1. Alcohol misuse and dependence Dr. Mohamed Shekhani

2. Introduction: Alcohol consumption associated with social, psychological& physical problems constitutes harmful use. Approximately one-quarter of male patients in general hospital medical wards in the UK have a current or previous alcohol problem.

3. Aetiology Availability of alcohol social patterns of use appear to be the most important factors. Genetic factors may play some part in predisposition to dependence. The majority of alcoholics do not have an associated psy- chiatric illness, but a few drink heavily in an attempt to relieve anxiety or depression

4. Diagnosis Alcohol misuse may emerge during the patient’s history, although patients may minimise their intake. It may also present via its effects on one or more aspects of the patient’s life. Alcohol dependence commonly presents with withdrawal in those admitted to hospital, as they can no longer maintain their high alcohol intake.

5. Diagnosis

6. Complications of chronic alcohol misuse Social problems: Absence from work Unemployment Marital tensions Child abuse Financial difficulties Problems with the law, such as violence & traffic offences.

7. Complications of chronic alcohol misuse Psychological problems 1.Depression is common: Alcohol has a direct depressant effect& heavy drinking creates numerous social problems. Attempted &completed suicide are often associated with alcohol misuse. 2. Anxiety is relieved by alcohol. People socially anxious may use alcohol & develop dependence& alcohol withdrawal incr anxiety. 3. Alcoholic hallucinosis is a rare condition in which alcoholic individuals experience auditory hallucination in clear consciousness. Alcohol withdrawal Symptoms usually become maximal about 2 days after the last drink and can include seizures (‘rum fits’). 4.Delirium tremens: delirium associated with severe alcohol withdrawal. With significant mortality and morbidity

8. Brain effects: 1.The familiar features of drunkenness are ataxia, slurred speech, emotional incontinence, aggression. 2. ‘alcoholic blackouts’: Very heavy drinkers may experience periods of amnesia for events during bouts of intoxication. 3.Alcoholic dementia : from Established alcoholism with global cognitive impairment resembling Alzheimer’s disease, but which does not progress&may even improve on abstinent. 4.Indirect effects on behaviour can result from head injury, hypoglycaemia& encephalopathy.

9. Brain effects: 5.Wernicke–Korsakoff syndrome, A rare but important effect of chronic alcohol misuse; an organic brain disorder results from damage to the mamillary bodies, dorsomedial nuclei of the thalamus&adjacent areas of periventricular grey matter. It is caused by a deficiency of thiamin (vitamin B1), which is most commonly caused by long-standing heavy drinking& an inadequate diet. Without prompt treatment, the acute presentation of Wernicke’s encephalopathy (nystagmus, ophthalmoplegia, ataxia, confusion) can progress to the irreversible deficits of Korsakoff’s syndrome (severe short-term memory deficits& confabulation). In those who die in the acute stage, microscopic examination of the brain shows hyperaemia, petechial haemorrhages&astrocytic proliferation

10. Other effects: These are protean & virtually any organ can be involved; alcohol has replaced syphilis as the great neurological mimic.

13. Management : advice Clear information from a doctor about the harmful effects of alcohol & safe levels of consumption is often all that is needed. In more serious cases, patients may have to be advised to alter leisure activities or change jobs if these are contributing to the problem.

14. Management:Psychological Psychological treatment is used for patients who have recurrent relapses &usually available at specialised centres. Support is also provided by voluntary organisations, such as Alcoholics Anonymous (AA) in the UK. If alcohol dependence is suspected, withdrawal syndromes can be prevented, or treated once established, with benzodiazepines. Large doses may be required (e.g. diazepam 20 mg 6-hourly), tailed off over a period of 5–7 days as symptoms subside.

15. Management:WKC Prevention of the Wernicke–Korsakoff complex requires the immediate use of high doses of thiamin( parenteral Pabrinex) There is no treatment for Korsakoff’s syndrome once it has arisen. The risk of side-effects, such as respiratory depression with benzodiazepines& anaphylaxis with Pabrinex, is small when weighed against the risks of no treatment.

16. Management:drugs Disulfiram (200–400 mg daily) can be given as a deterrent to patients who have difficulty resisting the impulse to drink after becoming abstinent. It blocks the metabolism of alcohol, causing acetaldehyde to accumulat when alcohol is consumed, an unpleasant reaction follows with headache, flushing and nausea. Disulfiram is always adjunct to other, esp supportive psychotherapy Acamprosate (666 mg 8-hourly) has recently been introduced to maintain abstinence by reducing the craving for alcohol. Only rarely are antidepressants required; depressive symptoms, if present, usually resolve with abstinence. Antipsychotics (e.g. chlorpromazine 100 mg 8-hourly) are required for alcoholic hallucinosis.

17. prognosis Many but not all who become dependent on alcohol relapse after treatment. Chronic alcohol misuse greatly increases the risk of death from accidents, disease & suicide.

18. Single choice Qs: 1. Psychiatric complications of chronic alcohol abuse include all except: A.Depresion. B.Anxiety. C.Bipolar disease. D.Hallucinations. E. Delirium.

19. Single choice Qs: 2. Now the great neurological mimic is: A. Syphilis. B.Alcoholism. C. MS. D. B12 deficiency. E.TB.

20. Single choice Qs: 3. Regarding chronic alcoholism brain effects, all are reversible by abstinence except: A. Korsakof syndrome. B.Acute Korsakof encephalopathy. C. Alcohol dementia. D. Cerebellar ataxia. E. Alcoholic blackouts.

21. Single choice Qs: 14. The following help alcoholics by reducing craving to alcohol: A.Disulpharam. B. Accomprosate. C. Vitamin B1. D. Benzodiazepines. E.Antibiotics.