Alcohol Use and Dependency - The clinical Perspective

Transcription

1 DDICTION, LCOHOL BUSE ND DEPENDENCY DEPT.OF PSYCH. UNIV.OF PÉCS the clinical importance of alcohol-related disorders is essential for the practice of psychiatry. lcohol intoxication can cause irritability, violent behavior, feelings of depression, and, in rare instances hallucinations and delusions. Longer-term, escalating levels of alcohol consumption can produce tolerance as well as such intense adaptation of the body (dependency) that cessation of use can precipitate a withdrawal syndrome usually marked by insomnia, evidence of hyperactivity of the autonomic nervous system, and feelings of anxiety. DSM-IV criteria for substance abuse. 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: 1. Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home 2. Recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile 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 by the substance (e.g., arguments with spouse about consequences of intoxication, physical fights) DSM-IV criteria for substance dependence maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period: 1. Tolerance, as defined by either of the following: a. Need for markedly increased amounts of the substance to achieve intoxication or desired effect b. Markedly diminished effect with continued use of the same amount of the substance 2. Withdrawal, as manifested by either of the following: a. The characteristic withdrawal syndrome for the substance b. The same (or closely related) substance is taken to relieve or avoid withdrawal symptoms 3. The substance is often taken in larger amounts or over a longer period than was intended 4. There is a persistent desire or unsuccessful efforts to cut down or control substance use DSM-IV criteria for substance dependence 5. great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chain-smoking), or recover from its effects 6. Important social, occupational, or recreational activities are given up or reduced because of substance use 7. The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., current cocaine use despite the recognition of cocaineinduced depression, lcohol withdrawal syndromes Minor withdrawal ("the shakes") lcoholic seizures ("rum fits") lcoholic hallucinosis lcoholic withdrawal delirium (delirium tremens) Specify if: With physiological dependence: evidence of tolerance or withdrawal (i.e., either item 1 or 2 is present) Without physiological dependence: no evidence of tolerance or withdrawal (i.e., neither item 1 nor 2 is present) 1

2 DSM-IV criteria for alcohol withdrawal. Cessation of (or reduction in) alcohol use that has been heavy and prolonged. B. Two (or more) of the following, developing within several hours to a few days after criterion : 1. utonomic hyperactivity (e.g., sweating or pulse rate greater than 100) 2. Increased hand tremor 3. Insomnia 4. Nausea or vomiting 5. Transient visual, tactile, or auditory hallucinations or illusions 6. Psychomotor agitation 7. nxiety 8. Grand mal seizures C. The symptoms in criterion B cause significant distress or impairment in social, occupational, or other important areas of functioning. D. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder. Categories and Definitions for Patterns of lcohol Use Category Definition Organization lcohol abuse P P lcohol dependence Pattern of pathologic, maladaptive use, recurrent alcohol-related legal problems (e.g., citations for driving under the influence), continued use despite social or interpersonal problems caused or exacerbated by alcohol tolerance; increased amounts to achieve effect; diminished effects from same amount; withdrawal (abstinence) syndrome; a great deal of time spent obtaining alcohol, using it, or recovering from its effects; important activities given up or reduced because of alcohol; drinking more or longer than intended; persistent desire or unsuccessful efforts to cut down or control alcohol use; continued use despite knowledge of a psychological problem caused or exacerbated by alcohol, loss of control P P Reasons individuals may give for drinking excessively Pleasure from the intoxicating effects. Boredom and loneliness ("alcohol is my best friend"). To treat depression (despite alcohol's being a depressant). To treat anxiety (despite increased anxiety during the withdrawal phase). To treat insomnia (despite impairment of deep sleep patterns). To cope with guilt and remorse (often over excessive drinking, creating a vicious cycle). To reduce physical pain. To reduce emotional pain (e.g., to numb feelings). To regain a feeling of normality ("I was born a pint low"). To come down from the effects of stimulants (e.g., cocaine, methylphe nidate). To augment the intoxicating effects of other depressants (i.e., barbiturates, heroin, chloral hydrate). Historical models - aetiology Ethical model (moralisation, guilt, holiday rite) Disease model (learning, self-medicalisation) Sociological model (deviancy) psychological, psychiatric, neurobiological models (failure in socialisation process, family games or enzim def...) genetic vulnerability, depressive spectrum integrative model? The self-destructive nature of alcoholism has both chronic and acute aspects. In addition to cirrhosis of the liver and other medical complications, chronic self-destructive consequences of alcoholism include the disruption of family and other social relationships, destruction of personal reputation, jeopardizing of employment, and other economic disadvantages. cutely self-destructive behavior involves vulnerability to arrest, accidents fighting, and suicide. In some reported series of suicides, alcoholism was the second most frequent retrospective psychiatric diagnosis (after severe depression). Chemical and behavioural dependency spectrum - loss of control Vulnerability, enzimes, genetic background Primary or secundary (dual diagnosis) culturally prescribed, or tolerated habits, availability, individual personality traits, direct group-impacts, interpersonal conflicts 2

3 Neurobiological Considerations The neurotransmitters GB and glutamate are both involved in the mechanism of action of alcohol intoxication and withdrawal syndrome lcohol increases the activity of the inhibitory neurotransmitter GB and decreases the activity of the excitatory neurotransmitter glutamate. When alcohol use suddenly stops after intoxication, the effects of alcohol on these two neurotransmitters are suddenly lost - GB activity decreases - Glutamate activity increases. Changes in these two neurotransmitters work in concert during acute alcohol withdrawal to increase membrane excitability and the potential for seizure activity (i.e., alcohol withdrawal seizures): cute alcohol withdrawal is a hyperexcitability state. Repeated episodes of alcohol withdrawal may sensitize (i.e., kindle) membrane excitability, further increasing the risk of future withdrawal seizures. Currently, GBergic agents (BZDs) are the primary medications used to treat alcohol withdrawal symptoms. However, glutamate inhibitors hold great promise as medications to reverse alcohol withdrawal states. Etiological Formulations of lcohol-related Disorders Genetic/familial formulations: lcohol-related disorders are more prominent in individuals with a family history of alcohol-related disorders. Men and women differ in their ability to detoxify alcohol, possibly due to differences in lean body mass, liver size, or the activity of enzymes that metabolize alcohol in the liver. Behavioral and learning formulations: lcohol-related disorders develop because the individual learns by observing, during the developmental years, family members who drink. Psychoanalytic formulations: lcohol reduces stress caused by an overpunitive superego (e.g., to reduce self-imposed guilt over heavy drinking). lcohol reduces inhibition (i.e., the superego "dissolves" in alcohol), and as a consequence, drinking continues. Etiological Formulations of lcohol- Related Disorders Social and cultural formulations: Certain social settings predispose to excessive drinking (e.g., college campuses, military bases). Certain cultural groups predispose to excessive drinking (e.g., adolescents, Hispanics, Native mericans). Psychological formulations: lcohol is used to self-medicate or modulate anxiety, depression, and/or psychosis. Developmental formulations: Individuals with alcohol-related disorders have a greater likelihood of having a personality disorder, DHD, or conduct disorder. Integrative pathogenetic model Early losses Hereditary, Genetic gender ffective temperament Stress Limbic dysfunction Chemical dependency, alcohol, suicide 3

4 Marylin Monroe CSE Study in Hungary, some conclusions (n=4408; adolescents y, self-reported, anonymous ) direct and indirect self destruction overlap significant alcohol and illegal drug consumption in the suicide group (also cannabis, nicotin) In the suicide group, in 70% of the cases occurred past month heavy drinking Marihuana/hasis consumption occurred past month in 9% of the sample, in 25% of suicide attempters, in 40% of the repeaters (more males than females) How often in the past month have you had so much to drink that you were really drunk? male female Have you taken Hashish/marijuana/cannabis during the past month (ie. last thirty days)? Never 49,5% 66,7% male female Once 22,7% 20,9% No 75% 86% 2-3 times 19,8% 9,4% Yes, in the past month 11,5% 5,5% 4-10 times 4,2% 1,8% Yes, in the past year 13,2% 7% More than 10 times 3,2% 0,5% Some socio-cultural and public health care relations availability (e.g. Gorbatschev-alcohol law) cultural factors (in the islamic countries low illegal drug use and suicide rates) family background poor social network, negativeambivalent, aggressive communication of the family members) CONSEQUENCES FOR THE PREVENTION Therapy (1)detoxification, involving medications and supportive measures to minimize effects of the drug and of its withdrawal; (2) substitution therapy with related drugs, which may be temporary (as in withdrawal of sedatives) (3) deterrents to further ingestion of alcohol (e.g., disulfiram) (4) antianxiety or antidepressant medication; (5) group and individual psychotherapies intended to alter neurotic characteristiscs that promote psychological dependence. 4

5 Management of alcohol withdrawal syndromes Treatment of alcohol dependence begins with detoxification aimed at normalization of metabolic processes and prevention of withdrawal delirium and seizures. correction of electrolyte imbalance; treatment of infection; and (usually) administration of intravenous fluids with glucose. These therapies should continue until the medical condition has normalized. 1. Thiamine; folic acid 2. Phenytoin or carbamazepine, in patients with a history of withdrawal seizures 3. Haloperidol: 2-5 mg bid for patients with alcoholic hallucinosis 4. For delirium tremens: - Iv. im. per os diazepam 10 mg (or lorazepam 2-4 mg), followed by 5-mg doses every 5 minutes until calm. Once the patient is stabilized, the dose may be tapered slowly over 4 or 5 days - Seclusion and restraints as necessary - dequate hydration and nutrition Considerations for the therapy ntipsychotic medications can help reduce psychotic symptoms (e.g., hallucinations) or escalating anxiety or agitation. Benzodiazepines and alpha2-adrenergic agonists (e.g., clonidine) can help reduce excessive autonomic hyperactivity (e.g., elevated blood pressure, elevated pulse). Beta-blockers (e.g., propranolol) can help reduce excessive autonomic hyperactivity and somatic anxiety For persons experiencing withdrawal seizures, an antiepileptic medication (e.g., phenytoin, carbamazepine) is often used prophylactically if seizure activity continues fter detoxification, recommendations include one of the following: Continued treatment on an outpatient basis. Continued somatic and/or psychosocial treatment in a 21- to 28-day inpatient treatment program (helpful for patients who fail to stop drinking after repeated attempts at detoxification), possibly followed by a 6- to 24-month program in a long-term treatment facility. Recommendations for management of alcoholism 1. The alcoholic person needs acceptance, not blame. 2. lthough it is tempting to refuse treatment to the chronic alcoholic person because of his or her history of failure, it is always possible that the next rehabilitation may work. 3. Treatment of withdrawal syndromes should take place in an inpatient setting if the patient has a history of severe "shakes," hallucinations, seizures, or delirium tremens. Other patients (the majority) can be handled as outpatients. benzodiazepines (e.g.,clorazepam) work well. 4. Be sure to manage the patient's other emotional problems as well (e.g., panic disorder, depression), because if untreated, they may lead to a resumption of drinking. 5. Refer the patient to lcoholics nonymous to provide ongoing support and encouragement from persons similarly affected. 6. Be sure to include the family in the treatment process. lcoholism affects every member of the family, and unresolved issues may lead to relapse. Family members should be encouraged to attend l-non, a support group for relatives of alcoholic persons. Support meetings : lcoholics nonymous and lateen are 12-step programs focusing on total abstinence, reduction of stress, and a "one day at a time" philosophy. Frequent meetings (e.g., "30 meetings in 30 days") and a sponsor who has been alcohol-free for at least 1 year are recommended. The first step is to acknowledge lack of power over drinking. l-non provides support for spouses and family members of individ-uals with drinking problems. dult Children of lcoholics (CO), pioneered by Dr. Janet Woititz, provides support for adult children of a parent or parents who are alcohol dependent. 5

6 lcoholics nonymus () is a well-known selfhelp organization for both nonpracticing and practicing alcoholics that has the primary goal of perpetual sobriety for its members. The approach is inspirational ans spiritual, and members are expected to assist in rehabilitating other alcholics whom they bring to regular group meetings. This program has considerable apeal for a number of alcoholics, who receive limitless support in their struggles to maintain sobriety, recover self-esteem, and rebuild relationships with families, neighbors, and employers 6