Alcohol is the most widely used psychoactive substance in the population. Due to the fact that not all cases of abuse are in the field of medical observation, epidemiological data on the alcoholization of the population, in addition to the number of patients with relevant diagnoses undergoing treatment, are obtained in a variety of ways: per capita consumption, life expectancy, suicide rate, germinal alcoholic the syndrome, the prevalence of cirrhosis of the liver, the cost of treatment for somatic diseases caused by alcoholism, the cost of lost as a result of alcoholism What time is it?
Morbidity varies greatly depending on geographical and socio-cultural conditions. In some countries, alcohol consumption is considered high (Russia, France, Scandinavia, Ireland, Korea), in some – low (China, countries of the Islamic world and the Mediterranean basin).
Mostly alcohol problems are typical for men; there are also significant transcultural differences. In women, pathological alcoholism begins later, spontaneous remissions are less likely. Pathology is most common at a young age (15-30 years), in individuals divorced or single, with lower levels of education and antisocial tendencies in adolescence. There is no systematic data on the role of the profession in the occurrence of the disease, however, there was a significant predominance of cases of liver cirrhosis in the service sector and literary circles.
Alcoholization is associated with 50% of road accidents, 50% of homicides, 25% of suicides. As a result of cirrhosis of the liver and a number of generalized somatic diseases provoked by alcoholism, the average life expectancy of patients is shortened by 10 years compared with the healthy population. Patients with alcoholism have the same risk of suicide as depressive patients – 15% of them complete their lives in this way.
Etiology. The disease is apparently the end result of a complex interaction of the biological vulnerability of the body and the influence of environmental factors. Hereditary burden plays an absolute role, although the mechanism of genetic transmission is still unknown. Children of alcoholics are 4 times more likely to get sick than non-alcoholic children, even if they were not brought up by their biological parents. In the presence of hereditary burden, the clinical picture is characterized by a more severe course.
The concordance of alcoholism among identical twins is twice as high as that of opposing people of the same sex. Neuropsychiatric pathology in childhood contributes to the development of the disease, for example, behavioral disorders (F91) or tic disorders (F95). A number of metabolic products when exposed to alcohol causes a change in the neurochemical adaptation of the brain at the cellular level. Perhaps this makes the body dependent on alcohol to maintain established pathological homeostasis. Alcohol can also lead to increased activity of endorphins or morphine-like substances.
The theory of learning was also used to explain the emergence of dependence. Temporary relieving of internal tension, fear, and the concomitant feeling of success in one’s social behavior during the first episodes of alcohol abuse can play the role of positive reinforcement, fixing a behavioral pattern dependent on alcohol.From the point of view of psychoanalytic theory, alcohol addiction predisposes excessively expressed, learned in the course of upbringing, excessive demands on moral attitudes and social behavior (“Super-I”). Stress arising from the inconsistency of the patient with these standards, decreases with alcoholism (“Super-I dissolve in alcohol”). Psychological features formed in early childhood that are generally typical for the personality of an alcoholic are described. It is characterized by timidity, difficulty in establishing contacts, insufficient self-assertion, impatience, irritability, anxiety, hypersensitivity and taboo in the course of education sexuality. An increased level of aspirations is combined with insufficient opportunities to achieve goals. Alcohol can give an illusory feeling of inner strength and success.
F10.0 Acute alcohol intoxication
Clinic, The state develops soon after taking an excessive (different depending on individual tolerance, rate of absorption and metabolism) amount of alcohol. A variety of clinical manifestations include disorders of social behavior, intellectual functions, motility, affect, vegetatics. In some cases, there is an increased talkativeness and sociability, in others – the desire for solitude and dysphorically suppressed background mood. Affective lability can reach the level of intermittent episodes of laughter and crying.
Symptoms increase as the level of alcohol in the blood increases, but they can also decrease with a sufficiently high tolerance, despite continued administration.
Depending on the dosage, the clinical picture changes, ranging from a state of mild euphoria (0.3 mg% in blood with normal tolerance) to impaired coordination, ataxia (1 mg%), confusion, constriction of consciousness (2 mg%), coma, suppression respiration and, occasionally, death (at a level in excess of 4 mg%).
In addition to signs common for acute intoxication, the condition should meet the following criteria: 1) the presence of at least one of the following behavioral and cognitive impairments: a) disinhibition, b) conflict, c) aggressiveness, d) affective lability, e) concentration disorders, f) narrowing of mental abilities, g) decrease in mental and productive productivity; 2) the presence of at least one of the following neurological disorders: a) unsteadiness of gait, b) negative Romberg test, c) signs of dysarthria, d) nystagmus, d) impairment of consciousness (for example, somnolence, coma).Differential diagnosis is carried out with soporous comatose states of a different etiology: injuries of the skull and spine, diabetic and hepatic coma, cardiac arrhythmia, myasthenia, overdose with a combination of use with other psychoactive substances.
F10.07 Pathological intoxicationThe etiology is unknown.
Predisposing factors are organic brain damage (especially in connection with encephalitis and injuries), old age, general fatigue, and alcoholism while taking sedatives and hypnotics. Since this rare violation is more common in people with an increased level of anxiety, for whom aggressive behavior is generally not characteristic, it is assumed that alcohol, causing disorganization of mental processes and loss of self-control, may contribute to the release of aggressive impulses.
The condition is characterized by behavioral disorders that suddenly appear shortly after drinking small amounts of alcohol (the level in the blood is usually below 1.5 mg%). Behavior is characterized by impulsive aggressiveness with tendencies that are dangerous for others or, more rarely, for oneself against the background of confusion, disturbances of orientation and perception (illusions, transient visual hallucinations and delusions). The condition lasts up to several hours, ending with a long sleep, followed by amnesia of the episode.
In addition to the fact that pathological intoxication occurs after taking a dose that does not cause a state of intoxication in most people and the signs common to Flx.0 are observed, the following criteria must be met: 1) the presence of verbal and / or non-verbal aggression towards others, which is atypical for a person sober condition, 2) the condition develops very quickly, usually within a few minutes after taking alcohol, 3) there is no data on the presence of any other cerebral or mental disorders.The differential diagnosis is carried out with episodes of sudden behavioral changes in temporal epilepsy.
The focus is on preventing the consequences of allo- and auto-aggressive behavior. Motor restriction may be necessary, but difficult because of the suddenness of development of the state. Plegiruyuschiy effect (if possible) is achieved by injection of antipsychotic (haloperidol).
F10.1 Harmful use of alcoholClinic.
Massive use of alcohol causes reversible fatty infiltration of the liver – the center of alcohol catabolism. It is not yet known exactly how this infiltration contributes to the occurrence of cirrhosis of the liver. Inflammation and, then, destruction of liver cells in cirrhosis is fatal in 10–30% of carriers of this disease.
Alcohol dissolves the gastrointestinal mucosa, causing irritation and bleeding, and contributes to achlorhydria, gastritis, and stomach ulcers. Diseases of the small intestine, pancreatic insufficiency and pancreatitis are also associated with alcoholism (75% of patients with pancreatitis are alcoholics). Alcohol interferes with the normal processes of digestion and absorption of food, reducing the intestinal absorption of a number of important nutrients, including vitamins and amino acids.
Chronic alcohol consumption violates the performance and rhythm of the heart, myocardial oxygenation, causing cardiomyopathy after 10 years or more of alcohol abuse. Chronic alcoholism due to a decrease in the number of leukocytes reduces the body’s resistance to infectious and oncological diseases, adversely affecting the body’s immunity.
As a result of direct effects on testosterone levels and testicular atrophy, alcohol reduces sexual and reproductive functions in men. Increasing the level of female hormones leads to female type of hair growth and an increase in the mammary glands in 50% of alcoholics. The indirect toxic effect of alcohol in the zone of limbic structures and the hypothalamus, as well as the neuropathy of the peripheral parasympathetic nerves involved in erection, also plays a role in impaired sexual function. In alcoholic women, there are dysfunctions of the sex glands, accompanied by insufficient production of female hormones, changes in secondary sexual characteristics, extinction of the menstrual cycle, infertility.
Alcohol use during pregnancy is fraught with the emergence of the so-called fetus in the fetus. fetal alcohol syndrome (slow growth before or after childbirth, abnormal configuration of the face and skull with a decrease in head circumference and flattening of facial features, signs of mental retardation and behavioral disturbances).
F10.2 Alcohol addiction syndrome
In addition to common for F1x. 2 manifestations of the syndrome of addiction should be mentioned that the specificity of chronic alcoholism includes various stereotypes of alcoholism. Drinking significant amounts of alcohol can be daily or limited to weekends. Alcohol abuse for several days / weeks / months (binges) can be interrupted by long periods of abstinence (dipsomanic stereotype). Daily alcoholism during off-hours can be accompanied for a long time by relatively safe professional status and lack of awareness of uncontrollable abuse.Binges can also be of a different nature, ending either spontaneously or involuntarily as a result of the corresponding complications of the social situation or physical condition (the latter is called “gamma-alcoholism” in the USA).
Characteristic signs are also episodes of complete or partial amnesia (the so-called palimpsests) of the period of intoxication, during which the patient could make the impression of a person with a safe mind on others.Amnestic manifestations generally correlate with the severity and duration of the disease.
The tendency to the use of non-food alcohol (technical alcohol, polish, brake fluid, etc.) is quite typical, increasing with the social degradation.Diagnosis. Diagnosis of addiction syndrome, especially in its initial stages, as a rule, complicates the tendency of patients to reject alcohol abuse. Sometimes the family of the patient takes the same position. The clinician should pay attention to such signs of early problems associated with alcoholism, such as difficulties in communicating with the spouse partner, loss of contact with children, loss of interest in family problems, frequent outbreaks of irritability.
Alcohol can be used both to relieve sexual lethargy and to avoid sexual contact. Late arrivals, inability to properly organize work, and meet the deadlines become typical for professional activities. Morning vomiting, diarrhea, gastritis, liver enlargement, cigarette burns on the fingers can be early somatic stigmas.
Central is the problem of abstinence from alcohol. Due to the fact that the so-called. controlled use still represents a high risk of relapse, the patient should be offered complete and lifelong abstinence, on the assumption that there is no condition: “recovered alcoholic”.The formation of motivation for total abstinence determines the overall success of treatment and depends on the proper use of intrapsychic and social factors that are important for motivation. Here, a proper assessment is needed in each case of an individual complex system of hereditary factors, conditions for early development, personal structure, socio-cultural and family influences, and concomitant psychiatric pathology.
The pessimistic conclusion about the lack of motivation for treatment too often hides the inability of the doctor to find an individual approach to the patient, to establish a therapeutically productive relationship with him.
At the initial stages, individual psychotherapy sets the tasks of emotional support for the patient with a gradual analysis of the mechanisms of dependence on others, lack of self-esteem, aggressive impulses, and such maladaptive psychological defenses as lies and denial. The most successful is a combined psychotherapeutic approach, which includes both identifying the internal causes of alcoholism (lack of resistance to social stress, low self-affirmation, etc.) with the development of more effective strategies for resolving behavior, and connecting with emotionally stimulating social influences that are important for the patient ( family relations, goal-setting behavior in the professional sphere).
Here, various group and matrimonial therapy programs are very effective, carried out both in inpatient conditions and for the purpose of long-term supportive psychotherapy in outpatient settings, including self-help groups (the most famous of them is the Alcoholic Anonymous program).
f it is impossible to correct the pathogenic influence of the family and close social environment, it is advisable to temporarily place the patient after the inpatient treatment in specially structured conditions of out-of-hospital residence.
The latter have not yet received practical distribution in Russia.Of the drugs, the most widely used is antabuse (disulfiram), the metabolism of which is accompanied by the accumulation of acetaldehyde in the blood when even small amounts of alcohol are consumed. The toxic reaction caused by a daily dose of 250 mg of antabus includes facial flushing, feeling of heat in the sclera, upper limbs and chest, nausea, dizziness, marked malaise, blurred vision, tachycardia, feeling of suffocation, numbness of the extremities.
The most serious consequence is a pronounced decrease in blood pressure. The reaction usually lasts 30-60 minutes. At higher doses of antabus, impaired consciousness and memory disorders may develop. The success of therapy depends on the motivation of the patient to regularly receive antabus.
At the initial stages of withdrawal symptoms of anxiety, anxiety, sleep disturbances dominate, which are controlled by anxiolytics; the clinical severity of depression during this period necessitates the use of antidepressants, lithium.
To relieve anxiety, behavioral therapy techniques can be successfully used (relaxation programs, self-control, self-affirmation enhancement). Chemical observational conditioning (apomorphine, against the background of which alcohol intake causes vomiting), as well as various suggestive methods (acupuncture, shock psychotherapy, coding, therapeutic vows, etc.) have a long-term effect only in a narrow category of highly motivated to treatment. patients, by virtue of which they are not funded by the insurance system, and they find much more limited use in world narcology than in Russia.
F10.3 Cancellation status due to alcohol use
Clinic. The condition is characterized primarily by a variety of vegetative symptoms, gross rapid-frequency generalized tremor, aggravated by movement or excitement. Due to the reduction in alcohol by the convulsive threshold, often within the first day, large convulsive seizures may develop, especially if they are in history. Usually disturbed sleep, accompanied by vivid nightmare dreams. Symptoms are enhanced by prolonged use of significant doses, dipsomanic alcoholism stereotype, general weakening of the body as a result of overwork, malnutrition, concomitant physical illness or depressive state.
The syndrome develops in 24–48 hours after stopping the intake and does reverse development within 5–7 days (including without treatment), although irritability and sleep disturbances can last even longer. In some cases, the development of symptoms leads to the resumption of alcohol intake for its removal.
In order to make a diagnosis, in addition to meeting the general criteria for withdrawal syndrome (Flx.3), at least 3 of the following symptoms should be observed: a) tremor of the fingers of the hands extended in front, the tip of the tongue or the eyelids, b) sweating, c) foul condition, nausea, vomiting, d) tachycardia or hypertension, e) psychomotor agitation, e) headaches, g) insomnia, h) malaise, weakness, and) transient visual, tactile or auditory hallucinations or illusions, j) large convulsive seizures.
Symptomatic treatment with bed rest, rehydration with severe fluid loss (sweating, vomiting, low-grade fever), elimination of vitamin B12 deficiency and folic acid. With reduced nutrition, thiamine is injected parenterally (before glucose, since the latter can impede the absorption of thiamine). If there is information about convulsive seizures in the history, magnesia sulphate is prescribed (2.0 50% w / m 4 times a day for two days). In general, anticonvulsants are less effective in preventing and treating convulsive manifestations with withdrawal syndrome.
In this regard, as well as to relieve hyperactivity of the sympathetic nervous system, benzodiazepines (diazepam, chlordiazepoxide) are more effective.
F10.4 Cancellation status with delirium due to alcohol use
The condition is also known as delirium tremens (delirium tremens). This is the most severe manifestation of withdrawal syndrome; it develops within a week after stopping or reducing doses, most often at the age of 30–40 years after 5–15 years of consuming significant doses. It develops in about 5% of alcoholics who are on a permanent basis, often being the first sign of alcoholism not previously diagnosed. Dipsomanic stereotype of alcoholism and concomitant somatic pathology contributes to the emergence.
Vegetative disturbances (tachycardia, sweating, hypertension), low-grade fever, wakefulness of perception (often visual and tactile, in the form of insects, small animals) and rudimentary delusional ideas defining the patient’s behavior, often dangerous, join signs common for delirium (F05). for myself and others. Large convulsive seizures are common, usually anticipating the onset of delirium in a third of patients with convulsive syndrome, most likely due to the deficiency of pyri-doxin (vitamin B6). Increases the pressure of the liquor and the level of globulin in it. In half of the cases transient albuminuria is noted.
The syndrome differs from delirium of non-alcoholic genesis by more severe impairments of consciousness and behavior, deeper amnesia of the episode at the exit from it, and greater vestige-related concomitant delusions.In the absence of complications, death is relatively rare (3-4%). The presence of auditory hallucinations is a prognostic sign of a more protracted course. In the absence of recovery, the state progresses to the formation of Korsakov syndrome in 15% of cases. If untreated, as a result of concomitant somatic pathology (pneumonia, fat embolism, renal, hepatic or heart failure as a result of hypohydration and hyperkalemia) delirium can be fatal in 20% of cases.
The most reliable way of dealing with delyriya is its prevention. 25-50 ‘mg of Elenium (chlordiazepoxide) every 2-4 hours during the most dangerous period of the withdrawal syndrome usually prove to be sufficient. If delirium could not be prevented, the dose is increased to 50-100 mg every 4 hours. The use of phenothiazine preparations should be avoided due to the fact that they lower the threshold of convulsive readiness, and may also contribute to a further reduction in liver function.Important is a high-calorie diet rich in carbohydrates and vitamins, if necessary – measures for rehydration.
The physical limitation of agitated patients is impractical, since they usually do not stop their attempts to free themselves, continuing to complete exhaustion. Skillful sedative psychotherapy may be important.
F10.5 Psychotic disorders as a result of alcohol
Manifestations of alcoholic hallucinosis (usually auditory) usually begin within 48 hours after the cessation of alcoholism and persist after the withdrawal of withdrawal syndrome, while not being a component of possibly accompanying delirious symptoms. The content of votes is usually unpleasant for the patient, causing reactions of fear and anxiety, sometimes defining behavior and making it dangerous. This is usually a critical, threatening or offensive comment, where the patient is mentioned in the third person. Auditory deceptions can take on the character of elementary sounds (for example, calls).
The disorder is relatively rare, more common in men; the syndrome appears at any age, but against the background of an already formed dependence on alcohol. Its duration is varied – from several weeks to several months.Psychotic disorders can take on the character of paranoiac symptoms or systematized delusions, the most famous of which is the alcoholic delirium of jealousy.
The diagnosis of the latter can be complicated by the existence of real justifications for jealousy due to the sometimes existing decline in sexual function and the loss of the patient’s interest in family matters.
From schizophrenia and affective disorders, these conditions are distinguished by the lack of relevant data in history, a temporary connection with the abolition of alcohol, the relative short duration of the course, the characteristic content of votes. The syndrome differs from alcoholic delirium by preservation of consciousness, the preferred appearance of hallucinations not at night.Treatment includes primarily activities carried out with withdrawal syndrome. In the absence of effect, small doses of high-potency neuroleptics can be used with discontinuation after the symptoms have been eliminated.
F10.6 Alcohol-based Amnesia Syndrome
Wernicke’s encephalopathy (delirium, ataxia, nystagmus, ophthalmoplegia), acutely developing amid perennial alcohol abuse with concomitant tiamin deficiency due to nutritional deficiencies and vitamin B1 absorption, in 85% of cases without treatment ends with amnestic syndrome (psychosis) of Korsakov, nature a feature of which is a violation of short-term memory (but not direct memorization) against the background of an unbroken consciousness with the impossibility of transition of short-term memory into long-term yu Both disorders sometimes designate Wernicke-Korsakov syndrome.
The syndrome in recent years has become increasingly rare due to the routine use of thiamine during detoxification. The common amnesia disorder can be accompanied by the usual somatic and neurological consequences of alcohol abuse. With daily use of 50-100 mg of thiamine chloride, it is possible to achieve different degrees of recovery, but in most cases, Korsakov’s syndrome remains irreversible, despite withdrawal and continued administration of thiamine. Structural deficiency of the trunk and diencephalic brain regions is determined pathologically.