Disorders in Alcohol Use from Kaplan Flashcards
Alcohol Use Disorder
Diagnostic and Statistical Manual of Mental Disorders (DSM-5)
Strongly suggest alcohol dependence and alcohol abuse:
• a need for daily use of large amounts of alcohol for adequate functioning,
• a regular pattern of heavy drinking limited to weekends,
and
• long periods of sobriety interspersed with binges of heavy alcohol intake lasting for weeks or months
• inability to cut down or stop drinking
• repeated efforts to control or reduce excessive drinking by “going on the wagon” (periods of temporary abstinence) or by restricting drinking to certain times of the day
• binges (remaining intoxicated throughout the day for at least 2 days)
• occasional consumption of a fifth of spirits (or its equivalent in wine or beer)
• amnestic periods for events occurring while intoxicated
(blackouts)
• the continuation of drinking of drinking despite a serious physical disorder that the person knows is exacerbated by alcohol use
• drinking non-beverage alcohol, such as fuel and commercial products containing alcohol
Drinking patterns often associated with certain behaviors
persons with alcohol dependence and alcohol abuse show impaired social or occupational functioning because of:
- alcohol use (e.g. violence while intoxicated, absence from work, job loss)
- legal difficulties (e.g. arrest for intoxicated behavior and traffic accidents while intoxicated)
- arguments or difficulties with family members or friends about excessive alcohol consumption
late onset, few childhood risk factors, relatively mild dependence, few alcohol-related problems, and little psychopathology
Type A alcohol dependence
respond to interactional psychotherapies
Type A alcohol dependence
many childhood risk factors severe dependence early onset of alcohol-related problems much psychopathology strong family of alcohol abuse frequent polysubstance abuse long history of alcohol treatment a lot of severe life stresses
Type B alcohol dependence
respond to training in coping skills
Type B alcohol dependence
who do not yet have complete alcohol
dependence syndromes
Early stage
who tend to drink daily in moderate amounts in social settings
Affiliative
who have severe dependence and tend to drink in binges and often alone
Schizoid-isolated
concerns control problems in which persons are unable to stop drinking once they start when drinking is terminated as a result of ill health or lack of money, these persons can abstain for varying periods
Gamma alcohol dependence
must drink a certain amount each day but are unaware of a lack of control may not be discovered until a person who must stop drinking for some reason exhibits withdrawal symptoms
Delta alcohol dependence
late onset,
more evidence of psychological than of physical dependence
Type I, male limited
onset at an early age,
spontaneous seeking of alcohol for consumption socially disruptive set of behaviors when intoxicated
Type II, male limited
predominance in men, a poor prognosis, early onset of alcohol-related problems
Antisocial alcoholism
primary tendency for alcohol abuse that is exacerbated with time as cultural expectations foster increased opportunities to drink
Developmentally cumulative alcoholism
common in women, likely to use alcohol for mood regulation and to help ease social relationships
Negative-effect alcoholism
Frequent bouts of consuming large amounts of alcohol; the bouts become less frequent as a person age and respond to the increased expectations of society about their jobs and families
Developmentally limited alcoholism
- alcohol drunkenness
- based on evidence of recent ingestion of ethanol, maladaptive behavior, and at least one of several possible physiological correlates of intoxication
- legal definition of intoxication 80-100 mg/dL or 0.08 - 0.10 g/dL
Alcohol Intoxication
signs of alcohol intoxication
o slurred speech o dizziness o incoordination o unsteady gait o nystagmus o impairment in attention or memory o stupor or coma o double vision
anyone who does not show significant levels of impairment in motor and mental performance at approximately 150 mg/dL probably has
significant pharmacodynamic tolerance
slowed motor performance and decreased
thinking ability
20-30 mg/dL
Increases in motor and cognitive problem
30-80 mg/dL
Increases in incoordination and judgement
errors
Mood lability
Deterioration in cognition
80-200 mg/dL
Nystagmus, marked slurring of speech,
and alcoholic blackouts
200-300 mg/dL
Impaired vital signs and possible death
> 300 mg/dL
• can be serious even without delirium • seizures and autonomic hyperactivity • conditions that may predispose to or aggravate withdrawal symptoms: o fatigue o malnutrition o physical illness o depression
Alcohol Withdrawal
DSM 5: require the cessation or reduction of alcohol use that was heavy and prolonged as well as the presence of specific physical or neuropsychiatric symptoms - also allows for the specification “with perceptual disturbances”
Alcohol Withdrawal
study of blood flow during alcohol withdrawal in otherwise healthy persons with alcohol dependence reported a globally low rate of metabolic activity
- further inspection – activity was especially
low in the left parietal and right frontal areas
Positron emission tomography (PET)
Alcohol Withdrawal classic signs:
o tremulousness – although the spectrum of
symptoms can expand to include psychotic
and perceptual symptoms, seizures and the
symptoms of delirium tremens
▪ commonly called “shakes” or the
“jitters”
▪ develop 6 to 8 hours after cessation of drinking
o psychotic and perceptual symptoms – 8-12 hours
o seizures in 12-24 hours
o DT anytime during the first 72 hours
The syndrome of withdrawal sometimes skips the usual progression and, for example, goes directly to
Delirium and tremor
– continuous tremor of
great amplitude and of >8Hz
physiological tremor
– bursts of tremor activity
<8Hz
familial tremor
- stereotyped, generalized, and tonic-clonic in character
- patients often have more than one seizure 3-6 hours after the first seizures
- status epilepticus – relatively rare and occurs in less than 3% of patients
Withdrawal Seizures
long term alcohol abuse – can result in
hypoglycemia, hyponatremia and hypomagnesemia; all of which are associated with seizures
primary meds to control alcohol withdrawal
o help control seizure activity, delirium, anxiety, tachycardia, hypertension, diaphoresis, and tremor
o orally or parenteral
Benzodiazepines
should be given IM
o bec of their erratic absorption by this route
Diazepam or Chlordiazepoxide
as effective as benzodiazepines and has the added benefit of minimum abuse liability
Carbamazepine 800 mg daily
– used to block the symptoms of sympathetic hyperactivity
o but neither drug is an effective treatment for
seizures or delirium
β-adrenergic receptor antagonist and Clonidine
o autonomic hyperactivity
▪ tachycardia
▪ diaphoresis
▪ fever
▪ anxiety
▪ insomnia
▪ hypertension
o perceptual distortions, most frequently visual or tactile hallucinations
o fluctuating levels of psychomotor activity,
ranging from hyperexcitability to lethargy
features of alcohol intoxication delirium
episodes of DTs
30s or 40s after 5 to 15 years of heavy
drinking, typically of the binge type
patients withdrawing from alcohol who exhibit
withdrawal phenomena should receive
benzodiazepine
o chlordiazepoxide 25-50 mg every 2-4 hours
until they seem to be out of danger
o once delirium appears – chlordiazepoxide 50-100 mg every 4 hours orally OR lorazepam
IM
– avoided bec it may reduce seizure
threshold
antipsychotics
What is not useful in preventing or treating alcohol withdrawal convulsions?
Nonbenzodiazepine anticonvulsant
• global decreases in intellectual functioning, cognitive abilities, and memory are observed
• recent memory difficulties are consistent with global cognitive impairment – distinguishes this from alcohol induced persisting amnestic disorder
• brain functioning improves with abstinence
• half of affected patients – long term and even
permanent disabilities in memory and thinking
Alcohol-Induced Persisting Dementia
50-70% Alcohol-Induced Persisting Dementia, what happens to their brain?
inc size of brain ventricles and shrinkage of
the cerebral sulci
- essential feature – disturbance in short term memory caused by prolonged heavy use of alcohol
- persons who have been drinking heavily for many years
- rare in <35 years old
Alcohol-Induced Persisting Amnestic Disorder
o acute
o completely reversible
Wernicke encephalopathy
o chronic
o only about 20% recover
Korsakoff’s syndrome
o poor nutritional habits
o malabsorption problems
thiamine deficiency
cofactor for several enzymes and may also
be involved in the conduction of the axon potential along the axon and in synaptic transmission
thiamine
What are symmetrical and paraventricular involving o mamillary bodies o thalamus o midbrain o pons o medulla o fornix o cerebellum
neuropathological lesions
• acute neurological disorder • characterized by: o ataxia (affecting gait) o vestibular dysfunction o confusion o variety of ocular motility abn ▪ horizontal nystagmus ▪ lateral orbital palsy ▪ gaze palsy o eye signs ▪ usually bilateral but not necessarily symmetrical ▪ sluggish reaction to light ▪ anisocoria • may clear spontaneously in a few days or weeks or may progress to Korsakoff’s syndrome
Wernicke’s encephalopathy (alcoholic encephalopathy)
responds to large doses of parenteral thiamine (effective in preventing the progression into Korsakoff’s syndrome)
early staged of WE
• chronic amnestic syndrome that can follow WE
• cardinal features:
o impaired mental syndrome (esp. recent
memory)
o anterograde amnesia in an alert and
responsive patient
• may or may not have the symptom of confabulation
Korsakoff’s syndrome
• 3% - experience auditory hallucinations or paranoid delusions
• most common auditory hallucinations are voices but they are often unstructured
o characteristically maligning, reproachful or
threatening
o some – pleasant and nondisruptive voices
• hallucinations – last <1week; impaired reality testing common
• hallucinations after withdrawal – rare and is distinct from withdrawal delirium
• can occur at any age but usually appear in long time alcohol abuse
Alcohol-Induced Psychotic Disorder
Alcohol-Induced Psychotic Disorder differentiated from hallucinations of schizophrenia by
o the temporal association with alcohol
withdrawal
o absence of a classic hx of schizophrenia
o usually short-lived duration
Alcohol-Induced Psychotic Disorder differentiated from the DTs
presence of clear sensorium
• heavy intake of alcohol – results in many symptoms in major depressive disorder
• intense sadness markedly improves within several days to 1 month of abstinence
• 80% of alcoholics - have intense depression
o including 30-40% who were depressed for 2 or more weeks at a time
Alcohol-Induced Mood Disorder
• common in the context of acute and protracted alcohol withdrawal
• 80% - report panic attacks during at least one acute withdrawal episode
o complaints can be sufficiently intense for the clinician to consider diagnosing panic disorder
• 1st 4 weeks or so of abstinence, people with severe alcohol problems are like to avoid some social situations for fear of being overwhelmed by anxiety; at times can be severe to resemble agoraphobia
Alcohol-Induced Anxiety Disorder
- variously called pathologic, complicated, atypical, and paranoid alcohol intoxication
- severe behavioral syndrome develops rapidly after a person consumes small amount of alcohol that would have minimal behavioral effects on most persons
Idiosyncratic Alcohol Intoxication
- often described to as confused and disoriented and is experiencing illusions, transitory delusions, and visual hallucinations
- may display greatly increased psychomotor activity and impulsive, aggressive behavior
- can be dangerous to others and may exhibit suicidal ideation and make suicide attempts
- lasting for a few hours terminates in prolonged sleep and those affected cannot recall the episodes on awakening
- most common in persons with high anxiety
Idiosyncratic Alcohol Intoxication
patients who appear to have WK but does not respond to thiamine
• Niacin deficiency (nicotinic acid)
• Treatment:
o Niacin 50 mg 4x daily oral or
o Niacin 25 mg 2-3x daily parenteral
Alcoholic Pellagra Encephalopathy
symptoms: o confusion o clouding of consciousness o myoclonus o oppositional hypertonias o fatigue o apathy o irritability o anorexia o insomnia o sometimes delirium
Alcoholic Pellagra Encephalopathy
