Archives of General Psychiatry, 40, 1085-1089. Schukit, M.A. (1984). Etiologic theories on alcoholism. In N.J. Estes & M.E. Heineman (Eds.), Alcoholism: Development, Consequences, and lnten.ention. (pp. 15-30).