Alcohol related disorders

Presenter mesay teshome (R1)

1
 Outline
• Introduction
• Epidemiology
• Comorbidities
• Effects of alcohol
• Features and diagnosis of the Disorders
• Prognosis
• Treatment

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 Introduction
• Alcohol is a potent drug that causes both acute and chronic
changes in almost all neurochemical systems
• In relation to psychiatry alcohol abuse can result in
temporary psychological symptoms such as depression,
anxiety, psychosis as well as tolerance and withdrawal
syndrome after long term heavy consumption
• Also some pre-existing psychiatric conditions like anti-social
personality disorder, bipolar disorder and schizophrenia
increase future possibility of AUDs
• In addition intoxication and withdrawal mimic many
psychiatric disorders
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 Epidemiology
• It affects more people and the associated cost much higher
than any other drug
• About 200,000 deaths each year are directly related to
alcohol abuse.
• Those who abuse alcohol are likely to die a decade or more
earlier
• common causes of death among persons with alcohol
related disorders include suicide, cancer, heart and liver
diseases
• Alcohol use is associated with about 50 percent of all
homicides and 25 percent of all suicides.

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 Cont…
• The lifetime risk for AUDs is approximately 15
percent for men and 10 percent for women
• Men to female proportion ~ 1.3 to 1
• The peak ages of onset of an AUD are from the
early 20s to 40.
• Whites more than blacks, men more than
women and appears in all socioeconomic
classes

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 Epidemiology of drinking
Condition Population (%)
Ever had a drink
90
Currently drinker
60-70
Temporary problems
40
abuse M
10+
F
5+
dependence M
10
F 3-5
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 Comorbidities
• The psychiatric conditions most commonly associated with alcohol
related disorders include antisocial personality disorder, mood and
anxiety disorders
• Its important to distinguish between temporary substance-related
psychopathology likely to disappear after abstinence versus an
independent syndrome that may require long-term medications
• As many as 80 percent of patients with AUDs report temporary
symptoms of sadness or anxiety during the course of their disorder
• These symptoms should be intense and persistent enough to meet
criteria for major psychiatric conditions, such as major depressive
episodes or panic disorder(which happens 40% of the time).

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 Cont…
Mood
• About 30 to 40 percent of persons with an alcohol-related
disorder meet the diagnostic criteria for major depressive
disorder at some point during their lifetimes
• those with heavier consumption and family history (alcohol
abuse) are at increased risk.
• This Depression tends to be more common in women and
the possibility of another substance use is higher.
• Patients with bipolar I disorder are also thought to be at
increased risk of developing alcohol related disorders which
might be related to self medication ( treating manic
episodes) 8
 Cont…
Anxiety
• Many patients take it for its efficacy in alleviating
anxiety
Suicide
• most estimate that the prevalence of suicide among
those with alcohol related disorders is around 10 -15 %
• Factors associated with higher suicide rates include
comorbid depression, unemployment, weak
psychosocial support, living alone and presence serious
medical comorbidities.
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 Absorption and metabolism
• It is a simple molecule well absorbed through the
mucosal lining if the digestive tract including the
mouth, esophagus and stomach
• Most prominent uptake occurs in the proximal small
intestine
• More rapid absorption on an empty stomach and in a
carbonated form
• Rapidly enters the bloodstream and distributed
throughout the body due to its high solubility in water

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 Cont…
• A standard drink (10-12 g) raises blood alcohol
concentration by 15-20 mg/dl, nearly the
same amount metabolized in an hour
• Peak blood concentration is reached in 30 to
90 minutes (usually in 45 to 60 minutes)
which depends on the speed of drinking and
presence of food in the stomach

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 Metabolism
• 90 percent of absorbed alcohol is metabolized through oxidation in the
liver; the remaining 10 percent is excreted unchanged by the kidneys
and lungs
• The body can metabolize about 15 mg/dL per hour (with a range of 10
to 34 mg/dL)
• It is metabolized to acetaldehyde by alcohol dehydrogenase (ADH) then
the acetaldehyde is converted to acetic acid by aldehyde
dehydrogenase (ALDH)
• Variants of these enzymes are related to higher reaction and lower
incidence of AUDs in Asian populations
• On the other end In persons with a history of excessive alcohol
consumption, up regulation of the necessary enzymes results in rapid
alcohol metabolism

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 Effects on the brain
• Alcohol is considered as a depressant (a group of
compounds that result in somnolence and decreased
neuronal activity ) along with BZDs and barbituates
• It has cross tolerance with these drugs
• It has a prominent effect on almost all neurochemical
systems
• The GABA complex is the one more prominently
affected (especially GABAA) contributing to its
sedating, sleep inducing, muscle relaxing and anti-
convulsant properties.
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 Cont…
• Affects glutamate-gated inotropic receptors(decrease their
stimulating effect during intoxication and heightened
activity during withdrawal)
• Acutely increases dopamine and its metabolites (chronic
drinking results in change the number of receptors and
sensitivity )
• Associated with results in alterations in the reward system
that runs from the VTA of the mid-brain
• Increases serotonin in synapses and upregulates serotonin
receptors ( low level of serotonin is associated with less
prominent response to alcohol)
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 Cont…
Tolerance a term used to describe the requirement of higher
doses of alcohol to produce similar effect with repeated
intake or significantly diminished effect when taking the same
amount
processes of tolerance
• Behavioral- through practice the persons learns how to
perform daily tasks while feeling the effects of alcohol
• Pharmacokinetic- adaptation of the metabolizing systems to
clear alcohol more rapidly
• Phamacodynamic -an adaptation of the nervous system so
that it can function despite high blood alcohol concentration

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 Cont…
Blackouts
• describes a situation in which there is an anterograde amnesia for the events during the
heavy drinking but the person remained awake
• results from the ability of alcohol to interfere with acquisition and solidification of
memory
• If repeated it might be a warning sign that AUD MAYBE PRESENT
Effect on sleep
• Alcohol affects sleep architecture though it may help to improve the ease of falling
asleep
• Results in awakening after few hours and difficulty reinitiating
• It decreases REM sleep and sage 4 sleep
• It is also associated with more fragmented sleep ( rapid alternation b/n sleep stages )
• More intense and frightening dreams later in the night
• These problems are more intense for those with AUDs and may take several months to
return to normal
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 Cont..
Cerebellar degeneration-
• results from combinations of effects of ethanol,
acetaldehyde, and vitamin deficiencies.
• Its Characterized by unsteady gait, inability to
stand still, and mild Nystagmus
• Treatment requires total abstinence and
vitamin supplementation, although complete
recovery is not usual

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 Cont…
Other systems
• Gastro intestinal system- esophgitis, esophageal
varicies, gastritis with gastric ulcers,
achlorohydria, pancreatic insufficiency, pancreatic
CA, problems with absorption and digestion
• Liver – fatty liver (acute), alcoholic hepatitis and
cirrhosis
• increased risk of MI and cerebro -vascular
diseases
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Drug Interactions-
• interaction between alcohol and other substances
can be dangerous
• The effects of alcohol and other central nervous
system (CNS) depressants are usually synergistic
• Because sedatives and other psychotropic drugs
can potentiate the effects of alcohol, patients
should be instructed about the dangers of
combining CNS depressants and alcohol
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 Features and diagnosis
of alcohol related disorders
Alcohol use disorder
• all substance use disorders use the same general
criteria
• The key to the diagnosis of an AUD is heavy and
repetitive use of alcohol to the point of developing
recurrent problems.
• Quantities and frequencies of alcohol intake, though
useful, are not by themselves sufficient to establish the
diagnosis because of the large variation in the amounts
of alcohol required
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 Cont…
• In the DSM-5 criteria an AUD is diagnosed as the
repeated presence of impairments in at least two
out of 11 major areas of life related to alcohol
over approximately the same 12-month period.
• The criteria are very similar to those listed for
abuse and dependence in DSM-IV, with the
exception that one DSM-IV item was dropped
(legal problems) and one new item was added
(craving).

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 Alcohol Use Disorder
Diagnostic Criteria

A. A problematic pattern of alcohol use leading to clinically significant impairment or

distress, as manifested by at least two of the following, occurring within a 12-month
period:
1. Alcohol is often taken in larger amounts or over a longer period than was intended.
2. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use.
3. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or
recover from its effects.
4. Craving, or a strong desire or urge to use alcohol.
5. Recurrent alcohol use resulting in a failure to fulfill major role obligations at work,
school, or home.
6. Continued alcohol use despite having persistent or recurrent social or interpersonal
problems caused or exacerbated by the effects of alcohol.
7. Important social, occupational, or recreational activities are given up or reduced
because of alcohol use.

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 Cont…
8. Recurrent alcohol use in situations in which it is physically hazardous.
9. Alcohol 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 alcohol.
10. Tolerance, as defined by either of the following:
• a. A need for markedly increased amounts of alcohol to achieve
intoxication or desired effect.
• b. A markedly diminished effect with continued use of the same amount
of alcohol.
11. Withdrawal, as manifested by either of the following:
• a. The characteristic withdrawal syndrome for alcohol
• b. Alcohol (or a closely related substance, such as a benzodiazepine) is
taken to relieve or avoid withdrawal symptoms.

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 Cont…
Specify if:
• In early remission: After full criteria for alcohol use disorder were previously
met, none of the criteria for alcohol use disorder have been met for at least
3 months but for less than 12 months (with the exception that Criterion A4,
“Craving, or a strong desire or urge to use alcohol,” may be met).
• In sustained remission: After full criteria for alcohol use disorder were
previously met, none of the criteria for alcohol use disorder have been met
at any time during a period of 12 months or longer (with the exception that
Criterion A4, “Craving, or a strong desire or urge to use alcohol,” may be
met).
Specify if:
• In a controlled environment: This additional specifier is used if the
individual is in an environment where access is restricted.

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 Cont…
Specify current severity:
• Mild: Presence of 2-3 symptoms.
• Moderate: Presence of 4-5 symptoms.
• Severe: Presence of 6 or more symptoms

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 Alcohol Intoxication
• Evidence of behavioral changes, a slowing in motor performance, and a
decrease in the ability to think clearly occurs at blood concentration levels
as low as 20 to 30 mg/dL,
• between 100 and 200 mg/dL problems such as impaired coordination
(ataxia), increasing lability of mood, and greater levels of cognitive
deterioration are likely.
• Anyone who does not show significant levels of impairment in motor and
mental performance at 150 mg/dL probably has significant
Phamacodynamic tolerance.
• With concentrations in the 200 to 300 mg/dL range, slurring of speech
becomes more intense, and memory impairment (alcoholic blackouts)
becomes pronounced. Further increases from this results in the first level of
anesthesia.
• the non-tolerant person who reaches 400 mg/dL or more risks respiratory
failure, coma, and death 26
 Alcohol Intoxication
Diagnostic Criteria

A. Recent ingestion of alcohol.

B. Clinically significant problematic behavioral or psychological changes (e.g.,
inappropriate sexual or aggressive behavior, mood lability, impaired
judgment) that developed during, or shortly after alcohol ingestion.
C. One (or more) of the following signs or symptoms developing during, or
shortly after, alcohol use:
• 1. Slurred speech.
• 2. Incoordination.
• 3. Unsteady gait.
• 4. Nystagmus.
• 5. Impairment in attention or memory.
• 6. Stupor or coma.
D. The signs or symptoms are not attributable to another medical condition and
are not better explained by another mental disorder, including intoxication
with another substance. 27
 Alcohol Withdrawal
• A syndrome that occurs when blood/tissue
concentration decline in an individual who had
maintained prolonged heavy use
• even without delirium, can be serious as it can
include seizures and autonomic hyperactivity.
• Conditions that may predispose to, or
aggravate, withdrawal symptoms include
fatigue, malnutrition, physical illness, and
depression.
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 Cont…
• The classic sign of alcohol withdrawal is tremulousness,
(commonly called the “shakes” or the “jitters”) although the
spectrum of symptoms can expand to psychotic and perceptual
symptoms (e.g., delusions and hallucinations), seizures, and the
symptoms of delirium tremens (DTs).
• Tremulousness develops 6 to 8 hours after the cessation of
drinking,
• the psychotic and perceptual symptoms begin in 8 to 12 hours,
• seizures in 12 to 24 hours, and
• DTs anytime during the first 72 hours, although we should watch
for the development of DTs for the first week of withdrawal.
• But The syndrome of withdrawal may sometimes skips the usual
progression and, for example, goes directly to DTs.
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 Cont…
• The tremor of alcohol withdrawal can be similar to
either physiological tremor, with a continuous tremor
of great amplitude and of more than 8 Hz, or familial
tremor, with bursts of tremor activity slower than 8 Hz.
• Other symptoms of withdrawal include general
irritability, gastrointestinal symptoms (e.g., nausea and
vomiting), and features of sympathetic hyperactivity,
including anxiety, arousal, sweating, facial flushing,
mydriasis, tachycardia, and mild hypertension.
• They are generally alert but may startle easily.

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 Withdrawal seizure
• Seizures associated with alcohol withdrawal are
stereotyped, generalized, and tonic–clonic in character.
• Patients often have more than one seizure but Status
epilepticus is relatively rare and occurs in less than 3
percent of patients.
• In alcohol abuse still other causative factors, such as
head injuries, CNS infections, CNS neoplasms, and other
cerebrovascular diseases should carefully be entertained
• long-term severe alcohol abuse can result in
hypoglycemia, hyponatremia, and hypomagnesemia—all
of which can also be associated with seizures (so that
investigations are important) 31
 Delirium
• the most severe form of the withdrawal syndrome, also known as
DTs.
• it is a medical emergency that can result in significant morbidity
and mortality.
• Because of the unpredictability of their behavior, patients with
delirium may be assaultive or suicidal or may act on hallucinations
or delusional thoughts as if they were genuine dangers.
• Untreated, DTs has a mortality rate of 20 percent, usually as a
result of an intercurrent medical illness such as pneumonia, renal
disease, hepatic insufficiency, or heart failure.
• Although withdrawal seizures commonly precede the
development of alcohol withdrawal delirium, delirium can also
appear unheralded.
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 Cont…
• In addition to the symptoms of delirium, the features of
alcohol intoxication delirium include autonomic
hyperactivity such as tachycardia, diaphoresis, fever,
anxiety, insomnia, and hypertension; perceptual
distortions, most frequently visual or tactile
hallucinations; and fluctuating levels of psychomotor
activity, ranging from hyper-excitability to lethargy.
• Episodes of DTs usually begin in a patient’s 30s or 40s
after 5 to 15 years of heavy drinking, typically of the
binge type.
• Physical illness (e.g., hepatitis or pancreatitis)
predisposes to the syndrome 33
Clinical institute withdrawal assesment scale (CIWASR)

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 Cont…
• The DSM-5 criteria for alcohol withdrawal
require the cessation or reduction of alcohol
use that was heavy and prolonged as well as
the presence of specific physical or
neuropsychiatric symptoms. The diagnosis
also allows for the specification “with
perceptual disturbances”.

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 Alcohol Withdrawal
Diagnostic Criteria
A. 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 the cessation
of (or reduction in) alcohol use described in Criterion A:
• 1. Autonomic hyperactivity (e.g., sweating or pulse rate greater than 100 bpm).
• 2. Increased hand tremor.
• 3. Insomnia.
• 4. Nausea or vomiting.
• 5. Transient visual, tactile, or auditory hallucinations or illusions.
• 6. Psychomotor agitation.
• 7. Anxiety.
• 8. Generalized tonic-clonic seizures.
C. The signs or symptoms in Criterion B cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
D. The signs or symptoms are not attributable to another medical condition and are not better
explained by another mental disorder, including intoxication or withdrawal from another
substance.
Specify if:
• With perceptual disturbances: hallucinations or illusions(in the absence of a delirium.) 36
 Prognosis of alcohol related Ds
• Accurately predicting whether any specific person will achieve
or maintain abstinence is impossible
• As most medical and psychiatric conditions early onset is
likely to be associated with greater severity.
• if an AUD begins in the mid-teens, it is often associated with
conduct disorder, concomitant drug difficulties, and antisocial
behaviors that are likely to precede the alcohol problems.
• At the other extreme, an onset after age 40 tends to be
associated with less severe social difficulties and more subtle
AUD signs and symptoms, but a greater likelihood of medical
problems.

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 Cont…
Favorable prognostic signs include.
 absence of preexisting antisocial personality disorder or a
diagnosis of other substance abuse or dependence.
 evidence of general life stability with a job, continuing close
family contacts, and the absence of severe legal problems
 Being able to stay for the full course of the initial rehabilitation
(possibly 2 to 4 weeks) b/c the chances of maintaining
abstinence are good.
• The combination of these three attributes predicts at least a 60
% chance for 1 or more years of abstinence.
• researchers agree that 1 year of abstinence is associated with a
good chance for continued abstinence over an extended period.
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 Cont…
• Many other factors that are intangible and difficult
to measure affect the clinical course significantly;
such factors include motivational level and the
quality of the patient’s social support system.
• For those with a preexisting psychiatric disorder,
the goal is to minimize the symptoms of the
independent psychiatric disorder in the hope that
greater life stability will be associated with a better
prognosis for the patient’s alcohol problems.

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 Treatment
Three general steps are involved in treating the
alcoholic person after the disorder has been
diagnosed:
• Intervention
• Detoxification
• Rehabilitation

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 Intervention
• Also called confrontation is designed to break through
feelings of denial and help the patient recognize the
adverse consequences likely to occur if the disorder is
not treated. Its aimed at maximizing motivation.
• It involves convincing patients that they are
responsible for their own actions while reminding
them of how alcohol has created problems.
• we can take advantage of the presenting compliant to
convince the patient how alcohol created problems
and how abstinence can improve them.
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 Cont…
• Better to use the same nonjudgmental but
persistent approach each time an alcohol-
related impairment is identified.
• It is the persistence rather than exceptional
interpersonal skills that usually gets results.
• A single intervention is rarely sufficient. Most
alcoholic persons need repeated reminders of
how alcohol contributed to each crisis.

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 Cont…
• The family can be of great help in the
intervention.
• Family members must learn not to protect the
patient from the problems caused by alcohol;
otherwise, the patient may not be able to
gather the energy and the motivation
necessary to stop drinking.

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 Detoxification
• Most persons with alcohol dependence have
relatively mild symptoms when they stop
drinking.
• Especially If the patient is in relatively good
health, is adequately nourished and has a good
social support system.
• The essential first step in detoxification is a
thorough physical examination AND
investigation.
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 Detoxification
Supportive measures
• Treating in quiet and protective environment
• Skillful verbal support
• IV fluids (if needed)
• Nutritional support (high calorie diet)
• Multivitamin preparations with folate, potassium
and magnesium
• Thiamine
• Frequent clinical assessment
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 Cont….

Mild-moderate withdrawal
• Giving sufficient brain depressant on the first day
to diminish symptoms and then weaning the
patient off the drug over the next 5 days offers
most patients optimal relief and minimizes the
possibility that severe withdrawal will develop.
• Benzodiazepines are used due to their relative
safety

46
 Cont…
Severe withdrawal
• occurs in 1 percent of alcoholic patients no optimal
treatment yet.
• Characterized by extreme autonomic dysfunction,
agitation, and confusion ( alcoholic withdrawal delirium)
• The first step is to ask why such a severe and relatively
uncommon withdrawal syndrome has occurred;
• the answer often relates to a severe concomitant
medical problem that needs immediate treatment.

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 Cont…
• Then withdrawal symptoms can be minimized
through the use of either benzodiazepines (in
which case high doses are sometimes required)
or antipsychotic agents, such as haloperidol
(only if needed).
• Antipsychotics like haloperidol should be used
for short term
• Once patient is calm and light somnolence is
achieved one can shift to fixed dose regimen
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 Fixed dose regimen for diazepam
Diazepam
• Day 1…….. (first 24 hours) 10mg (qid):- 10 mg + 10mg + 10mg + 10mg (+
use 10 mg prn)
• Day 2 ……..10 mg + 10mg + 10mg + 10mg
• Day 3 ……..10 mg + 10mg + 5mg + 10mg
• Day 4……...10 mg + 10mg + 0 + 10mg
• Day 5…….. 10 mg + 5mg + 0 + 10mg
• Day 6…….. 10 mg + 0 + 0 + 10mg
• Day 7…….. 5 mg + 0 + 0 + 10mg
• Day 8 ……..10 mg noct
• Day 9……...5 mg noct
• Day 10…….5 mg noct 10

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 Rehabilitation
• For most patients, rehabilitation includes
three major components:
(1) continued efforts to increase and maintain
high levels of motivation for abstinence;
(2) help the patient readjust to a lifestyle free of
alcohol; and
(3) relapse prevention.

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 Cont…
• Because these steps are carried out in the
context of acute and protracted withdrawal
syndromes and life crises, treatment requires
repeated presentations of similar materials
that remind the patient how important
abstinence is
• and also important to help the patient develop
new day-today support systems and coping
styles.
51
 Cont…
• The same general treatment approach is used in
inpatient and outpatient settings.
• Selection of the more expensive and intensive
inpatient treatment often depends on evidence of
 additional severe medical or psychiatric syndromes
 the absence of appropriate nearby outpatient
groups and facilities,
 and the patient’s history of having failed in
outpatient care.
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 Counseling
• Counseling efforts in the first several months
should focus on day-today life issues to help
patients maintain a high level of motivation
and enhance functioning.
• Psychotherapy techniques that provoke
anxiety or that require deep insights have not
been shown to be of benefit during the early
months of recovery( theoretically may actually
impair)
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 Cont..
• Counseling or therapy can be carried out in an individual or group
setting( few data indicate that either approach is superior.)
• The technique used is not likely to matter greatly and usually boils
down to simple day-to-day counseling or almost any behavioral or
psychotherapeutic approach focusing on the here and now.
• counseling is usually offered a minimum of three times a week for
the first 2 to 4 weeks, followed by less intense efforts, possibly once
a week, for the subsequent 3 to 6 months
• Discussions cover the need for a sober peer group, a plan for social
and recreational events without drinking, and approaches for
reestablishing communication with family members and friends

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 Cont..
About relapse prevention
• first identify situations in which the risk for relapse is high.
• help the patient develop modes of coping to be used when
the craving for alcohol increases or when any event or
emotional state makes a return to drinking likely.
• remind the patient about the appropriate attitude toward
slips. Short-term experiences with alcohol can never be used
as an excuse for returning to regular drinking.
• Rather Patients can use slips that occur to identify high-risk
situations and to develop more appropriate coping
techniques.
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 Pharmacotherapy for promotion of relapse
prevention
Drugs used include
• Naltrexone
• Acamprosate
• Dysulfam

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 References
• Kaplan and Sadock’s Comprehensive Textbook
of Psychiatry
• Practical clinical treatment guideline St paul
• Maudsley prescribing guideline

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