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ALCOHOL RELATED DISORDERS
Dr. Y R Bhattarai
TMU
Alcoholism: epidemiology
• The most costly health problem in USA.
• Alcohol is the most abused drug for all ages.
• Alcoholism rates are higher for the low socioeconomic
groups.
• In USA alcohol use has been implicated in 15% of all
auto accidents, 50% of all homicides & hospital
admissions.
• Asians less likely to develop alcoholism than Americans!
• Family history of alcoholism increases likelihood of
unipolar depression.
• Alcoholism is a complex, multifaceted disorder which
has long been recognized to run in families.
CRITERIA OF ALCOHOL DEPENDENCE
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Narrowing of the drinking repertoire
Priority of drinking over other activities
Tolerance of effects of alcohol
Repeated withdrawal symptoms
Relief of withdrawal symptoms by further drinking
Subjective compulsion to drink
Reinstatement of drinking behaviour after
abstinence.
CAGE questions
• Have you ever tried to Cut down on alcohol intake
and not succeeded?
• Have you ever been Annoyed about criticism
concerning your drinking?
• Have you ever felt Guilt about your drinking
behavior?
• Have you ever had to take a drink as an Eye opener in
the morning to relieve the anxiety and shakiness?
DSM-IV Diagnostic Criteria for Alcohol
Intoxication
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Recent ingestion of alcohol.
Clinically significant maladaptive behavioral or psychological changes that
developed during, or shortly after, alcohol ingestion.
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 are not due to a general medical condition and are not better
accounted for by another mental disorder
DSM-IV Diagnostic Criteria for Alcohol
Withdrawal
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Cessation of alcohol use that has been heavy and prolonged.
Two (or more) of the following, developing within several hours to a few
days after if – autonomic hyperactivity (e.g., sweating or pulse rate greater than 100)
– increased hand tremor
– insomnia
– nausea or vomiting
– transient visual, tactile, or auditory hallucinations or illusions
– psychomotor agitation
– anxiety
– grand mal seizures
The symptoms 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.
Laboratory Markers For Alcoholism
Increased
Decreased
ALT
Calcium
AST
Phosphorous
Amylase
WBC count
Uric acid
Platelet count
Triglyceride
Hematocrit
Cholesterol
• Breath analyzer
• MAST(Michigan Alcoholism Screening Test)
Problems caused by alcohol
Social problems
absenteeism from work, unemployment, marital
tensions, child abuse, financial difficulties, and
problems with law such as violence and traffic
offences.
Problems caused by alcohol
MEDICAL
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Cirrhosis
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Alcoholic hepatitis
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Pancreatitis
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Gastric or duodenal ulcer •
Esophageal varices
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GI cancer
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Hypertension
Peripheral neuropathy
Cardiomyopathy
CVA
Erectile dysfunctions
Vitamin deficiencies
Pernicious anemia
Wernicke-korsakoff
syndrome
Problems caused by alcohol
PSYCHOLOGICAL
• Depression, attempted suicide and
complicated suicide
• Anxiety is relieved by alcohol, conversely,
alcohol withdrawal increases anxiety
• Alcoholic hallucinosis especially auditory
• Alcohol withdrawal
• Delirium tremens
Problems caused by alcohol…
• Acute intoxication
– euphoria, flushed face, ataxia, slowed reaction time,
impaired motor performance, slurred speech, poor
concentration; in higher doses behavioral changes –
disinhibition of sexual and aggressive impulses, increased
suicidal and homicidal behaviour
• Pathological intoxication
– sudden change of consciousness with aggressive behaviour
and amnesia
• Dependence syndrome:
Contd…
– increased tolerance to alcohol, morning drinking, alcohol bouts,
blackouts, deterioration in occupational and marital life,
behavioural changes, withdrawal symptoms
• Withdrawal state:
– tremor, anxiety, easy getting startled, agitation, insomnia,
nausea, sweating, epileptic seizures and delirium tremens
Delirium tremens
– Acute organic brain syndrome
– usually starts in evening hours and is characterized
by– clouding of consciousness with disorientation in
time and place, severe agitation, anxiety and
perceptual distortion, marked autonomic
disturbances with tachycardia, fever, sweating,
hypertension and pupillary dilation, dehydration with
electrolyte imbalance.
– Most severe alcohol withdrawal syndrome
– a state seriously endangering patient's life
– Death if occurs is often due to cardiovascular collapse,
infection, hyperthermia or self inflicted injury.
– recovery after several days, retrograde amnesia
Other psychotic disorders:
Alcohol-Induced Mood Disorder
Alcohol-Induced Anxiety Disorder
Alcohol-Induced Sleep Disorder
Fetal Alcohol Syndrome
The leading known cause of mental retardation (down
syndrome is second!)
Alcohol & Pregnancy Do Not Mix
ALCOHOL IS A TERATOGENIC DRUG &
PRENATAL EXPOSURE CAN CAUSE:
Small Growth
Miscarriage &
& Stillbirth
Brain Damage &
Mental Retardation
THE DAMAGE
MAY NEVER
BE OUTGROWN
Face & Joint
Deformities
Learning &
Speech Problems
Hyperactivity & Behavior Problems
When Mom Drinks,
Baby Drinks!!!
Management
• Young and socially stable patients have a better prognosis
• Advice about the harmful effects of alcohol and safe levels of
consumption.
• In more serious cases, advise to alter leisure activities or
change jobs if these are contributing to the problem.
• Supportive psychotherapy to help the patient in changing
lifestyles.
• Psychological treatment for patients who have recurrent
relapses in specialized centers, also provided by alcoholics
anonymous.
• Treatment can be divided into four phases:
– Assessment and referral
– Detoxification and withdrawal management
– Active treatment
– Continuing care
Management….
• Psychological
– Twelve step programs
– Motivational interviewing
– Cognitive behavioral therapy
• Social
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– Residential Programs : total control of adolescents environment
– Intensive outpatient programs
Program characteristics associated with better outcomes include:
– longer duration of Rx
– available follow-up care
– family involvement
– social services
Pharmacologic treatment….
Disulfiram (antabuse)
• Effective for short treatment only
• Must be used with psychotherapy or 12 step
program
• by resisting sudden impulses to drink.
• Interaction with alcohol produces very
unpleasant symptoms of nausea, chest pain ,
hyperventilation, tachycardia and vomiting.
• Dosage 200-400mg daily
Acamprosate
• Helps prevent relapse
• Lowers the activity of the receptors for
glutamate (increased in chronic alcoholics)
• Dosage 666mg 8 hourly
Naltrexone
• Given to recovering alcoholics
• Reduces craving, drinks don’t taste good!
Helps them stop after first drink.
Prevention
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Public health education campaigns
Successful prevention programs:
target salient risk factors
skills-oriented
follow-up available
culturally-oriented towards the targeted community