Professional Documents
Culture Documents
Alcohol use disorders are common, lethal conditions that often masquerade
as other psychiatric syndromes. The average alcohol-dependent person
decreases his or her life span by 10 to 15 years, and alcohol contributes to
22.000 deaths and two million nonfatal injuries each year.
The alcohol-related disorders impact on all aspects of health care delivery
systems, especially psychiatric practice. At least 20 percent of the patients
in mental health settings have alcohol abuse or dependence, including
individuals from all socioeconomic strata and both genders.
The problems can begin early – a resent national evaluation of students on
college campuses reported a 12-month prevalence for alcohol dependence
of 6 percent and for abuse more than 20 percent – and alcohol has been
estimated to have contributed to at least 15, on deaths in students per year.
Of particular importance to the psychiatrist are the estimated 40 to 50
percent of alcoholics who develop alcohol – induced, but temporary,
clinical syndromes that resemble major depressive disorders, panic
disorders, generalized anxiety disorders, and additional mood or anxiety
conditions. In addition, men and women with several independent
psychiatric disorders have elevated risks fore the future development of
alcohol – related disorders, including those with manic – depressive
disease, schizophrenia, antisocial personality disorders, panic disorders,
and, possibly, generalized anxiety disorders. Because the optimal short-
and long-term treatments of substance-induced and independent
psychiatric conditions are often different the clinician must learn to
recognize and differentiate between these conditions.
2
are more at four potential areas of difficulties. These include repeated legal,
interpersonal, social, or occupational impairments related to alcohol as well
as use of alcohol in physically hazardous situations.
DSM-1v-TR reformulated the concept of abuse to identify criteria that were
not just a subset of those noted for dependence. Although abuse and
dependence both correlated with similar background characteristics,
including the family history of alcoholism, dependence has been reported
to be tied to future problems for as many as 80 percent. Approximately 50
percent of those with difficulties with alcohol abuse continue to have
alcohol problems, but fewer than 10 percent go on to dependence. A similar
definition of dependence is offered in the tenth revision of the International
Statistical Classification of diseases and Related Health Problems (ICD-10).
Here, however, the threshold for diagnosis is any three of six (rather than
seven) items. The criteria for ICD-10 dependence include all the concepts in
DSM-1v_TR, although they are expressed and numbered differently, and
some concepts are combined in a single criterion. ICD-10 also lists a second
and less intense alcohol use disorder known as harmful use. The definition
of this second syndrome is quite different from DSM-1v-TR abuse because
the ICD-10 approach is based on evidence of repeated interference with
psychological and physical health functioning and does not include social
impairment, legal problems, or use in physical hazardous situations. Some
authors have called for the recognition of a more sever early-onset alcohol
dependence syndrome, often accompanied by criminality and dependence
on other drugs, which has been labeled as type 11 or type B alcoholism.
These approaches are consistent with the recognition that an earlier-onset
alcohol dependence syndrome, like most medical and psychiatric disorders
is likely to have more severe course, but it appears as if some of the
prognostic significance of type 11 or B alcoholism rests with an elevated risk
for a concomitant antisocial personality disorders in the early-onset group.
4
Epidemiology
See Table-1.
Different groups in the U.S. have different rates of drinkers.
Generally, groups with high education and high socioeconomic status have
the highest proportion of people who currently imbibe. Among religious
groups, Jews have the highest proportions who consume alcohol but the
lowest number of people with alcohol dependence. Conservative
Protestants and Catholics are less likely to use alcohol than liberal
Protestants and Catholics.
Other groups, such as the Irish, have higher rates of severe alcohol
problems, but they also have significantly higher rates of abstention. Very
high rates of alcohol problems are found among most, but not all, American
Indian and Inuit Tribes.
In the U.S. in the mid-1990, the average person older than 14 years of age
consumed 2, 2 gallons of absolute alcohol a year.
Alcohol problems
the dose, with opposite actions during the intoxication and withdrawal.
Alcohol acutely increases dopamine and its metabolites, brain imaging
reveals enhanced activity in relevant areas of the brain, and chronic
drinking changes dopamine receptor numbers and sensitivity. Another key
neurochemical is serotonin, with alcohol causing changes in key aspects of
this transmitter and associated receptors, and levels of serotonin impact on
the amount of alcohol consumed.
Alcohol also acutely enhanced the functioning of the opioid-related brain
systems and impacts on adenosine, neurosteroids, and acetylcholine.
4. Tolerance
With repeated administration of alcohol, large and large doses of the drug
are required to produce the desired effect. This phenomenon, called
tolerance, is also the ability to tolerate higher and higher doses of the
substance and in the result of at least three processes.
- Behavioral tolerance reflects the ability of a person to learn how to
perform tasks effectively despite the effects of alcohol.
- Pharmacokinetic tolerance is an adaptation of the metabolizing
systems, including ADH and microsomal ethanol oxidizing system
(MEOS), to rid the body of alcohol rapidly.
- Pharmacodinamic or cellular tolerance is an adaptation of the
nervous systems so that it can function, despite very high blood
alcohol concentrations (e.g., as much as 600 mg/dl), by resisting the
actions of alcohol on the cell.
Once tolerance has developed for one of the brain depressants, an
individual is likely to demonstrate a similar reaction to a second drug of
that class (cross-tolerance). Therefore, a person who has been drinking
heavily has tolerance for alcohol, and then stops drinking can be expected
to require a higher dose of benzodiazepines for sleep induction. If the
10
individual took two depressant drags at the same time, tolerance is not
likely to be observed, and the mixing of two substances can have lethal
effects.
Aspects of tolerance decrease and even disappear with consecutive weeks of
abstinence. In addition, some clinicians and researchers have described a
phenomenon of reveals tolerance, increased sensitivity, or sensitization.
This is a complex situation that might relate to neurochemical adaptation
or other mechanisms.
5. Craving
6. Blackout
7. Sleep impairment
Alcohol intoxication can help a person fall asleep more quickly, but intake
in an evening is more than one or two drinks, the sleep pattern can be
significantly impaired. Most heavy drinkers awake after several hours and
can have problems falling back asleep.
Alcohol also tends to depress rapid eye movements and inhibit stage 4 sleep
and, thus, is likely to be associated with frequent alternations between sleep
stages (sleep fragmentation) and with more dreams late in the night as the
blood alcohol level falls.
8. Cerebellar Degeneration
Under certain circumstances, one to two drinks per day can have some
beneficial effects.
Low doses of ethanol appear to decrease the risk for myocardial infarction
and thrombotic stake, probably through decreasing platelet aggregation
and enhancing the beneficial impact of high-density lipoprotein cholesterol.
Low doses of alcohol have also been reported to decrease the risk of some
old age dementias, peripheral arterial disease, and gallstones.
12