Alcohol dependence is known as psychiatric diagnosis in which an individual is dependent upon drinking alcohol both physically or psychologically.Two kinds of abnormal drinking are frequently described: “addictive” and “non-addictive.” The non-addictive alcoholic retains the ability to stop whenever he desires; high grades of tolerance and severe abstinence syndromes are unusual. In contrast, the’ addictive drinker continues until stopped by poverty, nausea, or illness, and develops high grades of tolerance, serious physical dependence, and severe organic complications.
Pathogenesis.
The metabolism of alcohol is similar in periodic and chronic drinkers. Cellular tolerance develops in chronic drinkers so that only mild or moderate intoxication accompanies blood levels that initially were associated with stupor. Chronic alcoholics also become able to compensate for, or to conceal, the signs of drunkenness.
Protracted heavy drinking causes physical dependence manifested by tremors, convulsions, hallucinations, and delirium when the intake of alcohol is abruptly decreased or stopped. Abstinence symptoms depend more on a decline in blood alcohol than on absolute cessation of the drinking. This being the case, a chronic drinker who ordinarily ingests 600 ml. of alcohol (1200 ml. of whiskey) daily may develop abstinence symptoms if he reduces his intake to 480 ml. of alcohol (equivalent to a quart of whiskey) daily. Alcohol abstinence syndromes are not due to nutritional deficiencies or to liver damage. Like other abstinence syndromes, the symptoms are opposite to the acute effects of alcohol. Partial cross-tolerance and dose dependence occur between alcohol and the drugs listed in class I-B.
Clinical Manifestations of Alcoholism.
The incipient alcoholic simply drinks more than his peers. The wine drinker is no longer content with a glass at meals but drinks an entire bottle. Such drinking may persist for years, but gradually the pattern becomes exaggerated. The alcoholic continues to drink after the party is over and to the point of stupor. The wine drinker sips between and before meals and drifts into a constant alcoholic haze. Some go on binges of two or three days’ duration; others begin to drink alone at night. Eventually, the alcoholic’s family and associates realize the problem. Generally, their remonstrances and advice are rejected. Drinking becomes daily rather than periodic. The person is “hung over” each morning and begins to drink to alleviate the hangover, presaging the development of addiction.. Personality deterioration sets in.
The alcoholic becomes resentful of advice, blames hit drinking on others, is forgetful, unreliable, and quarrelsome. He loses his job, his social position, and his family. He becomes obsessed with obtaining and maintaining his supply, hiding bottles in various places against the time when he needs them. At this stage many patients experience alcoholic amnesia, remembering nothing after one or two drinks, awakening hours or days later in an unfamiliar place (“blackouts”). Many turn to poorer forms of alcohol: cheap wine, hair tonic, or lotions. At this stage, the alcoholic is likely to reinforce or replace alcohol, thereafter oscillating between alcohol and drugs. Finally, the alcoholic develops coma, pneumonia, or cirrhosis, and dies.
The progressive course just described varies greatly and may be arrested at any stage. Many alcoholics are unhappy, would prefer not to drink, and some succeed in stopping.The objective signs of excessive protracted drinking include obesity, flabbiness, dilatation of peripheral blood vessels around the nose and eyes, reddened conjunctivae, tremors, evidence of hepatic dysfunction or nutritional deficiency, and poor personal hygiene.
Abstinence Of Alcohol Dependence Syndrome.
A number of tremulous, agitated, hallucinated, convulsive, and delirious states occur after cessation of drinking or after reduction in alcohol intake, and have been described as distinct clinical entities. All these states, however, are merely quantitative and qualitative variants of the same underlying disorder. The alcoholic abstinence syndromes vary in intensity in proportion to the amount and duration of excessive drinking. They occur in lesser degrees after debauches of a week or two. The more severe forms follow heavy drinking of 400 to 600 ml. of alcohol daily for a month or more.
Alcoholic Tremulousness.
After the alcoholic first sobers up, he is alert, startles easily, and has difficulty in sleeping, anorexia, weakness, tachycardia, and tremulousness. The tremors vary from the barely perceptible to so strong that the patient cannot stand. The tremulous state may be the only overt abstinence manifestation, and may clear in a few days without treatment.
Alcoholic Hallucinosis.
The next stage is alcoholic hallucinosis, in which the patient experiences “nightmares,” misinterprets sounds or shadows, and has disturbances in perception of form and color. Most frequently the hallucinations are visual and animate and involve humans, insects, or animal life. Alcoholic hallucinosis is distinguished from delirium tremens by the fact that the patient is not markedly agitated, is not disoriented, and realizes that his experiences are unreal. The condition usually clears in a few days.
Acute Auditory Hallucinosis.
Acute auditory hallucinosis usually includes accusing voices, but without confusion or disorientation. However, insight is lost, and the patient generally reacts inappropriately. For example, he may notify the police, barricade himself, or commit suicide. Recovery usually occurs in days. A small proportion of such patients develop a chronic auditory hallucinosis in which the voices persist for months or years. Such cases may represent the triggering of a schizophrenic psychosis by alcohol or abstinence from it.
Delirium Tremens.
Delirium tremens is the most dramatic and dangerous form of reaction to abstinence from alcohol. It is characterized by agitation, increased autonomic activity, disorientation. confusion, and disordered sensory perception. Delirium tremens is frequently precipitated by a head injury, an infection, or a surgical operation. The condition begins about the third or fourth night after withdrawal, frequently following a seizure. Rarely, a quiet delirium is encountered, but usually the patient is agitated, constantly in motion, muttering, picking at the bedclothes, screaming, or wandering about the halls. He misidentified people and objects and does not know the date. He suffers with vivid and frightening visual hallucinations, frequently of animals or insects. He is drenched with sweat, and has tachycardia and fever. The symptoms are worse at night.
Delirium tremens frequently terminates after three to five days with a sudden sleep from which the patient awakens clear and lucid and with only partial memory of the episode. There is a 20 per cent mortality in cases complicated by infection, head injury, or other serious disease. Steadily rising temperature without infection is ominous.
Diagnosis.
The diagnosis of the alcoholic abstinence syndrome is based on signs, symptoms, and history. The chief conditions to be excluded are abstinence from hypnotics or convulsions and delirium due to other causes. The differential diagnosis between impending hepatic coma and delirium tremens may be difficult, but it is important since hypnotic drugs are contraindicated in hepatic coma. Advanced liver disease, gastrointestinal bleeding, lack of agitation, lack of vivid hallucinations, and the presence of asterisks all favor hepatic coma rather than delirium tremens.
Alcohol dependence Treatment Guidelines.
If the patient is a nonaddictive periodic drinker who has been drinking for less than a week, withdrawal treatment is usually unnecessary. If the patient is an addict who has been consuming a quart of whiskey or more daily for more than a week, withdrawal treatment in an institution is required.
The principles used in withdrawing alcohol are the same as those used in withdrawing hypnotics (see above). If possible, severe symptoms of abstinence should be avoided. Alcohol itself is unsatisfactory for conducting withdrawal because of its small margin of safety and because of its toxic effects on fat metabolism. Alcohol is stopped and one of the hypnotics listed in class I-B is substituted in sufficient dose to cause mild drunkenness, after which the dosage of the hypnotic is reduced over a period of days.
Paraldehyde is a classic drug for this purpose but has the disadvantage of unpleasant odor, gastric irritation, and unsuitability for injection.Pentobarbital is a very effective and flexible drug and can be used in withdrawing alcohol in exactly the same way as it is used in withdrawing hypnotics.
The steps are
- (1) stop the intake of alcohol;
- (2) after the patient is sober, give a test dose of 0.2 gram of pentobarbital;
- (3) examine the patient one and a half hours later; if he shows no evidence of abstinence, has slow inconstant nystagmus, and sways .slightly, the dose is right and may be repeated in six hours;
- (4) establish by titration the amount of pentobarbital required daily —”stabilization dose” -to maintain the desired degree of effect;
- (5) maintain this dosage for one to two days while completing necessary examinations and beginning treatment of other complicating conditions; and
- (6) reduce the daily stabilization dosage by no more than 0.1 gram daily. If the patient cannot or will not take the drug orally, treatment may be initiated intramuscular.
If serious symptoms of abstinence – convulsions, hallucinosis, or delirium —are present, the patient should be re intoxicated rapidly, using an initial dose of 0.2 gram of pentobarbital intramuscularly followed by reinforcing doses of 0.1 gram intramuscularly hourly until the patient is asleep. After he has slept for 8 to 12 hours, he is allowed to awaken, the stabilization dose is determined, and gradual withdrawal is performed as described above. Complicating medical or surgical conditions—gastritis, pneumonia, head injuries —are frequently the precipitating causes of stopping alcohol intake, and must be treated appropriately.
Physical And Drawal of Alcohol.
The physician must adopt a neutral attitude about the patient’s drinking; he should neither condemn nor condone it. The patient must be told firmly, however, that he reacts differently to alcohol than do other people, that he can never drink socially, and that if he wishes to be cured, absolute, and total abstinence is necessary. The patient must realize that he has a problem that he cannot manage alone, that he needs help, and that he must cooperate and contribute to his own treatment. If this hurdle is surmounted, psychotherapy, either individual or group, is carried out along customary lines. The patient should, if willing, be put in touch with Alcoholics Anonymous. It is generally best to avoid dependence-producing central nervous system depressants following completion of withdrawal. If drugs are used at all, hydroxyzine and chlorpromazine are best, for they do not cause dependence.
Disulfiram
(Antabuse) and citrated calcium carbide block the oxidation of alcohol at, the acetaldehyde stage so that a person who takes alcohol while ingesting these drugs will have nausea, vomiting, vasodilatation, and even
cardiovascular collapse because of accumulation of acetaldehyde. These drugs are effective only as long as the patient continues to take them. Since they have not been especially successful, and the alcohol-disulfiram reaction can be severe or fatal, these drugs are used very little in the United States.
Prognosis.
Perhaps 15 to 20 per cent of patients manage to abstain permanently. Others abstain for months or years, only to relapse during a period of stress. However, many patients have long intervals of productive and apparently fulfilling lives between relapses of this naturally chronic illness.
