Alcoholism is today the greatest medical and social problem. Due to the fact that it is
frequently connected with aggressiveness, it can also be defined as a great and frequent
forensic problem. The authors investigate the issue to what extent aggressiveness is medically
justified. They offer guidelines regarding this problem in accordance with their
everyday experience and medical criteria

B. Uglešić

D. Romac

G. Dodig

T. Glavina

Š. Janović

English

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Coll. Antropol. 25 (2001) 1: 239–244UDC 613.81:616.89-008.444.9Original scientific paperAggression and AlcoholismG. Dodig, T. Glavina, [. Janovi}, D. Romac and B. Ugle{i}Department of Psychiatry, University Hospital Split, Split, CroatiaA B S T R A C TAlcoholism is today the greatest medical and social problem. Due to the fact that it isfrequently connected with aggressiveness, it can also be defined as a great and frequentforensic problem. The authors investigate the issue to what extent aggressiveness is me-dically justified. They offer guidelines regarding this problem in accordance with theireveryday experience and medical criteria.IntroductionAn increase in alcoholism is, unfortu-nately, obvious both in our country and inthe world. Under the influence of alcoholman becomes the victim of worst ins-tincts. When alcoholism and alcohol arementioned one of the most frequent asso-ciations connected with those notions areaggression and whatever derives from it(impulsiveness, irritability, weakening ofinhibitory mechanisms, poor control ofone’s behavior etc)1. We can find almostevery psychiatric syndrome or clinicalpicture in situations of heavy drinking,while aggressive and criminogeneous ef-fects of alcohol have been proved by nu-merous research studies2.Aggressiveness in its biological senseis defined in the framework of interac-tions between a living creature and itsenvironment. The instinct of aggressionallows the individuals to impose upon theenvironment the necessity of meeting theirrequirements and their basic drives3.Neurophysiology has not yet identi-fied the »centers of aggressiveness«, but itis believed that the structures of the lim-bic system and the hypothalamus play acertain role in the expression of aggres-sive conduct4.The forms of aggressive behavior andthe situations in which aggressiveness isexpressed are varied; thus we talk aboutaggression provoked by fear, aggressionrelated to sex, maternal aggression etc,and more particularly about aggressive-ness as a »personality trait«5.Aggressiveness is a frequent form ofbehavior in children and adolescents; itdiminishes with years, but some peopleretain the »stability of aggressive behav-ior« even in their mature age.239Received for publication March 17, 2001.Acute alcoholic condition is marked byimpulsiveness, irritability, sudden out-bursts accompanied by weakening of in-hibitory mechanisms and poor controlover one’s actions... particularly duringaggressive outbursts6. Under the influ-ence of alcohol the overall conduct of aperson changes, while the self-controland sensibility are dulled, and a sense offalse confidence, power and strengtharise as well as the negligence of possibledangers7.On the other hand, a »chronic alco-holic« as a socially and ethically damagedperson with a deprived character per-forms a whole series odd acts rangingfrom »petty (banal) crimes« to crimes in-volving aggressive behavior such as fight-ing, assaults, physical harming, and theyoften become victims of the same kind ofbehaviour8.Summing up the traits of conduct un-der the influence of alcohol we ought tosay that alcohol diminishes the power ofconcentration, the speed and reliability ofthinking, and this becomes evident aftervery small doses: following a short in-crease of a sense of power and activitythere comes a sense of tiredness and a re-duction of mental and physical activity,which causes disturbances in the domainof volition and changes in disposition9.Taking into account all the afore-men-tioned factors, it seemed useful to try anddescribe the frequency of aggressive be-havior in alcoholics as well as to justifythe hospitalization in such cases bearingin mind the socio-cultural specificities ofthis region.The objective of the present paper wasto show to what extent aggressiveness ac-companies alcoholism and to what extentaggressiveness is the reason for hospital-ization and is justifiable from a medicalpoint of view; finally the object was alsoto determine the guidelines concerningthe solution of the problem.Patients and MethodsThe basic methodological instrumentwas the questionnaire by means of which60 randomly chosen alcoholics were tes-ted; these were the patients examinedfrom June to September 1999, in the psy-chiatric ER of the Psychiatric Clinic whichis part of the Clinical Hospital in Split. Astructured questionnaire consisting of 26questions was used which, besides gen-eral demographic features, encompassedalso some aspects of alcoholism and ag-gression as well as some clinical guide-lines to the afore-mentioned problem(Figure 1).Aggressive behavior was defined asphysical assault or readiness for assaultsor else provocation of fear in people sur-rounding the alcoholic10. The demogra-phic features include data relating to sex,age, marital status, work and socio-eco-nomic status as well as educational level.Contextual variables include aggres-sions, objects of aggression, previous ag-gressive behavior, the reason for hospital-ization, the assistance of Ministry of theInterior officers and previous legal sanc-tions. Clinical guidelines include the ini-tial diagnosis, the type and the quantityof consumed alcohol, alcoholism in thefamily, other possible addictions, changesin character, motivation for the treat-ment, duration of hospitalization as wellas previous alcoholism-related hospital-izations.Since numerical data worked out inpercentages seemed to be sufficient to ob-tain a clear illustration of results, a moresophisticated statistical processing ofdata was not necessary.ResultsThe results obtained from the group ofexaminees with demographic featureslargely confirm well-known facts concern-240G. Dodig et al.: Aggression and Alcoholism, Coll. Antropol. 25 (2001) 1: 239–244ing alcoholism and the alcoholics of ourregion (Table 1).The expected preponderance of themale sex (83.3 : 16.7) still does not pointto a considerable increase of female alco-holics which had that far been hiddenand inaccessible – due to social and cul-tural taboos – to scientific processing andevaluation11,12.Regarding the marital status, the per-centage of single examinees amounts to20.0%, of the married ones to 66.7%, of thedivorced ones to 10.0% and of the widowedones to 3.3%. The work status and thelevel of education are presented in Table 2.It is obvious that the unemployed(49.9%) and the retired (33.4%) are at thehead of our group of examinees. This fact,as well as the fact that in primary educa-tion the first place is held by the peoplewith »primary school« (56.7%) rankingnext to the examinees »without educa-241G. Dodig et al.: Aggression and Alcoholism, Coll. Antropol. 25 (2001) 1: 239–244INTERVIEW FOR ALCOHOLICSPatient number: ———————- Date: ———————————-Age: ———————————————Sex (male, female): ———————-Marital status (single, married, divorced): ———————————————Work status (attends school, employed, unemployed, retired): —————————Education (never attended school, primary,secondary, higher and high education): ———————————————Socio-economic status (low, middle, high): ———————————————Initial diagnosis: ————————————————————————-Alcohol in the family (yes, no): ———————————————————Reason for hospitalization: ——————————————————————Presence of Ministry for the Interior officer (yes, no): ————————————How long has he been drinking: ———————————————Type of alcohol: —————————Daily quantity: ——————————-Other addictions (yes, no): ——————if »yes« – which one(s): ———————————Changes in character and behavior (yes, no): ————————————-Aggressiveness (yes, no): ————————————if »yes« – physical, mental, mixed: ————————————-Object of aggression: ——————————-Previous aggressive behavior: ———————-Previous legal sanctions (yes, no): —————————-Previous psychiatric treatment (yes, no): ——————————-if »yes« —— how many times:————————-Motivation for treatment (yes, no): ——————————Result of examination (hospitalization, partial hospitalization, release): ———-if »release« – diagnosis at the moment of release: ————————————-Fig. 1. Questionnarie used for alcoholic patients in ER of the Psychiatric Clinic, Split.tion« (13.3%), clearly point to the socio-economic, educational and civilizationallevel of most alcoholics tested here.According to the obtained data, inmost examinees’ (53.2%) families thereare other alcohol addicts. That evidenceis in keeping with the one found in otherauthors13,14.Initial diagnosis as well as the oneconfirmed at admission to the hospital(which was actually the »reason« for hos-pitalization) differ greatly from clinicalpictures and entities — as is obvious fromTable 3. Whereas the most frequent ini-tial diagnosis of the examinees was alco-holism (73.4%), followed by DT (13.3%),the patients suffering from PTSD were inlow number (6.7%) just as those with in-toxication and psychosis (3.3% each).The »reasons« for hospitalization dif-fered greatly, the first reason being alco-holic delirium (56.7%) followed by »addic-tion to alcohol« (33.4%), while the otherdiagnosis – halucinosis, epilepsy and de-pression – comprised 3.3% each.The afore-mentioned diagnoses, whe-ther initial or those established at admis-sion, may not be accurate enough regard-ing a specific type of acute alcoholism i.e.»abnormal or pathological« drunkennesswhich is, among other symptoms, mani-fested by pronounced aggressiveness.The delineation between »normal« and»pathological« drunkenness definitelypresents a diagnostical problem in differ-entiation, but the question of the exis-tence and manifestation of aggressive-ness is here undoubtedly relevant.Whereas in the case of »normal« drun-kenness the mental links are to a certaindegree preserved and the »brakes« in thedomain of intellect and volition still func-tion, pathological drunkenness alters hu-242G. Dodig et al.: Aggression and Alcoholism, Coll. Antropol. 25 (2001) 1: 239–244TABLE 3INITIAL DIAGNOSIS AND REASONS FORHOSPITALIZATION IN EXAMINED GROUPOF ALCOHOLICSInitial diagnosis NAlcoholism 73.4Delirium tremens (DT) 13.3Post-traumatic stressdisorder (PTSD)6.7Psychosis 3.3Intoxication 3.3Reason for hospitalization % / NPredelirium (DT) 56.7 / 24Halucinosis 3.3 / 2Alcohol addiction 33.4 / 20Epilepsy 3.3 / 2Depression 3.3 / 2TABLE 2WORK STATUS AND THE LEVEL OF EDUCA-TION IN EXAMINED GROUP OF ALCOHOLICSWork status % / NEmployed 16.7 / 10Retired 33.4 / 20Unemployed 49.9 / 30Education % / NWithout education 13.3 / 8Primary education 56.7 / 34Secondary education 26.7 / 16Higher and high education 3.3 / 2TABLE 1AGE, SEX AND MARITAL STATUS INEXAMINED GROUP OF ALCOHOLICSAverage age 43.83 yearsSex % / NMale 83.3 / 50Female 16.7 / 10Marital status % / NMarried 66.7 / 40Divorced 10.3 / 6Single 20.6 / 12Widowed 3.3 / 2man behavior to such extent that it be-comes utterly modified, particularly whe-re aggressiveness is concerned15.Abnormal drunkenness is basically asyndrome of cerebral decompensationwhich is manifested by a series of psy-chopathological phenomena occurringquite suddenly and being accompanied bya prolonged and rather deep alteration ofconsciousness and great excitation, morespecifically by acts of violence and ex-treme aggressiveness16.The average duration of hospitaliza-tion was 16.3 days. The data concerningconsumption of beverages (which werecollected later) show that most examineesdrank wine (69.8%) which is in keepingwith the traditional ethno-cultural waysof Dalmatia; there were 16.8% examineesdrinking beer, but most of them »mixed«different kinds of alcohol (Table 4). Thequantity of consumed alcohol (expressedas equivalent to wine) amounts to 2 li-ters.Aggressive behavior was the reasonfor bringing the patient to the clinic in76.6 cases. The most frequent kind of ag-gressive behavior of examinees was phys-ical aggression (50% of cases) while »mi-xed« types of aggression were noticed in26.7% of cases. The highest number ofcases (83.2%) showed aggression towardsthe family, while in 16.8 cases the objectwas the environment (Table 5).There is a curious disproportion be-tween previous legal sanctions on ourexaminees (10.5%) and previous instan-ces of aggressive behavior (56%), whichimplies that in the majority of cases ag-gressive, violent conduct of alcoholics wasthe most important reason for legal sanc-tioning (Table 6). Most examinees (69.9%of them) had previously been hospitalizedin a psychiatric ward, and previous to ad-mission to a psychiatric institution theaverage number of hospitalizations perpatient was 1.73. The average duration ofhospitalization was 16.3 days which isunquestionably too short a period of timefor curing similar pathological conditions.243G. Dodig et al.: Aggression and Alcoholism, Coll. Antropol. 25 (2001) 1: 239–244TABLE 5TYPE AND OBJECT OF AGGRESION INEXAMINED GROUP OF ALCOHOLICSAggression precedingexamination%Yes 78.27No 21.73Type of aggression %Physical 50.0Mental 22.22Mixed 27.7Object of aggression %Family 83.2Environment 16.8Self-aggression 0.0TABLE 4CONSUMPTION OF BEVERAGES IN EXAMINEDGROUP OF ALCOHOLICSTypes of alcohol %Wine 69.9Beer 16.8Hot drinks 3.3«Mixed« 10.0Quantity of consumed alcohol(equivalent to wine)2.09 lit.TABLE 6PREVIOUS LEGAL SANCTIONS AND PREVIOUSHOSPITALIZATION IN EXAMINED GROUP OFALCOHOLICSPrevious legal sanctions % / NYes 10.0 / 6No 90.0 / 54Previous hospitalization % / NYes 69.9 / 42No 30.1 / 18Conclusion1. Aggression and aggressive behavioroften accompany the alcohol addicts andare symptoms of alcohol addiction. In ourstudy 76.6% of patients manifested ag-gressiveness immediately preceding psy-chiatric examination or during the exam-ination, while 56% of them had had pre-vious instances of aggressive behavior.2. Coordinating the views on the crite-ria for hospitalization when dealing withaggressive behavior of alcoholics couldbring about some therapeutical results(however paradoxical this might seem!)due to some repressive measures whichwould in that case be included into thetherapy.3. Primary prevention of alcoholism inall its aspects remains the most impor-tant part of preventing the developmentof addiction to alcohol and thus to aggres-siveness. Here we especially emphasizethe need for a social action and for the in-volvement of media in a campaignagainst alcohol and alcoholism.R E F E R E N C E S1. KUIKKA, J. T., J. TIIHONEN, K. A. BERG-STROM, J. KARHU, P. RASANEN, M. ERONEN,Neuroscience Letters, 253 (1998) 195. — 2. UGLE-[I], B., Psihijatrijska Njega, 1 (1979) 3. — 3. COR-NING, C. P., Biological aspects of aggressive behav-ior. In: FREEDMAN, B. J. (Ed.): Comprehensivetextbook of psychiatry. (Williams and Wilking, Balti-more, 1975). — 4. HARRISON, T. R.: Principals of in-ternal medicine. In Croat. 1st ed. (Placebo d.o.o.,Split, 1997). — 5. BLA@EVI], D.: Development oftheoretical concept of aggression. Oral presentation.(Galenika’s workshop on aggression, 1997). — 6.LANG, B., Alcoholism. In: MUA^EVI], V. (Ed.): Psy-chiatry. In Croat. (Medicinska naklada, Zagreb,1995). — 7. HUDOLIN, V.: Addiction diseases. (JU-MENA, Zagreb, 1977). — 8. HORVATI], @.: Elemen-tary Criminology. ([kolska knjiga, Zagreb, 1993). —9. REED, J., Br. J. Psychiatry, 170 Suppl. 32 (1997) 4.— 10. ZDRAVKOVI], J., Ethiology and psychopatho-logy. In: KECMANOVI], D. (Ed.): Psychiatry. In Croat.(Medicinska knjiga, Zagreb, 1990). — 11. LAPLAN-SHE, P.: Dictionary of psychoanalysis. In Croat. (Me-dicinska naklada, Zagreb, 1995). — 12. UGLE[I], B.,M. JAKELI], J. TOPI], H. M. A., 20 (1996) 83. — 13.CANATSEY, K., J. M. ROPER, Issues Ment. HealthNurs., 18 (1997) 35. — 14. SNOWDEN, P., Br. J.Psych., 170 Suppl. (1997) 32. — 15. BHATT, R. V., In-tern. J. Gynaecol. Obst., 63 Suppl. (1998) 25. — 16.McMAHON, M., A. KNOWLES, Psychiatry, Psychol-ogy and Law, 4 (1997) 207.G. DodigDepartment of Psychiatry, University Hospital Split, Spin~i}eva 1, 21000 Split, CroatiaAGRESIJA I ALKOHOLIZAMS A @ E T A KAlkoholizam je sigurno danas najve}i medicinsko-socijalni problem. Zbog ~injeniceda je ~esto »udru`en« s agresivno{}u, mo`emo ga ozna~iti velikim i ~estim sudsko-me-dicinskim problemom. U kojoj mjeri je agresivnost pratilac alkoholizma, u kojoj je mje-ri upravo agresivnost razlogom hospitalizacije i u kojoj je mjeri to medicinski oprav-dano, problem je koji autori istra`uju. Na temelju medicinskih kriterija i iskustva usvakodnevnom radu daju konkretne smjernice u pogledu rje{avanja navedenog pro-blema.244G. Dodig et al.: Aggression and Alcoholism, Coll. Antropol. 25 (2001) 1: 239–244

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