Psychiatry and Behavioral Health Rotation

Psychiatry EOR: Alcohol-related disorders (ReelDx)

600 REEL-DX-ENHANCED

A 31-year-old with anxiety, tremors, and hematemesis

Patient will present as → a 69-year-old male presents to the emergency department with sudden, severe onset epigastric pain that began while he was watching television. On physical exam is an unkempt male with pain upon palpation of the epigastric region. Labs are drawn and the patient has an elevated amylase and lipase. The patient is made NPO, an NG tube is placed, and the patient is given IV fluids. The patient is noted to be experiencing hallucinations. On his second hospital day, the patient has a seizure.

Key Points:

  • Alcohol use disorder is divided into two:
    • At-risk drinking: continuous use of alcohol (4 drinks/day or 14 drinks/week for men or 3 drinks/day or 7 drinks/week for women) to ameliorate symptoms of anxiety and emotional problems. According to CDC, a drink is defined as 12 Oz of beer, 8 Oz of malt liquor, 1.3 Oz of hard liquor (spirits) or 5 Oz of wine.
    • Moderate-severe drinking: recurrent use of alcohol despite personal, interpersonal and legal problems or risks.

Alcohol Withdrawal

DSM-5 Diagnostic Criteria

Alcohol Use Disorder DSM-5 Diagnostic Criteria

A problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:

  • Alcohol is often taken in larger amounts or over a longer period than was intended.
  • There is a persistent desire or unsuccessful efforts to cut down or control alcohol use.
  • A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects.
  • Craving, or a strong desire or urge to use alcohol.
  • Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home.
  • Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.
  • Important social, occupational, or recreational activities are given up or reduced because of alcohol use.
  • Recurrent alcohol use in situations in which it is physically hazardous.
  • Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.
  • Tolerance, as defined by either of the following:
    •  A need for markedly increased amounts of alcohol to achieve intoxication or desired effect.
    • A markedly diminished effect with continued use of the same amount of alcohol.
  • Withdrawal, as manifested by either of the following:
    • The characteristic withdrawal syndrome for alcohol
    • Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms.

Alcohol Intoxication DSM-5 Diagnostic Criteria

  • Recent ingestion of alcohol.
  • Clinically significant problematic behavioral or psychological changes (e.g., inappropriate sexual or aggressive behavior, mood lability, impaired judgment) that developed during, or shortly after, alcohol ingestion.
  • One (or more) of the following signs or symptoms developing during, or shortly after, alcohol use:
    • Slurred speech.
    • Incoordination.
    • Unsteady gait.
    • Nystagmus.
    • Impairment in attention or memory.
    • Stupor or coma.
  • The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication with another substance.

Alcohol Withdrawal DSM-5 Diagnostic Criteria

  • Cessation of (or reduction in) alcohol use that has been heavy and prolonged.
  • Two (or more) of the following, developing within several hours to a few days after the cessation of (or reduction in) alcohol use:
    • Autonomic hyperactivity (e.g., sweating or pulse rate greater than 100 bpm).
    • Increased hand tremor.
    • Insomnia.
    • Nausea or vomiting.
    • Transient visual, tactile, or auditory hallucinations or illusions.
    • Psychomotor agitation.
    • Anxiety.
    • Generalized tonic-clonic seizures.
  • The signs or symptoms of withdrawal cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  • The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication or withdrawal from another substance.

Treatment of at-risk drinking is multifactorial

  • Psychological: motivational interviewing
  • Social: social support from peers, family and organizations like Alcoholics Anonymous go a long way.
  • Pharmacotherapy:
    • Disulfiram ( 250-500 mg/day PO)
    • Naltrexone (50mg/day) lowers relapse after cessation of alcohol consumption.
    • Acamprosate (333-666mg/TID) reduces alcohol craving and hence lowers relapse after cessation.

Treatment of alcoholic hallucinosis involves the use of antipsychotics such as Haldol (5mg) with an appropriate taper.

Treatment of alcoholic withdrawal involves the use of benzodiazepines (long-acting such as diazepam) to depress the CNS excitation caused by the abrupt cessation of alcohol use. Fluid resuscitation, vitamins, thiamine, and electrolytes need to be replaced as well. NB: replace thiamine before giving any glucose-containing IV solutions in order to prevent Wernicke encephalopathy and Korsakoff psychosis.

Question 1
Which drug(s) is (are) useful in the treatment of alcohol withdrawal?
A
benzodiazepine
B
clonidine
C
barbiturates
D
anticonvulsants
E
all of the above
Question 1 Explanation: 
The mainstay of therapy is long-acting benzodiazepines such as diazepam, chlordiazepoxide, and clorazepate, given in decreasing doses. Clonidine is sometimes used to reduce noradrenergic symptoms. Antipsychotic agents such as haloperidol are useful in addition to benzodiazepines in patients with hallucinations and agitation. Barbiturates and anticonvulsants (carbamazepine and divalproex) sometimes are used as anticonvulsants.
Question 2
How is alcohol withdrawal syndrome best defined?
A
a state in which a syndrome of drug-specific withdrawal signs and symptoms follows the reduction or cessation of drug use
B
a state in which the physiologic or behavioral effects of a constant dose of a psychoactive substance decrease over time
C
a pathologic state that follows cessation or reduction in the amount of drug used
D
a and b
E
all of the above
Question 2 Explanation: 
Alcohol withdrawal syndrome is a substance-specific syndrome that develops after cessation or reduced intake of alcohol.
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