I can’t tell you how many times I’ve heard people ask this question of recovering alcoholics. “Are you sure you’re an alcoholic?”

Followed by something along these lines: “I never saw you drunk or out of control.”

Or, “You never got a DUI,” or “You hardly ever missed a day of work.”

And the real kicker, sometimes posed as the questioner takes a sip of wine, “Why not just drink in moderation?”

But really, it’s no wonder people get confused. Alcoholism differs from every other disease process in that it begins with symptoms indicating an improvement in functioning.

These early-stage symptoms make sense only when you understand that addiction to alcohol and other drugs is related to metabolic abnormalities and neurochemical adaptations, which initially enhance the pleasurable sensations of drinking while mitigating the unpleasant effects.

Only over time and with continued drug use can we see obvious physical and mental deterioration.

Early-stage symptoms of this progressive disease include:

  • Intense pleasure associated with drinking captured in this description by Mary Karr in her memoir The Liar’s Club: “Something like a big sunflower was opening at the very center of my being.”
  • Lower-intensity reaction which means that when early-stage alcoholics drink, a few beers or glasses of wine don’t create the same intoxicating effect as they might with a non-alcoholic. “Some people may therefore develop alcohol-related problems because they seek a response to alcohol that they can only perceive at higher levels of alcohol intake,” concludes psychiatrist-researcher Marc Schuckit. An individual’s low- or high-intensity reaction is strongly related to genetic factors.
  • Tolerance is the ability to drink a lot of alcohol without feeling or showing the effects. “I could drink everybody under the table. I took everyone else home,” recalled Marty Mann, the first woman to achieve long-term sobriety in A.A. Research clearly indicates that a high tolerance for alcohol is related to metabolic abnormalities – in other words, alcoholics’ bodies process and eliminate alcohol differently from non-alcoholics.
  • Preoccupation with alcohol: If drinking is so intensely pleasurable and you can “hold your liquor” better than most, how can it possibly be bad for you? Why would you want to stop? In her memoir Drinking: A Love Story, Caroline Knapp describes the comfort alcohol offered in the early stages of her disease. “Drinking was the best way I knew, the fastest and simplest, to let my feelings out and connect with another human being. I was an easier, stronger version of myself, as though I’d been coated from the inside out with a warm liquid armor.”

In the Middle Stage of alcoholism, life is not quite so easy or simple as it used to be. The predictable euphoria associated with drinking gradually begins to fade while periodic angry outbursts, general irritability, recurring anxiety, persistent depression, and emotional instability intensify.

Middle-stage symptoms include:

  • Withdrawal symptoms which, even in the middle stage, are often subtle and seem to bear little or no relationship to excess drinking — anxiety, insomnia, gastrointestinal distress, loss of appetite, elevated blood pressure or temperature, tremors (involuntary trembling).
  • Blackouts, defined as total memory loss for moments or hours. (Not every alcoholic experiences blackouts and binge drinking can also cause blackouts.)
  • Personality disintegration: Irritability, nervousness, paranoia, anxiety, and depression intensify as the disease progresses. The idea of a preexisting “alcoholic personality” has been debunked by numerous studies. In his classic work The Natural History of Alcoholism, Harvard psychiatrist George Vaillant concludes, “just as light passing through water confounds our perceptions, the illness of alcoholism profoundly distorts the individual’s personality, social stability, and his own recollection of relevant childhood variables.”
  • Denial is a symptom of a brain addled by addiction. Addicted brains do not think or react logically. I’ll write more about denial in my next column but keep this one fact in mind — the middle stage alcoholic’s brain literally needs (we’re long past “want”) the drug to function. Denial serves that need.

In the Late Stage of alcoholism, the balance of pleasure and pain tips precariously and unpredictably. Pleasure becomes short-lived; pain is ever-present.

This is the stage we associate with “real,” i.e., visibly damaged and deteriorated alcoholics (the drunk with no shoes in the gutter).

Late-stage symptoms include:

  • Severe withdrawal (convulsions, agitation, paranoia, hallucinations)
  • Irresistible craving for alcohol, sometimes termed a “physiological imperative”
  • Medical complications (heart, liver, gastrointestinal system, pancreas, central nervous system)
  • Loss of control: One of the telltale symptoms of alcoholism at every stage is the attempt to exert self-control by cutting down or quitting. As the disease progresses, the effort involved in control increases while the ability to control decreases.

Just as cancer doesn’t begin with a visible tumor, addiction doesn’t start when the disease is so visibly advanced that it cannot be denied.

A Japanese proverb captures addiction’s deadly progression: “First man takes the drink. Then drink takes the drink. Then drink takes the man.”