Alcohol Use Disorder
Compiled by- Akhilesh Parab
Zenobia Charania
Introduction
• Alcoholism is among the most common psychiatric
disorders observed in the Western world.
• Alcohol-related problems in the United States contribute
to 2 million injuries each year, including 22,000 deaths
• Alcohol is a potent drug that causes both acute and
chronic changes in almost all neurochemical systems.
• Long-term, escalating levels of alcohol consumption can
produce tolerance as well as such intense adaptation of
the body that cessation of use can precipitate a
withdrawal syndrome usually marked by insomnia,
evidence of hyperactivity of the autonomic nervous
system, and feelings of anxiety.
Alcohol Epidemiology
Condition Population (%)
Ever had a drink 90
Current Drinker 60-70
Temporary problems 40+
Abuse Male – 10+ Female -5+
Dependence Male- 10 Female- (3-5)
ETIOLOGY
• Social factors
• Religious factors
• Psychological factors
• Genetic factors
Important Terms
• Abuse: Use of any drug, usually by self-administration,
in a manner that is not approved by social or medical
patterns.
• Misuse: Similar to abuse, but usually applies to drugs
prescribed by physicians that are not used properly.
• Dependence: repeated use of a drug or chemical
substance, to function in daily life
• Tolerance: phenomenon in which, after repeated use, a
drug produces a decreased effect or increasingly larger
doses are required to obtain the effect observed with
the previous/original dose.
• Intoxication: a reversible syndrome caused by a specific substance, that
affects one or more of the following mental functions: memory,
orientation, mood, judgment, and behavioral, social or occupational
functioning.
• Withdrawal: a substance specific syndrome that occurs, after stopping or
reducing the substance that has been used regularly over prolonged
period. It is characterized by physiological signs and symptoms in addition
to psychological changes like disturbances in thinking, feeling or behaving.
Also known as abstinence or discontinuation syndrome.
• Cross tolerance: refers to the ability of one drug to be substituted for
another, each usually producing the same physiological and psychological
effect. Also known as cross dependence.
• Co-dependence: term used to refer to family members affected by or
influencing the behaviour of the substance abuser.
• Enabling: the act of facilitating the abuser's addictive behaviour. Also
includes the unwillingness of a family member to accept addiction as a
medical-psychiatric disorder or to deny that the person is abusing
Standard drink
• A standard drink is defined as 3IU of alcohol. It is
different in quantity for different types of drinks.
For India, one standard drink corresponds to
10ml of absolute alcohol.
• Vodka, Gin, Tequila, Rum and whiskey: 30 ml
• Beer: 330 ml (regular)
• Champagne: 100ml
• Wine: 125 ml
• Spirits : 30 ml
Types of Alcoholism
• Alpha- Earliest stage, to relieve pain, can control
drinking.
• Beta- Heavy drinkers, drink daily, physical symptoms,
no addiction, can quit, no withdrawal symptoms.
• Gamma- Loss of control in drinking, physical
dependence, can quit, withdrawal seen.
• Delta- Physical dependence, withdrawal seen, can't
quit.
• Epsilon- Final stage of drinking, continual and
insatiable urge to drink (craving) , compulsive drinking.
Types of Alcoholism
• Anti social : early onset, predominantly men, poor
prognosis, close relation with anti social personality
• Developmentally cumulative: primary tendency for
alcohol abuse that is exaggerated with cultural
expectations.
• Negative-affect alcoholism: more common in women
than men, for mood regulations and to ease relations
• Developmentally self-limited alcoholism: frequent
bouts of consuming large quantities of alcohol, become
less frequent with age and responsibility
Types of Alcohol-dependence
• Type A-late onset, less childhood risk factors,
relatively less chances for dependence, few
alcohol-related problems.
• Type B- early onset, more childhood risk
factors, severe dependence, strong family
history, long history of alcohol abuse and
treatment, more alcohol related health
problems.
Psychiatric comorbidities
• Mood disorders: 40-50% meet criteria for
major depressive disorder
• Anxiety disorders: 25-50% with AUD meet
criteria for anxiety disorder
• Suicide: 13% chances of committing a suicide
Neurochemical effects of Alcohol
• Alcohol has major effects on most neurochemical systems,
with opposite actions during intoxication and withdrawal.
• Intoxication and subsequent craving involve changes in
dopamine, with effects on the pleasure centers
• Alcohol also causes an increase in the concentration of
serotonin in the synapse upregulating serotonin receptors.
• Effects of alcohol, especially actions on the GABA-receptor
(GABA), enhance the acute sedating, sleep-inducing,
anticonvulsant, and muscle-relaxing properties of alcohol
• For the NMDA receptors, it has dampened effects during
intoxication and heightened activity during alcohol
withdrawal.
Absorption
• About 10% of alcohol ingested is absorbed into the stomach, rest 90% is
absorbed in the 2nd part of duodenum.
• In most cases, higher alcohol concentration, faster is the rate of
absorption. However, beyond a certain concentration, the rate decreases
due to delayed passage of alcohol from stomach to small intestine.
• Maximum absorption rate is seen with a beverage containing approx. 20-
25% alcohol, and rate decreases with beverages containing 40% or more
alcohol
• Absorption increases if the drink is taken empty stomach and vice versa.
• Peak blood concentration is reached within 30-90 minutes, usually within
45- 60 minutes. Alcohol is uniformly absorbed hence tissues containing
high absorb more alcohol. in body water proportion of water
• The intoxicating effects are higher when the blood alcohol is rising than
when it is falling. (Mellanby effect)
Blood Alcohol Concentration (BAC)
It is the units of alcohol i.e. percentage of ethanol in the blood
in alcohol per volume of blood per mass of blood.
At higher levels, the following can be manifested:
• 20-30mg/dL-slowed motor performance and decreased
thinking ability
• 30-80mg/dL-increased motor and cognitive deficits
• 80-200mg/dL- in coordination and judgment errors, mood
lability
• 200-300mg/dL- nystagmus, slurring of speech, blackouts
• >300mg/dL- impaired vital signs
• >400mg/dL- respiratory failure, coma, death
Intoxication
• Acc. To DSM-V: Recent ingestion of alcohol,
maladaptive behaviour and one of the
following:
• Slurring of speech, in coordination, ataxic gait,
nystagmus, impaired attention concentration,
stupor or coma
Withdrawal
• Cessation of alcohol use which was heavy and
prolonged.
• Classic sign of withdrawal is tremulousness.
Duration since last intake Signs and Symptoms
6 to 8 hours Tremulousness, irritability, autonomic hyperactivity
8 to 12 hours Psychotic and perceptual abnormalities
12 to 24 hours Seizures (can occur within first 72 hours of withdrawal)
Up to 72 hours Delirium tremens
DSM 5 DIAGNOSTIC CRITERIA
FOR SUBSTANCE ABUSE DISORDER
A. development of a reversible substance-specific
syndrome due to the recent ingestion of a substance.
B. The clinically significant problematic behavioral or
psychological changes associated with intoxication (e.g.,
belligerence, mood lability, impaired judgment) are
attributable to the physiological effects of the substance
on the central nervous system and develop during or
shortly after use of the substance
C. The symptoms are not attributable to another medical
condition and are not better explained by another
mental disorder.
Diagnostic criteria for Alcohol use
disorder (DSM 5)
• A. 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:
• 1. Alcohol is often taken in larger amounts or over a
longer period than was intended.
• 2. There is a persistent desire or unsuccessful efforts to
cut down or control alcohol use.
• 3. A great deal of time is spent in activities necessary to
obtain alcohol, use alcohol, or recover from its effects.
• 4. Craving, or a strong desire or urge to use alcohol.
• 5. Recurrent alcohol use resulting in a failure to fulfil
major role obligations at work, school, or home.
6. Continued alcohol use despite having persistent or
recurrent social or interpersonal problems caused or
exacerbated by the effects of alcohol.
7. Important social, occupational, or recreational
activities are given up or reduced because of alcohol
use.
8. Recurrent alcohol use in situations in which it is
physically hazardous.
9. 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.
10. Tolerance, as defined by either of the
following:
a. A need for markedly increased amounts of
alcohol to achieve intoxication or desiredeffect.
b. A markedly diminished effect with continued
use of the same amount of alcohol.
11. Withdrawal, as manifested by either of the
following:
a. The characteristic withdrawal syndrome for
alcohol.
b. Alcohol (or a closely related substance, such
as a benzodiazepine) is taken to
relieve or avoid withdrawal symptoms.
COMMON CHANGES WITH
SUBSTANCE INTOXICATION
• disturbances of perception,
• wakefulness,
• attention,
• thinking,
• judgment,
• psychomotor behavior and interpersonal
behaviour.
• NOTE: short term or acute changes maybe
different from long term or chronic changes.
Prevalence and Course
• Individuals ages 18-24 years have relatively high prevalence rates for
the use of virtually every substance.
• Intoxication is usually the initial substance-related disorder and
often begins in the teens.
• Withdrawal can occur at any age as long as the relevant drug has
been taken in sufficient doses over an extended period of time
• Characterized by periods of remission and relapse.
• Decision to stop drinking - often in response to a crisis - likely to be
followed by a period of weeks or more of abstinence - often
followed by limited periods of controlled or non problematic
drinking.
• However, once alcohol intake resumes, it is highly likely that
consumption will rapidly escalate and that severe problems will
once again develop.
IMPACT
• Alcohol is considered to be one of the more
sedating drugs (including hypnotics, or
anxiolytics) and can produce prominent and
clinically significant depressive disorders during
intoxication.
• Anxiety conditions are likely to be observed
during withdrawal syndromes from these
substances.
• Chances of producing significant but temporary
sleep and sexual distrubances.
• Important contributor to suicide risk
OTHER PHYSIOLOGICAL PROBLEMS
• Problems with the gastrointestinal tract (gastritis,
stomach or duodenal ulcers)
• about 15% of individuals who use alcohol heavily
develop liver cirrhosis and/or pancreatitis
• problems with the cardiovascular system (low grade
hypertension)
• problems with the central and peripheral nervous
systems
• increased rate of cancer of the esophagus, stomach,
and other parts of the gastrointestinal tract.
-increases in levels of triglycerides and low-density
lipoprotein cholesterol.
-elevated risk of heart disease.
- Peripheral neuropathy may be evidenced by
muscular weakness, paresthesias, and decreased
peripheral sensation.
- More persistent central nervous
system effects include cognitive deficits, severe
memory impairment, and degenerative
changes in the cerebellum.
-Wemicke-Korsakoff syndrome (rare alcohol-induced
persisting amnestic disorder in which the ability to
encode new memory is severely impaired.
Differential Diagnosis
• Sedative, hypnotic, or anxiolytic use disorder
• Conduct disorder in childhood and adult
antisocial personality disorder.
TREATMENT
• Behavioral Treatment is the most popular choice
• Cognitive Behavioural Therapy (CBT)
• Dialectical Behaviour Therapy (DBT)
• Motivational Interviewing (MI)
• Contingency Management (CM)
• The Importance of Family and Peer Support
• Group Therapy
• Alternative and Holistic care options
THANK YOU
