(From Behavioral, 3/5 Oct 2000, by Brian Buschman)
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There are many approaches to defining alcohol abuse. They include:
1) The psychoanalytic theory which says theory says that people are stuck in the oral phase.
2) The transactional analysis theory says that people don’t want to think about something so they put themselves in a position not to think.
3) Behaviorists see it as a learned skill.
4) The medical model sees it as a progressive disease.
The DMS-IV has definitions for four things associated with alcohol abuse which can interplay or be independent. They include:
Intoxication is based on signs of a person being medically intoxicated at a given point in time. A diagnosis of intoxication can be independent of any other diagnosis or can be combined with any of the below.
Alcohol abuse is defined as three or more problems related to alcohol across the period of one year. They could be any type of problems like DUIs, marriage problems or whatever.
Alcohol dependence is the signs of alcohol abuse mixed with signs of tolerance, withdrawal symptoms or excessive time spent related to the drug. You must progress from abuse to dependence because, by definition, you cannot have both at the same time.
Alcohol withdraw is based on symptoms of withdraw at a point in time. It must be diagnosed with dependence. You can have dependence without withdraw but you must have dependence to have withdraw.
Reverse tolerance is when tolerance begins to slowly go away because of liver damage.
There is a classic family response with six common steps when a family member becomes an alcoholic.
1) Denial that there is a problem with a family member.
2) Attempts to eliminate the problem. This probably includes trying to get them to stop drinking.
3) Disorientation and chaos of the family erupts. This happens as fights start, bills go unpaid and things just go to pot.
4) Reorganization takes place where the rest of the family learns to function independently of the alcoholic.
5) Efforts to escape, primarily divorce, lead to the separations. If they stay together the family begins to function around the alcoholic and they live parallel lives in the same house.
6) Family reorganization after the divorce or other escape.
Codependent persons are addicted to people that have addictions. They gain self esteem from trying to help other get out of their problems to the point of ignoring their own needs. Often after they divorce an alcoholic they will end up getting married to another alcoholic.
Children of alcoholics are usually genetically more likely to develop alcoholism.
With fetal alcohol syndrome you see babies with:
1) Low birth weight.
2) Small head size
3) Low IQ
4) Low, flat nasal bridge
You make the diagnosis of alcoholism based on either the CAGE or MAST questions. CAGE questions are four questions to stick in the interview that two yes questions indicate a likelihood of alcoholism. The MAST questions are 25 yes/no questions that can be put into a survey for the patient to take. Five or more yes answers is suggestive of alcoholism.
As a physician you should confront the patient in a non-threating way, often with the family if possible. They may need to be hospitalized for detox or may be just fine at home for it.
Don’t refer them to social workers. The social worker will try to solve the social problems thinking that after that the alcoholism will go away. They need to solve the drinking so the social problems will go away.
12 step programs like AA have proven to be VERY effective.
Alcoholic hepatitis is cause by drinking 100g of alcohol (12 beers) daily for a year. Patients present with:
On lab exam you will see slightly elevated AP and elevated liver enzymes.
Liver cirrhosis is caused by toxic effects of nutritional deficiency. You will see portal hypertension and liver damage starting in the center of the liver and working out.
Clinically you may see ascites from either back pressure or decreased albumen synthesis. You will see effects of portal hypertension. Gynocomastia may be present from increase of estrogens and from testicular atrophy.
You also see B12 deficiency and B1 induces CHF (Wet Beri beri).
You see peripheral neuropathy, CN VI palsy, cerebellar dysfunction and coma.
Wernicke-Korsakoff’s Syndrome includes retrograde amnesia, confabulation, apathy, peripheral neuropathy, CN VI palsy and nystagmus. Wernicke’s part is the neurological stuff and Korsakoff’s part is the memory loss. It is rarely reversible but some can be helped with thiamine.
Alcoholic withdraw may start up to three days after the patient stops drinking. They show orthostatic hypertension, visual hallucinations and DT (delirium tremors).
It starts about 48 hours after they stop drinking and ends within two weeks. It includes auditory hallucinations and things similar to schizophrenia. This can stimulate schizophrenia.
Marijuana abuse shows acute anxiety, cannabis psychosis, euphoria, increased appetite, memory loss and amotivational syndrome.
Pot and hallucinogens are the only two classes of drugs that do not have a set of withdraw symptoms.
Hallucinogens cause visual hallucinations, hypertension, tachycardia, hyperthermia and flashbacks.
Tactile hallucinations, hyperthermia and insomnia.
Withdraw can cause hypersomia, nightmares, REM rebound (vivid dreams) and suicidal attempts.
Respiratory depression, hypotension and depression of reflexes.
Withdraw causes dilated pupils, lacrimation and agitation. They come on 8-10 hours after stopping and last about 7 days.
Opoid intoxication can be treated with naloxone. Signs include DLOC and pin point pupils. Usually dilated when they are in a coma.
Inhalants cause pulmonary edema, liver and kidney damage, delirium and dementia.
After heavy use (400mg/day of phenobarbital, 40mg/day of diazepam). Symptoms include seizures, hyperreflexia, anxiety and cardiovascular collapse.
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