Chapter 11.

Alcohol Related Disorders

Substance Dependence
Substance Abuse
DSM-IV defines substance abuse as being characterized by the presence of at least one
specific symptom that indicates that substance use has interfered with the person's life.
EPIDEMIOLOGY
Prevalence of a diagnosis of substance abuse or dependence among the United States
population over the age of 18 was 16.7 percent. The lifetime prevalence for alcohol abuse or
dependence was 13.8 percent, and for nonalcohol substances it was 6.2 percent
Abuse and dependence on substances is more common in men than in women, with
the difference more marked for nonalcohol substances than for alcohol. Substance use is not
limited to adults. As shown by a recent survey of high school seniors, about 30 percent of them
had tried a nonalcohol substance at least once, and about 16 percent of them had tried a
nonalcohol, nonmarijuana substance (for example, amphetamine, hallucinogen, sedative, or
cocaine) at least once.
Diagnostic Criteria for Substance Dependence
A maladaptive pattern of substance use, leading to clinically significant impairment or distress,
as manifested by three (or more) of the following, occurring at any time in the same 12-month
period:
(1) tolerance, as defined by either of the following:
(a) a need for markedly increased amounts of the substance to achieve intoxication or desired
effect
(b) markedly diminished effect with continued use of the same amount of the substance
(2) withdrawal, as manifested by either of the following:
(a) the characteristic withdrawal syndrome for the substance
(b) the same (or closely related) substance is taken to relieve or avoid withdrawal symptoms
(3) the substance is often taken in larger amounts or over a longer period than was intended
(4) there is a persistent desire or unsuccessful efforts to cut down or control substance use
(5) a great deal of time is spent in activities necessary to obtain the substance (e.g., visiting
multiple doctors or driving long distances), use the substance, or recover from its effects
(6) important social, occupational, or recreational activities are given up or reduced because of
substance use
(7) the substance use is continued despite knowledge of having a persistent or recurrent
physical or psychological problem that is likely to have been caused or exacerbated by the
substance .
Diagnostic Criteria for Substance Abuse
A. A maladaptive pattern of substance use leading to clinically significant impairment or
distress, as manifested by one (or more) of the following, occurring within a 12-month period:
(1) recurrent substance use resulting in a failure to fulfill major role obligations at work,
school, or home

(2) recurrent substance use in situations in which it is physically hazardous (e.g., driving an
automobile or operating a machine when impaired by substance use)
(3) recurrent substance-related legal problems (e.g., arrests for substance-related disorderly
conduct)
(4) continued substance use despite having persistent or recurrent social or interpersonal
problems caused or exacerbated by the effects of the substance
Alcohol-Related Disorders
Alcohol abuse and dependence are commonly referred to as alcoholism; however,
because "alcoholism" lacks a precise definition, it is not used in the fourth edition of Diagnostic
and Statistical Manual of Mental Disorders (DSM-IV) or in most other officially recognized
diagnostic systems.
EPIDEMIOLOGY
About 85 percent of all United States residents have had an alcohol-containing drink at least
once in their lives, and about 51 percent of all United States adults are current users of alcohol.
After heart disease and cancer, alcohol-related disorders constitute the third largest health
problem. About 30 to 45 percent of all adults in the United States have had at least one
transient episode of alcohol-related problems, usually involving an alcohol-induced amnestic
episode (for example, a blackout), driving a motor vehicle while intoxicated, or having missed
school or work because of excessive drinking. About 200,000 deaths each year are directly
related to alcohol abuse. About half of all automotive fatalities involve a drunken driver.
Alcohol use and alcohol-related disorders are also associated with about 50 percent of all
homicides and 25 percent of all suicides. Alcohol abuse reduces life expectancy by about 10
years.
Age and Sex
The age group with the highest percentage of active alcohol users, which is also the age group
that consumes the most alcohol, is the group in the ages from 20 to 35. More men than women
use alcohol, and the ratio of men to women for alcohol-related disorder diagnoses is ABOUT 2 TO
1 OR 3 TO 1.
Comorbidity (Dual Diagnosis) with other Mental Disorders
Comorbidity usually means the presence of additional psychiatric diagnoses in a person who
has a diagnosis of an alcohol related disorder. The most often associated psychiatric diagnoses
with the alcohol-related disorders are other substance-related disorders, antisocial personality
disorder, mood disorders, and anxiety disorders. Most data suggest that persons with alcoholrelated disorders have a markedly higher suicide rate than do the general population.
Antisocial personality disorder. A relation between antisocial personality disorder and
alcohol-related disorders has frequently been reported. Some studies have suggested that
antisocial personality disorder is particularly common in men with an alcohol-related disorder.

Mood disorders. About 30 to 40 percent of person with an alcohol-related disorder meet the
diagnostic criteria for major depressive disorder sometime during the lifetimes. Depression is
more common in alcoholic women than in alcoholic men. Persons with alcohol-related disorder
and major depressive disorder are at great risk for attempting suicide. Bipolar disorder patients
are thought to be at risk for the development of an alcohol-relate disorder because they may
use alcohol to self-medical their manic episodes.
Anxiety disorders. Alcohol is effective in alleviating anxiety, and many persons use alcohol
for that reason. Although the comorbidity between alcohol-related disorders and mood
disorders is fairly widely recognized, it less well known that perhaps 25 to 50 percent of all
persons with alcohol-related disorders also meet the diagnostic criteria for an anxiety disorder
ALCOHOL - RELATED DISORDERS
Diagnostic criteria for alcohol intoxication
A. Resent ingestion of alcohol
Clinically significant maladaptive behavior or psychological. changes (inappropriate sexual or
aggressive behavior, mood liability, impaired judgment, impaired social or occupational
functioning) that developed during, or shortly after, alcohol ingestion.
C. One or more of the following signs, developing during or shortly after alcohol use
(1) slurred speech
(2) Incoordination
(3) unsteady gait
(4) nystagmus
(5) impairment in attention or memory
(6) stupor or coma

Diagnostic Criteria for Alcohol Withdrawal

A.

Cessation of (or reduction in) alcohol use that has been heavy and prolonged.

B. Two (or more) of the following, developing within several hours to a few days after criterion
A:
(1) autonomic hyperactivity (sweating or pulse rat greater than 100)
(2) increased hand tremor
(3) insomnia
(4) nursing or vomiting
(5) transient visual, tactile or auditory hallucinations or illusions
(6) psychomotor agitation
(7) anxiety
(8) grand mal seizures
C. The symptoms In criterion cause clinically significant distress or impairment in social ,
occupational or other areas of functions.
In DSM 1Y all substens related disorders use the same criteria for dependence and abuse. With
regard to alcohol dependence and alcohol abuse, seek man need for the daily use of large

amounts of alcohol for adequate functioning. A regular pattern of heavy drinking are strongly
suggestive of those alcohol use disorders. The patterns are often associated with such
behaviors as:
(1) the inability to cut down or stop drinking,
(2) repeated efforts to control or reduce excessive drinking
(3) binges (remaining intoxicated throughout the day for at least two days),
(4) the occasional consumption of a fifth of spirits
(5) amnestic periods for events occurring while intoxicated (blackouts),
(6) the continuation of drinking despite a serious physical disorder that the person knows is
exacerbated by alcohol use,
(7) the drinking of nonbeverage alcohol, such as fuel and commercial products containing
alcohol.
In addition, people with alcohol dependence and alcohol abuse show impaired social or
occupational functioning because of alcohol use. Such as violence while intoxicated, absence
from work, loss of job, legal difficulties (for example, arrest for intoxicated behavior and traffic
accidents while intoxicated), and arguments or difficulties with family members or friends because of excessive alcohol use.
Subtypes of alcohol dependence. Various researchers have attempted to divide alcohol
dependence into subtypes, based primarily on phenomenological characteristics.
One recent classification notes that persons with type A alcohol dependence have a late
onset, few childhood risk factors, few alcohol related problems, and little psychopathology.
Persons with type alcohol dependence have many childhood risk factors, severe
dependence, an early onset of alcohol-related problems, much psychopathology, a strong
family history of alcohol abuse, frequent polysubstance abuse, a long history of alcohol
treatment, and a high number of severe life stresses.
Some researchers have found that type A alcohol-dependent persons may respond to
interactional psychotherapies, whereas type alcohol-dependent persons may respond best
to the training of coping skills.
Another investigator's describe gamma alcohol dependence. Such persons are unable to stop
drinking once they start. If the drinking ends as a result of ill health or lack of money, they are
capable of abstaining for varying periods of time. In delta alcohol dependence the alcoholdependent person must drink a certain amount each day but is unaware of a lack of control.
The alcohol use disorder may not be discovered until the person must stop drinking for some
reason and then feels the symptoms of withdrawal.
Still another investigator suggested the type /, male-limited subtype of alcohol dependence;
it is characterized by a late onset, more evidence of psychological dependence than of
physical dependence, and the presence of guilt feelings concerning the use of alcohol. Type ,
male-limited alcohol dependence is characterized by an onset at an early age, the
spontaneous seeking of alcohol for consumption, and a socially disruptive set of behaviors
when the person is intoxicated.
Alcohol Intoxication

Diagnosis and clinical features. Alcohol intoxication is not a trivial condition. Extreme
alcohol intoxication can lead to coma, respiratory depression, and death, either because of
respiratory arrest or because of the aspiration of vomitus. Treatment for severe alcohol
intoxication involves mechanical ventilatory support in an intensive care unit, with attention to
the patient's acid base balance, electrolytes, and temperature.
The severity of the symptoms of alcohol intoxication correlates roughly with the blood
concentration of alcohol, which reflects the alcohol concentration in the brain. At the onset of
intoxication, some persons become talkative and gregarious; some become withdrawn and
sullen; other become belligerent. Some patients show a lability of mood with intermittent
episodes of laughing and crying. A short term tolerance to alcohol may occur, such that the
person seems to be less intoxicated after many hours of drinking than after only a few hours.
The medical complications of intoxication include those that result from falls, such as
subdural hematomas and fractures. Telltale signs of frequent intoxication are facial
hematomas, particularly about the eyes, which are the result of falls or fights while drunk. In
cold climates, hypothermia and death may occur. A person with alcohol intoxication may also
be predisposed to infections, secondary to a suppression of the immune system.
Alcohol Withdrawal
Diagnosis and clinical features. The classic sign of alcohol withdrawal is tremulousness,
seizures, and the symptoms of delirium tremens (DTs. Tremulousness develops six to eight
hours after the cessation of drinking, the psychotic and perceptual symptoms start in 8 to 12
hours, seizures in 12 to 24 hours, and DTs within 72 hours, although physicians should watch
for the development of DTs for the first week of withdrawal. The syndrome of withdrawal
sometimes skips the usual progression and, for example, goes directly to DTs.
Except the tremor other symptoms of withdrawal include general irritability, gastrointestinal
symptoms (for example, nausea and vomiting), and sympathetic autonomic hyperactivity,
including anxiety, arousal, sweating, facial flushing, mydriasis, tachycardia, and mild
hypertension. Patients experiencing alcohol withdrawal are generally alert but may startle
easily.
Withdrawal

seizures. Seizures associated with alcohol withdrawal are stereotyped,

generalized, and tonic-clonic in character. Patients often have more than one seizure in the
three to six hours after the first seizure. Status epilepticus is relatively rare in alcohol
withdrawal patients, occurring in less than 3 percent of all patients. Long-term severe alcohol
abuse can result in hypoglycemia, hyponatremia, and hypomagnesemiaall of which can also
be associated with seizures.
Treatment. The primary medications for the control of alcohol withdrawal symptoms are the
benzodiazepines. Many studies have found that benzodiazepines help control seizure activity,
delirium, anxiety, tachycardia, hypertension, diaphoresis, and tremor associated with alcohol
withdrawal. Benzodiazepines can be given either orally or parenterally, however, neither
diazepam (Valium) nor chlordiazepoxide (Librium) should be given intramuscularly (IM)
because of their erratic absorption by that route. The clinician must titrate the dosage of the
benzodiazepine, starting with a high dosage and lowering the dosage as the patient recovers.

Although benzodiazepines are the standard treatment of alcohol withdrawal, a number

of studies have shown at carbamazepine (Tegretol) in dosages of 800 mg a day as effective as
benzodiazepines and has the added benefit minimal abuse liability. That use of carbamzepine
is gradually becoming common in the United States and Europe. The b-adrenergic receptor
antagonists and clonidine (Catapres) have also been used to block the symptoms of
symmpathetic hyperactivity; however, neither of those drugs an effective treatment for
seizures or delirium.
Delirium
Diagnosis

and clinical features. Alcohol withdrawal delirium is a medical

emergency it can result in significant morbidity and mortality. Delirious patients are a danger
to themselves and to others because of the unpredictability of their behavior. The patients may
be suicidal or may be acting on hallucinations or delusional thoughts as if they were genuine
dangers. Untreated, DTs has a mortality rate of 20 percent, usually as a result of an
intercurrent medical illness, such as pneumonia, renal disease, hepatic insufficiency, or heart
failure. The essential feature of the syndrome is delirium that occurs within one week after the
person stops drinking or reduces his or her intake of alcohol. In addition to the symptoms
delirium. In addition to the symptoms delirium the features include (1) autonomic
hyperactivity, such as tachycardia, diaphoresis, fever, anxiety, insomnia, and hypertension; (2)
perceptual distortions, which are most frequently visual or tactile hallucinations; and

(3)

fluctuating levels of psychomotor activity, ranging from hyperexcitability to lethargy.

About 5 percent of all alcoholic persons who are hospitalized have DTs. Since the syndrome
usually develops the third hospital day, a patient admitted for a united condition may
unexpectedly go into an episode of delirium, which is the first sign of a previously undiagnosed
alcohol-related disorder. Episodes of DTs usually begin in patient's 30s or 40s after 5 to 15
years of heavy drinking, typically of the binge type.

A 43-year-old divorced carpenter was

examined in a hospital emergency observation ward. The patient's sister was available to
provide some information. She reported that the patient had consumed large quantities of
cheap wine daily for more than five years. He had had a reasonably stable home life and job
record until his wife left him for another man five years before. The sister indicated that the
patient had been consuming more than a fifth of wine a day since his divorce. He often had
blackouts from drinking and had missed days from work; consequently, he had been fired from
several jobs. Fortunately for him, carpenters are in great demand, and he had been able to
provide marginally for himself during those years. However, three days before hospitalization,
he had run out of money and wine and had to beg on the street to buy a meal. The patient had
been poorly nourished, eating perhaps one meal a day and evidently relying on wine for
nourishment.
The morning after his last day of drinking (three days earlier), he felt increasingly
tremulous, his hands shaking so grossly that he could hardly light a cigarette. He also had an
increasing sense of inner panic, which had made him virtually unable to sleep. A neighbor
became concerned about the patient when he seemed not to be making sense and was clearly
unable to take care of himself. The neighbor called the sister, who brought him to the hospital.

On examination, the patient alternated between apprehension and chatty, superficial

warmth. He was keyed up and talked almost constantly in a rambling and unfocused manner.
At times he recognized the doctor, but at other times he got confused and thought the doctor
was his older brother. Twice during the examination he called the doctor by his older brother's
name and asked when he had arrived, evidently having lost track entirely of the interview up
to that point. He had a gross hand tremor at rest. He was disoriented and thought that he was
in a supermarket parking lot, rather than in a hospital. He indicated that he felt he was fighting
against a terrifying sense that the world was ending in a holocaust. He was startled every few
minutes by sounds and scenes of fiery car crashes (evidently provoked by the sound of rolling
carts in the hall). Efforts to test his memory and his calculation ability failed because his
attention

shifted

rapidly.

An

electroencephalogram

indicated

pattern

of

diffuse

encephalopathy.
Treatment. The best treatment for DTs is its prevention. Patients who are withdrawing from
alcohol should receive a benzodiazepine, such as 25 to 50 mg of chlordiazepoxide (Librium)
every two to four hours until they seem to be out of danger. Once the delirium appears,
however, 50 to 100 mg of chlordiazepoxide should be given every four hours orally, or
intravenous lorazepam (Ativan) should be used if oral medication is not possible. A highcalorie, high-carbohydrate diet supplemented by multivitamins is also important. When patients are disorderly and uncontrollable, a seclusion room can be used. Dehydration, often
contributed to by diaphoresis and fever, can be corrected with fluids by mouth or
intravenously. Anorexia, vomiting, and diarrhea often occur during withdrawal. Antipsychotic
medications should be avoided because they may reduce the seizure threshold in the patient.
Nonbenzodiazepine anticonvulsant medication is not useful in preventing or treating
alcohol withdrawal convulsions, although benzodiazepines are generally effective.
Alcohol-Induced Persisting Dementia
Some clinicians and researchers believe that it is difficult to separate the toxic effects of
alcohol abuse from the CNS damage done by poor nutrition, multiple trauma, and the CNS
damage that follows the malfunctioning of other bodily organs (for example, the liver, the
pancreas, and the kidneys). Although several studies have found enlarged ventricles and
cortical atrophy in persons with dementia and a history of alcohol dependence, the studies do
not help clarify the cause of the dementia.
Alcohol-Induced Persisting Amnestic Disorder
Diagnosis and clinical features. The diagnostic criteria of alcohol-induced persisting
amnestic disorder are contained in the DSM-IV category of substance-induced persisting
amnestic disorder. The essential feature of alcohol-induced persisting amnestic disorder is a
disturbance in short-term memory caused by the prolonged heavy use of alcohol. Since the
disorder usually occurs in persons who have been drinking heavily for many years, the disorder
is rare in persons under the age of 35.
Wemicke's and Korsakof 's syndromes. The classic names for alcohol-induced persisting
amnestic disorder are Wernicke's syndrome (a set of acute symptoms) and Korsakoffs
syndrome (a chronic condition). Whereas Wernicke's syndrome is completely reversible with

treatment,

only

about

20

percent

of

Korsakoffs

syndrome

patients

recover.

The

pathophysiological connection between the two syndromes is thiamine deficiency, caused

either by poor nutritional habits or by malabsorption problems. Thiamine is a cofactor for
several important enzymes, and it may also be involved in the conduction of the axon po tential
along the axon and in synaptic transmission.
Wernicke's syndrome, also called alcoholic encephalopathy, is an acute neurological
disorder characterized by ataxia (affecting primarily the gait), vestibular dysfunction,
confusion, and a variety of ocular motility abnormalities, including horizontal nystagmus,
lateral rectal palsy, and gaze palsy. Usually, those eye signs are bilateral, although not
necessarily symmetrical. Other eye signs may include a sluggish reaction to light and
anisocoria. Wernicke's syndrome may clear spontaneously in a few days or weeks, or it may
progress into Korsakoffs syndrome.
Treatment. The early stages of Wernicke's syndrome respond rapidly to large doses of
parenteral thiamine, which is believed to be effective in preventing the progression into
Korsakoffs syndrome. The dosage of thiamine is usually initiated at 100 mg by mouth two to
three times daily and is continued for one to two weeks. In patients with alcohol-related
disorders who are being given intravenous (IV) administrations of glucose solution, it is good
practice to include 100 mg of thiamine in each liter of the glucose solution.
Korsakoffs syndrome is the chronic amnestic syndrome that can follow Wernicke's
syndrome, and the two syndromes are believed to be pathophysiologically related. The
cardinal features of Korsakoffs syndrome are impaired mental syndrome (especially recent
memory) and anterograde amnesia in an alert and responsive patient. The patient may or may
not have the symptom of confabulation. Treatment of Korsakoffs syndrome is also thiamine
given 100 mg by mouth two to three times daily; the treatment should be continued for 3 to 12
months. Few patients who progress to Korsakoffs syndrome ever fully recover, although a
substantial proportion have some improvement in their cognitive abilities with thiamine and
nutritional support.
A clinical case example of Wernicke-Korsakoff syndrome follows:
A 46-year-old house painter was admitted to a hospital with a history of 30 years of heavy
drinking. He had had two previous admissions for detoxification, but his family stated that he
had not had a drink in several weeks, and he showed no signs of alcohol withdrawal. He looked
malnourished, however, and on examination was found to be ataxic and to have a bilateral
sixth-cranial-nerve palsy. He appeared to be confused and mistook one of his physicians for a
dead uncle.
Within a week the patient walked normally. He seemed to be less confused than at admission
and could find his way to the bathroom without direction. He remembered the names and the
birthdays of his siblings but had difficulty naming the past five United States Presidents. He
had great difficulty in retaining information for longer than a few minutes. He could repeat a
list of numbers immediately after he had heard them but a few minutes later did not recall
being asked to perform the task. Shown three objects (keys, comb, ring), he could not recall
them three minutes later. He did not seem to be worried about his memory failure. Asked if he

could recall the name of his doctor, he replied, "Certainly," and proceeded to call him "Dr.
Masters" (not his name), whom he claimed he had first met during the Korean War. He told a
long untrue story about how he and "Dr. Masters" had served as fellow soldiers.
The patient was calm, alert, and friendly. Because of his intact immediate memory and spotty
but sometimes adequate remote memory, one could be with him for a short period and not
realize that he had a severe memory impairment. His amnesia, in short, was largely
anterograde. Although treated with high doses of thiamine, the short-term memory deficit
persisted and appeared to be irreversible.
Blackouts. Blackouts are similar to episodes of transient global amnesia in that they are
discrete episodes of anterograde amnesia, although blackouts occur in association with alcohol
intoxication. The periods of amnesia can be particularly distressing because people may fear
that they have unknowingly harmed. During a blackout, people have relatively intact remote
memory; however, they experience a specific short-term memory deficit in which they are
unable to recall events that happened in the previous 5 or 10 minutes. Because their other
intellectual faculties are well preserved, they can perform complicated tasks and appear to be
normal to the casual observer.
Alcohol-Induced Psychotic Disorder
Diagnosis and clinical features. The diagnostic criteria for alcohol-induced psychotic
disorder (for example, delusions, hallucinations) are found in the DSM-IV category of
substance-induced psychotic disorder. The most common hallucinations are auditory, usually
voices, but they are often unstructured. The voices are characteristically maligning,
reproachful, or threatening, although some patients report that the voices are pleasant and
nondisruptive. The hallucinations usually last less than a week, although during that week
impaired reality testing is common. After the episode, most patients realize the hallucinatory
nature of the symptoms.
Hallucinations after alcohol withdrawal are considered rare symptoms, and the syndrome is
distinct from that of alcohol withdrawal delirium. The hallucinations can occur at any age, but
they are usually associated with persons who have been abusing alcohol for a long time. Al cohol

withdrawal-related

hallucinations

are

differentiated

from

the

hallucinations

of

schizophrenia by the temporal association with alcohol withdrawal, the absence of a classic
history of schizophrenia, and the usually short-lived duration of the hallucinations. Alcohol
withdrawal-related hallucinations are differentiated from the DTs by the presence of a clear
sensorium in the patients.
Treatment. The treatment of alcohol withdrawal-related hallucinations is much like the
treatment of DTs benzodiazepines, adequate nutrition, and fluids if necessary. If that regimen
fails and in long-term cases, antipsychotics may be used.
A 44-year-old unemployed man who lived alone in a single-room-occupancy hotel was brought
to an emergency room by the police, to whom he had gone for help, complaining that he was
frightened by hearing voices of men in the street below his window talking about him and
threatening him with harm. When he looked out the window, the men had always "disappeared."

The patient had a 20-year history of almost daily alcohol use, was commonly drunk each day,
and often experienced the shakes on awakening. On the previous day he had reduced his
intake to one pint of vodka because of gastrointestinal distress. He was fully alert and oriented
on the mental status examination.
Alcohol-induced mood disorder. DSM-IV allows for the diagnosis of alcohol-induced mood
disorder with manic, depressive, or mixed features and also for the specification of onset
during either intoxication or withdrawal. As with all the secondary and substance-induced
disorders, the clinician must consider whether the abused substance and the symptoms have a
causal relations.
Alcohol-induced anxiety disorder. DSM-IV allows for the diagnosis of alcohol-induced
anxiety disorder. DSM-IV further suggests that the diagnosis specify whether the symptoms are
those of generalized anxiety panic attacks, obsessive-compulsive symptoms, or phobic
symptoms and whether the onset was during intoxication or during withdrawal.
Alcohol-induced sexual dysfunction. DSM-IV allows for the diagnosis of symptoms of
sexual dysfunction associated with alcohol intoxication. The formal diagnosis is alcohol-induced
sexual dysfunction .
Alcohol-induced sleep disorder. DSM-IV allows for the diagnosis of sleep disorders that
have their onset during either alcohol intoxication or alcohol withdrawal. The diagnostic criteria
for alcohol-induced sleep disorder are found in the sleep disorders section .
Neurological and Medical Complications of Alcohol Use
Nutritional diseases of the nervous system secondary to alcohol abuse
Peripheral neuropathy
Optic neuropathy
Alcoholic cerebral atrophy
Systemic diseases due to alcohol with secondary neurological complications
Liver disease
Hepatic encephalopathy
Gastrointestinal diseases
Possible pancreatic encephalopathy
Cardiovascular diseases
Electrolyte imbalances leading to acute confusional states and rarely
focal neurological signs and symptoms
Hypoglycemia
Hyperglycemia
Hyponatremia
Hypercalcemia
Hypomagnesemia
Hypophosphatemja
Increased incidence of trauma
Epidural, subdural, and intracerebral hematoma
Spinal cord injury

Posttraumatic seizure disorders

Fetal Alcohol Syndrome
Fetal alcohol syndrome is the result of exposing fetuses to alcohol in utero when their
mothers drink alcohol. Fetal alcohol syndrome is the leading cause of mental retardation.
The risk of an alcoholic woman's having a defective child is as high as 35 percent. Although
the precise mechanism of the damage to the fetus is unknown, the damage seems to be the
result of exposure in utero to ethanol or its metabolites. Alcohol may also cause hormone
imbalances that increase the risk of abnormalities.
TREATMENT
Although some clinicians and groups are proponents of the concept of controlled drinking,
most clinicians and the majority of well-controlled research studies indicate the complete
abstinence from alcohol has to be the centerpiece of a successful treatment strategy for
alcohol abuse. Most people with alcohol-related disorders come to treatment as a result of
pressure from a spouse or an employer or fear that continued drinking will have a fatal
outcome. The patients who are persuaded, encouraged, or even coerced into treatment by
persons who are meaningful to them a more apt to remain in treatment and have a better
prognosis than are those who are not so pressured. The best prognosis, however, is for the
affected persons who come to a mental health worker voluntarily because they nclude that
they are alcoholics and that they need help.
Psychotherapy
When psychotherapy focuses on the reasons that the person drinks, it is more
successful than when it focuses on vague psychodynamic issues. The specific focus is or the
situations in which the patient drinks, the motivating forces behind the drinking, the expected
results from drinking, and alternate ways of dealing with those situations. Involving an
interested and cooperative spouse in conjoint therapy for at least some of the sessions is
highly effective initial contact The initial contact with a person with an alcohol-related disorder
is crucial to successful treatment. In the early because patients with alcohol problems often
anticipate rejection and may misinterpret a passive therapeutic rule to therapy, and they may
miss appointments or have relapses with regard to drinking. Many therapists attempt to view
alcohol abuse less in terms of an individual patient and more in terms of how that patient
interacts with family members, work or school colleagues, and society in general.
The therapist must also deal with alcohol as a psychological defense; the removal of the
emotional and intellectual barriers between the patient and the therapist should be an early
goal. The therapist must be prepared to have the therapeutic bond tested again and again and
cannot hide behind the screen of the patient's lack of motivation when relapses become
threatening to the therapist. Depressions can be countered by the active, supportive role of
the therapist and at times by the addition of antidepressant drug medication.
Medication
Disulfiram

Disulfiram (Antabuse) is used in the treatment of alcohol dependence. Its main effect is to
produce an unpleasant reaction in a person who ingests even a small amount of alcohol while
taking disulfiram. However, because of the risk of severe and even fatal disulfiram-alcohol
reactions, disulfiram therapy is used less often today than previously.
THERAPEUTIC INDICATIONS
The primary indication for disulfiram use is as an aversive conditioning treatment for alcohol
dependence. Either the fear of having a disulfiram-alcohol reaction or the memory of having
had one is meant to condition the patient not to use alcohol. It is usually sufficient to describe
the severity and the unpleasantness of the disulfiram-alcohol reaction graphically enough to
discourage the patient from imbibing alcohol. Disulfiram treatment should be combined with
such treatments as psychotherapy, group therapy, and support groups like Alcoholic
Anonymous (AA).
Psychotropics. Both antianxiety agents and antidepressants may be useful in the treatment
of anxiety and depressive symptoms in patients with alhol-related disorders. However,
increasing attention is being given to the possibility of using psychoactive drugs ill the control
of the sensation of craving for alcohol. Some evidence indicates that the serotonin-specific
reuptake inhibitors or trazodone (Desyrel) may be effective.
Alcoholics Anonymous
Alcoholics Anonymous (AA) is a voluntary supportive fellowship of hundreds of thousands of
persons with alcohol-related disorders that was founded in 1935 by two alcohol-dependent
men, a stockbroker and a surgeon. Physicians should be refer alcoholic patients to AA as part
of multiple treatment approach. Frequently, patients who object when AA is initially suggested
later derive much benefit from the organization and become enthusiastic participation. Its
members make a public admission of there alcohol-related disorder, and abstinence is the rule.
Al-Anon, Al-Anon is an organization for the spouses of persons with alcohol-related disorders;
it is structured along the same lines as AA. The aim of Ai-Anon are through group support, to
assist the efforts of the spouses, to regain self esteem, to refrain from feeling responsible for
the spouse's drinking, and to develop a rewarding life for themselves and their families