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Alcohol Free Forever

This powerful guide walks you step-by-step through exactly what you need to do to free yourself from your alcohol addiction without going through AA meetings or expensive sessions. There are three main types of relaxation techniques you can practice when you feel upset and stressed. If you practice regularly, they will become part of your lifestyle and you may find yourself habitually more relaxed as a result. Part 2 will exercise Neuro Linguistic Programming to release thoughts and a technique of progressive muscle relaxation also negative situations. Because of the mind body connection, exercises to relax the body will also flow through the mind. Much of the stress we feel is because of our resistance to certain feelings or emotions. Alcohol Free Forever is a lifesaver ebook. This guide was extremely eye-opening and the daily emails make it extremely easy to quit and to establish a routine that did not involve alcohol. Read more...

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The alcohol dependence syndrome Clinical description

In 1976, Edwards and Gross proposed the existence of alcohol dependence within a syndrome model.(3) Their description was based on the clinical observation that certain heavy drinkers manifested an interrelated clustering of signs and symptoms. They hypothesized that dependence was not an all-or-nothing phenomenon but existed in degrees of severity. The elements of the syndrome, as originally formulated, are summarized in TableJ. Not all the elements need always be present, nor always present with the same intensity. Edwards and Gross(3) also acknowledged the fact that not everyone who drinks too much is necessarily dependent on alcohol. They hypothesized that alcohol dependence should be conceptually distinguished from alcohol-related problems. Table 1 Key elements of the alcohol dependence syndrome By drawing a clear distinction between the alcohol dependence syndrome and alcohol-related disabilities, Edwards and Gross introduced the concept of a biaxial model. This was described...

Establishment of the validity of the alcohol dependence syndrome

Since 1976, the alcohol dependence syndrome has assumed a position of increasing importance and has stimulated considerable research. Studies have focused on the degree to which the elements of the syndrome co-occur. (1, ,, , , Z,,18 and 9 Other areas of research have included construct validity, (29 concurrent validity 1, ,2122) and predictive validity.(2 24) Field trials conducted as background to the preparation of ICD-10, DSM-IIIR, and DSM-IV, have all contributed to the body of research evidence 6,2.5,,2.6,2 2 and 29) Difficulties have been encountered in operationalizing elements such as narrowing of repertoire, subjective change, and reinstatement. (29)

Influence of the alcohol dependence syndrome on later formulations of dependence ICD9

The concept of the alcohol dependence syndrome presented a significant challenge to researchers and clinicians, requiring them to re-think many fundamental concepts and definitions. In ICD-9 the term 'alcoholism' was dropped in favour of the 'alcohol dependence syndrome'. (39 It was, however, still classified under the category 'Other non-psychotic mental disorders'. The ICD-9 definition of alcohol dependence may have been somewhat premature, because the theoretical process was still evolving at that time.(2)

Nonaddictive alcohol use disorders Alcohol abuse

The term 'alcohol abuse' appeared infrequently in the American literature before 1970, when the United States National Institute on Alcohol Abuse and Alcoholism was formed. It was adopted as a formal diagnostic category by DSM-III,(31.) which defined abuse as a behavioural concept 'A pattern of pathological use for at least a month that causes impairment in social or occupational functioning'. Although enshrined in DSM-IIIR and DSM-IV, the term 'abuse' has been variously regarded as 'unscientific and pejorative'(34) and 'oppobrious' and 'vindictive'.(35)

Alcohol Dependence Sleep and Immunity

Diagnostic criteria for alcohol dependence include at least three of seven patterns of substance use causing significant impairment over a 12-month period. Criteria can include tolerance to alcohol, presence of withdrawal symptoms, intake of larger amounts than intended, persistent desire to drink, much time spent in activities related to drinking, abandonment of occupational, social or recreational activities because of alcohol use, and continued intake despite recurrent problems related to drinking (American Psychiatric Association and American Psychiatric Association, Task Force on DSM-IV 1994). When immune parameters are examined more specifically in alcohol dependence, studies show that these patients have decreases in NK activity, interleukin-2 (IL-2) stimulated killer cell activity (LAK activity), and ex vivo production of IL-6 (Irwin and Miller 2000). There is also a shift in cytokine In contrast, in vitro production assays, in which whole blood is stimulated with an antigen...

Treatment for Alcoholism

The immediate concern in the treatment of alcoholics is detoxification and management of the ethanol withdrawal syndrome. Once the patient is detoxified, long-term treatment requires complete abstinence, psychiatric treatment, family involvement, and frequently support from lay organizations such as Alcoholics Anonymous.

Methods For Induction Of Alcohol Dependence And For Monitoring Withdrawal Seizures

As in humans, an alcohol withdrawal syndrome that includes generalized tonic-clonic seizures has been observed in the mouse, rat, cat, dog, monkey, and chimpanzee (Ellis and Pick, 1970 Essig et al., 1969 Freund, 1969 Guerrero-Figueroa et al., 1970 Majchrowicz, 1975 Pieper et al., 1972). In all species, the signs of alcohol withdrawal last for 1 to 3 days, after which behavior returns to normal and there is no enhanced seizure susceptibility. Rodents are the most common species used in laboratory studies of alcohol withdrawal seizures. Here we describe methods for the induction of alcohol dependence and for inducing and scoring withdrawal seizures in the rodent species that are most frequently used in laboratory experiments. The intragastric intubation method was originally developed in studies with rats and is mainly applied in this species. In contrast, inhalation methods are most commonly used in mice. The liquid diet procedure is applied in both mice and rats. The experimental...

Singleneuron Firing During Cellular Electrophysiology Of Alcohol Withdrawal Seizures

During alcohol withdrawal-related AGS, the cortical electroencephalogram typically shows no sign of paroxysmal activity compatible with the idea that the seizures are mediated largely in the brainstem (Hunter et al., 1973 Maxson and Sze, 1976). Nevertheless, epileptiform activity has been observed in the hippocampus, but with a significant delay after the onset of AGS, suggesting a role in the propagation rather than in the initial generation of the seizures (Hunter et al., 1973). Acute alcohol intoxication suppresses spontaneously and acoustically evoked neuronal firing in the IC central nucleus, whereas alcohol withdrawal is accompanied by significant increases of these responses (Faingold and Riaz, 1995). Electrophysiologic studies have revealed that, at the transition to seizure, the IC central nucleus exhibits sustained increases in firing that persist during wild running, the initial phase of AGS (Chakravarty and Faingold, 1998). It has therefore been suggested that the IC...

QTLs for Alcohol Withdrawal

The goal of any QTL mapping project is to progress from locus to gene. Two clear examples of such progress are now available for alcohol traits. The first is an ongoing project in the laboratory of Kari Buck. In collaboration with John Belknap, Buck is pursuing several QTLs that harbor genes influencing the severity of acute withdrawal from alcohol. When 4 g kg ethanol is administered intraperitoneally to a mouse, it is sedated for 2-3 h. However, between 3 and 24 h after injection, an acute withdrawal reaction can be seen, where mice display handling-induced convulsions (HICs) that wax and then wane, peaking at about 7 h after injection (30). This reaction, first noted in the early 1970s (31), indicates a state of modest physical dependence on alcohol. The reaction becomes more pronounced when alcohol is administered chronically. Goldstein demonstrated through a short breeding project that the severity of alcohol withdrawal from vapor inhalation was heritable (32), which we later...

Effectiveness of Physician Counseling Alcohol Abuse

There is a reasonable amount of evidence that physician counseling can decrease drinking in patients who abuse alcohol. At least three randomized trials have been conducted, all showing that counseling led to a decreased amount of drinking.74-76 In one such study, providers were trained to provide a brief (5 to 10 minutes) counseling intervention, and an office support system was used that screened patients and cued providers to intervene, in addition to making patient education materials available.76 The intervention led to a decrease of 5.8 drinks per week compared with a usual care condition.76,77 Two other large studies showed decreases in the range of 10 drinks per week in the intervention condition, compared to the control condition.74,75 Although not all studies have shown positive effects,78 two meta-analyses have shown that brief interventions, typically conducted by physicians, are effective at decreasing alcohol intake among heavy drinkers in outpatient settings.79,80

Recommendations of Professional Groups Alcohol Abuse

Recommendations for alcohol use differ in several ways between organizations, mainly based on the group toward which the recommendations are targeted. No safe level of alcohol intake has been identified, as the epidemiologic studies typically compared high versus low intake, rather than examining a possible threshold effect.27 Given the data supporting the cardiac benefits of moderate alcohol and the effects of alcohol on blood pressure, the American Heart Association recommends a limit of one drink per day for women and a limit of two drinks per day for men.99 The American Cancer Society is less specific, noting only if you drink alcoholic beverages, limit consumption. 96

Neurobiological and Molecular Bases of Alcohol Craving and Relapse 21 General Considerations

The neurobiological and molecular bases of alcohol craving and relapse are still not well understood however, preclinical as well as clinical data strongly imply that craving and relapse for alcohol (and other drugs of abuse) can be induced through different mechanisms (34). A first pathway may induce alcohol craving and relapse due to the mood-enhancing, positive reinforcing effects of alcohol consumption (35). This pathway seems to involve opioidergic and dopaminergic systems in the ventral striatum (36,37). The role of the dopaminergic system may lie in the direction of attention toward reward-indicating stimuli (38), whereas the induction of euphoria and positive mood states may be mediated by opioidergic systems (36). Associative learning may, in turn, transform positive mood states and previously neutral environmental stimuli into alcohol-associated cues that acquire positive motivational salience and induce reward craving (26). A second and potentially independent pathway may...

Efficacy of Risk Reduction Alcohol Abuse

Nearly one-third of U.S. adults drink an excessive amount of alcohol.26 Excessive alcohol use appears to be associated with cancers of the breast, oropharynx, pharynx, esophagus, and liver.27-31 Little evidence exists examining the effect on changes in alcohol consumption on the risk of breast or other cancers. Two studies from Italy observed that, although stopping smoking decreased the risk of laryngeal cancer within only a few years, stopping drinking led to a much smaller decline in laryngeal and esophageal cancer risk after more than a decade.32'33

Testing Pharmacological Agents In Animal Models Of Alcohol Withdrawal Seizures

Because alcohol withdrawal-related AGS and HIC can be elicited at the will of the experimenter during a defined period after cessation of alcohol intake, the anticonvulsant properties of pharmacologic agents can be easily studied (unlike the situation with spontaneous seizure models, where seizures occur unpredictably, requiring sophisticated monitoring systems and less robust trial designs). A limitation of these models is that AGS or HIC do not occur in every animal. However, the incidence (and severity) of AGS can be increased with intermittent ethanol administration (C.L. Faingold, personal communication). The peak incidence of AGS occurs at about 24 hours following alcohol withdrawal. Thus pharmacologic agents are typically tested between hour 20 and 28 following alcohol withdrawal, which encompasses a period of high seizure likelihood. Pharmacologic substances are typically administered 30 to 60 minutes before the time at which the AGS is elicited, but the choice of interval for...

Benzodiazepine dependence and alcohol dependence the overlap

There are high reported rates of alcohol dependence among the homeless, and there are substantial reports of benzodiazepine abuse and dependence in this population also. Cross-tolerance between benzodiazepines and alcohol permits individuals who are alcohol dependent to tolerate high doses of benzodiazepines. Patients may be prescribed benzodiazepines to manage alcohol withdrawal, but injudicious prescribing that is not targeted towards the management of alcohol withdrawal symptoms may result in iatrogenic benzodiazepine dependence. The extensive research on pharmacological interventions for management of alcohol withdrawal in alcohol-dependent patients has been examined in a meta-analysis by Mayo-Smith, who subsequently produced a systematic review with treatment guidelines. (17) This review supports the use of benzodiazepines as the treatment of choice for managing withdrawal symptoms for patients whose symptoms are of sufficient severity to warrant medication. Alternative agents...

Relevance Of Alcohol Withdrawal Seizures In Rodents To The Human Condition

Although alcohol withdrawal seizures in rodents do not represent a perfect model of human alcohol withdrawal seizures, the available evidence indicates that the animal models are valid in many respects. As noted, most alcohol withdrawal seizures in humans are generalized tonic-clonic seizures. Similarly, the various forms of alcohol withdrawal seizures in rodents represent generalized convulsions. In both humans and rodents, the peak incidence of alcohol withdrawal related generalized seizures occurs between 20 to 24 hours following cessation of alcohol intake. In addition to exhibiting shared behavioral features, the brain systems underlying alcohol withdrawal seizures in humans and rodents are likely to be similar across species. There is no cortical paroxysmal activity in the electroencephalogram during auditory-evoked tonic-clonic alcohol withdrawal seizures in rodents (Hunter et al., 1973 Maxson and Sze, 1976). Epileptiform activity is also rare in the electroencephalogram...

Neuropathological Effects Of Alcohol Withdrawal

In humans, alcohol withdrawal seizures have been associated with ventricular and sulcal enlargement as well as significantly smaller volume of temporal lobe white matter and hippocampal sclerosis (Essardas-Daryanani et al., 1994). In animal models, there is evidence that alcohol intoxication can lead to selective damage to specific brain regions, including the hippocampus (Ikonomidou et al., 2000 Walker et al., 1980). Withdrawal from long-term alcohol consumption can aggravate alcohol-induced neurodegeneration. Indeed alcohol withdrawal is associated with augmented loss of CA1 and CA3 pyramidal neurons, mossy fiber-CA3 synapses, and dentate gyrus granule cells (Cadete-Leite et al., 1989 Paula-Barbosa et al., 1993 Scorza et al., 2003). The mechanisms underlying alcohol withdrawal-induced neurodegeneration are not completely understood. However, alcohol withdrawal, but not alcohol intoxication, is thought to be associated with significant increases in free intracellular calcium in...

Alcohol Withdrawal Seizures

Ethyl alcohol (ethanol) is a central nervous system (CNS) depressant that exerts diverse behavioral actions. At low blood concentrations, alcohol produces euphoria and behavioral excitation, and at concentrations greater than 0.08 g dl (17 mM), it significantly impairs motor skills. Concentrations of 0.15 to 0.30 g dl induce acute intoxication, which manifests as drowsiness, ataxia, slurred speech, stupor, and coma. The acute effects of alcohol on brain function are believed to result largely from its actions on ligand-gated and voltage-gated ion channels, resulting in alterations in neuronal signaling (Crews et al., 1996 Deitrich and Erwin, 1996 Nevo and Hamon, 1995). Chronic alcohol consumption leads to the development of tolerance and physical dependence, which may result from compensatory changes in neuronal signaling that balance the acute effects of alcohol. Abrupt cessation of chronic alcohol consumption unmasks the compensatory physiologic change, leading to a cluster of...

Metabolic Changes Following Alcohol Withdrawal

Alcohol intoxication decreases local cerebral glucose utilization (LCGU) in many areas of the brain, including the limbic system, cerebellum, and motor system (Eckardt et al., 1992). The most striking effects on LCGU are observed in the IC (Grunwald et al., 1993), in accordance with other evidence indicating that this brain site is a major target of alcohol. Alcohol withdrawal is associated with increased brain glucose uptake, oxygen consumption, and blood flow (Eckardt et al., 1992 Hemmingsen et al., 1979 Newman et al., 1985). Significant increases in LCGU with alcohol withdrawal have been reported in motor systems, the auditory system (including IC), and the mammillary bodies-anterior thalamus-cingulate cortex pathway (Eckard et al., 1992), although one study reported decreases with acute withdrawal in most limbic regions and no changes in cerebellum and subcortical structures (Clemmesen et al., 1988). Animals that had experienced spontaneous withdrawal seizures exhibited relatively...

Neuroactive Steroids In Alcohol Dependence And Withdrawal

A universal consequence of chronic alcohol consumption in humans and rodents is the activation of the hypothalamic-pituitary-adrenal (HPA) axis, with resulting elevations of circulating CRF, ACTH, and glucocorticoids, similar to other stressors (34-36). In human alcoholics, Romeo et al. (37) have also found markedly decreased levels of allopregnanolone during early withdrawal from alcohol. The chronic stressor effect of alcohol withdrawal is supported by the demonstration by Spencer and McEwen (38) of adrenal atrophy and thymus involution following several weeks of ethanol exposure. Allopregnanolone has been shown to protect against bicuculline-induced seizures in alcohol-dependent rats (29). Furthermore, these alcohol-withdrawn rats are sensitized to the anticonvulsant effects of allopregnanolone, where they show a 5 to 15-fold increase in the maximal anticonvulsant effect of allopregnanolone on bicuculline-induced seizures, compared to controls (39). These results suggest that...

Abstinence or controlled drinking

Harmful or hazardous use of alcohol without severe dependence can sometimes revert to risk-free drinking. Patients with social supports (family and job) and without impulsive personalities and many social problems are most likely to succeed. For others, including most of those dependent on alcohol, the goal of abstinence is better. In patients attending specialized outpatient clinics, the proportion who can sustain problem-free drinking for at least 1 year is small 5 per cent is a typical findingA.7., and 19) A randomized trial comparing the goals of controlled drinking and abstinence did not favour controlled drinking. (20 However, for patients without established dependence, reduction programmes (whether or not towards abstinence) using FRAMES (Tib. ,,,2.) proved to be more effective than no intervention. 2 22 and 23 Interventions in primary care are discussed in Ch,a,p e.L,4. .2 2. .5,. If controlled drinking is the agreed goal, the patient and physician collaborate to monitor the...

Effects Of Heavy Drinking

10.1 Effects of Abstinence on the Brain Quantitative MRI and MR Spectroscopic Imaging in Chronic Alcohol Abuse (31) Structural brain damage, especially to white matter, is well documented in chronic alcohol abuse, and there is also evidence for brain metabolic abnormalities in this condition. It is unknown, however, to what extent these structural and metabolic changes are still detectable in long-term abstinent alcoholics compared to active chronic drinkers. Therefore we compared 12 recovering alcoholics, who had been abstinent from alcohol for an average of 2 years, to 8 active heavily drinking subjects with similar alcohol use variables. Metabolite concentrations in whole-brain and in gray matter and white matter of brain lobes did not differ significantly between the recovering alcoholics and active drinkers. However, active heavily drinking subjects had less frontal white matter than abstinent alcoholics and less gray matter in the orbital frontal pole and postcentral gyrus....

Formulation of definitions of alcohol dependence 19481974

From the time of its inception in 1948, WHO played a major role in formulating public health definitions of 'alcoholism', 'addiction', and 'dependence' through a series of expert committees. Early definitions stressed the sociological rather than the physical aspects of dependence. (7) 'Alcoholics' were defined as (7) those excessive drinkers whose dependence upon alcohol has attained such a degree that it shows a noticeable mental disturbance or an interference with their bodily and mental health, their inter-personal relations, and their smooth social and economic functioning or who show the prodromal signs of such developments. This definition had limited utility for biological research and psychiatric classification. (8) Therefore the 1955 Committee of Experts on Alcohol and Alcoholism highlighted the importance of physical criteria describing 'alcoholism' as (9,1 ) 'Alcoholism' was classified under 'Other non-psychotic mental disorders' in ICD-8. ( 1 This definition of...

Alcohol problems

Not everyone experiencing an alcohol problem or alcohol-related disability will be suffering from alcohol dependence. Both dependent and non-dependent drinkers, particularly binge drinkers, are at risk of problems related to heavy alcohol consumption. Indeed, epidemiological evidence supports the view that most alcohol-related harm in the general population occurs in heavy non-dependent drinkers. Alcohol problems are extremely diverse. They have been defined as 'those problems that may arise in individuals around their use of beverage alcohol, and that may require an appropriate treatment response for their optimum management'.'36) The phrases 'alcohol problems' or 'alcohol-related problem' contain an assumption of causality.'37) This issue is a complex one, involving individual differences and the social context of drinking as well as the pattern, duration, and intensity of alcohol use. Alcohol problems can be related to the acute or chronic consumption of alcohol. A fractured ankle...

Alcoholics Anonymous

Alcoholism is viewed by AA as a physical, psychological, and spiritual illness, which can be arrested (by avoiding another drink) but cannot be cured. The meetings offer a new social network. Emotional openness is encouraged. Members learn to express warmth, and to accept that they and others have failings. The AA advice on coping with emotions and relationship difficulties has much in common with cognitive-behavioural therapy and relapse prevention therapy. The method has some attractively simple concepts ('Just don't pick up that first drink's 'HALT' being alert to four of the most common triggers to relapse, i.e. hunger, anger, loneliness, tiredness). There is a deeper aspect which is to replace preoccupation with self by handing over to the group process, or to a 'Higher Power'. (32) A psychiatrist can introduce patients to AA through a contact member who will tell the patient how AA works, will not ask personal details, and will extend an invitation to a meeting. Doctors are...

Alcohol Intake

The ADA recommend that if individuals choose to drink alcohol, daily intake should be limited to one drink for adult women and two drinks for adult men. It should be avoided by pregnant women and people with other medical problems, like pancreatitis, advanced neuropathy, severe hypertriglyceridemia or alcohol abuse. Since it can have both hypoglycemic or hyperglycemic effects in people with diabetes, alcohol should be consumed during meals. It has been shown that moderate amounts of alcohol ingestion (5-15g day) is associated with a decreased risk of coronary heart disease. The DNSG also agrees with the recommendation of moderate alcohol intake in diabetes (10g day for women, 20g day for men) provided that it is consumed during meals (especially by patients using insulin). The Joslin Clinic does not have any specific recommendations for alcohol, whereas the AACE recommends that patients with diabetes should avoid or limit the use of alcohol, because predicting or anticipating its...


Alcoholism is among the major health problems in most countries. Dependence on ethanol, as with other addictive drugs, is expressed as drug-seeking behavior and is associated with a withdrawal syndrome that occurs after abrupt cessation of drinking. The ethanol withdrawal syndrome is characterized by tremors, seizures, hyper-thermia, hallucinations, and autonomic hyperactivity. in alcoholics cancer may develop in advanced stages of hepatic disease. A variety of pathological problems involving the CNS have been described in chronic alcoholics, the main ones being Wernicke's encephalopathy and Korsakoff's psychosis. Brain damage from chronic ethanol consumption can be especially severe in the elderly and may accelerate aging.

Psychiatry and health in lowincome populations

In 1995 my colleagues and I completed a report on world mental health. ( It outlines the extent of the problems and the priorities for intervention among low-income populations. Our most prominent finding was the interconnectedness of health problems, such as depression, heart and lung diseases, sexually transmitted diseases, and other behaviour-related diseases, on the one hand, and of psychosocial pathologies, such as violence, alcoholism, abuse of women and children, and underlying social conditions such as war, poverty, and discrimination, on the other. They form self-perpetuating spirals.

The burden of mental illness

Using the DALY as the basic statistic, the World Development Report(2) concludes that mental health problems make up 8.1 per cent of the total GBD. Of that 8.1 per cent, the largest contributors are depressive disorders, self-inflicted injuries. Alzheimer's disease and other dementia, and alcohol dependence, followed by epilepsy, psychoses, drug dependence, and post-traumatic stress disorder. Depressive and anxiety disorders account for between one-quarter and one-third of all primary-health-care visits worldwide.(3,,4) When appropriately diagnosed and treated, suffering is alleviated, disability prevented, and function restored when ignored, major losses persist.(5) By the year 2025, three-quarters of all elderly persons with dementia (about 80 million) will live in low-income societies. Mental retardation and epilepsy rates are three to five times higher in low-income societies compared with industrialized countries. In some Asian and African countries, up to 90 per cent of patients...

Epidemiological aspects

Although acute and chronic alcohol abuse is associated with an increased frequency of arrhythmias, moderate intake may have a protective effect on coronary heart disease and cardiac arrest by increasing 'protective' lipid concentrations. Other poorly understood factors may be involved in cardiac arrest. There is a circadian

Oral Cavity and Oropharynx

Squamous intraepithelial lesions in the oral cavity and oropharynx are associated with tobacco, whether smoked, chewed or used as snuff, which seems to be the major carcinogen in this region 165, 171, 247, 298, 316, 389 . Smoking 20 or more cigarettes per day, particularly non-filtered, as well as drinking alcohol, particularly fortified wines and spirits, is an important risk for the development of oral dysplasia in the European population. Tobacco is a stronger independent risk factor for oral SILs than alcohol 165 . The use of smokeless tobacco in the western world has a rather lower correlation with oral precancerous and cancerous lesions than south-east Asia, where chewing habits, including betel quid, strongly correlate with oral precancer and cancer development 298 . Alcohol has been considered the second most important risk factor for oral and pharyn-geal cancer development 247 , and its synergistic effect with tobacco is particularly evident 170, 171 . The risk of the...

Year III of residencyspecific goals and objectives

The goal of this year is to enhance the resident's acquired competencies in ambulatory care by supervised experience in more complex arenas of psychiatric service. A whole variety of new competencies are derived from this emphasis on mastering the problems of psychiatric assessment and treatment in unique domains within the health-care system. The resident continues to treat patients in an office-based practice, but, through a comprehensive outpatient service, also has closely supervised experience in the assessment and treatment of chronic schizophrenia and affective disorders, anxiety disorders, drug and alcohol disorders, and sexual disorders. Special treatment experiences psychopharmacology for chronic disorders, couples therapy, family therapy are provided under close supervision along with an extended series of psychodynamically oriented lecture demonstrations. A significant exposure to community-based psychiatry is provided, including rehabilitative and outreach services.

Risks and dangers of the international classification

Another danger is that operationalized diagnosis could be used in a simplistic manner in clinical practice without applying the diagnostic criteria as demanded by ICD-10.(79 ICD-10 contains a large number of diagnoses (e.g. 50 ways of coding depression), but few are used regularly. Thus a comparison of the statistics of psychiatric diagnoses in psychiatric departments in different countries showed that only a few diagnoses were used. (71 For instance, 40 per cent of the initial diagnoses of psychiatric inpatients in Germany fall into only three categories alcoholism, depression, and adjustment disorder.

Summary and pathophysiological conclusions

Alcoholism (Jable 4) The best known neuropathological feature of alcoholism is Wernicke's encephalopathy, which is characterized by degenerative changes including gliosis and small hemorrhages in structures surrounding the third ventricle and aqueduct (i.e. the mamillary bodies, hypothalamus, mediodorsal thalamic nucleus, colliculi, and midbrain tegmentum), as well as cerebellar atrophy. Most of the clinical features associated with the Wernicke-Korsakoff syndrome including ophthalmoplegia, nystagmus, ataxia, and mental symptoms such as confusion, disorientation, and even coma can be related to damaged functional systems in the hypothalamus, midbrain, and cerebellum 56) Other important neuropathological manifestations of chronic alcoholism are central pontine myelinolysis, Marchiafava syndrome, and fetal alcohol syndrome (see Chapterii4.i2.2.3).

Studies on alcoholspecific brain damage

Most of the changes mentioned above occur in association with thiamin deficiency, which is frequently, but not always, correlated with the long-term use of excessive amounts of alcohol. One major challenge is to identify those lesions caused by alcohol itself (uncomplicated alcoholism (5Z ) and those caused by other common alcohol-related factors, principally thiamin deficiency. The following summarizes recent results in this field, which has been reviewed in detail by others. (5 5 ) Brain shrinkage can be found in uncomplicated alcoholism, which can largely be accounted for by loss of white matter. Some of this damage appears to be reversible. However, alcohol-related neuronal loss has been documented in specific regions of the cerebral cortex (superior frontal association cortex), hypothalamus (supraoptic and paraventricular nuclei), and cerebellum. The data are conflicting for the hippocampus, amygdala, and locus coeruleus. No changes are found in the basal ganglia, nucleus...

Summary and pathophysiological considerations

Thiamin deficiency accounts for a major component of the brain damage in alcoholics. Animal models suggest that the distribution and extent of neuronal loss seems to depend on the duration of alcohol exposure, the magnitude and mode of exposure (ingestion, inhalation, etc.), the genetic susceptibility of the species, and the strain of animals studied. (5Z) It has been suggested that alcohol withdrawal may play a role in brain damage, evidenced by the fact that a number of workers have shown loss of granule cells in the dentate gyrus of the hippocampus continues even after alcohol exposure stops. (59 It was furthermore suggested that up-regulation of N-methyl-D-aspartate receptors may lead to withdrawal seizures and enhanced susceptibility to excitotoxicity, which may explain the continuing damage described.6.'

Second Primary Tumours

The risk of developing an SPT closely correlates with the use of tobacco and alcohol abuse, and is more than doubled in patients who smoke and drink compared with those who do not smoke and drink 207 . Moreover, there is a direct dose-dependent relationship between tobacco and alcohol exposure and the risk of SPT.

Effects of psychoactive drugs

Drugs of abuse, particularly alcohol, have adverse effects on various aspects of immunity and susceptibility to infectious diseases. (3 35) Fetal alcohol exposure can permanently affect endocrine and immune responses. Alcohol inhibits production of proinflammatory cytokines, reduces NK cell activity and suppresses B- and T-cell immunity. Alcoholics are infection prone. Although HIV-seronegative heroin addicts generally have reduced immune functions, persons maintained on methadone in a state of steady tolerance have normal immunity. Marijuana suppresses production of a- and b-interferon and the cytolytic activity of macrophages. Other psychoative drugs often have immune effects. Benzodiazepines antagonize suppression of NK cell activity by corticotrophin-releasing factor and thus may modify stress effects on immunity 36)

Paroxysmal Forms of Chorea

Paroxysmal choreoathetosis with spasticity was localized to 1p.21 in one family 7 . Episodes of dystonia, choreoatherosis, dysarthria, spasticity and imbalance were precipitated by exercise, stress, alcohol consumption and sleep deprivation. In between attacks, spasticity was persistent.

Psychophysiological parameters

In general, the search for unique biological markers of psychiatric diagnoses has produced disappointing results. A good diagnostic marker is one that possesses sufficient sensitivity (i.e. high detection rate of a specific disease) and specificity (i.e. strong discrimination between a specific disease and other diseases). Although psychophysiological research has discovered a variety of deviations in psychiatric populations, ranging from an excess of fast EEG activity in alcoholism to abnormal eye-tracking movements in schizophrenia 3,38 none of these deviations satisfy the criteria for being good markers. Apparently, the organizing principle behind these deviations is quite different from that of the Diagnostic and Statistical Manual of Mental Disorders (DSM). This has led some authors to conclude that we should stop looking for biological markers of the nosological categories listed in the DSM. After all, there is no reason to treat the taxonomy provided by the DSM as the gold...

Physician as Catalyst

Given this environment, how the physician sees himself or herself in the doctor-patient relationship is important. Primary care physicians shift between various doctor-patient roles throughout the day. For instance, a patient who presents to the office having just experienced the death of a spouse needs a physician who will empathetically listen more than talk. In this situation, the physician is a counselor. For the patient presenting with an anaphylactic reaction, the physician must quickly take action. It is not time to be a counselor but instead to take control and make rapid decisions. In either case, the physician's role is based on the presenting needs of the patient. Treating patients with tobacco dependency, alcoholism, or drug addiction requires a triage approach that is different from treating hypertension or diabetes. My responsibility is to identify how willing a patient is to fight an addiction and then be a catalyst in providing the right intervention at the right...

Nineteenth century psychiatry

Until the end of the nineteenth century, psychiatry was chiefly concerned with the custodial care of the insane in asylums. Insanity was believed to be caused by disease of the brain, although it was recognized that the brain displayed no obvious signs of abnormality at post-mortem in some common forms of insanity. Mental illness was considered to be a sign of degeneration, perhaps caused by factors like alcoholism in one or other parent.

Agitation and aggression

Early agitation may be followed by more intractable aggressive behaviour.(51* A major predictor of aggression is antisocial behaviour before the head injury. Other predictors of aggressive behaviour include confusion and disorientation, personality change with disinhibition or impulsivity, and epilepsy and anticonvulsant use. (52* Otherwise the predictors of aggressive behaviour are by and large no different from those found in the absence of head injury. Symptoms of mental illness, however, may not be immediately obvious because of communication difficulties. It is therefore necessary to search for evidence of persecutory delusions, mania, depression, and anxiety. Drug and alcohol dependence may be especially problematic.

Alcohol and head injury

Alcohol dependence complicates the management of the head-injured person several-fold. The person may have suffered several previous head injuries, as well as the effects of alcoholic brain damage before the head injury. A blow to the head may result in much greater brain injury for reasons that are poorly understood. (53) Poor physical health is likely to prejudice immediate management after the head injury. Subdural haematomas may be problematic. Alcohol craving may interfere with medical care and rehabilitation.(54* Social networks are often poor, thus complicating discharge from hospital. Very occasionally a head injury seems to cure the alcohol dependence. Unfortunately alcohol dependence often gets worse, indeed some patients develop alcohol dependence when they find that alcohol relieves their anxiety symptoms.

Drug Interactions

Unlike quinidine, disopyramide does not increase the plasma concentration of digoxin in patients receiving a maintenance dose of the cardiac glycoside. Hypoglycemia has been reported with the use of disopyramide, particularly in conjunction with moderate or excessive alcohol intake.

Structural neuroimaging

Neuroimaging studies (CT and magnetic resonance imaging (MRI)) comparing recently detoxified alcoholics without obvious cognitive impairment with age-matched controls confirm that the alcoholics show evidence of reduced cortical brain volume affecting both grey and white matter, and also increased cerebrospinal fluid spaces 17) These changes in brain structure are evident in young 'social drinkers', (18) but are more prominent in older age groups. Women appear to be particularly vulnerable. However, clinico-radiological comparisons have been equivocal, with measures of radiological change failing to correlate consistently with either duration of drinking or the severity of cognitive impairment. The role of concurrent liver disease is likewise poorly understood. Abstinence leads to reversibility of brain shrinkage 19 this is most marked in younger individuals and in women 20 However, many abstinent alcoholics continue to have enlarged ventricles. CT studies have also reported altered...

Functional neuroimaging

Functional imaging studies have shown hypometabolism in the frontal and parietal cortices of chronic alcoholics without major neurological impairment when compared with normal controls 2,2 and 30) These abnormalities improve following abstinence,(3 31) mainly during the 16 to 30 days after the last use of alcohol. Metabolic recovery is most marked in the frontal area.(30)

Neuropsychological deficits

Many individuals with a history of chronic excessive alcohol consumption show evidence of moderate impairment in short- and long-term memory, learning, visuoperceptual abstraction, visuospatial organization, the maintenance of cognitive set, and impulse control. (35) This tendency for alcoholics to show proportionally greater visuospatial than language-related impairments suggests that alcohol might have a selective effect on the right hemisphere the so-called 'right hemisphere hypothesis'.(36) However, right hemisphere functions also decline with ageing and the current view is that the functional lateralities of 'alcoholics' and ageing individuals are similar to normal controls.(36) Individuals with alcohol-induced brain damage and cognitive impairment are a heterogeneous group. The underlying mechanisms are probably numerous, complex, and interrelated. Alcohol and acetaldehyde neurotoxicity, thiamine depletion, and metabolic factors, such as hypoxia, electrolyte imbalance, and...

Psychological processes and treatment implications

Other cognitive therapies also make significant contributions to treatment. Relapse prevention involves the teaching of cognitive and behavioural strategies for dealing with high-risk situations and mental states.(1B 9) Other cognitive-behavioural therapies, including extinction of conditioning, contingency management, community reinforcement techniques 20 and indeed Beck's cognitive therapy, (2 have been effectively applied to substance misuse. The recent very large Project MATCH (matching alcoholism treatments to client heterogenity) study of alcohol treatments compared three types of treatment and found that motivational enhancement, 12-step facilitation, and cognitive-behavioural therapy were equally effective overall, although each therapy excelled in certain subgroups. (2,23) Based on these results it seems likely that specific therapies targetted at specific issues of importance in patients with addiction are roughly equally effective overall, but that we do not yet know enough...

Personality variables and the genetics of addiction

The genetics of drug abuse are beginning to be unravelled and already these studies have thrown up some important insights in relation to personality. The best studied dependence is that on alcohol, where the Scandinavian adoption studies have found the risk of alcoholism in male children of male alcoholics is the same regardless of whether the child is reared with the alcoholic father or by a non-drinking adoptive family. Building on these data, Cloninger (27) has identified two main forms of alcoholism. Type I is the late-onset form that has low inheritance and is associated with anxiety and stress which drinking is used to relieve, often in binges. In contrast, type II alcoholism starts at a younger age with a heavy regular intake and is associated with antisocial personality traits and criminality. This form is male limited, is associated with impulsivity, and may be related to underfunctioning of brain 5-hydroxytryptamine systems, as genetic polymorphisms of 5-hydroxytryptamine...

Gastroduodenal sources

While melena and hematemesis alone may be caused by any lesion in the upper gastrointestinal tract, the appearance of coffee-ground vomitus or gastric aspirate indicates that blood has been in contact with acidic gastric contents. Erosive gastroduodenitis is suspected when a patient with upper gastrointestinal bleeding gives a history of having recently ingested non-steroidal anti-inflammatory drugs or significant amounts of alcohol. These patients may also give a history of upper abdominal discomfort, occurring irregularly for days or weeks prior to the bleeding episode, and may have noted that liquid antacids provided them with temporary relief. The alcoholic patient with erosive gastritis may be either a chronic or a binge drinker bleeding from such lesions may occur at any age. Stress ulceration is a process similar to erosive gastritis, but occurs primarily in patients confined to intensive care units, suffering from severe injuries, infections, or cardiovascular problems, and...

Chapter References

George, D.T., Nutt, D.J., Dwyer, B.A., and Linnoila, M. (1990). Alcoholism and panic disorder is the comorbidity more than coincidence Acta Psychiatrica Scandinavica, 81, 97-107. 2. Marshall, J.R. (1994). The diagnosis and treatment of social phobia and alcohol abuse. Bulletin of the Menninger Clinic, 58, 58-66. 9. Tiffany, S.T., Singleton, E., Haertzen, C.A., and Henningfield, J.E. (1993). The development of a cocaine craving questionnaire. Drug and Alcohol Dependence, 34, 19-28. 20. Stitzer, M.L. and Higgins, S.T. (1995). Behavioral treatment of drug and alcohol abuse. In Psychopharmacology the fourth generation of progress (ed. F.E. Bloom and D.J. Kupfer), pp. 1807-19. Raven Press, New York. 22. Project MATCH Research Group (1997). Matching alcoholism treatments to client heterogenity Project MATCH postreatment drinking outcomes. Journal of Studies on Alcohol, 58, 7-29. 24. Miller, W.R., Brown, J.M., Simpson, T.L., et al. (1995). What works A methodological analysis of the alcohol...

Individual vulnerability Genetic influences

The most powerful predictor of alcohol misuse in any individual is the occurrence of alcoholism in first-degree relatives. Men and women belonging to families with alcoholic parents and or siblings are twice as likely to develop the disorder than those without such family history. The risk is threefold when the disorder is present also in second- or third-degree relatives.(20) More comprehensive analyses demonstrate that family aggregation is true as well for addictive substances other than alcohol.(2i The excess probability observed within single family groups suggests that alcohol misuse could be a genetically transmitted behaviour, and several The comparison of concordance rates for alcoholism in monozygotic and dizygotic twins permits to test the genetic basis of the disorder. Since monozygotic pairs have a common genetic stock, while dizygotic ones share on average only 50 per cent of their genes, any condition of genetic origin would be found to co-occur more in them than in...

Eventrelated potentials

Alcoholics have been found to present a lower than normal amplitude of the P300 wave, when such brain potential is evoked through complex visuomotor tasks. The P300 potential is thought to measure attentional and memory processes, and its amplitude tends to increase with age and neurological maturity. Subsequent work demonstrated that low P300 amplitude could be observed also in young offspring of alcoholics, both male and female, who had not yet started drinking. It is consequently suggested that such neurophysiological finding might be a biological marker of biological vulnerability to alcoholism. (39 However, P300 anomalies are not specific to alcoholism and are observed also in other psychiatric disorders.

Comparisons of the Dsmiiir Dsmiv and ICD10 definitions of alcohol dependenc32

Research shows that agreement between the three systems on diagnosis of alcohol dependence is good to excellent for 'past year, prior to past year, and life-time diagnoses, for men and women, different ethnic groups and older and younger respondents'.(32) Thus the international effort to integrate the two major classification systems has been successful with respect to the dependence category. The DSM-IIIR classification is the most inclusive, requiring three of nine positive criteria for diagnosis, and the ICD-10 classification the most exclusive, requiring three of six positive criteria. The DSM-IV classification is intermediate, requiring three of seven positive criteria for diagnosis.

Types of alcoholrelated problems

There is a continuity between moderate and excessive drinking and between harmless drinking and drinking that results in harm or in problems. Such problem-clustering may reflect alcohol dependence, certainly amongst a proportion of these drinkers. Given this heterogeneity, no one form of treatment is likely to be effective for all individuals with alcohol problems. (36) A range of treatments is required and it should be possible for non-specialists to offer brief interventions (see Chapter _4_._2.2_._4.). The study of alcohol-related problems remains underdeveloped, compared with the study of alcohol dependence. (38) There may be several reasons for this, not least the difficulties inherent in measuring alcohol-related problems. (39) Another important issue, central to these difficulties, is the extent to which alcohol is causally related to the problem.3. Several questionnaires, measuring a variety of alcohol-related problems, have been developed. (38,4.0) The Alcohol Problems...

Withdrawal without complications

When alcohol is completely withdrawn or substantially reduced a characteristic withdrawal syndrome can develop. It includes autonomic hyperactivity like hand tremor, insomnia, sweating, tachycardia, hypertension, and anxiety. The symptoms generally occur between 6 and 12 h after the last alcohol consumption. Depending on their severity they may last for up to 4 or 5 days. The neurobiological basis for withdrawal is a gradual upregulation of W-methyl-D-aspartate receptors under the influence of chronic alcohol use. As soon as the alcohol, which acts as a central nervous system depressant, is withdrawn, we observe an overwhelming excitatory action on the brain mediated by the glutamatergic system.

Alcoholinduced mood disorders

Alcohol is a central nervous system depressant. Taken regularly in high doses it may provoke feelings of sadness. Episodes of withdrawal or relative withdrawal can lead to excitability and nervousness, including anxiety. The more a person drinks, the more likely it is that these symptoms will occur. Finally in the stage of alcohol dependence, up to 80 per cent of people report depressive symptoms at some time in their life. About one-third of male patients and up to 50 per cent of female patients have experienced longer periods of severe depression.( ) These high prevalence rates are noteworthy, since more than 20 per cent of alcoholics have attempted suicide once or more and about 15 per cent die in their attempt. Besides depressive features, alcohol-induced mood disorders may also comprise manic symptoms or mixed features. However, the diagnosis should only be used when the symptoms cause clinically significant impairment or distress in social, occupational, or other areas of...

Alcoholinduced anxiety disorders

This diagnosis should only be used when anxiety symptoms are thought to be related to the direct physiological effects of alcohol. The symptomatology may involve anxiety, panic attacks, and phobias. Both alcohol-induced anxiety disorders and mood disorders can develop during intoxication, withdrawal, or up to 4 weeks after cessation of alcohol consumption. During intoxication or withdrawal, the diagnosis should only be given when the symptomatology clearly exceeds what would be expected from anxiety or depressive symptoms during a regular intoxication or withdrawal episode. Anxiety disorders are among the most common groups of psychiatric disorders in the general population, with prevalence rates of up to 25 per cent. (6) In clinical studies between 20 and 70 per cent of patients with alcoholism also suffer from anxiety disorders. (7) On the other hand, between 20 and 45 per cent of patients with anxiety disorders also have histories of alcoholism.(8) However, it has been argued that...

Effects on the brain Cerebral cortex

Chronic alcohol consumption leads to structural and functional changes in the brain. Alcoholic dementia is dealt with in Ch.apteL4,1.12. Most of the tissue loss from the cerebral hemispheres in alcoholics is accounted for by a reduction in the volume of the cerebral white matter, additionally there is a slight reduction in the volume of the cerebral cortex. This has been demonstrated both pathologically(13) and using magnetic resonance imaging with quantitative morphometry 4 Harper et al l5 documented neuronal loss in alcoholics. There was a 22 per cent reduction in the number of neurones in the superior frontal cortex (Brodmann's area 8), while surviving neurones showed shrinkage in the superior frontal, motor, and frontal cingulate cortices. (16) This finding of cortical damage in alcoholics is consistent with neuroradiological studies. (1i

Cerebellar degeneration

Many alcoholic patients develop a chronic cerebellar syndrome related to the degeneration of Purkinje cells in the cerebellar cortex. Quantitative studies revealed a significant loss of cerebellar Purkinje cells (by 10-35 per cent) and shrinkage of the cerebellar vermal, molecular, and granular cell layers. (19) Evidence for a direct toxic effect caused by ethanol is provided by animal models.(20) In neuroimaging studies, however, cerebellar ataxia in alcoholics does not correlate with the daily, annual, or lifetime consumption of ethanol. As in Wernicke's encephalopathy, thiamine deficiency due to poor nutrition has also been implicated. Cerebellar atrophy has been reported to occur in about 40 per cent of chronic alcoholics. (1.9) In a clinical study of alcoholic inpatients, 49 per cent had at least discrete clinical signs of cerebellar atrophy 21

Hepatocerebral degeneration

Hepatic encephalopathy develops in many alcoholics with liver disease, and is characterized by altered sensorium, frontal release signs, 'metabolic' flapping tremor, hyper-reflexia, extensor plantar responses, and occasional seizures. Whereas some patients progress from stupor to coma and then death, others recover and suffer recurrent episodes. The brains of patients with hepatic encephalopathy show enlargement and proliferation of protoplasmic astrocytes in the basal ganglia, thalamus, red nucleus, pons, and cerebellum, in the absence of neuronal loss or other glial changes. (23)

Fetal alcohol syndrome

Malnutrition can be a consequence of deficient food intake. More important in alcoholics seem to be maldigestion and malabsorbtion ('secondary malnutrition'). Apart from the direct toxic effect of alcohol on most body tissues, malnutrition is an important contributor to organ damage in alcoholics. (28) Vitamin metabolism may be profoundly affected by chronic alcohol consumption. As a consequence, many alcoholics have deficiencies in vitamins B 1 (thiamine), A, D, B6, and E, and folate. This can lead to a variety of physical consequences, including damage to different organs.

A chronic relapsing disorder

Some people repeatedly put themselves or others at risk by drinking. One view is that such people could drink sensibly if they were more considerate and used more will power. Another increasingly accepted view is that many such individuals are in a state, existing in degrees of severity, in which the freedom to decide whether to change their drinking, and to adhere to that decision, is reduced compared with other drinkers. This state partly depends on perceived pay-offs for changing, and on acquired dispositions which are less accessible to conscious control. Such persons become aware of a wish, or urge, to drink which overcomes rational thought. They may then make up an explanation, for example 'No wonder I feel like a drink, I've had a hard day's. Such individuals benefit from help to unlearn those patterns, and to learn different approaches to problems. Discussion, care, and encouragement from others can bolster their will to do so. Assistance to set up controls within or from...

Starting treatment The initial interview

Patients may or may not have been referred for help with alcohol problems. Even if they have, the interview should begin with enquiry into the patient's current concerns. Reflective listening(3) helps the patient to clarify these concerns, conveys empathy, and avoids premature closure. A spirit of collaborative enquiry helps patients to reach their own conclusions about the role of alcohol in their troubles. This will be more convincing than a recitation of medical advice. People are more likely to believe what they hear themselves say than what others tell them. The interview is less likely to slip into confrontation if the doctor conveys recognition that, for the patient, drinking alcohol has been pleasurable. Therefore the assessment should not proceed in a series of closed questions, such as 'Do you drink more than you intend to ' 'Does alcohol make you depressed ' Instead, ask open-ended questions 'Tell me about your pattern of drinking. What are the good aspects and what are the...

Medical assistance for withdrawal

If dependence is severe, especially in an unplanned situation where a very heavy drinker is suddenly deprived of alcohol because of an accident, illness, or police arrest, care must be taken to prevent the life-threatening complications of convulsions or delirium. Anticipation is the key. When the patient's aim is 'controlled drinking'(see below), this may also entail an initial stage of withdrawal, as the final goal is more likely to be achieved after abstinence for 2 or 3 months.

Advice to patient on withdrawing from alcohol at home

If you have been chemically dependent on alcohol, stopping drinking causes you to get tense, edgy, perhaps shaky or sweaty, and unable to sleep. There can be vomiting or diarrhoea. This 'rebound' of the nervous system can be severe. Medication controls the symptoms while the body adjusts to being without alcohol. This usually takes 3 to 7 days from the time of your last alcoholic drink. If you did not take medication, the symptoms would be worst in the first 48 h, and then gradually disappear. This is why the dose starts high and then reduces. You have agreed not to drink alcohol You may get thirsty. Drink fruit juices and water but do not overdo it. You do not have to 'flush' alcohol out of the body. More than 3 litres of fluid could be too much. Do not drink more than three cups of coffee or five cups of tea. These contain caffeine which disturbs sleep and causes nervousness.

Preventing convulsions

Deaths have occurred in hospital, prison, and police cells from repeated alcohol withdrawal fits. When withdrawal is planned in patients with a history of fits of any cause the risk can be reduced by commencing phenytoin (300 mg daily) 4 days before the cessation of drinking. In an acute situation, larger than normal doses of long-acting benzodiazepines are given in the first 36 h without waiting until the blood alcohol level has fallen to zero. The benzodiazepine should be started as soon as the blood alcohol level can be presumed to be falling, even though the patient still smells of alcohol or has a positive breath test, provided that he or she is sober enough to understand and co-operate with the procedure.

Interventions to reduce relapse The evidence

With appropriate help, withdrawing from alcohol is not the dependent drinker's main difficulty. The main difficulty is avoiding later relapse into further problematic Until recently no treatments had been tested in a randomized controlled trial. Therapists explored with patients possible personality or psychological causes of their excessive drinking trying to find out 'why '. However, there was no evidence that this reduced relapse. Indeed, it could have had an adverse effect by creating transference problems which triggered drinking and by reinforcing the drinkers's perception of having a need to drink. (9) Similarly, non-directive counselling could act as a confessional, with a sense of absolution allowing further drinking.

Helping motivation the social matrix

It is said that the only successful way to change your drinking is to do it for yourself. Nevertheless, research and experience shows that those dependent on alcohol can start on the road to recovery when their reason is pressure from outside. This may be from the court which is seeking evidence, before deciding on sentence, that offenders have taken steps to alter harmful drinking patterns. The driving licence may have been withdrawn following a drink-drive offence and evidence that drinking is under control is required before its return. Perhaps the partner is ready to take a firm line, even to demand a separation or divorce, or the employer has given a warning. Friends, partners, colleagues at work, and even employers sometimes adopt an approach that they believe to be motivating but which has the opposite effect and enables the drinker to continue drinking. They may cover up, gloss over, make excuses, or even start blaming themselves for what is going wrong. This cushions drinkers...

Behavioural marital therapy

Violence in the partnership may require specific attention. If the drinker is intoxicated, the partner is advised to back off and avoid argument. Sometimes each partner is asked to sign an agreement that neither will threaten or hit the other. If they do, time-out in another room is agreed in advance to permit slow-breathing to aid calming down, or one of them will leave the house and go to a designated place for 36 to 72 h. The partner 'bringing up the past' can be a major irritant to the drinker. This can be reframed as the partner 'helping the couple not repeat their past'. A partner who feels heard and understood is more ready to look at other ways of achieving these goals.

Treatment of coexisting disorders Affective disorder

Depression is common in patients who are dependent on alcohol. The drinking may have alienated friends, family, or employer, with resulting feelings of hopelessness, guilt, and lack of direction. Alcohol can reduce appetite, energy, and sexual drive. The drinker wakes in the small hours of the night feeling anxious owing to the rebound wakefulness of alcohol withdrawal. Those signs and symptoms suggesting depressive illness commonly clear with abstinence and help in tackling or tolerating personal problems and improving relationships. Sometimes (more often in women than in men) a depressive episode precedes the alcohol dependence. Alcohol was taken in part as self-medication. Sometimes depressive symptoms continue despite abstinence. In these cases, antidepressants should be offered in the usual way. (6 64 Relapsing alcoholism, secondary to depressive illness, is an indication for long-term antidepressants. Lithium is not a treatment for alcohol dependence itself, but is effective if...

Anxiety and panic disorder

Some patients have had panic attacks for years before discovering that alcohol can end or prevent them. Others have a first panic attack during alcohol withdrawal, but the attacks continue independently even during sustained abstinence. In either case, cognitive-behavioural therapy and or medication are indicated. Three studies suggest that the serotonin agonist buspirone can help reduce both drinking and anxiety. (65) Tricyclic antidepressants and selective serotonin-reuptake inhibitors (SSRIs) have been shown to be effective in randomized controlled trials of panic disorders, but alcohol dependence has been an exclusion criterion in these trials. Newly abstaining alcohol-dependent patients seem particularly susceptible to the unwanted effects of serotonergic medication (see above). Some patients with long histories of alcohol dependence and severe panic disorders fail to respond to psychological or antidepressant treatments. For these patients the risk of complications from repeated...

Residential and inpatient treatment

It is debatable whether a period of inpatient treatment can improve the eventual outcome. Some studies have compared outcomes after patients have been randomly allocated to either inpatient or outpatient treatment. Usually no difference has been found. However, the interpretation of these results and their extrapolation to clinical reality has been debated. Finney et al.6) concluded that the studies often lacked statistical power. Furthermore, the more seriously affected patients had sometimes been excluded before randomization 6. 6.Z) While evidence that it is inpatient treatment rather than intensity of treatment which improves outcome is lacking (6,69) admission to hospital can provide valuable respite for the drinker and the family when life is severely disorganized because drinking is out of control. Perhaps such respite need not be offered in a relatively expensive medical environment. However, if the patient has become suicidal as difficulties increase or has developed serious...

Matching patients to treatments The problem

It is recognized that people with alcohol dependence present a range of problems, come from various backgrounds, and have different personality characteristics. Some have no accompanying emotional disturbance others have a psychiatric disorder. The poor outcomes of treatment for alcohol dependence have been attributed to their use with unsuitable patient, and better matching of patients to treatments has been sought. A North American study of 1726 outpatients (Project MATCH) set out to test hypotheses about matching treatments to patients. Three treatments were studied, each established in previous randomized controlled trials as more effective than 'supportive therapy' motivational enhancement therapy, cognitive-behavioural therapy, and instruction in the AA approach with encouragement to take part in AA meetings ('12-step facilitation'). Another marker of who benefits most from AA emerged in the 3-year Project MATCH data. Patients who came from a social milieu where they mixed a lot...

Physicians as patients

Doctors have a raised rate of alcohol dependence. Their outcome, once in treatment, tends to be better than average, if they can return to their practice. This is probably partly due to the requirement by the licensing body that the 'impaired physician' accept monitoring by an independent specialist to corroborate that he or she is following advice and continuing to progress. (78 Doctors' reluctance to accept help for their illnesses, and their tendency to treat themselves, is well known and is especially true for substance misuse. Initial denial often means that problems escalate until there are disciplinary or court proceedings, and attempts to treat their own alcohol dependence may result in dependence on other substances.

A spectrum of disorders needing a range of services

The provision of services for alcohol use disorders historically has been driven by the prevailing view of their nature and prevalence. Following the Second World War, the disease concept of alcoholism gained increasing support in both the United States and the United Kingdom. (1 ) According to this concept, alcoholism is an all-or-nothing phenomenon affecting a relatively small subgroup of the population, and requires intensive specialist treatment. In the United Kingdom this led to the development of specialist alcohol treatment centres with an emphasis on intensive inpatient treatment over several weeks or months, and involving group therapy, often with close affiliation to the Alcoholic Anonymous (AA) fellowship. Such programmes tended to be targeted at relatively socially stable, articulate, and affluent males, and universally only catering for the more severely alcohol dependent. (2) In the 1970s and 1980s, with the development of epidemiological and psychological research, came...

Location and intensity of treatment Specialist treatments

The main treatment response to alcohol use disorders continues to be delivered by specialists. There has been extensive research on the location and intensity of specialist treatment. An early influential study was that of Edwards et al.(7) in which 100 alcohol-dependent men referred to the Maudsley Hospital in London were randomized to receive either intensive specialist treatment, including inpatient care in an alcoholism treatment unit, or one session of counselling. At 1-year follow-up there was no difference in outcome between the two treatments. It was concluded that the reliance on intensive treatments up to that time was called into question by the findings. This controversial study gave rise to considerable debate and several studies have subsequently investigated the same issues. Another British study attempted to replicate the Edwards study and found only modest differences between advice only and extended treatment in a randomized controlled trial at 2 years's...

Communitybased specialist treatments

The growth of studies questioning the value of specialist inpatient treatment and a move towards cost containment in health care have led to a shift in resources aimed at treating alcohol use disorders in the community setting. One North American study, for example, found that the proportion of outpatient treatment units more than doubled between 1982 and 1990, consistent with the efforts of managed care organizations to decrease the utilization of inpatient services. (22) Apart from the potential advantage of lower cost, community-based treatment provides the least social disruption for the individual and offers the opportunity to mobilize existing community resources to support, hopefully, sustained recovery. In the United Kingdom, the past 20 years has seen the widespread development of the community alcohol team model of treatment following the original Maudsley Alcohol Pilot Project. (23 The main principle of the community alcohol team model is that the specialist team (typically...

Matching and stepped care

The Institute of Medicine report, while drawing attention to the need for a range of interventions catering for a wider range of alcohol use disorders, also emphasized the need to match the level of intervention to the severity and nature of the presenting problems. (6) There is some empirical evidence of matching effects. (43 Indeed a later follow-up of the Edwards cohort found that more severely dependent drinkers benefited more from intensive treatment. (44 Up until recently, however, matching effects have generally been explored in post hoc analyses in studies that lacked statistical power. The recent large-scale Project MATCH study in the United States aimed to assess a wide range of matching hypotheses in a prospective design, but found no strong matching effects (45 (see Chapter However, it should be noted that most controlled trials, including MATCH, excluded the more severely problematic patients, including those with limited social support and those with severe...

Financial considerations

With a general move towards containment of health-care costs in industrialized societies, there has been an increase in the application of health economic research in the alcohol treatment field. The cost of treating alcohol use disorders represents a substantial burden on health-care budgets. It has been estimated that the annual direct treatment costs of alcohol use disorders by specialist treatment agencies amounted to approximately 10.5 billion in the United States and about 400 million in the United Kingdom in 1990.(4950) Thus there is a need to demonstrate the cost effectiveness of treatments for alcohol use disorders. There has been relatively little research into the cost effectiveness of specialist treatments, and methodologies for examining cost effectiveness is still at an early stage of development in the alcohol field. However, some work has been done. In a 14-year longitudinal study of 'alcoholic' employees within the United States, Holder and Blose(55) found that those...

Access and helpseeking

So far we have concentrated on the effectiveness of interventions at an individual level. However, the overall population impact of treatment interventions is dependent upon the availability and ease of access to treatment programmes, as well as their effectiveness. From a public health perspective the effectiveness of the treatment response to alcohol problems will depend upon the number of people accessing and engaging with interventions. This will be dependent upon two main factors characteristics of the alcohol-misusing population, and characteristics of the treatment service. There is also likely to be an interplay between these two factors.

Characteristics of the alcoholmisusing population

Specialist alcohol treatment services typically attract younger, male, single patients of lower socio-economic and educational background, with more severe alcohol dependence. Relative to the prevalence of alcohol use disorders in the general population, women, older people, and people from ethnic minorities are typically under-represented, as are the homeless. Further, there are few examples of specific services for young people. This is of particular concern as the prevalence of alcohol use disorders is increasing in these groups in the United Kingdom. The factors involved in women's help-seeking have recently been the subject of increased research activity. Thom and Green have identified three main factors that may account for the underrepresentation of women in alcohol treatment.(61) Women tend to perceive their problems differently from men, less often identifying themselves as 'alcoholic'. This may in part be related to negative public stereotypes of female drinking and negative...

Services for individuals with comorbidity

There is an increasing recognition of the problems associated with alcohol and other drug misuse and mental illness (see Chapter. Often alcohol misuse is complicated by multiple substance misuse. For example, in the Epidemiologic Catchment Area Study half of all patients with schizophrenia also had a substance misuse disorder,(76 and a recent British survey of psychotic patients found that 36 per cent misused drugs or alcohol. (77) However, there is currently no consensus on the most appropriate treatment services for patients with comorbidity.(78) Substance misuse can be particularly problematic in the context of mental illness, and is associated with higher rates of violence and poor treatment outcome (see Chipie.L11 4.4). Such patients are often non-compliant and disruptive in mental health services, and typically do not engage in alcohol or drug services. Assertive community outreach and integrated service models, covering both mental illness and substance misuse, have...

Evidence on effectiveness

Persuasional media campaigns have also been a favourite modality in many places in recent decades for the prevention of alcohol problems. In general, evaluations of such campaigns have been able to demonstrate impacts on knowledge and awareness about substance use problems, but can show only modest success in affecting attitudes and behaviours. As with school education approaches, there are hints in the literature that success may come more from influencing the community environment around the drinker in terms of attitudes of significant others, or popular support for alcohol policy measures than from directly persuading the drinker him- or herself. Thus, media messages can be effective as agenda-setting mechanisms in the community, increasing or sustaining public support for other preventive strategies.1)

Insulating use from harm

A major social strategy for reducing alcohol-related problems in many societies has been measures to separate the drinking, and particularly heavy drinking, from potential harm. This separation can be physical (in terms of distance or walls), it can be temporal, or it can be cultural (e.g. defining the drinking occasion as 'time out' from normal responsibilities). These 'harm reduction' strategies, as they are called in the context of illicit drugs, are often built into cultural arrangements around drinking, but can also be the object of purposive programmes and policies. ( 8

The effectiveness of specific types of regulation of availability

Generally, consumers show some response to the price of alcoholic beverages, as of all other commodities. If the price goes up, the drinker will drink less data from developed societies suggests this is at least as true of the heavy drinker as of the occasional drinker. (13) Studies have found that alcohol tax increases reduce the rates of traffic casualties, of cirrhosis mortality, and of incidents of violence. (2 ,29 There is a substantial literature showing that levels and patterns of alcohol consumption, and rates of alcohol-related casualties and other problems, are influenced by such sales restrictions, which typically make the purchase of alcoholic beverages slightly inconvenient, or influence the setting of and after drinking. ( 3 Enforced rules influencing 'house policies' in drinking places on not serving intoxicated customers etc. have also been shown to have some effect. (26) Studies of the effects of privatizing retail alcohol monopolies have often shown some increase in...

Social and religious movements and community action

Substantial reductions in alcohol-related problems have often been the result of spontaneous social and religious movements which put a major emphasis on quitting intoxication or drinking. In recent decades, there have also been efforts to form partnerships between state organizations and non-governmental groups to work on alcohol problems, often at the level of the local community. There has been an active tradition of community action projects on alcohol problems, often using a range of prevention strategies 3 ,32,3 and 34) School-based prevention efforts have also moved increasingly to try to involve the community, in line with general perceptions that such multifaceted strategies will be more effective.(9) While some of the largest historical reductions in rates of alcohol problems have resulted from spontaneous and autonomous social or religious movements, support or collaboration from a government can easily be perceived as official co-optation or manipulation. (35 Thus, there...

Treatment and other help

Providing effective treatment or other help for these drinkers who find they cannot control their drinking can be regarded as an obligation of a just and humane society. The help can take several forms a specific treatment system for alcohol problems, professional help in general health or welfare systems, or non-professional assistance in mutual-help movements. To the extent such help is effective, it is also a means of preventing or reducing future alcohol-related problems. Treatments for alcohol problems need not be complex or expensive. The evaluation literature suggests that brief outpatient interventions aimed at changing cognitions and behaviour around drinking are as effective in most circumstances as longer and more intensive treatment. (37,38) Positive results from such interventions in a primary health care settings were shown in a World Health Organization study including a number of countries. (39)

Building an integrated societal alcohol policy

Often the different strategies for preventing alcohol problems appear to be synergistic in their effects. (51) Controls of availability, for instance, are more likely to be adopted, continued, and respected when the public has been successfully persuaded of their effects and effectiveness. But strategies can also work at cross-purposes a prohibition policy, for instance, makes it difficult to pursue measures which insulate drinking from harm. In terms of strategies we have reviewed for managing and reducing the rates of alcohol problems in society, there is clear evidence for effectiveness and cost-effectiveness of measures regulating the availability and conditions of use, and measures that insulate use from harm. With respect to some aspects of alcohol problems, notably drink-driving, deterrence measures also fall in the same category. Despite their perennial popularity, evidence of the effectiveness of education persuasion and treatment strategies in reducing societal rates of...

Consequences of drug use for young people

Drug and alcohol abuse among the seriously mentally ill is associated with greater consumption of inpatient care and poorer compliance with treatment. (18 The prevalence of violence is higher than in severe mental illness alone. (19) In the United States, specialized services for 'dual-diagnosis' patients have evolved and appear more effective than general psychiatric units.(20)

Psychiatric comorbidity

Several studies have found that 70 per cent of addicts meet diagnostic criteria for a current psychiatric disorder, frequently depression, antisocial personality, and alcohol dependency 5,1.6) Such diagnoses may be primary or secondary to opiate abuse, and a careful assessment of mental state and social functioning when opiate free should be performed. Many will have had childhood behavioural problems such as conduct disorder, and studies suggest that attention-deficit hyperactivity disorder, truanting, and juvenile offending are markers for subsequent use. (1D Clearly, comorbid psychiatric disorders should be treated in their own right especially if it is felt that they are important in maintaining opiate use. (18) Opiate dependence is also a strong risk factor for suicide, which accounts for up to a third of all deaths among intravenous drug users.(,19)

The range of service providers and the impact of treatment

Those who experience problems with opiates may present to wide range of professionals within the health-care, social, and legal systems. The range of treatment options available within statutory and non-statutory agencies will vary, as will the provision of either maintenance or detoxification for opiate dependents depending upon differing treatment philosophies and treatment settings. Partly in response to this diversity of resource provision, an ongoing multicentre prospective outcome study (National Treatment Outcome Research Study) was set up in 1995 to compare the impact of different treatment approaches on subsequent drug use as well as upon psychosocial and physical outcomes. Preliminary results2** suggested that all four types of intervention (residential rehabilitation, inpatient drug dependency units, methadone maintenance, and reduction) led to reductions in illicit drug use and criminal activity as well as reductions in injecting and sharing behaviours. Least impact was...

Precipitating Factors

Unless related to omission of insulin therapy, DKA is usually precipitated by coexisting illness. The most common factor is infection ranging from trivial viral infections to full-blown septicaemia. Other precipitating factors are cardiovascular events (myocardial infarction, stroke), gastrointestinal disease, inflammatory diseases, pancreatitis, trauma and major surgery, alcohol abuse and drugs (e.g. glucocorticoids). All of these factors induce insulin resistance due to stress hormone responses. Furthermore, poor appetite and food deprivation will often lead the patient to take less insulin, erroneously of course. In this context gastrointestinal disease with nausea and vomiting poses a specific problem and it may be necessary to admit such

Physical complications from MDMA

Concurrent administration of cocaine and amphetamine will potentiate the stimulant effects of MDMA and may increase the likelihood of hyperthermic and cardiac problems. Some users take benzodiazepines and other depressant drugs to treat insomnia and restlessness. Stimulant drugs reduce the individual's awareness of intoxication by alcohol and may lead to higher alcohol consumption and hence increase the risk of accidents.

Pancreas and Differences to Chronic Alcoholic Pancreatitis

According to Kuroda et al. 35 , the myofibroblasts play an important role in pancreatic fibrosis in alcoholics. Based on their diameter and location, the fine filaments (8-15 nm in diameter) presenting between the myofibroblasts and collagen fibrils are considered to probably be collagen filaments in nature (fig. 8). The presence of collagen filaments around the myofibroblasts may indicate that myofibroblasts produce the collagen filaments and fibers. Hence, they suggest that alcohol has an effect on the initial stage of periacinar collage-nization in intralobular fibrosis via the activation of myofibroblasts. Prolyl hydroxylase (PH), located in microsomes, is an enzyme that hydrox-ylates peptide-bound proline in the process of collagen biosynthesis 36 . Our previous study 37 showed that the immunoreactivity of PH in the pancreas is mainly localized in the acinar cells (fig. 9), and seems to play a role in pancreatic fibrosis. Moreover, Kuroda et al. 35 also notes that protein...

Adult smoking disadvantage and dependence

The most striking feature of the evolution of smoking in developed Western countries over the past 20 years has been the increasing association of cigarettes with markers of disadvantage, whether it be socioeconomic position, or a range of factors indicating stressful living circumstances. (47) High rates of smoking are seen in the unemployed, lone parents, people who are divorced or separated, the homeless (United Kingdom Office of Population Censuses and Surveys), heavy drinkers, (47) drug users (United Kingdom Office of Population Censuses and Surveys), and prisoners. (48) Cigarette smoking is strongly associated with psychiatric illness, whether it be schizophrenia 49,50 depressive illness 51 or a variety of other neurotic disorders. ty The association of cigarettes with lowered levels of psychological well being is not confined to those with a formal psychiatric diagnosis, but extends also into the general population of smokers. (5 53) Between 1973 and 1994 rates of smoking among...

The drug user with comorbidity

There is increasing recognition of the importance of managing individuals with comorbidity and special needs. Particular attention should be paid to comorbidities associated with drug use across physical and psychological health domains. At entry to treatment, many individuals with substance use disorders also experience psychiatric symptoms and disorders 5,53) Across several countries, large-scale surveys have gathered data that suggest high concordance between drug and alcohol use disorders and affective and personality disorders.(54,55,5 and 5Z) According to one major study from the United States, approximately one in seven individuals with a current mental health disorder also has a substance use disorder.(55) Special attention may need to be given to the health care needs of drug users who are affected by such comorbidities irrespective of their dependent or non-dependent drug use status. Recognition of the importance of understanding the links between substance use behaviours...

Familygenetic vulnerability

The offspring of depressed parents are at greatly increased risk of depression, especially in childhood and early adult life (Wickramaratne & Weissman, 1998). Many other forms of psychopathology are increased among these children (Wickramaratne & Weissman, 1998), and they are also at increased risk of medical problems (Kramer et al., 1998). Several prospective longitudinal studies have suggested that these increased risks extend for many years (Beardslee et al., 1993 Hammen, 1991 Weissman et al., 1997). For example, Weissman and her colleagues (Weissman et al., 1997) evaluated the effects of parental depression on offspring over a 10-year period. High rates of depression, panic disorder, and alcoholism were found among the children.

The Initial Stage of Periacinar Collagenization

Contents of zymogen granules and the rough endoplasmic reticulum to the cytoplasm and around acinar cells, is preceded by alcohol intake, and may contribute to the severe damage to acinar cells and the development of periacinar collageniza-tion. Further studies on the myofibroblasts around the acini and changes in acinar cells, especially the abnormalities in zymogen granules and GERL, will be useful for understanding periacinar collagenization followed by intralobular sclerosis. In another study, we demonstrated prolyl hydroxylase immunohistochemically in acinar cells 41 . Intracytoplasmic filaments up to 7-8 nm in diameter have also been investigated in degenerative acinar cells. The filaments were found in close proximity to the degenerative zymogen granules and lysosomes, and were confirmed to be caused by alcohol-enhanced metabolic injury to the acinar cells 32, 42 . Although it is known that several types of filaments or fibrils have also been found in the acinar cells during...

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