Alcohol Related Disorders

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ALCOHOL RELATED DISORDERS

• Dr. Ravi Paul

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definition of some terms

• Dependence behavioral dependence
  substance-seeking activities and related evidence
  of pathologic use patterns with or without
  physical dependence,Physical dependence indicates
  an altered physiologic state due to repeated
  administration of a drug, the cessation of which
  results in a specific syndrome
• Abuse Use of any drug, usually by
  self-administration, in a manner that deviates
  from approved social or medical patterns
• Misuse Similar to abuse but usually applies to
  drugs prescribed by physicians that are not used
  properly

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definition of some terms contd

• Addiction The repeated and increased use of a
  substance, the deprivation of which gives rise to
  symptoms of distress and an irresistible urge to
  use the agent again and which leads also to
  physical and mental deterioration.
• Intoxication A reversible syndrome caused by a
  specific substance (e.g., alcohol) that effects
  one or more of the following mental functions
  memory, orientation, mood, judgment, and
  behavioral, social, or occupational functioning.
• Withdrawal The development of a
  substance-specific syndrome due to the cessation
  (or reduction) of substance use that has been
  heavy and prolonged.
• Tolerance Phenomenon in which, after repeated
  administration, a given dose of a drug produces a
  decreased effect or increasingly larger doses
  must be administered to obtain the effect
  observed with the original dose

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• Alcoholism is a alcohol seeking and consumption
  behavior that is harmful.
• The hallmarks of this disorder are addiction to
  alcohol- repeated and increased use of alcohol,
  the deprivation of which gives rise to symptoms
  of distress and an irresistible urge to use
  alcohol again and which leads to physical and
  mental detoriation.
• Alcohol related disorders can affect the persons
  metabolism, git, nervous system, BM and endocrine
  system.
• Additionally it can result in nutritional
  deficiencies, such as vit def, alterations in
  sugar and fat levels in blood.

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• . It does not describe a specific mental
  disorder, the disorders associated with
  alcoholism generally can be divided into three
  groups
• (i) disorders related to the direct effects of
  alcohol on the brain (including alcohol
  intoxication, withdrawal, withdrawal delirium,
  and hallucinosis)
• (ii) disorders related to behavior associated
  with alcohol (alcohol abuse and dependence) and
• (iii) disorders with persisting effects
  (including alcohol-induced persisting amnestic
  disorder, dementia, Wernickes encephalopathy,
  and Korsakoffs syndrome).

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Epidemiology

• Alcohol use disorders are among the most common
  psychiatric disorders observed in the western
  world.
• Alcohol is the fifth leading risk factor for
  premature death and disability across the world.
• Alcohol use and alcohol related disorders are
  associated with about 25 of all suicides.

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(i) disorders related to the direct effects of
alcohol on the brain(A) alcohol intoxication

• Definition Alcohol intoxication, also called
  simple drunkenness, is the recent ingestion of a
  sufficient amount of alcohol to produce acute
  maladaptive behavioral changes.
• The absorption and elimination rates of alcohol
  are variable and depend on many factors,
  including age, sex, body weight, chronic nature
  of use, duration of consumption, food in the
  stomach, and the state of nutrition and liver
  health.
• In addition the effects of EtOH also depend on
  the blood alcohol level (BAL).
• Signs, and symptomsmild intoxication may produce
  a relaxed, talkative, euphoric, or disinhibited
  person,
• severe intoxication often leads to more
  maladaptive changes, such as aggressiveness,
  irritability, labile mood, impaired judgment, and
  impaired social or work functioning, among others.

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alcohol intoxication contd

• Stages of alcohol intoxication and effects on
  behavior at different blood alcohol levels(BAL).
• BAL(mg/dL) Likely Impairment
• 2030 Slowed motor performance and
  decreased thinking ability
• 3080 Increases in motor and
  cognitive problems
• 80200 Increases in incoordination and
  judgment errors
• Mood lability
• Deterioration in
  cognition
• 200300 Nystagmus, marked slurring of
  speech, and alcoholic blackouts
• gt300 Impaired vital signs and
  possible death

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alcohol intoxication contd

• Diagnosis One (or more) of the following signs,
  developing during, or shortly after, alcohol use
  
• slurred speech
• incoordination
• unsteady gait
• nystagmus
• impairment in attention or memory
• stupor or coma
• The symptoms should not be due to a general
  medical condition and should not be better
  accounted for by another mental disorder.
• Tests Breathalyzer test, commonly used by police
  enforcement.
• Blood/urine testing more accurate

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alcohol intoxication contd

• management
• a. Usually only supportive.
• b. May give nutrients (especially thiamine,
  vitamin B12, folate).
• c. Observation for complications (e.g.,
  combativeness, coma, head injury, falling) may be
  required.
• d. Severely intoxicated patient may require
  mechanical ventilation with
• attention to acidbase balance, temperature, and
  electrolytes while he or she is recovering

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(B)alcohol withdrawal

• Its a syndrome that can occur following a
  cessation or reduction in alcohol use after a
  period of prolonged use.
• Atleast two of the following must be present
  autonomic hyperactivity((diaphoresis,
  tachycardia, hypertension) hand tremor, insomnia,
  nausea or vomiting, transient illusions or
  hallucinations, anxiety, grand mal seizures, and
  psychomotor agitation.
• The symptoms in this Criterion cause clinically
  significant distress or impairment in social,
  occupational, or other important areas of
  functioning.
• The symptoms are not due to a general medical
  condition and are not better accounted for by
  another mental disorder.

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alcohol withdrawal contd

• EtOH withdrawal symptoms usually begin in 624
  hours and last 27 days.
• Mild Irritability, tremor, insomnia.
• Moderate Diaphoresis, hypertension, tachycardia,
  fever, disorientation.
• Severe Tonic-clonic seizures, DTs,
  hallucinations.

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Drug Therapy for Alcohol Intoxication and
Withdrawal
Clinical Problem Drug Route Dosage Comment
Tremulousness and mild to moderate agitation Chlordiazepoxide Oral 25-100 mg every 4-6 hr Initial dose can be repeated every 2 hr until patient is calm subsequent doses must be individualized and titrated
Tremulousness and mild to moderate agitation Diazepam Oral 5-20 mg every 4-6 hr Initial dose can be repeated every 2 hr until patient is calm subsequent doses must be individualized and titrated
Hallucinosis Lorazepam Oral 2-10 mg every 4-6 hr Initial dose can be repeated every 2 hr until patient is calm subsequent doses must be individualized and titrated
Extreme agitation Chlordiazepoxide Intravenous 0.5 mg/kg at 12.5 mg/min Give until patient is calm subsequent doses must be individualized and titrated
Withdrawal seizures Diazepam Intravenous 0.15 mg/kg at 2.5 mg/min Give until patient is calm subsequent doses must be individualized and titrated
Delirium tremens Lorazepam Intravenous 0.1 mg/kg at 2.0 mg/min Give until patient is calm subsequent doses must be individualized and titrated

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(C)withdrawal delirium

• Alcohol withdrawal delirium (delirium tremens
  DTs) Usually occurs only after recent
  cessation of or reduction in severe, heavy
  alcohol use in medically compromised patients
  with a long history of dependence.
• The most serious form of EtOH withdrawal
• Less common than uncomplicated alcohol
  withdrawal.
• Occurs in 1 to 3 of alcohol-dependent patients
• Age gt 30 and prior DTs increase the risk

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withdrawal delirium contd

• Diagnosis, signs, and symptoms
• a. Delirium.
• b. Marked autonomic hyperactivitytachycardia,
  sweating, fever, anxiety, or insomnia.
• c. Associated featuresvivid hallucinations that
  may be visual, tactile, or olfactory delusions
  agitation tremor fever and seizures or the
  so-called rum fits (if seizures develop, they
  always occur before delirium).
• d. Typical featuresparanoid delusions, visual
  hallucinations of insects or small animals, and
  tactile hallucinations
• There should be evidence from the history,
  physical examination, or laboratory findings that
  the symptoms above developed during, or shortly
  after, a withdrawal syndrome.

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withdrawal delirium contd

• management
• a. Take vital signs every 6 hours.
• b. Observe the patient constantly.
• c. Decrease stimulation.
• d. Correct electrolyte imbalances and treat
  coexisting medical problems (e.g., infection,
  head trauma).
• e. If the patient is dehydrated, hydrate
• f. Chlordiazepoxide (Librium) 25 to 100 mg
  orally every 6 hours to keep the patient calm and
  lightly sedated, then tapered down slowly.

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withdrawal delirium contd

• Thiamine, folic acid, and a multivitamin to treat
  nutritional deficiencies
• Check for signs of hepatic failure (e.g.,
  ascites, jaundice, caput medusae,coagulopathy

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(D)Alcohol-induced psychotic disorder, with
hallucinations (previously known as alcohol
hallucinosis)

• Vivid, persistent hallucinations (often visual
  and auditory), without delirium, following
  (usually within 2 days) a decrease in alcohol
  consumption in an alcohol-dependent person.
• May persist and progress to a more chronic form
  that is clinically similar to schizophrenia.
• Rare, male-to-female ratio is 41.
• The condition usually requires at least 10 years
  of alcohol dependence.
• In agitated patients possible treatments include
  benzodiazepines (e.g., 1 to 2 mg of lorazepam
  Ativan orally or intramuscularly, 5 to 10 mg of
  diazepam Valium) or low doses of a high-potency
  antipsychotic (e.g., 2 to 5 mg of haloperidol
  Haldol orally or intramuscularly as needed
  every 4 to 6 hours)

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(ii) disorders related to behavior associated
with alcohol alcohol dependence and abuse

• Alcohol dependence is a pattern of compulsive
  alcohol use, defined by the presence of three or
  more of the following major areas of impairment
  related to alcohol occurring within the same 12
  months.
• These areas include
• 1. tolerance or withdrawal,
• 2. spending a great deal of time using the
  substance,
• 3. returning to use despite adverse physical or
  psychological consequences, and
• 4. repeated unsuccessful attempts to control
  alcohol intake

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(ii) disorders related to behavior associated
with alcoholalcohol abuse

• A maladaptive pattern of substance use leading to
  clinically significant impairment or distress, as
  manifested by one (or more) of the following,
  occurring within a 12-month period
• recurrent substance use resulting in a failure to
  fulfil major role obligations at work, school, or
  home (e.g., repeated absences or poor work
  performance related to substance use
  substance-related absences, suspensions, or
  expulsions from school neglect of children or
  household)
• recurrent substance use in situations in which it
  is physically hazardous (e.g., driving an
  automobile or operating a machine when impaired
  by substance use)
• 3. recurrent substance-related legal problems
  (e.g., arrests for substance-related disorderly
  conduct)
• 4. continued substance use despite having
  persistent or recurrent social or interpersonal
  problems caused or exacerbated by the effects of
  the substance (e.g., arguments with spouse about
  consequences of intoxication, physical fights)

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alcohol dependence and abuse contd

• Alcohol abuse differs from alcohol dependence in
  that it does not include tolerance and withdrawal
  or a compulsive use pattern rather, it is
  defined by negative consequences of repeated use
• MANAGEMENTThe goal is the prolonged maintenance
  of total sobriety.
• 1. Insight. The patient must acknowledge that he
  or she has a drinking problem
• Critically necessary but is often difficult to
  achieve.
• Often, this requires the collaboration of family,
  friends, employers, and others

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alcohol dependence and abuse contd

• 2. Alcoholics Anonymous (AA) and Al-Anon.
  Supportive organizations emphasizes the inability
  of the member to cope alone with addiction to
  alcohol and encourages dependence on the group
  for support AA also utilizes many techniques of
  group therapy.
• 3. Psychosocial interventions.Family therapy
  should focus on describing the effects of alcohol
  use on other family members.
• Patients must be forced to relinquish the
  perception of their right to be able to drink and
  recognize the detrimental effects on the family
• 4. Psychopharmacotherapy(i) DisulfiramPatients
  taking disulfiram have an extremely unpleasant
  reaction(dyspnea, headache, flushing) when they
  ingest even small amounts of alcohol.

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• (ii) Naltrexonereduces the urge to drink and
  prevents heavy drinking by blocking the good
  feelings alcohol causes
• (iii) Acamprosate (Campral). This drug is used
  with patients who have already achieved
  abstinence.
• It helps patients remain abstinent by a yet
  unexplained mechanism involving neuronal
  excitation and inhibition.
• (iv) Topiramate It is used for maintaining
  alcohol abstinence

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(iii) disorders with persisting effects
(including alcohol-induced persisting amnestic
disorder, dementia, Wernickes encephalopathy,
and Korsakoffs syndrome)

• (A) alcohol-induced persisting amnestic disorder
• Disturbance in short term memory resulting from
  prolonged heavy use of alcohol rare in persons
  under the age of 35.
• The classic names for the disorder are Wernickes
  encephalopathy (an acute set of neurologic
  symptoms) and Korsakoffs syndrome (a chronic
  condition).
• The pathophysiological connection between the two
  syndromes is thiamine deficiency, caused either
  by poor nutritional habits or by malabsorption
  problems.

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Wernickes encephalopathy

• Wernickes encephalopathy (also known as
  alcoholic encephalopathy). An acute syndrome
  caused by thiamine deficiency.
• Characterized by nystagmus, abducens and
  conjugate gaze palsies, ataxia, and global
  confusion.
• Other symptoms may include confabulation,
  lethargy, indifference, mild delirium, anxious
  insomnia, and fear of the dark.
• Thiamine deficiency usually is secondary to
  chronic alcohol dependence.
• Wernicke's encephalopathy may clear
  spontaneously in a few days or weeks or may
  progress into Korsakoff's syndrome.

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management

• Early stages, 100 to 300mg parenteral thiamine,
  (effective in preventing the progression into
  Korsakoff's syndrome).
• Followed by 100 to 300mg mg orally and is
  continued for 1 to 2 weeks.
• In patients with alcohol-related disorders who
  are receiving IV administration of glucose
  solution, it is good practice to include 100 mg
  of thiamine in each litre of the glucose
  solution.

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Korsakoffs syndrome

• Korsakoffs syndrome (also known as Korsakoffs
  psychosis).
• A chronic condition, usually related to alcohol
  dependence, where in alcohol represents a large
  portion of the caloric intake for years.
• Caused by thiamine deficiency.
• Rare. Characterized by retrograde and anterograde
  amnesia.
• The patient also often exhibits confabulation,
  disorientation, and polyneuritis
• Often coexists with alcohol-related dementia

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Korsakoffs syndrome

• Treatment
• Thiamine 100 mg PO two to three times daily
• the treatment regimen should continue for 3 to
  12 months.
• Only about 20 percent of patients with
  Korsakoff's syndrome recover.

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Substance-induced persisting dementia

• Substance-induced persisting dementia This
  diagnosis should be made when other causes of
  dementia have been excluded and a history of
  chronic heavy alcohol abuse is evident.
• The symptoms persist past intoxication or
  withdrawal states.
• The dementia is usually mild.
• Management is similar to that for dementia of
  other causes.

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Fetal Alcohol Syndrome

• Women who are pregnant or are breast-feeding
  should not drink alcohol.
• When mothers drinking alcohol expose fetuses to
  alcohol in utero it inhibits intrauterine growth
  and postnatal development.
• Fetal alcohol syndrome is the leading cause of
  mental retardation in the United States
• Microcephaly, craniofacial malformations, and
  limb and heart defects are common in affected
  infants.
• Women with alcohol-related disorders have a 35
  percent risk of having a child with defects.

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questions

• 1. mention 3 groups with examples of alcohol
  related disoders?
• 2. what is the difference between alcohol
  dependence and alcohol abuse?
• 3. alcohol-induced persisting amnestic disorder
  is common in people below 35 years.
  True/false.give the reason for your answer.

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references

• Sadock, B.J., Sadock, V.A. and Ruiz, P.
  (2015)Kaplan and Sadocks synopsis of psychiatry
  behavioural science/ clinical psychiatry. 11th
  edition.
• Donald .W etal.. (2014) Introductory textbook of
  psychiatry 6th edition.
• Latha Ganti et al first aid for the psychiatry
  clerkship.4th edition