a homeless man drinking

Alcohol Related Disorders

Alcohol use disorder include:

  1. A need for daily use of large amounts of alcohol for adequate functioning.
  2. Long periods of sobriety interspersed with binges of heavy alcohol intake lasting for weeks or months.
  3. A regular pattern of heavy drinking limited to weekends.

(I) Alcohol Withdrawal

Diagnosis of alcohol withdrawal requires the cessation or reduction of alcohol use that was heavy & prolonged. it is characterized by following symptoms:

1. Tremors (Classical symptom)

2. Nausea/ Vomiting

3. Symptoms of autonomic Hyperactivity:

Anxiety, sweating, facial flushing, mydriasis, tachycardia & mild hypertension.

4. Withdrawal Seizures:

Seizures associated with alcohol withdrawal are generalised tonic-clonic in character. Patients often have more than one seizure 3-6 hours after the 1st seizure. But status epilepticus is rare.

5. Delirium Tremens:

This is the most severe form of alcohol withdrawal. It usually occurs 3-5 days after stopping/ reducing intake of alcohol in patients who used to drink heavy alcohol from last 5-15 years.

Clinical Features:

  • Confusion
  • Disorientation
  • Hallucinations (most commonly tactile)
  • Delusions
  • Tachycardia
  • Diaphoresis
  • Fever
  • Hypertension
  • Anxiety
  • Fluctuating levels of psychomotor activity (ranging from lethargy to agitation).

(II) Wernicke-Korsakoff Syndrome

The essential feature of Wernicke-Korsakoff syndrome is disturbance in short term memory. It usually occurs in persons who have been drinking heavily for many years. It is rare in persons below the age of 35 years. This syndrome results due to thiamine deficiency, caused by poor nutritional habits or malabsorption problems (Thiamine is a cofactor for several critical enzymes & may also be involved in the condition of axon potential along the axon & synaptic transmission). Wernicke-Korsakoff syndrome is classified into 2 categories:

1. Wernicke Encephalopathy:

It is an acute neurological disorder which is entirely reversible with the treatment. It is characterized by:

  • Ataxia
  • Vestibular dysfunction
  • Confusion
  • Ocular motility abnormalities including horizontal nystagmus, lateral orbital palsy & gaze palsy
  • Other Ocular Signs: sluggish reaction to light & anisocoria (unequal pupillary size).

Wernicke encephalopathy may resolve spontaneously in few days to weeks or may progress to Korsakoff syndrome.

2. Korsakoff Syndrome:

Korsakoff syndrome is a chronic amnestic syndrome & only about 20% of patients recover from this syndrome.

The cardinal feature of this syndrome is impaired mental syndrome (especially recent memory impairment) & anterograde amnesia in an alert & responsive patient. These patients may or may not have the symptom of confabulation.

(III) Blackouts

In this, patient may have intact remote memory but experience a specific short term memory deficit in which they are unable to recall events that happened in the previous 5-10 minutes.

This is directly caused by alcohol, which can block the consolidation of new memories into old memories, a process that likely involves the hippocampus & related temporal lobe structures.

(IV) Alcohol induced Psychotic Symptoms

  • Approximately 3% of Alcoholics experience auditory hallucinations or paranoid delusions.
  • Auditory hallucinations are usually threatening, but some patients experience pleasant voices.
  • The hallucinations can occur at any age but usually seen in persons abusing alcohol for a long time.
  • Symptoms usually last less than a week.

(V) Alcohol induced Mood Disorder

  • Approximately 80% of alcoholics experience depressive disorder.
  • Depression markedly improves within 1-4 weeks of abstinence without specific treatment for depression. SO, we should wait for at least 2-4 weeks. before starting antidepressant medication.

(VI) Alcohol induced Anxiety Disorder

  • Anxiety symptoms are common in alcoholics. About 80% of patients report panic attacks during at least one acute withdrawal episode.
  • During 1st 4 weeks of abstinence, patients are likely to avoid social situations because of the fear of anxiety. These symptoms sometimes resemble social phobia/ agoraphobia.
  • These symptoms usually diminish & disappear over time.

(VII) Fetal Alcohol Syndrome

  • Fetal Alcohol Syndrome is the leading cause of intellectual disability in United States.
  • It occurs when fetus is exposed to alcohol in utero.
  • Alcoholic mothers have a 35% risk of having a child with defects.
  • Alcohol inhibits intrauterine growth & postnatal development.

Clinical Presentation:

  • Microcephaly
  • Craniofacial malformations
  • Limb & Heart defects
  • Short stature
  • Maladaptive behaviour

(VIII) Alcoholic Pellagra Encephalopathy

If an alcoholic patient with features of Wernicke Korsakoff Syndrome does not respond to thiamine treatment, we should consider the diagnosis of Pellagra.

Clinical Features:

  • Confusion
  • Clouding of consciousness
  • Myoclonus
  • Oppositional hypertonias
  • Fatigue
  • Apathy
  • Irritability
  • Anorexia
  • Insomnia

Reference:

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