ALCOHOL USE

DISORDER
LOH ZHE QIANG
BMS 15091474
DEFINITION
ALCOHOL USE DISORDER is defined as
1. Repeated alcohol-related difficulties
2. In at least 2 of 11 life areas
3. That cluster together in the same12-month period
• Criterias were taken directly from the 7 dependence and 4 abuse criteria in
DSM-IV
• The lifetime risk is about 10–15% for men and 5–8% for women
• Severity of an alcohol use disorder
Mild - two or three items
Moderate - four or five
Severe - six or more
ALCOHOL
DEPENDENCE
SYNDROME
 ALCOHOL DEPENDENCE SYNDROME
• The Tenth Revision of the International Classification of Diseases and Health Problems
(ICD-10) defines Dependence Syndrome as :

-Cluster of physiological, behavioural, and cognitive phenomena in which the use of a

substance or a class of substances takes on a much higher priority for a given individual than
other behaviours that once had greater value.

*Characteristic of the dependence syndrome :

-Desire (often strong, sometimes overpowering) to take the psychoactive drugs
(which may or not have been medically prescribed), alcohol, or tobacco etc.
 Identification of the components of ADS
• According to Edwards6, dependence would be "an altered relationship between the person and his/her way
of drinking", in which the reasons why the individual started drinking are added to those related to
dependence. Therefore, dependence becomes a feedback behavior comprising much more than tolerance
and abstinence.

The elements of alcohol dependence syndrome are:

1) Narrowing of the repertoire

• Initially, users having flexible timetables, quantity and even type of beverage.
• Gradually, drinking reaches the point of consuming alcohol every day, in rising quantities & frequency.
• In advanced stages, consumption is uncontrolled, to relieve the symptoms of abstinence, without concern
with the organic, social or psychological harm.
• Their relationship with alcohol become strict and inflexible, in an all-or-nothing pattern.
2) Importance of the behavior of searching alcohol
• W/h narrowed drinking repertoire, subjects attempt to prioritize the
act of drinking in unacceptable situations (e.g. driving vehicles, at
work).
• Drinking becomes the center of the user’s life, above any other value.
(health, family, work)

3) Increase in the tolerance to alcohol

• As this syndrome evolves, there is the need of rising alcohol doses to
obtain the same effect achieved with lower doses.
4) Repeated symptoms of abstinence
• Decrease or interruption of alcohol consumptionsigns and symptoms of
variable intensity arise.
• At first, they are mild, intermittent and hardly incapacitating. In the severe
phases of dependence, the most significant symptoms may be intense
trembling and hallucinations.
 Physical: slight tremor on the
extremities up to generalized),
nausea, vomiting, sudoresis,
Descriptive headache, cramps, dizziness.

studies have
identified Affective: irritability, anxiety,
weakness, restlessness,
three groups depression.

of symptoms:
Sensoriperception: nightmares,
illusions, hallucinations (visual,
auditive or tactile).
5) Relief or avoidance of abstinence symptoms by increasing the ingestion of
alcohol
• Important symptom of ADS. It becomes more evident with the progression.
Patients admit their drinking in the morning to feel better, as they remained
all night without ingesting ethylic derivates.

6) Subjective perception of the need of drinking

• There is a psychological pressure to drink and relieve the symptoms of
abstinence.

7) Reinstallation after abstinence

• Even after long periods of abstinence, if patients relapse, they will rapidly
reestablish the former dependence pattern.
ALCOHOL DEPENDENCE (DX CRITERIA) (dsm-5)

(A) A maladaptive pattern of drinking, 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:
•Need for markedly increased amounts of alcohol to achieve intoxication or desired effect; or markedly diminished effect
with continued use of the same amount of alcohol

•The characteristic withdrawal syndrome for alcohol; or drinking (or using a closely related substance) to relieve or avoid
withdrawal symptoms

•Drinking in larger amounts or over a longer period than intended.

•Persistent desire or one or more unsuccessful efforts to cut down or control drinking

•Important social, occupational, or recreational activities given up or reduced because of drinking

•A great deal of time spent in activities necessary to obtain, to use, or to recover from the effects of drinking

•Continued drinking despite knowledge of having a persistent or recurrent physical or psychological problem that is likely
to be caused or exacerbated by drinking.

(B) No duration criterion separately specified, but several dependence criteria must occur repeatedly as specified by
duration qualifiers associated with criteria (e.g., “persistent,” “continued”).
REFERENCE
1.https://www.who.int/substance_abuse/terminology/definition1/en/
2.http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-
44462004000500004&lng=en&nrm=iso&tlng=en
3. Diagnostic and Statistical Manual of Mental Disorders, 5th Edition
(DSM-5)
Excessive alcohol
consumption
Jacintha
BMS 15091573
 Excessive alcohol consumption

• The level of drinking at which an individual is considered to

demonstrate excessive alcohol consumption is usually defined in
terms of the level of use associated with significant risk of alcohol-
related health and social problems.
• In everyday life, alcohol consumption can be measured by referring
to conventional measures such as pints of beer or glasses of wine.
• These measures have the advantage of being widely understood, but
they are imprecise because both beers and wines vary in strength.
• Alternatively, alcohol consumption can be measured in grams.
• This measure is precise and useful for scientific work, but is difficult
for many people to relate to everyday measures.
• Therefore, it is usually expressed in units of alcohol consumed per
week.
• A unit can be related to everyday measures because it corresponds
to half a pint of beer, one moderately-sized glass of table wine, one
conventional glass of sherry or port, and one single bar of spirits.
• In the UK, government advice published in 2015 suggests that men and
women should not regularly drink more than 14 units a week and that
those drinking towards the higher end of this range should spread their
drinking over 3 days or more.
Blood Alcohol Concentration
• Blood Alcohol Concentration (BAC) refers to the percent of alcohol
(ethyl alcohol or ethanol) in a person's blood stream.
• Depends on gender, weight, type and number of drinks and drinking
time.
• In Malaysia, a person is legally intoxicated if he/she has a BAC of
0.08% or higher.
• 0.05 % - thought, judgment, and restraint are
loosened and sometimes disrupted.

• 0.1 % - voluntary motor actions usually become

perceptibly clumsy.

• In most states, legal intoxication ranges from 0.1

to 0.15 % blood alcohol level.

• 0.2 % - function of the entire motor area of the

brain is measurably depressed, and the parts of
the brain that control emotional behavior are also
affected.

• 0.3% - a person is commonly confused or may

become stuporous;

• 0.4 to 0.5 % - coma.

• At higher levels, the primitive centers of the brain
that control breathing and heart rate are affected,
and death ensues secondary to direct respiratory
depression or the aspiration of vomitus.
• Persons with long-term histories of alcohol abuse, however, can tolerate
much higher concentrations of alcohol than can alcohol-naïve persons;
their alcohol tolerance may cause them to falsely appear less
intoxicated than they really are.
References
1. Benjamin James Sadock, M.D. (2015) Kaplan and Sadock’s Synopsis
of Psychiatry Behavioural Sciences/Clinical psychiatry, 11th Edition.
(p. 1349). Philadelphia, Wolters Klower.
2. Paul Harrison, Philip Cowen, Tom Burns, Mina Fazel. (2018) Shorter
Oxford Textbook of Psychiatry, 7th Edition (p. 566- 567). U.K., Oxford
University Press
Clinical Features
of
AUD
A.LALLITHA
BMS15091652
Symptoms Signs
• Recurrent intoxication • Regular alcohol concumption
• Tacycardia • Other substance abuse
• Amnesic episodes • Drug interactions
• Mood swings • Poor nutritions
• Depression • Frequent falls or minor trauma
• Insomnia • Accident, burns, violence, suicide
• Hallucination • Recurrent absenteeism from work or
school
• Tremor
• Child with fetal alcohol syndrome
• Unsteady gait
• Increased vulnerability
• Paraesthesia
• Memory loss
• Erectile dysfunction
• Problem drinking that becomes severe is given the medical diagnosis of 'Alcohol Use
Disorder'.
• A chronic relapsing brain disease characterized by compulsive alcohol use, loss of control
over alcohol intake and negative emotional state when not using.
• To be diagnosed, must meet certain criteria outlined in DSM-5.
• Clinically impairment or distress as manifested by 2 or more of the following criterias ,
occuring within 12 months period;

1. Recurrent substance use resulting failure in to fulfill major role obligations at work, school
or home.
2. Recurrent subtance use in situations in which it is physically hazardous.
3. Continue substance use despite having persistent or recurrent social or interpersonal
problem caused or exacerbated by the effects of substance.
4. Tolerance , as defined a need for markedly increased amounts of the substance to
achieve intoxication or desire effect.
5. Withdrawal, as manifested by either of the following ;
a) characteristic withdrawal syndrome for the substance
b) same substance is taken to relieve withdrawal symptoms
6. Substance always taken in large amount or over longer period than was intend.
7. There is persistent desire or unsuccessful to cut down or control substance use
8. A great deal of time is spent in activities necessary to obtain the substance or recover
from its effects
9. Important social , occupation or recreational activities are given up or reduced.
10. substance of use is continued despite knowledge of having persistent or recurrent
physical psychological problem that exacerabated by substance use
11. craving or a strong desire or urge to use specific substance.
Complication of alcohol use
disorder
MANAS KRAITHAD
BMS15091594
 Complication of alcohol use disorder
Alcohol Withdrawal
Symptoms that developed after the cessation of alcohol intake

After 6-8 hrs After 12-24 hrs After 24-48 hrs After 48-72 hours

Coarse tremors Alcoholic hallucinosis Alcohol withdrawal Delirium tremens

(hallucination in the seizures
absence of any • Cluster seizure
GI symptoms (N/V) disturbances of • Generalize/tonic-
consciousness) clonic
Sympathetic autonomic
hyperactivity(arousal,anx
iety,sweating,hypertensi
on,tachycardia,mydriasis
)
 Complication of alcohol use disorder
Alcohol Withdrawal
Symptoms that developed after the cessation of alcohol intake

• Delirium tremens
• Emergency condition, mortality rate 20% if untreated
• Signs and Symptoms
• Disturbances of consciousness
• Disoriented to people, time and space
• Hallucination (commonly visual)
• Coarse tremors
• Autonomic hyperactivity
• Mortality rate(with treatment) 5%
 Complication of alcohol use disorder
Alcohol induced disorder
Alcohol induced psychotic disorder Resolve within one month after
Alcohol induced bipolar disorder cessation of alcohol
Alcohol induced depressive disorder
Alcohol induced anxiety disorder
Alcohol induced sleep disorder
Alcohol induced sexual dysfunction
Alcohol induced neurocognitive disorder
 Complication of alcohol use disorder
• Alcohol induced neurocognitive disorder
amnestic disorder characterize by disturbance in short term memory

1. Wernicke’s encephalopathy
2. Korsakoff’s syndrome
3. Marchiafava bignami disease
 Alcohol induced neurocognitive disorder
1. Wernicke’s encephalopathy
• Acute complication
• Thiamine deficiency
• Neurological lesions
• Mammillary body
• Signs and Symptoms
• Mental changes
• confusion, drowsiness, obtundation, clouding of consciousness, pre-coma and coma
• Ophthalmoplegia
• 6th nerve palsy
• 3rd nerve palsy
• Ataxia
 Alcohol induced neurocognitive disorder
1. Wernicke’s encephalopathy

• Treatment
• High dose of parenteral thiamine (≥500 mg)
• Prognosis
• Residual ataxia and nystagmus remained
• If untreated
• 20% mortality rate
• 80% progress to Korsakoff’s syndrome  Wernicke–Korsakoff syndrome
 Alcohol induced neurocognitive disorder
2. Korsakoff’s syndrome
• Chronic complication
• Thiamine deficiency
• Neurological lesions
• Mammillary body
• Signs and Symptoms
• Anterograde amnesia (inability to form new memory)
• Retrograde amnesia (inability to recall memory)
• Confabulation (unintentionally fill in the memory gaps with false memory)
 Alcohol induced neurocognitive disorder
2. Korsakoff’s syndrome
• Treatment
• Oral thiamine for 3-12 months
• Prognosis
• 20% recover
 Alcohol induced neurocognitive disorder
3. Marchiafava bignami disease
• Rare
• Demyelination of
• Corpus callosum
• Optic tract
• Cerebella peduncle
• Signs and Symptoms
• Epilepsy
• Ataxia
• Dysarthria
• Hallucination
• Intellectual deterioration
Treatment and
Management
Moogambigai K Gnanamoorthy
BMS15091622
 Clinical Practice Guideline for Alcohol Abuse
Screening for Adults and Adolescents
• Screening to detect problem drinking abuse is recommended for all adult
(including pregnant women) and adolescent patients at the time of initial,
annual and interim visits to the primary care provider.
• Self-reporting of alcohol abuse may be inconsistent.
• If alcohol abuse is present or suspected, screening should include a history of
use, and utilization of standardized screening questionnaires.
• Documentation of the screening information should be noted in the medical
record.
• If substance abuse is present or suspected, consider referral for chemical
dependency assessment.
• Physician intervention has an impact in reduction of abuse.
 IDENTIFICATION OF THE ALCOHOLIC
• by asking questions about alcohol problems (AUDIT)
& noting laboratory test results.

• The two blood tests with ≥60% sensitivity and

specificity for heavy alcohol consumption are :

a. γ-glutamyl transferase (GGT) : (>35 U)

b. Carbohydrate deficient transferrin (CDT) :

(>20 U/L or >2.6%)

c. Other useful blood tests high-normal :

MCVs (≥91 μm3) & uric acid (>416 mol/L, or
7 mg/dL).
 CAGE
• Four clinical interview
questions, the CAGE questions
have proved useful helping to
make a diagnosis of alcoholism.
 Cutting
 Annoyance by criticism,
 Guilty feeling,
 Eye-openers.
• The CAGE questions are
sensitive and specific for
diagnosing alcoholism and drug
use.
Approach to Alcoholism
• Three general steps are involved in treating the alcoholic person after
the disorder has been diagnosed:
• intervention,
• detoxification,
• rehabilitation.
• These approaches assume that all possible efforts have been made to
optimize medical functioning and to address psychiatric emergencies.
• The patient with alcohol abuse or dependence must then be brought
face-to-face with the reality of the disorder (intervention), be
detoxified if needed, and begin rehabilitation.
• The essentials of these three steps for an alcoholic person with
independent psychiatric syndromes closely resemble the approaches
used for the primary alcoholic person without independent
psychiatric syndromes.
• In the former case, however, the treatments are applied after the
psychiatric disorder has been stabilized to the extent possible.
 INTERVENTION
• The goal in the intervention step, which has also been called
confrontation, is to :
 break through feelings of denial and help the patient recognize the adverse
consequences likely to occur if the disorder is not treated
a process aimed at maximizing the motivation for treatment and continued
abstinence (motivational interview)
often involves convincing patients that they are responsible for their own actions
while reminding them of how alcohol has created significant life impairments.
• The psychiatrist can then explain how alcohol has either created or
contributed to these problems and can reassure the patient that
abstinence can be achieved with a minimum of discomfort.
• A physician intervening with a patient can use the same
nonjudgmental but persistent approach each time an alcohol related
impairment is identified.
• It is the persistence rather than exceptional interpersonal skills that
usually gets results.
• A single intervention is rarely sufficient. Most alcoholic persons need
a series of reminders of how alcohol contributed to each developing
crisis before they seriously consider abstinence as a long-term option.
 Motivation Interview
• Develop an understanding regarding the consequences regarding
the ill effects of alcohol.
• Explaining the benefits of changing the behavior.
• Recognition of ambivalence of the patient towards abstinence .
• Show sensitivity towards the readiness of the patient to change.
• Resistance can be managed by discussions and and problem
solving rather than criticism and confrontation.
• Exercise: ask the patient to keep a book for noting the events
between visits for which relapse occurred or could have occurred.
Brief Intervention “FRAMES”
(Developed by Miller and Sanchez)
• Feedback to the patient
• Responsibility to be taken by patient
• Advice, on what needs to be done
• Menus of options that might be considered;
• Empathy for understanding patient’s thoughts and feelings
• Self-efficacy, i.e., offering support for the capacity of the patient to
make changes.
Extensive Intervention
• Engaging - establishing a helpful connection and working relationship
• Focusing - developing and maintaining specific direction in the
conversation about change
• Evoking - eliciting the patients motive about change
• Planning - developing commitment to change and forming a specific
action plan to change
Familial Help
• The family can be of great help in the intervention and
subsequent treatment.
• Relatives and friends need to learn to not protect the patient
from the problems caused by alcohol.
• Families can take help of support groups like AA (alcoholics
anonymous)
• Those support groups help family members and friends see
that they are not alone in their fears, worry, and feelings of
guilt.
• Members share coping strategies and help each other find
community resources.
• The groups can be useful in helping family members rebuild
their lives, even if the alcoholic person refuses to seek help.
DETOXIFICATION
• There are 2 main steps in the process of detoxification:
Thorough physical examination
Rest and supplementation of depleted nutrients of the body

• Majority people with alcohol dependence experience mild to

moderate levels of withdrawal.
• The usual duration of uncomplicated withdrawal syndrome is 7-14
days.
• The aim of detoxification is symptomatic management of emergent
withdrawal symptoms.
 Mild and Moderate Withdrawal
• Alcohol withdrawal develops because the brain has adapted to the presence of a
brain depressant and cannot function adequately in the absence of the alcohol.
• Treatment can focus on giving enough of a brain depressant on the first day to
diminish symptoms
• And then weaning the patient off alcohol over the next 5 days to both diminish
symptoms and minimize the possibility of a severe withdrawal.
• Any depressant, including barbiturates or a benzodiazepine, either short- acting
drugs, such as lorazepam or long acting like chlordiazepoxide and diazepam.
• When taking a short-acting drug, such as lorazepam, the patient must not miss any
dose because rapid changes in blood benzodiazepine concentrations may precipitate
a severe withdrawal.
• Others can also include newer anticonvulsants like gabapentin.
Severe Withdrawal
• For the less than 1 percent of alcoholic patients with extreme
autonomic dysfunction, agitation, and confusion—that is, also called
delirium tremens—there is no perfect treatment.
• The withdrawal symptoms can then be minimized either through the
use of benzodiazipines or through antipsychotic agents such as
haloperidol.
 Protracted Withdrawal
• Symptoms of anxiety, insomnia, and mild autonomic
overactivity are likely to continue for 2 to 6 months after
the acute withdrawal has disappeared.

• Although no pharmacological treatment for this syndrome

appears appropriate, it is possible that some medications for
the rehabilitation phase, especially acamprosate, may work
by diminishing some of these symptoms.

• Cognitive and behavior therapies help in relieving these

symptoms.
REHABILITATION
• The process of rehabilitation has the following
concepts:
1. continued efforts to increase and maintain high levels of
motivation for abstinence
2. work to help the patient re-adjust to a lifestyle free of
alcohol
3. relapse prevention.
 Counseling
• Counselling efforts in the first several months should focus
on day-to- day life issues to help patients maintain a high
level of motivation for abstinence and to enhance their
functioning.

• To optimise motivation, treatment sessions should explore

the consequences of drinking, the likely future course of
alcohol-related life problems, and the marked
improvement that can be expected with abstinence
• Whether in an inpatient or an outpatient setting,
individual or group counselling is usually offered a
minimum of three times a week for the first 2 to 4
weeks, followed by less intense efforts, perhaps once
a week, for the subsequent 3 to 6 months.

• Much time in counselling deals with how to build a

lifestyle free of alcohol.
Relapse
High risk situations:
• negative emotional states
• Positive emotional states
• Social gatherings/ occasions
• Social/ peer pressure
• Abstinent violation effect
 Relapse Set Up
• A series of covert decisions or choices, seeming inconsequential but
set up the person for high risk of relapse.
• AIDs- apparently irrelevant decisions
• Lifestyle factors
• Urge and cravings;
Urge: sudden impulse to engage in an act without thinking about the
consequences like alcohol consumption
Cravings: subjective desire to experience the effects or consequences of an
act like alcohol consumption
Relapse Prevention
• Intervention strategies: variety of cognitive and behavioral
approaches that can lead to prevention of relapse.
• Specific intervention strategies:
identifying and coping with high risk situations
enhancing self efficacy
elimination of myths and placebo effect
lapse management
cognitive restructuring
Global lifestyle self control strategies
Balanced life and positive addiction
Stimulus control techniques
Urge management techniques
Relapse road maps
PHARMACOLOGICAL
PREVENTION
 DISULFIRAM
• Action:
Inhibits alcohol metabolism and building the levels of aldehyde in the body leading to reactions
• Contraindication:
Use of alcohol
• Adverse reactions:
Flushing ,headache, nausea, sweating , tachycardia
• Serious adverse effects:
Hepatitis, optic neuritis, peripheral neuropathy, psychosis
• Dose:
125-500 mg daily in adults for 6 to 8 months
• Precautions:
Noṭ to take it till 12 hrs after alcohol consumption
Alcohol induced disulfiram reaction can occur unto 2 weeks after alcohol
 NALTREXONE
• Action:
Blocks opioid receptors and reduces craving and reduces reward in drinking
Prevents relapse of heavy drinking
• Contraindication:
Opioids, acute hepatitis and renal failure
• Adverse reactions:
Nausea , vomiting headache , anxiety, fatigue dizziness, constipation,
• Dose:
50-150 mg daily orally for 6 to 8 months
380mg IM once a month
• Precautions:
Consider urine toxicology monitoring to rule out current use of opioids Monitor LFT
 ACOMPROSATE
• Action:
Blocks GABA AND glutamate neurotransmitter
Promotes abstinence
• Contraindication:
Acute renal impairments
• Adverse effects:
Anxiety, depression, diarrhoea , flatulence, nausea, abdominal pain, headache, somnolence,
decreased libido, amnesia, confusion
• Dose:
333 mg thrice a day to 666mg thrice daily