ALCOHOL RELATED

DISORDERSPresenter- Dr. Swapnil Agrawal

Guide-

Dr.D.K.Sharma,

Professor & Head,

Department of Psychiatry,

Govt Medical College,

Kota

"... alcohol has existed longer than all human memory. It has outlived generations, nations and ages. It is a part of us, and that is fortunate indeed. For although alcohol will always be the master of some, for most of us it will continue to be the servant of man" Director of the National Institute on Alcohol Abuse and Alcoholism(Chafetz, 1965, p. 223).

Historical Aspects One of the most commonly used chemical

substances for intoxication by humans in history.

Word 'alcohol' originates from the Arabian term 'al-kuhul', meaning "the kohl" a powder for the eyes, which later came to mean "finely divided spirit".

..history No one knows when beverage alcohol was

first used

The discovery of late Stone Age beer jugs has established the fact that intentionally fermented beverages existed at least as early as 10,000 B.C.(Patrick, 1952, pp. 12-13).

In INDIA alcoholic beverages  appeared in between 3000 BC - 2000 BC. 

EPIDEMIOLOGY According to a study conducted by the NIMHANS for the

WHO, published in 2006, nearly 30% of adult men and <5% of women consume alcohol.

Male to female ratio of 6:1

Age- Men in their late teens or early 20s are heaviest drinkers. Occupation- more in chefs, barmen, executives, actors,

Doctors etc( as they have easy access to alcohol)

Average age of initiation has reduced from 28 years during the 80s to 20 years in recent years.

Alcohol-dependent person decreases his life span by 10 to 15 years.

allOverall prevalence~ 30%

Overall prevalence<5%

Alcohol content of different beverages

Expressed as `UNIT’. 1unit=8grams of alcohol.

BEVERAGE ALCOHOL

CONTENT(%)UNITS OF ALCOHOL

Ordinary Beer 3% 2 per pint

Strong Beer 5.5% 4 per pint

Extra strong Beer 7% 5 per pint

Table wine 8-10% 7 per bottle

Fortified wines(sherry, pot, vermouth)

13-16% 15 per bottle

Spirits(whisky, gin, brandy, vodka)

32% 30 per bottle

Risk of social and health problems

ALCOHOL INTAKE(units/week)

RISK OF PROBLEMS

MEN 0-21WOMEN 0-14

LOW

MEN 22-50WOMEN 15-35

INCREASING, particularly in smokers

MEN > 50WOMEN > 35

HIGH, particularly in smokers

ETIOLOGY Various theories to explain alcoholism-

1. Psychological theories

2. Psychodyanamic theories

3. Behavioral theories

4. Sociocultural theories

5. Genetic theories

6. Childhood history

ETIOLOGY Psychological Theories

Alcohol reduces tension, increase feelings of power, decrease the effect of psychological pain

Alcohol decreases nervousness, increased feeling of well being, help them to cope with day to day stresses of life.

Psychodynamic Theories Due to anxiety lowering effects of alcohol, people may

use this to help them deal with self-punitive harsh superegoes and to decrease unconscious stress levels.

Fixation at oral stage of development may also explain use of alcohol to relieve frustations by taking the substance by mouth.

Behavioral Theories Expectations about the rewarding effects of

alcohol, and subsequent reinforcement after alcohol intake all contribute to decision to drink again after first drink..

Sociocultural Theories Cultural attitudes toward drinking, and personal

responsibilities for consequences are important contributors to alcohol use..

Childhood history Childhood history of ADHD, conduct disorder,

antisocial personality disorder increases a child’s risk for an alcohol related disorder as an adult..

Genetic Theories Close family members have a fourfold

increased risk. The identical twin of an alcoholic person is at

higher risk than is a fraternal twin. Adopted-away children of alcoholic people

have a fourfold increased risk.

EFFECTS OF ALCOHOL ON BODY1) Absorption- 10% from stomach,

90%-small intestine(proximal).

2) Peak blood conc.- In 30-90 minutes.

3) Metabolism- 90% in liver

(by ADH and ALDH enzymes)

-10% ex unchanged by kidney

and lungs Body can metabolises ¾ ounce(1 ounce=28.35 gms)

of 40%spirits in 1 hour.

ACETIC ACID

ACETALDEHYDE

ALCOHOL

Disulfiramreaction.

ToxicCauses Histaminerelease

ADH

ALDH

Non- toxic

…EFFECT OF ALCOHOL ON BODY

EFFECT ON BRAIN(Pathophysiology)- Dopamine increase in limbic system- pleasure

(alcohol acutely increase dopamine levels in brain) Serotonin- related to amount of intake GABAA receptors NMDA receptors

…EFFECT OF ALCOHOL ON BODY1) EFFECT ON SLEEP- - decreased sleep latency, but

- decrease in REM and NREM stage 4

- more sleep fragmentation, and longer episodes of awakening

(thus overall harmful effect on sleep)

2) TOLERANCE- With repeated administration of alcohol, larger and larger

doses are required to produce the desired effect.

3) CRAVING- The state of motivation to seek out alcohol.

4) BLACKOUTS-

Blackout indicates a memory impairment (anterograde amnesia) for the period when the person was drinking heavily and was awake

5)PERIPHERAL NEUROPATHY

- tingling and numbness in hands & feet

- develops in about 10% alcoholics

6) CEREBELLAR DEGENERATION

7) CENTRAL PONTINE MYELINOSIS(present as quadriplegia, lethargy, and cognitive impairment )

8) MARCHIAFAVA- BIGNAMI SYNDROME(thinning of the corpus callosum along with a change in consciousness, ataxia, and possible dementia)

9) Pathological intoxication (mania a potu)-

- An extraordinary severe response to small amounts of alcohol

- marked by apparently senseless violent behaviour, usually followed by sleep, exhaustion & ‘amnesia’ for the episode.

GIT-

- Gatritis, fatty liver, alcoholic cirrhosis, pancreatitis.

CVS-

- Hypertension and increased risk of Stroke.

(Paradoxically, moderate drinkers i.e. about 7-10 units/week have lower risk of coronary artery disease than non-drinkers!!)

FETAL ALCOHOL SYNDROME-

- seen in about 5% children born to heavy-drinker mothers.

-severe mental retardation, microcephaly, facial defects, asd etc.

-even fetal death, and spontaneous abortion.

ICD-10- F10--F19 Mental and behavioural disorders due

to psychoactive substance use F10. -Alcohol F11.-Opioids F12.-Cannabinoids F13.- Sedatives or hypnotics F14.-Cocaine F15.-Other stimulants, including caffeine F16.-Hallucinogens F17. -Tobacco F18.-Volatile solvents F19.-Multiple drug use and use of other psychoactive

substances

CLASSIFICATION OF ALCOHOL-RELATED DISORDERS

ICD-101. F10.0 Intoxication

2. F10.1 Harmful use

3. F10.2 Dependence syndrome

4. F10.3 Withdrawal state

5. F10.4 Withdrawal state with delirium

6. F10.5 Psychotic disorders

7. F10.6 Amnestic syndrome

8. F10.7 Residual and late onset psychotic disorder

9. F10.8 Other mental and behavioral disorders

DSM-IV1. Intoxication2. Abuse3. Dependence4. Withdrawal5. Withdrawal delirium6. Psychotic disorders7. Mood disorders8. Anxiety disorders9. Amnestic disorders10. Dementia 11. Sexual dysfunction12. Sleep disorders

F10.0 ACUTE INTOXICATION

A transient syndrome

-due to recent substance ingestion

-that produces clinically significant psychological and physical impairment.

Changes are reversible upon elimination of substance from the body.

Legal definition of intoxication in USA is alcohol conc. > 80-100 mg/dl of blood.

LEVEL 20-30 mg/dl

30-80 mg/dl

80-200 mg/dl

200-300 mg/dl

>300 mg/dl

LIKELY IMPAIRMENT Slowed motor performance,

decreased thinking ability. Increase in motor & cognitive

problems. Increase in incoordination and

judgement errors. Lability of mood, Cognitive deterioration

Marked slurring of speech, Nystagmus, Blackouts.

Impirement in vital signs, possibly Death!.

F10.1 ALCOHOL HARMFUL USE

A pattern of psychoactive substance use -that is causing damage to health, -the damage may be physical or mental.Diagnostic guidelines Actual damage to physical or mental health.

Acute intoxication itself is not a sufficient evidence of the damage to health.

Harmful use should NOT be diagnosed if dependence syndrome, a psychotic disorder (F10.5), or another specific form of alcohol-related disorder is present.

F10.2 DEPENDENCE SYNDROME A cluster of physiological, behavioural, and

cognitive phenomena

-in which the use of a substance takes on a much higher priority for an individual than other behaviours that once had greater value.

Diagnostic guidelines for dependence syndrome-

Three or more of the following is necessary to

diagnosis in previous year.

a) Strong desire.

b) Progressive neglect of alternative pleasures or interests.

c) Evidence of tolerance.

d) Signs of withdrawal on attempted abstinence

e) Loss of control of consumption.

f) Continued drug use despite negative consequences.

Five-character codes for dependence F10.20 Currently abstinent

F10.21 Currently abstinent, but in a protected environment

F10.22 Currently on a clinically supervised maintenance or replacement regime [controlled dependence]

F10.23 Currently abstinent, but receiving treatment with aversive or blocking drugs (e.g. naltrexone or disulfiram)

F10.24 Currently using the substance [active dependence]

F10.25 Continuous use

F10.26 Episodic use [dipsomania]

Subtypes of Alcohol Dependence

Type A alcohol dependence Late onset Few childhood risk factors Mild dependence (with few alcohol related

problems and little psychopathology)

Type B alcohol dependence Early onset Many childhood risk factors Severe dependence( with a strong family history

and much psychopathology)

Some more subtypes….

Gamma alcohol dependence Represents alc. Dep. In those who are active in

Alcoholic Anonyms. These persons are unable to stop drinking once

they start, but if drinking is terminated (due to ill health or lack of money), they can abstain quite well..

Delta alcohol dependence Include those who must drink a certain amount

each day, but are unaware of a lack of control

Difference b/w harmful use and dependence- For a person meeting criteria of both harmful use

and dependence, the diagnosis of DEPENDENCE should be made.

Tolerance and Withdrawal state are features of DEPENDENCE.

Harmful use should NOT be diagnosed if dependence syndrome, a psychotic disorder (F10.5), or another specific form of alcohol-related

disorder is present.

F10.3 ALCOHOL WITHDRAWAL

“A group of symptoms and signs which occur on cessation or reduction of use of a psychoactive substance,

-that has been taken repeatedly, usually for a prolonged period and/ or in high doses.”

It can be- Uncomplicated- ocurring in 6-48 hrs and abates

after 2-5 days. Complicted- with seizures, delirum.

Diagnosis of alc. withdrawalA) Cessation of (or reduction in) alcohol use.

B) Two (or more) of the following, developing within several hours to a few days after Criterion A:   

(1) Autonomic hyperactivity (2) Increased hand tremor    (3) Insomnia    (4) Nausea or vomiting    (5) Transient hallucinations or illusions    (6) Psychomotor agitation    (7) Anxiety    (8) Grand mal seizures

C) Social & occupational functioning impairment.

D) Not due to a general medical condition or mental disorder.

S/S ALCOHOL WITHDRAWAL SYNDROME

Time withdrawal symptoms

6 to 12 hours Insomnia, tremulousness, mild anxiety, gastrointestinal upset, headache, diaphoresis, palpitations, anorexia

12 to 24 hours Alcoholic hallucinosis: visual, auditory, or tactile hallucinations

24 to 48 hours Withdrawal seizures: generalized tonic-clonic seizures

48 to 72 hours Alcohol withdrawal delirium (delirium tremens): hallucinations (predominately visual), disorientation, tachycardia, hypertension, low-grade fever, agitation, diaphoresis

ALCOHOL WITHDRAWAL SEIZURES 5-15% cases of alcohol withdrawal Within 24-48hrs but may up to 7days Tonic-clonic in nature Usually one or two episodes 30% of pts develop delirium

Give IV diazepam until seizure activity ceases 5-10mg IV initially, repeat if necessary every 15min up

to a maximum dose of 100mg Call to neurologist Avoid anticonvulsant unless history of primary SD

F10.4 DELIRIUM TREMENS Medical Emergency < 5% of Alcohol Withdrawal syndrome Usually begins in 48-96hrs. Last for 1-5 days May be associated with seizure(F10.41) In untreated cases mortality is up to 20%.

Triad of symptoms includes- - Clouding of consciousness, - Hallucinations and Illusions, - Marked tremors. Autonomic hyperactivity, dehydration, electrolyte imbalance. Delusions may be present May lead to circulatory collapse, coma & death

Management of Delirium tremens

IV Fluid for hydration.

Mainstay are BZDS-

-Lorazepam 2mg or Diazepam 10mg IV/IM.

-Repeated doses till symptoms clear

-Doses should be tapered in 5-7days

Thiamine 200-300mg IM daily for 3-5 days.

Oral Thiamine three times a day.

Monitor vitals 4hrly Closely observe for focal neurological deficit Pt should be on high calorie, high carbohydrate diet.

F10.5 PSYCHOTIC DISORDERS

Occur during or immediately after alcohol use and are characterized by-

.Vivid hallucinations (mainly auditory),

.Delusions or ideas of reference(morbid jealosy),

.Psychomotor disturbances (excitement or stupor), .Abnormal affect.

Sensorium is usually clear but some clouding of consciousness may be present.

The disorder typically resolves in 1-6 months.

Diagnostic guidelines.. A psychotic disorder occurring during or

immediately after drug use (usually within 48 hours)

- provided that it is not a manifestation of withdrawal state with delirium and

- should NOT be of late onset.

Late-onset psychotic disorders (with onset more than 2 weeks after substance use) should be coded as F10.75.

The diagnosis of psychotic state may be further specified by the following five character codes:

1. F10.50 Schizophrenia-like

2. F10.51 Predominantly delusional

3. F10.52 Predominantly hallucinatory (includes alcoholic hallucinosis)

4. F10.53 Predominantly polymorphic

5. F10.54 Predominantly depressive symptoms

6. F10.55 Predominantly manic symptoms

7. F10.56 Mixed

F10.6 AMNESTIC SYNDROMES A syndrome associated with chronic prominent impairment of RECENT memory; remote memory is sometimes impaired, while immediate recall is preserved.

Diagnostic guidelines-

1. Impairment of RECENT memory(learning of new material) ; Disturbance of time sense.

2. Preserved immediate recall;

3. Preserved consciousness; and absence of generalised cognitive impairment.

4. Evidence of chronic (high-dose) use of alcohol.

Includes:- Wernicke’s encephalopathy, &

Korsakov’s syndrome.

WERNICKE ENCEPHALOPATHY Acute onset Completely reversible

Global confusion Opthalmoplegia - Horizontal nystagmus, 6th n. palsy Ataxia, Vestibular dysfunction

Rapidly reversible with large parenteral doses 200-300mg of Thiamine. Then 100mg orally BD or TDS for 1-2 wk.

In pts. receiving iv fluids, include 100mg of thiamine in each liter of iv glucose solution.

G.O.A.

KORSAKOFF’S SYNDROME

Chronic condition

Reversible in only 20% of cases

Impaired Recent memory and anterograde amnesia in an alert and responsive pt.

Confabulation +/-

In most cases, the level of recent memory loss is out of proportion to the global level of cognitive impairment.

Thiamine100mg orally BD or TDS for 3 to 12 months.

F10.7 RESIDUAL & LATE ONSET PSYCHOTIC DISORDER A disorder in which alcohol-induced changes of cognition,

affect, personality, or behaviour persist beyond the period during which a direct alcohol-related effect might be assumed to be operating.

Further subdivided by the following five-character codes:- F10.70 Flashbacks F10.71 Personality or behaviour disorder F10.72 Residual affective disorder F10.73 Dementia F10.74 Other persisting cognitive impairment F10.75 Late-onset psychotic disorder

F10.8 Other mental and behavioural disorders Code here any other disorder in which the

use of a substance can be identified as contributing directly to the condition, but which does not meet the criteria for inclusion in any of the above disorders.

ALCOHOL INDUCED PERSISTING DEMENTIA

Global decreases in intellectual functioning, cognitive abilities, and memory.

But recent memory difficulties are consistent with the global cognitive impairment.

(an observation that distinguishes the syndrome from alcohol-induced persisting amnestic disorder.)

50-70% show increased size of the brain ventricles and atrophy of frontal lobe.

(these changes appear to be partially or completely reversible.)

Brain functioning improves with abstinence, but 1/2 of all affected patients have long-term and even

permanent memory and thinking disabilities.

ALCOHOL INDUCED ANXIETY DISORDERS Only two anxiety disorders may be more closely

tied to alcoholism: panic disorder & social phobia.

During the first 4 to 6 weeks of abstinence

Disappear with time alone.

ALCOHOL INDUCED SEXUAL DYSFUNCTION Alcohol in small doses appears to enhance

sexual receptivity in women and increase arousal to erotic stimuli in men.

Heavy continued drinking may cause significant sexual impairment:-

- impaired desire - impaired arousal - impaired orgasm - sexual pain.

Symptoms usually subside after 3-4 weeks of alcohol abstinence.

MANAGEMENTManagement of-

1) Alcohol Intoxication

2) Dependence & Withdrawal

3) With specific co-morbid conditions.

Mx of Alcohol intoxication Check for vital signs- blood pressure

- respiratory depression

- arrhythmias

Any signs of Hypoglycemia, Hepatic failure

If very aggressive- low dose lorazepam (1mg orally) or

-antipsychotic(5mg Haloperidol)

Ensure hydration (iv fluids)

Symptomatic and supportive treatment.

Mx of DependenceStep 1) Detection of alcohol dependence

Step 2)Intervention

Step 3) Detoxification (or withdrawal from alcohol)

Step 4) Relapse prevention (or maitenence of abstinence)

& Rehabilitation.

The Moral and Medical models

Moral model- Public drunkenness should be punished. Little evidence that it influences the behavior of

excessive drinkers!

Medical model- Jellinek in 1960- “The disease concept of alcoholism”. Instead of blame and punishment, Medical treatment

is provided to excessive drinkers.

By-1- Screening2- History taking3- Laboratory diagnosis

(A) DETECTION OF ALCOHOL MISUSE

SCREENING-

1. CAGE questionnaire

2. AUDIT questionnaire

CAGE Questionnaire

Consist of 4 questions-

1) Have you ever felt to Cut down on your drinking?

2) Have people Annoyed you by criticizing your drinking?

3) Have you ever felt Guilty about your drinking?

4) Have you ever had a morning drink (Eye opener) to get rid of hangover?

-> 2 or more yes= alcohol misuse.

-> Overall sensitivity is Good but modest specifity.

AUDIT questionnaire Ten questions. Designed at the request of WHO. Scores are given for each answer.

Score Intervention 8-15 - brief intervention based on

risk factors. 16-19 - brief intervention, regular

monitoring. 20-40 - diagnostic assessment,

detoxification, and other

treatments.

DRINKING HISTORY Describe a typical day’s drinking. What time you take first

drink of the day?

When did daily drinking start?

Any withdrawal symptoms in morning or after abstinence?

Previous attempts at treatment?

Medical complications?

Patient’s attitude towards drinking?

LABORATORY DIAGNOSISParameter Normal value Value in chronic

alcoholics

Serum level of γ-glutamyl transferase (GGT)

Men 4-25 U/LWomen 7-40 U/L

>30 U/L

Mean corpuscular volume(MCV)

80-98μm3 >100 µm3

Carbohydrate-deficienttransferrin

<60mg/l >1.3% of total transferrin concentration

AST & ALT <45 U/L AST:ALT, 2:1

Blood Alcohol conc.- if a person is not intoxicated even when blood alc. Levels are high, he is likely to be unusually tolerant to alcohol.

(B) INTERVENTION Goal is “to increase motivation” for treatment & continued

abstinence

Motivational interviewing

-Aim is to persuade pt. to engage in treatment programme.

-Express empathy

-Avoid arguing, let the pt.say

and then “roll with” resistance

-usually multiple sessions are required to persuade the pt.

In the meantime- Family may benefit from counselling or referral to self help groups like-

AL-Anon(for spouses of excessive drinkers) &

AL-Ateen(for their teenage children)

Also pt.can be encouraged to meet people recovering from alcohol, through AA(Alcohol Anonymous)

(C) DETOXIFICATION i.e Withdrawal of patient from alcohol. Step 1) Thorough Physical examination

(e.g. liver failure, gi bleed, arrhythmia, glucose or electrolyte imbalance; any combined drug abuse)

Step 2) Rest & Adequate nutrition

(Vit-B complex specially Thiamine)

Step 3) BZD & other symptomatic pharmacotherapy

Pharmacotherapy1) Benzodiazepines- -drug of choice -decreases s/s of withdrawal & prevents seizures & DT also -long acting(chlordiazepoxide,diazepam) are preferred

-Dose:- 20-30mg Chlordiazepoxide

or 5-10mg Diazepam.

(dose up to 250mg on day1 can be given in severe

withdrawal) - then decrease gradually and stop in 5-7 days.

(dose can be adjusted depending on s/s)

Oxazepam/Lorazepam/Temazepam for elderly or hepatic impairment pts.

6 hourly on day1

Common benzodiazepines used to treat patients with alcohol withdrawal SyndromeDrug Half Life Initial Dose Average

Dose/ DayMaximum Dose/Day

Chlordiaze-poxide

24-48 hours 25mg 50-100mg 250mg

Diazepam 20-90 hours 5mg 10-20mg 100mg

Lorazepam 10-20 hours 1mg 2-4mg 12mg

Oxazepam 4-14 hours 15mg 10-30mg 200mg

…pharmacotherapy

2) Thiamine & Magnesium Prevention & treatment of Wernicke’s enceph &

Korsakoff’s psychosis. No impact on s/s of withdrawal or seizures or DT.

Thiamine- 100 to 300mg im or orally daily. for at least 7 days

(..upto 1-2 wk in WE & upto 3-12 months in KP )

Thiamine should always precede glucose administration

…pharmacotherapy

Magnesium- HypoMagnesemia occurs in withdrawal Mg is required for normal utilization of Thiamine also!

In severe case deficiency is 1-2 meq/kg body wt.

Correct half of deficit on day1, then remaining on following 4 days

Dose- 30-45 meq(4 to 6 ampules) of mag.sulphate in 2 litre of iv fluid on day1

Half of above dose Daily for 4 days

…pharmacotherapy

OTHER DRUGS& ADJUNCTIVE THERAPIES

Sympatholytics--decreases autonomic hyperactivity in withdrawal.

-Clonidine(α2 agonist)- can cause postural hypotension

-Propanolol(β-blocker)- increases incidence of delirium

Barbiturates(Phenobarbital)-for withdrawal in pregnant women

-lack of sufficient evidence

…pharmacotherapy

Neuroleptics-

-Reduces symptoms of withdrawal(agitation & hallucinations)

-Haloperidol & Phenothiazines- but increases risk of seizures.

Carbamazepine-

-can reduce minor s/s of withdrawal

-no special benefit

(D)MAINTAINING ABSTINENCE & REHABILITAION

Pharmacological Rx

1. Disulfiram

2. Acamprosate

3. Naltrexone

4. Others

-SSRI

-Topiramate

-Ondansetron

-Baclofen

Psychosocial interventions

1. Brief interventions

2. Extended interventions

3. Group therapy

4. Family therapy

5. Self-Help groups(Alcohol Anonymous)

Disulfiram Inhibits Aldehyde dehydogenase(ALDH), so acetaldehyde

accumulates

Flushing, weakness, nausea, tachycardia on taking alcohol Thus acts as aversive Rx discouraging impulsive alcohol use

Before starting disulfiram pt. should be abstinent from alcohol for 12 hours

Disulfiram reactions can occur upto 2 weeks after last dose No tolerance with continous Rx of disulfiram

Dose-800mg on day1 then100-250mg daily C/I – heart failure, CAD, HTN, pregnancy, psychosis High risk of serious S/E so generally not preferred

Acamprosate Calcium acetyl homotaurinate Decreases the glutamenergic excitatory activity (NMDA)

& Increases GABA activity.

Supresses the urge to drink Abstinence rates appear to be Doubled

S/E – diarrhoea, skin rashes, decreased libido, anxiety, depression

C/I – severe renal impairment (eliminated completely by kidney)

Dose- 333mg 2TDS before meal (as food interferes with absorption)

Naltexone Opioid antagonist – blocks the reinforcing and

rewarding effects of alcohol.

Reduced Craving(anti-craving) and reduced rate of relapse

S/E- nausea, constipation, anxiety, fatigue C/I - in pt. taking opioids, hepatic failure

Dose- 50mg daily

BACLOFEN GABA-B agonist

Primarily used for the treatment of spastic movement disorders.

In 2012, Baclofen was approved for use in the treatment of alcoholism

Shown to enhance abstinence, reduce drinking quantity, reduce craving, and reduce anxiety in alcohol-dependent individuals.

Dose- 30mg/day

Antidepressants Useful in pt. who experience persistent

symptoms of major depression after detoxification.

May reduce drinking even in non-depressed subjects.

Only SSRIs are recommended

SSRIs may improve drinking outcome in Type 1

but may worsen outcome in Type 2 dependence.

Alcohol Anonymous

AA is an international self-help organisation founded in USA by two alcoholic men- Dr. Bob Smith(surgeon) & Bill Wilson(a stockbroker) in 1935.

AA says “its primary purpose is to stay sober and help other alcoholics achieve sobriety”

Members attend group meetings, usually twice weekly on long-term basis.

In crisis, immediate relief can be obtained from other members by telephone.

Treatment of specific co-morbid conditions

1) Alcoholism with depressive symptoms-

- increased risk for relapse

- psychosocial Rx like Group therapy

2) Alcoholism with major depression-

- SSRI(fluoxetine, tianeptine) may be started

- TCA(due to sympathetic s/e) are not used

3) Alcoholism with dysthymic disorder-

- frequent relapses are common

- cognitive behaviour therapy may be considered

4) Alcoholism with Anxiety- - for mild anxiety symptoms, Rx is deferred till pt. is

abstinent for 2 wks

- In pt. who experience anxiety disorder separately from any problem related to alcohol– anxiolytics (long acting BZD) can be started.

- Buspirone (bcoz of no evidence of its interaction with alcohol) can be used.

Take Home Message… For a person meeting criteria of both harmful

use and dependence, the diagnosis of DEPENDENCE should be made.

Repeated detoxifications can produce ‘Kindling effect’, so even mild withdrawal should be treated aggressively to prevent the increased severity of subsequent withdrawal episodes.

In alcohol withdrawal seizures, avoid anticonvulsants unless there is H/O primary seizure disorder. (mainstay of t/t here is iv diazepam)

In untreated DT mortality is upto 20%, so must be diagnosed and promptly treated.

In Amnestic syndrome- Recent memory is impaired with ABSENCE of generalised cognitive impairment

(presence of generalised cognitive impairment suggest dementia)

Mainstay of t/t for amnestic syndr is Thiamine.

(but has no role in t/t of withdrawal symptoms)

Magnesium should be included in t/t for alcohol dependence.

DOC for alcohol withdrawal is BZD (chlordiazepoxide or diazepam).

Disulfiram- should be prescribed in motivated pt. only after explaining its s/e.

….Free Yourself

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