3. INTRODUCTION
Alcohol dependence was previously called as alcoholism. This term much
like ‘addiction’ has been dropped due to its derogatory meaning.
1)strong desire
2)difficulties in controlling
3)a physiological withdrawal state
4)tolerance
5)neglect of pleasures
6)persisting with substance use despite overtly harmful consequences
4. CLASSIFICTION
According to Jellinek, there are
five ‘species’ of alcohol
dependence (alcoholism) on the
basis of the patterns of use
alpha
beta
gamma
delta
epsilon
5. A. Alpha (α)
i. Excessive and inappropriate
drinking to relieve physical and/or
emotional pain.
ii. No loss of control.
iii. Ability to abstain present.
B. Beta (β)
i. Excessive and inappropriate drinking.
ii. Physical complications (e.g. cirrhosis,
gastritis and neuritis) due to cultural drinking
patterns and poor nutrition.
iii. No dependence.
6. C. Gamma (γ)
i. Progressive course.
ii. Physical dependence with tolerance
and withdrawal symptoms.
iii. Psychological dependence, with
inability to control drinking.
D. Delta (δ)
i. Inability to abstain.
ii. Tolerance.
iii. Withdrawal symptoms.
iv. The amount of alcohol consumed can be
controlled.
v. Social disruption is minimal.
7. E. Epsilon (ε)
i. Dipsomania (compulsive-drinking).
ii. Spree-drinking.
8. Aetiological Factors in Substance Use
Disorders
Biological Factors
PSYCHOLOGICAL FACTORS
PSYCHOLOGICAL FACTORS
9. Biological Factors
i. Genetic vulnerability (family history of substance use disorder; for example in type II alcoholism)
ii. Co-morbid psychiatric disorder or personality disorder
iii. Co-morbid medical disorders
iv. Reinforcing effects of drugs (explains continuation of drug use)
v. Withdrawal effects and craving (explains continuation of drug use)
vi. Biochemical factors (for example, role of dopamine and norepinephrine in cocaine, ethanol and opioid dependence)
10. PSYCHOLOGICAL FACTORS
i. Curiosity; need for novelty seeking
ii. General rebelliousness and social non-conformity
iii. Early initiation of alcohol and tobacco
iv. Poor impulse control
v. Sensation-seeking (high)
vi. Low self-esteem (anomie)
vii. Concerns regarding personal autonomy
viii. Poor stress management skills
ix. Childhood trauma or loss
x. Relief from fatigue and/or boredom
xi. Escape from reality
xii. Lack of interest in conventional goals
xiii. Psychological distress
11. Social Factors
i. Peer pressure (often more important than parental factors)
ii. Modelling (imitating behaviour of important others)
iii. Ease of availability of alcohol and drugs
iv. Strictness of drug law enforcement
v. Intrafamilial conflicts
vi. Religious reasons
vii. Poor social/familial support
viii. ‘Perceived distance’ within the family
ix. Permissive social attitudes x. Rapid urbanisation.
12. laboratory markers
GGT (γ-glutyl-transferase)
MCV (mean corpuscular volume)
Other lab markers include alkaline phosphatase, AST, ALT,
uric acid, blood triglycerides and CK.
In addition, BAC (blood alcohol concentration) and breath
analyser can be used for the purpose of identification.
14. Acute Intoxication
After a brief period of excitation, there is a generalised central nervous system
depression with alcohol use. With increasing intoxication, there is increased reaction
time, slowed thinking, distractibility and poor motor control.
Later, dysarthria, ataxia and incoordination can occur. There is progressive loss of self-
control with frank disinhibited behaviour. The duration of intoxication depends on the
amount and the rapidity of ingestion of alcohol.
Usually the signs of intoxication are obvious with blood levels of 150-200 mg%. With
blood alcohol levels of 300-450 mg%, increasing drowsiness followed by coma and
respiratory depression develop.
Death occurs with blood alcohol levels between 400 to 800 mg% .
Occasionally a small dose of alcohol may produce acute intoxication in some persons.
This is known as pathological intoxication.
Another feature, sometimes seen in acute intoxication, is the development of amnesia
or blackouts.
15. Withdrawal Syndrome
The most common withdrawal syndrome is a hangover on the next
morning.
Mild tremors, nausea, vomiting, weakness, irritability, insomnia and anxiety
are the other common withdrawal symptoms.
Sometimes the withdrawal syndrome may be more severe, characterised
by one of the following three disturbances: delirium tremens, alcoholic
seizures and alcoholic hallucinosis.
It is important to remember that alcohol withdrawal syndrome can be
associated with marked morbidity as well as significant mortality, and it is
important to treat it correctly.
16. Delirium tremens (DT) is the most severe
alcohol withdrawal syndrome.
t occurs usually within 2-4 days of complete or significant abstinence from heavy alcohol drinking in about
5% of patients, as compared to acute tremulousness which occurs in about 34% of patients.
The course is short, with recovery occurring within 3-7 days.
This is an acute organic brain syndrome (delirium) with characteristic features of:
i. Clouding of consciousness with disorientation in time and place.
ii. Poor attention span and distractibility.
iii. Visual (and also auditory) hallucinations and illusions, which are often vivid and very frightening. Tactile
hallucinations of insects crawling over the body may occur.
iv. Marked autonomic disturbance with tachy cardia, fever, hypertension, sweating and pupillary dilatation.
v. Psychomotor agitation and ataxia.
vi. Insomnia, with a reversal of sleep-wake pattern.
vii. Dehydration with electrolyte imbalance..
DEATH
17. 2. Alcoholic seizures (‘ rum fits’)
Generalised tonic clonic seizures occur in about
10% of alcohol dependence patients, usually 12-48
hours after a heavy bout of drinking.
Often these patients have been drinking alcohol in
large amounts on a regular basis for many years.
Multiple seizures (2-6 at one time) are more
common than single seizures.
Sometimes, status epilepticus may be precipitated.
In about 30% of the cases, delirium tremens
follows.
18. 3. Alcoholic hallucinosis is characterised by the presence of
hallucinations (usually auditory) during partial or complete
abstinence, following regular alcohol intake.
It occurs in about 2% of patients. These hallucinations persist
after the withdrawal syndrome is over, and classically occur in
clear consciousness.
Usually recovery occurs within one month and the duration is
very rarely more than six months
19. Complications of Chronic Alcohol Use
I. Medical Complications
A. Gastrointestinal System
i. Fatty liver, cirrhosis of liver, hepatitis,
liver cell carcinoma, liver failure
ii. Gastritis, reflux oesophagitis,
oesophageal varices, Mallory-Weiss
syndrome, achlorhydria, peptic ulcer,
carcinoma stomach and oeso phagus
iii. Malabsorption syndrome, protein-
losing enteropathy iv. Pancreatitis: acute,
chronic, and relapsing
20. B. Central Nervous System
. Peripheral neuropathy
. Delirium tremens
. Rum fits (Alcohol withdrawal seizures)
. Alcoholic hallucinosis
. Alcoholic jealousy
. Wernicke-Korsakoff psychosis
. Alcoholic dementia
. Suicide
. Cerebellar degeneration
. Head injury and fractures.
21. Miscellaneous
i. Acne rosacea, palmar erythema,
rhinophyma, spider naevi, ascitis, parotid
enlargement
ii. Foetal alcohol syndrome (craniofacial
anomalies, growth retardation, major organ
system malformations)
iii. Alcoholic hypoglycaemia and
ketoacidosis
iv. Cardiomyopathy,
v. Alcoholic myopathy
vi. Anaemia, thrombocytopenia, Vitamin K
factor deficiency, haemolytic anaemia
22. vii. Accidental hypothermia
viii. Pseudo-Cushing’s syndrome, hypogonadism, gynaecomastia (in men),
amenorrhoea, infer tility, decreased testosterone and increa sed LH levels
ix. Risk for coronary artery disease
x. Malnutrition, pellagra
xi. Decreased immune function and proneness to infections such as
tuberculosis
xii. Sexual dysfunction
23. II. Social Complications
i. Accidents
ii. Marital disharmony
iii. Divorce
iv. Occupational problems, with loss of productive
man-hours
v. Increased incidence of drug dependence
vi. Criminality
vii. Financial difficulties
25. Detoxification is the treatment of alcohol withdrawal symptoms, i.e.
symptoms produced by the removal of the ‘toxin’ (alcohol).
The usual duration of uncomplicated withdrawal syndrome is 7-14 days.
The aim of detoxification is symptomatic management of emergent
withdrawal symptoms.
27. Vitamins should also be administered.
In patients suffering from (or likely to suffer
from) delirium tremens, peripheral
neuropathy, WernickeKorsakoff syndrome,
Thiamine (vitamin B1 ) should be
administered parenterally, twice everyday for
3-5 days.
This should be followed by oral
administration of vitamin B1 for at least 6
months
hydration
30. Group therapy
Of particular importance is the voluntary self-
help group known as AA
Group psychotherapy or group therapy is a form of psychotherapy in which one or more
therapists treat a small group of clients together as a group
31. AA ( Alcoholics Anonymous),
AA ( Alcoholics Anonymous), with branches
all over the world and a membership in
hundreds of thousands
32. Deterrent agents
Disulfiram (tetraethyl thiuram disulfide)
The usual dose of disulfiram is 250-500
mg/day
The effect begins within 12 hours of first
dose and remains for 7-10 days after the
last dose
GGT and MCV together can usually identify three out of four problem drinkers.
Death can occur in 5-10% of patients with delirium tremens and is often due to cardiovascular collapse, infection, hyperthermia or self-inflcted injury. At times, intercurrent medical illnesses such as pneumonia, fractures, liver disease or pulmonary tuberculosis may complicate the clinical picture
Before starting any treatment, it is important to follow these steps: i. Ruling out (or diagnosing) any physical disorder. ii. Ruling out (or diagnosing) any psychiatric disorder and/or co-morbid substance use disorder. iii. Assessment of motivation for treatment. iv. Assessment of social support system. v. Assessment of personality characteristics of the patient. vi. Assessment of current and past social, interpersonal and occupational functioning.
The patient should carry a warning card detailing the forbidden alcohol-containing articles, the possible effects and their emergency treatment, along with patient identification details
