Sei sulla pagina 1di 364

Otto-Michael Lesch

Henriette Walter
Christian Wetschka
Michie Hesselbrock
Victor Hesselbrock

Alcohol and Tobacco


Medical and Sociological Aspects
of Use, Abuse and Addiction
Otto Michael Lesch, MD
Henriette Walter, MD
Medical University of Vienna, Austria

Christian Wetschka, PhD


Vienna, Austria

Michie N. Hesselbrock, PhD


Victor Hesselbrock, PhD
University of Connecticut, Farmington, CT, USA

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Acknowledgements

After more than 30 years working with them for many interesting hours bring-
psychiatric patients especially with ad- ing in new and important research ide-
dicted patients I thank many friends, as. Especially I would like to thank H.
experts and researchers. At the begin- Poltnig, who died much to early, for pro-
ning of my work in 1972 Berner P., Mad- ducing the first LAT-documentation.
er R. and Strotzka H. supported my ed- Henriette Walter helped to produce the
ucation and they made it possible to first German manuscript, Christian Wet-
organize in a catchment area a social schka brought in his social therapeutic
psychiatric network. In this network a expertise and Michie and Victor Hessel-
long term treatment (chain: outpatient- brock included their knowledge about
inpatient-outpatient) could be devel- the subgroups of alcohol dependence
oped. There it was possible to investi- used in the United States.
gate the long term course of psychiatric, Last but not least I have to thank
especially of alcohol addicted patients. my family, especially my wife Elisabeth,
After 4 years of work the first results because they had to miss me many
could be published. In this ongoing re- weekends in the last 30 years. They for-
search an international discussion pro- med a climate to be able to relax and also
cess started. Boening J., Pelc I., Tabakoff made clear that beside working with
B., Platz W. and DeWitte P. have always addicted patients many other much
drawn my attention to the fact, that in more exiting sites in life exist.
addictive processes psychosocial fac-
tors have the same importance than Otto Lesch
biological vulnerabilities. These experts
but also a lot of others from many coun-
tries helped me to publish the most im-
portant results and invited me to many
international conferences to discuss
our data. My research team produced Assistant: Josefine Kalenda
many new results and I have to thank Translation: Miriam Mahler

V
Foreword

It is a pleasure to write this foreword for with the sequelae of alcohol and tobac-
the text by Professor Otto-Michael Lesch co use, including comorbidity with psy-
and colleagues dealing with the impor- chiatric syndromes. The emphasis on
tant topics of alcohol and tobacco. The comorbidities is an essential compo-
thoughts offered from this broad based nent for a clinically oriented text dea-
book are likely to be applicable to read- ling with alcohol and tobacco as psy-
ers with interests in a wide range of chiatric symptoms, especially anxiety
substances of abuse. An earlier version and depression, can both increase the
of this text, published in German, has risk for substance dependence and re-
stood the test of time, and the updated flect important consequences of their
chapters in this edition were developed clinical course.
in consultation with eminent clinicians A special strength of this book,
and researchers from sociology (Chris- not surprisingly, is a sophisticated de-
tian Wetschka), social work (Michie scription of a broad range of possible
Hesselbrock), and psychology (Victor typologies of alcohol and tobacco de-
Hesselbrock) – contributions that com- pendence. While much emphasis is
plement the approaches offered by placed on the approach developed by
Professor Lesch. Professor Lesch and his colleagues, the
The content reflects the wealth of text is careful to discuss additional ap-
experience of the authors, including proaches, including those related to ge-
the more than 30 years in the field netic predispositions.
expended by Professor Lesch. The in- Underscoring the clinical useful-
formation offered here includes obser- ness of the information offered is the
vations on the history of relevant diag- breadth of the discussion of treatments.
noses; descriptions of the importance These include combinations of socio-
to societies of alcohol and tobacco use logical and psychological approaches,
and problems; theories of factors that as well as a presentation of potentially
contribute to discussions of the diag- useful pharmacological therapies. The
nostic approaches of the American Psy- book also recognizes the interest that
chiatric Association’s DSM, as well as clinicians are likely to have in prevent-
those generated by the World Health ing alcohol- and nicotine-related disor-
Organization; along with expansions of ders.
these criteria to detecting substance re- In closing, this updated English
lated problems in clinical practice. An version of a well established text has
important part of the material deals much to offer a wide range of clinicians.

VII
Foreword

The book should be considered as po-


tentially important reading for students
entering our field as well as for well es-
tablished practitioners.

Marc A. Schuckit, MD,


Distinguished Professor of Psychiatry
Department of Psychiatry
University of California, San Diego
Editor, Journal of Studies on Alcohol
and Drugs
NIAAA’s Jack Mendelson Honorary
Award, NIAAA Keller Honorary Award,
Middleton Award for the best research
within the VA system, American Psy-
chiatric Association’s Hofheimer Prize
(now the APA Award for Research), So-
ciety for Biological Psychiatry’s Gold
Medal Award for lifetime achievement,
Research Society on Alcoholism’s Dis-
tinguished Scientist and Seixas
Awards, James B. Isaacson Memorial
Award, Jellinek Award.

VIII
Foreword

Alcoholism and smoking are the most lated causes (cancer, cardiovascular
frequent causes of addiction in our disease and respiratory diseases). Alco-
century. The extent to which alcohol is hol and tobacco dependence has re-
associated with health problems is re- markably wide-ranging effects on al-
markable, with Europe sadly adopting most all organs of the human body. For
a leading role. 55 million adult Europe- this reason, it is very important that not
ans use alcohol irresponsibly and 23 only psychiatrists and addiction ex-
million can be categorized as alcohol perts tackle this subject, but that physi-
dependent. The costs of treating the cians, regardless of their specialisation,
medical sequelae of alcohol abuse and are also aware of the problem and are
related occupational deficits, which are able to diagnose and choose adequate
paid by the health systems, are tremen- and timely interventions.
dous, e. g. Germany has reported costs With his book, “Alcohol and To-
of 20 billion Euros per annum. Besides bacco: Medical and Sociological As-
the dependence itself, a myriad of alco- pects of Use, Abuse and Addiction”,
hol related sequelae ranging from acci- Professor Otto-Michael Lesch, a psychi-
dents to suicide, as well as social and atrist of the highest international repu-
occupational problems (family prob- tation, with over 40 years of experience
lems, unemployment), need to be ex- in treating dependents, has not only
amined. A particular cause for concern explored all of the major issues, but has
is the permanently declining age of ini- also managed to consider most aspects
tiation for alcohol use, which in the of dependence (prevention, diagnos-
meantime has dropped to the age of tics, sequelae, therapy). Despite the
13–14. In view of the early onset of comprehensive scope of his book, the
chronic alcohol consumption, an in- authors have successfully managed to
crease in the number of alcohol de- discuss certain aspects in more depth
pendents and severe alcohol related without losing sight of the whole pic-
sequelae, e. g. liver cirrhosis, have to be ture. In this book, both theory-based
expected in the future. researchers as well as professionals in
Most alcohol dependents also practice will find the information they
smoke and, in fact, there are hardly any are looking for. Especially interesting
who do not. The effects of smoking are are a number of case studies from
similarly health damaging and a German practice which have been included in
study has shown that around 110,000 the book. Here, the authors have put
people die each year from tobacco-re- special emphasis on the typology of al-

IX
Foreword
Statement

cohol dependence which Lesch himself version is now available for many inter-
developed. Lesch’s typology of alcohol ested readers in the European Commu-
dependence has received wide accept- nity and I hope it helps to increase the
ance internationally and has recently quality of life of dependent patients.
been re-evaluated and structured by a
research group, directed by Lesch. The
reason why this typology is so impor-
tant is because it can be used as a tool Helmut K. Seitz, MD, PhD, AGAF
to predict both the assessment for prog- Distinguished Professor
noses, and therapeutic responses to of Internal Medicine,
different therapies. Gastroenterology and Alcohol Research,
With his work, Otto-Michael Lesch University of Heidelberg, Germany
continues the classical tradition of Ger- Honorary Professor, Huazhong
man-speaking psychiatrists in the do- University, Wuhan, P. R. China
main of alcohol research and treat- Director, Salem Medical Center,
ment. In this respect, he sets new Heidelberg, Germany
standards in almost all areas by intro- Head, Department of Medicine and
ducing modern viewpoints and new Center of Alcohol Research
scientific results. As President of the Liver Disease and Nutrition, Salem
European Society for Biomedical Re- Medical Center, Heidelberg,
search on Alcoholism (ESBRA), I would Germany President of European
like to congratulate Otto-Michael Lesch Society for Biomedical Reseach
and his colleagues on this work and on Alcoholism
also thank him sincerely. The English (ESBRA)

Statement
In as far as this book uses personal terms
and definitions, they apply equally to
women and men; for the sake of clarity,
and without any intention to discrimi-
nate, only one gender-specific denomi-
nation has been used.

X
Table of contents

1 Information about the origination of this book. . . . . . . . . . . . . . . . . . . . . . 1


1.1 Aims of this book . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
1.2 Personal reasons for the first author writing this book . . . . . . . . . . . . . . . . . . . . . 3 1
2 Addiction – a short overview of a widespread disease . . . . . . . . . . . . . 5
2.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
2.2
2.3
Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The Diagnosis addiction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6
6
2
2.4 Aetiology of addiction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
2.5 Secondary disorders and addiction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
2.6 Secondary diseases and brain functions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
2.7 Subgroups of addicts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
2.8 Motivation of addicts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
2.9 The path from motivation to therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
2.10 Addiction and relapse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
2.11 Specific groups of addicts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
2.11.1 Co-morbidity of tobacco and alcohol-addiction . . . . . . . . . . . . . . . . . . . . . . 11
2.11.2 Overweight, eating disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
2.11.3 Gender. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
2.12 Addiction and the homeless . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
2.13 Polytoxicomania . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
2.14 Non-substance dependence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

3 Aetiology of addiction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
3.1 The psycho-socio-biological model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
3.2 Psychological theories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.2.1 Behavioural approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
15
16
3
3.2.2 Models of depth psychology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
3.2.3 Depth psychological approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
3.2.4 Ego-psychological approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
3.2.5 The psychological model of object relations . . . . . . . . . . . . . . . . . . . . . . . . . 19
3.2.6 Theoretical approach of Narcissism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
3.2.7 Explanation models according to family psychotherapy. . . . . . . . . . . . . . . 20
3.3 Social explanation approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
3.4 Biological theories about the aetiology of tobacco and alcohol addiction . . . . 22
3.4.1 Important findings about tobacco and alcohol use from basic research 22

XI
Table of contents

3.4.2 Aspects of alcohol and tobacco metabolism . . . . . . . . . . . . . . . . . . . . . . . . . 23


3.4.3 Maternal tobacco and alcohol use during pregnancy:
a risk factor for the offspring?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
3.4.3.1 Smoking during pregnancy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
3.4.3.2 Alcohol use during pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
3.5 Aetiological aspects of tobacco and alcohol dependence from
an epidemiological perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
3.6 Aetiology of addiction from a psychiatric perspective . . . . . . . . . . . . . . . . . . . . . . 33

4 Prevention strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
4.1 Attitudes towards addictive drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
4 4.1.1 Attitudes towards alcohol consumption . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.1.2 Attitudes towards tobacco consumption. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
37
39
4.2 Primary prevention of tobacco and alcohol addiction . . . . . . . . . . . . . . . . . . . . . . 40
4.3 Secondary prevention: early diagnosis and intervention . . . . . . . . . . . . . . . . . . . 42
4.3.1 Conclusions for secondary prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
4.3.1.1 Measures concerning the addictive drug. . . . . . . . . . . . . . . . . . . . 43
4.3.1.2 Measures to help adolescents live a drug-free life . . . . . . . . . . . 44
4.4 Tertiary prevention (see chapter 9) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

5 Diagnosis of abuse and addiction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47


5.1 Problems concerning psychiatric diagnoses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
5 5.2
5.3
Development of the term “addiction” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Substance related diagnoses in the ICD-10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
48
49
5.3.1 Harmful use (ICD 10 F10.1, F 17.1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
5.3.2 Dependence syndrome (ICD 10 F10.2, F 17.2 ) . . . . . . . . . . . . . . . . . . . . . . . 50
5.3.3 Withdrawal state (ICD 10 F10.3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
5.4 Substance-related diagnosis in DSM-IV
(American Psychiatric Association. 1994) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
5.4.1 DSM-IV and the multidimensional diagnostic in five axes . . . . . . . . . . . . . 52
5.4.2 Diagnosis according to DSM-IV axis I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
5.4.2.1 Tobacco or alcohol abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
5.4.2.2 Tobacco-alcohol addiction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
5.4.3. Specifiers defining subgroups of dependence . . . . . . . . . . . . . . . . . . . . . . . . 54
5.4.3.1 Tolerance and withdrawal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
5.4.3.2 Course specifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
5.4.4 Therapeutic approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
5.4.5 Withdrawal symptoms of tobacco and alcohol . . . . . . . . . . . . . . . . . . . . . . . 55
5.5 Commonalities and differences of ICD-10 and DSM-IV. . . . . . . . . . . . . . . . . . . . . 56
5.6 Implication of these classification systems for therapy and research . . . . . . . . 56
5.6.1 Alcohol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
5.6.1.1 Studies on pharmacotherapy in relapse prevention
(according to Hester RK and Miller WR 2003) . . . . . . . . . . . . . . . 57
5.6.1.2 Studies on relapse prevention using psychotherapy . . . . . . . . . 58
5.6.1.3 Family psychotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
5.6.2 Tobacco . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

XII
Table of contents

6 Types, dimensions and aetiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63


6.1 Alcohol addiction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6.1.1 Development of typology research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
63
63 6
6.1.2 Important typologies for research and practice. . . . . . . . . . . . . . . . . . . . . . . 64
6.1.2.1 Two-cluster-solutions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
6.1.2.2 The four-cluster solutions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
6.1.3 Assessment of severity in different dimensions . . . . . . . . . . . . . . . . . . . . . . 69
6.1.3.1 Addiction Severity Index (ASI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
6.1.3.2 Syndrome diagnosis according to Scholz . . . . . . . . . . . . . . . . . . . 70
6.2 Tobacco addiction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
6.2.1 Smoking typology according to Schoberberger and Kunze. . . . . . . . . . . . . 71
6.2.2 Smoking Typology according to Fagerstroem. . . . . . . . . . . . . . . . . . . . . . . . . 71
6.2.2 European smoking classification system. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
6.3 Alcohol addiction – Lesch’s typology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
6.3.1 Framework for the definition of Lesch’s typology . . . . . . . . . . . . . . . . . . . . . 74
6.3.2 Alcohol addiction from a longitudinal perspective 1976–1982–1995 . . . . 75
6.3.3 The “Burgenland Modell” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
6.3.4 Methodology of the longitudinal study on alcohol dependent patients
(according to DSM-III and ICD-9), used for the development
of Lesch’s typology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
6.3.5 Stability in the longitudinal course. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
6.3.6 The four long-term illness courses used for Lesch’s typology. . . . . . . . . . . 82
6.3.7 Results of studies using the Lesch typology . . . . . . . . . . . . . . . . . . . . . . . . . . 84
6.3.7.1 Studies on prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
6.3.7.2 Studies on biology and genetics. . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
6.3.7.3. Relapse prevention studies, anti-craving substances . . . . . . . . . 85
6.3.7.4. Other results regarding Lesch’s typology . . . . . . . . . . . . . . . . . . . . 89
6.3.8 Lesch’s typology from an international comparative perspective . . . . . . . 91
6.4 The relationship between alcohol dependent patients according to Lesch’s
typology and the severity of tobacco addiction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92

7 Motives for alcohol-and/or tobacco addicted patients to seek


medical help. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
7.1
7.2
Tobacco addiction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Alcohol addiction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
95
95
7
7.3 Sequelae that bring patients into therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
7.3.1 Tobacco and sequelae . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
7.3.1.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
7.3.1.2 Tobacco and neurology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
7.3.1.3 Tobacco and internal medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
7.3.1.3.1 Heart diseases and circulatory disorders. . . . . . . . . . 98
7.3.1.3.2 Pulmonary diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
7.3.1.4 Oncological diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
7.3.1.5 Dentistry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
7.3.1.6 Psychiatry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99

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7.3.2 Alcohol and sequelae . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99


7.3.2.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
7.3.2.2 Alcohol’s significance for neurology and psychiatry . . . . . . . . . . 102
7.3.2.3 Alcohol and psychiatric disorders . . . . . . . . . . . . . . . . . . . . . . . . . . 103
7.3.2.3.1 Alcohol and affective disorders . . . . . . . . . . . . . . . . . . 104
7.3.2.3.2 Alcohol and Anxiety . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
7.3.2.4 Alcohol and neurological disorders . . . . . . . . . . . . . . . . . . . . . . . . 106
7.3.2.5 Alcohol and internal medicine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
7.3.2.5.1 Gastroenterology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
7.3.2.5.2 Cardiovascular system. . . . . . . . . . . . . . . . . . . . . . . . . . 110
7.3.2.5.2.1 Alcoholic Cardiomyopathy . . . . . . . . . . . . . . 110
7.3.2.5.2.2 Cardiac arrhythmia,
“Holiday-Heart-Syndrome” and
sudden cardiac arrest . . . . . . . . . . . . . . . . . . . 110
7.3.2.5.2.3 Coronary heart disease and
myocardial infarct . . . . . . . . . . . . . . . . . . . . . . 111
7.3.2.5.2.4 Hypertonia . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
7.3.2.5.2.5 Hypothesis on the aetiology of alcohol
addiction and heart diseases. . . . . . . . . . . . . 112
7.3.2.5.2.6 Alcohol typology according to Lesch –
Homocysteine level – Heart diseases. . . . . . 113
7.3.2.5.3 Oncological diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
7.3.2.6 Alcohol and medication for sequelae . . . . . . . . . . . . . . . . . . . . . . 117

8 Detection of alcohol and tobacco addiction . . . . . . . . . . . . . . . . . . . . . . . . . 119


8.1 Recommendations for the first contact . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
8 8.2 Assessment of drinking behaviour by using biological markers . . . . . . . . . . . . .
8.2.1 Trait markers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
122
122
8.2.2 State markers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
8.2.3 Associated markers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
8.2.4 Practical suggestions for the use of biological markers for
forensic purposes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
8.2.4.1 Blood alcohol measurement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
8.2.4.2 Blood alcohol concentration (BAC) . . . . . . . . . . . . . . . . . . . . . . . . 124
8.2.4.3 Widmark Formula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
8.2.4.4 Breath alcohol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
8.2.4.5 Products of alcohol metabolism . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
8.2.4.5.1 Ethyl glucuronide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
8.2.4.5.2 %CDT (Carbohydrate-deficient-transferrin) . . . . . . 126
8.3 The clinical dialogue in tobacco addiction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129

9 Therapeutic strategies in alcohol and tobacco addiction. . . . . . . . . . . 131


9.1 Motivation for therapy in different settings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
9 9.1.1 Motivational interviewing at the general practitioner’s . . . . . . . . . . . . . . . .
9.1.2 Motivational interviewing in internal medicine . . . . . . . . . . . . . . . . . . . . . .
131
132
9.1.3 Motivational interviewing during pregnancy. . . . . . . . . . . . . . . . . . . . . . . . . 132

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9.1.4 Motivational interviewing in psychiatric settings . . . . . . . . . . . . . . . . . . . . . 132


9.2 Pharmacotherapy of alcohol and tobacco addiction . . . . . . . . . . . . . . . . . . . . . . . 134
9.2.1 Alcohol addiction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
9.2.2 Tobacco addiction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
9.3 Pharmacotherapy of alcohol withdrawal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
9.3.1 Withdrawal syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
9.3.2 Therapy of withdrawal states . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
9.3.3 Therapy of the withdrawal syndromes according to Lesch’s typology . . . 145
9.3.3.1 Management of detoxification in
Lesch’s type I alcohol dependents . . . . . . . . . . . . . . . . . . . . . . . . . . 145
9.3.3.2 Management of detoxification in
Lesch’s type II alcohol dependents . . . . . . . . . . . . . . . . . . . . . . . . . 146
9.3.3.3 Management of detoxification in
Lesch’s type III alcohol dependents . . . . . . . . . . . . . . . . . . . . . . . . 148
9.3.3.4 Management of withdrawal in
Lesch’s type IV alcohol dependents . . . . . . . . . . . . . . . . . . . . . . . . 149
9.3.4 Complications in alcohol withdrawal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
9.3.4.1 Withdrawal seizures (Grand mal) . . . . . . . . . . . . . . . . . . . . . . . . . . 151
9.3.4.2 Delirant and associated states (meta-alcoholic psychosis) . . . . 151
9.4 Alternatives to withdrawal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
9.4.1 Gradual reduction of drinking amount, “Cut down drinking”,
method according to David Sinclair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
9.4.2 Case study: “Cut down drinking” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
9.5 Pharmacotherapy of tobacco withdrawal syndrome . . . . . . . . . . . . . . . . . . . . . . . 156
9.5.1 Symptoms of the tobacco withdrawal syndrome . . . . . . . . . . . . . . . . . . . . . 157
9.5.2 Therapy of the tobacco withdrawal syndrome. . . . . . . . . . . . . . . . . . . . . . . . 158
9.5.2.1 Withdrawal therapy of tobacco dependence with
Fagerstroem ≥ 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
9.5.2.2 Withdrawal therapy of tobacco dependence with
Fagerstroem ≤ 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
9.6 Medical strategies for relapse prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
9.6.1 General guidelines for relapse prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
9.6.2 Goals for relapse prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
9.6.3 Medication against so-called “positive” craving (= desire for
pleasurable, rewarding effects of the addictive substance) . . . . . . . . . . . . . 161
9.6.3.1 Alcohol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
9.6.3.2 Tobacco . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
9.6.4 Pharmacotherapy against the so-called “negative” craving (= desire for
addictive substances to relieve negative mood and anxiety) . . . . . . . . . . . 162
9.6.4.1 Alcohol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
9.6.4.2 Tobacco . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
9.6.5 Pharmacotherapy in relapse prevention in dependent patients . . . . . . . . 163
9.6.5.1 Alcohol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
9.6.5.2 Tobacco . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
9.6.6 Relapse prevention according to Lesch’s typology . . . . . . . . . . . . . . . . . . . . 164
9.6.6.1 Relapse prevention in Lesch’s type I . . . . . . . . . . . . . . . . . . . . . . . . 166

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9.6.6.2 Relapse prevention in Lesch’s type II . . . . . . . . . . . . . . . . . . . . . . . 166


9.6.6.3 Relapse prevention in Lesch’s type III. . . . . . . . . . . . . . . . . . . . . . . 167
9.6.6.4 Relapse prevention in Lesch’s type IV. . . . . . . . . . . . . . . . . . . . . . . 168
9.6.7 Treatment of relapses according to Lesch’s typology . . . . . . . . . . . . . . . . . . 169
9.6.8 Pharmacotherapy of relapse prevention in tobacco dependents . . . . . . . 170
9.6.8.1 Medication for relapse prevention of
tobacco dependents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
9.6.8.1.1 Nicotine replacement therapy . . . . . . . . . . . . . . . . . . 170
9.6.8.1.2 Varenicline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
9.6.8.1.3 Anti-depressants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
9.6.8.1.4 Bupropion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
9.6.8.1.5 Nortriptyline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
9.6.8.1.6 Doxepin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
9.6.8.1.7 Clonidine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
9.6.8.1.8 Rimonabant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
9.6.8.1.9 Topiramate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
9.6.8.2 Therapeutic procedure according to subgroups of
nicotine dependent patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
9.6.8.2.1 Subgroups according to Kunze and Schoberberger
(Lesch OM. 2007) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
9.6.8.2.2 Craving in subgroups of tobacco dependent
patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
9.6.8.3 Pharmacotherapy in relapse prevention in
tobacco dependence, according to subgroups. . . . . . . . . . . . . . . 175
9.6.8.3.1 Relapse prevention of cluster 1 . . . . . . . . . . . . . . . . . . 175
9.6.8.3.2 Relapse prevention of cluster II . . . . . . . . . . . . . . . . . . 175
9.6.8.3.3 Relapse prevention of cluster III . . . . . . . . . . . . . . . . . 175
9.6.8.3.4 Relapse prevention of cluster IV . . . . . . . . . . . . . . . . . 176
9.6.8.4 Medication of tobacco dependent patients in
special situations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176
9.6.8.4.1 Nicotine consumption in combination with other
dependencies and/or psychiatric disorders . . . . . . 176
9.6.8.4.2 Tobacco dependence and pregnancy. . . . . . . . . . . . . 177

10 Sociotherapy of alcohol-and tobacco dependents with regards


to Lesch’s typology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
10 10.1
10.2
Alcohol and Tobacco . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The sociotherapeutic mission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
179
180
10.3 Classification Psychotherapy- Sociotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
10.4 Sociogenesis and sociotherapeutic chances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
10.4.1 Primary, secondary and tertiary sociogenesis . . . . . . . . . . . . . . . . . . . . . . . . 189
10.4.2 Sociological factors on a macro-level. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190
10.4.3 Co-morbidity and marginal group identity . . . . . . . . . . . . . . . . . . . . . . . . . . 195
10.4.4 The link between social relationships (factors on a social micro level),
group coherence and resilience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
10.4.5 Analogy to Gerontology: an atrophy of the “social atom” . . . . . . . . . . . . . . 199

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10.5 Sociotherapy in the context of therapeutic phases . . . . . . . . . . . . . . . . . . . . . . . . . 202


10.5.1 Socio therapy location(s) (Schwendter 2000) . . . . . . . . . . . . . . . . . . . . . . . . . 202
10.5.2 Therapeutic phases and settings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
10.6 State of the Art: overlapping perspectives for sociotherapeutic housing and
support projects for alcohol dependents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
10.6.1 Standard categories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208
10.6.2 Excursus: supported housing projects – worlds of their own . . . . . . . . . . . 215
10.7 Motivation – a challenge for whom? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
10.7.1 Ambivalent functions of motivation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
10.7.2 The relationship between dependence and motivation systems. . . . . . . . 226
10.8 Sociotherapy as network promoter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228
10.8.1 Micro and meso levels of networking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
10.8.2 Macro levels of networking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
10.9 Sociotherapy with alcohol dependents in the context of Lesch’s typology . . . . 236
10.9.1 The critical relationship between psychiatry and sociotherapy . . . . . . . . 236
10.9.2 Application of the typology in sociotherapeutic contexts . . . . . . . . . . . . . . 237
10.9.3 The relationship between type and self-regulation . . . . . . . . . . . . . . . . . . . 239
10.9.4 Types and aims of therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
10.9.5 Sociotherapeutic aspects of therapy with alcohol dependents who are
fundamentally impaired in their performance . . . . . . . . . . . . . . . . . . . . . . . 246
10.9.5.1 Type IV characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246
10.9.5.2 Cerebral damages as a result of chronic alcohol abuse,
frontal lobe syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247
10.9.5.3 Executive Cognitive Functioning
(Giancola and Moss 1998, Frank 2002) . . . . . . . . . . . . . . . . . . . . . . 248
10.9.5.4 Coping with violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250
10.9.5.5 Sociotherapeutic structures instead of psychotherapy . . . . . . . 254
10.9.5.6 Stabilisation through social stimulation (SSS) . . . . . . . . . . . . . . . 257
10.9.5.7 Compliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
10.9.5.8 Overview of pedagogical context variables . . . . . . . . . . . . . . . . . 264
10.9.5.9 Over-challenge, “motivation” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
10.9.5.10 Case studies of long-term abstinent type IV patients . . . . . . . . 266
10.9.5.10.1 Norbert T., Type IV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 266
10.9.5.10.2 Peter N., Type IV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269
10.9.5.10.3 Karl H., Type IV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 270

Appendix 1 Lesch Alcoholism Typology – Questionnaire . . . . . . . . . . . . . . . . . 273

Appendix 2 Lesch European Smoker Classification . . . . . . . . . . . . . . . . . . . . . . 283

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347

About the Authors ......................................................... 353

XVII
1
Information about the origination
of this book

As alcohol and tobacco consumption ten, these authors use values which are
often occur concomitantly, scientific unacceptable today. Relapse is always
and therapeutic interest in both sub- viewed as something negative and the
stances has significantly increased over negative stigma of the “dependence”
the past years. The concomitant use diagnosis still remains a problem. This
has clearly more damaging effects than book will try to deliver objective infor-
alcohol or tobacco use by itself. In prac- mation which shows that a dependence
tice, patients have often mentioned that has nothing to do with faults or personal
they were able to quit the consumption weakness. Practitioners have divorced
of one substance without difficulty, but themselves from these general therapy
at the same increased the consumption guidelines and now use “individual
of the other (e. g. if the patients man- therapy for every patient”. These thera-
aged to quit smoking, their alcohol pies are “therapy according to dimen-
consumption significantly increased). sions”, “resource-oriented therapy” or
Our knowledge about dependencies is therapy which accepts unchangeable
permanently expanding and basic re- variables and seeks to influence change-
search keeps improving explainations able variables. Although we principally
of the functioning of specific brain cir- agree with these modern approaches,
cuits. Therefore it is very important for this book will nevertheless outline fac-
us to deliver findings that clinical prac- tors with global validity, which have
titioners can apply in therapy or during been shown to be effective in the the-
consultations with tobacco and alco- rapy of dependent patients. Scientific
hol dependents. A differentiation be- findings about subgroups according to
tween phenomena like the reward sys- Lesch’s typology form the basis of ther-
tem, dependence memory, withdrawal apy, but often need to be modified ac-
symptoms or the craving for tobacco cording to the individual. Classifications
and alcohol is needed in order to carry according to subgroups that suggest
out objective therapy and consultation. that dependencies are exclusively cau-
Very old concepts can still be found in sed by the effects of a substance, can
the literature today (Bleuler M. 1983; often be found in the literature. In this
Forel A. 1930, 1935; Haller R. 2007), book, we will outline different interac-
which are formulated into general rules tions between personality, environ-
for the therapy of dependents. Yet, of- ment and the effects of the substance.

1
1 Information on the origination of this book

1.1 Aims of this book overly heterogenically. Therefore sub-


groups like typologies have been devel-
Today we know that dependence is a oped which, depending on the clinical
disease that covers the individual in its problem, are based on sufficient scien-
entirety and which is linked to brain tific data which are relevant for therapy
dysfunctions, making the consumption and research, e. g. Fagerstroem positive
of addictive drugs often only a compli- vs. negative or the alcohol typology ac-
cating factor. Therefore in this books cording to Cloninger, Babor, Hesselbrock
chapters on prevention, diagnostic pro- or Lesch. Since 1999, large international
cedures, motivation and therapy (chap- bodies have been working towards im-
ters 4, 5 and 9) we will put particular proving this diagnostic and the DSM-V is
emphasis on factors, that help those planned to be available in 2011 and the
who are affected, and less on measures ICD-11 in 2014 (Fig. 1).
influencing tobacco- and alcohol avail- These diagnostic instruments
ability. According to the EU-resolution measure individual categories straight-
on addiction prevention 2005–2008, the forwardly and according to severity. At
prior prevention measure is to reduce the moment, there is discussion about
the demand for addictive drugs. The whether to include a “bottom-up diag-
reduction of substance availability is nosis”, so that, depending on the clini-
surely needed, but often only leads to a cal problem, a focus, stemming from
change in substances used. All other different categories, can be set within
measures, like bans and rules, influence the diagnosis. Animal studies and basis
substance abuse, but in no way impact research use very specific diagnostic ca-
the number of dependences. There is a tegories, e. g. withdrawal animal models
7 % lifetime prevalence of dependenc- or genetic animal models. When these
es, remaining the same across different results are transferred to research with
cultures, with the only difference being humans, this model transferred 1:1 to
in terms of the choice of substance. Yet the diagnosis dependence according to
smoking significantly contributes to- DMS-IV and ICD-10, it becomes clear
wards dependences in almost all cul- that the corresponding symptoms of
tures. In chapter 3.5 we will outline the these models need to be considered as
influence of smoking on the develop- well (e. g. if animal models have used a
ment of dependence, in particular al- withdrawal model, patients with acute
cohol dependence. withdrawal symptoms are consequent-
Chapter 5 will predominantly focus ly included in this study).
on dependence, abuse, withdrawal and As these different categories re-
sequelae, by employing ICD-10 and flect different biological vulnerabilities,
DSM-IV criteria. The current diagnostics internal circuits, which can be linked to
approach is in the form of “top-down di- clinical problems, will be described in
agnoses” (first the diagnosis of depend- chapter 7.3.2.2. These theoretical as-
ence is made and severity and treatability pects lead to a recommendation for
are rated). All therapists and researchers different medication for withdrawal,
with a clinical occupation are discontent relapse prophylaxis and treatment.
with this overly simple diagnostic ap- Many authors have emphasised
proach, which defines groups of diseases that dependence is based on a psycho-

2
Personal reasons for the rst author writing this book

Fig. 1 DSM-V Timeline Overview

DSM-V Timeline Overview


2003
Diagnostic Conference Prototype
Yokohama, Japan

DSM-V

2003-2007
12 Diagnostic Research Planning Conferences
APA / WHO / NIH
2011
2006-2011
DSM-V Workgroup Activities

2014
1999-2002 2006
A Research Agenda for DSM-V DSM-V Task Force Appointed
Chairs: Kupfer, Regier

ICD-11
2004
DSM-V Prelude website launched 2006
A Research Agenda II: Infants, Gender & Aging

Reggier D „Research Planning for future psychiatric classifications“


Sattelite Symposium Newport, Australia 2006

socio-biological development. As I am 1.2 Personal reasons for the rst


not aware of any disease which does author writing this book
not show any psycho-socio-biological
factors in its development, we will try By writing this book, I have sought to
to describe subgroups which illustrate present scientific findings from the past
the different weighting of these three 30 years in such a way that they can be
aetiologies. Psychological theories about integrated into daily practice of consul-
the development of dependence will be tation and treatment. Of course, I am
outlined in chapter 3.2, although these well aware that this aim cannot be fully
theories were shown to be therapeuti- realised and I would like to apologize to
cally relevant in behavioural therapy, all readers in advance because I am sure
systemic therapy and hypnotherapeu- that there are very important topics
tic concepts only. As dependencies are which have not been sufficiently tack-
more prevalent in marginal groups and led. Following the publication of the
can be linked to poverty, chapter 10 fo- German standard text, “Alcoholism –
cuses extensively on socio-therapeutic abuse and dependence. Genesis – con-
approaches. This chapter will introduce sequences-therapy”, which significantly
case studies which show that social in- influenced my clinical practice in 1975,
tegration improves drinking behaviour several great textbooks in English have
and quality of life even in severely de- been published (e. g. Johnson B et al.
prived dependents (e. g. homeless or 2003: “Handbook of Clinical Alcoholism
dependent individuals in prisons could Treatment”; Rommelspacher H. and
be re-socialised). Schuckit M. 1996: “Drugs of Abuse”) as

3
1 Information on the origination of this book

well as literature in German-speaking focus more on smoking. Blood vessels


countries (Batra A. 2005: “Tobacco de- previously damaged by alcohol and
pendence. Scientific principles and chronically irritated mucosa, often lead
treatment”; Wiesbeck GA. 2007: “Alco- to life-shortening diseases, caused by
holism-research – current knowledge, tobacco ingredients. This is why I want
future perspectives”). Following 32 years to outline the importance of both ad-
of collaborative work between many of dictive drugs in this book. The combi-
these authors and my research group, nation with illicit drugs, which is of
I would like now to summarize in this increasing importance, will only be dis-
book both our scientific findings and cussed briefly, as it is beyond the scope
our reflections on international re- of this book. Most chapters include
search. original quotations from international
Alongside my scientific work, my texts and from publications of our re-
practical work with patients is some- search group. As this book is intended
thing which I have always wanted to to be a practical document for practi-
maintain. Many patients have been tioners, I have only made citations if
very grateful and have kept in touch they seem very important. The com-
over the years. However, in the past ten plete literature can be found in the ap-
years, I have noticed more and more pendix. As I don’t consider myself an
that smoking has not been sufficiently expert on sociological models, my col-
considered in the past. Smoking behav- league, Christian Wetschka, who has
iour is extremely important in regards had many years of sociotherapeutic ex-
to life expectancy in long-term absti- perience, has written the chapter on
nence and dependence experts should sociotherapy.

4
2

Addiction – a short overview of a


widespread disease
2.1 Introduction als in the Mexican culture). However,
outside of its prescribed use in these
Many addictive drugs are primarily rituals, alcohol and tobacco consump-
made up of herbal substances and are tion was always severely punished, so-
certainly older than humanity. Other metimes even to the point of death.
addictive drugs are derived from fer- Already in the 3rd century B.C.,
mented fruits or distilled grains. Addic- distinct rules regarding the consump-
tive drugs are pharmacologically effec- tion of alcohol were recognized by Plato
tive substances and therefore comply and Plinius the Elder (who lived from
with the accepted pharmacological 23–79 A.D.) who specified these rules
rules. They have been applied by man- more precisely in the chapter “Medi-
kind for thousands of years and a range cine and Pharmacology” of his opus
of diseases have been treated with ad- “Naturalis Historiae” (Plinius Secundus
dictive drugs. It has been known for G. 1669). In one of his writings, he defi-
more than 2000 years that viruses can ned “abuse” and outlined several thera-
be driven away by using smoke (fire or peutic recommendations regarding the
tobacco smoke) and alcohol. Only 150 treatment of addictions.
years ago, contaminated water in Eu- These rules for the use of addic-
rope caused severe bodily discomfort tive drugs are as valid today as they
(sometimes even with lethal consequen- were over 2000 years ago. For instance,
ces). Yet, these adverse health effects Plato suggested that one shouldn’t car-
were in no case observable when alco-
hol was consumed in small amounts.
Alcohol is still used as a desinfectant Fig. 2 666th letter by Plato
agent and, even today, Shamans of the
• No alcohol should be consumed until the age of 18,
Upper Amazonas still use alcohol and so that not even more fire is added to existing fire
smoke to blow off viruses. The psy- and so that the exuberant feelings of the adolescents
won’t get out of control.
chopharmacological effects of alcohol
have always been known and in virtu- • Between age 19 and 42 low amounts should be
consumed at times and in a controlled fashion, but in
ally every culture there were distinct no case before consultations, treatments or when
rules stating at which doses, at what meeting a woman.
time and on which occasions alcohol • After age 43 the name of Dionysus should be called
and tobacco were allowed to be con- and excessive amounts of alcohol should be
consumed sporadically, so that the troubles of aging
sumed, and even enjoyed (Indian Ritu- can be endured and the soul stays euthymic.
als [e. g. calumet] or mandatory carous-

5
2 Addiction – a short overview over a widespread disease

ry out treatment or political consulta- dictive drug itself, combined with the
tions while intoxicated. Plato also high- effects of tobacco and alcohol, leading
lighted the various ways in which an to a variety of secondary disorders (e. g.
unborn child could be damaged by its tobacco causes pulmonary disease or
mother’s alcohol consumption. Of cour- alcohol causes liver disease). Conven-
se, in our times the age limit has clearly tional classification systems like the
shifted (43 years then is the equivalent ICD-10 and the DSM-IV each have their
to 70 years today). own very different history and have
been conceptualized for very different
2.2 Prevention reasons. The world health organisation
(WHO) has introduced the internation-
Within the field of prevention, meas- al classification system foremost be-
ures that are taken to reduce the de- cause it has sought to achieve a higher
mand for addictive drugs (primary pre- comparability of diseases and their fre-
vention) are distinguished from early quency in a wide range of countries.
interventions (“to look closely at the With this increased comparability, cri-
problem and recognize it instead of tur- teria, which lead to an improvement of
ning away ”), which start before the drug the medical care system in specific
is actually abused or in the very early countries, were to be developed. In the
stages of abuse (secondary prevention), case of a multiple diagnosis for one and
and strategies which treat abusers and the same patient, the different diag-
addicts (tertiary prevention). The best noses should be coded and, if possible,
prevention results are achieved when the type of therapeutic setting should
the problem is recognized and addres- be pinned down for each of the coded
sed early. Furthermore, sufficient inter- diseases (e. g. abstinence in an in-pa-
ventions should be offered to help tient or outpatient setting). ICD-10
those that are affected and these should classification has proven itself suitable
be more precisely tailored to suit spe- for the recording of a wide range of ad-
cific homogeneous risk groups (EU Re- dictions in different countries. In nu-
port 2007). merous countries this has lead to pub-
An important way to combine pre- lic health insurance sponsoring the
vention and intervention methods is therapies of addicts, but it has also re-
through counselling provided by absti- sulted in very general therapies being
nent addicts to high-risk youth. Teen- offered, some of which employ all sorts
agers learn from role models and absti- of methods (ranging from Shamanism
nent addicts act as deterrents to their in Brazil to electric cerebral stimulation
alcohol abuse (Lesch OM. 2007). in Russia). These forms of therapy are
often entirely inadequate methods of
2.3 The Diagnosis addiction treatment and this generalized way of
diagnosing an addiction is not diagnos-
Specific to their relevant addictive drug, tically conclusive enough for therapy.
abuse, addiction and withdrawal symp- Consequently, many definitions of
toms are defined in all classifications subgroups have since been developed
(e. g. DSM-IV, ICD-10). Yet, secondary which can be used for diverse purposes
disorders are mainly caused by the ad- (e. g. genetic studies, therapy studies,

6
Aetiology of addiction

aetiology studies). The American Psy- substance that can be harmful to the
chiatric Society has developed the health of both groups. Depending on
fourth version of its classification sys- dosage and frequency of intake, it can
tem (DSM-IV), in which the diagnoses even be fatal. Likewise, a rapid with-
are clearly narrower than in the ICD-10. drawal of sugar intake leads to severe
The DSM-IV already includes sub- bodily dysfunctions in Diabetes Melli-
groups and these diagnostic classifica- tus patients, which can even lead to
tions should be employed especially for death (diabetic coma, Grand Mal sei-
research purposes so that research re- zures, vegetative symptoms and ”Symp-
sults become more internationally com- tomatic transitory psychotic syndrome”
parable (Widinger TA. et al. 1994). The according to Wieck H., 1956, Berner P.,
DSM-IV Source Book indicates why 1986). This concept is mainly used in
specific criteria were incorporated in German speaking countries. Any dis-
the diagnostic of addiction and sug- turbances of the brain lead to cognitive
gests research approaches that should impairments. Independent of the cause
be continued (administration of re- of these disturbances, the location in
search). Today there is still dissatisfac- the brain and the speed of the develop-
tion with both sets of criterion and both ment of the “brain trauma” influences
the WHO and the American Psychiatric the depth of unconscious states, the
Association are working towards new level of cognitive impairment and the
and revised criteria (see chapter 5). (Le- severity of psychiatric symptoms. If the
sch OM 2009, Addiction in DSM V and developmental time is short, the per-
ICD-11 State of the Art), Fig. 1. son reacts with different stages of un-
consciousness. If the developmental
2.4 Aetiology of addiction time is longer, e. g. chronic alcohol
intoxication, different degrees of cog-
As already pointed out, the aetiology of nitive impairment occurs stepwise
abuse and addiction lies in the vulner- with different psychiatric symptoms.
ability of individuals and not in the ef- As shown in Fig. 3, transitional cogni-
fects of various drug substances. tive impairments produce step by step
We would like to explain this by these syndromes. During recovery, psy-
using the aetiology of “Diabetes Melli- chiatric syndromes lessen in severity.
tus” as an example. Diabetes Mellitus is For example, a Delirium Tremens chan-
a disease of the glucose metabolism ges to delusional states and then to af-
and other vulnerabilities (e. g. insulin fective mood disturbances and so on.
metabolism). Diabetes mellitus has Many addicts show a primary vul-
been divided into two subgroups. In nerability that may be genetic in origin,
one group, genetic vulnerabilities are or a vulnerability resulting from physi-
the prime factors (glucose metabolism, cal or psychiatric damage in the early
insulin sensitivity), whereas in the oth- years, often while in the womb during
er group, environmental factors, psy- the first weeks of pregnancy (e. g. as a
chological problems and the metabolic result of mothers who smoke and/or
syndrome affect symptomatology. Here, drink). Severe psychological trauma
the body can’t convert sugar that is tak- can combine with genetic vulnerabili-
en in high doses accordingly. Sugar is a ties (i. e., gene-environment interac-

7
2 Addiction – a short overview over a widespread disease

Fig. 3 Transitional Organic Impairment – psychiatric syndromes: steps of development


and recovery (Wieck H. 1956).

Transitional Organic Impairment


Steps of Development and recovery

delirium
paranoid ideas, hallucinating
Mood changes
Emotionally instable, irritable

reduction in cognitive
performance

tion), and this combination can be as ily be used of by individuals with vari-
important for the aetiology as the pri- ous psychiatric problems. Smoking
mary genetic vulnerabilities. Often, the obviously has a different function for
addictive substance is consequently patients coming from a schizophrenic
used as a strategy to cope with the dif- spectrum than for patients with an ob-
ficulties of everyday life. The psycho- sessive compulsive behaviour pattern
logical aetiology model of addiction, or an impulse control disorder (see
which has been developed according to chapter 3.6).
psychotherapeutic schools of thought,
only explains subaspects of develop- 2.5 Secondary disorders and
ment but has not led to an identifica-
addiction
tion of specific psychotherapeutic pro-
cedures. Tobacco- and alcohol abuse as well as
Methods of behavioral therapy addiction can damage most parts of the
(e. g. Brenda Method), family therapy as somatic system. Diseases that range
well as hypnotherapeutic treatments from changes in the vascular system to
are based upon scientific data which pre-cancerous and malignant tumours
suggest effectiveness. Nevertheless, there lead patients to various outpatient
are both positive as well as negative treatment centres, clinics and hospitals,
studies in this area (Hester RK and Mill- e. g. departments for internal medicine,
er WR, 2003; Volpicelli JR et al. 2001). surgery, acute medicine, psychiatry
Tobacco and alcohol are easily accessi- and to the general practitioner/prima-
ble everywhere. Therefore they can eas- ry care provider. Secondary disorders

8
Motivation of addicts

of this kind are caused not only by the chotic syndrome” according to Wieck”)
consumption behaviour, but also by and the different craving mechanisms
infectious diseases, maladaptive diet also need to be recognized too.
and a primary sensitivity of all kinds of
organs. Every individual has his own 2.7 Subgroups of addicts
unique organ system and when it is ex-
posed to unfavourable conditions, ill- The clinical heterogeneity of tobacco
ness can result. In chapter 7 important and alcohol addiction is undisputed,
somatic illnesses are introduced to with over 100 alcohol typologies having
highlight the medical significance of been developed worldwide. Today there
tobacco and alcohol, whilst at the end is some consensus that a four-group ty-
of this chapter the importance of the pology will capture and identify the
interaction between alcohol and medi- majority of patients. When comparing
cine taken for somatic diseases will be different typologies from different au-
highlighted. These interactions change thors it becomes apparent that there is
the effects and toxicity of most medi- considerable concordance across diffe-
cines. In many cases, these interactions rent classification systems. Results from
explain why medical treatment does the general population and clinical
not result in improvement or leads, in samples indicate that subgroup catego-
some cases, to an exacerbation of rization is relatively stable over at least
symptoms. This relationship between 5 years (see chapter 6). In our own re-
somatic changes and addictive substan- search group (Lesch & Walter), we have
ces can sometimes be examined using developed a typology of alcoholism
biological markers so that the alcohol/ that has been tested internationally by
drug consumption behaviour can be using physiological, biological, thera-
appropriately judged both cross-sec- peutic and genetic studies. This typol-
tionally and in the longterm course ogy seems quite suitable for testing a
(chapter 8.2). variety of clinical questions. These stud-
ies also confirm that the identified alco-
2.6 Secondary diseases and brain holic subgroups are relevant for thera-
peutic considerations and prognosis
functions
(see chapter 6.3). For example, even
Primary and secondary changes in cen- though nicotine addiction and smoking
tral nervous system functioning and behaviour are different from alcohol de-
the influence of addictive drugs on all pendence, using Lesch’s typology we
neurotransmitter systems are one of were able to identify therapy relevant
the basics understanding the psycho- subgroups of dependent smokers who
logical consequences of heavy use and certainly need different therapies (Lesch
the mechanisms leading to the genesis OM. et al. 2004, 2007, 2010).
and maintenance of dependent behav-
iour. The biology of the reward system 2.8 Motivation of addicts
as well as the biological mechanisms of
the drug addiction memory are func- An important aspect of every addiction
tions which are important for addiction is the fact that these patients are seldom
therapy (“Symptomatic transitory psy- motivated to change their consumption

9
2 Addiction – a short overview over a widespread disease

behaviour. This amotivational behav- the affected (e. g., in-patient psychiat-
iour is an important diagnostic criterion ric admittance in case of suicidal be-
of addiction. The patient should be haviour or esophageal bleeding may
made aware that there is an interest in lead to admission on to a surgery
him as a person and that he is being unit).
consulted. It is imperative that the pa-
tient has the freedom to define indepen- 2.9 The path from motivation to
dently the goals of therapy. Often the
therapy
first goal of the therapy is that the pa-
tient seeks contact more frequently with In the case of addiction, a therapeutic
the therapy centre and asks for infor- process can be effective since many af-
mation about the therapy planned and fected individuals need long-term sup-
the prognosis. In line with these con- port. Acute detoxification therapies are
versations and, apart from psycho edu- only recommended in combination
cation, a “motivation” process should with adequate medical management
be initiated. This process should lead which leads to a minimization of with-
to a decline in consumption behaviour drawal symptoms and reduces risk of
and maybe even to abstinence. Pro- seizures or other possible complica-
chaska and DiClemente have fittingly tions. In many cases, it is better to slow-
described the phases of motivation, and ly reduce the addictive substance in-
one should be aware of the patient’s stead of abruptly discontinuing the
current phase of motivation in order drug use (Pharmacological extinction
to start the motivation process (Pro- method according to Sinclair JD, 2001).
chaska. J. and DiClemente C. 1992). The In the majority of cases, in-patient the-
fundamental elements of motivation rapies should be kept as short as possi-
are to begin the process in the patient’s ble and afterwards an adequate out-
present phase and to be patient during patient/ambulatory setting should be
the therapeutic process in order to offered. Depending on the drug of ad-
achieve the goals of treatment. (see also diction and patient typology, a plethora
Miller WR. and Rollnick S. 2002: Moti- of measures is necessary. These meas-
vational interviewing: Preparing people ures are outlined in chapter 9. Assist-
for change). ance carried out with respect for the
The goals should be clearly for- patient’s dignity is the goal of every
mulated, realistic and achievable therapy. Relapses are to be accepted.
within a short time. It is important that They are part of the life course of addic-
both patient and therapist have mutu- tion; the patient can perceive his drink-
ally agreed upon a therapy goal. The ing behaviour as a relapse only after he
manner in which the motivation ac- himself has accepted “abstinence” as a
tivities are conducted depends upon therapy goal (Schmidt G. 1992).
the patient’s personality and the spe-
cific social setting. Secondary diseases 2.10 Addiction and relapse
or self-harming behaviour often en-
force an adherence to the crisis con- Today relapse is still seen as something
cept. Within this context, actions must negative, in spite of addiction research
be carried out to ensure the survival of being able to show that for patients in

10
Specic groups of addicts

Fig. 4 Old and new thinking about relapse

Old thinking New thinking


• Relapses are expressions of poor therapy • Relapses can actually show that
and personal failure something incrusted is being overcome
• A relapse means that the entire therapy • Relapses are chances for development
was useless • Relapses are to be respected as attempts
• Relapses are catastrophes to cope with one’s own problems
• Relapses are further step into self- • Relapses should be valued as forms of
destruction resistance
• Relapses are autonomous processes, • Relapses are attempts of self-healing (e.g.
“there is nothing one can do about it” Maintenance of self-esteem), they don’t
• Relapses end in a lingering illness appear from nowhere
• Relapses are an expression of a definite • Relapses are integral to every
decision to keep on drinking development
• The primal cause for a relapse is the • Abstinence is not the central indicator for
craving for alcohol judging a therapy
• The first glass ends in a loss of control • The path out of addiction requires time
• Relapses is not equal relapse

(see STAR-Training according to Koerkel and Schnidler)

a therapeutic process it is sometimes nence, even without any therapy, and


necessary and even beneficial to expe- only require an antidepressant medica-
rience relapse. There are subgroups of tion when the symptoms continue after
addicts whose primary therapy goal is three weeks. During abstinence, tran-
to reduce the severity of their relapses. quilizers and hypnotics should only be
New and old thinking about a relapse administered in exceptional cases for
is illustrated in Fig. 4 (see chapter 9.6). this group of patients with affective dis-
turbance.
2.11 Specic groups of addicts
2.11.2 Overweight, eating disorders
2.11.1 Co-morbidity of tobacco and
alcohol-addiction The problems of being overweight,
smoking and drinking to much alcohol,
Co-morbidity with other psychiatric show an obvious concordance in gene-
disorders needs to be considered for sis and aetiopathology. Post-menopau-
tobacco/nicotine dependence as well sal women who smoke to control their
as for alcohol addiction. Co-morbidity weight represent an even more specific
often influences the therapeutic proc- patient group of smokers. About 20 %
ess and is an important consideration of addicts have an eating disorder be-
for prognosis. Anxiety and depression fore the onset of addiction. As new sci-
symptoms are almost always observed entific information becomes available
during both alcohol intoxication and about these phenomena, new thera-
withdrawal. They usually subside with- peutic strategies also need to be con-
in two to three weeks of absolute absti- sidered.

11
2 Addiction – a short overview over a widespread disease

2.11.3 Gender dividuals were able to make very good


artistic contributions and when their
Today we know more than 50 consider- potential was utilized, the quality of the
able gender differences which need to results was often astonishing (see chap-
be considered in research and therapy ter 10). The football competition for the
of addicts. These differences are so im- homeless which takes place every year
portant that results which have been shows that homeless individuals can be
obtained in research with men, cannot good athletes and are able to play, e. g.
be transferred to women. Most studies football despite their physical disad-
don’t include enough women to be vantages.
able to make valid conclusions about
women. These gender differences don’t 2.13 Polytoxicomania
only manifest in alcohol metabolism,
but also in regard to coping strategies In the US as well as in some European
(coping with stress situations) in addic- countries like Portugal or Netherlands,
tion symptoms. Women already devel- the chaotic consumption of alcohol,
op severe bodily dysfunctions after five tobacco and illegal drugs is rather a
years of alcohol abuse whilst in men norm. German-speaking regions and
these dysfunction do not become ap- rural wine-growing districts also show
parent until twelve years later. Addicted this combination of alcohol and tobac-
women are left by their husbands, co, but this is rarely combined with
whilst addicted men are usually still the consumption of illegal drugs. Often
cared for by their wives, although their in the USA, it is merely possible to differ
husbands may treat them very offen- between addicts with rare or frequent
sively (verbally as well as physically). cocaine consumption. In France the
concomitant use of Benzodiazepines in
2.12 Addiction and the homeless addicts is rather the norm than the ex-
ception.
In regard to the development process This topic is exceedingly exten-
according to Lesch, addiction leads to sive and goes beyond the scope of this
severe social deprivation, in particular book. This disease group might have
in type IV, but also in type III. This is been well examined from a sociologi-
why a whole chapter (10) tackles the cal perspective, but from a medical-
social therapy of these marginal groups. psychiatric perspective, the literature
The chapter shows the massive deficits can only be judged as modest (see for
of the medical system in respect of this example Johnson BA et al. 2003; Rom-
“disease group” (which is often affected melsbacher H and Schuckit MA. 1996).
by homelessness), and demonstrates In 2007, a Portuguese research group
how it is possible to get very good re- published an article on subgroups of
sults using addiction therapy (Platz W. addicts, in which they provided sup-
2007). port for the theory that polytoxi-
Despite their social deprivations, comanic subgroups of adolescent ad-
these patients often have a very high dicts could be distinguished from all
individual potential. In a theatre group, other groups, as defined for example
we were able to show that homeless in- by the NETER typology or typology ac-

12
Non-substance dependence

cording to Lesch, and therefore should criteria for a delusion. Since as far as
be treated with a different therapy therapy and the progress of “monoma-
(Pombo S et al. 2007). Lesch’s types III nias” are concerned, little depends on
and IV could also be defined in opiate behaviour but much on the function of
dependent patients using a large sam- the “monomanias”, no specific therapy
ple of opiate addicts (n = 930). These recommendation can be made for non-
opiate addicts, separated into types substance dependences. For this rea-
III, IV and others, showed many differ- son, we shall not be addressing this pa-
ences in the degree of severity of their tient group in this book. It was a difficult
psychosocial disturbances, chose dif- process to get substance caused de-
ferent maintenance medication and pendence accepted as a medical con-
needed significantly different dura- dition so that its treatment can be fi-
tion of admission (Hermann P. and nanced by medical insurance. Too few
Wallner Ch. in preparation). paid therapies are available for tobacco
dependents with high biological de-
2.14 Non-substance dependence pendence (Fagerstroem score ≥ 5).
From a psychiatric perspective, the di-
These pathological behaviour patterns lution of the term “dependence” is ab-
(pathological gambling, work addiction, solutely counterproductive. Today it is
religious addiction etc.) affect a great very modern to define new disorders
number of people and have been coded (ranging from work to sex addiction),
in the ICD-10 and DSM-IV into the with each behaviour pattern being de-
categories “behavioural disorders” and fined as a separate disorder.
“impulse control disorders”. From our Here one needs to bear in mind
psychiatric knowledge, these behav- that these “new disorders” and their
iours should be combined as reactions definitions represent for many groups a
caused by different psychiatric disor- means of earning money or gaining
ders (in the German literature, the so other advantages. These new defini-
called “monomanias”). tions don’t actually help those affected,
Eating disorders seem to have but only serve to overburden the medi-
specific biological and psychological cal system. As a consequence, the funds
aetiologies and should therefore com- are lacking for the therapy of severely ill
prise a group in itself. The extent to psychiatric patients (e. g. there are no
which all of these disorders can be comprehensive intensive care facilities,
summarized as impulse control disor- not enough psychiatric liaison provi-
ders is being discussed around the sions in the medical and social care
world. Some of these forms of behav- systems, and too few hospital places for
iour and experiences meet the criteria psychiatric patients. As a result, we can
for delusional elements, as described only help these patients to a minimal
in the novel “The Gambler” by F. M. degree because we have no effective
Dostojewskij. The gambler knows that therapy methods at our disposal). The
in Roulette, e. g., number 13 will show. realization of effective and specific the-
He is absolutely certain that his inter- rapies according to subgroups of disor-
pretation is correct and is unshaken in ders would on the other hand save costs
his conviction, thereby meeting Jasper’s and thus relieve our medical system.

13
3
Aetiology of addiction

3.1 The psycho-socio-biological in chapter 6 which is suitable for the


model patient as it has psycho-educative as
well as motivational aspects. The mod-
Psychological, social, biological and ge- el also explains the dynamic process of
netic causes are assumed to play a role addiction as an interplay of cause and
in all psychological disorders but only effect in relation to the addictive drug,
little of this aetiological thinking has substance withdrawal and the conse-
led to practical approaches that can be quences.
realized in therapy. This has also been
the case in the field of addiction where 3.2 Psychological theories
the need to define psychological, bio-
logical, sociological and aetiological fac- There are numerous psychological the-
tors has repeatedly been posited. ories and virtually every psychological
The indisputable heterogeneity of school of thought has developed a mo-
addictions is tackled in chapter 5 and 6. del to explain the aetiopathogenesis of
Of course, the addiction sub-groupings addiction (Springer-Kremser M. and
draw on psychological, biological, so- Ekstein R. 1987). Many of these are lim-
ciological and aetiological factors as ited in their significance; others again
well, but the weighting and the impor- have proven to be valuable in therapy.
tance of the particular factors are each For many years, moral models have ob-
very different, depending on the sub- structed the perception of the causes of
group. Alcohol and tobacco dependents addictions, but during the last decades,
who regularly try to reduce withdrawal opinion has tended towards the rejec-
symptoms by administering alcohol or tion of moral models. As religious groups
tobacco, but otherwise don’t show any still make considerable contribution to
abnormalities in personality or in their the care of substance dependents, mor-
social environment, aetiologically dif- al perspectives should still not be un-
fer from alcohol and tobacco addicts, derestimated. The “point of no return”
who use alcohol and tobacco in specific as a central characteristic for the diag-
situations to cope with stress and have nosis of addiction shows that a lack of
no or only mild withdrawal symptoms. motivation to change one’s lifestyle, or
Following a description of indivi- to live without tobacco and alcohol, is
dual aetiological theories, a model with an essential part of addiction. During
a psychological, sociological and bio- intoxication and withdrawal, a state
logical perspective will be introduced which virtually always goes hand in

15
3 Aetiology of addiction

hand with a symptomatic transitory can strengthen or weaken the con-


psychotic syndrome, motivation is only sumption behaviour (Skinner BF. et al.
minimally subject to the patient’s acts 1938). The fact that the effects of nico-
of free will. tine and alcohol are immediate is per-
Psychological theories which are ceived as a positive stimulus, and this
today being discussed in connection stimulus acts in turn as an incentive to
with the causes of addiction and which smoke or drink. To sum up briefly, envi-
are, according to Lesch’s typology, used ronmental and individual stimuli affect
in psychotherapy as relapse prophy- consumption behaviour, and the im-
laxis, are outlined in the following para- mediate experienced effect is in itself
graphs. seen as a positive stimulus to further
consumption. Withdrawal symptoms,
3.2.1 Behavioural approaches which do not occur until later, are per-
ceived as punishment and have a weak
In behavioural explanation models, influence on the consumption behav-
questions regarding the functionality of iour as a result of the time lag (Schmitz
alcohol and mechanisms of consump- JM. and DeLaune 2003). In expectation
tion, which describe the prevention theory, it is postulated that the activat-
and the risk factors of the addiction ing stimulus, consumption behaviour
process, are predominant. Consump- and consequences can lead to an ex-
tion is understood as a learned behav- pectation which can constrain or pro-
iour which is affected by the respective mote intake anew. Six expectations can
life situation and individual variables. be defined in regards to alcohol con-
In 1943, Hull CL already formulated his sumption:
tension reduction theory, based on Pav-
lov’s classic conditioning model, which 1. the expectation that the addictive
indicated that individuals learn specific drug makes a perspective more
reactions to stimuli that lead to a re- positive and enjoyable
duction of states of tension in the body 2. the expectation that the addictive
(Hull CL. et al. 1943). According to this drug enhances individual and so-
theory, alcohol and tobacco addiction cial well-being
are behaviours that are learned through 3. the expectation that the addictive
reinforcement and which lead to a re- drug positively influences sexual-
duction of tension (often anxiety). Ho- ity
wever, the consumption behaviour leads 4. the expectation that the addictive
in turn to an increase in tension with drug enhances power and aggres-
the result that higher intake of alcohol sion
and nicotine is needed in order to pro- 5. the expectation that the addictive
duce the same effect i. e. to relieve the drug enhances social assertiveness
feelings of stress. This cycle is drawn 6. the expectation that the addictive
upon as an aetiological factor in the de- drug reduces and even removes
velopment of addictions. In Skinner tensions
BF.’s model (transactional model of op-
erant conditioning), it is also empha- This interplay between expectations
sized that positive and negative stimuli and the pharmacological effect of alco-

16
Psychological theories

hol and tobacco is also displayed bio- type I and type IV patients according to
logically and permits behavioural phar- Lesch.
macological thinking which is also of
therapeutic relevance. 3.2.2 Models of depth psychology
85 % of the population drink alco-
hol and, depending on age, 50 % of 18 These models predominantly present
year olds and 30 % of 50 year olds pre-morbid personality disorders. Child-
smoke. Adolescents learn on the basis hood development is a process that can
of a model and, early in their life, they be disrupted at certain points and ab-
learn that almost all festive occasions normal developments might occur that
are connected with alcohol. This social can lead to a disposition to develop an
learning also allows us to define places addiction. Zingerle (1994) emphasised
and situations in which people smoke three central functions of addiction in
and drink and which are today de- the light of depth psychology, which
scribed as “hot spots” (restaurant, party are, firstly, addiction as a means of
etc.). In the same manner, we can de- satisfaction, secondly, addiction as a
fine places and situations where people means of defence (e. g. depression and
neither smoke nor drink as so called anxiety) and thirdly, addiction as a
“cool spots” (e. g. sports and other ac- means of compensating e. g. for a sense
tivities). of inferiority (Zingerle H. 1994). In this
The greater an individual’s access regard, we have postulated in our work
to “cool spots”, and the more coping that the defence mechanisms of type
strategies he has, the lower the risk of III according to Lesch must be attended
his developing an addiction. Individu- to, while for type II according to Lesch
als, who live their lives mainly in “hot the compensation mechanisms in re-
spots”, and have a lower number of oth- gard to low self-esteem are to be prio-
er coping options, have a higher risk of ritized. Developmental and therapy
developing an addiction and it is more studies about these concepts, which
difficult for them to “free” themselves could connect Lesch’s typology with
from an addiction. Behavioural thera- depth psychological models, are still
peutic concepts are based especially on lacking. In a three-month in-patient,
theoretic learning models. In pharma- depth-psychological group concept, we
cological studies, behavioural therapy formed groups with type I and type II
is likely to be standardized and in these patients according to Lesch and then
studies of addicts, the behavioural ther- measured what kind of changes took
apeutic method has established itself place in patients and also in the thera-
in the form of a standardized interview pists after three months. In groups with
(Method according to BRENDA: B = Bio- type II patients, the analytic group work
psychosocial evaluation, R = Report was described as particularly interest-
[Report for the patient], E = Empathy, ing, challenging and also effective by
N = Need [Evaluation of needs], D = Di- both patients and therapists. In groups
rect advice, A = Evaluation of reaction; with type I patients, both patients and
according to Volpicelli JR et al. 2001). therapists perceived the regular group
In practice, this behavioural ther- meetings as especially tedious and to a
apeutic approach is highly relevant for certain extent even extremely boring

17
3 Aetiology of addiction

(Platz W. and Lesch OM., unpublished ingfully (Fenichel O 2006). Thus, alco-
data). hol helps to liberate the ego that is re-
stricted by the super-ego, which results
3.2.3 Depth psychological approach in a reduction of tension and anxiety
and hence an increase of pleasure.
Strotzka H. already formulated in 1982 Strotzka also describes the oral charac-
that addiction can be viewed as a fixa- ter as decisive for depression: “A patient
tion in the oral development stage with a severe depression is an orally de-
(Strotzka H. 1982). The daily satisfac- pendent individual who is deprived of
tion of drives by smoking and drinking vital supplies.”(Strotzka H 1982). In our
demonstrates the effort to solve drive work group it was therefore pointed out
conflicts, while the drive is uncontrol- that these aetiological suggestions are
led and unsublimated. Freud stressed extremely important for Lesch’s type III
the oral-erotic components and ex- and thus should be included in the
plained this by a deprivation of affec- therapeutic process. The common psy-
tion and by emotional dysfunctions in chological causes of addiction and de-
early childhood, with the delay of mat- pression can then be treated.
uration being a central aspect. Accord-
ing to Freud, changes in affects and the 3.2.4 Ego-psychological approaches
handling of emotions which is based on
underlying and unrealised insecurity, Dysfunctions in the ego organisation
anger and guilt are fundamental crite- lead to dysfunctions in perception,
ria for the development of an addiction. which results in a lack of differentiation
When intoxicated, an adult regresses, of emotions and their meaning, dys-
and inhibitions and defensive behav- functions in object relationships, which
iour are removed and therefore repres- are often connected to primitive de-
sed sources of pleasure are accessible fence mechanisms, frustration intoler-
again. The addictive drug enables the ance, affective and impulse control dys-
individual to step back from the princi- functions, dysfunctions of judgement,
ple of reality to the child’s principle of especially in anticipating the effect of
pleasure and therefore to escape reality one’s own behaviour on others, and de-
(Freud S. 1905; Innerhofer P. et al.; Vog- pendence conflicts between symbiotic
ler E. and Revenstorf D. 1978). For Freud, requirements and autonomy tenden-
masturbation is the prototype of addic- cies. Feuerlein W sees the consumption
tion and Rado even speaks of a “phar- of addictive drugs as a possible way of
maceutical orgasm” (Rado S. 1926, 1975). strengthening the ego that is weakened
One of the motives of consumption be- in its structure (type II according to
haviour is the urge to unleash one’s po- Lesch). Furthermore, Knight RP sees al-
tential for pleasure. Fenichel O sees the coholism as an attempt to solve emo-
causes of increased alcohol consump- tional conflicts which emerge from
tion in frustration and internal inhibi- heightened expectations regarding drive
tions, the weak ego is exposed to the satisfaction, aggression, guilt, regression
rivalling impulses of the “super-ego” and the tendency to punish oneself
and the “id” and it is unable to satisfy (Knight RP 1937). De Vito RA sees ex-
needs and desires for pleasure mean- cessive alcohol abuse as a protection

18
Psychological theories

against various threatening emotions, lapses. The “grandiose self” that has
e. g. strong and hostile affect states (De been maintained by external support,
Vito RA 1970). collapses into an insecure ego and ad-
At the same time, inhibitions are dictive drugs are then used to regulate
removed and the venting of these emo- this loss of self-worth (type II according
tions becomes possible. to Lesch; Heigl-Evers A et al. 1981;
Alcohol protects and stabilises the Heigl-Evers A and Standke G 1991; Heigl
weak ego by regulating affect and con- FS and Heigl-Evers A 1991). In this de-
straints and here alcohol functions like velopment, gender differences need to
the defence mechanisms of a healthy be considered (Kernberg OF 1979). A
individual (Feuerlein W. 1981, 1989). number of representatives of the object
Today we would like to discuss the relations’ psychological approach em-
weakness to control impulses in type I phasise the auto destructive tendencies
according to Lesch and the problem of of addiction. For example, Menninger KA
subject-object-relationship in Lesch’s sees self-destruction as a fundamental
type III, as well as ego weakness in characteristic of addiction, whereas he
type II. The link between weakness of views alcoholisms as a special form of
impulse and compulsion, as measured self-punishment, which corresponds
by Anton RF’s obsessive-compulsive to a slow and chronic suicide (type III
scale, is the cause for the drinking be- according to Lesch; Heigl FS and Heigl-
haviour in type IV patients, but further Evers A 1991, Menninger KA 1974).
research is still needed in this area (An-
ton RF et al. 1995). 3.2.6 Theoretical approach of Narcissism

3.2.5 The psychological model of object Traumata in an early development


relations stage, in which a child can’t regulate its
self-worth adequately, can cause ad-
Melanie Klein points out the important diction. A weak and inadequately inte-
function of the mother for develop- grated self and a deficiency of concep-
ment, where the nurturing, protecting tions and inner images lead to a strong
and good mother is compared with the sensitivity towards narcissistic insults
frustrated, harmful and bad mother and addictive drugs are supposed to
(Klein M 1972). If the internalisation of compensate for this effect but in fact,
the good mother doesn’t work out, a merely support the generally shallow
primitive and immature object rela- feeling of grandiosity (Menninger KA.
tionship is developed (Balint M 1970). 1974) and reduce the ability to be criti-
The differentiation of self and object cal about one’s own behaviour. In 1979,
representations has failed and thus Kemberg described how alcohol is
there is no stable balance between abused by narcissistic individuals in or-
these two object relationships. These der to protect their pathologically large
persons need external objects, often ego and to fend off the environment
social attachment figures, who should which is perceived as hostile and frus-
be available at any time to satisfy needs. trating (Adams JW. 1978; Kernberg OF.
If these external objects fail in these 1979; Kernberg OF. et al. 2000; Passett P.
functions, the primitive defence col- 1981; von Scheidt J. 1976).

19
3 Aetiology of addiction

3.2.7 Explanation models according to iour so difficult to break. Relatives or


family psychotherapy partners of all addicts go through the
process of co-addiction. In the begin-
From a systemic perspective, addic- ning, the relative or partner might ad-
tions are not only related to the indi- mire the addict for being able to drink
vidual, but also are a result of the dys- such large amounts of alcohol. After
function of an entire ecological system the first excesses, the consumption be-
in which the individual lives. A human haviour becomes noticeable to the rel-
being lives in balance between the in- ative and the addict promises to reduce
dividual, behaviour and the environ- his drinking; then control mechanisms
ment. Changes in this system and dys- are established and when these are not
functions of this balance demand an effective, the relative assumes the “role
adaptation of the perception and be- of a judge” and starts to make judge-
haviour of the individual. If the indivi- ments about the “morally wrong be-
dual is not able to stabilise this balance, haviour” (for more information on the
addictive drugs are used to influence topic Co-addiction see: Beiglboeck W.
these disordered cycles. Alcohol, for ex- et al. 2006).
ample, becomes the central principle
for organising the interaction with the 3.3 Social explanation approaches
partner and its main function is the
maintenance or restoration of the bal- Epidemiological studies have shown
anced state (Schmid C. 1993). Systemic that smoking and drinking behaviour
problems in type I alcohol addicts are to depends on social conditions. Coun-
be seen as secondary problems which tries with a permissive alcohol climate
are mainly caused by chronic intoxica- have considerably higher rates of alco-
tion and should be respected especially hol use and abuse than countries in
at the beginning of the therapy. The which drinking alcohol is an undesired
powerful and assertive partner of type behaviour (e. g. Christian countries vs.
II according to Lesch is an important Muslim countries). Countries with so-
aetiological and therapeutic factor in cial security, guaranteed education and
regard to the self-esteem of the addict. a secure workplace have a lower drug
In type III according to Lesch, missing problem than countries with insecuri-
closeness between partners and be- ties and insecure education. Addictive
tween the patient and the social envi- drug consumption is conditioned in
ronment is often an important aetio- families and is related to biological fac-
logical and therapeutic factor, with the tors, which will be described later (see
patient feeling extremely powerful. In chapter 3.4). Social learning, on the ba-
type IV according to Lesch, there is of- sis of the model of the beloved parents,
ten no partner or a partner who also certainly plays a significant role. The
drinks and the entire environment is socialisation of gender is very different,
perceived as negative and hostile. Only depending on culture, and certainly in-
during intoxication, are patients able to fluences smoking-and drinking behav-
mirror their aggression and these inter- iour. There is extensive literature sub-
actions then lead to those processes stantiating the fact that values taught
which make the consumption behav- adolescents by their families, and which

20
Social explanation approaches

dominate the peer groups to which be examined in more detail by experts


they belong, significantly influence be- on sociological questions (Cahalan D
haviour. “Peer group” research could 1970; Eisenmann G 1973; Engel U and
clearly show that the group’s attitude Hurrelmann K 1993; Niderberger JM
towards addictive drugs and behaviour 1987; Quensel S 2004; Reinhardt JD
is more important than individual atti- 2005; Schulz W. 1976; Springer A 1995;
tudes towards substance abuse. The Vogler E 1978; Zander M et al. 2006).
group decides whether its members Addictions are more or less equal-
smoke or drink. Social developments in ly common in all western societies. It is
a society, which provides adolescents assumed that around 7 % of the popu-
with no freedom or space to experi- lation in every culture develops the
ment, but only offers bans and rules, criteria of an addiction. However, the
support alcohol consumption behav- choice of substance depends on social
iour. Adolescents need to have time conditions, availability and the image
and room to live out their youth appro- of the addictive drug. Social develop-
priately. Rules that are too rigid and are ments and pressures which over time
not accepted as rules by adolescents, negatively impact an individual’s psy-
promote the consumption behaviour. chological state and rob him of per-
The world of grown-ups doesn’t ob- spectives for the future, lead to signifi-
serve rules or rituals anymore, but nev- cantly more psychiatric symptoms.
ertheless tries to prescribe these rituals The more often these appear, the
to adolescents. This double standard more likely it is that an addictive drug is
promotes substance abuse. Changes in used as a psychotropic. In the chapter
family structures (e. g. almost 60 % di- on prevention (4), factors are extracted
vorce rate in Vienna, patchwork fami- which need to be supported in order to
lies, 40% single mums, life lived at the reduce the development of addictions.
poverty level etc.) lead to developmen- Principally, such measures should be
tal dysfunctions, which in turn promote aimed at the individual according to
abuse (Jessor SL and Jessor R 1978; La- his/her system (the principle is to “to
zarus RS and Launier R 1978). The look at the problem and help” instead
greater the discrepancy in earning ca- of “looking away and making rules”).
pacity in a country, the higher the inci- The reduction in demand for the addic-
dence of substance abuse is. Gender tive drug is the goal of every method of
differences in salaries, but also in so- prevention. Reduction in the availabil-
cialisation (e. g. powerful, money earn- ity of an addictive drug usually leads to
ing male vs. dependant women or vice a shift to another addiction process and
versa) promote substance abuse. Mc- does not prevent a single addiction. In
Clelland DC et al. show that for exam- Russia, it was shown that despite fierce
ple men use alcohol to be able to better control and poverty that makes the
act out their power and strength (Mc- purchasing of addictive drugs finan-
Clelland DC et al. 1972). Yet, the extent cially difficult, adolescents reach for
to which the sociological aetiologies the cheapest drugs (for example inhal-
depend on culture and social wealth ing white gas) or breathe into a plastic
needs to be described in a way which is bag until they suffer from an intoxi-
more clearly differentiated and could cation or symptomatic transitory psy-

21
3 Aetiology of addiction

chotic syndrome. Cases of death when Burge R 1990; Collins AC 1990; Zacny JP
breathing into a plastic bag aren’t rare 1990). It has been suggested that tobac-
and have been observed in Western co amplifies the “to-feel-better” effect
Europe as well. Furthermore, the era of of alcohol, and this effect can be ex-
prohibition in the US did not result in a plained by the impact on mesolimbic
decline in the prevalence of alcohol dopaminergic receptors, located in the
addiction, but instead there was an nucleus accumbens (Koob GF. et al.
increase in criminality, primarily asso- 1998; Koob GF. 2006). The complex be-
ciated with an increase in illegal traf- haviour of smoking and drinking has
ficking. more recently been conceptualized as
an interplay between genetic factors
3.4 Biological theories about the and environmental influences. Heath
AC et al. state that the heritability of al-
aetiology of tobacco and alcohol
cohol dependence is about 64 % (Heath
addiction AC et al. 1997). Similar studies on nico-
Basic research literature on both alco- tine addiction show a heritability of ap-
hol and tobacco is very extensive and proximately 60 % (True WR et al. 1997).
therefore only selected studies will be The genetic basis of smoking and drink-
outlined in this book. This extensive lit- ing has been supported by twin and
erature focuses not only on diseases family studies. In a study of tobacco
like “addiction”, but also on associated and alcohol addicts, True et al. found a
phenomena like the effects of addictive genetic correlation of 0.68 %, support-
drugs, withdrawal symptoms, craving ing the notion that there may be com-
or sequelae in both humans and ani- mon genetic vulnerabilities underlying
mals. Information on biological addic- both alcohol and tobacco addiction
tion theories can be derived mainly (True WR et al.1999). The occurrence of
from neuronal models, animal experi- both forms of addiction in families is
ments, cell cultures, genetic data but however not entirely genetic, but could
also from developmental, clinical, and also be partially explained by intoxica-
twin/family studies in humans. The tion during pregnancy (a drinking and/
potentially damaging effects which to- or smoking mother). Linkage and ge-
bacco and alcohol have on a young in- nome-wide association studies have
dividual, and especially on brain devel- examined the human genome, but the
opment, is an important aetiological different loci identified to date have not
factor in the development of increased yet been replicated. However, almost
susceptibility to addiction throughout all of the specified loci appear to im-
childhood and adolescence. pact the regulation of the dopamine
system. Furthermore, there are other
3.4.1 Important ndings about tobacco findings implicating the noradrenalin
and alcohol use from basic research system, the serotonergic system and
the nicotine acetylcholine receptor.
Alcohol and tobacco consumption are Wodarz N et al. illustrated the role of
closely linked and often individuals the serotonergic systems in relation-
who consume alcohol in high amounts ship to drinking and smoking behav-
are also heavy smokers (Bien TH and iour (Wodarz N et al. 2004). In both al-

22
Biological theories about the aetiology of tobacco and alcohol addiction

cohol and nicotine addiction deficits of The cholinergic system is of cen-


serotonin were found. Here, especially tral interest, especially in regard to the
Cloninger type II alcoholism, an anti- interaction of smoking and alcohol.
social personality and symptoms like Ethanol affects and activates acetyl-
aggression, suicidal tendencies, fire choline nicotine receptors. This activa-
starting and pathological gambling tion of the nicotine receptors on dop-
were assosiated with serotonergic defi- amine neurons could help explain the
cits (Bailer UF et al. 2004, 2005, 2007; interaction of tobacco and alcohol ad-
Brown GL and Linnoila MI 1990; Clon- diction (Cardoso RA et al. 1999; Mann K
inger CR 1987; Frank GK et al. 2005; 2004; Soederpalm B et al. 2000). Dam-
Kruesi MJ et al. 1992, Virkunnen M et al. age to the cholinergic neurons in the
1994). Pettinati HM et al. showed that basal cortex has been found and this
both inhibitory as well as activating ser- damage could lead to a degradation of
otonergic functions play a role by sug- cholinergic functions. Further, neuroi-
gesting that an imbalance in the seroton- maging studies have shown that activi-
ergic system is crucial in the development ty in the hippocampus is reduced and
of addiction (Pettinati HM et al. 2003). thus these deficits in the cholinergic
Chronic biological aspects of the sero- system could be responsible for the cog-
tonergic system should not be underes- nitive dysfunction frequently seen in
timated (Praschak Rieder N et al. 2008). alcohol dependent individuals. (Arendt
Lallemand F et al. showed that changes F 1994).
in the glutamate-GABA systems can be Furthermore, the CB1-recepor is
observed with different chronological also assumed to have an indirect dop-
onsets in addiction and nicotine with- amine agonistic effect, although the ex-
drawal (Lallemand F et al. 2006. 2007). act mechanism of this action is still un-
The imbalance sometimes ceases to ex- known. Cannabionid receptor type 1
ist after an extended period of time. For (CB1) receptors are thought to be the
those patients who have severe with- most widely expressed G-protein cou-
drawal symptoms (Lesch type I) during pled receptors in the brain. It is sup-
abstinence, and who suffer from strong posed that CB1-receptor antagonists
alcohol cravings, medications to re- influence tobacco and alcohol con-
store this balance are recommended sumption behaviour (Soyka M et al.
(Acramprosate). 2008).
Previously, the opiate system,
which plays a modulating role in the 3.4.2 Aspects of alcohol and tobacco
dopaminergic system, has been dis- metabolism
cussed with increased interest. Results
from animal studies, which showed that Tobacco consists of about 4.800 differ-
opiate receptor blockers reduce drink- ent ingredients which can have varying
ing behaviour, have been replicated in effects on biological systems depend-
humans by O’Malley SS et al. 2002 and ing upon their combination. Nicotine
Volpicelli JR et al. 1997 (see chapter seems to be the most important ingre-
9.2.1). Alcohol aggravates the release of dient for affecting brain metabolism,
dopamine and this indirectly activates while carbon monoxide, acetaldehyde,
the dopamine system. methanol and other tobacco ingredi-

23
3 Aetiology of addiction

Fig. 5 Methanol content (mg/l) in alco- alcohols. Metabolic products like ace-
holic beverages taldehyde (Fig. 5) from alcohol, and
formaldehyde from methanol may also
Methanol content (mg/l) contribute to the development of ad-
in alcoholic beverages diction.
Beer 4–50 Sliwowitz 1500–4000 The metabolism of ethanol and
White wine 15–45 Rum 6–70
methanol clearly varies especially
Red wine 70–130 Scotch 100–130
Brandy 200–350 Irish 10–110 among alcohol dependent subjects
Cognac 180–370 Bourbon 200–300
compared to a healthy control sample.
Cherry brandy 1900–2500 Aquavit 5–650
Plum brandy 3000–4500 Gin 10–1350 Here, genetic variations in alcohol me-
Liqueur 10–560 Vodka 5–170
tabolism (aldehyde dehydrogenase)
Bonte W 1987 may be crucial aetiological factors. For
example, both ethanol and methanol
metabolism differ in the subgroups de-
ents have only received little attention. fined by the Lesch typology. The elimi-
Changes in the nicotine acetylcholine nation rates in this typology were ex-
receptor and effects on the monoamin- amined in 61 intoxicated alcoholics. In
eoxidase system (MAO) are very im- type I subjects, both ethanol and meth-
portant factors in the development of anol are rapidly eliminated, although
tobacco addictions. In addition to etha- an ethanol level of over 0, 2 mg/l still re-
nol, alcoholic beverages also contain mains in the blood. On the other hand,
methanol and other multiple chained the elimination of ethanol and metha-

Fig. 6 Methanolelimination in regard to Lesch’s typology

Methanolelimination – Lesch-typology
TYP I TYP II
10 10
Pat. N

Pat. N

5 5

0 0

<0.1 0.1–0.19 ≥0.2 <0.1 0.1–0.19 ≥0.2

TYP III TYP IV


10 10
Pat. N

Pat. N

5 5

0 0

<0.1 0.1–0.19 ≥0.2 <0.1 0.1–0.19 ≥0.2


N = 61 x² = 22.39965 p < 0.01
Sprung R, Bonte W, Lesch OM 1988

24
Biological theories about the aetiology of tobacco and alcohol addiction

nol in type IV occurred at a considera- For instance, new born infants of smok-
bly slower rate. (Sprung R et al. 1988). ing women have a three times higher
It is hypothesized that many of risk of dying from “sudden infant death
the damaging effects of heavy alcohol syndrome” (SIDS) during the first year
consumption are primarily generated of age (Jorch G 2001, Wisborg K et al.
by aldehydes with the peripheral dam- 2000).
age caused by alcohol itself. Aldehydes, Carcinogenic substances have
together with dopamine, condense into been found in the urine of newborns
TIQ’s (tetrahydroisoquinlines) and in- whose mothers’ smoked actively or
dolamines condense into beta-carboli- were exposed to passive smoking the-
nes. These beta-carbolines (norharma- reby increasing the children’s risk of
nes in particular) not only result from cancer. The children of mothers who
alcohol but from ingredients in tobacco smoked during pregnancy also show
as well. reduced pulmonary function during
the first years of life and are more likely
3.4.3 Maternal tobacco and alcohol use to develop acute respiratory disease
during pregnancy: a risk factor for the (ARDS) (Mutius Ev 2001; Trager JB and
offspring? Hanrahan JP 1995).
The children of smoking mothers
A potentially important precondition often show delays in their psychologi-
for the development of a biological ad- cal development (Naeye RL and Peters
diction is the potential damage to the ED 1984), possibly because smoking in-
developing foetal brain through mater- fluences brain development in the un-
nal use of addictive drugs. Smoking and born (Roy TS. and Sabherwal U 1994).
alcohol during pregnancy can lead to For instance, learning difficulties (Ara-
significant changes in the offspring’s makis VB et al. 2000; Butler R and Gold-
brain functioning. Maternal drinking stein H 1973; Fabian-Fine R et al. 2001),
behaviour is a common cause of foetal attention deficits (McCartney JS and
brain damage. Further, not only the Fried PA 1994) and behavioural prob-
mother’s smoking but also passive smo- lems at elementary school age can all
ke can be extremely damaging. In lower be ascribed to the negative effects of
socio-economic classes, families often maternal and paternal tobacco con-
live in very small cramped apartments sumption on the child’s central nervous
or houses. With many family members system (Makin J. and Fried PA. 1991;
smoking, the mother can be exposed to Wakschlag LS et al. 1997).
high levels of passive tobacco smoke. Childhood diabetes and an almost
two-fold risk for being severely over-
weight at elementary school age can be
3.4.3.1 Smoking during pregnancy
ascribed to an abnormality in metabol-
Numerous studies have shown that ic programming caused by foetal mal-
smoking during pregnancy has pro- nutrition. The foetus’ body has prena-
found negative effects on the unborn tally adjusted in order to be born into
child (Chantenoud L et al. 1998; Hau- an environment with poor nutritional
stein KO 2000; Kries RV 2001; Ledermair conditions. A lifelong insulin insuffi-
O 1988; Salafia C and Shiverick K 1999). ciency then develops along with an in-

25
3 Aetiology of addiction

creased tendency to store fat (Mont- several brain regions are especially af-
gomery SM and Ekborn A 2002). fected.

 The corpus callosum is reduced in


3.4.3.2 Alcohol use during pregnancy
size and these reductions are also
Chronic alcohol consumption during found in children with “Attention
pregnancy is one of the main causes of Deficit Hyperactivity Disorder”
fetal abnormalities. One of the most se- (ADHD) where the frontal area is
vere forms of abnormalities, described particularly affected. These hyper-
for the first time by the French paedia- active children with attention defi-
trician Paul Lemoine in 1968, is the “fe- cits are at increased risk for devel-
tal alcohol syndrome” (FAS or Alcohol oping an addiction in later life.
embryopathy). FAS is a differentially  The basal ganglia structures are
developed combination of diverse ab- not only important for motor
normalities and developmental prob- functioning, but also for cognitive
lems in children of alcoholic mothers. functioning, including affective
The frequency of occurrence of FAS in memory. MRI studies show the
western industrial nations is approxi- nucleus caudate to be most af-
mately 3 in 1000 newborn babies, but it fected.
is higher in certain ethnic groups and  The cerebellum, where cognitive
in underdeveloped countries. and autonomous motor functions
Although children with the “fetal are located, is also affected. Here
alcohol effect” (FAE) were exposed “in the dysfunction leads to clumsi-
utero” to ethanol, they do not show all ness and difficulty in appraising
of the symptoms of FAS. Nevertheless, and negotiating new situations.
these children bear the consequences
of the mother’s alcohol consumption Animal studies (Crew’s FT and Oberni-
during pregnancy, including learning er’s JA research groups) indicate that
difficulties, impaired language devel- after exposure to high doses of alcohol
opment etc. It has been estimated that over a few days, young and genetically
there are twice as many children with predisposed rats showed significant
FAE than children with FAS (up to 10 of morphological changes in different ar-
1000 new born children). Alcoholic eas of the brain. During complete ab-
mothers are often very reluctant to pro- stinent episodes, these same animals
vide information about their alcohol then showed cognitive deficits, includ-
use or addiction and therefore, in these ing difficulty generating new solutions
cases, research can only depend on es- to certain tasks (Crews FT et al. 2000;
timations. The combination of alcohol Crews FT and Braun CJ 2003; Obernier
use and smoking during pregnancy is JA et al. 2002). These findings are sup-
particularly damaging to the unborn. ported by a control study where young
The dopaminergic systems damaged rats had considerable difficulties exit-
by alcohol and smoking during their ing a water barrel, following exposure
development and cell positioning in to ethanol (Obernier JA et al. 2002).
the fetal brain, are of particular inter- In this study rats learned to es-
est. Neuroimaging studies show that cape the cold water by using an exit

26
Biological theories about the aetiology of tobacco and alcohol addiction

Fig. 7 The adolescent brain: alcohol–related damage


“Binge”drinking in adolescents and genetically predisposed rats leads to severe da-
mage of the brain.

400
P

350
Binge Ethanol *
Silver Stain (% of NP or Adult)
Induced 300 Adolescent

Brain Damage *
250
Is Greater in
Adolescent 200

And
150
Genetic NP Adult
Models 100

of Alcoholism
50

Crews FT et al. 2000 0


Crews FT and Braun CJ 2003 Perirhinal Perirhinal

(platform). After learning this task, the and agents. During this period, all of
rats were exposed to a “binge-drinking” the body cells can be damaged as a re-
experiment. Following three weeks of sult of inadequate tissue development.
complete abstinence this group of Since the liver of the fetus is de-
“binge-drinkers” was compared with a veloping, it is not able to metabolise
control group. Following relocation of ethanol like the liver of an adult. Alco-
the platform to another quadrant of the hol accumulates in the infant liver and
test chamber and after a “binge-drink- damages the organism. Furthermore,
ing” episode, the rats were not able to other fetal health consequences can be
find their way to the red spot again observed in pregnant addicts. A defi-
(Figs. 7 and 8). ciency of minerals, vitamins, zinc, mag-
Both alcohol and its Aldehyde me- nesium and calcium certainly has a
tabolites can enter the placenta and af- negative effect on the growth and de-
fect fetal cells. During the first twelve velopment of the child.
weeks of pregnancy (organ formation Embryonic damages that are cau-
in the embryo), there is a high sensitiv- sed by alcohol range from slight cogni-
ity to potentially damaging influences tive deficits, difficult to detect, to the

27
3 Aetiology of addiction

Fig. 8 Alcohol and Problem solving strategies


Short-term intoxicated rats in the relearning Morris Water Maze Test

Binge ethanol treated animals perseverate


Relearning-Morris Water Maze
Search path of rats. Open circle original
platform-red circle new location. Binge ethanol treated rats
perseverate on old location.

Time in Original Quadrant


40
CON
ETOH
Time (seconds)

30

20

10

1 2 3 4
Trial CON ETOH

Obernier JA et al. 2002

most severe physical disabilities and bined with social deficits can then, in
dysmorphology. We distinguish be- turn, lead to addiction. The fact that al-
tween the effects of alcohol on the fetus coholism runs in families, could, next
on the one hand, and alcohol related to genetic factors and the modelling of
embryopathy on the other, as summa- alcohol use behaviour by family mem-
rized by Majewski F, Streissgut AP and bers, be a result of these early dysfunc-
Loeser (Loeser H 1995; Majewski F tions. Apart from alcohol intoxication,
1987; Streissguth AP et al. 1990). tobacco and its ingredients can also
These lesser sequelae of alcohol, lead to damage of the unborn child, in-
which typically manifest in learning and cluding disruption of neuronal circuits.
behaviour difficulties, are often viewed Alcohol and smoking increase the
as minor dysfunctions, although they amount of free radicals, e. g. acetalde-
may have considerable influence on hyde found in the unborn.
the life development of those affected. When these changes lead to man-
Problems at school, low educational at- ifested damages of the organs, we speak
tainment and sometimes even criminal of “alcoholembryopathy”. Virtually all
activities are more frequently observed organs can be affected, although there
in FAE patients than in the normal pop- is still not enough research data regard-
ulation. These poor outcomes com- ing the contribution of maternal smok-

28
Biological theories about the aetiology of tobacco and alcohol addiction

Fig. 9 Fetal Alcohol Syndrome (FAS) Diagnostic Criteria

The criteria for the diagnosis of fetal alcohol syndrome,


after excluding other diagnoses, are:
A. Evidence of prenatal or postnatal growth impairment, as in at least 1 of the
following:
a. Birth weight or birth length at or below the 10th percentile for gestational age.
b. Height or weight at or below the 10th percentile for age.
c. Disproportionately low weight-to-height ratio (= 10th percentile).
B. Simultaneous presentation of all 3 of the following facial anomalies at any age:
a. Short palpebral fissure length (2 or more standard deviations below the mean).
b. Smooth or flattened philtrum (rank 4 or 5 on the lip-philtrum guide).
c. Thin upper lip (rank 4 or 5 on the lip-philtrum guide).
C. Evidence of impairment in 3 or more of the following central nervous system
domains: hard and soft neurologic signs; brain structure; cognition; communication;
academic achievement; memory; executive functioning and abstract reasoning; at-
tention deficit/hyperactivity; adaptive behaviour, social skills, social communication.
D. Confirmed (or unconfirmed) maternal alcohol exposure.

Fig. 10 Diagnostic criteria for the partial fetal alcohol syndrome and for alcohol rela-
ted neurodevelopmental disorder and for the term alcohol-related birth defects

The diagnostic criteria for partial fetal alcohol syndrome, after excluding other
diagnoses, are:
A. Simultaneous presentation of 2 of the following facial anomalies at any age:
a. Short palpebral fissure length (2 or more standard deviations below the mean).
b. Smooth or flattened philtrum (rank 4 or 5 on the lip-philtrum guide).
c. Thin upper lip (rank 4 or 5 on the lip-philtrum guide).
B. Evidence of impairment in 3 or more of the following central nervous system do-
mains: hard and soft neurologic signs; brain structure; cognition; communication;
academic achievement; memory; executive functioning and abstract reasoning;
attention deficit/hyperactivity; adaptive behaviour, social skills, social commu-
nication.
C. Confirmed maternal alcohol exposure.
The diagnostic criteria for alcohol-related neurodevelopmental disorder, after ex-
cluding other diagnoses, are:
A. Evidence of impairment in 3 or more of the following central nervous system
domains: hard and soft neurologic signs; brain structure; cognition; commu-
nication; academic achievement; memory; executive functioning and abstract
reasoning; attention deficit/hyperactivity; adaptive behaviour, social skills, social
communication.
B. Confirmed maternal alcohol exposure.
The term alcohol-related birth defects (ARBD) should not be used as an umbrella or
diagnostic term, for the spectrum of alcohol effects. ARBD constitutes a list of congeni-
tal anomalies, including malforma-tions and dysplasias and should be used with caution

29
3 Aetiology of addiction

ing in regard to possible damages. Dis- when do you smoke your first cigarette?
cussions are still taking place about How many cigarettes do you smoke per
how to diagnose the different syn- day? Heatherton TF et al. 1989) show a
dromes of the Foetal Alcohol Spectrum significantly increased rate of both al-
Disorder (FASD). Loeser H. and Streiss- cohol abuse and alcohol dependence.
guth AP. proposed to differentiate be- Further, the abuse of illegal drugs also
tween foetal alcohol effects and the correlates positively with these data,
foetal alcohol syndrome according to suggesting a strong, possibly common,
the definitions of Majewski F. (Loeser biological link across all addictive drugs.
H. 1995, Streissguth AP. et al. 1990, Ma- In a study, 1,870 18-year old men
jewski F. 1987). We will follow the Cana- from a certain catchment area, (4 % of
dian Guidelines for Diagnosis of the all 18 years old men in Austria), were
Foetal Alcohol Spectrum Disorder pub- tested by using questionnaires and bio-
lished by Chudley A.E. et al. 2005. They logical markers and results showed that
proposed to separate the Foetal Alco- the frequency of drug abuse is different
hol Syndrome (FAS, Fig. 9) from the depending on region. 962 (51.5 %) of
partial FAS and Alcohol Related Neu- these 1870 men smoke and 145 (7.8 %)
rodevelopmental Disorder. smoke with a HSI-index of Ú 4, with
An early diagnosis is essential to this being characterized as strongly ad-
allow access to interventions and re- dicted. The size of the hometown and
sources that may mitigate the develop- the accessibility of the city of Vienna
ment of subsequent “secondary disa- played a crucial role in determining
bilities” (e. g., unemployment, mental the frequency of illegal drugs taken.
health problems, trouble with the law, Whether these 18-year olds live in a
inappropriate sexual behaviour, dis- wine-growing district or an industrial
rupted school experience) among af- area had no impact on the occurrence
fected people. Furthermore, an early of alcohol addictions (Kapusta ND et
diagnosis will also allow appropriate al. 2006, 2007).
intervention, counselling and treat- When smoking behaviour was
ment for the mother and may prevent correlated with drinking behaviour,
the birth of affected children in the fu- smokers stated significantly more often
ture. that they drink alcohol because they
desire its psychopharmacological ef-
3.5 Aetiological aspects of tobacco fects. The CAGE Questionnaire consists
of four questions and when a question
and alcohol dependence from an
is answered positively, alcohol abuse
epidemiological perspective according to DSM-IV can be hypothe-
Research carried out by our group was sized. When two questions are an-
able to examine the aetiological con- swered positively, the diagnosis “alco-
nection between smoking and alcohol hol addiction” can be made according
consumption. Our findings indicate, to DSM-IV and ICD-10 (Kapusta ND et
that severely nicotine dependent ado- al.2006, 2007, Fig. 11).
lescents (Heavy Smoking index-HSI When this tool was used with
Ú 4 = defined by the two questions of smokers and non-smokers, a signifi-
the Fagerstroem Test: After waking up cantly higher number of alcohol abus-

30
Aetiological aspects of tobacco and alcohol dependence from an epidemiological perspective

Fig. 11 CAGE questionnaire (Mayfield D et al. 1974 and Ewing JA.1984):

CUT DOWN: Have you ever thought to cut down your drinking?
ANNOYED BY CRITICISM: Have you ever been upset because someone criticized your drinking behaviour?
GUILT FEELINGS: Have you ever felt badly or guilty because of your drinking?
EYE OPENER: Have you ever drunk alcohol first thing in the morning (a pick-me-up)
to ease your nerves or to get rid of a hangover?

ing and alcohol addicted adolescents cigarette after waking up in the morn-
were found amongst the smokers. Al- ing?” is asked, the relationship becomes
cohol addiction is twice as prevalent in even more explicit (Fagerstroem KO
smokers who were shown to have 14 and Schneider NG. 1989). The severity
times more cannabis in their urine. of biological nicotine addiction signifi-
Non-smokers consume opiates more cantly correlates with all other addic-
frequently than smokers, but all other tive drugs. 11.1 % of smokers who
substances correlate with those of the smoke their first cigarette immediately
smokers’ group. after waking up fulfil the criteria of an
If the severity of tobacco addic- alcohol addiction (CAGE Ú 2). Also, the
tion is being considered, and the ques- consumption of opiates significantly
tion “when do you smoke your first correlates with the severity of a biolo-

Fig. 12 Smoking as a predictor for drug abuse

Smoker Non–smoker Chi² p


(n = 978) (n = 907)
% %
Alcohol for taste 78.4 62.0 61.329 <0.001*
Alcohol for effect 36.0 21.8 45.471 <0.001*
CAGE >=1 19.6 10.4 31.409 <0.001*
CAGE >=2 4.2 2.1 6.719 <0.01*

THC 10.0 0.7 69.939 <0.001*


Opiate 2.2 3.1 1.286 0.257
Cocaine 0.7 0 6.510 (0.011*)
Amphetamine 0.5 0 4.645 (0.031*)
Benzodiazepine 0.1 0.2 0.262 0.609
Minimal one Ilicit drug 10.9 3.9 33.810 <0.001*

Kapusta ND et al. (2006) Epidemiology of substance use in a representative sample of 18-year-old males.
Alcohol & Alcoholism 41/2: 188-192.

31
3 Aetiology of addiction

Fig. 13 The first cigarette after rising and urine drug tests

till 5 min. 6–30 min. 31–60 min. >60 min. NR


Item (n=107) (n=390) (n=183) (n=282) (n=907) Chi² p
% % % % %

Alcohol tastes good 77.1 78.1 77.7 80.1 62.0 62.2 <0.001*
Drinking because 44.9 38.7 30.9 32.1 21.8 56.1 <0.001*
of the effect

CAGE=1 29.4 23.4 18.5 11.3 10.4 59.5 <0.001*


CAGE=2 11.1 4.5 2.1 2.1 2.1 28.5 <0.001*
THC 16.3 9.3 9.2 5.6 0.7 88.8 <0.001*
Opiates 4.5 2.0 2.7 1.4 3.1 4.5 0.345
Cocaine 3.6 0.3 1.1 - - 38.8 <0.001*
Amphetamines 2.7 - 0.5 - - 37.1 <0.001*

at least 1 illegal drug 20.0 10.8 11.4 7.1 3.9 52.7 <0.001*

Kapusta ND et al. (2007) Multiple substance use among yooung males. Pharmacology, Biochemistry and
Behavior 86:306-311

gical nicotine addiction, whereas the pending on the subgroups of alcohol


non-smoking group showed a higher addicts. Lesch types I, III, IV smoked
use of opiates than e. g. smokers who exceedingly more (Fagerstroem-posi-
smoke their first cigarette after one hour tive), whereas individuals of Lesch type
of awakening (3.1 % vs. 1.4 %). These re- II didn’t even meet 50 % of the criteria
sults show that there is a common aeti- for a smoking addiction (Fig. 14).
ology of tobacco and alcohol addiction
and cannabis abuse, while in regard to
Fig. 14 Nicotine dependence according
opiates there are different aetiological
to alcohol typology (Lesch)
paths to addiction (Figs. 12 and 13).
Although it is well known that al-
cohol addicts often smoke it is impor- N=100 Type I Type II Type III Type IV Total
tant to know which smoking behaviour Smoking
is used by which group of alcohol without 6 18 10 2 36
dependence
addicts (e. g. Fagerstroem positive vs. Nicotine
dependence 14 13 20 17 64
Fagerstroem negative). We therefore
conducted a study with 100 smoking Total 20 31 30 19 100
alcoholics and we were able to show
Publication in preparation
that the smoking behaviour varies de-

32
Aetiology of addiction from a psychiatric perspective

3.6 Aetiology of addiction from a explanation models often merely illumi-


psychiatric perspective nate singular features (e. g. the seroton-
ergic system). Although these simpli-
Emotions, contentment, but also happi- fications can be very important for
ness are important in people’s life and scientific research as far as clinical use
Damasio AR. (Damasio AR. 2003) was is concerned, they are the main reason
able to differentiate these from a more why medicines (like SSRIs) often have
purely biological perspective. Damasio limited effectiveness in the therapy of
contrasts six primary emotions: fear, an- addiction despite research showing their
ger, sadness, disgust, surprise and hap- effectiveness.
piness and distinguishes these from sec- The interplay of the basal ganglia,
ondary emotions like embarrassment, frontal brain, pituitary thyroid axis, ad-
jealousy, guilt and pride. These are fol- renal gland and fat metabolism is very
lowed by tertiary emotions like content- important for the well-being of every in-
ment, uneasiness, serenity, tenseness dividual. In 2004, Manzanares explained
and others. These emotions are repre- how alcohol affects each circuit and fur-
sented by very complex circuits in the thermore showed that each area of ad-
brain and a lack of balance in these cir- diction development, and therapeutic
cuits can certainly never be explained strategies, have different points of ac-
by an isolated dysfunction. Biological tion (Manzanares J. 2005) (Fig. 15).

Fig. 15 Effects of ethanol intake

ETHANOL x
Vulnerability
+ ? Na
+ + ltr
CANNABINOIDS x ex
Psychosocial Opioids on
conditions e
AM251 x
GABA
− Mesencephalic
Vulnerability ? x +
Dopamine
Mesencephalic
Personality (impulsivity, low Tegmental Area
selfesteem, search of new sensations)
Psychiatric Disorders (phobia, ADHD,
Nucleus Accumbens
affective disorders)

Reinforce Loss of control


behaviour

Progress to dependence Relapse


nach Manzanares J et al. 2005

33
3 Aetiology of addiction

In 2003 Johnson simplified this tive and use only becomes more fre-
system for pharmacotherapy and de- quent after several attempts, typically
scribed the interactions between the as a result of peer group pressure. The
nucleus accumbens, the ventral teg- addictive drug is then taken more fre-
mental area and the cortex (Johnson quently when the pharmacological ef-
BA et al. 2003). The primary emotional fects of smoking and tobacco ingredi-
state is regulated by activity in the nu- ents or alcohol begin to have a positive
cleus accumbens. External stimuli are pharmacological effect (key-lock prin-
regulated by the frontal basal brain re- ciple). The conditions which lead to the
gion which generates expectations in use of addictive drugs are very hetero-
regard to the effect of the addictive drug. genic (e. g. fear, difficulties relating to
These can be appraised as either pleas- people, tests of courage, depression, de-
urable, desirable but also as not accept- sired behaviour in a group and many
able. These functions are ascribed to more), and are therefore portrayed in a
the ventral tegmental area (Fig. 16). broad form as the input of the funnel in
In 1993, based upon our prospec- Fig. 17.
tive long-term studies of patients, we With increased consumption, the
summarized the developmental proc- affected individual often shifts between
ess of an addiction in a dynamic model poisoning, withdrawal and its sequelae
from a clinical perspective (Lesch OM and a certain percentage actually de-
et al. 1993). velop withdrawal symptoms. Alcohol
At the start of every addiction, the causes a variety of neuropsychological
substance’s effect is quickly experien- difficulties which can lead to a decline
ced as very enjoyable. However, the in cognitive functioning such as intel-
very first consumption of tobacco and ligence, creativity, imagination and the
alcohol is often experienced as nega- ability to think critically. As a conse-

Fig. 16 Biological mechanisms of craving in alcohol dependence

Craving in Alcohol dependence


Midbrain to NAcc
Increase GABA and decrease
GLU to VTA = Suppression of
DA input to NAcc
From NAcc to Cortex
Decrease GLU hypersensitivity
in HC & Cortex=Reduced
GABA/GLU and inhibition of
NAcc to cortex reward
Sum
Decreased facilitation of
midbrain to cortex brain
reward

From Johnson B.A., et al., © 2003

34
Aetiology of addiction from a psychiatric perspective

Fig. 17 Funnel model

Symptomatology of addiction
(Nicotine – Alcohol – Cocaine)
Homogenization of symptomes by chronic intoxication

g
Sleep disorders

l drinkin
Prima ithdrawal
ving,

Depression
r y cra

Habiuta
Anxiety
early w

rs
O th e
Positive pharmaceutical effect
Duration of intoxication

Therapeutic goal

i n terventi on

Classification
(basic data)

Increase of isolation and


Drug related disabilities Interactional problems
(e.g. liver, brain, AIDS,...)
Withdrawal syndromes (Lesch 1993)

quence, alcohol addicts are often rejec- again, thus permitting a psychothera-
ted by their social environment, lead- peutic treatment of the problem. Only
ing to increased isolation. The later a after the patient has reached this state,
patient is encountered in the develop- is he able to be compliant with treat-
mental process of an addiction, the ment, and long-time therapy goals can
more dramatic are the symptoms of in- then be rationally defined in way that is
toxication, sequelae, withdrawal and so- acceptable to both patient and thera-
cial isolation, and the more closely do pist.
the clinical pictures of these patients Smoking causes similar changes
(in regard to their behaviour, reactions to those produced by alcohol, although
and symptoms) resemble each other. it does not lead to social isolation and
The diagnostic criteria of ICD-10 and causes rather different sequelae (e. g.
DSM-IV describe the clinical picture breathing difficulties). It is these seque-
but fail to sufficiently consider the dis- lae that often lead the smoker to start
tinct aetiologies and primary personal- therapy. When the patient has both a
ity traits. Only after several weeks of nicotine and alcohol addiction, he of-
abstinence do the sequelae regress and ten displays more severe sequelae and
the personality traits become visible more acute withdrawal symptoms.

35
4
Prevention strategies

4.1 Attitudes towards addictive More recently, girls have started drink-
ing at an even earlier age, while boys
drugs
have slightly reduced and delayed their
4.1.1 Attitudes towards alcohol drinking behaviour (Eisenbach-Stangl I.
consumption 1991, 1994).
The consumption of alcohol in
For many centuries, many kinds of al- Europe is higher than for other conti-
coholic beverages (wine, beer and spir- nents (Eisenbach-Stangl I. 1991; Hurst
its) have been produced in central Eu- W et al. 1997), with central European
rope. Adolescents grow up in an alcohol countries showing a consumption of
permissive milieu and see that adult 14 litres per capita per year..
drinking is socially accepted and even Around 1900, a large-scale epide-
desired behaviour. The advantage of miological study was conducted in
initiating this consumption at a young Austria in which adolescents of differ-
age is that adolescents often learn how ent age groups from different types of
to use alcoholic beverages at an early school were interviewed about their al-
stage. A primary disadvantage are the cohol consumption. It was found that
increased risks associated with this ear- adolescent alcohol consumption in 1900
ly consumption and the development was about the same as adolescent alco-
of physical and psychological dysfunc- hol consumption in 1975, as measured
tions, as well as the learned attitude by sales data or other studies.
that alcohol can be used as a basic Around 1900, 3.2 % of 14-year old
food. boys had already consumed hard alco-
Almost 50 % of adults think that it hol (40 Vol.-% and over), mostly spirits
is acceptable for adolescents between of low quality. It can be assumed that
the age of 16 and 18 to consume alco- today slightly over 3 % of 14-year olds
hol at home or at parties, an attitude have already repeatedly consumed hard
which generally complies with regula- alcohol. Reports in the media which
tions of the protection of minors (child denounce adolescent binge drinking as
welfare). Depending upon the situa- boundary testing, and thereby serve to
tion, 9-18 % think that alcohol con- make drinking a focus of adolescent in-
sumption is acceptable even before the terest, were already published in mid-
age of 16. However 40 % of respondents dle Europe around 1900 and since then
would not dispense alcohol to their adolescent drinking has at repeated in-
children until the age of at least 18 years. tervals been a focus of news coverage.

37
4 Prevention strategies

Representing a personal-political ume of pure alcohol which is enjoyed in


mandate, the slogan of the social demo- different forms of beer, increased, while
cratic party at the beginning of the 20th wine consumption decreased. The con-
century was “A thinking worker doesn’t sumption of spirits has halved since
drink and a drinking worker doesn’t World War II (Eisenbach-Stangl I. 1991,
think”. This led to a decline in alcohol 1994) (Fig. 18).
consumption up until World War I. How- In Austria about 15–36 % of the
ever, with increasing prosperity after adult population are considered to be
World War II, the use of alcohol has been vulnerable to alcoholism, and 2.2–4 %
growing in Europe and elsewhere. Since of the total population are known to
the mid 70’s, the typical working envi- have an alcohol addiction. These num-
ronment has drastically changed (short- bers vary according to a gender specific
er work breaks, more regulated and con- vulnerability ratio. While Rathner G and
trolled working hours and laws which Dunkel D assume a 3:1 gender ratio
prohibit alcohol use while driving a (men to women), other studies suggest
motor vehicle, while at work etc.). This a ratio of 14:1 (Lesch OM. et al. 1989;
has lead to a restriction in the consump- Rathner G. and Dunkel D. 1998). Even if
tion of alcoholic beverages. As a conse- just usual hospital admissions of alco-
quence, a tendency to consume “lighter, hol-addicted individuals are consid-
lower calorie alcohol” developed all over ered, a ratio of 5:2 (men to women) is
Europe. In the 1990’s, the percent vol- observed (Fig. 19).

Fig. 18 Development of alcohol consumption in Austria 1881–1992

Development of alcohol consumption


in Austria 1881−1992
12

11

10

8
total
7
Litre

0
0 0 0 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90
–9 –9 –9 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19
81 81 81
18 18 18
Wlassak 1922, Eisenbach-Stangl 1991, data StZA, author’s calculation

38
Attitudes towards addictive drugs

Fig. 19 Alcohol use in Austria according to regions

Federal states
Pure
alcohol/week

Uhl A. Springer A. representative sample 1993–94; Lesch OM et al. 1989

A sample survey of 60 to 69 year addictive compound and the ingredi-


olds found a per capita alcohol con- ents of a cigarette are known to produce
sumption of 25 g alcohol/d, while the damage in different areas of the entire
70 to 99 year old age group consumed body. The European community has fi-
26 g alcohol/d (1 unit = 10 g of pure al- nally begun to restrict tobacco adver-
cohol = ca. 1/8 wine or 1/3 l beer) (Uhl A tisements and over the last 10 years,
and Springer A. 1996). individual countries have started to ad-
vise about the damaging effects of ci-
4.1.2 Attitudes towards tobacco garettes and to label cigarette boxes
consumption with health warnings. Apart from refer-
ences to the damaging consequences
Although it has been known for many of smoking, such as “Smoking kills” or
years that the ingredients of cigarettes “Smoking leads to a slow and painful
can cause various types of damage to death”, the ingredients of cigarettes like
the body, the tobacco industry has tar, nicotine, and carbon monoxide are
blocked all effective methods to reduce also listed. Despite this, the smoking
smoking. For many years it was claimed behaviour of adolescents has not sig-
that nicotine is not addictive and the nificantly changed and, today, smoking
tobacco industry produced new “light” is still the addiction with the highest
cigarettes which were advertised as be- mortality rate. (The only one single ef-
ing “healthier cigarettes”. Only in the fective prevention against bronchial
last fifteen years has this argumenta- carcinoma is a smoke-free life). As it
tion collapsed, and today it is quite ob- has become more widely known that
vious that there is no such thing as a passive smoking also damages health,
“healthy cigarette”. Nicotine is a highly smoke-free zones have been set-up in

39
4 Prevention strategies

several countries. In Austria this is only been a drug-free society and whether
being slowly introduced and in some this is desirable is still controversially
stressful situations (e. g. in hospitals) discussed. Yet it is important to change
people still smoke. the attitudes of a society in such a way
Approximately 30 % of the popu- that life without tobacco and alcohol,
lation smoke, although smoking behav- and all other addictive drugs, is per-
iour decreases with age. At the age of 18, ceived as desirable (catchphrase: hap-
more than 50 % of men smoke and simi- piness is life without drugs). When the
lar kinds of smoking behaviour can be reasons why adolescents start the con-
expected in women. Studies of female sumption of a drug are investigated,
smokers are needed in almost all areas. the following motives for starting to
20.3 % of 18-year old men who smoke smoke and drink include:
score five or more points on the Fager-
stroem scale: this group can be identi-  “I just wanted to try it out”. Here
fied as biologically addicted according experimentation is seen as part of
to the ICD-10 and DSM-IV criteria (Fag- natural development.
erstroem KO. et al. 1989; Heatherton TF.  Adolescents use tobacco and al-
et al. 1089, 1991; Kapusta ND. et al. 2007) cohol to feel “like adults”. (The la-
Half of all smokers are displeased bel “Smoking: only for adults”
with their tobacco consumption (“dis- leads to an increase in smoking
sonant smokers”). It is therefore not among adolescents).
surprising that by the age of 50, just un-  Adolescents want to smoke be-
der 30 % of the population still smoke. cause they want to be integrated
Yet it can be assumed that education into peer groups. If smoking is a
and the awareness of the risks of smok- desired behaviour in a particular
ing only seem to reach those individu- peer group, it is difficult not to
als who either abstain or abuse only smoke.
tobacco, while those smokers who meet  To demonstrate autonomy
criteria for a biological addiction are not  To have fun. Curiosity plays a big
influenced by prevention programmes. role in the initiation of smoking
It is this group that develops a with- and drinking
drawal symptom when the number of  To decrease anxiety in specific
cigarettes smoked is reduced and later situations, e. g. before exams.
also shows severe bodily sequelae as a  Tobacco is a psychotropic sub-
result of their smoking. stance which enhances memory
in the short-run. This is why ado-
4.2 Primary prevention of tobacco lescents use it for studying. It also
has an anti-depressive effect and
and alcohol addiction
is used to lift one’s spirits (Balfour
By “primary prevention of tobacco and DJ. and Ridley DL. 2000; Best JA.
alcohol addiction”, we mean measures et al. 1988; Merrill JC et al. 1999;
which attempt to change society by de- Sutherland I et al. 1998).
creasing the demand for an addictive
drug. Addictive drugs and smoking are For primary prevention efforts to be ef-
as old as humanity. There has never fective, all socio cultural factors and in-

40
Primary prevention of tobacco and alcohol addiction

Fig. 20 Socio cultural model of alcohol and tobacco use and abuse in adolescent and
young adults (Johnson BA et al., p. 34, 2003)

Background and Individual Environmental and Alcohol


Trait Factors Mediators Social Mediators Outcomes

Environment
Background Adult supervision
Gender Access to alcohol
Alcohol Beliefs
Age Peer drinking
Expectancies
Ethnicity Mass media
Perceived norms Alcohol Use
Academic
performance and Abuse
Family history Personal Responsibilities Quality/frequency
of alcoholism Motivations Academic Negative
Social Work consequences
Trait Academic or Family
Sensation seeking professional Civic
Impulsivity Religious
Socially deviant Athletic

dividual models must be drawn upon. and a drug permissive milieu, which
Accordingly, primary prevention uses a are more likely to push adolescents to-
plethora of measures and attempts to in- wards the path of addiction (tobacco,
fluence all factors in order to reduce the alcohol and other addictive drugs).
demand for addictive drugs (Fig. 20). As regards alcohol, tobacco and
From a socio-cultural perspective, marijuana consumption, 78.9 % de-
the individual causes leading to tobac- scribe curiosity as the most important
co and alcohol consumption remain in motivating factor, compared to 57.9 %
the background. Included in the socio- who stated this reason for trying opium
cultural model are factors, identified in and cocaine; on the other hand, 42.1 %
quality of life research, which signifi- stated interpersonal conflicts as being
cantly influence the consumption be- the primary motivation for starting to
haviour of adolescents and adults. Pre- abuse opium and cocaine, while only
ventative factors which protect against 5.3 % of alcohol, tobacco or marijuana
substance abuse include, for example, abusers indicated poor interpersonal re-
a high level of satisfaction in adoles- lations as the main reason (Fig. 21.)
cents, and a social environment can be Tobacco and alcohol consump-
created which enables adolescents to tion (including abuse) can be influen-
feel stable and secure. ced by increasing the unit price and
Another preventive element is be- taxes, and by other such measures,
ing a member of a group which values which make smoking and drinking
living without addictive substances. Re- more expensive. However, individuals
search has identified vulnerability fac- who already show a tobacco or alcohol
tors such as psychological pain, poverty addiction are typically not influenced

41
4 Prevention strategies

Fig. 21 Substance abuse factors which influence alcohol use in society

Factors influencing intake


Addictive drug Society
Accessibility Tolerance
Peer group Social freedom
Image of the drug Social coverage and
Level of effectiveness Social balance
Income
Individual Safety
Life quality Social climate
Level of confidence Cultural climate
(Happiness research) Level of industrialisation
Psychopathology
Novelty seeking
Conflicts

by such measures. The so-called “war 4.3 Secondary prevention: early


against drugs”, as has been proclaimed
diagnosis and intervention
in some countries, is useless without
the provision of measures to help af- In many peer groups, smoking and
fected adolescents, and normally leads drinking is a desired behaviour and is
to a shift to other addictive substances used as a ritual to demonstrate group
(drugs, pills etc) or to other behavioural cohesion. This often leads the adoles-
disorders (e. g. eating disorders). cent member to abuse addictive drugs
As illustrated in chapter 6.2, 6.3, like tobacco or alcohol in high doses
addiction is clinically very heterogene- and over a long period of time. Adoles-
ous. If we consider a separate aetiology cents who show a psychological or bio-
for each subgroup, three entirely differ- logical vulnerability (Rommelspacher H.
ent paths to an addiction arise. These 2007) often develop an addiction syn-
different paths obviously need different drome. This vulnerability sometimes
preventive measures. It is unrealistic to begins in the womb when the mother
expect that measures can be instituted regularly “poisons” the unborn child by
to entirely prevent these developments. active or passive smoking. Today we
Yet it is possible to imagine that an know that, especially up until the eighth
awareness of these mechanisms could week of pregnancy, the developing
facilitate early detection and support brain can be massively influenced by
could thus be initiated earlier. Today it alcohol and nicotine exposure, similary
is widely agreed that secondary preven- the reward system and addiction mem-
tion is the ideal way of prevention. ory (Chantenoud L et al. 1998; Haustein

42
Secondary prevention: early diagnosis and intervention

KO. 2000; Ledermair O. 1988; Salafia C model by smoking and drinking (smok-
and Shiverick K. 1999). ing and drinking parents, youth coach,
Within the socialisation process of teachers etc.). Adolescents learn from
the adolescent, traumata can lead to an role models and often unintentionally
insecure personality which is very de- adjust to these double standards. Aside
pendent on affection from his environ- from the above-described mechanism
ment. Insecure adolescents often fear of the development of addiction, many
they are not good enough or that they other susceptibility factors certainly
can’t meet their own expectations or exist. Early cerebral and psychological
the expectations of others. They go out damage often leads to early problems
of their way to serve their peer group and behavioural abnormalities (Brü-
and forget how to say “no”, and often ckensymptome = Bridge symptoms)
this insecurity is mirrored in their which are so severe that those affected
choice of partner: they tend to seek are not able to attend school and finish
powerful partners who reinforce their their diploma or degree, they often show
insecurity. These interactions between socially deviant behaviour and some-
an insecure personality and social ex- times even come into conflict with the
pectations lead to taxing situations, law. These marginal groups of society,
anxiety and stress, sometimes leading which represent about 10 % of the gen-
the adolescent to use addictive drugs eral population, should be offered help
such as tobacco and alcohol to cope in due time. Furthermore, interven-
with the taxing situations of every day tions that are acceptable to those af-
life. fected should be the primary interven-
Some adolescents experience a tions offered.
very strict upbringing based on rigid
values. The children love their adult at- 4.3.1 Conclusions for secondary
tachment figure very much and this is prevention
why they try to accept their values as
absolute and to adopt them as their 4.3.1.1 Measures concerning the addictive
own. As adolescents, they later learn drug
that these values and rules can’t always
be realised (e. g. the ‘internal’ command A reduction in the general availability
is: “Be a good student!” – but perform- of alcohol and tobacco products typi-
ance at school shows a different pic- cally reduces the abuse rate in the gen-
ture), and this leads to anxious-depres- eral population. A few examples are: to
sive reactions and the realization that offer tobacco products only at tobacco-
this uneasiness can be compensated by nists and only at certain times (approx-
the pharmacological action of the ad- imately from 5 am to 11am); no sale of
dictive drug. The beloved adults often cigarettes at petrol stations, in restau-
demonstrate double standards. Parents rants or through vending machines;
always talk about having to be well be- imposing a smoking ban for all public
haved and not being allowed to con- buildings such as hospitals, schools,
sume any drug. However, parents may agencies etc., including restaurants.
show a completely different behaviour Further, the public designation of smo-
pattern themselves and serve as a role king and non-smoking pubs would lead

43
4 Prevention strategies

to the consumer being able to chose educational programmes. Of course,


whether or not he wants to be exposed alcohol consumed in low amounts as a
to tobacco substances. Pubs with an pleasurable stimulant should not be
area of less than 50 m2 and which do not demonized, but it should be empha-
employ staff, should be allowed to call sized that alcohol is a drug which, even
themselves smoking bars (Employee when consumed in low amounts, re-
Protection Law). duces cognitive skills and coordination.
It would certainly be an improve- Alcohol should not be used when work-
ment if adolescent protection laws re- ing with dangerous machinery, when
garding both alcohol and tobacco were driving a car or when using public trans-
adhered to, and if alcohol and tobacco port (taxi, train, etc.). Like tobacco con-
were only available in selected shops sumption, the regular consumption of
and at certain times of the day. Thus, alcohol can damage the whole organ-
availability would be limited. The sale ism.
of alcohol in restaurants should be cou- Active smoking (and also passive
pled with food consumption during the smoking) during pregnancy should be
day and, in principle, only alcoholic an important topic in prevention. Not
drinks with low alcoholic content should only should educational and public
be served (an example of this can be service brochures (“0.0 ‰, 0 ppm”) be
found in Sweden). Additionally, prices distributed, but pregnant women who
(including taxes) should be increased, smoke should be motivated as early as
making it difficult for adolescents to possible to stop or at least reduce their
regularly drink and smoke. Ten percent smoking behaviour (Report of the med-
of the taxes collected for alcohol and ical-scientific fonds by the mayor of the
tobacco should be used for the preven- federal capital Vienna, 2005) and of-
tion and therapy of addiction. fered medical intervention (e. g. vareni-
Regular advertisement campaigns cline), when appropriate.
should educate the public about the
addictive nature of tobacco and the
4.3.1.2 Measures to help adolescents live a
many toxic substances it contains, em-
drug-free life
phasizing that tobacco isn’t a safe or a
pleasurable stimulant. Not only is a large All preventive measures should con-
amount of nicotine inhaled by smok- sider the following principles:
ing, but so are many other toxic sub- “The political credo of society
stances which play an important role in should be based upon the following
the development of an addiction. Once principles:
a tobacco addiction has developed, this In our society no child will be lost.
addiction seems to be a precursor for We care for every single child. There are
many other kinds of addictions. Ad- resources available to support a child
dicted smokers are much more likely to regardless of age, and every child should
become addicted to other legal and il- be provided with ideal educational op-
legal drugs than smokers not biologi- portunities, necessary medical care and
cally addicted (Kapusta ND et al. 2006, social opportunities.”
2007). The interrelationship of these Adolescents who face difficult sit-
addictions should be included in all uations (e. g. family, in school or at

44
Secondary prevention: early diagnosis and intervention

work) should be offered help. Here the of drug problems. The clearer the per-
basic rule is: “Look closely at the prob- sonal development possibilities are,
lem and don’t look away”. The earlier the lower the addictive drug consump-
the adolescent’s seemingly unresolved tion. A feeling of security provided by
problem is recognized, and the earlier the family, a circle of friends, and also
solutions can be offered and accepted by one’s own occupational situation
by the adolescent, the less likely it is can protect against substance abuse.
that the drug will be a problem for the The more purposeful the adolescent
adolescent. Young people are valuable perceives his function in the family and
members of society and the adults of social situation to be, and the more de-
this society should be encouraged to fined his role, the lower the risk of regu-
support and assist difficult adolescents. lar consumption of addictive drugs.
In Finland, for example, it is more dif- In puberty, adolescents often find
ficult than in German-speaking coun- it difficult to develop their own identity.
tries or the US to “expel or suspend” Their parents’ moral and ethic values are
adolescents from class or school. This questioned and compared with others.
responsibility of the part of families, Therefore adolescents need opportuni-
schools and all those involved, leads to ties to experiment, through which they
good results, as is reflected by the “PISA can try to develop their own identity
study”. and to set boundaries for themselves.
The peer group can provide a very Opportunities to experiment should be
important protective element and these supported by society so that the risk of
groups should be provided with the ac- adolescent physical and psychological
tivities they desire, for example active problems are reduced and kept as low
cultural activities (music or theatre as possible. Furthermore, the influence
groups), sport activities (from athletics of adults should be kept to a minimum.
to ball games) and especially sufficient Some adolescents can only accept some-
time and space to participate in these thing after having experienced it them-
activities safely whilst still offering some selves, and this experience can be pain-
independence and adventure. In terms ful. If an adolescent group can manage
of prevention, it is known that these this pain without the influence of adults,
low-risk forms of education enable ad- a feeling of solidarity can form within
olescents to live out their curiosity and the group which can provide protec-
are important to the development of a tion against the danger of addictive
healthy and positive personality. Prohi- drugs.
bitions and rules that aren’t accepted Specific preventative strategies
by the group are counterproductive should be offered to risk groups and
and can lead to the growth of marginal different measures are needed accord-
groups and an increase in the number ing to the nature of the risk group. An
of drug-taking adolescents. adolescent who is admitted to an in-
Improvement of the adolescents’ patient clinic due to severe intoxication,
social situation is a very crucial preven- is an emergency case who will certainly
tion factor. The loss of the peer group as need psychological-psychiatric support
a result of academic failure could be after he has been medically treated
another risk factor for the development (crisis concept). Families with multiple

45
4 Prevention strategies

Fig. 22 Risk groups their smoking, they are rarely able to


change their smoking behaviour. Here,
Target groups for the prevention of addiction therapeutic approaches for tobacco ad-
• Adolescents after severe intoxications dicts, as described in the following chap-
• Adolescents in emergency hospitalization ters, should be applied.
• Adolescents of addicted parents From the medical perspective, al-
• Adolescents, who were in touch with the police cohol addicts are ill and therefore need
• Children and adolescents from the streets therapeutic help. It is not useful to cre-
• Children and adolescents in corrective training ate rules regarding drinking behaviour
nor is constructive to tell them to pull
themselves together. They need profes-
sional therapeutic intervention. It can
addicted members require help for the also be beneficial to provide an envi-
whole family system. Children of these ronment in which they can talk to other
families are highly vulnerable and need affected individuals so that they be-
intensive support and intervention. come aware that their symptoms can
Even if the diagnosis of “addic- be improved and that there is someone
tion” is absent, these target groups need to support them in solving their prob-
the help of a therapeutic team (social lems. This help should be sought out-
worker, psychologist, physician etc.) that side of their usual environment (family,
is able to offer support to the adoles- work, school) and the therapists should
cent for many years. Furthermore, these have psychological and pharmacologi-
teams may need to intensify their ef- cal knowledge. An addict who feels that
forts when those affected individuals an interest is being taken in him that
show negative outcomes. isn’t too intrusive can often become al-
lied with a therapeutic network. These
4.4 Tertiary prevention alliances over a long period of time are
an important therapeutic agent (see
(see chapter 9)
chapter 9).
As already stated, almost half of all ado- Successfully treated alcohol or to-
lescents are biologically addicted smok- bacco addicts are able to lead abstinent
ers (= Fagerstroem 5 or above). The and smoke-free lives. In doing this, they
above-mentioned measures are typical- are excellent role models for adoles-
ly not effective in reducing substance cents by demonstrating how to live a
abuse in these groups. Although the drug-free life.
adolescents feel uncomfortable about

46
5
Diagnosis of abuse and addiction

5.1 Problems concerning sis of the diagnosis. However, abuse


and addiction have completely differ-
psychiatric diagnoses
ent developmental trajectories which
The diagnostic systems typically used depend the least on substance con-
in psychiatric hospitals are designed to sumption behaviour (see chapter 6.3).
define homogenous groups of patients As not all of the preconditions for
whose specific aetiology leads to certain addiction related disorders have been
symptoms. From this aetiology, a thera- established, more and more subgroups
py that is most effective for this disease of different addictions are being identi-
group should be planned. For a diagno- fied (see chapter 6). Nevertheless, two in-
sis of a disease the following should be ternational classification systems (ICD-
provided: 10 and DSM-IV) have been established
By defining a disease, its aetiology which have widespread use. The advan-
is also automatically defined. In addic- tage of these systems is that epidemio-
tions, smoking and drinking are often logical studies can compare the inci-
only secondary phenomena. The aeti- dence and prevalence of addictions in
ology of abuse and the causes of addic- different cultures. Further, in central
tion have always been seen as two dif- Europe this schema of diagnosis has
ferent constructs. been proven to be effective for invoic-
The implementation of the thera- ing insurers and other payment agen-
py is scientifically supported and de- cies. Therefore it was important that
fined according to the theoretical aeti- tobacco addiction was included in ICD-
ology and the clinical conditions at the 10 as a separate disorder. Unfortunately,
initiation of the therapy. At least 88 dif- in meeting the needs of these two goals
ferent therapies for addictions are used (epidemiology and the cover of costs)
all over the world: these therapies lead both systems became too general and
to both positive and negative results insufficient to allow development of
(Hester RK and Miller WR. 2003). The the- specific therapies. The therapies which
rapeutic procedure depends on many are offered at the moment have very
factors, but not usually on the consump- rigid guidelines and primarily comply
tion behaviour. The diagnosis of addic- with the needs of the inpatient and out-
tion merely describes one aspect of the patient institutions. Yet, they don’t suf-
whole problem. ficiently address the real needs and ca-
In many cases the natural course pabilities of affected individuals. Results
of a disease can be predicted on the ba- from basic research and pharmacologi-

47
5 Diagnosis of abuse and addiction

cal research can never actually be ap- 5.2 Development of the term
plied to all addicts (Koob GF and Le
“addiction”
Moal M. 2006). For both therapeutic
and research reasons, subgroups of ad- From a historical perspective, the term
dicted individuals were identified from “alcoholism” was introduced into the
these two classification systems to bet- medical literature by Magnus Huss in
ter meet the requirements of therapy 1852 (Huss M.1852), but already by the
and research. beginning of the 20th century different
Different factors are relevant for aetiologies for alcoholism had begun to
therapy in the course of the illness. evolve. Primary or secondary alcohol-
These could be either somatic factors, ism, alcoholism caused by a neurotic,
or factors occurring in the environment psychiatric or psychopathic personality
or the individual. In Fig. 23 the major and alcoholism due to physical vulner-
elements are shown, constituing the abilities were also defined at that time
basis for a multidimensional approach. (see Feuerlein W. 1975). In 1952, the

Fig. 23 Factors influencing therapy

Which factors influence therapy?


(Pharmacotherapy and psychotherapy)
Individual factors
1. Age
Somatic disorders 2. Gender
3. Personality
4. Genetic factors
5. Psychopathological syndroms
ICD, DSM, etc.
e.g. Schizophrenia, Alcohol- and tobacco addiction
MDK etc.

Changes in
symptomatology
Toxic effects Social and relation factors
1. Alcohol, nicotine, 1. Patient-therapist-relationship
hypnotics, anxiolytics 2. Knowledge about the disease length time
2. Amphetamines 3. Factors of the settings timing of
3. Opiates (in- or out patients) intervention
4. Cannabis 4. Acceptance of the changes the
5. Hallucinogens medication basis data for
6. Others (e.g. PCP) 5. Fear of punishment therapy research
7. Interactions among and with
other pharmaceutical drugs Lesch OM et al. 1990; Lesch OM et al. 2010

48
Substance related diagnoses in the ICD-10

World Health Organisation highlighted Mediterranean countries typically con-


the physical, psychological, social and sider twelve grams as a unit. Within the
economic consequences of excessive definition of addiction, the consump-
drinking. An expert commission of the tion of an addictive drug is accepted as
WHO suggested in 1977 a distinction an epiphenomenon. This is why the
between alcohol addiction and alcohol- ICD-10 criteria, for example, code the
related sequelae. The symptoms of ad- addictive drug only as secondary. Only
diction were defined by three criteria: in a few cases does abuse turn into an
addiction. Usually abuse remains a sta-
 increase in dosage ble behaviour over many years (Widi-
 withdrawal symptoms (psycho- ger TA et al. 1994).
logical and physical)
 loss of control over use of the 5.3 Substance related diagnoses in
drug.
the ICD-10
These three criteria are still part of the The WHO has developed the ICD clas-
ICD-10- and DSM-IV diagnostic crite- sification system on the basic principle
ria, although with regards to the devel- that a person can only be called healthy
opment of ICD-11 and DSM-V, there if he/she doesn’t suffer from somatic
is still considerable discussion about illness, is psychologically healthy and
whether an increase in dosage should has a stable and supportive social net-
remain a symptom of addiction. (The work. To achieve this goal, the WHO
problem is that all tobacco and alcohol is trying to support prevention pro-
consumers increase their intake/dos- grammes and the health care systems
age over time whether or not they have of many countries. With the introduc-
an addiction). About 1977, a distinction tion of the ICD-10 (Dilling H et al. 1991)
between alcohol abuse and alcohol ad- hospitals were advised to “follow the
diction was established and this differ- general rule to code as many diagnoses
entiation is found today in all current as required for the description of the
classification systems. It is now widely clinical image/condition. If there is more
accepted that the term “abuse” depends than one diagnosis, a primary diagnosis
on socio-cultural factors. Temperance with the “highest significance for thera-
societies, such as those found in Scan- py and development” should be made.
dinavian countries or the US, define The ICD-10 captures addicts with all
every immoderate use as an abuse (e. g. their sequelae (somatic-psychiatric), de-
“one-off drunk driving “ or “smoking a velopment and therapeutic settings.
cigarette” already meets the criteria for Under F1 all psychological and behav-
abuse), while alcohol permissive and ioural disorders which are caused by
alcohol producing countries use this psychotropic substances, are coded.
term more broadly. The first high-level Secondly, the addictive substance is in-
use, taken over longer periods of time, dicated (F10 dysfunctions caused by
is defined as abuse. This fact is often alcohol, F17 dysfunctions caused by to-
mirrored in the definition of an alcohol bacco). The fourth and fifth points de-
unit. In Northern Europe, eight grams scribe the clinical image (F10.00-07 or
of alcohol per unit are allowed, whereas F17.00-07), the acute intoxication with

49
5 Diagnosis of abuse and addiction

or without complications, the damag- the same drug in the same time
ing use (F10.1, F17.1) or the addiction period (except for acute intoxica-
syndrome (F10.2, F17.2). These points tion ICD 10 F1x.0).
will be discussed further below; other
points to be considered include drink- 5.3.2 Dependence syndrome
ing behaviour, withdrawal symptoms, (ICD 10 F10.2, F 17.2 )
psychotic dysfunctions, amnesic syn-
dromes and other psychological or A cluster of behavioural, cognitive, and
behavioural dysfunctions. This more physiological phenomena that develop
precise specification should allow com- after repeated substance use and that
parisons between different countries typically include a strong desire to take
and should lead to therapeutic think- the drug, difficulties in controlling its
ing such as: “Does this group of patients use, persistent use despite harmful con-
need hospitalization?” “Which clinical sequences, a higher priority given to
profession offers the best therapeutic drug use than to other activities and
setting?” etc. obligations, increased tolerance and
sometimes a physical withdrawal state.
5.3.1 Harmful use (ICD 10 F10.1, F 17.1) The dependence syndrome may
be present for a specific psychoactive
A pattern of psychoactive substance substance (e. g. tobacco, alcohol, or di-
use that is causing damage to health. azepam), for a class of substances (e. g.
The damage may be physical (as opioid drugs), or for a wider range of
in cases of hepatitis from the self-ad- pharmacologically different psychoac-
ministration of injected psychoactive tive substances.
substances) or mental (e. g. episodes of
depressive disorder secondary to the Diagnostic criteria
heavy consumption of alcohol). Three or more of the following mani-
festations should have occurred togeth-
Psychoactive substance abuse er for at least one month or, if they have
Diagnostic criteria persisted for periods of less than one
A. Clear evidence that the substance month, then they should have occurred
use was responsible for (or sub- together repeatedly within a twelve
stantially contributed to) physical month period.
or psychological harm, including
impaired judgement or dysfunc- (1) A strong desire or sense of com-
tional behaviour. pulsion to take the substance.
B. The nature of the harm should be (2) Impaired capacity to control sub-
clearly identifiable (and specified). stance-taking behaviour in terms
C. The pattern of use has persisted of onset, termination or level of
for at least one month or has oc- use, as evidenced by the substance
curred repeatedly within a twelve- often being taken in larger amounts
month period. or over a longer period than in-
D. The disorder does not meet the tended, or any unsuccessful ef-
criteria for any other mental or fort, or persistent desire, to cut
behavioural disorder related to down or control substance use.

50
Substance related diagnoses in the ICD-10

(3) A physiological withdrawal state  F1x.21 Currently abstinent but in


(see F1x.3 and F1x.4) when sub- a protected environment (e. g. in
stance use is reduced or ceased, hospital, in a therapeutic com-
as evidenced by the characteristic munity, in prison etc.)
withdrawal syndrome for the sub-  F1x.22 Currently on a clinically
stance, or use of the same (or close- supervised maintenance or re-
ly related) substance with the in- placement regime [controlled de-
tention of relieving or avoiding pendence]
withdrawal symptoms.  Flx.23 Currently abstinent, but re-
(4) Evidence of tolerance to the ef- ceiving treatment with aversive or
fects of the substance, such that blocking drugs (e. g. naltrexone or
there is a need for markedly in- disulfiram)
creased amounts of the substance  Flx.24 Currently using the sub-
to achieve intoxication or desired stance [active dependence]
effect, or that there is a markedly  F1x.240 Without physical features
diminished effect with continued  F1x.241 With physical features
use of the same amount of the
substance. The course of the dependence may be
(5) Preoccupation with substance use, further specified, if desired, as follows:
as manifested by important alter-
native pleasures or interests being  Flx.25 Continuous use
given up or reduced because of  F1x.26 Episodic use [dipsomania]
substance use; or a great deal of
time being spent in activities nec- 5.3.3 Withdrawal state (ICD 10 F10.3)
essary to obtain the substance,
take the substance, or recover from A group of symptoms of variable clus-
its effects. tering and severity occurring on abso-
(6) Persisting with substance use de- lute or relative withdrawal of a psycho-
spite clear evidence of harmful active substance, after persistent use of
consequences (see ICD 10 F1x.1), that substance. The onset and course of
as evidenced by continued use the withdrawal state are time-limited
when the person was actually and are related to the type of psychoac-
aware of, or could be expected to tive substance and dose being used im-
have been aware of the nature and mediately before cessation or reduc-
extent of harm. tion of use. The withdrawal state may
be complicated by convulsions.
Specfiers
The diagnosis of the dependence syn- Diagnostic Criteria
drome may be further specified by the G1. Clear evidence of recent cessation
following five character codes: or reduction of substance use, af-
ter repeated and usually prolonged
 F1x.20 Currently abstinent and/or high-dose use of that sub-
 F1x.200 Early remission stance.
 F1x.201 Partial remission G2. Symptoms and signs compatible
 F1x.202 Full remission with the known features of a with-

51
5 Diagnosis of abuse and addiction

drawal state from the particular five axes and should at least be de-
substance or substances (see be- scribed next to the axis-I diagnosis so
low). that the reader knows which group is
G3. Not accounted for by a medical the one concerned.
disorder unrelated to substance
use, and not better accounted for 5.4.1 DSM-IV and the multidimensional
by another mental or behavioural diagnostic in ve axes
disorder.
– Axis I
5.4 Substance-related diagnosis Clinical Disorders
Other Conditions That May Be a
in DSM-IV (American Psychiatric
Focus of Clinical Attention
Association. 1994) Alcohol and or Tobacco depend-
As the American Psychiatric Association ence, withdrawal states
would like to make the classification – Axis II
system more comparable for research Personality Disorders and Mental
and has acknowledged that psychiatric Retardation e. g. Antisocial Person-
diagnoses (affective disorder, schizo- ality Disorder, Cloninger Person-
phrenia, addiction) are too general, it ality Dimensions
was decided to include other categories – Axis III
that are additional to axis I (diagnosis of General Medical Condition
abuse, addiction, withdrawal syndrome) Deseases of the Respiratory Sys-
to be able to better describe the exam- tem, Deseases of the Digestive Sys-
ined groups of patients. tem
Today it is commonly known that – Axis IV
the long-term course of every psychiat- Psychosocial and Environmental
ric disorder is not only determined by Factors
an axis-I-diagnosis, but also by person- Degree of Social Support, Inter-
ality characteristics, somatic condi- actions with the Legal System,
tions, the degree of social deprivation Occupational Problems, Housing
and the level of social functioning. This Problems, Oeconomic Problems
multidimensional approach might be – Axis V
commonly known, but in most publi- Global Assessment of Function-
cations only axis-I-diagnoses are indi- ing
cated so that the results usually aren’t
transferrable to groups who have the 5.4.2 Diagnosis according to DSM-IV axis I
same disorder, but different psychoso-
cial positions. A 50-year old homeless 5.4.2.1 Tobacco or alcohol abuse
person with a drinking problem and
with severe liver cirrhosis obviously Friends and family members of the al-
needs different treatment than a 30- coholic are often the first to notice
year old depressive drinking woman problems and seek professional help.
with a dominant partner who starves Often, the alcoholic does not realize the
his wife emotionally. Every diagnostic severity of the problem or denies it.
process should therefore include all Some signs cannot go unnoticed, such

52
Substance-related diagnosis in DSM-IV (American Psychiatric Association. 1994)

as loss of a job, family problems, or ed by the effects of the sub-


penalties for driving under the influ- stance (e. g. arguments with
ence of alcohol. Dependence is indi- spouse about consequences of
cated by symptoms such as withdrawal, intoxication, physical fights)
injuries from accidents, or blackouts.  B The symptoms have never met
The American Psychiatric Associ- the criteria for Substance De-
ation has developed strict criteria for pendence for this class of sub-
the clinical diagnosis of abuse and de- stances.
pendence.
Most often, abuse is diagnosed in indi-
The Diagnostic and Statistical Manual- viduals who have recently begun using
IV (DSM-IV) defines abuse as follows: alcohol. Over time, abuse may progress
to dependence. However, some alcohol
Criteria for Alcohol and Tobacco Abuse users abuse alcohol for long periods
without developing dependence.
 A maladaptive pattern of sub-
stance use leading to clinically sig-
5.4.2.2 Tobacco-alcohol addiction
nificant impairment or distress,
as manifested by one (or more) of DSM-IV defines dependence as:
the following, occurring within a
12-month period: Criteria for Substance Dependence
1. recurrent substance use result-  A maladaptive pattern of sub-
ing in a failure to fulfill major stance use, leading to clinically
role obligations at work, school, significant impairment or dis-
home (e. g. repeated absences tress, as manifested by three (or
or poor work performance re- more) of the following, occurring
lated to substance use; sub- at any time in the same 12-month
stance-related absences, sus- period:
pensions, or expulsions from 1. tolerance, as defined by either
school; neglect of children or of the following:
household) • a need for markedly increased
2. recurrent substance use in situ- amounts of the substance to
ations in which it is physically achieve intoxication or de-
hazardous (e. g. driving an au- sired effect
tomobile or operating a ma- • markedly diminished effect
chine when impaired by sub- with continued use of the
stance use) same amount of substance
3. recurrent substance-related le- 2. withdrawal, as manifested by
gal problems (e. g. arrests for either of the following:
substance-related disorderly • he characteristic withdrawal
conduct) syndrome for the substance
4. continued substance use de- • the same (or a closely related)
spite having persistent or re- substance is taken to relieve
current social or interpersonal or avoid withdrawal symp-
problems, caused or exacerbat- toms

53
5 Diagnosis of abuse and addiction

3. the substance is often taken in drawal (Criterion 2). In these indi-


larger amounts or over a longer viduals, Substance Dependence is
period than was intended characterized by a pattern of com-
4. there is a persistent desire or pulsive use (at least three items
unsuccessful efforts to cut down from Criteria 3–7).
or control substance use
5. a great deal of time is spent in 5.4.3.2 Course speciers
activities to obtain the sub-
stance, use the substance, or Early Full Remission
recover from its effects
6. important social, occupational  Early Partial Remission
or recreational activities are  Sustained Full Remission
given up or reduced because of  Sustained Partial Remission
substance use  On Agonist Therapy
7. the substance use is continued  In a Controlled Environment
despite knowledge of having a
persistent or recurrent physical Six course specifiers are available for
or psychological problem that is Substance Dependence. The four Re-
likely to have been caused or ex- mission specifiers can be applied only
acerbated by the substance (e. g. after none of the criteria for Substance
continued drinking despite rec- Dependence or Substance Abuse have
ognition that an ulcer was made been present for at least one month.
worse by alcohol consumption) The definition of these four types of Re-
mission is based on the interval of time
5.4.3. Speciers dening subgroups of that has elapsed since the cessation of
dependence Dependence (Early versus Sustained
Remission) and whether there is a con-
Tolerance and withdrawal may be asso- tinued presence of one or more of the
ciated with a higher risk for immediate items included in the criteria sets for
general medical problems and a higher Dependence or Abuse (Partial versus
relapse rate. Specifiers are provided to Full Remission). A diagnosis of Sub-
note their presence or absence: stance Abuse is preempted by the diag-
nosis of Substance Dependence if the
5.4.3.1 Tolerance and withdrawal individual’s pattern of substance use
has at any point met the criteria for De-
1. With Physiological Dependence. pendence for that class of substances.
This specifier should be used
when Substance Dependence is Early Remission: Because the first 12
accompanied by evidence of tol- months following Dependence is a time
erance (Criterion 1) or withdrawal of particularly high risk for relapse, this
(Criterion 2). period is designated Early Remission.
2. Without Physological Depend- There are two categories:
ence. This specifier should be used
when there is no evidence of tol-  Early Full Remission: This specifi-
erance (Criterion 1) with with- er is used if, for at least 1 month,

54
Substance-related diagnosis in DSM-IV (American Psychiatric Association. 1994)

but for less than 12 months, no  In a Controlled Environment: This


criteria for Dependence or Abuse specifier is used if the individual is
have been met. in an environment where access to
 Early Partial Remission: This spec- alcohol and controlled substances
ifier is used if, for at least 1 month, is restricted, and no criteria for De-
but less than 12 months, one or pendence or Abuse have been met
more criteria for Dependence or for at least the past month. Exam-
Abuse have been met (but the full ples of these environments are
criteria for Dependence have not closely supervised and substance-
been met). free jails, therapeutic communi-
ties, or locked hospital units.
Sustained Remission:
After 12 months of Early Remission 5.4.5 Withdrawal symptoms of tobacco
have passed without relapse to De- and alcohol
pendence, the person enters into Sus-
tained Remission. There are two cate- After prolonged abuse of alcohol and/
gories: Sustained Full Remission: this or tobacco, reduction or cessation of
specifier is used, if none of the criteria intake often lead to maladaptive be-
for Dependence or Abuse have been havioural changes with psychological
met at any time during a period of 12 and cognitive concomitants. Alcohol
months or longer. Sustained Partial Re- and tobacco produce different symp-
mission: this specifier is used if full cri- toms during withdrawal and it is im-
teria for Dependence have not been portant to establish that the ‘withdraw-
met for a period of 12 months or longer; al’ is really substance related before the
however, one or more criteria for De- definition can be applied. During with-
pendence or Abuse have been met. drawal, craving is important and, es-
pecially in smoking, a main cause of re-
5.4.4 Therapeutic approach lapse. In alcohol withdrawal, the leading
symptoms are tremor, hyperhidrosis
The following specifiers apply if the in- and agitation.
dividual is on agonist therapy or in a
controlled environment:
Criteria for alcohol/tobacco withdrawal
 On Agonist Therapy: This specifier A. The development of an alcohol/
is used if the individual is on a tobacco-specific syndrome due to
prescribed agonist medication, the cessation of (or reduction in)
and no criteria for Dependence or substance use that has been heavy
Abuse have been met for that class and prolonged.
of medication for at least the past B. The alcohol/tobacco-specific syn-
month (except tolerance to, or drome causes clinically significant
withdrawal from, the agonist). This distress or impairment in social,
category also applies to those be- occupational, or other important
ing treated for dependence using areas of functioning.
a partial agonist or an agonist/an- C. The symptoms are not due to a
tagonist. general medical condition and are

55
5 Diagnosis of abuse and addiction

not better accounted for by an- in this direction. In regard to eating


other mental disorder. disorders, and especially anorexic pa-
tients, this delusional system has fre-
5.5 Commonalities and differences quently been described. This classi-
fication, which is still under discussion
of ICD-10 and DSM-IV
from various perspectives, is particu-
Both diagnostic systems emphasize that larly important in regard to treatment
compulsive consumption and the lack with anti-craving substances. Yet, crav-
of motivation to refrain from addictive ing in both, smoking and drinking is a
drugs are a fundamental part of the di- phenomenon whose strength can vary
agnosis. Thus, motivational work is al- in the course of addiction. It can be
ways the starting point of every therapy. heavily reinforced by situations and
Furthermore, a further criterion of di- emotions and therefore three different
agnosis is that the craving for an ad- kinds of craving need to be differenti-
dictive substance is so strong that it ated: 1.) Craving to enhance mood. 2.)
cannot be deliberately or sufficiently Craving to inhibit aggravating feelings.
reduced. Therefore relapses become an 3.) Craving which is supported by situa-
essential part of addiction. The ICD-10 tions and other stimuli (“key exposure”;
describes “craving” as a strong subjec- Pavlov’s principle). During in-patient
tive urge to consume a substance and therapy craving is rarely reported be-
craving is listed as the first criterion of a cause drinking has never been condi-
diagnosis. This phenomenon is a cen- tioned in these institutions (cool spots).
tral symptom of an addiction and is of The in-patient clinical staff therefore
prime importance for smoking and al- often underrates craving and only 6 %
cohol, but also for other addictive of addicts leave their in-patient therapy
drugs. The DSM-IV does not put “crav- with an anti-craving medication.
ing” in the centre of the diagnosis.
Strong craving, irrespective of addictive 5.6 Implication of these
substance, e. g. the urge to gamble or
classication systems for therapy
the compelling urge to eat etc., is coded
as a behavioural disorder in both clas- and research
sification systems. These monomanias
are viewed as completely different phe- 5.6.1 Alcohol
nomena. From my experience, phe-
nomena that can be seen in a gambling Above all, as a result of these far too
addiction, for example, are predomi- broad systems of classification, there are
nant in a similar way in the interpreta- various therapeutic approaches which
tions of normal perception. Sometimes are defined primarily by their organisa-
pathological perceptions can be found tional backgrounds or an ideological
and at times even delusions can be seen. perspective. There is no one method or
Future classification systems should medication which can consistently claim
subsume psychological addictions in positive effects (e. g. longer abstinence
the category of impulse control disor- rates), either from a pharmacological
ders. Discussions of expert panels on or a psychotherapeutic perspective. Re-
DSM-V and ICD-11 are already heading search leading to a definition of an ad-

56
Implication of these classication systems for therapy and research

diction-vulnerable personality can now with Clometiazol, Tiapride and Car-


be viewed as completed (McCord W et bamazepine, and in Italy with Gam-
al. 1960; Lesch OM. 1985). Sociological mahydroxibutanoic acid and Baclofen.
research, which tries to explain the ad- In Austria, it can be clearly seen that
diction process by poverty, unemploy- Benzodiazepines are used particularly
ment, cultural conditions or “broken- in intensive care units, while Tiapride
home”situations, is discovering more and Carbamazepine are mostly used in
and more that addiction occurs in all psychiatric hospitals. Meprobamate is
social situations and classes. However, also still prescribed although no longer
the course of addiction seems to be in- recommended in the literature. Cur-
fluenced by social factors and person- rently it is being taken off the market in
ality dimensions. Biologically based Austria (Lesch OM et al. 2010). At the
genetic research ranging from pharma- Medical University of Vienna, Depart-
cological studies on animals to therapy ment of Psychiatry, withdrawal medi-
studies of addicts consistently delivers cations are used according to specific
positive results and highlights are pub- subgroups (see chapter 9.3). Hester RK
lished in leading journals which, how- and Miller WR have compiled therapy
ever, are then either not replicable or methods which are internationally used
are refuted by other research groups as relapse prophylaxis. If examples of
(Koob GF and Le Moal M. 2006). medication, psychotherapy and socio-
Pharmacotherapy research has therapy are chosen from this book, it
clearly shown that the recommended should be recognized that there is
detox medication in the case of alcohol no method with completely positive
depends on the patient’s socio-cultural data. Today, Disulfiram, Naltrexone and
background, medical care system and, Acamprosate are the primary medica-
last but not least, the selection criteria tions used for relapse prophylaxis.
which indicate which subgroup of ad-
dicts should be treated by which medi- 5.6.1.1 Studies on pharmacotherapy in
cation, for example, in France with Di- relapse prevention (according to Hester RK
azepam and Meprobamat, in Germany and Miller WR 2003)

Fig. 24 Studies on Disulfiram used for relapse prevention in alcohol addicts

Disulfiram
16 studies of good quality:
• 6 studies − positive results, few relapses (Fuller RK et al. 1986; Caroll KM et
al. 2000; Azrin NH et al. 1982; Chick J et al. 1992; Wilson A et al. 1978 and 1980)

• 6 studies − negative results, increased relapses (Aliyev NN. 1993; Ling W et


al. 1983; Powell BJ et al. 1985; Johnsen J et al. 1987;
Dahlgren L and Willander A. 1989; Johnsen and Morland J. 1991)

• 4 studies − no significant changes in the rate of relapses (Ludwig A et al. 1969;


Miller WR et al. 2001; Smith JE et al. 1998; Fuller RK and Roth HP, 1979)

57
5 Diagnosis of abuse and addiction

Fig. 25 Studies on Naltrexone and Acamprosate for relapse prevention in alcohol addiction

Naltrexone and Acamprosate


Several studies show that Naltrexone and Acamprosate significantly improve
the relapse rates (Volpicelli et al. 1992; O’Malley et al. 1992; Geerlings et al.
1995; Pelc et al. 1997; Sass et al. 1996; Whitworth et al. 1996).

Several studies show no effect of Naltrexone and Acamprosate


(Gastpar et al. 2002; Krystal et al. 2001; Chick et al. 2000; Mason et al. 2001).

Conclusion from the existent studies:


Acamprosate prolongs the duration of abstinence, while Naltrexone
ameliorates the severity and the duration of the drinking episodes.

5.6.1.2 Studies on relapse prevention using relapse prophylaxis. An exception is


psychotherapy Client-centred Therapy according to
Rogers CR (1951). Confrontational psy-
Controlled studies of individual or chotherapeutic methods, like those used
group psychotherapy show surprisingly for a while in the USA, show continu-
consistent, negative results in regard to ously negative results. “Motivational in-

Fig. 26 Studies on psychotherapy used for relapse prevention in alcohol addicts

Psychotherapy
6 studies of good quality:
• 4 studies − negative results, increased relapses (Wells-Parker E et al. 1988;
Peniston EG and Kulkosky PJ. 1989; Bowers TG and Al-Redha MR. 1990;
Formigoni MLOS and Neumann BRG. 1995)

• 2 studies − no significant changes in relapse rate (Ludwig A et al. 1969;


Oejehagen A et al. 1992).

13 studies of low quality:


• 2 studies − positive results, few relapses (Rhead JC et al. 1977; Smith TL
et al. 1999)

• 3 studies − negative results, increases relapses (Conrad KJ et al. 1998;


Swenson PR et al. 1981; Olson RP et al. 1981)

• 8 studies − no significant changes in relapses (Potamianos G et al.1986;


Kish GB et al. 1980; Sandahl C et al. 1998; Glotzbach LD. 1984; Johnson FG.
1970; Bruun K. 1963; Jacobson NO and Silfverskiold NP. 1973; Zimberg S. 1974)

58
Implication of these classication systems for therapy and research

terviewing”, according to Miller WR and tion in AA groups. These results can be


Rollnick S., in combination with client- explained by the heterogeneity of pa-
centred therapy, however, has shown tients included in these studies. There-
the best results (Miller WR and Rollnick fore it is absolutely necessary to identify
S. 2002). homogeneous subgroups of patients, for
Social learning and behavioural which specific therapy methods should
therapeutic learning methods are often be made available. For more than 100
used for self-monitoring. Here the data years, attempts have been made to de-
are also equivocal. scribe the various dimensions of addic-
Research on sociotherapy also tion and the specific therapies which
shows varied results, as can be seen, for should be used to treat them. Practising
example, in milieu therapy or participa- therapists often use catchphrases like

Fig. 27 Studies on behavioural therapy for relapse prevention in alcohol addicts

Behavioural therapeutic learning for self-control


22 studies of good quality:

• 7 studies − positive results, less relapses (Harris KB and Miller WR. 1990;
Brown RA. 1980; Alden LE. 1988; Baker TB et al. 1975; Sobell MB and Sobell
LC. 1973; Caddy GR and Lovibond SH. 1976; Hester RK and Delaney HD. 1997)

• 2 studies − negative results, increase of relapses (Connors GJ et al. 1992;


Foy DW et al. 1984)

• 13 studies − no significant changes in relapse rate (Miller WR et al. 1980b;


Robertson I et al. 1986; Baldwin S et al. 1991; Alden L. 1980; Vogler RE et al.
1977; Miller WR et al. 1981; Pomerleau O et al. 1978; Sanchez-Craig M et al.
1989; Skutle A and Berg G. 1987; Miller WR. 1978; Sanchez-Craig M. et al.
1984; 1991; Miller WR and Taylor CA. 1980a)

Fig. 28 Studies on relapse prevention in alcohol addicts with “social learning” therapy

Social learning
8 studies of good quality:

• 4 studies – positive results, less relapses (Azrin NH et al. 1982; Chaney ER


et al. 1978; Erikson L et al. 1986; West PT. 1979)

• 1 study − negative results, increase of relapses (Sannibale C. 1989)

• 3 studies − no significant changes in number of relapses (Oei TPS and


Jackson PR. 1982; Cooney NL et al. 1991; Miller WR et al. 1980b)

59
5 Diagnosis of abuse and addiction

“dimensional diagnostic” and “dimen- not having done so in the specific case
sion-related therapy” or therapy accord- concerned, should be documented. The
ing to the patient’s resources. These large American study Project MATCH
therapists define the patient’s treatable included abusers and addicts and no
resources and in treating these, try to specific therapy method was found that
improve the course of disease. genuinely fits or benefits a groups’ pro-
Principally, there is no reason why file.
dimensional or resource-based therapy
should not be used, especially when one
5.6.1.3 Family psychotherapy
is in the midst of a long-term therapeu-
tic process with a patient. However, one As every therapist who is trained in sys-
should not forget that there are gener- temic therapy knows, drinking behav-
ally accepted rules for the pratice of psy- iour and how one handles alcohol is
chiatric therapy and for the processes of only understood as part of the person’s
therapy of addicted individuals that systemic relationships and systemic
have proven themselves over many equilibrium. In systemic therapy, diag-
years (Berner P et al. 1986; Bleuer M. nosis is of little or no significance.
1983; Feuerlein W. 1989; Lenz G. and Ku- The medication that is used to
efferle B. 2002; Lesch OM et al. 2010; manage withdrawal, relapse prophy-
Moeller HJ. 1993; Rommelspacher H and laxis and for treatment of a relapse can
Schuckit M. 1996; Uexkuell Tv. 1996). show considerable differences across
If one choses not to use an “evi- patients. In order to appropriately as-
dence-based” therapy, justification for sess these effects it is very important to

Fig. 29 Studies on the relapse prevention in alcohol addicts who take part in AA
groups and milieu therapy

AA-Groups
3 studies of good quality:
• 2 studies − negative results, increase of relapses (Ditman KS et al. 1967;
Brandsma JM et al. 1980)
• 1 study − no significant changes in the number of relapses (Walsh DC et
al. 1991)

Milieu therapy
6 studies of good quality:
• 2 studies − negative results, increase of relapses (Chapman PLH and
Huygens I. 1988; Longabaugh R et al. 1983)
• 4 studies − no significant changes in the number of relapses
(McLachlan JFC and Stein RL. 1982; Pittman DJ and Tate RL. 1972;
Rychtarik RG et al. 2000; Edwards G and Guthrie S. 1967).

60
Implication of these classication systems for therapy and research

clearly define patient groups with dif- In recent clinical trials, two new
ferent types of biological dysfunctions classes of medications seem to provide
which can be favourably treated by interesting results. Varenicline is effec-
medication. tive for those patients in which the vul-
nerability of the nicotine receptor is the
5.6.2 Tobacco essential pathological factor.
Varenicline is a partial nicotine
A variety of clinical studies from both receptor agonist (Alpha4Beta2). This
the medical and psychological fields selectivity leads us to expect that its ef-
also support the heterogeneity of To- fectiveness as a nicotine substitute is
bacco-addiction. It has been repeatedly considerably greater for some smokers.
confirmed that clear medical advice However, smokers in whom other sub-
for subgroups of addicts – 20–30 % are units of the receptor play a role might
indicated in the literature – significant- profit less. Clinical studies showed a du-
ly reduces the number of cigarettes plication of abstinence rates and there-
smoked per day and may even com- fore 1 mg Varenicline twice daily can be
pletely stop smoking (Fiore MC et al. described for nicotine withdrawal and
2000; US Department of Health and nicotine craving (Fagerstroem score 5
Human Services; World Health Orga- or more) (Tonstad S. et al. 2006; Zierler-
nization 2003; Henningfield JE et al. Brown SL and Kyle JA. 2007; Oncken C.
2005). et al. 2006; Williams KE. et al. 2007; Coe
Pharmacological therapy, espe- JW et al. 2005; Gonzales DH. et al. 2006;
cially nicotine supplements and anti- Cochrane Review Cahill K et al. 2007).
depressants like Bupropion, Nortryp- In a study comparing Varenicline with
tiline and Doxepin, is used, as the Bupropion 150 mg and placebo, the
effectiveness of these agents is gener- former clearly showed better results.
ally accepted. The fact that nicotine This effect could also be demonstrated
supplements are only effective in Fag- 53 weeks later. In a review (Cahill K et
erstroem positive smokers and anti- al.) of Varenicline, the data for daily
depressants primarily in tobacco ad- practice were summarized as follows:
dicts with low Fagerstroem scores, once
more demonstrates the heterogeneity 1. Varenicline improves smoking be-
of addiction, including nicotine (Be- haviour three times better than
nowitz NL et al. 1988; Shiffman S et al. placebo, also in the long run.
1996; Henningfield JE et al. 2005; Swee- 2. In smokers, Varenicline is superior
ney CT. et al. 2001; Tonnesen P. et al. to Bupropion. Studies that com-
1999; Le Foll B. et al. 2005; J. Clin Psy- bine Varenicline and other thera-
chiatry Monograph 2003; National In- peutic methods are still lacking
stitute for Clinical Excellence 2004; and most research groups agree
Lerman C et al. 2004; Fiore MC. et al. that the administration of Vareni-
2000; Scharf D and Shiffman S. 2004; cline for smoking withdrawal
Shiffman S. et al. 2000; Jorenby DE et needs further examination.
al. 2004; Ferry LH. 1999; Prochazka AV
et al. 1998; Hall SM et al. 1998; Edwards Other subgroups of tobacco addicts
NB. et al. 1988; Murphy JK et al. 1990). could have vulnerabilities in the CB1-

61
5 Diagnosis of abuse and addiction

receptor system and there are data Ferstl. 1996; Hughes JR. 2000; Prochas-
about CB1-antagonists (Rimonabant) ka J and DiClemente C. 1992; Schober-
which support an amelioration of im- berger R. 2006, 2002; Batra A. 2005;
pulse control in eating, alcohol and Kienast T et al. 2007). Again, these re-
smoking. A clinical definition of this sults support the heterogeneity of to-
subgroup is however still lacking. Stud- bacco addiction and there are data to
ies included occasional smokers as well suggest that tobacco addicts can be
as smokers with a Fagerstroem-score of grouped into four clusters or subgroups
five or more and results show a twice as as well, although the craving mecha-
high abstinence rate with simultaneous nisms for tobacco vs. alcohol should be
weight loss, not only in comparison to viewed differently (see chapter 9.2; Eu-
placebo but also to Bupropion (Despres ropean Smoker Classification System –
JP et al. 2005; Pi-Sunyer FX et al. 2006; Appendix 2; Lesch OM. 2007).
Cohen C et al. 2002; Anthenelli R. 2004; Over the last 100 years, these crav-
Klesges RC et al. 1997; Klesges RC et al. ing mechanisms have been extensively
1989; Soyka M. et al. 2007). Based upon investigated, leading to different defi-
our own research, we found that anti- nitions of types of alcohol and tobacco
depressants are especially effective in addicts. These different types of addic-
the subgroup using tobacco as an anti- tion obviously have a different aetio-
depressant. Women clearly smoke more logical course and development and
frequently because of a chronic depres- therefore need very different therapies.
sive mood and for weight control. Our These more specific classifications of
data showed that these subgroups of homogeneous types of addicts have a
tobacco addicts respond to 20 mg of Ri- stronger validity than just the diagnosis
monabant daily (Lesch OM et al. 2004; “addiction”. Those classifications help
Lesch OM. 2007). The warnings in re- guide the initial treatment plan for the
gard to depressive reactions of Rimona- addicts and are helpful for medical in-
bant need further study. The impact of tervention, for motivating the patient
the absence of tobacco, with its antide- and also for classification into a psy-
pressant effects, should be viewed sep- chotherapeutic school of thought. Most
arately. (see chapter 9.6.8.1.8). addicts do not want intensive psycho-
The utilisation of psychotherapy therapy and often stay with the general
for tobacco addicts is only well studied practitioner or with social agencies. In
in relation to behavioural therapeutic relation to the psychotherapeutic proc-
approaches. Behavioural therapy self- ess, patient characteristics, his ability
control techniques paired with strate- to cope with stress and other resources
gies for relapse prevention have shown of the patients are clearly more impor-
average long-term success rates of 25– tant than the psychiatric diagnosis.
30 % abstinence (Hanewinkel, Burow,

62
6
Types, dimensions and aetiology

6.1 Alcohol addiction recorded only once during in-patient


admission and lead to very different ty-
6.1.1 Development of typology research pologies according to the researcher’s
point of view and the criteria for select-
As already emphasized in the last chap- ed patients. The number of subgroups
ter, it has long been known that alcohol of the alcohol dependent typology’s
dependents are not a homogenous ranged from two to ten, but nowadays
group. Studies that have used the DMS- there is consensus that a four-cluster so-
IV in order to categorize alcohol de- lution should be preferred. Four groups
pendents into groups were able to show seem to be most suitable for basis re-
that the majority of patients either have search and therapy (Hesselbrock VM
a second axis-I or an axis-II diagnosis and Hesselbrock MN. 2006).
or both an axis-I and an axis-II diagno-
sis. Typology according to Jellinek
A research group lead by Driessen The drinking behaviour-based typolo-
M. described the high co-morbidity on gy according to Jellinek (Jellinek EM.
axis-I and axis-II in several studies. 1960), which has established itself in-
More than 50 % of the patients show ternationally due to its simplicity, was
psychiatric co-morbidity with 24 % hav- neither able to support basis research,
ing an additional diagnosis on axis I. In nor provide information for therapy.
addition, 17.2 % have a further axis-I Yet this typology was very important for
dysfunction as well as another axis-II- the development of diagnostic meth-
dysfunction and 16.4 % have, next to ods and especially for the WHO in de-
the diagnosis of alcohol dependence, fining dependence and abuse. Yet this
an axis-II diagnosis (Zimmermann P et typology is not mentioned by any rec-
al. 2003; Driessen M et al. 2001). ognised journal nor is it documented in
Due to this heterogeneity, at- any therapy study.
tempts have been made to categorize
subgroups of alcohol dependents, in Typology according to Foucault
such a way that factors such as drinking The French school, which has clearly
history, consumption of other drugs, always taken considerably more ac-
biographical information and other count of the aetiology and course of
psychiatric disorders, sequelae or per- mental disorders than the German
sonality disorders are taken into con- speaking psychiatric schools, devel-
sideration. These factors were usually oped by Foucault M. 1980 and Malka R

63
6 Types, dimensions and aetiology

et al. 1983, a typology which pays spe- within 14 to 21 days only ofabsolute ab-
cial attention to aetiology and seque- stinence (Schuckit MA. 1985).
lae. The type “alcoolite” shows gender
differences (about 60 % of male and 5 % 6.1.2.1.2 Cloninger’s typology
of female alcohol dependents). The As a result of genetic studies, in 1981
type “alcoolose” is marked by psycho- Bohman MS. et al. and Cloninger CR. et
logical disorders, often displays an epi- al. differentiated between two types of
sodic intoxicating drinking behaviour alcoholics (Knorring et al. 1985).
and can be found in type III according to Type I according to Cloninger is
Lesch. Independent of drinking behav- characterized by varying alcohol abuse
iour the type “somaalcoolose” often shows (sometimes occasional, sometimes
somatic symptoms, like severe polyneu- heavy). Their fathers don’t show any
ropathy or real epilepsies, and it is very delinquent behaviour and they belong
similar to Lesch’s type IV. to the upper classes. The biological
Multivariate and multidimensio- mother is often alcohol dependent.
nal typologies (like e. g. Bleuler M. 1983; Type I dependents according to Clon-
Rounsaville BJ. et al. 1987; More LC and inger have lesser alcohol-related social
Blashfield RK. 1981; Skinner HA. 1982; problems with less frequent in-patient
Tarter REH. et al. 1977) have led to re- admittances, and the onset of alcohol
search tools which are suitable for de- dependence occurs after the age of 25.
fining different groups of alcohol de- The dependents are easily influenced
pendents, but further studies in regard by their environment (“high reward de-
to basis research and therapy of these pendence”), very careful and often re-
subgroups are still needed. act with avoidance behaviour (“high
harm avoidance”). They are very reluc-
6.1.2 Important typologies for research tant to put themselves in risk situations
and practice (“low novelty situations”) (Kiefer F et al.
2007).
6.1.2.1 Two-cluster-solutions Cloninger type II patients often
have more alcoholics in their family
6.1.2.1.1 Schuckit’s typology next to their alcohol dependent moth-
In 1985, Schuckit differentiated between er. Type II alcohol dependents accord-
primary and secondary alcoholics. Pri- ing to Cloninger grow up in very diffi-
mary alcoholics don’t show any mental cult social conditions and aggression
disorders before the onset of alcohol and violence are frequent factors in
abuse, whereas secondary alcoholics these families. The patients can also
show psychological disorders before turn aggressive for minor reasons or no
the onset of alcohol addiction. Second- reason at all. They often take other
ary alcoholics tried to “treat” these dis- drugs and the addiction process starts
orders by using alcohol as a form of self- before the age of 25. According to Clon-
therapy. In regard to this process, inger’s personality dimensions they can
Schuckit MA showed that the regression be characterized by a high readiness to
of psychical symptoms like those in enter risk situations (“high novelty
anxiety or depression occurs in many seeking”), a love of unstable life situa-
patients even without a specific therapy tions (“low harm avoidance”) and act

64
Alcohol addiction

like they are very independent from typology, as type IV shows an early on-
their environment (“low reward de- set of addiction and is defined by severe
pendence”). These types are biologi- psychiatric and neurological complica-
cally validated (type II shows a high tions.
MAO-activity) and the classification has
been used by researchers in therapy 6.1.2.1.3 Typology according to Babor
studies which showed that Acampro- In 1992 Babor TF examined 321 female
sate and Topiramate show different ef- and male alcohol dependents during
fects in Cloninger’s types (Kiefer F. et al. their in-patient admission. 17 catego-
2005 and Johnson B. et al. 2004). Clon- ries were used for a multi-dimensional
inger types are continuously used for classification and he recorded premor-
genetic studies. TypeII patients ac- bid risk factors, abuse of alcohol, the
cording to Cloninger show higher her- use of other addictive substances, chro-
itability than type I patients. Further- nifications in the process and alcohol-
more, type II patients are more related sequelae (Babor TF et al. 1992).
frequently admitted into in-patient Similar to Cloninger’s type, Type A
clinics and suffer from severe mental according to Babor shows symptoms
problems (Van den Bree MBM. et al. such as a late onset of dependence, few
1998; Gilligan SB. et al. 1987). problems during childhood and less
Cloninger’s typology has also been psychopathological symptoms.
included in several pharmaceutical re- Type B according to Babor has a
lapse studies, in which type II clearly high prevalence of infantile behaviour
shows better results in regard to anti- disorders and multiple alcoholic mem-
craving substances. Naltrexone reduces bers in the family; early manifestation
relapses in type II (Kiefer F et al. 2007). of alcohol addiction symptoms in the
Ondansetrone also showed better re- individual’s life and acute life stress fac-
sults in type II (Johnson BA et al. 2000). tors can be observed. This group of de-
This data shows that the biological pendents require lengthier treatment
mechanisms of craving are heterogenic and individuals have often been in in-
in type II and this is in line with Lesch’s patient care. The symptomatic is very

Fig. 30 Cloninger Type I and II

Type I Type II
Onset of alcohol dependence after Onset of alcohol dependence before
the age of 25 the age 25
Men and women Only men
Mild alcohol-related sequelae Problems with the police and
Few problems with aggression and aggressions
the law No avoidance behaviour, but acting
Avoidance behaviour in regards to out their aggressions
social difficulties High “novelty-seeking” potential
Doesn’t like surprises

65
6 Types, dimensions and aetiology

similar to Cloninger’s type II. Other au- est and the number of subjects exam-
thors (e. g. Brown J et al. 1994; Del Boca ined, more recent studies typically iden-
FK. 1994 Del Boca FK and Hesselbrock tify 3–5 subtypes.
MN. 1996) were able to verify these syn- The indeterminate nature of clus-
dromes according to Babor A and Ba- ter-derived typologies (and a limit of
bor B, in their patients. the statistical procedure) is best exem-
Babor’s typology has also been in- plified by a re-analysis of the Babor et
cluded in therapy studies in which SS- al. data by Del Boca and Hesselbrock
RIs lead to an improvement of the proc- (1996). Their results showed four clus-
ess, especially in type B (Kranzler HR et ters as functional solutions that distin-
al. 1996). Only recently, Johnson showed guished alcohol dependent persons
that Ondansetrone significantly reduc- along gender and several clinically im-
es the relapse rate especially in “early portant dimensions.
onset” dependents and in Babor type B
(Roache JD et al. 2008). Cluster Low Risk/Low Severity (LR/LS)
Since 1992, primarily the team The largest subtype, containing ap-
around Schuckit MA has continued to proximately one third of the cases (39 %
research Babor’s typology (e. g. Schuckit of female and 29 % of male) was char-
MA et al. 1995), whereas other research- acterized as relatively Low Risk and
ers were not able to match some cases Low Severity, while 22 % of female and
with the typologies according to Babor 22 % of male were classified as High
and Cloninger, so that the two-cluster Risk and High Severity. The Low Risk/
solution was described as not satisfac- Low Severity (LR/LS) groups were char-
tory by some authors (Hesselbrock VM acterized as having a mild form of alco-
and Hesselbrock MN.2006). hol dependence, with a late onset of
alcoholism, low alcohol involvement,
with no alcoholic family members or
6.1.2.2 The four-cluster solutions
co-morbid psychopathology
6.1.2.2.1 Del Bocca and Hesselbrock’s
typology Cluster High Risk/High Severity (HR/HS)
Several studies have found that two In contrast, the High Risk/High Severity
group solutions seldom fully capture (HR/HS) group was characterized as
the clinical entity or adequately classify having a severe form of alcohol depend-
general population samples. The varia- ence, an early onset of alcohol use and
bility in the number of subtypes could dependence, a positive family history of
be a consequence of the data reduction alcoholism, high alcohol involvement,
technique used (e. g., cluster analysis, behaviour problems, poly drug use, de-
factor analysis), since most are not gov- pression and antisocial personality dis-
erned by prescribed rules. Further, the order. There were no gender differences
final solution could also be influenced in terms of the proportions or character-
by a variety of factors including sample istics of subjects among both mild and
characteristics and sample size, availa- severe forms of alcohol dependence.
bility of clinical information and the Two other identified clusters can
theory underlying the original analysis. be characterized as moderate forms of
Depending upon the variables of inter- alcohol dependence and were labelled

66
Alcohol addiction

as Internalizing and Externalizing to regular drinking or treatment ranged


groups. Gender specific differences were from 52 % to 57 % of women in the oth-
found for both groups. er three clusters.
At the three-year post-discharge
Cluster Internalizing type follow-up, a similar trend continued to
The Internalizing type included a high- be found. Both the High Risk/High Se-
er proportion of women (32 %) than verity group and the External group
men (11 %). This group was character- continued to report high rates of re-
ized as depressed, anxious, and having lapse to drinking for both the men and
severe alcohol dependence. They also women, while the men, regardless of
reported medical and/or physical prob- their cluster assignment, tended to re-
lems resulting from chronic alcohol port higher rates of relapse than the
use, but a moderate family history of women. Nearly 4 out of 5 men in the
alcoholism risk. HR/HS group and the Externalizing
group continued to relapse to regular
Cluster Externalizing type drinking or receiving treatment, as com-
The Externalizing subtype was pre- pared to approximately half of the
dominantly male (38 % of men and 7 % men in the LR/LS and the Internalizing
of women) and was characterized as groups. There were no differences in
having a moderate alcoholism family the rates of relapse among women by
history risk, high levels of alcohol use, cluster subgroups. Regardless of their
social consequences and antisocial per- cluster assignment, approximately half
sonality, but no depression or anxiety of the women were either abstinent or
disorders. engaged only in occasional drinking at
While many studies of alcoholic the three-year follow-up. However, the
typologies do not have long term fol- number of women in each cluster was
low-up or treatment outcome data, small and these findings should be in-
subjects in the Del Boca and Hessel- terpreted with caution.
brock’s study completed one and three A 25-year post-treatment follow-
year follow-up interviews. In addition, up of this sample was made through a
25-year mortality data have also been search of the Social Security Death In-
obtained. At the one year follow up, the dex records, death certificates and au-
majority of men in the Externalizing, topsy results. An overall crude death
High Risk/High Severity and Internal- rate as of December 2005 was 45.7 % for
izing clusters relapsed to regular drink- men and 41.7 % for women. The crude
ing and/or sought treatment of alcohol death rate was highest among the “Low
problems (86 %, 74 %, and 72 % respec- Risk/Low Severity“(53.0 %) and “In-
tively) while a little over half (56 %) of ternalizing”(55.6 %) clusters for men
men in the Low Risk/Low Severity group and Low Risk/Low Severity cluster for
reported regular drinking and/or seek- women. Both men and women in the
ing treatment. Among women, five of High Risk/High Severity cluster had the
six who were classified as Externalizers lowest crude death rates (29.4 and 21.1 %
relapsed to regular drinking or received respectively). These crude death rates
treatment. The remaining subtypes of are reflective of the discrepancy in the
women fared better; the rates of relapse different clusters’ ages at the time of

67
6 Types, dimensions and aetiology

their admission to the treatment centre tal death was slightly higher among
(baseline). The average age of the HR/ men than women (6 % vs. 3 %). Among
HS group was youngest at admission, the 7 men who committed suicide, three
27.7 years old, followed by the External- men each were from the Externalizer
izing and Internalizing groups (40.5 yrs and Internalizer groups, while one man
and 40.0 yrs respectively), with LR/LS was from LR/LS subgroup. Among the
group being the oldest (44.7 years). Con- 5 women who committed suicide, three
sequently, the age of death for the HR/ were from the Internalizer group and
HS group was youngest, 49.5 yrs for men two from the LR/LS groups.
and 47.8 yrs for women, followed by the In order to adjust for the variation
Externalizing group (58.6 yrs for men in age among the four cluster groups, a
and 53.8 yrs for women). The LR/LS standard mortality ratio (SMR) was cal-
group had the oldest age of death (62.8 culated for each cluster by gender us-
for men and 60.2 for women). The avail- ing the State of Connecticut mortality
able death certificates were reviewed by table for1980 to 2005. Overall, the SMR
two physicians and classified into three was quite high, with the rate for women
categories: definitely related to alcohol, being much higher than that of men
definitely not related to alcohol, cannot (5.41 (CF 3.77–7.52) for women vs 2.82
be determined. The two reviewers were (CF 2.30–3.43) for men). The SMR was
mostly in agreement, but in a few cases, highest among High Risk/High Severity
a third person was asked to review the group men and women (4.72 for men
certificates and discuss his reviews with and 6.60 for women). The SMR was also
the other two to determine the appro- high among men in the Externalizing
priate category. Among those subjects group (3.18 (2.27–4.33)), while the SMR
whose deaths could be determined, 6 of for both Low Risk/Low Severity and the
7 HR/HS men’s deaths were alcohol re- Internalizing clusters were similar and
lated. Approximately half of the Exter- the lowest (2.42 and 2.09). Unlike the
nalizing and LR/LS men’s deaths were men, the SMR was also high among
related to alcohol, while less than half Low Risk/Low Severity and Internaliz-
of the Internalizing group deaths were ing cluster women. However, the results
related to the use of alcohol. There were for women could be biased since the
no statistically significant differences number of women in each cluster was
in alcohol-related deaths by cluster very small.
among women. Approximately 50 % of As expected, the grouping of al-
all deaths were related to alcohol among cohol dependent persons into more
all clusters, but the number of women homogeneous clusters provided impor-
whose cause of death could be deter- tant information regarding the long-
mined was too small for meaningful term course of alcohol dependence
analysis (the number ranged 0 to 6). among treated persons. The High Risk,
We were able to determine the High Severity group was particularly
manner of death for 117 subjects. Most associated with early onset alcohol de-
subjects died of natural causes (86 % pendence, severe multiple addictions,
for men and 80 % for women). The sui- psychiatric co-morbidity at baseline,
cide rate was higher among women one-year and three-year follow-ups,
than men (17 % vs 8 %), while acciden- and impacted on long term survival.

68
Alcohol addiction

These findings again demonstrate the cantly more men have been defined,
potential clinical importance of group- whereas more women were defined in
ing patients into homogeneous clusters clusters 1–3. These clusters are in line
since different clusters/typologies do with the clusters described by Zucker
present with different clinical symptom RA. and Gomberg E, Schuckit MA, Del
profiles and have different short and Boca FK and Hesselbrock MN, Hessel-
long-term prognoses,and such differ- brock VM and Lesch OM. (Hesselbrock
ent types of alcoholics also require dif- VM. and Hesselbrock MN 2006).
ferent treatment plans.
6.1.2.2.3 Foroud’s typology
6.1.2.2.2 Windle and Scheidt’s typology In 1998, Foroud T defined alcohol de-
These authors also identified four clus- pendents according to the disease’s se-
ters of addiction by using a similar meth- verity and also described four clusters:
od of data collection as the one used by patients with almost no alcohol-related
Babor. They defined a mild progression sequelae, patients with a minor prob-
with multiple addictive drugs and com- lematic, a group with medium severity
pared this to an alcohol addiction with and a group with serious dysfunctions
a depressive symptomatic and a chronic in psycho-socio-biological areas. This
progression with an antisocial person- classification was also used for genetic
ality disorder. studies, however no replicated data is
available yet (Foroud T et al. 1998).
Cluster 1
The mild progression showed less in- 6.1.3 Assessment of severity in different
fantile behavioural disorders and a later dimensions
onset of alcohol addiction with this
group drinking less than the other group. Besides the establishment of defini-
Additionally withdrawal syndromes oc- tions and typologies, attempts have
curred. been made for several years to describe
the severity of addictive diseases ac-
Cluster 2 cording to several dimensions. The re-
In cluster 2 the highest concomitant search tools which are required for this,
use of other addictive drugs, especially also assess the intensity of the dimen-
Benzodiazepines was found. sional therapeutic intervention. In par-
ticular McLellan AT.’s Addiction Severi-
Cluster 3 ty Index (ASI) has established itself
In cluster 3 the most acute manifesta- internationally and in Austria the mul-
tion of affective and anxiety disorders tidimensional diagnostic by Scholz H is
was found. an approved method (McLellan AT et
al. 1980; Scholz H. 1996).
Cluster 4
In cluster 4 the highest level of alcohol
6.1.3.1 Addiction Severity Index (ASI)
abuse in regard to both amount and
duration was found. The ASI divides severity into seven di-
These clusters showed significant mensions and defines whether therapy
gender differences. In Cluster 4 signifi- is needed for these specific areas. This

69
6 Types, dimensions and aetiology

Fig. 31 Addiction severity index (ASI) ensure that the studies’ results from
different countries are more compara-
Problems 0 1 2 3 4 5 6 7 8 9
ble. A German language validated ver-
physical
sion has already been published (Gsell-
work/expenses
hofer E-M et al. 1993, 1999; van den
alcohol
Brink W et al. 2006).
drugs
legal
family/social
6.1.3.2 Syndrome diagnosis according to
Scholz
psychological
In Austria, five dimensions to capture
0−1 No real problem, no treatment needed
addictive diseases have been proposed
2−3 Minimal problem, possibly no treatment required by Scholz H.
4−5 Medium problem, treatment recommended These strategies are summarized
6−7 High problem, treatment required
8−9 Extreme problem, treatment absolutely required
in the book “Syndrome related therapy
of alcoholism” by Scholz H (1996). The
assessment according to Scholz has
also been compared with Lesch’s typol-
instrument was developed in the Unit- ogy. As the types according to Lesch
ed States and has been adopted in most show different profiles, this typology
European countries. can also be assigned to the method
In 2003, Van den Brink stated that according to Scholz (see chapter 6.3;
a consensus conference of the ECNP in Lesch OM and Walter H. 2006).
Nizza suggested that all therapy studies Most of these typologies showed,
on addictive diseases and of course al- that they are able to define more ho-
cohol addiction should use the ASI to mogenous groups of patients than it is

Fig. 32 Diagnosis of syndromes according to Scholz


Intensity

0 Dysfunctions
PS OPS O E/A SOZ/FAM

PS: Actual psychopathological syndrome and basic disturbances


OPS: Cognitive impairment
O: Other organ diseases
E/A: Lack of insight, defensive attitude, lack of motivation
FAM/SOZ: Family-/social problems

70
Tobacco addiction

possible to achieve through the diag- Fig. 33 Types of smokers according to


nosis of addiction according to DSM-IV Schoberberger R and Kunze M
and ICD-10. Yet, many of these typolo-
What kind of smoker are you?
gies were only described cross-section-
ally and psychological, biological and Do you smoke regularly throughout the
therapeutic validations that record the day, e.g. every half or every hour?

stability of these types over time are


lacking. All these typologies agree about You don‘t have any desire to smoke
throughout the day, but only in certain
the existence of an acute chronic pro- situations, in which you smoke several
gression type, a mild progression with- cigarettes?

out serious sequelae, a cluster in which


alcohol is used as an anti-depressant Your smoking is regularly throughout the
day and in certain situations you smoke
and anxiolytic. Furthermore, they agree more top?
that the development of an anti-social
personality, together with the compli-
cating factors of an alcohol addiction,
has its’ own pattern of progression. smoking behavior (Schoberberger R
In their article on subgroups of al- and Kunze M. 1999).
coholics, Hesselbrock VM. and Hessel-
brock MN. call for an examination of “Level-smokers”
these clusters in regard to their genetic This term describes smokers who smoke
vulnerability, biological aetiology and evenly throughout the day on a regular
in terms of their stability and treatabil- basis.
ity. As a result, such examinations could
lead to detections of the clusters’ aeti- “Peak smokers”
ologies and psychological and pharma- Peak smokers usually smoke few or no
cological therapies could then be ex- cigarettes, but when they get into a
amined in long-term settings (Lesch stressful situation they smoke a lot
OM and Walter H.1996; Kadden RM et within a short time.
al. 2001; Basu D et al. 2004; Kranzler HR
et al. 1996). Most patients belong to mixed types
between these two groups.
6.2 Tobacco addiction About 60 % of smokers are unhap-
py with their smoking habits (dissonant
6.2.1 Smoking typology according to smokers) and would like to stop or at
Schoberberger and Kunze least reduce their smoking (Schober-
berger R and Kunze M. 1999).
From a psychiatric perspective, research
on tobacco dependence is in its early 6.2.2 Smoking Typology according to
stages and, so far, specialists in internal Fagerstroem
medicine, especially pulmonary physi-
cians, have dealt with tobacco research. In 1989, Fagerstroem KO and Schneider
Social medicine has described sub- NG and later Heatherton TF et al. (1991)
groups of alcohol addicts according to developed the Fagerstroem test to
the Jellinek scheme in regard to their measure the severity of biological to-

71
6 Types, dimensions and aetiology

bacco addiction. This test enables a logical tobacco addiction. They are re-
classification according to the severity ferred to as the Heavy Smoking Index
of the nicotine addiction: (HSI) (Kapusta ND. et al. 2006; Heath-
erton TF. et al. 1989, 1991). A HSI-score
Score 0-2: very low (or no) nicotine ad- of 1–3 suggests a low nicotine addiction
diction and a score of four or more is associ-
Score 3-4: low nicotine addiction ated with a strong nicotine addiction
Score 5-10: medium to high nicotine (Diaz FJ et al. 2005). If these instruments
addiction (Fagerstroem Test or HSI) are used to
measure smoking behaviour, no corre-
The Fagerstroem score measures the lation between motivation to change
severity of the biological tobacco ad- the smoking behaviour and smoke-free
diction and Fig. 35 shows that the Fag- intervals could be found. The Fager-
erstroem score correlates with carbon stroem score also can’t predict the na-
monoxide levels and that scores of five ture of tobacco craving. However, this
or more correlate very strongly with to- test offers sufficient information about
bacco sequelae and with the severity of the severity of withdrawal syndromes
withdrawal symptoms. and about the kind of pharmaceutical
Two questions of the Fagerstroem therapy needed (Nicotine supplements
Test (question 1 and 4) have turned out or Varenicline) in order to determine
to be the most significant and these two the dose of nicotine supplement thera-
questions are being used to define bio- py (Henningfield JE et al. 2005; Le Foll B

Fig. 34 Fagerstroem Test

How soon after you wake up do you smoke your first cigarette?

within 3 minutes (3) 6−30 minutes (2)


31−60 minutes (1) after 60 minutes (0)

Do you find it difficult to refrain from smoking in places where it is forbidden?


yes (1) no (0)

Which cigarette would you hate most to give up?


the first in the morning (1) any other (0)

How many cigarettes per day do you smoke?


10 or less (0) 11−20 (1)
21−30 (2) 31 or more (3)

Do you smoke more frequently during the first hours after awakening than during the rest of the day?
yes (1) no (0)

Do you smoke even if you are so ill that you are in bed most of the day?
yes (1) no (0)

72
Tobacco addiction

Fig. 35 The validity of the Fagerstroem- logical dysfunctions which should be


Test in regard to different dependence considered for pharmacotherapy and
dimensions in tobacco dependents ac- motivational strategies.
cording to ICD-10 (Lesch OM et al. 2004) Our research group was able to
A Fagerstroem score of ≥ 5 correlates with show that four different dimensions
1. Severity of dependency (ICD-10) (Fig. 36) of craving need to be differen-
2. Duration of dependency tiated, which are unequally distributed
3. Level smoking between genders. (Figs. 36 and 37)
4. Number of cigarettes It is very likely that these different
5. Duration and severity of nicotine mechanisms of craving have different
withdrawal syndrome biological causes. Within relapse pre-
n=330 vention medication has only been ex-
amined in regard to all tobacco de-
pendents. Only the Fagerstroem score
et al. 2005; National Institute for Clini- has been considered in these studies.
cal Excellence 2004). The various distinct types of craving,
such as those described by Pomerleau
6.2.3 European smoking classication CS, Fagerstroem KO and the research
system group around Lesch OM., should be
considered in future relapse studies.
Since 1973 researchers have tried to Gender differences in regard to coping
correlate personality factors with smok- with stress and tobacco craving should
ing behaviour. Using this procedure, be incorporated into such studies.
Patton D. et al. developed a typology Women smoke mainly to ameliorate a
which includes different personality negative mood, while men mostly try to
traits. Unfortunately no longitudinal enhance a positive mood state (Lesch
and no therapy studies in regard to OM et al. 2006).
these subgroups have been performed Motivation strategies and diverse
(Eysenck J. 1973; Patton D et al. 1997). relapse prophylaxes are unfortunately
Pomerleau together with Fagerstroem still not sufficiently researched. Shiff-
described the heterogeneity of tobacco man has investigated the differences in
dependence and suggested that three motivation and differentiated motiva-
different mechanisms should be differ- tion in regard to different types of
entiated in regard to nicotine craving smoking behaviours (Shiffman S. 1996).
(Pomerleau CS et al. 2000):
Fig. 36 Factor analysis of craving in
 Smoking to ameliorate negative tobacco dependents, n = 330
mood, like depression or anxiety (Lesch OM. et al. 2004, 2006, 2007)
 Smoking to enhance positive mood
 Smoking as a habit as a result of Factor analysis: craving for cigarette smoking
heavy smoking in the social envi- • relaxation
ronment • coping
• stress
He also suggests that these three mech- • depression Lesch OM et al. 2004
anisms are reflected by different bio-

73
6 Types, dimensions and aetiology

Fig. 37 Tobacco craving according to gender, n = 330 (Lesch OM et al. 2004, 2006, 2007)

0 20 40 60 80 100 120

Anxiety
Depressive mood
Restlessness
Difficulty to fall asleep
Sleep disturbance
Stress
Boredom
Indigestion
Increase in weight
Other

female male

Behavioural therapeutic studies and search than the description provided


hypnotherapeutic studies in regard to by conventional classification systems.
these subgroups are also seperately As our clinic always puts equal empha-
needed (Lesch OM. 2007). sis on both the French school of thought
(Pichot, Alliere) and the German-speak-
6.3 Alcohol addiction – ing school of thought (Schneider, Bleu-
ler, Kraepelin), progression research
Lesch’s typology
according to the French paradigms and
6.3.1 Framework for the denition of cross-sectional research with instru-
Lesch’s typology ments according to paradigms from
German-speaking countries have al-
In 1972, a research group was formed at ways been equally important (Berner P.
the university hospital for psychiatry in 1986).
Vienna under the direction of Peter In cooperation with the University
Berner which has devoted itself to the Hospital for Psychiatry in Vienna and
topic of alcohol addiction and which is the Anton-Proksch-Institute, an ambu-
still active today. At that time, the direc- lant care unit for mentally ill was found-
tion of research at the psychiatric hos- ed in Burgenland, a province of Austria.
pital in Vienna was shaped by research In 1972, Peter Berner, Head of the Uni-
on psychopathology and the definition versity Hospital for Psychiatry and Ru-
of syndromes which describe psycho- dolf Mader, Director of the Anton-
pathological stages. It was attempted to Proksch-institute, commissioned me
evaluate these syndromes in therapy to setup the very patchy outpatient care
studies (e. g. delusional disorders or con- of this province and also to assume
current disorders) which led to the hy- leadership of the team for outpatient
pothesis that these syndromes are more care (Lesch OM et al. 1980, 1983, 1984;
suitable for providing information about Lesch OM. 1985; Spielhofer H and
the choice of therapy and for basis re- Lesch OM. 1980). This activity has led

74
Alcohol addiction – Lesch’s typology

to the Psychosocial Service (PSD) Bur- into unipolar and bipolar 1 or 2 was not
genland which today supplies the en- only important for therapy, but also for
tire province. Already in 1973, for scien- the co-morbidity of alcohol addiction.
tific purposes, we defined a “catchment Both researchers were able to show that
area” which encompassed around mainly bipolar progressions are linked
160.000 inhabitants (see Fig. 38). The to alcohol addiction, while this was not
established care system enabled us to the case for unipolar progressions (Bleu-
prospectively examine the long-term ler M. 1972; Angst J. 1973; Angst et al.
progression of diverse disorders such 2006; Berner P. 1986).
as paraphrenic psychoses, depressive
disorders and alcohol addiction (Lesch 6.3.3 The “Burgenland Modell”
OM et al. 1985).
Alcohol dependents were of course Since 1953, the diagnosis “addiction” is
also cared for in this setting and these accepted, like any other diagnosis, as a
were cross-sectionally assessed so that diagnosis of disease by national insur-
they could be included in prospective ance institutions in Austria. Since then,
therapy studies and basis research the costs of outpatient as well as in-pa-
(Lesch OM et al. 1983). The opportu- tient treatment have been funded by
nites which were offered here for long- public health insurance. If patients are
term support and long-term scientific not insured, the local province pays for
observation, led to Lesch’s typology. the costs. The fact that every alcohol
dependent has the right to publicly
6.3.2 Alcohol addiction from a longitudi- funded therapy has led to the concept
nal perspective 1976–1982–1995 of long-term support for alcohol de-
pendents. In the province of Burgen-
The observable trend in psychiatry to land, nine counselling centres (with
describe medical conditions by using social workers, psychologists and doc-
brief psycho-pathogenetic or even sole- tors) support alcohol dependents ei-
ly cross-sectional methods, and then to ther on an outpatient or, if required, on
merely assign these syndromes to com- a short-term in-patient basis. This con-
mon diagnosis systems (ICD-10, DSM- cept is only possible because of the
IV), often leads to a diagnosis that is close collaboration between field doc-
hardly relevant for the patient’s long- tors and medical specialists in psychia-
term progression. try and neurology. When an alcohol de-
As a result of this fact, very differ- pendent was admitted as an in-patient
ent long-term progressions have been to one of the following hospitals: Uni-
described for all major psychiatric disor- versity Hospital for Psychiatry in Vien-
ders. For instance, Kraeplin and Bleuer na, University Hospital for Psychiatry
observed different progressions in schiz- in Graz, Psychiatric Hospital Mauer-
ophrenic disorders (remission, course of Oeling, Psychiatric Hospital Graz Sig-
the disease process, progress in episodes, mund Freud or Anton-Proksch-Insti-
episodic progress). In their prospective tute Vienna, this patient was visited by
longitudinal study, Angst and Perris in- the staff of the counselling centres re-
vestigated the progression of affective sponsible. During these visits, the at-
disorders. Their division of progression tending therapists were informed about

75
6 Types, dimensions and aetiology

the patient’s family situation (home pology (Lesch OM. 1985). Longitudinal
visits were made previously) and pa- studies of alcohol addicts showed that
tients were encouraged to continue smoking behaviour massively affects
therapy in the counselling centre or in health even if the patient is totally ab-
another care institution. If patients stinent. Despite total abstinence, high
were unable to adjust to this setting, mortality rates can be ascribed particu-
they were visited at home during the larly to smoking (Lesch OM and Walter
forthcoming weeks and in some cases H. 1984). Due to these facts, we started
it was possible to develop a therapy in 2002 to examine smoking behaviour
plan with these patients. The low mi- in more detail. For this project, we used
gration rate during this time and this findings from alcohol research about
particular support concept enabled typology and research tools (methods
secondary research to be carried out of data collection) and from this devel-
with very low drop-out rates, which ul- oped a smoker typology (see Appen-
timately led to the formation of sub- dix 2; Lesch OM et al. 2004).
groups as summarized by Lesch’s ty-

Fig. 38 Longitudinal course of alcohol dependent patients, according to DSM-III and


ICD-9
Study design (n = 444)

Long−term course of alcohol dependence in DSM-III


Diagnosis: Region: A: inhabitants 48 347; admission rate 182 (0.38%)
chronic alcoholism B: inhabitants 43 949; admission rate 116 (0.26%)
(DSM III, ICD 9) C: inhabitants 40 043; admission rate 84 (0.21%)
D: inhabitants 33 558; admission rate 54 (0.16%)
Time unrelated evaluation

Hypothesis
444 Pat. 436 Pat. 335 Pat. 326 Pat.
8 Drop out (101 † since 1976) 9 Drop out (143 † since 1982)

Jan. 76 – 1982 94–95


Dec. 78
15 m
≥ 48 m
≥ 12 y

Visits at home Evaluation done Evaluation by home visits


and in hospital by visits at the (in case of death discussion
patients home with family or local doctor)
+ questionnaire for course
examination (DGS)

72.2% of our sample could be assessed during the long-term course (drop-out rate 27.8%). During the 1st
period of the design (1976–1982) 4 sub-groups of alcohol dependent patients could be defined.
These types reflect different biological, psychological and social patterns. During the 2nd period we
confirmed the stability of the courses.
modified from Lesch OM et al. 1988, Forensic Science Int.

76
Alcohol addiction – Lesch’s typology

6.3.4 Methodology of the longitudinal death. The progress previously defined


study on alcohol dependent patients by the literature was then correlated with
(according to DSM-III and ICD-9), used for the information (biography, diseases)
the development of Lesch’s typology which had been documented at admis-
sion. From 1985, the different progres-
From January to December 1978, all pa- sions were published with the data and
tients treated as in-patients and living in therapy recorded at admission. Twelve
the four northern districts of Burgen- years later (1994/95), the alcoholics who
land were included in the study. A total were still alive (335 patients) and/or their
of 444 patients were recruited of which family members were examined in a
8 died within the first 24 hours after ad- personal interview by two independent
mission, therefore only 436 patients psychiatrists, in order to document the
could be included in the study. These stability of progression. Also in an inde-
patients were visited during clinic ad- pendent evaluation after twelve years,
mission which was followed by an as- both patients and family members of
sessment. Patients were assessed by a deceased patients (= 143) were inter-
social worker in the form of a personal viewed (Lesch OM et al. 1985, 1988).
interview which took place six times a The four northern districts of
year over a minimum of four years. The Burgenland were chosen because of
assessment in the hospital was backed their very diverse socio-cultural back-
up by house calls to the family. After grounds, e. g. region A: rich winegrow-
those four years, I could either visit pa- ers, region C: no wine production and
tients at home or in the institutions. I many inhabitants of this region drive to
used a multidimensional questionaire Vienna for work (high commuter rate),
with 136 items and this observation stage region D: rural structures with signifi-
lasted two years. When patients died cantly lower income than region A and
(n = 101), family members were asked to no alcohol production. The significant-
document the course of the disease until ly different admission rates with an ad-

Fig. 39 Long-term progression of alcohol dependent patients according to DSM-III


(n = 335)

Absolut abstinent 18,53 %

Slips 25,56 %

episodically
31,74 %

Drinking throughout
the progression 24,15 %

modified from Lesch OM et al. 1988, Forensic Science Int.

77
6 Types, dimensions and aetiology

Fig. 40 Location and type of admission and progression (Lesch OM et al. Forensic
Science 1988)

Psychiatric hospital : 338 alcohol dependents


307 patients voluntarily
31 patients compulsory

Specilized alcohol unit: 87 patients − all voluntarily

11 patients both compulsory in the psychiatric hospital


and voluntarily in the specialized alcohol unit

There was no correlation between location and type of admission and progression.
Aftercare had a significant influence on the illness course.

Lesch OM et al. 1988, Forensic Science Int.

diction diagnosis (region A has more Aftercare had a significant influ-


than twice as many in-patient alcohol ence on the illness course (Lesch OM et
admissions than region D) had no effect al. Forensic Science 1988).
on the longitudinal progression. After a No correlation was found between
minimum of four and a maximum of the location of admission (psychiatric
seven years, the progressions were re- hospital vs. specialised addiction clin-
lated to drinking behaviour which has ic) and the further course of the illness.
led to the definition of four types of Furthermore, there was no corre-
progressions. lation between voluntarily admitted
As illustrated in Fig. 39, we were patients and patients that were ad-
able to show that 18.5 % of patients mitted involuntarily and longitudinal
were totally abstinent during the entire course (Lesch OM.1985; Lesch OM et
observation period and also did not re- al. 1988).
port any acute social-psychiatric prob- The frequency and regularity of
lems. 25.6 % reported short drinking the continuing outpatient therapy had a
episodes but no loss of control during significant influence on the longitudinal
the observation period, whereas these course. The patients who regularly kept
short relapses had no negative impact appointments more often showed good
on their mental, social or somatic well- progression, whereas patients that didn’t
being. 31.7 % showed an alternating seek help at counselling centres showed
progression which could often be ob- more frequent relapsing progressions
served at regular intervals. Even after with acute sequelae. This data clearly
in-patient treatment, 24.2 % showed no suggests that long-term support is more
change in their drinking progression important than the nature and place of
and an acute psychosocial impairment admission (Fig. 41).
with a high mortality rate.
There was no correlation between
location and type of admission and
progression.

78
Alcohol addiction – Lesch’s typology

Fig. 41 Utilisation of aftercare and illness course

Occasionally or
Regularly None Total
irregularly

Optimal 44 ↑ 10 12 66

Good 50 ↑ 29 12 91

Fluctuating 47 43 22 112
Poor 16 38 ↑ 32 ↑ 86

Total 157 120 78 355


One patient has dropped out, p < 0,0001 Lesch OM. 1983

6.3.5 Stability in the longitudinal course Figure 42 A and B illustrates the


high stability in the progression of sub-
Twelve years later, this patient group groups I, III, and IV.
was again examined during home visits When the progression of both liv-
by two independent psychiatrists. As ing and deceased patients during the
143 patients died during the second entire observation phase is included, it
observation phase, the recording of the becomes apparent that patients whose
course up until the patient’s death via disease course could be assigned to
interviews with family members and type II (slips without loss of control)
therapists was extremely important. could be reassigned to other groups

Fig. 42 A Stability of progressions

Alcohol study 1976-1982-1995


Stability of progressions (Living + deceased patients) (n=315)

good insignificant relapses undulating-cascading poor


120

100
29,1%
Number of patients

80
20,7%
1,6%
60
34,4% 50,7%
42,7%
56,3%
40 9,8%

17,1% 40,6%
20 54,1%
6,8%
19,5% 4,3%
7,8% 4,3%
0
optimal nearly good problematic poor

Progression assessment 1976-1982 p < 0,001

79
6 Types, dimensions and aetiology

Fig. 42 B Stability of illness course

Alcohol study 1976-1982-1995


Stability of progressions (Living patients) (n=181)

good insignificant relapses undulating-cascading poor


60

50 5,9%
15,7%
22,9%
Number of patients

40
45,1%
12,5%
30 56,9%
41,9%
20 21,6%
64,6%
13,7% 41,9%
10 27,5% 6,5%
13,7%
9,7%
0
optimal nearly good problematic poor

Progression assessment 1976-1982 p < 0,001

Fig. 43 Long-term course and mortality rates

Alcohol study 1976-1982-1995


Progression during the first four years and mortality prognosis (n=326)

alive 1995 deceased 1995


120

100
Number of patients

80
50,9%
38,8%
60
23,8%
56,9%
40

76,2% 61,2% 49,1%


20 43,1%

0
optimal nearly good problematic poor

Progression assessment 1976-1982 p < 0,001

80
Alcohol addiction – Lesch’s typology

over the following twelve years. Chronic 45,1 % changed to an episodic progres-
intoxications lead to symptoms, which sion and only 5,9 % shifted to a very
result in type I, III or IV classifications. negative drinking progression. Those
In later stages of the progression, patients that were classified into the
cranio-cerebral injury, caused by high other three groups (type I, III and IV)
intoxication or a withdrawal episode, during the first phase of observation
can simulate type IV progressions. The largely remained in their groups, though
social deprivation of type IV alcohol many patients from groups III and IV
addicts can lead to suicide attempts died.
during abstinence and thus need a type The severity of the disease alcohol
III classification etc. The longer the pa- addiction is demonstrated by this high
tients are damaged by the addiction, mortality rate. The fact that 8 out of 436
the more their biological sequelae and patients died during the first 24 hours of
withdrawal symptoms ressemble each admission; a further 101 (22.7 %) pa-
other. If one disregards the deceased tients died during the first four years
patients, and tests only the patients and in the following twelve years anoth-
who were still alive at the end of the er 143 patients (32.2 %) died. When this
longitudinal study, the results are much mortality rate is compared to a non-
more positive. Only 21,6 % of the type II alcohol dependent control group from
patients ended up in the group with the same borough with the help of the
good progression and insignificant re- borough’s practitioners, it shows that
lapses. 27,5 % were entirely abstinent, the lives of alcohol dependents are on

Fig. 44 Life expectancy of alcohol dependents (Lesch OM et al. 1986)

Age distribution at time of death


alcoholics versus controls
Alcoholics n=101 (mean age 50 ± 9.8 years)
25 Controls n=101 (mean age 73.9 ± 12.5 years)

20

15

10
number of deceased

0
20 30 35 40 45 50 55 60 65 70 75 80 85 90

age at time of death

81
6 Types, dimensions and aetiology

average 23. 9 years shorter than the be put into a progression group. For ex-
lifespan of the control group of the same ample, it was shown that an acute Enu-
region (Lesch OM and Walter H. 1984). resis nocturna (more than half a year,
This high mortality rate also shows socially impairing for the patient e. g.
that chronic intoxication causes acute spending the night at a friend’s house is
somatic damages, although the smok- impossible) only occurred in irregular
ing behaviour of alcohol dependents and negative progressions. Patients had
should not be underestimated (see chap- an episodic progression when a co-
ter 7.3). Furthermore this high mortality existence of Enuresis nocturna and
rate shows the severity of these somatic pre-existing psychiatric conditions (co-
damages.This is why it is so important morbidity of an affective disease before,
to start with therapy as early as possi- or independent of, drinking behaviour)
ble. There are still therapeutic drop-in or a suicide attempt, independent of al-
centres that hypothesize that in order cohol and withdrawal, was found. Pa-
to be “genuinely” motivated, patients tients with no additional co-morbidity
must first hit rock bottom. This thesis always showed a negative progression.
must clearly be rejected. The refusal of Patients with Enuresis nocturna mostly
therapy only because the patient states showed other acute dysfunctions be-
that he/she doesn’t have the motiva- fore the age of 14 such as epileptic con-
tion for a lifelong abstinence is abso- vulsions in childhood. Because of this,
lutely to be rejected in view of the high it was important that these symptoms
mortality rate of alcohol dependents were weighted in the decision tree be-
(“Look at the problem instead of look- cause symptoms like acute withdrawal
ing away”, “Rapid and sufficient help symptoms were less significant for the
instead of permanent plans”). longitudinal progression than a suicide
attempt during abstinence or epilepsy
6.3.6 The four long-term illness courses in childhood, for example. The decision
used for Lesch’s typology tree that was developed in this study
was published in 1990 (Lesch OM et al.
These four types of disease courses were 1990).
correlated with symptoms that were re- Herbert Poltnig subsequently de-
corded before and during admission veloped a computer algorithm that pro-
and were then later organized and the duced classifications by group. Data
findings weighted to form “Lesch’s ty- are entered into the computer pro-
pology” in a decision tree. gramme which is based on the decision
A total of 136 items (social, bio- tree. The programme automatically clas-
graphical, somatic, consumption be- sifies the Lesch types. In the decision
haviour, withdrawal symptoms etc.) tree the diagnostic procedure starts
were correlated with progression and it with the symptoms of type IV and only
was shown that only some items were if none of these items is present, is the
clearly related to disease progression. patient assigned to type III, I or II, ac-
When several items were related, the cording to symptoms. If the patient has
most important item was used for diag- type III symptoms, he/she is grouped
nostic purposes. Some items were so into type III, even if symptoms for type
dominant that they were sufficient to I or II are present. If no symptoms of

82
Alcohol addiction – Lesch’s typology

Fig. 45 Decision tree for Lesch’s typology

Perinatal trauma
Brain contusions
Other acute brain diseases or type IV
Acute polyneuropathy with neurological dysfunctions or
Epilepsy or
Nail biting and stuttering (for months):

Nocturnal enuresis after the age of 3: (for a longer period of time and socially
impairing) type IV or type III
In case of nocturnal enuresis:

No periodic drinking behaviour or


No sleep-maintenance insomnia or type IV
No severe depressive episode (ICD-10) or
No severe suicidal tendencies without alcohol

In case of no nocturnal enuresis:

Periodic drinking behaviour


Sleep-maintenance insomnia
Severe depressive episode (ICD-10) or type III
Severe suicidal tendencies without the influence of alcohol

Severe physical withdrawal syndrome with strong type I


vegetative withdrawal symptoms and three-dimensional tremor or
Withdrawal seizures (grand mal)

type II
Alcohol as a coping strategy or dependent personality disorder according to ICD-10

type IV and III are present, severe with- Danish, English, French, Greek, Italian,
drawal symptoms and/or withdrawal Norwegian, Portuguese, Russian). Vari-
seizures then determine whether the ous research groups have validated
patient is assigned to type I or type II. these subgroups, which were tested in
Type II is a miscellaneousgroup with no regard to their prognostic significance
symptoms of type I, III or IV, although and therapeutic procedure.
the diagnosis “alcohol dependence” ac- Today, data on typology exists in
cording to DSM-IV or ICD-10 does exist regard to various kinds of withdrawal
for this group (type II). symptoms, underlying personality char-
As international therapy centres acteristics, different craving and relapse
and research groups were keen to make mechanisms, prognosis and mortality
use of this classification system from as as well as different kinds of sequelae.
early as 1990 onwards, this tool (www. Basis research offers data on alcohol
lat-online.at) has been translated into metabolism, condensation products, ge-
several languages (Bulgarian, Czech, netic vulnerabilities, neurophysiologi-

83
6 Types, dimensions and aetiology

cal mechanisms like dynamic pupillom- New therapy methods improve


etry, imaging diagnostics and therapy the long-term course of alcohol de-
research (medication, hypnosis thera- pendent patients. Furthermore, it was
py, sociotherapeutic concepts; over- shown that 50 % of type IV patients who
view on biological data: Hillemacher T received specific therapy over a year
and Bleich S. 2008; overview on treat- were able to permanently stay absti-
ment data: Leggio et al. 2009, Zago-Go- nent (graduate dissertation Tiefengra-
mez, et al. 2009, Pombo S et al. 2009). ber D. 2008). These results were also
supported by W. Platz in Berlin, who re-
6.3.7 Results of studies using the Lesch ports a 42 % abstinence rate in group IV
typology after having received specific therapy
over two years (Platz W. 2007).
6.3.7.1 Studies on prognosis
6.3.7.2 Studies on biology and genetics
In the realm of a prospective appraisal
of the prognosis of 84 alcohol depend- A study with intoxicated alcohol de-
ents according to DSM-IV and ICD-10 pendents showed that elimination rates
in a normal therapeutic setting (after of ethanol and methanol significantly
an in-patient admission), the CAD (cu- correlate with typology (Leitner A et al.
mulative duration of abstinence) was 1994). Condensation products like the
measured. The results of the nine- norharmanes significantly correlate with
month study highlighted the typology’s typology, although this might be linked
usefulness for prognosis. Several thera- to smoking behaviour because type I
py studies using placebo groups show patients nearly almost always smoke
that the prognosis clearly depends on (Fagerstroem-positive) (Leitner A et al.
typology (Walter et al. 2001; Lesch et al. 1994). Another study, in which alcohol
1996, 2001; Kiefer et al. 2005). After dependents with or without polyneu-
three months, type II patients show the ropathy were examined, showed that
best abstinence rates, type I patients patients with acute polyneuropathy
are either abstinent or suffer from an (type IV-patients) eliminated ethanol
acute relapse (loss of control), while and methanol at a significantly slower
type IV-patients only rarely change rate than patients with no polyneurop-
their drinking behaviour even after athy (type I, II or III patients). These
therapy. Therefore in regard to forming results suggest that ethanol and me-
a psychiatric opinion, Lesch’s typology thanol are linked to peripheral nerve
is recommended as a parameter for a damages, while central symptoms (with-
successful prognosis and its therapeu- drawal symptoms or withdrawal at-
tic recommendations (Platz W. 2007). tacks) are mainly linked to aldehydes
Gender differences have been found in that are centrally active. For many years
the progression of alcohol dependents. alcohol addiction has been associated
As there are significantly more women with increased homocysteine levels
belonging to the type III group of pa- (Hultberg B et al. 1993; Bleich S et al.
tients, and more men in the type IV 2004). Homocysteine is intensively dis-
group, these differences should be tak- cussed in regard to damages to the car-
en into account in therapy. diovascular system (Stanger O et al.

84
Alcohol addiction – Lesch’s typology

2001) although the mechanisms are not F et al. 2003; Kim DJ et al. 2005; Kraus T
entirely clear (De Bree A et al. 2002). In et al. 2005; Addolorato G et al. 2006).
2004 Bleich was able to show that the Hillemacher has pointed to a positive
homocysteine level is only heightened correlation between leptin and Lesch’s
in intoxicated type I patients with or type I-and type II alcohol dependents,
without epileptic withdrawal convul- whereas ghrelin only significantly cor-
sions. These high levels rapidly de- related with Lesch’s type I (Hillemacher
crease during abstinence or can be re- T et al. 2007).
duced with folic acid therapy if drinking In 1988 Gruenberger J et al. showed
behaviour is continued (Bleich et al. that the four types of alcohol depend-
2004). An unpublished study found that ent patients are significantly different
especially type I dependents are admit- in the assessment with dynamic pupil-
ted to cardiologic units. Kiefer F was lometry, indicating differences in ace-
able to support the notion that only tylcholinergic activities (Gruenberger J
type I patients benefit from Acampro- et al. 1988, 2007). The spontaneous
sate. This suggests that homocysteine fluctuation of the pupil’s diameter,
could be a biological indicator for a maximal pupil contraction and the ab-
successful response to Acamprosate as solute change were measured in 117
a relapse prophylaxis in alcohol-related female and male typologically classified
heart diseases (Kiefer F et al. 2005). alcohol dependents by means of Josef
Genetic studies from various cen- Gruenberger’s dynamic pupillometry.
tres show significant differences be- These participants were then compared
tween the types (Samochowiec J et al. to 107 control participants (no psychi-
2007; Saffroy R et al. 2004; Boensch D et atric diagnosis and alcohol abuse).
al. 2006). Lesch’s type I patients differed from
Neuroendocrinological studies both the other types and the control
showed that the HPA-axis is linked to group. In type II and type III, signifi-
drinking behaviour, withdrawal, and cantly fewer spontaneous fluctuations
craving during abstinence (Hillemacher could be observed in comparison to the
T et al. 2007; Kiefer F et al. 2001a/2001b, control group. All types significantly
2005). CRH-and ACTH-changes are as- differed from the control group with re-
sociated with craving. Prolactin, which gards to an absolute change, whereas
is closely related to dopaminergic func- type I was characterized by the highest
tions, is also highly significant in regard absolute change. During the last two
to craving. Hillemacher was able to years, these differences were examined
show that especially in the case of type in 300 alcoholics and the first results
II alcohol dependents, intensity of crav- were largely confirmed (presentation
ing and changes in prolactin levels go ESBRA 2007, publication in preparation,
hand in hand (Hillemacher T et al. 2006). Friedrich F, et al. 2010 in preparation).
Another important aspect is the rela-
tionship between leptin and ghrelin
6.3.7.3. Relapse prevention studies,
and the regulation of the intensity of
anti-craving substances
hunger and appetite. Inconsistent fin-
dings exist in the literature (Kiefer F et In 2006 Hillemacher et al. examined al-
al. 2001a,b; Nicolas JM et al. 2001; Wurst cohol dependents that were classified

85
6 Types, dimensions and aetiology

Fig. 46 Craving with regards to Lesch’s typology (Hillemacher T et al. 2006)

Mean Values
Lesch Type 1 Lesch Type 2 Lesch Type 3 Lesch Type 4 Population
(N = 37) (N = 94) (N = 38) (N = 23) (N = 192)
OCDS Totala 17,4 ± 7,3 21,0 ± 7,2 19,0 ± 7,9 24,3 ± 6,9 20,3 ± 7,6
OCDS Activity 6,8 ± 3,7 8,8 ± 4,8 7,7 ± 5,0 9,8 ± 5,3 8,3 ± 4,9
OCDS 10,5 ± 3,7 12,1 ± 3,5 11,3 ± 3,6 14,5 ± 3,2 12,0 ± 3,7
Compulsive thoughtsa
Age (years) 43,3 ± 8,8 43,9 ± 9,0 44,8 ± 8,2 41,4 ± 9,3 43,7 ± 8,8
Onset of disease (years) 25,8 ± 10,6 26,2 ± 9,2 24,9 ± 9,5 22,4 ± 8,1 25,4 ± 9,4
Number of previous 9,0 ± 10,4 8,2 ± 10,1 14,7 ± 29,1 18,8 ± 17,1 10,9 ± 16,8
detoxificationa
Daily intake in g 217,9 ± 123,3 263,3 ± 219,0 233,9 ± 190,0 230,1 ± 108,6 244,8 ± 186,9
a
significant differences between the types according to Lesch examined by the Kruskal-Wallis-Test for
independent samples (OCDS total score Chi-square p < 0,05)

according to Lesch’s typology in regard al symptoms and correlated with the


to different craving mechanisms. By most severe craving symptoms. A sig-
using Anton’s OCDS (Anton RF et al. nificant relationship between craving
1995), they were able to show that type and the number of earlier detoxifica-
IV had the highest craving-scores. Fur- tions could only be found in type I,
thermore type II had higher craving Fig. 46, (Hillemacher T et al. 2006).
scores than type I and III. Type IV had There are different opinions about
the highest number of acute withdraw- the craving mechanisms of Lesch’s types.

Fig. 47 Craving according to Lesch’s typology and scientific hypotheses of craving


(Walter et al, 2006)

Type I – The effect of alcohol on withdrawal symptoms


(Neuroadaptation)

Type II – Alcohol as an anxiolytic


(social learning and cognitive models)

Type III – Alcohol as an antidepressant

Type IV – Alcohol as an impulse control disorder and/or


a compulsion with previous cerebral damage,
alcohol to cope with social situations
(socio-cultural-organic model)

86
Alcohol addiction – Lesch’s typology

Individual subgroups use alcohol as a reduces the amount of alcohol con-


sedative, anti-depressant or as medi- sumed and the duration of periods of
cation against withdrawal symptoms. drinking. Therefore it can be suggested
These different effects and their possible that abstinent progressions, namely
biological aetiologies have been sum- type I and II, can be influenced by acam-
marized in 1997. From this, the following prosate, while naltrexone has a better
considerations for research in regard to effect for sporadic or permanent drink-
animal models and clinical therapy re- ing progressions. Based upon this, Dav-
search can be suggested, Fig. 47, (Lesch id Sinclair administers naltrexone as a
OM et al. 1997): so called “extinction method” in alco-
These considerations suggest that hol dependents (Sinclair JD. 2001). In a
different etiological vulnerabilities need placebo-controlled acamprosate study,
different pharmacological and psycho- in which alcohol dependents received
therapeutic therapies. Relapse preven- acamprosate over a 1 year period, our
tion studies with disulfiram, acampro- research group was able to demon-
sate, naltrexone, flupentixol, baclofene strate that acamprosate only signifi-
and neramexane clearly showed that cantly improves abstinence in type I and
the relapse rate can be both positively type II (Lesch et al. 1996). In a three-
and negatively influenced by each indi- monthly acamprosate-naltrexone-pla-
vidual medication. Acamprosate and cebo study in 2005, Kiefer F et al.
naltrexone are internationally used as showed that acamprosate is only effec-
anti-craving substances. Animal stud- tive in type I, because after three months
ies clearly show that acamprosate im- the abstinence rate in type II patients is
proves abstinence, while naltrexone still satisfactory and no medication is

Fig. 48 Acamprosate as a relapse prophylaxis in alcohol dependents and Lesch’s


typology

87
6 Types, dimensions and aetiology

Fig. 49 Acamprosate and naltrexone as relapse prophylaxis in alcohol dependents


according to Lesch’s typology

effective. Type III and IV can be signifi- pentixol study (D2-antagonist) was
cantly improved by naltrexone, which carried out under the direction of Wies-
suggests that a combination of naltrex- beck G and it was shown that particu-
on and acamprosate significantly wors- larly type I-and type III patients had a
ens the results in type III and IV. A flu- higher relapse rate with flupentixol than

88
Alcohol addiction – Lesch’s typology

Fig. 50 Flupentixol as relapse prophylaxis in alcohol dependents according to Lesch’s


typology

with placebo (Wiesbeck G et al. 2001; demonstrated that hypnotherapeutic


Walter H et al. 2001). groups are best suited for Lesch’s type
Neramexane (NMDA-antagonist) II-and type III patients (Hertling I et al.
worsened the progression in type III, 2002).
while it didn’t have an impact on type I, Summerizing our results and in-
II and IV (unpublished data). cluding our experience of 20 years prac-
CB1-antagonists or SSRIs like tical work with withdrawal and relapse
Ritansarin showed no changes in drink- prevention treatment we recommend
ing behaviour and also no differences the following medication (Fig. 51, Lesch
in regard to typology (unpublished et al. 2010)
studies, Soyka M. et al. 2008).
In conclusion, there are data on 6.3.7.4. Other results regarding Lesch’s
relapse prophylaxis in regard to typol- typology
ogy for various medications and this
is why our recommendations for re- Sequelae are also expected to differ
lapse prophylaxis medication are always among types, which explains why the
made in accord with typologies. As the frequency of types admitted into differ-
symptomatic of withdrawal symptoms ent therapeutic settings clearly differs.
differ with types, withdrawal symptoms Alcoholics that receive psychiatric ther-
should also be treated differently. apy have already been typologically de-
From the psychotherapeutic field, scribed (type I 18.53 %, type II 25.56 %,
only studies on hypnosis therapy are type III 31.74 %, type IV 24.15%). Sper-
available in regard to typology. It was ling et al. have examined the distribu-

89
6 Types, dimensions and aetiology

Fig. 51 Overview medication for alcohol dependence according to types

Summary of the pharmacotherapy


according to the typology of Lesch

Naltrexone, Antidepressants e.g.


Milnacipran, Sertaline, Carbama-
zepine, Gamma-Hydroxy-Butyric
Acid, Cave: D1-Antagonists,
Topiramate ???
Naltrexone, Nootropics, Gamma-
Hydroxy-Butyric Acid, Atypical Neu-
roleptics, Ondansetrone ???
Lesch an Soyka, 2010

tion of types in regard to gender and show that 49 % of type IV patients, 38 %


found that type III prevails more fre- of type III patients and 13 % of type II
quently among women, whereas type patients were detained in these pris-
IV is more frequent in men (Sperling W. ons. No single type I patient was as-
et al. 1999). sessed in prison. Contrary to this, she
The types also differ as regards se- showed that more type I-and type II
quelae, like the severity of liver disease patients than type III-and type IV pa-
or biological markers. Wirnsberger et tients were admitted to a specific in-
al. examined 333 alcohol dependents patient addiction therapy centre (An-
(according to ICD-10 and DSM-IV) (172 ton-Proksch-Institute). Mainly type III
men and 161 women) who were in-pa- patients were admitted to psychiatric
tients at the psychiatric hospital in Vi- hospitals. A German research group ex-
enna. Liver damage was significantly amined alcohol dependents that com-
severer in Type I and type IV than in mitted murder and found that offend-
type II and III (Wirnsberger et al. ES- ers were mostly type II, type III and type
BRA 2007). IV patients. In this case, type II patients
Our study of 509 alcohol depend- were usually first offenders, whereas
ents according to DSM-IV was not able type III and type IV patients had already
to find a relationship between typology previously committed criminal acts
and exposure to alcoholism in the fam- (Reulbach U et al. 2007). Today we are
ily (unpublished studies). convinced that differences in therapy
In her graduate dissertation, Bar- between various care institutions (emer-
bara Koenig investigated the classifica- gency units, internal surgery depart-
tion of types in prisons and was able to ments, psychiatric departments, prisons,

90
Alcohol addiction – Lesch’s typology

Fig. 52 Gender distribution

Fig. 53 Mean value of liver function and % CDT in regard to Lesch’s typology

ALAT U/I ASAT U/I

Type I

Type II

Type III

Type IV

Signifikance

homeless shelters or specific addic- 6.3.8 Lesch’s typology from an internatio-


tion hospitals) are due to the fact that nal comparative perspective
different subgroups of alcohol depend-
ents, as defined by Lesch, are treated All typologies in alcohol dependents
in different institutions. In his article, overlap to a certain extent. Typologies
Wetschka Ch. discusses which socio- that differentiate two subgroups (e. g.
therapeutic concepts should be recom- Cloninger CR and Babor TF) are often
mended for type IV and type III groups described more precisely by typologies
(see chapter 10). that define four subgroups. The onsetof

91
6 Types, dimensions and aetiology

an alcohol dependence, which Clonin- factors which solely, or in interaction,


ger CR and Babor TF describe as a fun- cause a relapse, it shows that there are
damental factor, does not play an im- also other important dimensions (Fig.
portant role in Schuckit’s MA or Lesch’s 55). Lesch developed a structured inter-
OM typology. The so called “primary view including all these important
alcoholism” according to Schuckit is items. One page of this instrument is
represented by Lesch’s type I and IV, used for the assessment for Lesch typol-
whereas the “secondary alcoholism” ac- ogy (www.lat-online.at).
cording to Schuckit is in line with Lesch’s When factors described by the
type II and III. Figure 54 illustrates that pathway analysis are linked to current
those typologies which are divided into literature on relapse prophylaxis, it be-
four subgroups, show a clear concord- comes clear that social or family-relat-
ance. Mild and episodic disease pro- ed factors play an important role along-
gressions, as well as the progression ac- side the typologies. Our survey tool
companied by social problems, are (PC-version) includes one page that ex-
mirrored by the respective types ac- clusively tackles typology. All other pages
cording to Lesch, namely type II (mild deal with factors which have been de-
progression), III (episodic progression) scribed by the pathway analysis and in
and IV (negative progression). Lesch’s relapse prophylaxis literature (Fig. 55).
type I, which is only defined by regular For several years we have been carrying
and high amounts of drinking with out research in which we use the PC-ver-
acute withdrawal symptoms and/or sion of this survey tool and try to cor-
withdrawal seizures, has no matching relate other factors with the typologies.
typologies (US and England). Typolo- The computerized survey tools
gies originating from the US and Eng- (www.lat-online.at – Lesch Alcoholism
land always include a group of polytox- Typology) for a precise assessment of
icomanics. In those countries, Lesch’s alcohol dependents (according to crite-
type I patients might fall into the group ria like onset of addiction, genetic vul-
of polytoxicomanics. In Portugal, Car- nerabilities and typology) can be found
doso showed a significant correlation in Appendix 1.
between the Neter-typology and types
II, III and IV according to Lesch, but he 6.4 The relationship between
also defined a group of very young poly- alcohol dependent patients accor-
toxicomanics as a separate subgroup
ding to Lesch’s typology and the
(Cardoso Neves JM et al. 2006; Prombo
S et al. 2008). Alongside this typological
severity of tobacco addiction
classification, other factors play an im- As alcohol and tobacco are often con-
portant role. As depicted by many other sumed in combination, it makes sense
studies, the onset of the alcohol addic- to use Lesch’s Alcoholism Typology (LAT)
tion, genetic vulnerabilities and an an- together with the European Smoker
tisocial personality disorder seem to be Classification Scale. Our research group
important factors, significant for thera- was able to show that the intensity of
py and progression. If, however, a path- craving was significantly stronger when
way analysis is carried out on alcohol the individual was abusing both alco-
dependents in order to determine the hol and nicotine than when only one

92
The relationship between alcohol dependent patients
according to Lesch’s typology and the severity of tobacco addiction

Fig. 54 Comparison of different typologies

Fig. 55 Factors influencing relapse, presented by a pathway analysis

93
6 Types, dimensions and aetiology

addiction was present (Hertling I et al. hol dependents with tobacco addiction
2005). This increase in craving was score positive on the Fagerstroem-scale.
found in all forms of craving. Alcohol We assume that tobacco ingredients
dependent smokers showed depressive are used as a drug substitute by type I
symptoms and sleep disorders signifi- and type IV alcohol dependents, where-
cantly more often, whereas nicotine de- as type III-patients use both alcohol and
pendents who didn’t abuse alcohol tobacco as therapy for their basic dys-
mainly smoked for weight control and function. These considerations should
to cope with stress. Especially type I, furthermore be integrated into thera-
type III and type IV but not type II alco- py.

94
7
Motives for alcohol-and/or
tobacco addicted patients to seek
medical help
7.1 Tobacco addiction actual disease, this disease should be
treated primarily. The patient should
60 % of tobacco dependents describe feel that there is interest in his well-be-
themselves as “dissonant” smokers. They ing and that there are people to help
try temporarily or permanently to re- him get a better quality of life. This mo-
duce their smoking or even try to quit. tivational work takes time and a number
Knowing that smoking leads to seque- of appointments are required. The link-
lae, knowing their withdrawal symp- age to a therapy centre, a regular check-
toms, this group often needs an impulse up at the practitioner’s or with an ap-
from the social environment (partner, propriate medical specialist should be
work place etc.) or somatic symptoms the first goal. After a therapist has been
(shortness of breath, stomach pain, contacted, an exact date for the reduc-
pregnancy etc.) to quit. By contacting a tion or abstinence of smoking should
therapist, the dissonant smoker group be set and a clear goal should be for-
shows that they have realized their nic- mulated. The therapeutic procedure for
otine problem. When these individuals reaching this goal should be accepted
get effective help, they are easy to moti- by patient and therapist and should be
vate to reduce or even quit smoking. realistic. Withdrawal symptoms should
About 40 % of tobacco dependents be treated in order to cause as little
are “consonant” smokers. They perceive brain damage as possible (nicotine sub-
smoking as an important part of their stitution therapy e. g. with the right
life and think that every therapy de- supplement at a well combined, suffi-
prives them of something pleasurable. cient dosage). Relapse prevention and
This group starts therapy during a later withdrawal symptoms will be discussed
phase of their dependence develop- in more depth in the section on therapy
ment. They never seek help voluntarily (Lesch OM. 2007).
but only when forced by external fac-
tors (e. g. smoking ban at work or so- 7.2 Alcohol addiction
matic sequelae that are connected to
smoking: COPD, stroke etc.) to change We assume that the majority of alcohol-
their smoking habit. addicted patients meet the diagnosis
In this group, education about the criteria for an alcohol addiction already
relationship between tobacco ingredi- during adolescence. We could show
ents and their present diseases is ex- that, for example, 3.2 % of 18-year-old
tremely important. In the case of an men have already “reached” the diag-

95
7 Motives for alcohol-and/or tobacco addicted patients to seek medical help

nostic for an alcohol addiction (Kapus- cepted, an absolute abstinence until


ta ND et al. 2006, 2007). As drinking is the next appointment (preferably no
an accepted behaviour in wine produc- later than seven days). The possibility
ing countries, alcohol dependents drink of relapses occurring during this time
many years before they notice that they should also be discussed. The patient is
have alcohol-related health problems asked to describe these relapses so that
or problems with the partner, or at better therapeutic strategies can be of-
work, or with their driving license. In fered. If these patients desperately want
the beginning high amounts of drink- an in-patient admission, their wish
ing are usually admired by the environ- should definitely be granted, but they
ment and it takes many years until it is should only be transferred to institu-
realised that the alcohol dependent in- tions that offer stable psychotherapeu-
dividual has a serious alcohol problem. tic support after a short (up to 14 days)
The environment and also the employ- in-patient stay. It is recommended that
er usually react with control and rules, one specific person or a selected team
which the individual often can’t follow. should be in charge of counselling be-
This process also lasts several years fore, during and after in-patient admis-
and only when health problems set in sion. The principle “out-patient care
(sequelae, withdrawal symptoms or comes prior to in-patient care” is of
even withdrawal seizures) is the patient course also valid for alcohol dependent
forced by the environment to consult a patients. Rigid and lengthy therapy
doctor, psychotherapist or psycholo- concepts and rules, which serve the in-
gist. This means that at the initial meet- stitution rather than the patient, should
ing the patient expects “to hear new be rejected.
rules” which he knows he/she probably If pressure from the closer envi-
won’t be able to follow. ronment enforce the treatment, the pa-
The diagnostic process should be tient should primarily be treated out-
started immediately if the patient comes side of this environment structure. If
to treatment without any sequelae and problems with the partner play a pivotal
no severe intoxication. The patient’s role, it is important to first establish a
history should also be explored in terms trusting bond with the patient. Conver-
of whether there have been any lengthy sations and therapeutic concepts that
periods of abstinence. If there have incorporate the partner should be in-
been, the patient should be questioned troduced later (e. g. five one-hour meet-
about what helped him to stay abstinent. ings with the patients and the sixth ses-
This might represent a strategy, which sion with the partner on the patient’s
could be followed again in therapy. approval). In the case of pressure from
The severity of the expected with- the workplace, clear rules should be for-
drawal syndrome should be explored. mulated regarding which information
The majority of patients have experi- should be provided to the employer or
enced several withdrawals without ther- to the labour union. The patient’s con-
apy and are able to describe this experi- sent is needed if the cost of treatment is
ence very well (see chapter 9.1). The covered by the employer, or if the em-
primary therapy goal should be the re- ployer requires regular therapy reports.
duction of drinking behaviour or, if ac- Yet, defined rules have a positive thera-

96
Sequelae that bring patients into therapy

peutic effect for this relationship (pa- When patients feel that their se-
tient-doctor-employee). If the loss of a quelae have been treated adequately,
driving licence is the main reason for they are often also motivated to seek
treatment, a prognosis can be made for treatment for their alcohol dependence.
alcohol dependents according to type Patient information and a clear therapy
after three or nine months and it is sug- concept are beneficial in helping pa-
gested that the driving licence be is- tients. If they are sent to another insti-
sued for a limited period of two years. tution for treatment, patients often feel
Here the patient should provide a ther- very disappointed and usually termi-
apy report in order to be eligible to drive nate therapy. For these patients, in-
a car. patient withdrawal therapy is usually
If the motivation for receiving ther- not required. Often regular outpatient
apy is influenced by sequelae, the proce- appointments and therapeutic strate-
dure needs to be modified according to gies according to Lesch’s typology are
the severity of the sequelae. Decompen- enough.
sated liver cirrhosis or a metastasising
carcinoma requires a different treatment 7.3 Sequelae that bring patients
procedure than slightly elevated liver
into therapy
functions or mild anaemia. It is suggest-
ed that therapy is carried out in the spe- 7.3.1 Tobacco and sequelae
cific department which is treating the
sequelae (e. g. individuals with a liver 7.3.1.1 Introduction
disease should receive gastroenterologi-
cal treatment or heart patients cardio- Tobacco and its ingredients impair vir-
logical treatment first). At these special- tually all bodily functions and all fields
ized departments, an addiction therapist of medical specialisation refer to the
or a psychiatrist who has a liaison with partial aetiology of “smoking”. In 2007,
this department should be available. we described these damages in more
At the clinical department for depth in a collection of essays but not all
transplantation and the clinical depart- disciplines were considered. In Austria,
ment for gastroenterology and hepatol- 8 million inhabitants, around 14,000
ogy, in collaboration with the out- deaths per year are related to tobacco
patient centre for alcohol related health abuse. The combination of tobacco and
problems, together with a ward for cri- alcohol abuse with overweight and little
sis intervention at the University Hos- exercise is in fact life shortening.
pital for Psychiatry in Vienna, we were
able to show that this type of provision
7.3.1.2 Tobacco and neurology
leads to improvement and also to clear-
er indications for transplantation. In a Smoking belongs to the most modifia-
few studies, we were also able to show ble risk factors for diabetes mellitus or
that this concept not only improves ab- arterial hypertonia or alcohol abuse.
stinence rates, but also the quality of When smoking, the risk of an ischemic
life of those affected with liver disease stroke is doubled and a total of 25 % of
(Berlakovich GA et al. 1999; Baischer W all strokes are directly or indirectly
et al. 1995). linked to smoking. Smoking potenti-

97
7 Motives for alcohol-and/or tobacco addicted patients to seek medical help

ates the risks of other factors such as al. 2004). At the Mayo Clinic, the influ-
the consumption of oral contracep- ence of smoking and the risk of myo-
tives. cardial infarction and death after trans-
As passive smoking also increases dermal coronary intervention (PCI)
the risks in a similar way to active smok- were examined. After PCI and quitting
ing, it can be assumed that there is a smoking the risk had been completely
“threshold” which increases the risk normalised. In PCI-patients, smoking
and that the dose response relationship led to an increase of risk of myocardial
is not linear. After a stroke, a smoke- infarction (MI) (+ 108 %) and cardiovas-
free lifestyle significantly decreases the cular death (+ 76 %) (Hasdai D et al.
risk of another stroke. Giving up smok- 1997). Similar studies exist for aortic
ing is clearly more effective than pre- aneurysm, peripheral arterial obstruc-
vention with aspirin. After as little as tive disease and for diabetes type II. In
twelve months of abstinence, a 50 % re- obesity research, the metabolic syn-
duced vascular risk can be observed drome and the interaction between
and, after a further five years without smoking, depression, alcohol and obes-
smoking, the risk for vascular diseases ity plays a major role. A regular increase
is almost as low as it is for a non-smok- in weight in regard to age is linear. This
er. (Sander D et al. 2006; Goldstein LB linear curve increases with adverse life
et al. 2006; Wold PA et al. 1988). situations and severe stress causes epi-
sodic increases in weight (Melis T et al.
2007; Unachuku CN. 2006).
7.3.1.3 Tobacco and internal medicine
7.3.1.3.2 Pulmonary diseases
7.3.1.3.1 Heart diseases and circulatory Tobacco withdrawal is the most impor-
disorders tant and the only effective pneumologi-
Everyone knows that smoking causes cal therapy. In Austria, smokers face an
heart attacks and the commonly used average shortening of life by 23 years.
term “smoker’s leg” suggests that indi- In Austria in the year 2000, around
viduals are well aware that smoking 2,700 smokers died of a bronchus carci-
causes peripheral arterial obstructive noma and around 1,000 of COPD (Vu-
disease. The INTERHEART study shows tuc C et al. 2004). Since 1970, the bron-
that 36 % of primary heart attacks are chus carcinoma mortality rate in women
caused by smoking (Yusuf S et al. 2004). has doubled. Even with acute COPD,
There are also clear gender differences. quitting smoking significantly improves
A man who smokes 20 cigarettes daily the progression. Patients might not fully
increases his risk of a heart attack by recover their health but the process and
three times. Women between the age of worsening of the respiratory disease
35 and 52 who smoke increase their risk can at least be slowed down.
of a heart attack by six times (Bolego C
et al. 2002). The cigarettes smoked daily
7.3.1.4 Oncological diseases
show a linear relationship to the fre-
quency of heart attacks. The more ciga- Besides the previously discussed bron-
rettes smoked, the higher the risk of an chus carcinoma, smoking also signifi-
acute myocardial infarction (Yusuf S et cantly increases the risk for other carci-

98
Sequelae that bring patients into therapy

noma. This is the case for all kind of and other alcohols. Methanol, in par-
cancer (breast, prostate etc.) but clear ticular, seems to be an important factor
data exists in particular regarding an in cerebral damage. Depending on the
increased risk for larynx, pharynx and type of alcohol beverage, there are mil-
mouth cancer. Smoking increases the ligram or gram dosages of methanol in
risk for these carcinoma by 24 times one litre (see Fig. 5).
and the risk for oesophagus by 7.5 Ethanol and other concomitant
times. A smoke-free life can improve the substances change haematopoesis, fat
progression of these severe carcinoma. metabolism and also all other metab-
olism processes. An enlargement of
erythrocytes, elevated blood lipids and
7.3.1.5 Dentistry
elevated uric acid with retarded blood
Apart from the ugly smoker’s plaque clotting and pathological liver func-
and periodontitis, smoking also plays a tions are all related to alcohol. The hu-
role in tooth transplantations (Ness L et man’s immune system is weakened by
al. 1977). The healing processes in the alcohol abuse. In the literature, small
mouth area, are considerably slowed amounts of alcohol are often consid-
down by smoking (Tonetti MS et al. ered healthy. This perspective is only
1995; Trombelli L et al. 1999; AAP 2005). valid for healthy patients who have
The increased risk for oral cancer has never abused alcohol before or only
already been pointed out. temporarily. From our experience, we
know that there are only very few indi-
viduals who do not drink increased
7.3.1.6 Psychiatry
amounts of alcohol over a longer peri-
Individuals with a schizophrenic psy- od of time during adolescence or after-
chosis often heavily abuse tobacco dur- wards. The alcohol-related change in
ing neuroleptic treatment. Tobacco de- diet (lots of fat and meat, few vegeta-
creases the blood level of neuroleptics bles and fruits) is an important factor
and is also effective against the extrapy- in somatic damage (e. g. lack of thia-
ramidal side effects of classic neurolep- mine). In an epidemiological study in
tics. Nicotine acts as a dopamine ago- Austria, we were able to show that 29 %
nist and thus has antidepressant effects. of all admissions to units for internal
Patients with a schizoaffective psycho- medicine abused alcohol, which could
sis often smoke to elevate their mood. be objectified by an elevated % CDT. In
the case of planned surgeries, 12 % of
7.3.2 Alcohol and sequelae patients admitted showed an elevat-
ed % CDT level (Lesch OM et al. 1996).
7.3.2.1 Introduction This is also the fact when % CDT levels
are measured at a surgical intensive
Depending on duration of consump- care unit. In Berlin it was found that
tion and drinking behaviour (dosage, patients with elevated % CDT were
daily alcohol consumption, temporary more likely to develop somatic prob-
binge drinking), alcohol damages all lems than patients with a low % CDT.
organs. Alcoholic beverages do not only Patients with increased % CDT also
consist of ethanol, but also of methanol showed a doubled length of stay in hos-

99
7 Motives for alcohol-and/or tobacco addicted patients to seek medical help

Fig. 56 Number of alcohol abusers in general medical practice 2,000 patients


Lesch E et al., unpublished data

1.000 men 1.000 women

Health damaging amounts of alcohol, without any indication of addiction


Alcohol problem, but no addiction
Alcohol addiction

pital (Spiess C et al. 2000). A quarter of When alcohol dependent patients


the patients seen by general praction- are compared to a healthy population,
ers are treated for alcohol abuse, in life expectancy in the former is short-
which clear gender differences exist. ened by 23.9 years. The control group
Alcohol dependent patients who was recruited from general practition-
don’t change their drinking behaviour ers. These patients were recruited from
after an in-patient treatment (type III- the same catchment area as the alcohol
and type IV progressions) need signifi- patients (see Fig. 44).
cantly more in-patient admission at a As already documented in the
somatic ward than type I-or II course. longitudinal study, twice as many type

Fig. 57 Alcohol study 1976–1982–1995

Alkohol study 1976-1982-1995


Number of hospitalizations (1983-1995)
(n = 181)

100
Sequelae that bring patients into therapy

Fig. 58 Mortality and alcohol (illness course of 5,766 workers, with 1,643 persons
dying within 21 years)

mortality – alcohol use


All fatalities
Mortality assessed according to risk groups

Group of A (p = 0,0003)
Group of B (p = 0,12)
Group of C (p = 0,22)

A = in regard to age

B = in regard to age, smoking, cholesterol,


BMI, adjusted FEV, social class (six
groups) father’s social class
(six groups), education, use of car,
twins, loss of social status, Angina
pectoris, Ischemia in ECG, Bronchitis.

C = in regard to age, smoking, cholesterol,


BMI, adjusted FEV, social class (six
groups), father’s social class (six
groups), education, lack of exercise,
twins, loss of social status, Angina
pectoris, Ischiemia in ECG, Bronchitis,
RR diastolic.

Alcohol intake in U/week 1U = 10 g pure alcohol

III-and type IV patients die as type I pa- entered as a search criterion into e. g.
tients (see Fig. 43). the “British Medical Journal” more than
Alcohol increases mortality rates 2,700 publications are listed. There is
in a dosage dependent way. The in- virtually no medical journal which does
crease in alcohol abuse especially with not contain articles on alcohol. Due to
fuel or bootleg alcohols (e. g. in Russia) the high number of publications, most
has lead to a clear reduction of life ex- textbooks concentrate on a few of the
pectancies in Russia (Alcohol kills Rus- most important medical manifesta-
sian working men, Haaga JV et al. 1997; tions and we have had to do the same
Ogurtsov PP et al. 2001). in this textbook although we are well
In a study on Scottish workers that aware that, in so doing, some very im-
considered educational levels and oth- portant aspects have been neglected.
er risk factors, researchers were able The European Society for Biomedical
to demonstrate that the total mortal- Research on Alcoholism (ESBRA, www.
ity rate was related to dosage in its esbra.com), the International Society
progression. A very low dosage showed for Addiction Medicine and many oth-
a levelled progression, but mortality rates ers emphasize the importance of alco-
increased with a dosage of three-eighths hol abuse and alcohol addiction in all
of a litre of wine daily or 21-eighths per medical disciplines and are attempting
week (factors Hart C et al. 2007; Smith D to create programmes that consider the
et al. 1998; Fig. 58). sub-aetiology of alcoholism in most
In almost all somatic disciplines, somatic diseases. In some disciplines,
it is highlighted that alcohol is a risk the diseases caused by alcohol have al-
factor and when the term “alcohol” is ready been clearly described (Ranging

101
7 Motives for alcohol-and/or tobacco addicted patients to seek medical help

from Wernicke’s Encephalopathy, Alco- in different forms during alcohol in-


holic Amblyopathy, Alcoholic Cardio- toxication, depending on the amount,
myopathy to the Holiday Heart Syn- and rapidity, of alcohol drunk. Large
drome, Johnson BA et al. 2003). amounts of alcohol consumed very
quickly (drinking contests with e. g. 1 l
Vodkas), can result in a loss of con-
7.3.2.2 Alcohol’s signicance for neurology
sciousness with different coma stages,
and psychiatry
which can be life threatening. A dim-
As already highlighted, alcohol changes ming of consciousness is not the domi-
all functions in all cerebral circuits. nant factor when alcohol is slowly re-
Both intoxication and withdrawal im- sorbed. Here the significant factors are
pair the neuronal membranes. Neuro- psychomotor changes and the con-
nal damage is not only caused by alco- comitant symptomatic transitory psy-
hol and its aldehydes but also through chotic syndrome (Wieck HH. 1956).
malnutrition (especially vitamin defi- Chronic alcohol intoxication leads
ciency) and craniocerebral injury. Pre- to a reduction of neuropsychological
vious cerebral damage (hypoxia during performance (different functions of in-
birth, cerebral traumata with neuro- telligence, such as thinking, associating
logical deficits, childhood epilepsies) and memory performance). Psycho-
sensitise the brain for alcohol. It is now pathological reactions might set in, de-
known that severe mnestic disorders pending on the severity of this reduced
are frequent in groups with previous performance. Sensitivity to light and
impairments (Lesch’s type IV). Further- noise together with an emotional irrita-
more, the “symptomatic transitory psy- bility (e. g. dysphoria in the morning
chotic syndrome”see page 7, 8 manifests after an alcohol overdose the night be-

Fig. 59 Progression of development and remission in steps

Transitional Organic Impairment


Steps of Development and recovery

delirium
paranoid ideas, hallucinating
Mood changes
Emotionally instable, irritable

reduction in cognitive
performance

102
Sequelae that bring patients into therapy

fore) occur. During severe impairment, The recovery of delirant patterns that
virtually all patients react with affective are caused by alcohol takes approxi-
symptoms which are characterized by mately six weeks until the point when
dysfunctions in chronobiology (sleep no more psychopathological patterns
disorders) and changes in drive and exist.
mood. If a reduction of performance
due to intoxication or illness continues,
7.3.2.3 Alcohol and psychiatric disorders
the patient’s perception changes and
he might experience subjective delu- As already highlighted in chapter 6.1.1,
sional interpretations, often reflected other DSM-IV axis-I-diagnoses are of-
by changing affectivity. These delusion- ten present in the course of alcohol de-
al elements often lead to a paranoid- pendence. Schizophrenic patients rarely
hallucinatory syndrome. Hallucination regularly drink alcohol. 10 % of these
may also manifest. If performance is patients discover that alcohol has phar-
furthermore reduced, confusion and macologically positive effects which
severe anxiety with hallucinations can help them to cope with their psycho-
be observed. This condition is called logical symptoms. Patients with severe
“delirant symptomatic transitory psy- affective and cognitive “filter” dysfunc-
chotic syndrome”, which is often com- tions suffer immensely from stimulus
plicated by vegetative syndromes and in overflow and notice that alcohol helps
20 % by epileptic seizures. Delirant syn- them to tolerate this overstimulation.
dromes without vegetative syndromes As alcohol changes the dopamine re-
are not usually caused by alcohol but ceptors, these patients are therefore
rather by other organic disorders. Fur- more sensitive to neuroleptics that af-
ther impairments lead to a clouding of fect D2 receptors. Often severe extrapy-
consciousness up to the point of coma ramidal side effects occur. This patient
(all neurological levels). The recovery of group especially benefits from atypical
these syndromes follows the same steps neuroleptics which have GABAergic ef-
as the development of these sympto- fects (e. g. Clozapine).
matic transitory psychotic syndromes.

Fig. 60 Co-morbidity alcohol and depression based on gender

Alcohol Alcohol
addiction abuse
Men Women Men Women

Major
depression

Dysthymia

103
7 Motives for alcohol-and/or tobacco addicted patients to seek medical help

Fig. 61 Psychopathological relationships during in-patient admission

Fig. 62 Psychopathological relationships after twelve months in outpatient treatment


(with same relationships showing at both times).

7.3.2.3.1 Alcohol and affective disorders 1997; Berner P et al. 1986; Driessen M
A large US epidemiological study which et al. 2008).
investigated the relationship between In a prospective longitudinal
depression and alcohol addiction, found study on alcohol dependent patients,
significant gender differences. It seems Lesch OM 1985 examined the link be-
that women are more affected by affec- tween psychopathological symptoms
tive disorders than men (Kessler RC during an in-patient admission at

104
Sequelae that bring patients into therapy

twelve months and four years after the ditionally. These symptoms are symp-
admission into an outpatient setting tomatic transitory syndromes and sub-
(Lesch OM. 1985, Lesch OM et al. 1988; side after detox or with the diminishing
Figs. 61 and 62). of withdrawal symptoms without any
During admission mental symp- therapy. Here the principle is: Alcohol
toms like reduction of performance and addiction is treated first and if the psy-
sleep disorders significantly correlated chiatric symptomatic still exists after
with intoxication and withdrawal symp- two to three weeks of abstinence, then
toms. Suicidal tendencies did not cor- the (other) psychiatric axis-I-diagnosis
relate with psychiatric syndromes and should be treated (recommendation of
are likely to be caused by the difficult the Plinius Maior Society, www.alcoweb.
life situation of the affected at the time com).
of admission.
A clearly differentiated pattern 7.3.2.3.2 Alcohol and Anxiety
shows after twelve months or four years, Diverse forms of anxiety disorders show
which shows two evolving groups. One similarities in their longitudinal pro-
patient group showed symptoms that gression in that two thirds of patients
correlated with alcohol intoxication with anxiety disorders develop alcohol
or withdrawal symptomatic. The other or substance abuse. Only one third of
group showed chronobiological dys- anxiety patients reject medication, and
functions which correlated with affective also alcohol and tobacco consumption.
symptoms, suicide attempts and sui- An investigation of 100 anxiety patients
cides. These results clearly demonstrate with different forms of anxiety showed
that chronobiological dysfunctions can that anxiety patients who did not con-
be defined as a major symptom of an af- sume any alcohol had normal norhar-
fective disorder (comorbidity; Berner P mane blood levels, while anxiety pa-
et al. 1986; Dvorak A et al. 2003, Lesch tients who temporarily abused alcohol
OM et al. 1988). had elevated norharmane levels even
In a prospective longitudinal study during abstinence (Leitner A et al. 1994).
Angst et al. were able to show that main- With regards to anxiety syndromes that
ly bipolar affective disorders lateron later lead to abuse, it is important to
also meet the diagnostic criteria for an first treat the abusing behaviour, which
alcohol dependence, whereas there is then enables therapy of the anxiety
no difference between patients with syndrome (therapy of alcohol depend-
unipolar disorders and the normal pop- ents with anxiety or affective disorders
ulation (the older the patients the more should follow similar rules). Anxious or
bipolar diagnoses, Angst J et al. 2006). depressive symptomatic transitory syn-
The patient group which drinks alcohol dromes (in connection with intoxication
to self-medicate their psychological or withdrawal) should clearly be sepa-
disorder are classified into type III ac- rated from real co-morbidities (anxiety
cording to Lesch’s typology. Depressive disorders or affective disorders) (Wieck
syndromes with sleeping disorders, HH. 1967).
linked to alcohol intoxication or alco- Basic disturbances of alcohol de-
hol withdrawal, should not have an pendence and affective disorders are
axis-I-diagnosis (affective disorder) ad- often due to pathological differences in

105
7 Motives for alcohol-and/or tobacco addicted patients to seek medical help

temperament. The Temps scale was de- These different temperaments


veloped and has been validated in dif- also fit with a German study on persons
ferent languages and is able to assess who committed homicides showing
the different temperament dimensions. that only Type II alcohol dependents
(Erfurth A et al. 2005). Hyperthymic have no criminal careers (Fig. 64). (Re-
temperaments with different psychiat- ulbach et al., 2007)
ric diseases are often associated with
positive outcomes. Cyclothymic tem-
7.3.2.4 Alcohol and neurological disorders
peraments (genetic or very early distur-
bances in brain development) influ- If memory impairment is combined
ence psychiatric syndromes, increase with a disturbance of time conscious-
co-morbidity rates and admissions to ness (the chronological organisation of
psychiatric wards and are often con- events at certain times is not possible
nected with poor outcomes and in- and the patient often confabulates) and
creased mortality rates. We were able to additionally apathy, nystagmus and
show in a sample of 116 alcohol de- ataxia set in, the symptomatic is de-
pendent patients according to ICD-10 scribed as Wernick’s encephalopathy.
and DSM IV that Lesch type I patients Besides the damage caused by alcohol,
have mostly a hypothymic tempera- thiamine deficiency and genetic dys-
ment and Lesch type IV patients suffer function of thiamine metabolism are
from a cyclothymic temperament lead- discussed in the following paragraphs.
ing to very difficult social behaviours. Rapid reduction of drinking can
These results fit very well with our pro- lead to epileptic “grand mal” withdraw-
spective long term results showing that al seizures. Haemorrhagic, embolic and
type I patients are often still sober after also thrombotic strokes are very fre-
two years and type IV patients relapse quent in alcohol dependents. Often ad-
very often. ditional to these severe neurological

Fig. 63 Lesch typology and temperament

Vyssoki B, Lesch OM, Erfurth A, in preparation

106
Sequelae that bring patients into therapy

Fig. 64 Homocide and alcohol dependence defined by Lesch’s typology

disorders are diabetes mellitus and hy- 5 to 15 % of all alcohol dependents


perlipidemia with atherosclerotic dis- develop peripheral polyneuropathy that
ease and/or coagulopathy. Also alcohol usually starts in the legs and can then
and smoking increase the risk of suffer- shift to the arms. This symptomatic gen-
ing a seizure. erally starts with paraesthesias which
Around 1 % of alcohol dependents feel like the patient is wearing socks or
develop cerebellar diseases. Cerebellar gloves. Weakness, paraesthesias of burn-
cells are degenerated, coordination is ing character and pain are the prevailing
increasingly impaired and severe ataxia symptoms. With the progression of the
of the legs is often observed. Arms are disease, atrophy and weakness of mus-
not as severely affected. A wide-legged cles are typically found in the peronae-
style of walking with arms held at the us area. The Achilles reflex is alleviated
side is characteristic in these patients. or removed. Later the patella tendon
In 1999, a research group of the MUW reflex is also affected. A distal motor
(Medical University Vienna) showed polyneuropathy, which primarily affects
that cerebral diseases, which were the legs, develops in later stages. Be-
measured by platform posturography, sides alcohol’s effects, thiamine deficits
significantly correlated with the dura- are a topic of ongoing discussion. Alco-
tion of drinking behaviour (Woeber C hol dependents with severe poly-
et al. 1999). From a neurological per- neuropathy always show a poor type IV
spective, this symptomatology can also course and have a very slow ethanol and
be observed in Wernicke’s encephalop- methanol elimination rate (see Fig. 6).
athy (type IV alcohol dependents ac- Alcohol induced psychotic disor-
cording to Lesch). ders (Pathologischer Rausch), which can

107
7 Motives for alcohol-and/or tobacco addicted patients to seek medical help

be caused by only small amounts of al- gery often don’t tolerate as much alco-
cohol, are rarely seen and often inter- hol as they did before. Diarrhoea after
preted as “partial epilepsy” or “dreamy alcohol abuse is a sign of irritation of
states”. During abstinence these patients the large intestine. A portal hyperten-
show a normal EEG, during provocation sion might develop due to alcohol re-
(sleep withdrawal or alcohol), however, lated liver damage and therefore inter-
“Spike and Wave” patterns were ob- nal and external haemorrhoids or
served in the temporal brain areas. oesophagus varices bleeding are often
It is now proven that alcohol in- observed. As alcohol is metabolized by
terferes with normal sleep pattern and the liver in the so called “first pass ef-
that, as a result, individuals do not go fect”, alcohol consumed over a longer
through the healthy stages of sleep. If period of time can damage the liver
previous sleep disorders are present even in low doses (pure alcohol: 20g/
(e. g. nightly awakening in depression), daily for women; 40g/daily for men).
alcohol aggravates these sleep disor- Alcohol impairs gluconeogenesis and
ders. Transitory depressive symptoms, turns carbohydrate metabolism into
caused by alcohol, or which set in dur- fat production. According to the dura-
ing withdrawal, usually regress auto- tion and amount of alcohol consump-
matically after two or three weeks, with tion, a fatty liver and alcoholic hepati-
an improvement in the quality of sleep tis can develop. Maintained over longer
(Schuckit MA et al. 1997). periods, this can lead to irreversible fi-
brosis and eventually to liver cirrhosis.
Decompensated liver cirrhosis is char-
7.3.2.5 Alcohol and internal medicine
acterized by a liver cell dysfunction in
which portal hypertension with a
7.3.2.5.1 Gastroenterology splenomegaly, often with oesophagus
Alcohol impairs the entire gastrointes- varices and ascites, are present. Chang-
tinal system. Oral inflammation and es in hormone levels and weakness of
peptic oesophagitis are often a result the immune system with correspond-
of alcohol abuse. Acetaldehyde and ing inflammations are often observa-
formaldehyde seem to be the toxic ble. At the onset of liver disease, ASAT
agents within this damage. As acetal- is clearly higher than ALAT (positive
dehyde is also caused by smoking, de Ritis Factor) with a significantly ele-
these diseases are very numerous in vated Gamma GT. In a fibrous recon-
smoking alcohol dependents struction, the Gamma GT usually in-
(Salaspuro VJ et al. 2006; Salaspuro VJ creases and at the same time ALAT gets
and Salaspuro M. 2004). Alcohol caus- on the same level or even higher than
es anacide gastritis in the stomach ASAT. Yet not all alcohol dependents
which secondarily leads to dysfunc- develop liver cirrhosis. When all alco-
tions in resorption, e. g. in vitamins. holic dependents, treated at a psychi-
As around 40 % of alcohol is metabo- atric hospital, are examined for evi-
lized in the stomach, the breakdown of dence of liver disease, it is apparent
alcohol in the stomach is an important that especially type I and type IV pa-
process for the liver and brain. There- tients according to Lesch are affected
fore individuals who had stomach sur- by severe liver damage. On gastroen-

108
Sequelae that bring patients into therapy

terological wards treating primary liver and the MEOS-system or the catalase
diseases we could show that more than are likely to be involved, e. g. catalase
50 % has been diagnosed as Lesch Type deficiency damages liver cells. Genetic
II patients. The rate of affective disor- variants of the hydrogenases, but also
ders and suicidal tendency were sig- diet and changes in vitamin levels espe-
nificantly lower in internal wards than cially B6, also seem to be crucial factors.
in patients admitted with the diagno- Why some forms of alcoholic hepatiti
sis of alcohol dependence at psychiat- later cause liver carcinoma is still unex-
ric wards (Vyssoki B.et al. accepted in plained. Genetic and biochemical mod-
Alcohol and Alcoholism). els are discussed herein (Mihas AA et al.
As a fifth of all elevated liver func- 2007). If the liver is so severely damaged
tions has an aetiology other than alco- that a liver transplantation is needed,
hol, it should be noted that either infec- preparation and aftercare with regards
tious diseases, cholostases or other rare to drinking behaviour is just as impor-
diseases may be the reason for this ele- tant as surgery. The Vienna research
vation (see path diagnosis of the com- group was able to show that in 97 alco-
puter version of Lesch’s typology (www. hol dependents with liver transplanta-
lat-online.at), Baischer W et al. 1995; tions, prognosis with regular psychiat-
Mihas AA et al. 2007; Maher JJ. 2007; ric aftercare was very positive in regard
National Institute of Health Consensus to drinking behaviour (Berlakovich GA
Development Conference Statement: et al. 1999).
management of hepatitis C. 2002). The Pancreatitis only develops in a few
mechanisms of how alcohol causes liv- patients. If the pancreas is affected,
er damage are not yet clear. The metab- often a chronic pancreatitis develops
olising in the liver via hydrogenases (with a shortened life expectancy). This

Fig. 65 Liver transplantation and relapse rates

Total relapse rates: the number below the lines indicates the abstinent group, group 1: subjects with liver
transplantations before 1993 (n = 31) vs. group 2: liver transplantation from 1993 to May 1997 (n = 66).

109
7 Motives for alcohol-and/or tobacco addicted patients to seek medical help

inflammation of the pancreas can lead asymptomatic, while cardiomyopathy


to diabetes mellitus. Abnormal protein clinically manifests with a systolic dys-
formation in the liver leads to dysfunc- function. The diagnosis is predomi-
tions in blood clotting and therefore nantly a diagnosis of exclusion inclu-
haematoma can often be observed in sive of a long lasting alcohol anamnesis
these patients. Consequently, esopha- (Piano MR. 2002).
geal varices and haemorrhoidal bleed- The progression of heart diseases
ing become more difficult to treat and is often reversible during abstinence.
often cause death. With further alcohol abuse a heart insuf-
ficiency develops, which clearly short-
7.3.2.5.2 Cardiovascular system ens life expectancy. Less than a quarter
Heart diseases like e. g. cardiomyopa- survive the following three years after
thy, heart rhythm dysfunction, coro- diagnosis (Wynne J and Braunwald E.
nary heart disease and blood pressure 2005).
dysfunctions are more frequent in in-
dividuals who chronically abuse alco- 7.3.2.5.2.2 Cardiac arrhythmia, “Holi-
hol. Yet these underlying diseases can day-Heart-Syndrome” and sudden car-
only be treated in a state-of-the art diac arrest
fashion if alcohol abuse is terminated Many studies have documented the re-
or at least controlled (Preedy VR and lationship between increased alcohol
Richardson PJ. 1994; Strotmann J and consumption and cardiac arrhythmia
Ertl G. 2005). (supraventricular arrhythmia like atrial
fibrillation and ventricular arrhythmia;
7.3.2.5.2.1 Alcoholic Cardiomyopathy Rosenqvist M. 1998; Singer MV and
In industrial countries, alcohol related Teyssen S. 2005). Chronic alcohol abuse
cardiomyopathy is the primary form of leads to changes in the structure of the
secondary dilated cardiomyopathy. It is myocardium like fibrosis, hypertrophy,
characterized by a dilating left ventricle fatty infiltrations and a lowered resting
(LV), an enlarged LV mass, a normal or membrane potential (Schoppet M and
decreased LV thickness and a dysfunc- Maisch B. 2001). In acute cases, alcohol
tion of ventricles with reduced secre- can lead to an increased release of cat-
tion. A diastolic dysfunction is usually echolamines and an increase in heart

Fig. 66 Supraventricular arrhythmia in alcohol consumption

Rhythm alcohol consumption

6+ <1 Relative risk p-value*


for
Number Number

Atrial fibrillation
Atrial flutter
Supraventricular Tachycardia
Supraventricular Extrasystoles
Fibrillation, fluttering or
supraventricular Tachycardia

*p-values for samples determined with McNemar-Test

110
Sequelae that bring patients into therapy

frequency (Rosenqvist M. 1998; Huseyin Singer MV and Teyssen S. (2005)


U et al. 2005). propose that a moderate consumption
A case-control study showed that can actually protect the cardiovascular
the relative risk for individuals who system. It is probable to suggest a U-
consume more than 420 grams/day of formed progression. For example, Deev
suffering from atrial fibrillation was A. et al. found that level 1 drinkers suf-
2.4x as high, as in the normal popula- fer more from cardiovascular diseases
tion (Ruigomez A. et al. 2002). Another than level 2-and level 3 drinkers, while
study showed that the risk for men who the risk again increased for level 4 indi-
consumed comparable amounts of al- viduals (stronger drinkers) (Deev A. et
cohol was 1.46 times higher than in the al. 1998).
normal population (Frost L. and Vest- Results from a longitudinal Nor-
ergaard P. 2004). The term “Holiday- wegian study which examined 40,000
Heart-Syndrome” evolved from su- participants over 40 years suggest that
praventricular cardiac arrhythmia that alcohol consumers are 2.5 times more
was frequently observed at weekends likely to suffer from cardiovascular dis-
and during holidays as a result of in- ease (Rossow I. and Amundsen A. 1997).
creased alcohol consumption (Singer Another study was not able to support
MV and Teyssen S. 2005). Ventricular the link between coronary heart dis-
arrhythmia is associated with QT- ease (CHD) and beer consumption, al-
lengthening in ECG, which points to an though the risk of fatal heart attack was
abnormal cardiac repolarisation. This increased 6 times (Kauhanen J et al.
form of arrhythmia is responsible for 1997). Other studies have found a high-
sudden cardiac arrest and is caused by er CHD risk in individuals who severely
the re-entry-mechanism with its cir- abuse alcohol (Overview by Davidson
culating excitations in the heart DM. 1989; Dyer A. et al. 1977; Malyutina
(Rosenqvist M. 1998; Singer MV. and S et al. 2002).
Teyssen S. 2005). Lengthened QT-in-
tervals (Cuculi F. et al. 2006) and cardi- 7.3.2.5.2.4 Hypertonia
ac arrhythmia (Rosenqvist M. 1998) According to the WHO, hypertonia is
are also frequently observed in with- defined by a blood pressure value (RR)
drawal. of 140/90 or above. Alcohol consumers
Significantly more supraventricu- are four times more likely to suffer from
lar, tachycardic arrhythmias were ob- hypertension (Arkwright PD et al. 1982).
served when 60 grams of pure alcohol Marmot MG et al. have found that the
were consumed daily in comparison to blood pressure value (RR) of men who
only 10 grams daily (cited by Singer MV. consume more than 400 g of alcohol per
and Teyssen S. 2005). week rises on average by 4.6/3 mmHg
(Marmot MG et al. 1994). The RR in
7.3.2.5.2.3 Coronary heart disease and women who consumed more than 240 g
myocardial infarction per week increased by 3.9/3.1 mmHg.
The relationship between ischaemic Contrary to the diastolic blood pressure,
heart disease and alcohol has been the systolic blood pressure strongly
controversially discussed in the litera- correlates with the amount of ethanol
ture. consumed (p < 0.001, Arkwright PD et

111
7 Motives for alcohol-and/or tobacco addicted patients to seek medical help

al. 1982). The RR drops with the reduc- cysteine (Hcy) level already increased
tion of alcohol, with the systolic RR to 18 % after small doses over six weeks.
more strongly correlating than the di- Here the Hcy increased slightly more
astolic blood pressure (Puddey IB et al. with red wine and spirit than with beer.
1985). These effects of alcohol on blood A further study showed similar results,
pressure are independent of age, weight, suggesting that homocysteine levels of
smoking behaviour, exercise and salt alcohol dependents were twice as high
secretion (Arkwright P.D et al. 1982; as in an abstinent population (Cravo
Puddey IB et al. 1985; Marmot MG et al. ML and Camilo ME. 2000).
1994). Hultberg B. et al. observed higher
homocysteine levels during alcohol in-
7.3.2.5.2.5 Hypothesis on the aetiology toxication, with normal levels in absti-
of alcohol addiction and heart diseases nence (Hultberg B et al. 1993). Kenyon
Additional to changes in lipid metabo- S. H. et al. illuminated the link between
lism and the reduction of oxygen avail- alcohol abuse and hyperhomocystein-
ability, we will also discuss the homo- aemia by examining the influence of
cysteine metabolism in regard to both ethanol on homocysteine. The homo-
alcohol dependence and cardiovascu- cysteine metabolism can be portrayed
lar diseases. Numerous studies point as follows (Kenyon SH et al. 1998).
to a connection between alcohol con- The influence of alcohol is best
sumption and an increase of blood ho- explained by the effect of acetaldehyde
mocysteine levels (Hcy). Bleich S et al. on methionine synthesis as acetalde-
showed that even with low amounts hyde directly blocks this synthesis. As
(30 g) of alcohol per day the Hcy signifi- this enzyme depends on vitamin B12,
cantly increased (750 ml beer or 3/8 the effect of B12 should also be consid-
wine; Bleich S et al. 2001). The homo- ered (Hultberg B. et al. 1993).

Fig. 67 Intracellular homocysteine metabolism

Dimethylglycine Methionine F

5,10-Methylene-TH F
BHMT MS
B 12 MTHFR
B2

Betaine Homocysteine
5-Methyl-TH F
CBS
B6
Cystathionine
C
B6

Cysteine
BHMT = Betaine-Homocysteine Methyltransferase, B2 = Vitamin B2, B6 = Vitamin B6,
B12 = Vitamin B12, C = 웂-Cystathioninase, CBS = Cystathionin-웁-Synthase, F = Folic acid,

MS = Methioninsynthase, MTHFR = 5,10-Methylentetrahydrofolat-Reduktase,

THF = Tetrahydrofolicacid.

112
Sequelae that bring patients into therapy

Blood vessel damage is very di- 7.3.2.5.2.6 Alcohol typology according to


verse and in the case of alcohol de- Lesch – Homocysteine level – Heart dis-
pendents, homocysteine metabolism eases
has been suggested as playing a role Bleich S and his research group showed
(Stanger O. et al. 2003). Heart insuffi- that homocysteine levels are only ele-
ciency and coronary heart diseases are vated in Lesch type I alcohol depend-
also being discussed in regard to ho- ent patients (Bleich S et al. 2004). ‘Grand
mocysteine metabolism (Hermann M et mal’ epileptic withdrawal seizures seem
al. 2005; Vasan RS et al. 2003; Nygard O to be an important indicator for high
et al. 1997). homocysteine levels. During absti-
This relationship is also repre- nence in typeI patients, the homo-
sented by the survival rates of patients cysteine level regresses within one to
with coronary heart diseases in regard two weeks. Type I alcohol dependents
to homocysteine levels (Nygard O et al. with withdrawal seizures showed sig-
1997). nificantly higher plasma-homocysteine

Fig. 68 Mortality rates and homocysteine level

1.00

0.95
< 9.0 μmol/liter

0.90
Proportion Surviving

9.0– 14.9 μmol/liter

0.85

0.80 15.0– 19.9 μmol/liter

0.75

0.70
≥ 20.0 μmol/liter

0 1 2 3 4 5 6
Years

113
7 Motives for alcohol-and/or tobacco addicted patients to seek medical help

Fig. 69 Frequency of MTHFR genotypes and serum homocysteine level in alcohol de-
pendents, classified according to Lesch’s typology, in comparison to healthy control
groups

CONTROLS LESCH TYPE I LESCH TYPE II LESCH TYPE III LESCH TYPE IV

HOMOCYSTEINE

Saffroy R et al. 2008

levels (55.8 ± 30.7 nmol/l) while type II, Today we know how homocysteine is
III-and IV patients had a homocysteine generated from methionine metabo-
level of 39.7 ± 21.9 during intoxication. lism and how pyridoxine, folic acid, co-
Furthermore, at admission type I pa- balamine and the homocysteine level
tients showed significantly higher alco- are associated in the blood (Devlin AM
hol levels (Bleich S et al. 2004). As type I et al. 2006, De Bree A et al. 2002, Stan-
tend to consume the highest amounts ger O et al. 2003.)
of alcohol in regular doses throughout A German study showed that the
the day (Jellinek’s delta-type), it is pos- MTHFR-393-polymorphism-CC-CA-
sible that the homocysteine level re- AA is elevated in type IV according to
mains high for years. The complicated Lesch and results also suggest that this
mechanism of homocysteine suggests polymorphism frequently occurs in
that different substances but also dif- type I (Boensch D et al. 2006).
ferent genetics correlate with the devel- The above-cited results from basic
opment of the subtypes of alcohol de- research highlight the different mecha-
pendence and with blood vessel or nisms of homocysteine metabolism.
heart disease. Yet the results in regard to subgroups of
Saffroy R. and colleagues exam- alcohol dependents are still to be inter-
ined alcohol dependent patients who preted with caution. From a clinical
they classified according to Lesch’s ty- perspective, all aspects of this metabo-
pology and Babor’s typology. Results lism should be taken into consideration
showed that the methylentetrahydro- when examining the relationship be-
folate reductase gene, which influences tween alcohol and heart disease.
homocysteine, is associated with type III The relationship between homo-
according to Lesch. Furthermore, type B cysteine level and survival rate in heart
according to Babor showed a signifi- disease suggests that homocysteine has
cantly lower frequency of the MTHFR- toxic effects on the heart and circula-
677TT gene (Saffroy R et al. 2004, 2008). tion. From an alcohol research perspec-

114
Sequelae that bring patients into therapy

Fig. 70 MTHFR and the typology according to Lesch

Folic acid-producing reductase MTHFR

MTHFR-393 polymorphism

tive, the relationship between type I al- cancer forms presented in Fig. 71 are
cohol dependence, homocysteine and linked to alcohol.
heart disease is important because clear Every year, 5.2 % of men and 1.7 %
therapeutic consequences can be de- of women are diagnosed with alcohol
rived from it. Homocysteine may be a related cancer (Baan R et al. 2007;
biological marker for the effectiveness Bofetta P 2006a, 2006b). The link be-
of acamprosate in alcohol abusing in- tween amounts of alcohol consumed
dividuals with heart disease. This is and the risk of developing a carcinoma
supported by the fact that type I de- is undisputed. The risk of suffering
pendents are characterized by their high from cancer of the pharynx-gastroin-
homocysteine levels and that an ad- testinal tract is already increased with
ministration of acamprosate doubles a consumption of 50–80 g of alcohol
abstinence rate.. If patients do not stop per day. Elevated acetaldehyde levels,
drinking, administration of folic acid but also alcohol by itself irritates the
could reduce homocysteine levels in entire mucous membrane of the mouth-
(drinking) type I patients and will pre- stomach-intestinal tract. Therefore it is
vent cardiac sequelae. not surprising that 85 % of patients
with mouth-pharynx carcinomas are
7.3.2.5.3 Oncological diseases diagnosed as alcohol dependent. Alco-
Alcohol in combination with overweight hol reduces salivation and increases
and smoking increases the risk of vari- the secretion’s viscosity. This impairs
ous forms of carcinoma (Teschke R and the mechanical cleansing of the mu-
Goeke R. 2005). With reference to the cous membrane and the teeth and
“Global Burden of Disease Project”, the weakens the immune system. Patho-
WHO indicates that every year 1.8 mil- genic germs then cause an inflamma-
lion people worldwide die from alcohol tion of the mucous membrane (e. g.
related cancer. These represent 3.2 % of gingivitis and paradontitis). These con-
all deaths per year. There are many ditions increase the vulnerability to
forms of cancer associated with alco- carcinogens. Acetaldehyde activates
hol, but there is consensus that the these carcinogens. The damaged mu-

115
7 Motives for alcohol-and/or tobacco addicted patients to seek medical help

Fig. 71 Alcohol-Tobacco: sites of tumours (Seitz HK and Stickel F 2007)

Associations between chronic alcohol and/or tobacco consumption and


malignant tumours of different organs.
(-) no association; (+) possible association; (+) additive effect;
(+++) potentiating effect; + signicant association
Increased risk of carcinom
Sites of tumours
Alcohol Tobacco Alcohol + Tobacco
Oral cavity
Pharynx
Larynx
Lungs
Oesophagus
Stomach
Small intestine
Colon
Rectum
Liver
Pancreas
Mamma
Thyroid
Skin
Prostate
Urinary bladder

cosa stimulates cell regeneration via The heightened risk for liver cell carci-
genetic changes (acetaldehyde has noma has been described in numerous
multiple mutagenic effects on the studies, although additional infections
DNA) and dysplasia, leukoplakia and (hepatitis B and C) have not sufficiently
eventually carcinoma develop (Seitz been considered (Petry W et al. 1997).
HK and Stickel F. 2007; Hoermann K Although alcohol by itself represents a
and Riedel F. 2005). Adequate pre-and moderate risk only, in combination
postoperative support of alcohol de- with hepatitis B the risk for a primary
pendent cancer patients significantly liver cell carcinoma significantly in-
reduces complications and halves the creases. As already emphasized, alco-
duration of in-patient admissions. Ab- hol metabolism, in particular aldehyde
stinence not only decreases the risk for plays an essential role in the genesis of
carcinoma, but is also important for carcinoma. Alcohol related carcinoma
the prognosis of a cancerous disease. of the oesophagus is linked to Aldehyd-
Alcohol clearly increases the risk edehydrogenase-2*2( ALDH-2*2)-al-
for breast cancer in women and in men lele. Besides these alleles, it has been
abuse of alcohol is associated with argued that other genetic variants like
prostate cancer (Terry MB et al. 2006). alcohol dehydrogenase 1C*1(ADH-1C*1)

116
Sequelae that bring patients into therapy

Fig. 72 Alcohol and carcinoma: possible pathways

Chronic alcohol consumption

cytoplasmatic alcohol microsomal mitochondrial


dehydrogenase  cytochrome P-450 2E1  acetaldehyde dehydrogenase 

microsomal microsomal
ethanol oxidizing system  acetaldehyde oxidizing system 

ethanol acetaldehyde  acetate

covalent binding at DNA, RNA, macro proteins

chromosome aberrations, mutations, cancer cell

tumour

homozygotes and methyl-tetrahydrofol cause e. g. alcohol related alterations in


reductase (MTHFR)-677CT variants, in- metabolism can change the effects and
crease the alcohol related risk for carci- side effects of chemotherapeutics.
noma. Variants of MTHFR have been
examined in regard to the alcohol ty-
7.3.2.6 Alcohol and medication for
pologies according to Lesch and Babor
sequelae
and it is interesting to see whether Bar-
bor’s type B or Lesch’s type III have a Depression and anxiety in particular
higher risk for cancer. Yet research on are treated by psychopharmaceutical
this issue is still lacking(Seitz HK and agents and the fact that most of these
Stickel F. 2007; Saffroy R et al. 2004). medications interact with alcohol is
Teschke R and Goeke R have intro- rarely considered. In the chapter on on-
duced a concept which considers dif- cology (7.3.1.4) we have already pointed
ferent factors that can cause a tumour. out to this interaction. Today, we differ-
The above findings should be integrat- entiate between the impact of an acute
ed into this concept (Teschke R and alcohol intoxication on the effects of
Goke R. 2005). different medications and the influ-
The role of alcohol should not be ence of chronic alcohol intoxication on
underestimated with regards to therapy the pharmacological aspects of medi-
and the progression of carcinoma be- cation. Principally, an acute alcohol in-

117
7 Motives for alcohol-and/or tobacco addicted patients to seek medical help

toxication increases the effective levels by the cytochrome P450 metabolism or


of medication, while chronic intoxica- that has effects on cerebral functions
tion leads to enzyme induction, which whose vulnerability has been changed
clearly reduces the effectiveness of med- by alcohol, is influenced in its effect.
ications (Ramskogler K et al. 2001). For example, alcohol sensitizes the
These two figures only show the dopamine receptor and this is why clas-
most prevalent interactions. Ultimately sic neuroleptics or antiemetics often
every medication which is eliminated cause severe extrapyramidal sequelae.

Fig. 73 Acute Alcohol abuse and medication

Medication Type of interaction Clinical effect


NSAIDs Activity reduction Increase in plasma level
of ADH of ethanol and pharmacon
Psychopharmaca Competition with ethanol Synergistic effect with
(benzodiazepines, on the binding receptor at increase in sedation
barbiturates, tri-and the cytochrome P 450 and deterioration of
tetracyclic psychomotoric functions
antidepressants,
clomethiazole)
Antiepileptics, oral As above Lengthening of
antidiabetics, half live time with a
anticoagulants, risk of over-dose and
antihypertensives, related complications
paracetamol
Disulfiram, antidiabetics Inhibition of ALDH Flushing- facial rash,
(sulfonyl carbamide- blood pressure problems,
type) antibiotics nausea and vomiting

Fig. 74 Chronic alcohol abuse and medication

Medication Type of interaction Clinical effect


NSAIDs Activity reduction Increase of plasma
of ADH level of ethanol and
pharmacon
Psychopharmaca, Accelerated metabolism Shortening of half
antiepileptics, oral of substances via the life time with
antidiabetics, induced cytochrome P450 reduced clinical effect
anticoagulants, (especially 2E1)
antihypertensives,
rifampicine
Anaesthetics, isoniacid, As above hepatotoxic
phenylbutazone, metabolites increased
paracetamol

118
8
Detection of alcohol
and tobacco addiction
8.1 Recommendations for the rst and dependents know their problem,
contact which they experience as failure, and
for which they often feel guilt or shame.
Clinician’s dialogue regarding alcohol Antoine de Saint-Exupery has brilliant-
addiction ly described this situation in the 12th
chapter of his book “The Little Prince”
85 % of all adults in central Europe (1943), Fig. 75.
drink alcohol more or less regularly and The patient is afraid that his alco-
this is why the question “do you drink hol abuse will be discovered and at the
alcohol” is almost always answered with same time he knows that he can only be
“yes”. But this answer does not provide helped if his alcohol consumption is
any information about the interaction addressed. This strong ambivalence
of psycho-social-biological problems leads to a change of behaviour in the
caused by alcohol and therefore this patient. There are times when patients
question should be avoided. Abusers are more easily motivated and times

Fig. 75 Shame and alcohol abuse

The next planet was inhabited by a tippler. This was a very short visit, but it plunged
the little prince into deep dejection.

“What are you doing there?” he said to the tippler, whom he found settled down in
silence before a collection of empty bottles and also a collection of full bottles.
“I am drinking,” replied the tippler, with a lugubrious air.
“Why are you drinking?” demanded the little prince.
“So that I may forget,” replied the tippler.
“Forget what?” inquired the little prince, who already was sorry for him.
“Forget that I am ashamed,” the tippler confessed, hanging his head.
“Ashamed of what?” insisted the little prince, who wanted to help him.
“Ashamed of drinking!” The tippler brought his speech to an end, and shut himself
up in an impregnable silence.

And the little prince went away, puzzled.

“The grown-ups are certainly very, very odd,” he said to himself, as he continued on his
journey.

119
8 Detection of alcohol and tobacco addiction

when motivation towards a lifestyle with open questions, which show the
change is in fact impossible. The nature patient that there is an interest in him
of interaction between therapist and as a person and that there is someone
patients is therefore of great impor- to help him. Every question, which
tance. The guidelines for therapeutic could be interpreted as senseless curi-
dialogue should always be considered. osity, should be avoided. In this conver-
Basic conditions like a comfortable at- sation, the relationship between prob-
mosphere (a quiet room without a tel- lems, wishes, feelings, thoughts, fears
ephone) and sufficient time (the initial and the effect of alcohol should be elab-
meeting should last at least 35 minutes) orated gradually. Ambivalences should
are necessary. Clinicians should defi- be amplified. Positive factors concern-
nitely be aware of transference and ing drinking (e. g. drinks taste good and
countertransference issues. Like in any eliminate negative feelings) and nega-
other psychotherapy, the therapist starts tive factors, which argue for a reduction

Fig. 76 The following questions may be asked to find out about the perceived value of
alcohol:

 Do you like the taste of alcohol or do you drink alcohol because of its effects?
 If yes, what effects do you wish for (to get drunk, changes in mood, to cope with
anxiety etc.)?
 Describe any positive effects of alcohol. Can you also think of any negative effects
and consequences of alcohol?
 Is there any link between the problems, for which you consulted me and the dis-
comforts caused by alcohol ?
 When you stop drinking for a few days, does your condition improve or deterio-
rate?
 Are there any other ways to alleviate your (psychological or physical) complaints?
 Does drinking alcohol help? If yes, how much do you drink to alleviate your com-
plaints? How much alcohol can you handle?
 When you have had too much alcohol at a party, do you have alcohol-related
symptoms the next day (headache, circulatory problems, unrest, agitation)? Do
you then drink again to alleviate these symptoms? How much alcohol do you need
for this?
 When taking medication for your symptoms, were you able to reduce or even ter-
minate alcohol consumption? If you weren’t able to reduce drinking, what were
the reasons for this? (e. g. withdrawal symptoms, psychological or social problems
etc.)?
 Did you feel better when you didn’t drink over several months? What helped you to
stay abstinent? Why don’t you try this again?
 Are there any places or situations, in which you find it very difficult not to drink
(so-called “hot spots”), and are there places and situation, in which you never
drink any alcohol (so-called “Cool Spots”)?

120
Recommendations for the rst contact

and termination of drinking (reinforce- Once the interaction between al-


ment of problems, psycho-social rea- cohol intake and the medical condition
sons etc.), should be clearly discussed has been elaborated, the next step is to
(Fig. 76). clarify whether alcohol abuse or de-
The aim of the initial meeting is to pendence is present. For this the ICD-
determine factors that provide infor- 10 or DSM-IV (see chapter 5) should
mation about the value that alcohol has be used. As general practitioners often
for the patient’s well-being. Every ob- have too little time for this diagnostic,
jectification of the drinking behaviour there are instruments available that en-
or alcohol sequelae is helpful, e. g. se- able an objectification by using only a
verity of liver disease, assessment of few questions. Within medical practi-
withdrawal syndrome and objectifica- tioner or non-psychiatric medical spe-
tion of the intoxication (e. g. via a breath- cialist settings, four questions have pre-
alyzer). If the therapist observes during vailed, as summarized by CAGE (Fig. 11,
the initial meeting that the value attrib- Ewing JA. 1984).
uted to alcohol is consistent with an If one of these questions is an-
abuse or addiction, the aim of this meet- swered with “yes”, patients almost al-
ing is the planning of further meetings. ways meet the diagnostic criteria for
These meetings should be conducted alcohol abuse according to DSM-IV or
by the therapist who conducted the ini- ICD-10. If two or more questions are
tial meeting or with experts who have answered with “yes” then a DSM-IV or
relevant psychotherapeutic and phar- ICD-10 diagnosis of alcohol depend-
macotherapeutic competencies. Pa- ence is very likely (Chan AW et al. 1994;
tients can quit treatment at any time Liskow B et al. 1995; Bradley KA et al.
and it is recommended that the thera- 2001; Saremi A et al. 2001). If the diag-
peutic location be changed as seldom nosis is made according to ICD-10 or
as possible. The aetiology and diagnos- DSM-IV, Lesch’s survey tool can be used
tic of alcohol dependence and the link for a more specific diagnosis (see Ap-
to medical conditions can only explic- pendix 1). This computer programme
itly be made after several meetings. If assesses most of the important criteria
the patient is strongly intoxicated dur- that should be employed for the treat-
ing the initial meeting (blood alcohol ment and prognosis of alcohol depend-
or breath alcohol level above 1.5 mg), ents (e. g. alcohol-positive family an-
the meeting should be brief, but if amneses, onset of acute alcohol abuse
possible another meeting, taking place etc). Only one page of this survey tool is
within the next 24 hours, preferably in concerned with the classification of the
the morning, should be offered. If the typology. Adequate withdrawal treat-
patient mentions developing acute de- ment and relapse prevention can only
lirium over night or urgently wanting to be commenced after a classification
drink alcohol in the morning, an ade- has been made (Lesch OM et al. 1990,
quate medication for his withdrawal the typology computer programme can
symptoms (see chapter 9) should be be found at www.lat-online.at).
prescribed, before drinking can be re-
duced.

121
8 Detection of alcohol and tobacco addiction

8.2 Assessment of drinking beha- 8.2.2 State markers


viour by using biological markers
State markers provide information
Markers for a predisposition and for an about drinking amount and drinking
early detection, as well as markers which profile. Acute intoxication is best meas-
objectify an existing alcohol use or ured by identifying the type of alcohol
abuse, and markers which are associ- and its degradation products (breath
ated with alcohol dependence, have and blood alcohol). Nowadays breath
been differentiated (Overview Fig. 77). measurements for assessing the alco-
hol level in unconscious persons are
8.2.1 Trait markers available. If the last intoxication dates
back a few days, metabolites of alcohol
All these markers differ between alco- in the blood and urine can provide in-
hol dependent patients and the normal formation, e. g. ethyl glucuronide (Wur-
population (Pettinati HM et al. 2003; st F, et al. 2010). The drinking behaviour
Koob GF and Le Moal M. 2006; Lale- of the last 14 days is best measured by
mand F et al. 2006). In the last year, %CDT but with only 63 % sensitivity.
these markers have also been further Even with a massive increase of alcohol
investigated in regard to Lesch’s sub- consumption (more than 80 g of pure
groups, personality dimensions and alcohol daily for more than three weeks)
Cloninger’s types. Significant differenc- 37 % don’t show an elevation of %CDT.
es were found in these subgroups (ge- Liver parameters and MCV are able to
netic differences as well as differences detect longer periods of alcohol abuse.
in alcohol metabolism and amino ac- If ASAT is twice as high as ALAT, an alco-
ids). The differences in Lesch’s typology hol abuse is very likely (De-Ritis-Quo-
illustrate that these types seem to have tient, Singer MV and Teyssen S. 2005;
different enzyme equipments (Fig. 6, Renz-Polster H et al. 2007). If ALAT is
Hillemacher T and Bleich S. 2008). above 200 or slightly higher, the eleva-
tion of ASAT is usually also caused by

Fig. 77 Trait markers, state markers and markers associated with alcohol dependence
(according to Koller G and Soyka M. 2001)

• Trait markers • State markers


• Monoaminooxidase • Blood alcohol level
• MAO-B • Acetaldehydes and formaledehyde
• Dopamine receptor genetics condensation products
• Dopamine Beta Hydroxylase • Acetate
• Endocrine parameter like ACTH, cortisol, • Ethyl glucuronide
prolactine, TSH, TRH • Methanol
• Alcohol dehydrogenase (ADH2, ADH3) • Alkaline phosphatase
• Aldehyde dehydrogenase (ALDH2, ALDH3) • Blood and urinary beta-hexoaminidase
• Adenylate cyclase • MCV
• Induced potentials • ASAT; ALAT; GAMMA GT
• Tryptophan hydroxylase (5-HIAA) • % CDT

• Associated markers
• Blood groups (MMS-blood group)
• HLA Antigens
• Transcetolases

122
Assessment of drinking behaviour by using biological markers

Fig. 78 Overview biological state markers of alcohol abuse

Biological markers that indicate


alcohol abuse
• Sensitivy Specicity Normalisation
in abstinence
• Breath alcohol 100 % 100 % Hours
• Ethyl glucuronide 100 % 100 % Days
• MCV & GGT 63 % 80 % 1–10 Weeks
• % CDT 65 % 96 % 2–4 Weeks

• Cut-off-points:
• Breath alcohol =  2,5 ‰. chronic abuse
• ASAT > ALAT = Alcohol; ALAT > ASAT = liver disease
• Gamma-GT = >1,3-times the upper standard value
• MCV = > 95, suspected alcohol abuse
= > 98, alcohol abuse
• % CDT =  2,6 % (new cut-off; without trisialo)
Lesch OM, Walter H, 1995

other liver diseases. 20 % of all elevated of scientific interest, they are investigat-
Gamma GT levels are not caused by al- ed by only few research centres (Wurst
cohol and a third of all heavily drinking FM. 2001).
alcohol dependents show normal liver
function tests. MCV above 95 indicates 8.2.4 Practical suggestions for the use of
alcohol abuse and in 80 % of patients a biological markers for forensic purposes
MCV above 98 indicates a massive and
lengthy alcohol abuse. The degradation 8.2.4.1 Blood alcohol measurement
of liver function tests often takes sev-
eral weeks and very high Gamma GT Alcohol is absorbed by the mucous
values (e. g. > 300) often don’t completely membrane of the gastrointestinal tract,
degrade despite abstinence (e. g. only a mainly by the stomach, metabolised by
value between 60 and 80 is reached). the liver and only minor quantities are
The degradation of MCV usually takes eleminated by respiration. Therefore
even longer than degradation of liver alcohol can be measured in the blood
function tests. and also in the breath. The absorption
depends on many factors (weight, diet,
8.2.3 Associated markers speed of drinking etc.). The elimination
depends on liver functioning and alco-
A connection between these markers hol degradation is accelerated by liver
and alcohol abuse can be expected. enzyme induction. If other medication
These markers aim especially at giving which takes the same degradation path
information about the etiological caus- (P450 etc.), is taken in addition to alco-
es of alcohol abuse. Although primarily hol, it leads to severe interactions (see

123
8 Detection of alcohol and tobacco addiction

chapter 7.3.2.6) and consequent chang- mula.


es in blood levels. It is assumed that
persons without a genetic vulnerability Fig. 79 BAC retrograde calculation
for alcohol dependence (e. g. no alco-
hol dependent father or mother), who The following procedures enable
rarely drink alcohol, eliminate around the intoxication to be calculated back-
0.12 ‰ alcohol per hour, while patients wards to a point of time in the past:
with a genetic vulnerability who regu- – Widmark’s formula
– Widmark’s procedure
larly drink alcohol are able to eliminate – Vidic’s procedure
up to 0.25 ‰ of alcohol per hour. The – Fous’s formula
severity of a liver disease (e. g. decom- – Watson’s formula
pensated liver cirrhosis, child B or C)
clearly changes these elimination rates.
The analytical procedure consists
of four single measurements with two The Widmark formula forms the basis
different measuring methods (gas chro- of all these procedures and is interna-
matography, ADH process, Widmark tionally accepted. It allows a retrograde
process). The mean value of these four calculation of the alcohol concentra-
single values, rounded to two decimals, tion.
adds up to the blood alcohol concen-
tration (BAC).
8.2.4.3 Widmark Formula
The maximal tolerance between
these single values may only be 10 % of By calculating the maximal BAC c from
the mean value. Precision and accuracy alcohol consumed amount A in grams
of these measurements are permanently and the body weight p, the alcohol
monitored by commercially produced amount can be measured according to
control samples with known content. the formula c = A/(p*r) as proposed by
Intercomparison programmes regulate Widmark in 1932 (with r=reduction
external quality control. factor). As alcohol is water soluble, it
Procedures which do not include does not disperse to the bones and to
four values with two measurements are the fatty tissue and therefore these
controversial, e. g. in persons who have body dimensions are not included. The
an accident, whose blood is only tested mean value for men is r = 0.7, whereas
by using the ADH process. the mean value in women is r = 0.6 as
they have more fatty tissue. New ap-
proaches, e. g. by Watson, consider
8.2.4.2 Blood alcohol concentration (BAC)
size, age and gender additional to body
The alcohol amount in venous blood is dimensions. In modified form, these
indicated by g/l or per mille (1 g/l = formulas are the basis of all calculation
1 ‰). programmes.
For forensic purposes it is often
necessary to count back from a specific
8.2.4.4 Breath alcohol
value, for which the following options
are often used. All these assessments Blood alcohol is released from the al-
are based mainly on the Widmark for- veolae of the lung to the inhaled air,

124
Assessment of drinking behaviour by using biological markers

whereby alcohol is measured during ally excludes all sources of error like re-
exhalation (0,4 mg/l = 0,84 ‰). This ra- sidual alcohol in the mouth, manipu-
tio is not constant and changes with lation of breathing technique, cross
time, a process in which individual fac- sensitivity for other substances like ac-
tors, especially body temperature, plays etone etc. If both processes show con-
a role. During the absorption phase, the sistent values, the results are directly
alcohol distribution between arterial written in mg/l respiration air.
and venous circulation also has power-
ful effects on the balance of dispersion
8.2.4.5 Products of alcohol metabolism
of blood/breath alcohol. Therefore all
attempts to accurately (fluctuation at 8.2.4.5.1 Ethyl glucuronide
0.1 mg/l) calculate blood alcohol con- In 1967, “activated” glucuronic acid (Uri-
centration via conversion from meas- din-5-diphospho-ß-glucuronic acid) was
ured breath alcohol concentration have detected in human urine for the first
principally failed. Yet for clinical pur- time. This acid is generated like a direct
poses and for approximate evaluations alcohol metabolite and its existence can
in road traffic situations, the breath al- be proven over a relative long period
cohol value is absolutely sufficient. (around 80 hours) in the urine or serum.
The present generation of breath Quantitative analysis via GC/MS
alcohol analysers which are recalibrated as trimethylsilyl ether (fragments: 160,
every six months (so called “approved 261, 405) with d5-ethylglucuronide is
instruments”), analyze two independ- an internal standard (Wurst F. 2001;
ent breath samples in brief consecutive 2010 Hartmann S et al. 2007).
order with an infrared optical and an Alcoholic beverages don’t only
electro chemical measuring system, consist of ethanol, but also of methanol
with an additional standardization of and long-chain alcohols. When drink-
breath temperature to 34 °C. This virtu- ing alcohol, both ethanol and methanol

Fig. 80 Elimination of ethanol (BEC) and methanol (BMC)

BEC BMC
BMC

BEC

hours

125
8 Detection of alcohol and tobacco addiction

are absorbed and ethanol is more quick- methanol level often above 10 mg/l))
ly eliminated than methanol. Methanol additional to the elevated ethanol level
is not eliminated until a level of 0.4 g/l (Sprung R et al. 1988; Bonte W. 1987;
ethanol is reached. Leitner A et al. 1994).
Additional to the normal degrada- If these measurements are repeat-
tion pathway, alcohol dependents acti- ed after one hour and the patient does
vate the MEOS system and catalase for not only eliminate ethanol but also
the degradation of methanol in order to eliminates methanol despite the ele-
eliminate methanol despite a high eth- vated ethanol level, we can conclude
anol level (alcohol dependent patients that the MEOS and catalase systems are
who continuously drink alcohol don’t activated. This suggests that the patient
reach less than 0. 4 g and therefore have metabolises alcohol differently than
too much methanol in their bodies). healthy individuals. These patients al-
Lesch’s types, however, differ in terms most always meet the diagnostic crite-
of degradation speed (Fig. 6). ria for an alcohol dependence accord-
By summarizing these results, we ing to DSM-IV and ICD-10.
can see that by analysing both, metha-
nol and ethanol, we can draw conclu- 8.2.4.5.2 %CDT (Carbohydrate-decient-
sions about the acute or chronic use of transferrin)
alcohol, and partially also about the In 1976, a transferrin variant was dis-
consumption behaviour of alcohol de- covered in the serum of alcohol depend-
pendents. ent patients. In the following years,
Alcohol intoxication in patients transferrin research showed that the car-
who are normally abstinent, elevates bohydrate deficient transferrin (%CDT)
the ethanol level, but the methanol is more specific than all other markers.
level remains low. Serum transferrin has a polypeptide
If a patient is continuously intoxi- structure with polysaccharide side
cated, methanol levels are elevated (a chains. The absence of such side chains

Fig. 81 CDT-molecule

126
Assessment of drinking behaviour by using biological markers

has been pinpointed as a consequence didn’t correlate with the amount or du-
of the effects of alcohol. ration of drinking, suggesting that dif-
The specificity is high, between ferent sensitivities are influencing the
75 % and 98 % (Stibler H and Borg S. %CDT value, independent of drinking
1986). behaviour.
The sensitivity is reported mostly Those patients who react sensi-
between 63 % (Lesch OM et al. 1996) tively to alcohol with %CDT (which
and 80 % (Litten R and Allen J. 1992) means that they had already reached
(Review by Walter H et al. 2001). In Eu- an elevated %CDT value previously)
rope, the sensitivity in studies which show an increase in %CDT even after
have included clinical alcohol depend- the consumption of low amounts. Our
ents according to DSM-IV, is almost al- therapy studies showed that %CDT can
ways indicated around 63 %. be used as a biological marker of re-
We were able to examine %CDT of lapse. After three weeks of absolute ab-
healthy participants in a drinking ex- stinence patients reach an individual
periment and results showed that even basis value. The basis value correlates
a daily amount of 80 gram of pure alco- with relapse if its value is increased by
hol over three weeks does not elevate 0.8 % within the standard value. The
the %CDT in healthy persons (Lesch %CDT is not influenced by other dis-
OM et al. 1996). 63 % of alcohol de- eases (e. g. diabetes etc). Only in severe
pendent patients showed an elevated liver diseases, which lead to a signifi-
%CDT during intoxication, which de- cant reduction in blood coagulation as-
graded after two to three weeks of con- sessed by normotest, the %CDT value
trolled abstinence. The %CDT value correlates with the severity of the liver

Fig. 82 Degradation of %CDT in alcohol intoxicated alcohol dependents

127
8 Detection of alcohol and tobacco addiction

Fig. 83 Liver cirrhosis and alcohol dependence: relationship between Prothrombine


time and %CDT

Prothrombine time

damage and not the drinking behaviour. stinence (Berlakovich GA et al. 1999).
If blood coagulation is so severely In the long term course after liver
impaired that the normotest is below transplantation percentage CDT shows
75 %, the %CDT loses its significance as a sensitivity of 92 % and a specificity of
a marker because the elevation of the 98 % according to alcohol intake.
%CDT now depends on the severity of As most alcohol dependents smoke,
liver damage. the %CDT has been examined in re-
After a liver transplantation, the gards to smoking and it has been shown
%CDT is able to document further ab- that it can be used as a marker for ac-

Fig. 84 %CDT as control for abstinence in alcohol dependents with liver transplanta-
tions

n = 97 Alcohol dependence Sensitivity % =


(11/11 + 1) x 100 = 92 %

%CDT Specicity % =
Relapse No relapse
83/2 * 83) x 100 = 98 %

Positive 11 2
Negative 1 83

128
The clinical dialogue in tobacco addiction

tive drinking in alcohol dependents (ASAT, ALAT, de Ritis Factor, Gamma-


who smoke (Whitfield JB et al. 1998). GT, as well as the MCV and the %CDT).
Additional to these very specific The sensitivity of these different mark-
markers for drinking behaviour, indi- ers is also influenced by genetic and
rect markers are available which mirror other causes. The relationship between
alcohol-related changes. Obviously these these markers is still unclear. This in-
changes might have other causes too. fluence can be seen by the fact, that the
Hepatitis, e. g. or choleostasis can ele- different markers do not correlate to
vate liver levels in the same way. Such each other (Fig. 85).
acute chronic diseases change the
haemogram, like for example the MCV. 8.3 The clinical dialogue in
The advantage of these markers is the
tobacco addiction
fact that they are still detectable after
a period of abstinence (weeks up to In essence, similar rules apply for to-
months). As blood clotting is of emi- bacco dependents as for alcohol de-
nent importance for surgical interven- pendents, although stigmatisation and
tion and alcohol dependents with liver shame play a less important role. Smok-
damage often have blood coagulation ing should be directly tackled as a risk
disorders, these markers can be used factor for health and the relationship
to confirm long-term abstinence (over between problems and smoking should
weeks). The combination of these mark- be the focus of exploration. The distinc-
ers increases sensitivity at the costs of tion between abuse and dependence
specificity. Liver parameters are clini- and a precise diagnosis of smoking de-
cally the most common markers today pendence are the next steps. An objec-

Fig. 85 The relationship between different markers (n = 56) in alcohol dependent


patients
males ASAT ALAT

ASAT

ALAT

129
8 Detection of alcohol and tobacco addiction

tive evaluation of the number of ciga- logue. Spirometric findings document


rettes smoked and the expected the direct impact of smoking on respi-
withdrawal syndrome, as assessed by ration (Lesch OM. 2007). Diagnosing
using a Smokerlyzer (measuring the and addressing tobacco dependence
level of carbon monoxide in respiratory significantly increases motivation to
air), is helpful for the motivational dia- reduce or quit smoking.

130
9
Therapeutic strategies in alcohol
and tobacco addiction
9.1 Motivation for therapy in patients who are highly motivated to
undergo specific therapy should be sent
different settings
without delay to specialists (e. g. de-
If an alcohol and/or tobacco problem toxification centres). These institutions
forms part of the clinical picture of the should possess a therapeutic chain
patient, it is important to initiate thera- (outpatient – inpatient – outpatient)
peutically available strategies that meet and should offer outpatients a psycho-
the patient at the point that feels sub- therapeutic setting with the option of
jectively “right” to him i.e. the demands brief inpatient admission. The duration
made on the patient should be modest of an inpatient admission depends on
at the beginning. This will vary accord- the psychiatric and somatic symptoms
ing to setting. One can easily imagine and typology.
that the therapeutic options available Patients who consult a medical
at the general practitioner’s are differ- practitioner because of somatic prob-
ent to those in a homeless shelter or in lems,, but deny their alcohol problem,
a specific addiction treatment centre. should be confronted with their prob-
lem by using the guidelines of the Plin-
9.1.1 Motivational interviewing at the ius Maior Society (www.alcoweb.de).
general practitioner’s These guidelines describe mechanisms
to raise the patient’s awareness of his
Somatic problems are the most fre- drinking behaviour and offer motiva-
quent reason why alcohol and tobacco tional strategies to change drinking be-
dependent patients consult a practi- haviour. Absolute abstinence is an ac-
tioner. Patients seldom seek assistance ceptable goal, but also dosage reduction
for social problems at the general prac- as well as the reduction in the duration
titioner’s and only a small minority reg- and severity of drinking episodes, are
ularly request a medical check-up. Most acceptable therapy goals.
patients have a relationship of trust If one of the above therapy goals
with their practitioner, who is the piv- is accepted, withdrawal treatment or
otal element in every course of treat- a reduction of drinking (“Cut down
ment. A medical specialist is rarely con- drinking” according to the method of
sulted. Only in exceptional cases, can Sinclair D) can start. The goal of with-
patients be motivated to consult a psy- drawal treatment is to make the first
chiatrist or to seek admission to a de- phases of abstinence easier and to re-
toxification centre. In this case, these duce the craving for tobacco and alco-

131
9 Therapeutic strategies in alcohol and tobacco addiction

hol. An inpatient withdrawal treatment psychotherapeutic-psychiatric-setting.


should only be recommended if it is the Type IV patients can be cared for by so-
patient’s explicit wish and/or if severe cial workers qualified in addiction, to-
withdrawal or sequelae are diagnosed. gether with an internist.
Suicidal patients and patients with very
adverse circumstances (e. g. the home- 9.1.3 Motivational interviewing during
less) should be admitted immediately. pregnancy
If the patient can’t be motivated
towards an inpatient admission or if As it is already known that not only to-
none of the points above apply, with- bacco but also alcohol damages the un-
drawal therapy can be carried out at born child, the gynaecologist should
home. Besides adequate medication, tell every woman not to smoke nor drink
simple recommendations on self-care alcohol during pregnancy. If a woman
are very helpful for withdrawal. It is smokes and/or drinks alcohol during
crucial that regular check-up appoint- pregnancy, the motivating dialogue
ments are made at short intervals. should address the topic of abstinence.
The Viennese research group showed
9.1.2 Motivational interviewing in internal that this talk motivates most women to
medicine quit smoking and drinking. Only those
who are not able to reduce smoking de-
In essence, this procedure is not very spite these recommendations should
different to the motivational dialogue take part in a withdrawal programme.
at the general practitioner’s. These pa- As passive smoking is also an impor-
tients more often have acute somatic tant topic for pregnant women, their
problems, sometimes even life-threat- families should also be invited to join
ening (e. g. bleedings in liver cirrhosis, these programmes.
dyspnoea in COPD etc). Therapy of the
somatic disease is pivotal and the situ- 9.1.4 Motivational interviewing in
ation should be used to start a with- psychiatric settings
drawal therapy. In this situation pa-
tients are often more approachable and As expected, most patients primarily
more likely to accept a therapy setting enter a psychiatric setting because of
that offers relapse prophylaxis over a mental symptoms like anxiety or de-
longer period of time. The interaction pression. They usually expect to receive
between withdrawal medication, re- psychopharmacological treatment, e. g.
quired medication for the somatic dis- anti-depressants. As far as this group is
ease, withdrawal symptoms and the concerned, it is important to address
actual somatic disease needs to be con- the tobacco and alcohol problem and
sidered. After the withdrawal symp- to make the patient aware that the first
toms subside, it is appropriate to set up important step in therapy of the psy-
an ambulant therapy setting which of- chiatric symptoms is either to reduce
fers different options according to ty- consumption or to become abstinent.
pology. Lesch’s type I patients should In the case of abstinence, the pa-
be further treated by an internist, while tient needs adequate withdrawal med-
type II-and type III-patients need a ication. Therapy for the psychiatric

132
Motivation for therapy in different settings

symptoms should be started after four- is extremely important. A calm and pa-
teen days of abstinence. If antidepres- tient way of listening is needed. One
sants, e. g. tricyclics are administered in must wait until a stable emotional basis
an early phase of withdrawal, the symp- has been formed between patient and
tomatology of the transitory psychotic therapist. Approaches that structure
syndrome (see page 8) might be aggra- too early might be successful in the
vated and could lead to delirant states short run (several months), but do lead
or epileptic seizures. Reducing smok- to relapse if no changes are made in
ing often changes psychiatric symp- lifestyle and in the mechanisms to deal
toms (anxiety disorder is ameliorated, with adverse situations and stress (al-
but in some cases depressions might cohol for relief). Depressive symptoms
get worse). and feelings of guilt often follow. This
If the patient is suicidal, admis- often leads to the patient stopping
sion to a stable setting is recommend- therapy. Inpatient therapies with rigidly
ed. Regular short-term outpatient ap- structured procedures and without con-
pointments are absolutely categorical tinuing therapy after discharge often
and different styles of motivation and lead to a severe suicidal crisis in re-
psychotherapeutic behaviour should be lapsed patients. The commitment of the
used depending on the specific sub- patient to a stable outpatient relation-
group. ship (crisis concept) after inpatient
While Lesch’s type I-and type IV- treatment is essential.
patients require education and a behav- Certain detoxification centres em-
iourally oriented therapeutic approach, ploy very rigid therapeutic concepts
type II patients need stabilisation (and which serve the organisation of the in-
often meet the criteria of a dependent stitutions but rarely the patients. These
personality). It is common for the part- concepts are often divided into four
ner, who is usually powerful, to want to stages which include: (1) detoxification
“put” the patient into therapy (image: (2) motivation (3) activation and (4) plan-
like a car into service). Type II patients ning of long-term treatment.
need protection, support, rewards and There are institutions which only
realistic short-term therapy goals. offer stage 2 and stage 3 for usually six
Performance-oriented, type III- to eight weeks in an inpatient setting.
patients have usually already informed Some wards only offer stages 1–3, so
themselves about the therapeutic proc- that detoxification is included in the
ess by reading books or using the inter- eight-week inpatient admission. Few
net. Mostly they want to cut down their institutions have sufficient programmes
drinking. They are very often quite re- for all stages. Ideal would be a pro-
sistant to changing their lifestyle (and gramme in which the therapist, or the
their subjective convictions of having therapeutic team, assists the patient
to be perfect). The aim of motivation in before inpatient admission, is respon-
Lesch’s type III patients is to help them sible for him during inpatient admis-
learn to understand the pathogenic sion, and is also in charge of a two-year
process, which often takes several outpatient therapy after discharge. Out-
months to up to half a year. “Therapeu- patient therapy should help to amelio-
tic abstinence” during the first months rate problems by offering regular psy-

133
9 Therapeutic strategies in alcohol and tobacco addiction

chotherapeutic sessions (individual) fect of alcohol is the activation of subu-


and specific pharmacological therapy. nits alpha3beta2 and alpha3beta4 of
Relapses should be a cause for modify- the nicotine receptor (Cardoso RA et al.
ing the therapeutic concept, but should 1999).
never be a reason for terminating ther- Chronic consumption, however,
apy. leads to the opposite effects. In order to
maintain homoeostasis, GABA-A-recep-
9.2 Pharmacotherapy of alcohol tors are functionally changed and gluta-
mate receptors and opiate receptors
and tobacco addiction
are increased in numbers. Dopamine is
Biological principles of pharmacother- gradually reduced and, only after absti-
apy (see chapter 3.4) nence, does the dopamine system slow-
ly recover. Also the sedating and eupho-
9.2.1 Alcohol addiction rising effects decrease. More alcohol
needs to be consumed to attain the
Acute Alcohol consumption activates original effects (increase in dosage).
GABA-A, blocks NMDA-receptors, stim- As alcohol dependents/abusers
ulates ß-endorphin and dopamine re- consume alcohol in large amounts over
lease and activates the serotonin sys- a long period of time, they can be viewed
tem (Tabakoff B and Hoffman PL. 1991). as chronically intoxicated. Standard al-
Higher concentrations of serotonin are cohol not only contains ethanol but
caused by either an increase in release, also methanol, propanol, butanol and
or partial blockade, of the presynaptic other ingrediants. All of these are re-
reuptake (Le Marquand D et al. 1994). sorbed in the gastrointestinal tract.
This is what causes the sedating and Stomach and liver functions are very
euphorising effects. Another acute ef- important as a large proportion of these

Fig. 86 Effect of acute alcohol consumption on transmitter systems

NEUROTRANSMITTLER CHANGES IN THE BRAIN


AFTER ACUTE ALCOHOL CONSUMPTION
AChE
NA
5-HT
Opiates
Inhibitory amino acids
(GABA, taurine)
CL flux
Neuronal excitability
= increase; = reduction
AChE = acetylcholinesterase, NA = noradrenergic; 5-HT = serotonine

134
Pharmacotherapy of alcohol and tobacco addiction

Fig. 87 Changes in transmitters after chronic alcohol consumption

increase reduction

alcohols is already inactivated by these tions over time. TIQs, in particular, oc-
organs. Stomach function impairments, cupy the opiate receptor. There has been
reduced intestinal functions (e. g. stom- discussion about whether this mecha-
ach surgery, Billroth II) and acute dis- nism can partly explain the so-called
turbances in liver function significantly “endogenous craving” for alcohol (Bon-
increase the alcohol content in the blood te W. 1987; Sprung R et al. 1988; Muss-
and brain. hoff F et al. 2005). However alcohol also
The effects of alcohol on the brain stimulates the release of ß-endorphin-
are not only inhibitory and, for this rea- like peptides and met-encephaline in
son, alcohol is used not only as a tran- the hypothalamus and striatum. Chron-
quilizer or a sleep-inducing agent, but ic alcohol consumption leads to an ele-
is also consumed for its mood altering vated availability of binding sites (re-
effects and its ability to affect drive. To- ceptors).
day it is known that chronic alcohol con- Early onset of drinking or trau-
sumption changes neurotransmission matic disorders (mental or somatic
in practically all systems (activating, but trauma) interferes with normal brain
also inhibiting). development. This leads to an increased
Besides, aldehydes, the first deg- vulnerability and to an aggravation of
radation products, combine with dopa- the existing brain impairment. Also
mine to form THBCs or the so-called early consumption and prenatal effects
tetrahydroisoquinolines ( TIQs). The of alcohol lead to long-term learning
binding of aldehyde with indolamines disabilities. When patients with high al-
produces beta-carbolines. Both con- cohol consumption were compared to
densation products change brain func- abstinent individuals, the former groups’

135
9 Therapeutic strategies in alcohol and tobacco addiction

hippocampus was reduced in size, sug- tic effect is connected with GABA-ago-
gesting that less tissue is available for nistic and glutamate-antagonistic effects
the neuronal network that is responsi- (in particular an AMPA-[alpha-amino-
ble for learning and memory (Beresford 3-hydroxy-5-methylisoxazole-4-propi-
et al. 2006). From an aetiological per- onic acid] and a kainate-receptor-antag-
spective, this result can be linked to onism) (Nguyen SA et al. 2007; Johnson
high cortisone levels (Beresford TP et BA. 2004; Johnson BA et al. 2004). It has
al. 2006a). been shown that this effect profile is
Addiction memory is activated successful in reducing symptoms of
and addiction-related information is nicotine withdrawal (Ait-Daoud N et al.
stored in the limbic system. The limbic 2006).
system is involved in pleasure, emotion, Glutamate is an activating neuro-
experiences, drive and also supports transmitter with various sub-receptors
cognitive functions. Chronic stimulation (NMDA, AMPA and Kainate). Alcohol
activates the dopaminergic reward sys- primarily binds to the N-Methyl-D-As-
tem (ventral tegmental area – nucleus partate subreceptors (NMDA). The abil-
accumbens), which leads to an adapta- ity to bind with NMDA receptors, blocks
tion of this system. The neurotransmit- activity and can be linked to the anal-
ter dopamine controls the extrapyram- gesic effects of alcohol. Through this
idal motor function (impairment of blockage, the number and sensitivity of
these functions is visible in intoxicated NMDA receptors increases in order to
individuals). An over-activation of this compensate. Thus there is more stimu-
transmitter leads to psychotic states. A lation in the CNS and more GABA activ-
deficiency leads to motor dysfunctions ity is required. This leads to an increase
like M. Parkinson. When alcohol is con- in dosage to avoid withdrawal symp-
sumed occasionally, dopamine is re- toms. Furthermore, this glutamate ac-
leased, lifting the mood and sometimes tivation is associated with cell loss and
even causing euphoria. Chronic de- corresponding cerebral sequelae like
pendence leads to dopamine depletion cognitive dysfunctions, Korsakov’s de-
and to typical motor dysfunctions mentia etc.
(therefore, not every motor dysfunction The glutamate system influences
has polyneuropathic causes). In inter- the nucleus accumbens via afferents.
action with noradrenalin, dopamine Next to topiramate, acamprosate has
controls the activity of the cholinergic positive pharmacotherapeutic effects
system. Acetylcholine is important in in alcohol dependence and works by re-
connection with smoking as nicotine ducing corticomesolimbic glutamate ac-
receptors are cholinergic receptors. tivity. Acamprosate antagonises NMDA
Studies which have tried to reduce and the Kainate receptor subtype 5
craving by classical neuroleptics antag- (mGlur5; De Witte P et al. 2005). Studies
onising the dopamine receptor, have on conditioned alcohol cues showed
mostly failed (Wiesbeck G et al. 2001; that acamprosate works by reducing
Walter H et al. 2001). More recent studies autonomous reactions to these cues,
on topiramate, which controls dopamine while the mμ-opiate antagonist nal-
release, seem to be more promising, es- trexone could reduce craving overall
pecially since the dopamine antagonis- (Ooteman W et al. 2007). Ooteman et al.

136
Pharmacotherapy of alcohol and tobacco addiction

did not find that these medications had and interact with dopamine and ace-
any effect on cortisol. This is contrary tylcholine. CB-1-and CB-2-receptors
to other authors who found that nal- have been researched and CB-1-recep-
trexone activates the HPA-axis (hypoth- tors were mainly localised in limbic
alamic-pituitary-adrenocortical-axis), brain areas. The CB-1-antagonist, ri-
as a result of which they suggested that monabant, has been discussed as a
naltrexone is more effective in women very promising alternative to current
(Kiefer F et al. 2005). If patients are di- pharmaceutics for nicotine depend-
vided into subgroups, clinical effects ence (Cohen C et al. 2005), alcohol de-
are more clearly distinguishable. For pendence and overweight (Simiand J et
example, it was found that acampro- al. 1998). Alcohol related dopamine re-
sate had better abstinence rates in type lease is antagonised by CB-1-blockers,
I and II according to Lesch (Lesch OM whereby no positive emotional rein-
et al. 2001). These results have been forcement occurs. Animal experiments
replicated for type I (Kiefer F et al. showed that CB-1-antagonists reduce
2005a). In this study, the abstinence the amounts of alcohol drunk (Colom-
rate in the placebo group of type II, bo G et al. 1998). Later studies demon-
even after three months, was so good strated a relationship between CB-1-
that neither acamprosate nor naltrex- receptors and opiate receptors and
one was able to show any effect. In this pointed to a possible clinical combina-
study, Kiefer showed that naltrexone tion of opiate antagonists and CB-1-
significantly improved abstinence rates antagonists (Colombo G et al. 2005; Co-
in types III and IV (Kiefer F. et al. 2005a). hen C et al. 2002; Anthenelli R. 2004;
These results can be supported by data Klesges RC et al. 1997, 1989; Soyka M et
from basic research, since if treatment al. 2008)
runs smoothly, acamprosate reduces Serotonin stimulates dopamine
craving mainly during abstinence, while release in mid brain (VTA) and there-
naltrexone is able to reduce the amounts fore advocates the subjectively pleas-
and the duration of drinking (Volpicelli urable, so called “reward effects” of al-
JR et al. 1997; Garbutt JC et al. 2005; cohol (Lovinger DM. 1997). Clinical
O’Malley SS et al. 2007). observations of the frequent co-mor-
Studies with the NMDA-antago- bidity of alcohol dependence with anx-
nist neramexane were not able to pro- iety and depression (van Praag HM et
duce an increase in abstinence rates al. 1991; Virkkunen M et al. 1994, 1996)
(unpublished data). or impulse control disorders (Linnoila
A hypofunction of NMDA-recep- M et al. 1983; Virkkunen M et al. 1997)
tor subtypes of cortical limbic afferents suggest a dysfunction of the serotonin
has recently received attention from system. Alcohol related heightened se-
schizophrenia research and has been rotonin release seems to play a role in
linked to the high prevalence (85 %) of “relief drinking” (drinking to reduce
indirect glutamate activating substance anxiety and depression) (Cooper ML et
abuse (stimulants) in schizophrenic al. 1995; Markou A et al. 1998). Howev-
patients (Coyle JT. 2006). er, it must be noted that experiments
Endocannabinoids influence with animals showed more positive re-
GABAergic and glutamatergic synapses sults than later clinical studies with SS-

137
9 Therapeutic strategies in alcohol and tobacco addiction

RIs (Heinz A et al. 2001; Johnson BA. frequency of drinking in patients with
2000; Lovinger DM. 1997; LeMarquand an early onset of drinking (Johnson BA.
D et al. 1994; Naranjo CA and Knoke 2004). Reduced MAO activity has also
DM. 2001; Pettinati HM et al. 2003; Gar- been found by several researchers (An-
but JC et al. 1999; Johnson BA and Ait- thenelli RM et al. 1995; Demir B et al.
Daoud N. 2000; Kranzler HR et al. 1996; 2002; Rommelspacher H et al. 1994;
Litten RZ and Allen JP.1998). These Sullivan J et al. 1990). Pettinati has em-
studies probably failed because co- phasized that multiple dysfunctions in
morbidities were excluded and no sub- the serotonin system play a role in de-
groups were used and possible effects pendents as well as in excessive drink-
on subgroups could not therefore be ers. Yet it is likely that the original acute
observed. Lovinger’s work points to an effects of alcohol are merely restored by
elevation of reuptake (Lovinger DM. a simple increase of serotonin in the
1997). Genetic studies on serotonin synaptic cleft (e. g. with SSRIs). Clini-
transporters show an unclear picture cally, this could also be the case as SS-
(Caspi A et al. 2003; Hill EM et al. 2002; RIs could potentially promote a relapse
Kranzler HR et al. 2002). Patients with when no other medicine is adminis-
an early onset of drinking, in particular, tered (Pettinati HM et al. 2003).
show dysfunctions of the serotonin sys- In animal experiments, reduced
tem (Benkelfat C et al. 1991; Buydens- pre-synaptic noradrenalin reuptake (in
Branchey L et al. 1989; Demir B et al. the locus coeruleus) has been linked to
2002; Javors M et al. 2000; Krystal JH et alcohol consumption (Hwang BH et al.
al. 1994; Swann AS et al. 1999; Virkkunen 2000). Due to fact that research has fo-
M and Linnoila M. 1997). When pa- cused a great deal of attention on the
tients had an early onset of drinking, dopamine reward system, the noradren-
their subjective reasons for doing so are ergic reward system has been relatively
often that they could tolerate alcohol neglected and is only now gradually be-
“well”. Schuckit MA et al. (2006) showed ginning to receive more attention (Wein-
that this patient group is especially at shenker D and Schroeder JP. 2006).
risk. This alcohol tolerance might be
connected to a serotonergic hypofunc- 9.2.2 Tobacco addiction
tion, which might be caused by genetic
or previous social stress factors (Caspi Tobacco contains about 4,800 pharma-
A and Moffitt TE. 2006). This tolerance cologically active substances. Together
apparently reduces the GABAergic ef- with the mono-amino-oxidase-system,
fects of alcohol and individuals are less nicotine seems to be the most funda-
sedated than those with no genetic vul- mental substance for the development
nerabilities. This suggests a genetic dis- of an addiction. Nicotine activates nic-
position for excessive alcohol con- otinic acetylcholine receptors. These
sumption. are ionic channels whose walls are made
In alcohol dependents with an up of five protein chains. Acetylcholine
early onset of drinking, alcohol modu- binding changes the structures in the
lates the 5-HT-3 receptor. Also on- cell membrane so that sodium and/or
dansetrone, a 5-HT3-antagonist, is ef- calcium can enter the neuron. The for-
fective in reducing the quantity and mation of the protein chains that build

138
Pharmacotherapy of alcohol and tobacco addiction

up the wall of the receptor varies and is in relapse prevention. Nicotine substi-
characteristic of specific organs and tutes are also active via this mechanism.
functions. For example, the receptors Varenicline stimulates receptors slightly
in the brain are made of α4β2- or α7- to moderately, but blocks the stimula-
subunits. A relatively large amount of tion of nicotine. The dopaminergic neu-
calcium can pass these cells and be- rons are stimulated also by endorphin-
cause of this, they are very suitable for ergic and endocannabinoidergic
the formation of memory. In fact, ani- neurons. This is very important for treat-
mal experiments showed that nicotine ment with the μ-opioid receptor-antag-
promotes memory formation. Further- onist, naltrexone, and the cannabinoid-
more, it was shown that memory for- 1-receptor-antagonist, rimonabant,
mation plays an important role in to- respectively.
bacco dependence. Findings from positron emission
Smoking stimuli are therefore es- tomography, an imaging technique
pecially “effective” because memory has which makes visible nicotinic receptors
been intensively channelled by nico- in the brain are very surprising (Brody
tine. In animal experiments, this chan- AL et al. 2006). A single drag from a cig-
nelling was still present after months of arette already leads to the occupation
abstinence. of nicotinic α4β2-receptors for around
Nicotinic receptors stimulate me- three hours in several brain regions. Af-
solimbic-mesocortical dopaminergic ter one cigarette, around 90 % of recep-
neurons in the ventral tegmentum. tors are switched off for at least two and
These effects explain why a partial α4β2- a half hours, after two or more ciga-
receptor antagonist like e. g. varenicline rettes receptors are switched off even
can be used as an anti-craving substance longer. Researchers have concluded

Fig. 88 Nicotinic acetylcholine receptor (nAChR)

a: Arrangement of
subunits. The nAChR
consists of either
identical (e. g. α7) or
different peptides or
(e. g. α4β2; left)
Nidation of a single
subunit into the mem-
brane (right)

b: Nicotinic receptors
are located at several
points of the neuron.
The receptors at the
presynapse stimulate
the release of neurot-
ransmitters like e. g.
acetylcholine and
glutamate.

139
9 Therapeutic strategies in alcohol and tobacco addiction

that a smoker who smokes 20 cigarettes stimulation of the mesolimbic dopa-


a day, for example, does not have any minergic neurons. In in-vivo microdi-
α4β2-receptors available. Experiments alysis experiments with animals, it was
with cell cultures showed that these re- found that the application of β-car-
ceptors are inactivated by nicotine only bolines (norharmanes und harmanes)
a few seconds after stimulation (down- leads to the release of dopamine in the
regulation by phosphorylation). These nucleus accumbens and therefore
studies on dosage dependence also changes the central relay stations in the
showed that craving only diminishes reward system (Sallstrom-Baum S et al.
when more than 75 % of receptors are 1995, 1996). Although β-carbolines can
occupied. It was concluded from these be found in low concentrations in the
data that the avoidance of craving is a body, they are formed from tryptophan
central motive for continuing to smoke. via pyrolysis and then inhaled. They ac-
This also explains why the dependence cumulate in the brain, with regions like
potential and risk for relapse in tobacco the substantia nigra and the ventral
smoking is so high in comparison to tegmentum showing levels of norhar-
other addictive substances. It is very manes with an almost thirty times
difficult for an ex-smoker to avoid cues higher concentration. This relationship
about his tobacco dependence (ciga- is schematically portrayed in the fol-
rette automat, remembering the feeling lowing figure (Rommelspacher H et al.
of relaxation after a cigarette etc.) 2007).
How is it possible that smoking
can still have desirable effects despite Conclusion
these conditions? In order to explain  Nicotine and alcohol consump-
this, it must be acknowledged that to- tion have much in common and,
bacco smoke contains around 4,800 from a biological perspective, two
substances (German Cancer Research directions in regards to anti-crav-
Centre Heidelberg, 2006). Thus, many ing-effect and relapse prophylaxis
other substances play a role in the are currently apparent :

Fig. 89 Changes caused by chronic smoking and rebound phenomena


A: At the beginning of smoking B: After nicotine application C: After smoking one to two cigarettes

Nicotine Nicotine
receptor receptor
Nicotine

Dendrites/cell body in Dendrites/cell


the ventral tegmentum body in the ventral
tegmentum
Action potentials which
are characteristic for
dopaminergic neurons
Release of dopamine
in the nucleus ac-
Release of dopamine cumbens stimulated
in the nucleus by other tobacco
accumbens ingredients like
beta-carbolines
(norharmane and
harmane)

140
Pharmacotherapy of alcohol withdrawal

 Opioid/dopaminergic effects are The primary goal of the therapy is


associated with rewards and need the specific therapy of withdrawal symp-
an opiatantagonistic, a CB-1-an- toms. Medication should be chosen and
tagonistic and partly also a gluta- dosed according to the severity of the
matantagonistic profile for phar- intoxication, the severity of alcohol se-
macological therapy. quelae (e. g. a liver damage changes the
 Serotonin and GABA/Glutamate metabolising of most medicaments)
are associated with reliefs (relief and the nature and severity of with-
drinking, relief smoking) and re- drawal symptoms. Withdrawal medica-
quire pharmacological treatment tion should meet the following criteria:
with antidepressants, anxiolytics  Prevention of withdrawal symp-
and anti-glutamatergic drugs. toms (early start of therapy, high
doses at the start)
 Avoidance of secondary damages
9.3 Pharmacotherapy of alcohol
caused by the medication (aggra-
withdrawal
vation of liver damage; cave: car-
9.3.1 Withdrawal syndrome diac arrhythmia, cave: seizures)
 The medication should not dis-
Chronic alcohol consumption up-reg- turb the motivation process (heavy
ulates the glutamate system, GABA- sedation does not allow a motiva-
stimulation is terminated and an exci- tional dialogue)
tatory clinical picture of varying strength  No polypragmasy needed
develops. Withdrawal symptoms usu-
ally set in after alcohol consumption is Goals should be defined according to
decreased or completely terminated. withdrawal symptoms, which are dif-
In severely dependent patients, ferent for each of Lesch’s types.
who are admitted with more than In type I, the withdrawal symp-
2,5 ‰ breath alcohol, the withdrawal toms usually subside after five days,
symptoms usually set in at two per mil while it takes 14 days to subside in type
breath alcohol. There are somatic and II and III. The withdrawal symptoms in
psychological withdrawal symptoms. type IV are a combination of previous
The CIWA-Ar-scale is suitable for meas- cerebral damage and cognitive dysfunc-
uring somatic and psychological with- tion with symptomatic transitory psy-
drawal symptoms (Stuppaeck CH et al. chotic syndromes and these symptoms
1994; Pittman B et al. 2007), Fig. 90. can set in over months again and again.
Typical withdrawal symptoms are Therefore goals and medications are
tremor, sweating, anxiety and agitation. different for each group and need to be
defined accordingly (see chapter 9.3.3).
9.3.2 Therapy of withdrawal states The duration of treatment de-
pends on the typology. If the sympto-
Withdrawal can be carried out in an matic does not develop according to a
outpatient or inpatient setting, depend- typical course type, often other factors
ing on the severity of the withdrawal (combinations with tranquilizers) or
symptom and the somatic-medical other somatic diseases need to be de-
situation. fined as causes of this atypical sympto-

141
9 Therapeutic strategies in alcohol and tobacco addiction

Fig. 90 Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar)


(Sullivan J T 1989)

Alcohol Withdrawal Assessment Scoring Guidelines (CIWA – Ar)


Vital Assesment
Nausea/Vomiting – Rate on scale 0–7 Tremors – have patient extend arms & spread fingers.
Rate on scale 0–7.
0 – None 0 – No tremor
1 – Mild nausea with no vomiting 1 – Not visible, but can be felt fingertip to fingertip
2 2
3 3
4 – Intermittent nausea 4 – Moderate, with patient’s arms extended
5 5
6 6
7 – Constant nausea and frequent dry heaves and vomiting 7 – severe, even w/arms not extended

Anxiety – Rate on scale 0 – 7 Agitation – Rate on scale 0–7


0 – no anxiety, patient at ease 0 – normal activity
1 – mildly anxious 1 – somewhat normal activity
2 2
3 3
4 – moderately anxious or guarded, so anxiety is inferred 4 – moderately fidgety and restless
5 5
6 6
7 – equivalent to acute panic states seen in severe delirium 7 – paces back and forth, or constantly thrashes about
or acute schizophrenic reactions.

Paroxysmal Sweats – Rate on Scale 0–7. Orientation and clouding of sensorium – Ask, “What day is
0 – no sweats this? Where are you? Who am I?” Rate scale 0–4
1– barely perceptible sweating, palms moist 0 – Oriented
2 1 – cannot do serial additions or is uncertain about date
3
4 – beads of sweat obvious on forehead 2 – disoriented to date by no more than 2 calendar days
5
6 3 – disoriented to date by more than 2 calendar days
7 – drenching sweats 4 – Disoriented to place and/or person

Tactile disturbances – Ask, “Have you experienced any Auditory Disturbances – Ask, “Are you more aware of sounds
itching, pins & needles sensation, burning or numbness, or around you? Are they harsh? Do they startle you? Do you hear
a feeling of bugs crawling on or under your skin?” anything that disturbs you or that you know isn’t there?”
0 – none 0 – not present
1 – very mild itching, pins & needles, burning, or numbness 1 – Very mild harshness or ability to startle
2 – mild itching, pins & needles, burning, or numbness 2 – mild harshness or ability to startle
3 – moderate itching, pins & needles, burning, or numbness 3 – moderate harshness or ability to startle
4 – moderate hallucinations 4 – moderate hallucinations
5 – severe hallucinations 5 – severe hallucinations
6 – extremely severe hallucinations 6 – extremely severe hallucinations
7 – continuous hallucinations 7 – continuous hallucinations

Visual disturbances – Ask, “Does the light appear to be too Headache – Ask, “Does your head feel different than usual?
bright? Is its color different than normal? Does it hurt your Does it feel like there is a band around your head?” Do not rate
eyes? Are you seeing anything that disturbs you or that you dizziness or lightheadedness.
know isn’t there?”
0 – not present 0 – not present
1 – very mild sensitivity 1 – very mild
2 – mild sensitivity 2 – mild
3 – moderate sensitivity 3 – moderate
4 – moderate hallucinations 4 – moderately severe
5 – severe hallucinations 5 – severe
6 – extremely severe hallucinations 6 – very severe
7 – continuous hallucinations 7 – extremely severe

142
Pharmacotherapy of alcohol withdrawal

matic (e. g. diabetes mellitus, cerebral The dosage should be adequately


bleeding). high at the beginning of withdrawal.
According to current research, The amount of dosage depends on the
withdrawal medication should have the quantity and nature of the addictive
following characteristics: drug(s) consumed, and the frequency
at which it is consumed, and needs to
 Effects of medication should im- be modified according to age, somatic
prove the underlying biological impairments (e. g. decompensated liver
dysfunctions that are caused by cirrhosis, renal damages due to abuse
giving up alcohol of analgetics, cardiac arrhythmia). When
 The medication’s effects set in determining the correct dosage, it is
quickly and are controllable helpful to ask the patients how much
 The medication does not cause alcohol they normally need to cope with
any long lasting cognitive impair- their withdrawal symptoms.
ment Important elements of a with-
 The medication has a low addic- drawal therapy are education about
tion potential symptoms and the withdrawal progres-
 The medication shows a low liver sion, and the creation of an environ-
toxicity ment in which the patient feels safe and
 The medication has few side ef- secure.
fects and there is no vital risk when As mentioned most of the cases
relapsing (cave: interactions) can be treated in an outpatient setting,
but in figure 90 some situations are listed
Besides oral administration, the med- when inpatient treatment is needed.
ication should also be available in a Patients who feel informed and
parenteral form so that no medication comfortable and who have a carefully
change is needed during the treat- scheduled activity programme require
ment. significantly lower amounts of with-

Procedure:
1. Assess and rate each of the 10 criteria of the CIWA scale. Each criterion is rated
on a scale from 0 to 7, except for “Orientation and clouding of sensorium”
which is rated on scale 0 to 4. Add up the scores for all ten criteria. This is the
total CIWA-Ar score for the patient at that time. Prophylactic medication should
be started for any patient with a total CIWA-Ar score of 8 or greater (ie. start on
withdrawal medication). If started on scheduled medication, additional PRN
medication should be given for a total CIWA-Ar score of 15 or greater.
2. Document vitals and CIWA-Ar assessment on the Withdrawal Assessment
Sheet. Document administration of PRN medications on the assessment sheet
as well.
3. The CIWA-Ar scale is the most sensitive tool for assessment of the patient
experiencing alcohol withdrawal. Nursing assessment is vitlly important. Early
intervention for CIWA-Ar score of 8 or greate provides the best means to prevet
the progressio of witdraa.

143
9 Therapeutic strategies in alcohol and tobacco addiction

Fig. 91 Recommondations for inpatient withdrawal treatment

 In case of the home environment being unsupportive in regards to the patient’s ab-
stinence and animating the patients towards drinking
 In case of previous withdrawal seizures or delirium tremens
 In case of polytoxikomania
 In case of strong tremor and tachycardia in present intoxication
 In case of orientation difficulties or hallucinations
 In case of suicidal tendencies
 In case of jaundice, liver cirrhosis or other signs of physical weakness and acute
malnutrition
 In case of several home-based withdrawals having failed in the past
 In case of the patient preferring an inpatient admission

drawal medication. Furthermore, these form patients about the danger of


patients have fewer critical incidents combining medication and alcohol.
than patients in different conditions They should also be told not to drive a
(e. g. accident victims with high levels car or handle domestic appliances
of aggression in a hospital corridor (mixer, electric knife, iron etc) or dan-
with stressed staff ). If withdrawal ther- gerous machinery. Simple advisory
apy is done at home, as it is in the brochures can be very helpful (www.
majority of cases, it is important to in- alcoweb.com).

Fig. 92 Recommendations for home-based withdrawals

144
Pharmacotherapy of alcohol withdrawal

9.3.3 Therapy of the withdrawal syndro- hyde levels even during abstinence).
mes according to Lesch’s typology Withdrawal should be perceived as a
rebound phenomenon (GABA-hyper-
9.3.3.1 Management of detoxication in sensitivity, GLUTAMAT-GABA-imbal-
Lesch’s type I alcohol dependents ance). Furthermore a depletion of the
dopaminergic system has been ob-
Withdrawal symptoms served.
Type I patients are often highly intoxi-
cated when coming to the first therapy Duration
meeting (> 1.2 mg/l). Withdrawal symp- Acute withdrawal symptoms are present
toms can already set in after reducing for approximately three to five days. Af-
the alcohol amount: three-dimensional ter that, symptoms are very mild or
tremor, heavy perspiration and vegeta- non-existent.
tive instability (blood pressure and pulse
fluctuations, instable cardiovascular sys- Withdrawal therapy
tem). The existing sleep onset and sleep From the start, benzodiazepines with a
maintenance insomnia lead to higher good antiepileptic profile should be
levels of anxiety and agitation (very administered in high doses, e. g.: ox-
high scores on the items tremors, anxi- azepam, diazepam or chlordiazepox-
ety, and agitation of the CIWA-Ar- ide. Instead of waiting until acute with-
scale, Fig. 90). drawal symptoms set in, symptoms
Patients are familiar with these should be treated as early as possible
symptoms from previous experiences (severity of liver damage must be con-
and therefore know that the first three sidered when titrating the dose). If
days are usually the most difficult. They there is a history of withdrawal seizures
fear these symptoms and have tried to and/or delirium tremens, medication
combat them with alcohol in the past. has to be dosed high enough. In order
Around 20 % are at risk for developing to specify the dosage, the patient should
complications: grand mal seizures can be asked, how much alcohol he/she
occur on the first or second day after normally needs, in order to eliminate
reducing the amount of alcohol. Often withdrawal symptoms. If very high dos-
patients report a history of previous ages of benzodiazepines are needed,
seizures. Delirium tremens can set in they should slowly be reduced over a
together with, or independent of, grand period of 10 to 14 days. When transfer-
mal seizures. This delirium tremens is ring the patient (inpatient to outpatient,
characterized by heavy respiration, high intensive unit to normal unit), it is im-
suggestibility, a loss of orientation and portant to continue following exactly
optical hallucinations of small objects the medication reduction programme
(micropsia). which has already been devised. Abrupt
termination of medication can lead to
Aetiology grand mal epileptic seizures. If there is a
This group uses alcohol as a medica- high risk for grand mal seizures, antie-
tion to ameliorate withdrawal symp- pileptic therapy can be added. In suf-
toms. A biological vulnerability has been ficient dosage, benzodiazepines do
hypothesized (elevation of acetalde- have sufficient antiepileptic effects.

145
9 Therapeutic strategies in alcohol and tobacco addiction

For strong alcohol craving despite clear sentences which are easily under-
sufficient benzodiazepine therapy, we standable; short-term goals should be
suggest administering caroverine 60– agreed upon (no long-term plans at this
120 mg daily, an anti-glutamatergic sub- stage). During withdrawal, patients suf-
stance which reduces alcohol craving. fer, above all, from disturbances of con-
Acamprosate (relapse prophylaxis) is centration and memory. Therefore the
started immediately to reduce the in- contents of what has been discussed
tensity of craving. Thiamine is admin- will need to be repeated again and again.
istered parenterally in doses between If patients do not feel they have a sup-
150–300 mg to improve cognitive per- portive environment at home and that
formance. abstinence won’t be possible, a short
inpatient treatment (10–14 days) might
Further important factors are: be suggested.
 Fluid and electrolyte substitution
 Monitoring in case of severe veg- Therapy goals
etative instability Total abstinence is central to a solution
 Cave: no parenteral administra- and can be achieved if the above-men-
tion of beta-blocker (risk for car- tioned therapy is followed.
diac arrest)!
 Anti-dopaminergic neuroleptics
9.3.3.2 Management of detoxication in
can increase later on relapse rate
Lesch’s type II alcohol dependents
Motivation Withdrawal symptoms
These patients have an impaired alco- During the course of treatment, patients
hol metabolism with dysfunctions in of this group usually show low blood al-
neurotransmitter interaction. Type I cohol levels and alcohol consumption is
patients suffer from withdrawal symp- interrupted by more frequent but short-
toms and severe alcohol craving. There er periods of abstinence. During with-
is no history of psychiatric illness. Ade- drawal, anxiety, emotional instability
quate explanation of the medical caus- and sleeping disorders (difficulty falling
es of the problem, as is the case with asleep) frequently occur. Patients feel
every chronic, somatic illness, e. g. dia- tense, woebegone and are seeking help.
betes mellitus, is of paramount impor- Crying alternates with aggressive out-
tance. After reaching an understanding bursts, especially when drunk. Blood
of the subjective intolerance of alcohol pressure and heart rates are increased.
(like an “allergy”), motivation for an Acute sweating of the palms and mild
abstinence lasting for at least several sweating of the trunk are present. A fine,
months can be achieved. Abstinence is two-dimensional tension tremor only
only attainable if withdrawal states are shows when patients are asked to stretch
treated sufficiently (no abstinence at- both arms forward. In the case history,
tainable without enough medication no severe withdrawal symptoms are re-
and enough motivational work). ported, with no seizures and no poly-
During abstinence, the motto is neuropathy. The withdrawal is a mixture
“protect and support”. When speaking of mild alcohol withdrawal and a basic
to clients, it is important to use simple, anxiety disturbance.

146
Pharmacotherapy of alcohol withdrawal

Aetiology Motivation
Alcohol is used like an anti-anxiety med- All that promises support and protec-
ication, especially in situations of con- tion is helpful in this group of patients
flict (abused for relief of tension). It is because of their primary low selfes-
assumed that an increased activity of teem. They don’t feel safe and secure.
the MAO system (mono-amin-oxidas- The aim of motivation is to make the
er) is the cause of the biological vulner- patient understand that psychotherapy
ability. is crucial to enhancing self-worth. Fur-
thermore, it is important that the fol-
Duration lowing topics are tackled in psycho-
Withdrawal symptoms last for 10 to14 therapy: coping with anxiety, aggression
days. If some symptoms last for a long- and stress; separation strategies and re-
er time, then either they don’t originate ciprocal and balanced relationships
from alcohol but from a basic distur- with others.
bance, or they might be caused by a Another responsibility of motiva-
longer intake of benzodiazepines or tional work is to educate the patient
other hypnotics. about the relationship between the ef-
fects of alcohol and their insecure per-
Withdrawal therapy sonality and inadequate strategies to
Non-benzodiazepine anxiolytic sub- cope with stress. It is also essential to
stances work best. We recommend e. g. define factors that perpetuate alcohol
tiapride, trazodone or doxepine. Dos- consumption and factors that promote
age should be according to the severity abstinence. These different factors rep-
of the anxiety states as well as the se- resent the patient’s inner ambivalence,
verity of the sleep onset insomnia. In which can be used to motivate him to-
most cases, 150 to 300 mg tiapride or wards long-term abstinence.
trazodone are sufficient. There is no
need for antiepiletic treatment. Therapy goals
Benzodiazepines and sodium oxi- The most important therapy goal is the
bate should not be used because the strengthening of the ego and the acqui-
patient is in great danger of shifting his sition of adequate separation strate-
dependence from alcohol to these com- gies, which on the one hand enhance
pounds. coping skills for dealing with stress, but
Withdrawal medication with ben- can also prevent stress from developing
zodiazepines is only carried out in cas- in the first place. The patient’s drinking
es of concomitant abuse of tranquiliz- behaviour is not a central aspect of
ers. In such a case, withdrawal therapy therapy. During psychotherapy minor
is then conducted according to the cri- relapses (“slips”) are to be expected.
teria for benzodiazepine withdrawal These “lapses” are of short duration
(saturation with benzodiazepines until and usually don’t involve any loss of
the patient is free of symptoms, fol- control.
lowed by a slow reduction over the
course of several months and gradual
adjustment to anti-depressants).

147
9 Therapeutic strategies in alcohol and tobacco addiction

9.3.3.3 Management of detoxication in ally originate from personality disor-


Lesch’s type III alcohol dependents ders or concomitant consumption, e. g.
of benzodiazepines.
Withdrawal symptoms
This group consists of patients with Withdrawal therapy
very different degrees of intoxication. Anxiolytic substances that don’t belong
Sometimes type III patients are actually to the benzodiazepine group are used
completely abstinent when coming to for withdrawal therapy in this group.
the initial meeting. Gammahydroxybutyric acid or trazo-
Withdrawal symptoms: elevated done are predominant. An antiepilep-
blood pressure and heart frequency; tic therapy is usually not necessary.
heavy hand perspiration, light trunk Suggestion for dosage of gam-
perspiration; a two-dimensional tremor mahydroxy butyric acid: four times
is only observed in patients holding up 7.5–10 ml per day (1 ml contains 175 mg
an arm. Patients are usually very strained sodium oxibate). On no accounte should
and show suicidal tendencies. They of- this dosage be increased. Effects are re-
ten suffer from feelings of guilt, perceive ported very shortly after intake. If this
themselves as a failure and show insta- dosage does not positively affect the
ble, but also incontinent mood (as man- withdrawal symptoms, benzodiazepine
ifested by e. g. crying fits during intoxi- abuse is to be expected. If this is case,
cation). Furthermore, patients suffer withdrawal therapy is then conducted
from sleep onset and sleep maintenance according to criteria for benzodiazepine
insomnia. The case history shows low to withdrawal (saturation with benzo-
medium withdrawal syndromes, mostly diazepines until the patient is free of
without withdrawal seizures, and severe symptoms, followed by a slow reduc-
polyneuropathy is absent. tion over the course of several months
and graduate adjustment to anti-de-
Aetiology pressants).
Alcohol is abused because of its mood
lifting and sleep inducing effects. Al- Motivation
though alcohol might induce sleep, it When educating patients, it should be
still has disturbing effects on the archi- noted that they have probably already
tecture of sleep and most chronobio- sought information about the disorder
logical functions such as drive, mood from popular scientific literature. Be
and sleep). prepared to meet a partially informed
Limbic system dysfunctions and patient. Patients may have already tried
disturbances in the hypophysis-thyroid to apply some methods that were rec-
axis are signs of a biological vulnerabil- ommended by magazines.
ity. The symptoms can be described as The first step in therapy is to elu-
a combination of alcohol withdrawal cidate the relationship between the ef-
and depressive disorders fects of alcohol as a buffer for a per-
formance-oriented and controlled life
Duration (“Tellenbach personality”) and the in-
Detoxification lasts 10 to 14 days. Pos- teraction between the effects of alcohol
sible symptoms which occur later, usu- and the lack of experience-related and

148
Pharmacotherapy of alcohol withdrawal

pleasurable activities. If type III pa- 9.3.3.4 Management of withdrawal in


tients manage to remain abstinent for Lesch’s type IV alcohol dependents
14 days, they are very likely to continue
this abstinence for a few months. Dur- Withdrawal symptoms
ing these months, normal “function- Patients show different degrees of in-
ing” is reported by the individual and toxication when starting therapy. With-
the people in his/her social environ- drawal symptoms: fine tremor (like a
ment, without any therapy, and pa- lithium tremor), sweaty hand palms (at
tients are only marginally willing to times no signs of perspiration during
change their lifestyle. During therapy it withdrawal = “dry withdrawal”), nor-
is important to use the first months to mal blood pressure, stable cardiovas-
clarify the ambivalence in regard to cular system.
drinking and lifestyle. Significant cognitive impairment
It is also important that the thera- to the point of orientation problems or
pist refrains from giving any advice. If confusion is a predominant symptom.
therapy is structured too early, the pa- Light-induced activation and/or
tient might not allow any fundamental professional personal attention can of-
changes to his/her perception and be- ten re-orientate the patient. However,
haviour despite managing to stay ab- during nights, deam-light and with no
stinent. The psychotherapeutic proc- professional support, an orientation
ess should start slowly in order to avoid dysfunction may turn into complete
patients reacting with their learned confusion. False memory and even hal-
performance-oriented mechanisms. lucinations can set in. Patients are very
This behaviour may change over the suggestible and often present an amen-
course of therapy. Due to narcissistic tiell picture which is marked by help-
tendencies, the patient often perceives lessness and affective and/or paranoid
and judges therapy in a comparative symptomatic transitory psychotic syn-
way. dromes. Due to severe cognitive dys-
functions, long-term therapy plans are
Therapy goal impossible to make in the beginning. It
Important therapy goals are both the is recommended that short sentences
reduction of heavy drinking episodes be formulated with clear short-term as-
after months of abstinence and the signment of tasks. Anxious or agitated
treatment of the patient’s personality states are conditioned by orientation
disorder (Tellenbach personality). This dysfunctions and misinterpretations of
is crucial because these personality interactive processes.
traits cause psychological strain in pa- Often epileptic seizures, which
tients and their social environment, occur independently of alcohol con-
which leads to severe changes in mood sumption and withdrawal, were record-
regardless of a relapse. ed in the case history. If such seizures
Further therapy goals are the re- have been recorded, it is important to
duction of relapse duration and fre- be aware of the fact that GM seizures
quency and severity of depressive symp- can set in at later stages of abstinence
toms (Cave: suicidal tendencies). (after the tenth day of abstinence) or
even later.

149
9 Therapeutic strategies in alcohol and tobacco addiction

Often patients have a gait distur- portant than any medication (most suit-
bance which is both cerebellar and due able is one-to-one support)
to severe polyneuropathies. When se- Biologically active light and, if pos-
dated, sometimes a “delirium in dorsal sible, brightly illuminated rooms with
position” develops in patients with spe- different sensomotor activities improve
cific somatic problems, e. g. pneumo- symptoms. As no cardiac and vegetative
nia. This can quickly turn into a vital instability is at hand, patients should be
risk. mobilized as quickly as possible, possi-
bly by including their families.
Aetiology Nootropics to improve cognitive
Due to premature cerebral damage (be- performance and anticonvulsive medi-
fore the age of 14, before brain develop- cation (e.g Carbamazepine) are recom-
ment is complete) and its consequenc- mended. Dispersion time needs to be
es, patients start consuming alcohol taken into account due to a high risk of
because they can’t withstand the social seizures. On average the dosage of Car-
pressure of our society to drink. Alco- bamazepine should not exceed 900 mg
hol is merely a complicating factor per day.
within a bigger picture(adverse sociali- Sodium oxibate’s effects are anxi-
sation and cognitive impairments). The olytic. Furthermore, it does not have
severity of performance reduction and any sedating properties with a dosage
psychopathological changes mainly cor- of four times 10 ml, does not signifi-
relate with previous cerebral damage cantly reduce cognitive performance,
and only secondarily with alcohol does not have any toxic effects on the
amounts consumed. Performance re- liver and reduces alcohol craving. The
duction is mainly caused by lack of short half-life time of sodium oxibate
ability and/or cerebral damages prior makes this medication well controlla-
to the age of 14. Patients find it difficult ble. From our experience, patients of
to organise and add sense to everyday this group who take sodium oxibate
life. Furthermore, retarded alcohol elim- are more easily motivated to start with-
ination is a sign of a biological dysfunc- drawal therapy. As sodium oxibate is
tion, which causes damages that are not an antiepileptic, it needs to be com-
predominantly caused by the alcohol bined with common antiepileptics
per se than by its aldehydes. (e. g. Carbamazepine).
All medications which negatively
Duration influence cognitive performance, ag-
As the causes of these symptoms are gravate symptoms. Therefore sedating
due to organic brain dysfunctions, re- substances, like benzodiazepines, are
gression of symptoms often takes weeks contraindicated.
even months despite absolute absti- Benzodiazepines lead to confu-
nence. In some patients, no significant sion, noopsychological impairment and
decline in symptoms can be observed. symptomatic transitory psychotic syn-
dromes.
Withdrawal therapy Atypical neuroleptics can be ad-
For these patients, activation by light ministered at short notice, e. g. quetiap-
and personal counselling is more im- ine, olanzapine in case of productive

150
Pharmacotherapy of alcohol withdrawal

syndromes and unrest at night (with- justment should be effected when se-
out vegetative symptoms). vere craniocerebral injuries have been
recorded by case history or when sei-
Motivation zures are already known from previous
Motivational strategies should take ac- withdrawal therapies. Seizures in type I
count of impaired performance. Pa- patients should be viewed as rebound
tients have difficulties following com- phenomenon. In type III patients, this
plicated matters and often tend to could be a rebound, mainly caused by
forget the things said. Only uncom- benzodiazepines, while seizures in type
plicated sentences, without multiple IV should be viewed as a provocation of
statements, should be used in conver- well-known seizure occurrences.
sation with these patients. Motivational
work should be short and carried out Therapy
regularly over several times a day. It is When treating these disorders with the
important to work on a structure for according antiepileptic medication (e. g.
everyday life. Patients should be en- hydantoin, valproic acid, carbamaze-
couraged to include more and more ac- pine and others), we have to be aware
tivities when structuring their day. that according to pharmacodynamics,
these medications need time to reach
Therapy goals effective dosages. Seizures setting in af-
As patients are easily influenced by ter day five suggest that these seizures
people in their social environment who are not only caused by alcohol with-
also drink, and are reduced in their drawal. Reasons could be a too rapid
ability to give and receive criticism, se- reduction of the withdrawal medica-
vere relapses are not only to be expect- tion, but also epileptic occurrences in-
ed but are rather the norm. dependent of the alcohol dependence.
Benzodiazepines, with their antiepilep-
Therapy goals: tic effect, are suitable for the treatment
 Reduction of severity and frequen- of type I and III patients. If benzodi-
cy of relapses (“the aim is to sur- azepines are dosed sufficiently, in most
vive”) cases no further antiepileptics are
 Relief from severe somatic prob- needed. Seizures of type IV patients
lems should primarily be treated with antie-
 Extension of abstinence periods pileptics.
 Creating a daily structure
9.3.4.2 Delirant and associated states
9.3.4 Complications in alcohol withdrawal
(meta-alcoholic psychosis)
9.3.4.1 Withdrawal seizures (Grand mal) In DSM-IV, these psychopathological
syndromes are separated into psychot-
Grand mal seizures can induce deliri- ic, mood or anxiety disorders.
um tremens, but can also set in within A fundamental factor in the gene-
the context of this condition. Therefore sis of this condition is a dopamine re-
20 % of patients require anticonvulsive ceptor hypersensitivity. Meta-alcoholic
adjustment. This pharmacological ad- psychoses are in line with Wieck’s

151
9 Therapeutic strategies in alcohol and tobacco addiction

symptomatic transitory psychotic syn- tile hallucinations, fumbling with blan-


dromes (Wieck HH. 1967; Fig. 59, see ket, false memory, high suggestibility,
explanation page 102 f.). Its gradual heavy perspiration, rough three-di-
progression of development and degra- mensional tremor. The severity of with-
dation corresponds with the deficits drawal can be measured through pal-
and recovery of single neuronal circuits pable muscular fibrillations which can
(Glutamate-Dopamine-Endorphin, agi- be felt by slightly gripping the thenar.
tation-mood-reward-relief). Cardiovascular instability and an elec-
Delirium tremens (in type 1 pa- trolyte shift are life threatening (rapid
tients, infrequently type III patients) changes in blood pressure, increase and
Delirium tremens usually sets in decrease in heart frequency, arrhyth-
on the first or second day after abruptly mia). If delirium tremens does not set
changing or terminating alcohol use. in until the third day of abstinence,
Thus, it is suggested that a precise case there are more causal factors than pure
history be taken covering especially al- alcohol withdrawal. For example, abrupt
cohol, withdrawal symptoms and al- discontinuation of withdrawal medica-
cohol sequelae. The use of biological tion or previous consumption of non-
markers that indicate chronic abuse, prescribed tranquillizers could play a
even if patients are admitted for non- role.
psychiatric reasons (e. g. admission into
a surgery unit), are recommended. Es- Therapy
tablished factors in surgery preparation Besides psychiatric symptoms, cardio-
are: MCV above 98 fl., gamma GT that is vascular conditions, electrolyte metab-
1.3 times higher than the highest stand- olism and vegetative lability need to be
ard value, ASAT twice as high as ALAT considered. Therefore cardiac monitor-
(De-Ritis-quotient) and especially the ing is a standard measure in these in-
%CDT (carbohydrate-deficient trans- ternist psychiatric emergencies (Lesch
ferrin). OM et al. 1986). Arrhythmia and ven-
Precursors of these conditions are tricular fibrillation are the most com-
already apparent weeks before acute mon causes of death in delirium tre-
symptoms manifest. Frequent signs mens (Cave: parenteral beta-blockers
that have been reported are depressive can lead to cardiac arrest). For the treat-
or/and anxious mood, unrest and jump- ment of dehydration, it is recommend-
iness. Patients often report insomnia ed that liquids be infused with an elec-
with colourful and vivid dreams, which trolyte substitute and B vitamins (B 1,
they experienced as very real and they B 6 and B 12). Hypokaliaemia in plasma
find it difficult to separate dreams from should be carefully substituted, because
reality. often an intracellular hyperkaliaemia
exists, which could be worsened by en-
Symptoms forcing potassium substitution. Tran-
Disorientation or erroneous orienta- quilizers in sufficient doses and in rare
tion (delirious impairment of orienta- cases antiepileptics are needed. Neu-
tion, e. g. patient in hospital believes he roleptics should not be administered
is at the workplace), motor disturbance because they firstly lower the seizure
with optical (mostly micropsia) or tac- threshold, secondly lead to severe ex-

152
Alternatives to withdrawal

trapyramidal conditions and thirdly This symptomatic is caused by chronic


have adverse effects on long-term pro- thiamine deficiency. Diet is often very
gression (Walter H et al. 2001). poor, as patients predominantly “live
on” alcohol. This behaviour causes se-
Alcohol paranoia vere nutritional deficiencies (e. g. folic
(mostly type IV patients) acid and vitamin E deficiency, insuffi-
The reduction of mental performance cient trace elements etc.).
caused by long-term alcohol depend- Symptoms: motor ophthalmopa-
ence and by an adverse family situation thy (e. g. horizontal nystagmus), ataxia,
often causes conflicts in the family. In polyneuropathy, frontal signs positive
some patients these can develop to the (palmo-and policomental reflex), diso-
point of delusions (e. g. delusional jeal- rientation, sometimes delusions (Kor-
ousy). Often the female partner or the sakov psychosis).
parents are the targets of such paranoid Time and location based orienta-
delusional interpretations. Aggressive tion is often deferred to the past and
attacks often might be directed at these patients are highly suggestible. Misin-
persons. Aggressive individuals need to terpretations of normal perceptions
be admitted into inpatient care, be- produce euphoric but also anxious con-
cause they can become dangerous for ditions. Memory gaps are often filled
their environment. with imaginary stories (confabulations).
Therapy: absolute alcohol absti- This symptomatic may be irreversible
nence; withdrawal therapy according and can turn into a Korsakow-like de-
to typology (see above). The delusional mentia. Progression evaluation is pos-
disorder often needs specific neurolep- sible six months after absolute con-
tic therapy (e. g. quetiapine). As in type trolled abstinence at the earliest and
IV, treatment requires long-term con- only within intensive rehabilitation
cepts within a stable setting. programmes.

Alcoholic hallucinosis Therapy


(mostly type IV patients) Absolute abstinence, vitamin supple-
Cerebral reductions in performance mentation, with mainly thiamine par-
and reduced inhibition mechanisms enterally in high dosage over three
lead to both acoustic and optic halluci- days. Nootropics, inpatient admission
nations without interpretations. If veg- (thorough examination: such symp-
etative signs are weak, anxious condi- toms often have other additional caus-
tions with denouncing voices, mainly es).
in the second person, are very frequent.
Suicidal tendencies are also frequent. 9.4 Alternatives to withdrawal
Orientation is normal.
Therapy: absolute abstinence and Animal experiments support clinical
neuroleptic therapy. Inpatient admis- observations that even higher amounts
sion is often unavoidable. of alcohol (and tobacco) are consumed
after temporary abstinence (Spanagel R
Alcohol-induced Wernicke-Korsakow and Hoelter SM. 1999). It has been ob-
Syndrome (type I, III or IV patients) served that animals that didn’t receive

153
9 Therapeutic strategies in alcohol and tobacco addiction

any alcohol for several days, consumed The FDA already certified this
significantly more amounts of alcohol method in the US in 1994. Interna-
with higher alcohol content after ab- tional acceptance of this method has
stinence. If severe withdrawals are ex- evolved slowly and sporadically, prob-
pected, gradual reduction of alcohol ably due to possible competition with
amounts should be considered as an established therapy institutions and
alternative (Sinclair JD. 2001). self-help groups. In the project “Com-
bine”, it was shown that Naltrexone
9.4.1 Gradual reduction of drinking worked on its own and that additional,
amount, “Cut down drinking”, specialised “counselling” did not lead
method according to David Sinclair to further improvement (Anton RF et
al. 2006). In contrast, Chick et al. found
The so-called “extinction-method” (Da- that naltrexone is especially effective in
vid Sinclair) is an alternative treatment combination with regular therapeutic
for alcohol dependence. It reduces al- conversations (Chick J et al. 2000).
cohol craving with opiate-antagonists A disadvantage of this method is
(naltrexone) and, together with cogni- the up-regulation of opioid receptors. A
tive therapy, thus slowly weakens the further disadvantage is that not all pa-
learned process that has caused the al- tients respond to naltrexone. Around
cohol dependence (“pharmacological 10 % of patients are not able to reduce
extinction”) (Hernandez-Avila CA et al. the amount they are drinking despite
2006). The association of stimuli “alco- naltrexone intake. Reducing alcohol in-
hol consumption-pleasurable feeling, take improves depressive symptoms,
positive reward” is gradually uncou- lowers the usually heightened blood
pled, because no pleasurable feeling pressure, reduces cardiovascular prob-
and feelings of reward set in due to the lems and lowers high cholesterol levels
effects of opiate-antagonists (“pharma- and elevated liver function tests. In some
cological extinction”). Alcohol depend- cases, naltrexone can’t be administered.
ents should be in their normal environ- This applies to (infrequent) allergic re-
ment (in which the dependence has actions, concomitant use of opiates and
developed) and should experience that severe liver damage.
alcohol doesn’t have the “old”, familiar A variation of the extinction meth-
effect anymore. This is due to the ab- od can be employed during standby
sence of endorphin effects caused by periods before inpatient admission. By
an mμ-receptor blockade. The associa- gradually reducing drinking amounts
tion between alcohol consumption and with naltrexone and arranging check-
pleasurable sensation is gradually loos- up appointments (every two days),
ened over a period of three months. waiting time is used in a meaningful
The keeping of a drinking diary can way. At present this method is offered
visualize the success and regular dia- as pre-treatment at the Medical Uni-
logues (according to so-called “coun- versity of Vienna, Department of Psy-
selling standards”) support the reduc- chiatry and Psychotherapy to a limited
tion of drinking amounts. This method extent. In some patients this pre-treat-
is employed by so-called “ContrAL clin- ment was so successful that the planned
ics” in the US and Europe. admission was no longer necessary.

154
Alternatives to withdrawal

Other patients were able to reduce duced the pain. Nevertheless, she still
their drinking by up to two thirds, which keeps on drinking without a break (al-
facilitated withdrawal. Less withdraw- most always associated with a loss of
al medication was needed and the control). She shows a 40-year long con-
withdrawal period was significantly comitant use of beer, wine and hard
shortened. This does not only save liquor and mentions an insatiable crav-
costs but also prevents possible cere- ing for alcohol. She reports that she has
bral damage, which can be caused by been drinking increasingly more than
withdrawal (Crews FT et a;. 2004). Neu- she did previously, especially during
rotoxic damage caused by withdrawal is the last two years. The patient suffers
especially dominant in women (Hashi- from feelings of guilt about not being
moto JG and Wiren KM. 2008). able to stay abstinent and hopes that
From personal and clinical expe- an inpatient admission will help her
rience, this therapy is suitable for Le- with this. The accompanying husband
sch’s types I, II and IV. The time before is supportive and does not put any
withdrawal is used in a meaningful way pressure on the patient.
(waiting time before inpatient admis- A type IV alcohol dependence was
sion) by motivating patients, sensitis- diagnosed in exploration. There are no
ing them to watch the amounts they occurrences of alcohol dependence or
are drinking and might positively inte- psychiatric disorders in her family.
grate partners and prevents the patient Alcohol dependence started after the
from experiencing severe withdrawal age of 25 (“late onset”). The drinking
and sometimes even avoids the need amount is indicated at around 200 g
for inpatient admission. The applica- daily and a withdrawal syndrome, like
tion of this concept also prevents the the one observed in type I patients, is
conditioning of external stimuli and identified. An inpatient admission is
withdrawal symptoms arranged and the patient is likely to be
admitted in three to four weeks.
9.4.2 Case study: “Cut down drinking” Naltrexone is prescribed as pre-
liminary therapy at the first appoint-
Accompanied by her partner, a patient, ment. The patient receives the follow-
aged 48, comes to the “outpatient cen- ing information about the programme:
tre for individuals at risk of alcohol re-
lated illness” of the Medical University 1. Daily intake of naltrexone; she is
of Vienna, Department of Psychiatry told that she is allowed to con-
and Psychotherapy. She is a housewife sume alcohol, but she should try
and has two adult sons. She states she to manage with the lowest re-
is afraid of nearly everything (espe- quired amount. In any case, she
cially of the dark). She has been drink- should drink the amount of alco-
ing to cope with her anxiety and, for hol that is needed to prevent with-
the past two years, has also been drink- drawal symptoms.
ing to alleviate her stomach pain (she 2. She should keep a drinking diary:
also takes H2-blockers) and arthritic one column each for wine, beer
knee pain. Knee surgery was success- and hard liquor. Every eighth of
fully carried out this year, which re- wine, beer (0.3) and shots is to be

155
9 Therapeutic strategies in alcohol and tobacco addiction

written down in the specific col- and beer to 1.5 litres. She decided to
umn. continue without inpatient admission,
3. At the beginning, a check-up ap- because she wants to continue with this
pointment is arranged on every programme.
second day, which is cut down to Three months after the start, the
every third day by week three. patient shows a daily alcohol consump-
tion of 1.5 litres of beer. Another two
Further, the patient is informed about months, she has replaced this with
the effects of naltrexone (fewer pleas- three bottles of alcohol-free beer, which
urable feelings, gradually lessened crav- she reduces to two bottles per week
ing for alcohol) and possible side ef- nine months after the start of the “cut
fects (slight nausea, possible allergies). down drinking” programme.
The patient starts with half a tablet on After eleven months, the patient
the first day, which is increased to one wished to terminate the intake of naltrex-
tablet a day from the second day on- one. This was discussed and implement-
wards. An appointment for the next day ed. To this day, 14 months after the begin-
is arranged. ning of therapy, the patient is still drinking
The patient is to bring the drink- two bottles of alcohol-free beer per week.
ing diary to this appointment. The re- No dosage increase was needed and the
corded drinking amounts are discussed patient did not relapse. A test of bio-
and consideration is given to when it logical markers confirmed abstinence
would be easiest for her to abstain from (%CDT = 0.77 %, cholesterol 206 mg/fl,
drinking. MCV: 93 fl, liver function tests in normal
The drinking diary shows a daily range). She still regularly attends the
consumption of 2.5 litre beer, five sixths therapy meetings with her husband.
of brandy and five eighths of wine (re-
duction to 150g pure alcohol daily). 9.5 Pharmacotherapy of tobacco
Naltrexone is well tolerated and
withdrawal syndrome
the drinking amount is reduced by 30 %
over the next nine days. Light perspira- By addressing the smoking behaviour
tion and trembling diminished within and offering individual advice, the
the next eight days. Blood sample: el- amount of cigarettes smoked is signifi-
evated liver function tests, cholesterol cantly reduced in 20 to 30 % of tobacco
332 mg/dl, %CDT 2.8 %, MCV 106 fl. The abusing cases. A reduction of smoking
patient’s %CDT is sensitive, which makes behaviour reduces the number of se-
it very suitable for controlling absti- quelae and improves long-term pro-
nence (a possible increase of 0.8 % indi- gression of these diseases (e. g. COPD;
cates a relapse). Marginal values are of Fiore MC et al. 2000). Regular follow-up
secondary importance in this long-term meetings, in which the smoker is con-
monitoring. sulted, clearly improve results and are
The patient is encouraged to first more important than shortterm phar-
abstain from brandy and then wine, so macotherapy (also see Lesch OM. 1985;
that only beer remains. After three weeks 2007). The keyword “advice is effective”
the patient has reduced consumption of has internationally and repeatedly been
brandy to one sixth, wine to two eighths supported (Fiore MC et al. 2000, 2008;

156
Pharmacotherapy of tobacco withdrawal syndrome

US Department of Health and Human withdrawal syndrome. Strong nicotine


Services; World health Organization craving is however the most important
2003; Henningfield JE et al. 2005). reason for relapse. Yet this craving
Different pharmacotherapy can should not be evaluated as merely a
even improve (sometimes even double) withdrawal symptom because it has
abstinence rates in tobacco abusers very different qualities, e. g. craving due
who don’t meet the diagnostic criteria to adephagia and the patient not want-
for dependence according to ICD-10 ing to gain any weight, or strong crav-
(Henningfield JE et al. 2005). Neverthe- ing experienced when in the places and
less, there is a large group of smokers situations in which one used to smoke
who don’t change their smoking behav- (“hot spots”). Symptoms of nicotine
iour despite taking anti-craving sub- withdrawal syndrome are much more
stances. This should make therapists difficult to distinguish from the mecha-
aware of the fact that often several ther- nisms of craving, which are important
apy meetings are needed to attain suc- for relapse prophylaxis, as is the case in
cess. Patient support often marks the alcohol dependence.
beginning of enduring improvements In a study with 330 tobacco de-
in smoking behaviour. pendents according to ICD-10, we were
able to show that only 55 patients
9.5.1 Symptoms of the tobacco (16.7 %) had severe withdrawal symp-
withdrawal syndrome toms, while 128 patients (38.8 %) de-
scribed mild withdrawal symptoms.
The definition of the tobacco with- The remaining 147 patients reported
drawal syndrome is still controversially no withdrawal symptoms. Changes in
discussed, but the following symptoms mood, impatience and strong craving
have been agreed upon (see also Widi- are essential withdrawal symptoms.
ger T et al. 1994): Many patients only had specific with-
drawal symptoms, the combination of
Fig. 93 two withdrawal symptoms was com-
mon and only 20.6 % of patients experi-
 shift in mood enced all symptoms listed above (Lesch
 irritability OM et al. 2004), see Fig. 94.
 depressive mood The duration of the withdrawal
syndrome varies. It has been suggested
 nervousness and agitation
that it lasts up to three months, but
 higher vulnerability to stress
there is not enough scientific evidence
 heightened aggression to support this.
 impatience The Fagerstroem test correlates
 insomnia well with the severity of withdrawal
 strong nicotine craving symptoms and sequelae.
Today, nicotine withdrawal thera-
py in patients with Fagerstroem scores
of five or above is carried out with nico-
Nicotine abuse and strong nicotine tine supplements or varenicline.
craving are not part of the tobacco

157
9 Therapeutic strategies in alcohol and tobacco addiction

Fig. 94 Constellation of tobacco withdrawal symptoms

Withdrawal syndrome
marked by … N = 330
(In percentage)

Changes
in mood
Not
specified

Insatiable
craving

Vegetative
dysfunction

9.5.2 Therapy of the tobacco withdrawal several weeks and often the adminis-
syndrome tration of nicotine supplements is ter-
minated too early. We recommend a
9.5.2.1 Withdrawal therapy of tobacco continuous therapy of at least three
dependence with Fagerstroem  5 months. From our perspective, there
are not enough high quality studies on
Nicotine supplements the duration of nicotine supplement
Nicotine should be substituted in ade- therapy. Nicotine supplement is often
quate doses (chewing gum, patches, combined in order to mix basis doses
inhaler and others). with rapid diffusion times (e. g. nicotine
Level-smokers should use nico- patches and inhaler).
tine supplements which provide a con-
tinuous nicotine supply, e. g. nicotine Varenicline
patches. Peak smokers, who smoke lots Varenicline is a partial agonist of the
of cigarettes over a short period of time α4β2 subtype of the nicotinic acetylcho-
depending on the situation, might re- line receptor. In addition it acts on α3β4
quire high amounts of nicotine sup- and weakly on α3β2 and α6-containing
plied very quickly (e. g. inhaler). With- receptors. A full agonism was displayed
drawal symptoms and craving lasts for on α7-receptors. This selectivity sug-

158
Medical strategies for relapse prevention

gests that some smokers respond bet- tobacco-and alcohol consumption.


ter than others: smokers, in whom dif- The therapy plan in this phase should
ferent subunits of receptors play a role, be straightforward. Patients should feel
profit less. Clinical studies have shown secure and should be helped to see that
doubled abstinence rates and thus abstinence means an enhanced quality
varenicline 1 mg twice daily can be rec- of life and not merely the loss of an ad-
ommended for nicotine withdrawal and dictive drug). Withdrawal therapy and
craving (Fagerstroem 5 or above, Tons- relapse prophylaxis should be based
tad S et al. 2006; Zierler-Brown SL and on a well-connected therapy chain
Kyle JA. 2007; Oncken C et al. 2006; Wil- (outpatient, semi inpatient, inpatient).
liams KE et al. 2007; Coe JW et al. 2005; This enables quick and efficient inter-
Gonzales DH et al. 2006; Cochrane Re- ventions in case of relapses. Medical/
view Cahill K et al. 2007). Due to its ef- biological, psychotherapeutic and so-
fects, varenicline is recommended as a ciotherapeutic competencies are need-
withdrawal medication, yet studies on ed in therapy. Teams should be well
dosage titration for withdrawal medi- staffed, with stable personnel that are
cation are still lacking in quality. Many easily approachable for patients. Only
patients complain about feelings of organisations like this can guarantee
nausea. long-term therapy which runs effi-
ciently. Obviously this requires more
cost expenditures than commonly
9.5.2.2 Withdrawal therapy of tobacco
available for addiction therapy, but
dependence with Fagerstroem  4
also saves money by reducing inpa-
These withdrawal symptoms can be tient admissions (e. g. severe with-
treated with nicotine supplements or drawal with acute admissions to in-
varenicline, but bupropion is also suit- tensive units, more frequent
able. In this group, bupropion can be admissions due to sequelae). Early in-
used for relapse prophylaxis and no re- terventions made by the counselling
adjustment of medication is needed. team, reduce the severity and duration
The extent to which antidepres- of relapses. Merely providing short-
sants, new CB-1-antagonists and cloni- term outpatient or inpatient crisis in-
dine can be used as a medication for tervention, without a concept of what
withdrawal symptoms should be fur- the next steps are, is insufficient.
ther investigated. Realistic and attainable therapy
goals need to be agreed upon in which
9.6 Medical strategies for relapse abstinence, the ultimate goal of thera-
py, should not be neglected even if only
prevention
a reduction of substance consumption
9.6.1 General guidelines for relapse can be attained at first. Some patients
prevention require long-term substance substitu-
tion therapy despite all therapy options.
The goal of withdrawal therapy is to Substitution therapy (sodium oxibate
maintain abstinence and a drug-free in type IV alcohol dependents, mor-
life. Of central interest is the therapy of phine supplements in opiate depend-
basic dysfunctions, which have led to ents) promotes social stabilisation and

159
9 Therapeutic strategies in alcohol and tobacco addiction

Fig. 95 Cornerstones in relapse prevention

 Availibility and stability of the therapeutic team


 Individual pharmaco- and psychotherapeutic offers
 Earliest possible start of treatment and
 Modification of withdrawal treatment according to the underlying basis dysfunc-
tion (e. g. different treatment according to Lesch’s typology)
 Incorporation of (stabilising) family members and treating possible co-dependen-
cies (e. g. brochures for the affected and their family members – “Alcohol relapse,
what next?” etc.)

permits other therapeutic/psychother- to ensure that this feeling is passed on


apeutic interventions. Changes in dos- to the patients and the team. One re-
age of maintainance therapy should be lapse is often succeeded by another,
made carefully and slowly. Even with and then followed by long-lasting ab-
withdrawal therapy, some patients can’t stinence.
come off addictive substances. In some Motivational work in therapy:
cases, therapy is aimed at improving Every alcohol dependent has different
secondary complications and sequelae. personality traits, which require the
Alcohol dependence is a disease with a implementation of appropriately suit-
recurrent progression and it is well ed motivational methods (e. g. more
known that at least 50 % of patients re- imperturbability and calmness in Le-
lapse during the first three months. sch’s type II; the freedom to choose, the
Early and quick detection and flexible freedom not to have to do something in
handling of relapses (e. g. medical ad- Lesch’s type III and type IV).
justment, psychiatric and psychother- Some patients are faced with a le-
apeutic intervention, short inpatient gal situation which requires them to
admission) are one of the most impor- have psychotherapy (inpatient or out-
tant goals. patient). These forms of therapy, with
their stipulations about specific treat-
9.6.2 Goals for relapse prevention ment approaches, are scarcely wel-
comed by patients or therapists. How-
Definition of a realistic therapy goal: ever, positive progressions have often
absolute abstinence or reduction of ad- resulted from these therapies.
dictive substance or “only” supporting Psychotherapy in relapse preven-
the patient, which was shown to reduce tion differentiates between the therapy
mortality rates. of those psychological disorders which
If the patient is still abusing the perpetuate substance consumption,
addictive substance, one goal might be and therapy of those disorders which
to at least reduce secondary complica- form the basis of addictive substance
tions (e. g. risk for infections, road safe- consumption (e. g. personality disor-
ty). It is important never to give up and ders).

160
Medical strategies for relapse prevention

Despite diverse psychopharma- (only in the case of relapse) instead of


therapeutic approaches, there is no daily dosing (Hernandez-Avila CA et al.
single standardized therapy for with- 2006).
drawal and relapse prevention world- The established pharmaceutical,
wide. Throughout the world, the differ- disulfiram, which inhibits the break-
ence between wishing to combat down of acetaldehydes, is clinically ef-
negative emotions and wishing to en- fective. Yet one limitation is the patient’s
hance well-being is acknowledged frequent lack of compliance regarding
intake, which is typical in the case of
9.6.3 Medication against so-called aversive medication. From experience,
“positive” craving (= desire for this medication has positive clinical ef-
pleasurable, rewarding effects of the fects, but data shows a different picture
addictive substance) (Blanc M and Daeppen JP. 2005). More
recent studies, with a controlled intake
9.6.3.1 Alcohol of medication, suggest disulfiram to be
more effective than naltrexone (De Sou-
Dopamine antagonists (neuroleptic sa A and De Sousa A. 2004). Disulfiram,
substances) don’t have any relapse in- the inhibitor of dopamine beta-hydrox-
hibiting effects (Wiesbeck G et al. 2001). ylase, which is important for noradren-
In therapy, 5-HT2A antagonists have alin biosynthesis, is a further indicator
been used as atypical neuroleptics. of the importance of the reward system
Quetiapine was shown to have positive (Weinshenker D and Schroeder JP. 2006).
effects in Babor type B patients (early The necessity of regular monitoring of
onset, severe progression of alcohol de- liver functions during disulfiram thera-
pendence), but not in Babor type B py is emphasized. (Chick J. 2004).
(late onset, mild progression) (Kamp- As already mentioned, topiramate
man KM et al. 2007). Animal experi- inhibits dopamine release, but at the
ments showed that the CB-1 antagonist same time also has partial GABA ago-
rimonabant prevents nicotine-associ- nistic and glutamate antagonistic ef-
ated alcohol relapses (Lopez-Moreno fects and thus suggests a new future
JA et al. 2007). direction (Ma JZ et al. 2006).
The mμ-opiate antagonist Nal- Partial CB-1 antagonists have been
trexone has repeatedly been shown to and will be developed because the en-
reduce the amount of drinking and the docannabinoid system plays an impor-
effects of relapse (Volpicelli JR et al. tant role in craving. Therefore, it has
1992; 1997). All studies on the effects of been assumed that a blockade of this
naltrexone point to a reduction in the system reduces craving and balances
amount and duration of drinking.(Vol- activity of the endocannabinoid sys-
picelli JR et al. 1997; Petrakis IL et al. tems (in regard to increased appetite
2004; O’Malley SS et al. 2007). With this and overweight) (Xie S et al. 2007). Up
pharmaceutical, a gradual dosage re- until now, the partial CB-1 antagonist,
duction can be considered as an alter- rimonabant, has been approved in Eu-
native to alcohol withdrawal (Pettinati rope as a medication for the metabolic
HM et al. 2006). There is also discussion syndrome. It may also be effective in re-
about the possibility of directed dosing lapse prophylaxis or in reducing drink-

161
9 Therapeutic strategies in alcohol and tobacco addiction

ing amounts (Colombo G et al. 1998; their own addictive potential. Gaba-B
Lopez-Moreno JA et al. 2007). The stress receptors also influence the effect of al-
reducing effects of tricyclic antidepres- cohol on cells, namely via the influence
sants (effects on the HPA axis), in par- of protein kinases. An examination of
ticular, seem to be entirely or at least baclofen showed that it was able to re-
partly moderated by the endocannabi- duce the alcohol associated up-regula-
noid system (Hill EM et al. 2002). tion of alpha subunits in protein kinase
(Lee HY et al. 2007).
Antidepressants that go beyond a
9.6.3.2 Tobacco
pure re-uptake inhibition can be suitable
There have been positive results for (e. g. dual anti-depressants, tricyclic anti-
varenicline as well as nicotine supple- depressants, partly also SSRIs, Pettinati
ments and partly positive results re- HM. 2001). 5HT-1A has protective effects
garding rimonabant (Reid RD et al. against stress-induced hippocampal
2007). A CB-1receptor antagonist seems changes (Joca SR et al. 2007). Antihista-
to be more suitable for this group of pa- minergic substances have calmative
tients as the partial nicotine agonist and sleep-inducing effects. The central
varenicline leads to dopamine release alpha-2-adrenergic agonist clonidine
(Cahill K and Ussher M. 2007). The CB-1 is especially effective against vegeta-
antagonist, rimonabant, was shown to tive overstimulation during withdrawal
inhibit pharmacologic peak releases of (Schnoll RA and Lerman C. 2006).
dopamine that are induced by addic- Acamprosate seems to be the most
tive substances (Cheer JF et al. 2007). well-known substance with anti-gluta-
The warning that depressive symptoms matergic effects that has been properly
in rimonabant treated tobacco depend- investigated by alcohol research (Lesch
ent patients is increasing, should be OM and Walter H. 1996; Withworth AB
investigated in prospective controlled et al.1996; Spanagel R and Zieglgan-
studies. Also naltrexone has been test- sberger W. 1997; Chick J. 1995; Lesch
ed as an augmentation of nicotine sub- OM et al. 2001; Mann K et al. 2004; Ver-
stitution (O’Malley SS et al. 2006). heul R et al. 2005).
Caroverine, oral or as an infusion,
9.6.4 Pharmacotherapy against the has proven to be clinically effective for
so-called “negative” craving (= desire for withdrawal (Koppi S et al. 1987), but
addictive substances to relieve negative has not been further tested. Positive ef-
mood and anxiety) fects on withdrawal have been found in
lamotrigine (inhibits glutamate release),
9.6.4.1 Alcohol memantine and the AMPA/kainate an-
tagonist, topiramate (Krupitsky EM et
The required pharmacologic profile al. 2007).
needs to have antidepressant, anxiolyt- Against all expectations (Hoelter
ic, calmative and anti-glutamatergic ef- SM et al. 1996; Danysz W et al. 2002;
fects. Gaba-A effective medications, Nagy J. 2004), relapse prevention stud-
like diazepam, are used in withdrawal ies on the glutamate antagonists, me-
worldwide but need to be reduced and/ mantine and neramexane, have only
or terminated early enough because of produced negative or no continuous

162
Medical strategies for relapse prevention

positive effects on abstinence (Evans ing relationship of different therapy ap-


SM et al. 2007). proaches. Accordingly, and in practice,
Animal experiments showed that medication, which is effective in differ-
the nicotinic acetylcholine agonist, ent ways, has been introduced for re-
varenicline, is successful in reducing lapse prophylaxis of alcohol and tobac-
drinking amounts (Steensland P et al. co dependence. These have been proven
2007). Also CRF (corticotrophin releas- to be effective in subgroups of alcohol
ing factors) antagonists (Heilig M and and tobacco dependents, see Fig. 96.
Koob GF. 2007) could be used as medica- These different mechanisms of
tion in relapse prophylaxis in the future. action require a more precise diagnos-
tic than recommended by ICD-10 and
DSM-IV for the diagnosis of depend-
9.6.4.2 Tobacco
ence. Therefore, the establishment of
Nicotine is hypothesized to have anti- subgroups of tobacco and alcohol de-
depressant effects. Therefore, nicotine pendents is essential for specific phar-
supplements may be suitable for the pe- macotherapy. There is sufficient data
riod following the termination of smok- on the specific therapy of alcohol de-
ing. For nicotine withdrawal and its pendence (see chapter 6). Several typol-
negative craving symptoms, the anti- ogies have been shown to be clinically
depressant bupropion is an approved relevant, with the following frequently
medication. During and after nicotine used in therapy studies: within the two
withdrawal, dysphoric mood, irritability cluster solutions, especially the typolo-
and even depressive symptoms set in gy according to Cloninger (Cloninger et
frequently. The continuation or restart al. 1988) with type 1 (anxious, passive-
of smoking could be prevented by these dependent, rapid tolerance develop-
antidepressant effects, especially in com- ment) and type 2 (antisocial personali-
bination with nicotine supplements ty, patients seeking the euphorising
(Covey LS et al. 2007). Yet there are also effect, early onset of drinking) as well as
studies on bupropion that show nega- the typology according to Babor (Type
tive results (Simon JA et al. 2004; Stead L A: late onset, mild progression; type B:
and Lancaster T. 2007). Dopamine an- more risk factors in childhood, positive
tagonists, opiate antagonists and CB-1 family anamnesis regarding alcohol,
antagonists are not expected to be effec- early onset of drinking, more psycho-
tive in this group of patients. Partial nic- logical dysfunctions). Within the four
otine agonists like varenicline might cluster solution, Lesch’s typology has
have positive effects in the above men- been used in therapy studies. Leggio
tioned group (Rollema H et al. 2007). published 2009 the medications having
accepted data for subgroups of alcohol
9.6.5 Pharmacotherapy in relapse dependent patients (see Fig. 97).
prevention in dependent patients
9.6.5.1 Alcohol 9.6.5.2 Tobacco
The information in the above para- Relapse prevention in tobacco depend-
graphs has underlined the complexity ence show also very different treatment
of the neuronal and neuron-modulat- approaches and some medications are

163
9 Therapeutic strategies in alcohol and tobacco addiction

Fig. 96 Pharmaceuticals and their effects in relapse prevention of alcohol depen-


dents

Comparison of pharmaceuticals, which are approved in different


countries for relapse prevention of alcohol dependence

Substance Mechanism Effect


Acamprosate NMDA-receptor blockade competitive Prevention of “conditioned pseudo
withdrawal syndrome”, approved for
anti craving therapy
Naltrexone Blockade of the n-opioid receptor Reduction of ethanol intake, ap-
with indirect inhibition of dopamine proved for anti-craving therapy
release in the striatum
Topiramate Facilitation of GABA-A-effects, block- Studies have pointed to a craving re-
ade of ionotropic AMPA-receptors ducing effect
Memantine Non-competitive blockade of the Animal studies have pointed to a
NMDA-receptor craving reducing effect
Baclofen GABA-B receptor Anti-craving effect in placebo control-
led studies
antagonist
Ondansetrone 5-HT3-receptor antagonist Clinical studies have shown anti-
craving effects and a reduction in al-
cohol intake
Sodium Praesynaptic dopamine agonist Reduction of Reward craving
Oxibate
Disulram Increase of Acetaldehyde Aversive reaction

Lenz B, Hillemacher T, Kornhuber J, Bleich S 2007

listed internationally accepted as effective apy is based on personality traits, per-


reducing craving and tobacco smoking in sonality disorders and the patient’s
tobacco dependent patients, see Fig. 98. coping strategies. Different coping strat-
egies, which can be influenced by e. g.
9.6.6 Relapse prevention according to gender, need to be incorporated into
Lesch’s typology the psychotherapeutic setting. Although
Lesch’s typology offers directions for a
Relapse prevention primarily complies correct psychotherapeutic procedure,
with the underlying dysfunctions and it still lacks specificity for therapeutic
the function of alcohol in that particular work. The very fact that type IV patients
person. In the beginning, “stabilisation often describe their drinking behaviour
and protection” are most important. as compulsive, or type III patients use
After a few weeks of total abstinence, the effect of alcohol to improve nega-
specific psychotherapeutic agreements tive emotions, or type II patients use
can be made and individual therapy alcohol to improve their interpersonal
can begin. This psychotherapeutic ther- skills, might provide information, but is

164
Medical strategies for relapse prevention

Fig. 97 Alcohol Typologies and medical relapse prevention treatment

Medication for relapse Hypothesis:


prevention according to Medication for relapse
typologies (evidence prevention
based)

LO-A: Late onset alcohol dependence EO-A: Early onset alcoholism

Fig. 98 Pharmaceutic relapse prevention in tobacco dependence

Substance Mechanism Effect


Nicotine Occupation of nicotine receptor and Reduction of biological craving in
supplements dopamine agonist Fagerstroem  5
Vareniclin Partial Alpha4Beta2 Nicotine receptor Reduction of biological craving in
antagonist Fagerstroem  5
Bupropion Anti-depressant with dopamine Improvement of the basis dysfunction
agonistic effects and mood-related craving
Nortriptyline and Anti-depressant with cholinergic and Improvement of the basis dysfunction
Doxepin dopaminergic effects and mood-related craving
Clonidine Alpha-adrenergic agonist Reduction of situation-based craving
Rimonabant CB1 antagonist and dopamine Impulse control and reduction of
agonist craving in weight problems
Topiramate Unclear mechanisms Reduction of compulsive behaviour
and improvement of impulse control

not a substitute for a personality diag- egies. The choice of anti-craving sub-
nostic as provided by axis II of DSM-IV. stances also depends on types and is
The severity of a relapse regardless of discussed in depth in the following.
loss of control is type-specific and there- A type-specific choice of an ade-
fore this therapy requires different strat- quate anti-craving substance can dou-

165
9 Therapeutic strategies in alcohol and tobacco addiction

ble abstinence rates (e. g. acamprosate 9.6.6.2 Relapse prevention in Lesch’s type II
in type I or II according to Lesch, nal-
trexone in type III or IV according to Minor relapses (so-called “slips”) don’t
Lesch), whereas the wrong medica- have any impact on the course of the ill-
ment for the wrong type can double the ness as a whole. Patients in this group
occurrence of relapses (e. g. flupentixol don’t seek any euphorising effects, but
in Lesch’s type I or III ). rather suffer from negative craving (de-
sire for anxiolytic and calmative effects)
(similar to Cloninger type I patients).
9.6.6.1 Relapse prevention in Lesch’s type I
Therefore this group requires adminis-
From a medical perspective, NMDA-an- tration of NMDA-antagonists for at least
tagonism is the most important relapse- 12 to 14 months in order to reduce
preventive mechanism in type I. Acamp- craving. Anxiolytic antidepressants in
rosate matches this profile especially in particular (e. g. buspirone), have been
regards to long-term effects. The aver- shown to be clinically effective. Kranzler
sive substance, disulfiram, is also recom- HR (1994) found that patients who were
mended for type I and can be perfectly administered buspirone showed more
combined with acamprosate. It inhibits abstinent days, a significant reduction of
an oxidative degradation of acetalde- anxiety and the period of time before
hyde into acetate, whereby acetaldehyde onset of the first relapse was longer.
accumulates in the blood, simultaneous Malcolm R’s (1992) study did not sup-
with alcohol consumption, and symp- port these results. Malec et al. have con-
toms like headache, flush, hyperventi- cluded that buspirone is effective as an
lation, hyperhidrosis, high blood pres- additional therapy for alcohol depend-
sure and vomiting set in. Disulfiram does ence with anxiety co-morbidity (Malec
not have any known or clinically ob- E et al. 1996; Malec TS et al. 1996). Ser-
served anti-craving-effects. By combin- traline only had positive effects on absti-
ing disulfiram and acamprosate, an anti- nence rates in type A patients according
craving effect is additionally obtained. to Babor (late onset, mild progression)
Besson J et al. (1998) showed that a com- (Pettinati HM et al. 2000). Moclobemide
bination of disulfiram and acamprosate in a dosage between 300 and 600 mg re-
delivers optimal results. duces the MAO turnover and therefore
As there are no psychological co- can be used as an anticraving substance
morbidities in type I patients, group in this subgroup.
psychotherapy is pointless. What is im- Regular psychotherapy and ego
portant is that total abstinence is main- stabilisation is the most important meas-
tained, and that the intake of relapse ure in type II patients. Self-help, which is
prophylactic medication is taken for based on the twelve steps used by alco-
long enough (up to 15 months). Regu- holic anonymous groups, is often coun-
lar check-ups are important and as this terproductive in type II patients. This is
group is hyperthymic, they like to have especially the case for Wikipedia cited
regular check-ups. The abstinence-ori- steps one (to accept that one is power-
ented self-help group is also suitable for less against one’s own problems), two
type I patients) (e. g. AA-groups, family (to believe that there is only one power
clubs). greater than oneself which can rehabili-

166
Medical strategies for relapse prevention

tate the psychological condition), three decreases after approximately three


(to decide to entrust one’s will and life to months. This medication has been ob-
God, however he is perceived/under- served as having only a mildly depres-
stood), six (to be willing to let God re- sive effect. The co-morbidity of alcohol
move “faults in character”) and seven (to dependence and depressive mood al-
humbly ask God to remove all personal ways raises the risk of suicide (Cornelius
“faults”). For type II patients, it is crucial JR et al. 1995; Yates G et al. 1988). Both
that they are in charge of their own life in disorders aggravate each other and in-
order to get out of the passive-anxious fluence the neuronal signal system in
role and develop more self-esteem. such a way that established therapies
AA groups are not sufficient. We are ineffective or may even have coun-
learned that groups to increase self-es- terproductive effects (Pettinati HM et
teem or to reduce anxiety, often in a al. 2000; Johnson BA et al. 2000). There-
hypnotherapeutic setting, are sufficient. fore it is vital for this group of patients,
in particular, that more work be done
to improve and develop pharmacologi-
9.6.6.3 Relapse prevention in Lesch’s type III
cal options. In her overview, Pettinati
Similar to type 2 according to Clonin- concludes that SSRIs are effective for
ger, patients seek the euphorising ef- maintaining abstinence in uncompli-
fects of alcohol due to their personality cated alcohol dependents. Yet they are
disorder (Tellenbach personality, and ineffective or even disadvantageous in
often also narcissistic tendencies) on patients with a depressive co-morbidi-
the one hand, and depressive co-mor- ty (Pettinati HM et al. 2001). Imipramine
bidity on the other. Type III patients are and desipramine showed positive re-
often abstinent for a long time and tend sults in regard to relapse and the reduc-
not to have slips. Relapses in the case of tion of drinking amounts (McGrath PJ
these patients, are rather severe. Nal- et al. 1996; Mason BJ et al. 1996). There
trexone was shown to be effective in is only one study on dual acting antide-
relapse prophylaxis (Kiefer F et al. pressants with milnacipran (Lesch OM
2005). It has been frequently discussed, et al. 2004). This six month trial has
whether it is better to administer nal- shown that milnacipran is able to re-
trexone as a daily therapy or intermit- duce relapses. Recently Pettinati et al.
tently and directed in the case of re- published that the combination of ser-
lapse (Hernandez-Avila CA et al. 2006). taline (200 mg daily) with naltrexone
Even in longitudinal studies, a depot (100 mg daily) achieved significantly
injection (with 380 mg) once per month higher rates in abstinence and that this
resulted in a significant reduction in combination delayed also relapses to
the number of drinking days compared heavy drinking. At the end of this trial
with a placebo (Garbutt JC et al. 2005; fewer serious reverse events were re-
O’Brian CP. 2005); side effects were ported and the patients tended not to be
nausea and headaches. Nevertheless, it depressed (Pettinati H. M. et al. 2010).
should be emphasized that it has been The 5HT-3 antagonist, ondanset-
clinically observed in type III patients ron, seems to be effective against crav-
(individuals with a vulnerability to de- ing and significantly reduces drinking
pression) that the effect of naltrexone in “early-onset” alcohol dependents

167
9 Therapeutic strategies in alcohol and tobacco addiction

(Johnson BA et al. 2000). A combination oneself being a queen or a king, beauti-


of ondansetrone and naltrexone signif- fully dressed, standing on a hill and
icantly reduced drinking amounts in a looking over his/her country and all is
placebo comparison study and there- peaceful …)
fore is more effective than both medi-
cations on their own (Johnson BA et al.
9.6.6.4 Relapse prevention in Lesch’s type IV
2000).
Topiramate antagonises glutama- Naltrexone, in oral form or as a depot
te and promotes GABA functions, which (Garbutt JC et al. 2005) reduces the
reduces dopamine release in the mes- amount and duration of drinking. Within
olimbic system. These combined ef- the group of anticonvulsive medication,
fects also reduce the “reward effect”. valproic acid, carbamazepine and topira-
Topiramate has been found to be suc- mate have been examined. The attempt
cessful in both “early onset” and “late was to reduce protracted withdrawal
onset” types with regards to craving symptoms with anti-convulsives and to
and the reduction of drinking amounts increase impulse control. Furthermore,
(Johnson BA et al. 2003). 61 % of pa- it was attempted to use mood-stabiliz-
tients with bipolar affective disorders ing effects for affective symptoms. Val-
consume increased amounts of alco- proic acid had positive effects in regard
hol. Topiramate seems to have mood to abstinence rates (Longo LP et al.
stabilizing and anti-craving effects. 2002) and irritability (Brady KT et al.
Psychotherapy is very important in type 2002). Carbamazepine was able to ex-
III patients. The aim of the therapy is to tend the time until the first relapse, but
loosen an overly tight structure so that this effect did not last over the entire
patients no longer define their self- period of the study (Mueller TI et al.
worth solely in terms of their perform- 1997). Further recommendations are
ance, and increase their ability to cope ondansetrone, topiramate, pregabalin,
with narcissistic offences in everyday nootropics and if necessary atypical
life, without relapsing. neuroleptics (e. g. quetiapine; Kamp-
In regard to self-help approaches, man KM et al. 2007). This type shows a
step number twelve of the alcoholic high cerebral vulnerability possibly due
anonymous programme is rather coun- to frequent withdrawals. Often epilepsy
terproductive (“Pass on the message to develops independently from the alco-
others after having been spiritually en- hol dependence and anticonvulsive
lightened ...”), because this is exactly therapy is needed.
what type III patients should learn not Many type IV patients are very
to do (not to always be there for others, difficult to treat within an outpatient
not to take the lead, not to be overly setting due to previous cognitive dam-
smart). In case of narcissistic tenden- age (impaired critical faculty often re-
cies, step four can be very helpful how- sulting in a high discrepancy between
ever (“to make a thorough and fearless their “wishes” and their “social possi-
inventory about oneself”). bilities”), a lack of socialisation (isola-
This could form a good basis for tion as a stress factor) or due to their
further therapy, which should also in- own specific socialisation (an example:
clude narcissistic gain (e. g. imagine a patient’s recently transplanted liver is

168
Medical strategies for relapse prevention

damaged as a result of drinking alcohol to abstinence or to an alleged belief of


with friends). Therefore these patients being in control, no matter what.
need long-term inpatient admission Pharmacotherapy and psycho-
with psychotherapy that is specially therapy should be ongoing.
adapted to this group. In an outpatient If a relapse lasts longer than ex-
setting, sociotherapy can be particularly pected and the patient requests an ad-
effective. Likewise, self-help groups justment of medication, the anti-gluta-
that function according to the Synanon matergic, caroverine (three times two
model can be helpful (living in a com- tablets) should be administered for a
munity, own activities, motto: everyone couple of days, and for craving, on-
has the ability to live abstinently). How- dansetrone (5-HT-3-blockade) in addi-
ever, type IV specific self-help groups tion to anxiety relieving medication or
need to accept relapses as part of the alternatively SSRIs can be adjusted to
symptomatology, which often becomes dual action anti-depressants.
one of the biggest obstacles. These pa- Lesch’s type III patients usually
tients tend to display a cyclothymic relapse after a longer period of absti-
temperament and changes of mood and nence and should be advised before
activity are often reflected by changing the start of therapy that relapses are to
levels of motivation. The most impor- be expected, if no significant changes
tant therapeutic tool is to keep in touch in lifestyle (e. g. the tendency to exces-
with these patients on a regular basis. sively burden oneself) are made or if
phases of depression are still setting in.
9.6.7 Treatment of relapses according to In case of a relapse, it is important to
Lesch’s typology help the patient to overcome feelings of
guilt and to provide objective informa-
Relapses in type I patients can be treat- tion on how to combat relapses (e. g. to
ed with Naltrexone for several days. The explain the “buffer” effects of alcohol).
administration of acamprosate should In regards to medical treatment, it
not be terminated. Benzodiazepines is important to continue naltrexone for
that are administered over a few days relapse prevention and to additionally
should help terminate the relapse and administer gamma-hydroxybutyric acid
can be administered together with vita- on a short-term basis in order to stop
min B1. Therapy sessions should be the relapse. Afterwards, antidepressant
short, but closely monitored. Admis- medication can be increased or adjust-
sions lasting one to three days are rec- ed to a different antidepressant sub-
ommended. stance. Topiramate, ondansetron or
Arguments, agitation, anxiety and baclofen should be taken into consid-
stress are typical factors that lead to a eration. Antihistamines can have sleep
relapse in type II patients. A decisive inducing and antidepressant effects
factor is the inability “to say no” to oth- (e. g. diphenhydramine).
ers’ expectations. Therapy aims at help- Type IV patients relapse more fre-
ing patients to find the courage to make quently than all other types. In the case
one’s own decisions. This new “deci- of a relapse, these types of patients
siveness” or learned ability to say “no”, should receive sociotherapeutic treat-
might encourage the patient to say “no” ment additionally to naltrexone. Phar-

169
9 Therapeutic strategies in alcohol and tobacco addiction

maceutically, ondansetrone, topiramate, Besides the risk of addiction, nic-


pregabaline and if necessary neurolep- otine has effects that are actively sought
tics should be considered (e. g. quetiap- by individuals, which is why they con-
ine; Kampman KM et al. 2007). tinue to smoke. For example, nicotine
In conclusion, it can be said that has been described as having the ef-
relapses in type I progression require fects of enhancing concentration, re-
medical intervention, whereas type II ducing appetite and positively influ-
and III predominantly need psycho- encing one’s psychological state. Often
therapy and type IV is best treated by a cigarette is smoked to reduce anxiety
using medical and sociotherapeutic in stressful situations and to elevate
competencies. The pharmacological mood. But also habits and ritualised
recommendations mentioned above activities, like e. g. coffee and a cigarette
might define the scopes of therapy, but or a cigarette after eating, play an im-
the patient is always the central aspect portant role. The breaking of these hab-
in the treatment of the relapse. There- its is one of the biggest challenges next
fore it is essential to understand the to the treatment of physical depend-
patient’s current situation, to reduce ence. When medically supporting pa-
stress, to focus away from the patient’s tients, it is not only important to edu-
failures and concentrate more on things cate and inform them about the effects
that were successfully done. Further- of smoking, but also to help them cope
more, the patient should be helped to with withdrawal. Besides a precise di-
perceive things that are unchangeable agnosis of the dependence pattern, a
(e. g. paralysis after seizure, few psy- therapy that is precisely adjusted to the
chological and cognitive stress com- patients needs is required because the
pensation possibilities, unable to do same kind of therapy is not effective in
physical exercises and therefore often a every patient.
dysphoric mood leads to relapse) as a
consequence of positive aspects in
9.6.8.1 Medication for relapse prevention
one’s life (e. g. my body had to pay a
of tobacco dependents
price for all the things achieved in life)
or as part of the current situation (e. g. 9.6.8.1.1 Nicotine replacement therapy
it is important to concentrate on what I These products substitute the effects of
can do for myself today). nicotine at the nicotinic acetylcholine
receptor and most likely the effects on
9.6.8 Pharmacotherapy of relapse preven- the MAO system as well. The “normal”
tion in tobacco dependents smoker, smoking 20 cigarettes a day, re-
sorbs 20 to 40 mg of nicotine daily and
Tobacco dependence is a very hetero- has plasma concentrations of 23 to
genic phenomenon which can be de- 35 ng/ml (Benowitz NL et al. 1988). Nic-
fined by the commonality of nicotine otine supplements often don’t reach
consumption, but the aetiology as well these concentrations and therefore dif-
as the craving for tobacco have very dif- ferent forms of administration have
ferent causes (Hesselbrock VM and been developed. The nicotine patch,
Hesselbrock MN. 2006; Lesch OM et al. which is available in different dosages,
2004). is suitable for a basis dosage. During

170
Medical strategies for relapse prevention

states of craving, during which strong Cahill et al. published a review on varen-
nicotine cravings are triggered, rapid icline and summarized data for daily
dispersion times, reaching higher con- practice:
centrations, are required. The sublin-
gual tablet, the nicotine nasal spray as 1. Varenicline is three times better
well as the nicotine inhaler seem to be than placebo at improving smok-
sufficient supplements for these states. ing even in the longitudinal course
Compliance with nicotine patches is 2. In smokers, varenicline is superior
usually very positive, but acute forms to bupropion. Studies combining
of nicotine supplementation show a varenicline and other therapeutic
different picture (Shiffman S et al. measures are still lacking and there
1996). The nicotine gum provides a ba- is still research needed to better
sis medication and can be used in acute document the role of varenicline
situations. Yet it needs to be chewed in smoking withdrawal.
slowly, which is very difficult for smok-
ers who suffer from strong cravings. All Further, dose titration studies and stud-
of these products are often under-dosed ies that investigate symptoms which
and therefore have inadequate effects. are a result of terminating medical
Today we know that nicotine supple- therapy after long-term administration
ments are especially effective in tobac- of varenicline, are needed. However, all
co dependent patients who have a Fag- in all, side effects seem to be uncom-
erstroem score of five or above. These mon. Nausea was the most frequently
supplements are suitable in withdrawal reported side effect.
therapy as well as for cravings in smoke-
free episodes and for the reduction of 9.6.8.1.3 Anti-depressants
the amounts of cigarettes smoked Mostly dopamine-agonistic and no-
(Henningfield JE et al. 2005; Sweeney radrenergic active anti-depressants are
CT et al. 2001; Tonnesen P et al. 1999; discussed in line with nicotine depend-
Le Foll B et al. 2005; J. Clin Psychiatric ence. There is clinical data on bupropi-
Monograph 2003; National Institute for on, nortriptyline and doxepin.
Clinical Excellence 2004). Several new dual anti-depressants
The most significant side effects might also have positive effects.
of nicotine supplements are nausea,
headaches and sometimes states of diz- 9.6.8.1.4 Bupropion
ziness and vertigo. Usually these side Bupropion doubles abstinence rates in
effects are of low severity and often re- both women and men. Studies have
gress after several days. used 300 mg of bupropion, which was
halved into two daily doses of 150 mg.
9.6.8.1.2 Varenicline One study was able to show that a com-
A study that compared varenicline with bination of nicotine supplements was
bupropion and a placebo showed that able to improve the progression. Fur-
varenicline increased abstinence rates ther publications reported an improve-
in smokers more significantly than bu- ment of depressive symptoms and in
propion and placebo. This effect could smoking behaviour (Lerman C et al.
still be verified after 52 weeks. In 2007, 2004; Fiore MC et al. 2000; Scharf D and

171
9 Therapeutic strategies in alcohol and tobacco addiction

Shiffman S. 2004; Shiffman S et al. 2000; 9.6.8.1.8 Rimonabant


Jorenby DE et al. 1999). Rimonabant is a CB1-antagonist and
data suggests a decrease of impulse
9.6.8.1.5 Nortriptyline control in eating, which also applies to
Also nortriptyline improves depressive alcohol (Soyka M et al. 2007; Despres JP
symptoms, but it has the biggest effect et al. 2005; Pi-Sunyer FX et al. 2006). As
on smoking behaviour. This applies to impulse control also plays a role in
both types of tobacco dependents, smokers, rimonabant has been tested
those who show depression co-mor- in studies on smoking reduction. In
bidity and those without any depres- these studies, 20 mg rimonabant was
sive symptoms (Henningfield JE et al. administered daily and smoking behav-
1998; Huges J et al. 2004; Ferry LH. 1999; iour and weight were monitored. Light
Prochazka AV et al. 1998; Hall SM et al. smokers and smokers with a Fagerstro-
1998). em score of five or above were included
in the study and results showed that
9.6.8.1.6 Doxepine abstinence rates were twice as high and
In older studies, this medication has al- weight was more significantly reduced
ready been proven to be effective for than in the placebo group (Cohen C et
both nicotine withdrawal syndrome al. 2002; Anthenelli R. 2004; Klesges RC
and tobacco craving (Edwards NB et al. et al. 1997; Klesges RC et al. 1989). Dose
1988; Murphy JK et al. 1990). titration studies are also lacking for ri-
All of these anti-depressants have monabant. Our study shows that wom-
well known side effects. These are ele- en who smoke are especially suitable
vated heart frequency, dry mouth, for these studies as they smoke signifi-
changes in blood pressure and in- cantly more often in order to control
creased risk for urinary retention in their weight than men. The extent to
men. Narrow angle glaucoma is a con- which combinations of anti-depressant
traindication for tricyclic anti-depres- medication can be effective should
sants. definitely be examined. Women also
smoke more frequently because of a
9.6.8.1.7 Clonidine prevailing depressive mood (Lesch OM
Clonidine is an alpha-2-noradrenergic et al. 2004). Nausea is one of the most
active agonist, which is used in opiate- frequently reported side effects of ri-
and alcohol withdrawal. A study includ- monabant (Soyka M et al. 2007). Ri-
ed smokers that were not able to stop monabant in daily practice showed an
smoking despite being motivated to increase in depressive symptoms and
quit. Results showed that twice as many we believe that further studies in this
smokers taking clonidine were able to mechanism are necessary.
quit smoking within four weeks when
compared to a placebo group (Glass- 9.6.8.1.9 Topiramate
man AH. et al. 1988). These positive re- This anti-epileptic has been examined
sults could still be observed after six in alcohol dependents over a period of
months. As side effects of clonidine are three months and results showed a sig-
quite common, it tends to be a second nificant improvement in alcohol de-
choice in therapy. pendents’ impulse control. The starting

172
Medical strategies for relapse prevention

dose of 25 mg/daily was gradually in- nostic instrument which has divided
creased to 300 mg of topiramate and nicotine dependence into four differ-
was well tolerated by patients. Results ent clusters. Different forms of craving
also showed significant improvement (relaxation, coping, stress and depres-
in smoking behaviour, which was con- sion) are considered. These four clus-
trolled by using cotinine levels. The role ters with their different craving mech-
of topiramate or similar substances in anisms comprise then homogenous
smoking cessation needs to be further groups which are also based on shared
examined (Johnson BA et al. 2003; biological and psychological aetiolo-
Johnson BA et al. 2005). gies. (Lesch OM et al. 2004), Fig. 99.
All other substances that are of A decision tree is suitable for the
theoretical interest lack sufficient data definition of particular subgroups. The
to be recommended for smoking cessa- severity of each dimension is exempli-
tion (e. g. nicotine vaccine, dual anti- fied by simple and weighted categories
depressants, ondansetrone etc.). and thus clear decisions can be derived
In conclusion, it can be stated that from this. The score of the Fagerstroem
the smoker’s response to anti-craving test is very important in withdrawal
substances as well as behaviourally ori- therapy, but for relapse prophylaxis
ented therapy approaches are impor- therapy, consecutive symptoms, like in-
tant factors in withdrawal therapy. Fur- fantile behavioural disorders, seem to
thermore, patience and the ability to be more important than the Fagerstro-
encourage motivation time and again em score.
are crucial issues for supporting smok-
ers. The recommended medications 9.6.8.2.1 Subgroups according to Kunze and
have very different mechanisms and Schoberberger (Lesch OM. 2007)
clinical data suggests that they are only Moreover, Kunze has introduced three
effective for certain subgroups of to- types of smokers, namely level smoker,
bacco dependents (e. g. improvement peak smoker and mixed types, which
of abstinence rates from 20 % to 40 %, are defined as follows (Fig. 33):
but this still leaves 60 % that don’t profit
from this method). The subgroups de- 1. Level smoker: smoking is evenly
scribed in chapter 6.2 and different distributed across the day
forms of craving have different biologi- 2. Peak smoker: consumption in spe-
cal mechanisms and therefore future cific situations or notably more at
studies need to consider these factors. specific times of the day (= peak
times), then only little or no smok-
ing for longer periods
9.6.8.2 Therapeutic procedure according to
3. Mixed types: regularly smoking at
subgroups of nicotine dependent patients
steady intervals, but more inten-
The Institute for Social Medicine and sive on certain occasions
Centre for Public Health with pulmo-
nary specialists qualified in counselling 9.6.8.2.2 Craving in subgroups of tobacco
smokers, and the Medical University of dependent patients
Vienna, Department of Psychiatry and Data on subgroups needs to be con-
Psychotherapy, have developed a diag- firmed by further research and there

173
9 Therapeutic strategies in alcohol and tobacco addiction

Fig. 99 Decision tree for the classification of smokers into groups

Perinatal damages or
Contusio cerebri or
Other severe brain diseases or
Severe polyneuropathy with neurological deficiencies or Type IV
Epilepsy or
Biting nails and stuttering (over months)

Nocturnal enuresis after the age of three Type III or type IV


(prolonged and socially disturbing)

In case of nocturnal enuresis:


No periodic smoking or
No sleep-maintenance problems or Type IV
No acute depressive episode (ICD-10) or
No severe SM-tendencies

In case of no nocturnal enuresis:


Periodic smoking or
Sleep maintenance problems or Type III
Acute depressive episode (ICD-10) or
Severe SM-tendencies

Fagerstroem-Test (Fig.34): Fagerstroem 5 points or above Type I

Type II
Smoking as a coping strategy

are only few therapy studies on sub- 2. Smoking to cope with situations
groups. Nevertheless, we would like to (smoking as a coping mechanism)
introduce a therapeutic scheme for sub- 3. Smoking to better cope with stress
groups, which should be examined by 4. Smoking to elevate mood
research in the future. Today we know
that there are four dimensions of crav- These different types of craving have
ing additional to the four clusters of different biological mechanisms and it
tobacco dependence (Lesch OM et al. is widely known that men tend to smoke
2004). for relaxation, due to boredom or to in-
crease well-being, whereas women tend
1. Smoking to increase relaxation to smoke in order to control weight and
and well-being to elevate their mood.

174
Medical strategies for relapse prevention

9.6.8.3 Pharmacotherapy in relapse are no signs of psychiatric co-morbidi-


prevention in tobacco dependence, ty, no premature cerebral damages, no
according to subgroups behavioural disorder and no symptoms
that suggest a classification to sub-
9.6.8.3.1 Relapse prevention of cluster I group III and IV.
This subgroup of tobacco dependents
has a Fagerstroem score of ≥ 5 points, Pharmaceutical relapse prevention
but there is no prevalence of psychiat- To which extent dopamine agonists or
ric co-morbidities, premature cerebral MAO-A antagonists play a role in this
damage, behavioural disorders and no group has not been documented by re-
other symptoms, which demand a clas- search, but in theory these substances
sification to subgroups III or IV. should have a positive effect on smok-
ing behaviour.
Pharmaceutical relapse prophylaxis Long-term changes in the gluta-
The effectiveness of nicotine supple- mate-taurine quotient are also to be
ments has been proven, but there is no expected, suggesting the use of NMDA
scientific data on duration and dosage antagonists in relapse prevention. Acam-
in long-term administration. In case of prosate and neramexane are being
relapse, it is essential to begin a nico- discussed in line with this indication.
tine supplement therapy as in withdraw- Anti-depressants (e. g. Bupropion, nor-
al therapy (nicotine patches, nicotine triptyline, doxepine, moclobemide) are
gum, inhaler, sublingual tablet). Vareni- likely to be effective in this group.
cline could be a useful additional drug Combinations of these medica-
for withdrawal therapy, and also for re- ments might be effective, but this has
lapse prophylaxis. not yet been supported by research.
To which extent dopamine ago-
nists or MAO-A antagonists play are role 9.6.8.3.3 Relapse prevention of cluster III
in this group has not been investigated Symptoms of subgroup IV must be
yet, but in theory these substances absent. Long-term enuresis nocturna,
should have a positive influence on which significantly influences the devel-
smoking behaviour (e. g. moclobemide). opment of the adolescent, is no reason
Long-term changes in the gluta- for exclusion, if a psychiatric co-morbid-
mate-taurine quotient are expected, ity, usually with a major depressive dis-
which suggests using NMDA antago- order or suicidal tendency has been
nists for relapse prophylaxis. Acampro- recorded in the case history. Often an
sate and neramexane are being discussed association between the severity of
in line with this indication. symptoms and smoking behaviour in
Combining these medications recurrent psychiatric disorders has
could be effective, but has not yet been been documented (e. g. heavy smoking
scientifically investigated. during severe depressive phases). These
patients have often high, but sometimes
9.6.8.3.2 Relapse prevention of cluster II also low, Fagerstroem scores.
This subgroup of tobacco dependent
patients smokes Fagerstroem-negative Pharmacological relapse prevention
(Fagerstroem-score ≤ 4 points). There The dose of psychotropic drugs needs

175
9 Therapeutic strategies in alcohol and tobacco addiction

to be adjusted in the smoke-free phase riod of time. Atypical neuroleptics, or


(anti-depressants, see also group II). topiramate, other antiepileptics and
Bupropion is the first choice in this NMDA antagonists are likely to im-
group, but nortryptiline is still a possi- prove impulse control. Scientific data
ble option in this subgroup. for this group is missing however. Varen-
Nicotine supplements have been icline might be effective in improving
shown to be effective in the Fagerstro- the patient’s condition, especially if
em group with ≥ 5 points, but there is nicotine supplements turn out to be in-
no data on duration and dosage for effective. If these patients also abuse
long-term administration of these sup- alcohol a combination with naltrexone
plements. In case of a relapse a nicotine is a good option.
supplement therapy should be started
immediately, as is the case in with-
9.6.8.4 Medication of tobacco dependent
drawal therapy (nicotine patches, nico-
patients in special situations
tine gum, inhaler, sublingual tablet).
As there are usually more women
in this group, who tend to smoke for 9.6.8.4.1 Nicotine consumption in
weight control, CB1 antagonists like ri- combination with other dependences and/or
monabant might be suitable, but need psychiatric disorders
clearly a combination with antidepres- This subgroup of tobacco dependent
sants. patients smokes in addition to a sec-
ondary dependence or in order to re-
9.6.8.3.4 Relapse prevention of cluster IV duce symptoms of other psychiatric
Infantile cerebral impairments, somat- disorders.
ic diseases and/or infantile behavioural
disorders lead to considerable develop- Tobacco dependence in combination
mental disorders. Often, smoking is an with alcohol dependence
additional complicating factor. Critical Therapeutic procedure should be in
thinking about one’s own health behav- line with the recommendations of Le-
iour is reduced in several domains. sch’s typology of alcohol dependents.
Smoking is only one of these phenom- Type I alcohol dependents, who have
ena. In addition, temporary severe al- stopped drinking, but who consume ex-
cohol abuse has often been observed in orbitant amounts of tobacco, still have
this group. Primarily, individuals of this a shortened life expectancy, just as if
group tend to be intellectually impaired they were still drinking. Also the prog-
and are easily influenced by their peer nosis of alcohol dependence is better if
group. Secondary problems are social tobacco dependence is treated at the
difficulties, reactive depressive epi- same time. Effective control of nicotine
sodes and more than 70 % of these pa- supplement therapy and smoking re-
tients have a Fagerstroem score of ≥ 5 duction is done by measuring nicotine
points. and cotinine in urine or by measuring
carbon monoxide satiation.
Pharmacological relapse prevention
In this group, nicotine supplements Tobacco dependence in schizophrenia
need to be administered over a long pe- If a schizophrenic patient is tobacco

176
Medical strategies for relapse prevention

dependent, it should be borne in mind 9.6.8.4.2 Tobacco dependence and


that not only do high doses of nicotine pregnancy
reduce the level of neuroleptics in the The embryo is extremely sensitive to
blood, but also that the schizophrenic tobacco abuse during the first three
patient often experiences the sedating months of pregnancy, but also later on.
effects of nicotine positively, as it lowers Impaired circulation of the placenta
extrapyramidal symptoms (e. g. akatisia). and a low birth weight of the child are
However, direct dopaminergic effects of only a few consequences worth men-
nicotine aggravate schizophrenic symp- tioning. Changes in tobacco dosage
toms. In individual cases, we were able seem to severely damage the growing
to show that a reduction of nicotine con- embryo. It is important to reduce to-
sumption leads to an improvement in bacco consumption especially during
psychopathological symptoms. Princi- pregnancy, in which case the use of nico-
pally, it is suggested that dose adjust- tine supplements at least enables the
ments of neuroleptics be considered in avoidance of other tobacco ingredients.
this group of patients. This medical-psychiatric presen-
tation of tobacco and alcohol depend-
Tobacco dependence in affective disor- ence has put particular emphasis on
ders axis I to III to DSM-IV. The following
Especially in the case of manic disor- chapter describes the treatment of alco-
ders, the same rules as for schizophre- hol dependents from a socio-pedagogi-
nia apply. Yet there is no scientific re- cal perspective. Mr. Christian Wetschka
search on this topic. However, from has delivered excellent scientific data
experience, the onset of a manic and/ from supporting (homeless projects)
or depressive episode is often marked and motivating dependents to take an
by excessive smoking, and sometimes active part in life (theatre projects) and
by increased alcohol consumption (as incorporating social institutions into
a sign of the incipient increase of ener- therapy. Every psychiatric diagnosis
gy and unrest). As the first signs of an stands in the context of sociology, psy-
episode of illness episode set in, some chology and biology and it is our aim
patients have reported a clearly in- to provide sufficient space in this book
creased craving for nicotine. for a sociological perspective.

177
10
Sociotherapy of alcohol-and
tobacco dependents with regards
to Lesch’s typology
Written by Christian Wetschka

10.1 Alcohol and Tobacco A factor in tobacco dependence


Studies have repeatedly supported the of socially disadvantaged individuals,
assumption of general practitioners that which should not be underestimated,
alcohol and tobacco occur together in is that a disproportional amount of in-
psychosocial practice. come (often up to 50 %) is spent onr
In “sociotherapy”, alcohol depend- buying cigarettes, which often leads to
ence is of prior importance, especially further debt. This factor can negatively
because it interferes with re-attaining influence self-preservation and social
the ability to regulate oneself and thus integration, for example, if the partici-
complicates any attempts towards sta- pation in certain leisure activities with
ble social integration. Tobacco depend- others is not possible for financial rea-
ence is often a complicating factor ad- sons. Further limitations in socialising
ditional to alcohol dependence, with activities concern the increasing num-
relapses in both forms of dependences ber of bans on smoking in pubs, agen-
being influenced by social stimuli. cies, hospitals and public transport,
As we shall discuss in the section which means that e. g. individuals might
on sociogenesis, there is a correlation chose to miss out on an excursion, or a
between socio-economic status and the visit to a theatre, rather than not be able
development of dependence. Poverty, to smoke for two hours in a train/in the
social stigmatisation (affiliation with a theatre.
marginal group) and social isolation are There are established models and
important factors that determine the institutions for the support of alcohol
development of somatic and psycho- dependents in socially precarious con-
logical disorders. The concomitant oc- ditions (e. g. homeless) which concen-
currence of alcohol and tobacco de- trate on alcohol dependence, while
pendence increases the risk for sequelae, nicotine dependence often remains un-
like dental damage, obesity, malnutri- considered. To some extent, there is
tion or cardiovascular diseases. resignation towards smoking. Models

179
10 Sociotherapy of alcohol-and tobacco dependents with regards to Lesch’s typology

which contribute towards the reduc- The worst of this scenario is this
tion of tobacco dependence in under- emptiness, this hollowness, this ab-
privileged groups, are needed. solute soullessness … rehabilitation
merely means that either you turn
10.2 The sociotherapeutic1 mission into something useful, that is inte-
grated, or you are segregated, which
Before we can address dependence- means you become a hopeless case …
specific interventions with regards to
subgroups, the following section will Each one of these “human ob-
first describe and define the nature of ject gawkers” knows best what he
“sociotherapy”, in particular because it (the affected) is lacking, what he
is distinct from the related disciplines needs, where he belongs etc. and
of social work, social pedagogy and therefore, after a while, you don’t
psychotherapy. In comparison to these really know who you are any-
fields, “sociotherapy” puts more em- more … the aftercare consists of a
phasis on a mutual and active shaping number of activities. Here every af-
of the social environment. On the other fected person asks himeself about
hand, it is undisputed that all these the purpose of these institutions and
forms of intervention overlap and rep- to which extent they are able to gen-
resent variations of “networking proc- uinely help …
esses”.
As social aspects are of great im- The affected person feels that
portance for the development of every no institution or any group is a real
dependence, socio therapeutic inter- community, everything is imposed
ventions for people with addictions, due to the disease, and this helps lay
especially for those in socio-economi- groups or other groups to exist only
cally poor conditions, are pivotal. because of the disease, you have to
be psychologically ill in order to be-
long to the group. Therefore the dis-
Herrmann Spaeth, a psychiatric pa- ease is the only value the community
tient, talking about his experiences in has, and that’s it. The individual his-
the “therapeutic chain”: tory of the affected becomes unim-
“To me, aftercare is a gloomy portant due to these conditions, one
issue … In a sense the symbol of the must adapt to the ill community …
topic is the desk. Room numbers, Like in industry, this ill community
agencies, desks and the particular consists of sub-branches, informa-
kind of people who sit behind their tion centres, workshops for the
desks, control the scenario … What handicapped (sheltered workshops)
remains? An act, a sad act unfortu- and residential care facilities, this
nately, a person that is taking notes, industry is then called psychiatric
who is playing a sad role in this act. aftercare …
His despair is the hunger for
1 The terms sociotherapy and social therapy are used normality …”
synonymous in relevant literature. In America, the
term “multi-systemic therapy” is also used in cer-
(Hermann Spaeth, cited by Keupp
tain contexts. and Rerrich 1982).

180
The sociotherapeutic mission

This critique by an affected person ex- scribes as a “method of modern psycho-


plains the primary essence of socio- therapy” that seeks to influence and
therapy: the overcoming of contexts that change the “social environment” in or-
are determined by the disease, which, der to help the psychologically ill, espe-
confine patients to their patient role, a cially if psychotherapy is not possible.
role which often continues to define This is a highly problematic definition,
them far beyond their period of psychi- above all because it defines sociothera-
atric admission, in the striving towards py as going beyond actual psychother-
“normality”. apy (Schwendter 2000). In the sixties of
At the same time, for the alcohol the 20th century, the psychiatric attribu-
and tobacco dependent, the pursuit of tion processes made via diagnostics
“normality” is a social contradiction, be- and psychiatric institutions were sub-
cause society perceives alcohol and to- jected to international criticism (Ba-
bacco consumption as “normal” and not saglia, Szasz, Laing, Foucault …). At the
as “abnormal/pathological”. Children same time (during late 60s and early
and adolescents adopt the behaviour 70s), a number of terms in regard to so-
that their parents and/or peers exhibit ciotherapy were developed, in which
as “normal”. Growing up continues to be the distinction between sociotherapy
linked with the right to determine for and related methods, such as psycho-
oneself one’s contact with psychoactive therapy, social work and social peda-
substances. Therapy must support a dis- gogy, was a recurrent theme (Baer
sociation with these patterns of sociali- 1991/2005). It must be emphasized that
sation, or, in other words: the affected sociotherapy is more than just the fur-
needs to redefine “normalisation”. ther development of social work and
The term sociotherapy has been social pedagogy; rather, it is an inde-
increasingly differentiated, apart from pendent discipline (in theory at least).
earlier singular attempts (for example In the meantime, specific educational
in Elias Salomon, cited by Haag 1976), curricula for sociotherapists have been
in the decades since World War II. Like introduced, we can now speak of a con-
psychotherapy, it can be viewed as a vergence of concepts which allows for a
counter strategy against the objectifica- stable definition. On the other hand, it
tion or alienation of the self, as well as should be noted, that, in its role as a
an attempt, within the context of cer- mediator, sociotherapy is (and needs to
tain institutions and measures, to safe- be) “caught between two stools”, those
guard or rather reclaim human subjec- of the disease-oriented realities of psy-
tivity (self-determination, experimental chiatry and “normality”. Doerner and
ability, access to, and utilisation of, re- Plog state: “Sociotherapy seems to be
sources). much too general for it to be defined
This became more apparent after from the perspective of only one occu-
the two world wars, during which hu- pation. Arguably, it can be said that the
mans were used as “cannon fodder” or/ purpose of sociotherapy is to point to
and turned into victims of ideological the generalized handling of rules and
and political manipulation. In 1947, norms, responsibilities and liberties,
Viktor von Weizsaecker picked up the individuality … and social issues” (Do-
term “sociotherapy” again, which he de- erner et al. 2002, p. 553).

181
10 Sociotherapy of alcohol-and tobacco dependents with regards to Lesch’s typology

As an example of this aspiration Alongside the call for interdisciplinary


towards a convergence of concepts, we “diagnoses” and treatments”, an orien-
will cite two definitions. The first one is tation towards the social field is em-
by Rolf Schwendter, whose “Introduc- phasized, implying that sociotherapy
tion to Social Therapy” (2000) still be- acts in the everyday life of the affected,
longs to the standards works, and the by integrating those relationships which
second by Hilarion Petzold, founder of occur naturally in his life. The final as-
integrative therapy and an important pect of the definition is of no minor im-
theorist in sociotherapy. Both strive to portance: the specific attention given
highlight the autonomy of sociotherapy to disadvantaged population groups,
in comparison to other phenomena in often marginal groups, who don’t have
the psychosocial support continuum, the option of treatment. This points to
not least because these definitional clar- the sociotherapy’s mandate to criticise
ifications pin down specific education institutions and society.
curricula (Gesamthochschule Kassel,
Fritz-Perls-Institute Duesseldorf).
Hilarion Petzold:
“Sociotherapy and psychosocial
Rolf Schwendter: counselling can be described as the-
“Social therapy is perceived as ory-driven, planned work with peo-
an integrating concept of action ple in social systems which main-
which connects social, psychological tains an awareness of the influence
and therapeutic interventions re- of such systems and contexts at a
spectively. (...) Socialtherapy can be micro and meso level, by using
understood as an interdisciplinary methods of intervention that struc-
approach which seeks to develop the ture these problem situations. The
ability to reflect and act. Social ther- aim of this is to strengthen social
apy is a special form of perceptual competencies and performances of
diagnosis, treatment and exploration individual groups so that they can
of the psychosocial distress of the in- better cope with their personal and
dividual, families and groups. The social life. Sociotherapy also encour-
term social therapy implies that the ages the shaping of one’s own life as
suffering individual is not separate well as mutually co-operative behav-
from the social situation which has iour and social creativity. In this
caused the problems, but that thera- way, it is possible to change institu-
peutic approaches (via a double tions and social domains and to mo-
perspective) address both social tivate people living and working in
and psychological conflicts. Social these social areas towards an en-
therapy is directed at the misery of gagement in personal issues, psycho-
socially disadvantaged population social health and a humane quality
groups, who are usually neglected of life. In order to reach these goals,
by conventional, predominantly a broad, multi-theoretical model
individual therapeutic approaches“ of psychosocial interventions is
(Schwendter 2000, p.8). needed, in which differently tested
methodological counselling and

182
The sociotherapeutic mission

therapeutic approaches are inte- on, compulsory psychiatric treatment,


grated” (Petzold 2003, p. 927). residential homes, approved schools
and the like). With the mandate of re-
For Petzold, whose definition is based establishing “normality”, sociotherapy
not least on practical work with mar- becomes the manager of the friction
ginal groups migrant workers and eld- which exists between different reali-
erly people, the goal of sociotherapy is ties, which obstructs the development
to change and shape the social environ- of the personal potential of those af-
ment by promoting behaviour which fected. As a mediator between what
expresses solidarity, and by valuing the are at times extremely different per-
quality of life. Sociotherapy is not re- spectives, sociotherapy is “trans-disci-
sponsible for changing only individu- plinary” in essence.
als, but also institutions. Form a historical and practical
Furthermore, interdisciplinariness perspective, sociotherapy has originat-
(“multi-theoretically based model of ed from a “grey area” between social
psychosocial intervention”) is an es- work and psychotherapy. In addition,
sential part of sociotherapy. The equa- other required competencies and skills
tion of psychosocial counselling and stem from the know-how and experi-
sociotherapy is of no lesser importance. ence of pedagogy, art therapy, sociology
Petzold underlines the possibility of so- and social psychiatry.
ciotherapy for the socially disadvan- The occupational profile of the
taged, such as those “difficult” individ- socio-therapist has been confined to
uals (e. g. psychotic, drug-addicted and diverse educational contexts (e. g. as an
borderline patients), who only profit additional qualification for social work-
from psychotherapy under specific con- ers or psychotherapists), however the
ditions, provided that they want to en- professionalization of sociotherapeutic
gage in such an extensive process and work which has to date taken place, is
are able to persevere with it over a long only a variation of the same thing. In
period of time – a phenomenon which practice, large numbers of sociothera-
we will encounter again in the typology peutic interventions are carried out by
of alcoholism and in discussing its con- persons who are directly involved in
sequences for therapy. the individual’s everyday life. These are
The sociotherapist needs to work of course social workers, psychothera-
at psychosocial hotspots (troubled pists and social pedagogues, but in
neighbourhoods), where the interven- many cases, and presumably to a much
tional repertoire of social work and psy- greater extent, they also consist of fam-
chotherapy is not able to offer help, not ily members, friends, nursing staff,
least because of discrimination, and home helps, creative, leisure, and self-
where the social environment needs to help groups, who don’t have any socio-
be changed to the advantage of those therapeutic awareness or self-concept.
affected. Psychosocial hotspots can Clearly this is related to the grass-root-
however be (total) institutions which edness of sociotherapy. Its goals are to
are anti-psychotherapy in character normalise the organisation of everyday
and in which psychotherapy comes up life, where it is most effective, i.e. in the
against institutional boundaries (pris- everyday life of the affected. Due to this

183
10 Sociotherapy of alcohol-and tobacco dependents with regards to Lesch’s typology

fact, there is probably no other domain als, who are blinded by routine” (Sch-
which is as open to individuals working wendter 2000, p.280)
on an honorary basis (or as “volun-
teers”) and who already, by dint of their Example:
life circumstances, embody and com- Peter H., 56 years old, was living in
municate “normality”. In addition, they a sociotherapeutic home for alco-
are rarely completely identified with hol dependents for two years until
institutions, as is inevitably the case he was able to move to a council
with professional staff. flat. As Peter is a social person, it
was a challenge for him to live by
Example: himself in a flat. After a relapse, he
In a flat-share for type IV alcohol increasingly sought contact with
dependents in Vienna, we have people from his old home. Then he
deliberately not employed special- found out that his former room-
ised staff and have thereby done mate was in hospital with cancer.
without all associated “rituals of During the following period, he
social administration” which might visited his colleague three to four
provoke a feeling of social differ- times a week and was virtually in
ence. It was more important that a charge of the patient. The staff of
network of honorary workers was the hospital was very grateful be-
in regular contact with residents cause they did not have enough
(e. g. at weekly game evenings, time and energy resources them-
helping to clean up the room, in selves for these demanding patient
leisure activities etc.). visits. As all parties concerned ex-
perienced Peter H.’s visits as very
In this context, Rolf Schwendter high- positive, the team decided to ask
lights the integration of affected indi- Peter H. to visit patients in the
viduals who have undergone similar hospital more often.
experiences and can assist people with
comparable problems, for example the Fig. 100 Interdisciplinary dimensions of
ex-abuser in drug (socio)therapy, the sociotherapy
ex-homeless, the ex-alcoholic (the self-
help group scene springs to mind, in
particular, in this connection) etc. Not Psycho-
integrating the wealth of experiences of Social work
therapy
“laypersons” who, especially by dint of
their non-professionalism, are able to in- Socio-
troduce alternative perspectives, would therapy
be going against the grain of sociother-
apy. Schwendter: “Helping laypersons
are able to contribute qualifications,
points of views, sociotherapeutic expe-
rience, in short, ‘educational elements’ Pedagogy
into sociotherapeutic work, which of-
ten seem to be neglected by profession-

184
Classication Psychotherapy-Sociotherapy

The relationship of sociotherapy and sions between psychotherapeutic and


unprofessional support staff needs to be sociotherapeutic procedures to arise
discursive, which means that it works in (e. g. in care or social work), especially if
a complementary and respectful way. all interactions are interpreted from a
Therefore, approaches that link socio- “psychotherapeutic” perspective and if
therapeutic action only to certain edu- there is little room provided for “nor-
cational backgrounds, or try to classify it mality”.
into a hierarchical system (e. g. as being
above social work and social pedagogy, Example
but below psychotherapy and psychia- “Imagine a situation, in which
try), need to be viewed critically. patients are only perceived from
The “hunger for normality” (Spa- a psychoanalytical, behavioural
eth) is probably most intense where the therapeutic or client centred per-
alienation of subjects through institu- spective. In every meeting, the
tions is most apparent. As this issue is psychotherapist acts according to
linked to the need for increased self- his therapeutic approach and per-
determination, sociotherapy continues ceptions: he verbalises the pa-
with its major project of education/ tient’s feelings, attends to trans-
empowerment. Of course, the call for ference aspects only and hesitates
“empowerment” (Stark 1996). has al- before he acts on the basis that
most become a platitude and, as is al- any instantaneous action could
ways the case with such fundamental reinforce the patient’s avoidance
dimensions in pedagogical contexts, this behaviour. The therapist is not in-
call often remains unheard, frequently terested in the rules that the nurs-
due to the physical restrictions of the es use for regulating cohabitation
institutions. This is especially the case in the ward, as he is only interest-
for “total institutions”, in which com- ed in implementing psychothera-
pulsory therapy always holds a precari- py.” (Doerner et al. 2002, p. 555).
ous position, but also for relatively
“normal institutions”, like transitional
or permanent homes, which impose In addition Doerner and Plog allego-
different restrictions natures (rules of rize in their critical textbook:
the house, counselling agreement, ob- “Sociotherapy is the basis! It
ligation to attend group sessions and can’t be positioned as just one of
more). Sociotherapy needs to be aware many techniques. In fact, it makes
of tensions and precarious power rela- the application of other techniques
tionships and needs to counteract them possible. From this perspective, we
when they obstruct the development of conclude that the nursing staff
personal potential. (e. g. because of their constant
presence) are in charge of socio-
10.3 Classication Psychotherapy- therapy more than anyone else.”
(Doerner et al. 2002, p. 556).
Sociotherapy
In psychosocial practice, such as in psy-
chiatric institutions, it is easy for ten-

185
10 Sociotherapy of alcohol-and tobacco dependents with regards to Lesch’s typology

Fig. 101 Differentiation Sociotherapy – Psychotherapy

Sociotherapy Psychotherapy/Withdrawal
100 % dependents 100 % dependents
Dependents with severe physical and Dependents without severe physical and
psychological sequelae (high proportion psychological sequelae
of co-morbidities)
Organic brain impairment Neuropsychological deficits of rather
subclinical nature
Social disintegration with often disastrous To some degree socially integrated
outcomes

Fig. 102 Classification sociotherapy – psychotherapy

Sociotherapy Psychotherapy
Low admission threshold, little motivation High threshold, high motivation require-
requirements, “disease acceptance”, ability ments, “disease acceptance”, ability to
to introspect and verbalise cooperate and introspect

Sociotherapy supports normal, “non- psychotherapy is more biography-ori-


pathological”, healthy aspects of the ented, while sociotherapy concentrates
patient (Doerner et al. 2002, p.556) and, on what is at hand, thus being more ex-
in this respect, complements medical perience, practice and theme focussed
and psychotherapeutic care, from which, (Baer 1991/2005).
however, it fundamentally and/or par- Often characteristics of sociother-
tially differs. Affected persons are those apy are influenced by clients’ and pa-
who become permanently or tempo- tients’ personality traits. Usually pa-
rarily limited in organizing everyday tients are considerably impaired in
life, which in many cases, often goes organising and structuring their life.
hand in hand with deficient or instable Contrary to psychotherapy patients,
ego structures. In line with this, there organic brain damages and somatic
is a difference between sociotherapy and psychological sequelae prevail and
and psychotherapy on a methodologi- patients are often socially disintegrat-
cal level, e. g. in the handling of trans- ed. In some cases, inner structures
ference symptoms. Psychotherapy aims (“self-regulation”) that are needed for
at “changing the basic patterns” of per- leading a self-reliant life have to be es-
sonality and in this, the addressing of tablished and secured (“formation of
transference phenomena is standard. structure”). Steingass2 (2001) compared
Transferences also emerge in sociother- patients of in-patient psychotherapeu-
apeutic contexts but they are not ac- tic and sociotherapeutic institutions, a
tively addressed. That is, transference is differentiation that needs to be modi-
recognized and in some circumstances
also defined, but never applied by so- 2 Steingass is the director of a sociotherapeutic home
ciotherapists (Walter 2004). In this light, for alcohol dependents in Remscheid.

186
Classication Psychotherapy-Sociotherapy

fied for outpatient services and shel- Here is where learning and practic-
tered housing (for example aftercare, ing to cope with emotional tensions
residential homes). This striking dichot- without using old pathological pat-
omisation of a factual overlapping of terns should take place. If the patient
both disciplines is rarely observed this is too reserved or inhibited to ex-
clearly in practice, but the divergences press himself or take part in activi-
are nevertheless apparent when com- ties, the sociotherapist should not fo-
pared. cus on interpreting the patient’s
Clients who receive sociothera- behaviour. Instead, the therapist
peutic support are often extremely so- should attempt to motivate the pa-
cially disintegrated. There is no contact tient towards participation and ac-
to family members, relationships are tivity by using available potential
broken and socio-demographic varia- and resources. The crucial point is
bles suggest low educational back- not the elaboration of pathological
ground, no school leaving certificates behaviour, but the encouragement of
and unemployment. This is also repre- self-worth, by increasing and stabil-
sented by different admission criteria ising experiences, successfully com-
for various kinds of therapy. In ex- pleting assigned (small) tasks or the
treme cases, street work can be inter- mastering of difficulties, and coping
preted as a sociotherapeutic activity with specific moods or situations.”
because this is where support is pro- (Bosch)
vided or planned.
Bosch (Expert committee in soci- Sociotherapy can support psychother-
otherapy of the AHG scientific council apeutic work, and in some cases even
2000, S. 111–124) defines sociotherapy be substitutive, especially if psycho-
as inversely related to psychotherapy. therapeutic work is not possible or not
While psychotherapy can afford to have efficient. Sociotherapeutic approaches
its own attitude, which is useful for emphasize self-awareness in confront-
therapeutic processes but detached ing the objective and social environ-
from reality, even “escapist”, in order to ment and the mastering of self-chosen
test, experience or discover something aims and tasks. The scope and specific
that is otherwise unthinkable, socio- aims of sociotherapy always depend on
therapy works “in touch with reality” the client’s abilities and deficits. In re-
and tries to activate healthy aspects of gard to clients with severe psychologi-
the affected3. cal impairments, this can only be done
in gradual steps and within a structured
“Pathological aspects are framework. The aim of the sociothera-
neither repressed, nor particularly peutic process is the expansion of au-
emphasised. While dynamics of rela- tonomy in the client’s personality and
tionships are predominant in group life with particular emphasis on learn-
psychotherapy, sociotherapeutic ing how to cope with everyday life.
group work is generally issue related. More important than “personality de-
velopment” or “self-effectuation”, apart
3 A fi nding that has also been documented by
Doerner and Plog in their textbook (Doerner and
from staying abstinent, is that clients
Plog 2002). are able to find their way around their

187
10 Sociotherapy of alcohol-and tobacco dependents with regards to Lesch’s typology

Fig. 103 Classification Sociotherapy – Psychotherapy

Sociotherapy Psychotherapy
Pragmatism and Eclecticisms in the Often purism in the selection of methods
selection of methods (depth psychology, behavioural therapy)
Pedagogical, psycho-educative Psychotherapeutic method repertoire
Active and directive interventions, Abstinence, neutrality, professional
“Assisting”, participating, sharing distance, demanding
Behaviour oriented Verbal orientation
Focus on problem solving and coping Focus on the therapy of pathologic,
abnormal or deviant aspects
Focus on normal, everyday training of life Creation of artificial “as if” situations
skills
Everyday language Artificial language (“Feedback”...)
Stable, clear transparent and obligatory
daily structure
Neuropsychological methods, everyday Usually no neuropsychological measures
life related brain training

neighbourhood, e. g. being able to go to Mr E.’s despondence and resist-


the supermarket and to maintain a cer- ance towards behavioural change
tain level of hygiene. While psychother- and often have to cheer him up.
apy seeks “individuation”, sociotherapy An honorary employee takes re-
aims at “socialisation”. sponsibility for accompanying Mr
E. to the nearest supermarket and
Example: helps him to buy groceries which
Mr E. has moved to a partially he can use for preparing a meal.
supported living community with- After a few months Mr E. is capa-
in the residential care home after ble of cooking for his flatmates.
the nursing staff has advised him
to do so. He lives there together The complementary relationship of so-
with four other alcohol depend- ciotherapy and psychotherapy is re-
ents. Due to his experience in pris- flected by sociotherapeutic methods
on (for years), hospitalisation in a which are based on the everyday needs
home and alcohol-related degra- of the clients/patients. These methods
dation process, he is overburdened occasionally compensate deficits in a
by many everyday tasks. The first “palpable” fashion:
issue is self-support; although he Sociotherapy is everyday life-ori-
used to be a baker, Mr. E. has no ented and less reflecting than psycho-
clue about cooking. It took a lot therapy. It’s a learning process that takes
for the flatmates to show Mr E. place through helping, demonstrating,
how to open tin cans again and participating, instructing, showing, ex-
heat them up in the microwave. In emplifying “normal behaviours”, but
doing this, they have to put up with also through control. This usually con-

188
Sociogenesis and sociotherapeutic chances

cerns the skills needed for everyday life, Unfortunately, laymen assistance
like shopping, cooking, washing, iron- is repeatedly usurped by professional
ing, cleaning, gardening, personal hy- therapy instead of being seen as some-
giene, handling of money, recreational thing that interconnects with, and sup-
activities, celebrating etc. ports, it.
Rolf Schwendter’s term, “therapy
of the poor” (Schwendter 2000, p. 255), Example:
characterises an interesting grey area Mrs D. lives in a residential facility
for sociotherapy, which is underrated, let for women. In the in-house cafe-
alone noticed, in the age of profession- teria, she meets an honorary
alization, job-specific classifications and member of staff, Mr D., a teacher
demonstrations of self-esteem. of religion, who is usually accom-
The “therapy of the poor” repre- panied by his wife, on duty in the
sents a therapeutic domain, in which cafeteria every Saturday. At times,
professional resources aren’t effective the women sit together and play
or accepted by clients, despite their “Ludo”. Mr D. enjoys playing with
need for support. Therapeutic relation- them. On a quite night, when the
ships to professional or layman helpers cafeteria was almost empty, Mrs
are often formed and this is where help- D. uses the opportunity to tell Mr
ful therapeutic processes take place. D. her life story. After several un-
The helper temporarily turns into a successful and hurtful relation-
“helping-self”, strengthens or weakens ships, Mrs D. has developed a de-
certain attitudes, projections and trans- fensive attitude towards all men in
ferences in everyday contact are ques- general. Some weeks later Mr D.
tioned and loosened and new interpre- invited Mrs D. to a family trip, an
tations of the social context are virtually invitation which Mrs D. accepts
formed “along the way”. “Therapy of with mixed feelings. It was a posi-
the poor” implies that psychotherapy tive experience. Due to the posi-
can also take place aside from the clas- tive contact to Mr D., Mrs D. man-
sic (paid, regulated, professional) con- ages to put her disappointment
text, namely in everyday life and in with men into perspective.
“normal” relationships, namely, where
“psychotherapy” has taken place for 10.4 Sociogenesis and
hundreds and thousands of years. Psy-
sociotherapeutic chances
chotherapists are not solely responsible
for the application of “therapeutic 10.4.1 Primary, secondary and tertiary
methods” anymore, but methods have sociogenesis
been incorporated with different non-
therapeutic forms of interventions (su- The preferred “subjects for therapeutic
pervision, mediation, life and social treatment” in sociotherapy are those
counselling, theme-centred interaction, medical conditions that are to a high
self-help-conversational groups, soci- degree socially determined. Strotzka
ometry, role playing and art therapy (1971) differentiates primary, second-
etc.), and this is also the case for socio- ary and tertiary sociogenesis. Primary
therapeutic work. sociogenesis are diseases that are di-

189
10 Sociotherapy of alcohol-and tobacco dependents with regards to Lesch’s typology

rectly caused by social circumstances term unemployment, broken relation-


(which does not imply the absence of ships, poverty etc.), to receive adequate
other factors); secondary sociogenesis treatment. Diagnostic criteria (Petzold
implies the indirect influence of social 2003) for some of these “social disor-
factors on dependence genesis in the ders” don’t even exist, implying that
sense that “organic causes in themselves there is no prospect of health insurance
are again causes for the social condi- funds assuming the costs.
tion”. By tertiary sociogenesis, Strotzka Apart from the lack of “social dis-
understands the influence of the social order” categories, even existing op-
environment on the progression and tions, like the axes IV and V of DSM-IV,
manifestation of psychological disor- are rarely used. By considering the di-
ders. All forms of sociogenesis apply mensions listed on these axes, the aeti-
differently to the genesis of depend- ology and progression of the disorder
ences. The typology according to Lesch can be more comprehensively under-
also attempts to focus more precisely stood, as social aspects and thus the
on the extent of the impact of social patient’s or client’s life environment are
conditions in comparison to other fac- included. Axis IV assesses psychosocial
tors. The sociogenesis in type I depend- and environmental problems (descrip-
ents can be described as secondary and tive) and axis V assesses psychosocial
tertiary due to biological/genetic fac- functioning (global assessment of func-
tors (biological vulnerability and high tioning). A scale is available for the lat-
social responsiveness, e. g. social drink ter (Global Assessment of Functioning,
catalysts), while socio-genetic condi- GAF). Additional to the psychiatric and
tions in type IV dependents suggest a medical diagnosis of axis I, II and III,
primary sociogenesis (infantile depri- this scale only assesses psychological,
vation/deprivation in early childhood). social and occupational functioning.
With regards to practice, the ques-
tion concerning the extent to which so- 10.4.2 Sociological factors on
ciogenesis is significant for diagnostics a macro-level4
and therapy, always raises itself. It
needs to be borne in mind that, within The findings that sociological causes
the current diagnostic paradigm, a pri- are underrepresented by addiction re-
mary sociogenesis cannot be diagnosed search, as stated by Tasseit (1994) a few
as the health and/or pension insurance years ago, are still valid. On the other
companies only authorizes a restricted hand, “the biopsychosocial structure of
code of medical indications, in regards condition” of dependence, and there-
to ICD-10. While “recognized neuroses” fore the significance of social relation-
like depression, anxiety and obsessive- ships, has clearly been recognized.
compulsive disorders are permitted psy- However, it is the case that research lit-
chotherapeutic treatment, it is very dif-
ficult for socially disadvantaged groups, 4 In sociology, social processes are examined on
three levels: macro-, meso- and micro level. The
who predominantly suffer from disor- macro level includes phenomena of the entire so-
ders that have social causes (e. g. acute ciety (e. g. social stratification), the micro level in-
cludes phenomena of smaller groups (e. g. families)
psychosomatic disorders due to stress, and individuals, where sociology often overlaps
psychological problems due to long- with sociopsychology.

190
Sociogenesis and sociotherapeutic chances

Fig. 104 Global Assessment of Functioning Scale (DSM-IV)

Global Assessment of Functioning Scale (DSM IV)


The Global Assessment of Functioning (GAF) is a numeric scale (0 through 100) used by
mental health clinicians and physicians to subjectively rate the social, occupational
and psychological functioning of adults on a hypothetical continuum ranging from
psychological health to disease. Impairment in functioning, which has physical or en-
vironmental causes should not be included.

Code (Note: Please use according interim values, e. g. 45, 68, 72)

91–100 Superior functioning in a wide range of activities, life’s problems never seem
to get out of hand, is sought out by others because of his or her many quali-
ties. No symptoms.
81–90 Absent or minimal symptoms, good functioning in all areas, interested and
involved in a wide range of activities, socially effective, generally satisfied
with life, no more than everyday problems or concerns.
71–80 If symptoms are present they are transient and expectable reactions to psy-
chosocial stresses; no more than slight impairment in social, occupational,
or school functioning.
61–70 Some mild symptoms OR some difficulty in social, occupational, or school
functioning, but generally functioning pretty well, has some meaningful
interpersonal relationships.
51–60 Moderate symptoms OR any moderate difficulty in social, occupational, or
school functioning.
41–50 Serious symptoms OR any serious impairment in social, occupational, or
school functioning.
31–40 Some impairment in reality testing or communication OR major impair-
ment in several areas, such as work or school, family relations, judgment,
thinking, or mood.
21–30 Behavior is considerably influenced by delusions or hallucinations OR seri-
ous impairment in communications or judgment OR inability to function in
all areas.
11–20 Some danger of hurting self or others OR occasionally fails to maintain mi-
nimal personal hygiene OR gross impairment in communication.
1–10 Persistent danger of severely hurting self or others OR persistent inability to
maintain minimum personal hygiene OR serious suicidal act with clear ex-
pectation of death.
0 Not enough information available to provide GAF.

erature predominantly examines psy- and incoherence of different depend-


chological and biomedical factors, ence theories and data emphasise that
whereas sociological factors are mostly there is still no “integrative theory of
neglected. It is recommended that gen- dependence” which examines and sys-
eral health-sociologic factors be consid- tematically correlates all facts on de-
ered, which are all significant for the pendence development (Schmidt et al.
development of an addiction, especially 1999, Renn 1991), despite frequent calls
because this is where the border be- for such a theory.
tween psychotherapy and pharmacol- In the light of globalisation-relat-
ogy lies, e. g. in relation to socioeco- ed social change, which promotes so-
nomic status and health. The imbalance cial inequalities (Razum et al. 2006), an

191
10 Sociotherapy of alcohol-and tobacco dependents with regards to Lesch’s typology

awareness of sociological aspects is in consideration) and permissive-dys-


needed. functional cultures (allowing alcohol
Puls (2003) differentiated three so- excesses). Yet, the relationship between
ciological perspectives to explain de- social norms, genesis and the progres-
pendence behaviour: sion of a dependence is continuously
put into perspective by research. There-
a) the Stress-Coping Paradigm (al- fore we know that social factors are very
cohol modulates the stress reac- important for the acquisition of specific
tion, assists in coping with stress) high-risk patterns of consumption, but
b) Theories of Socialisation (long- that this importance decreases with the
term socialisation processes, e. g. progression of dependence develop-
through family, which influence ment (Schmidt et al. 1999).
consumption behaviour) Social research has shown “socio-
c) Theory of abnormal behaviour economic status” to be the most im-
(socio-structural conditions or the portant social factor for determining
environment’s reaction towards the health behaviour and health status
the consumption behaviour). of a population (Hurrelmann 2006).
This has also been supported by the
The stress-coping paradigm can be WHO5. The socioeconomic indicator
used on a macro but also micro social points to the relative position of persons
level. Brenner’s (1975, in German 1979) in social structures of privilege and
established time series analysis has al- prosperity. Associations between finan-
ready shown a relationship between cial resources, level of education, social
economic indicators, like inflation rate, acceptance, and physical and psycho-
unemployment rate, average income, logical disorders have been document-
and diverse health indicators, like psy- ed. There is a higher prevalence of dis-
chiatric admissions and alcohol con- orders among lower classes than among
sumption. For example, psychiatric hos- upper classes (see table below). Even
pitalisations of persons with an alcohol rich smokers live longer than poor ones.
psychosis sharply increased during re- Social conditions during child-
cessions and decreased again during hood, adolescence and adulthood also
economic growth. Economic stress play a role in the dependence aetiology
clearly seems to be an additional stress (of subgroups). As co-morbidities play
factor (an argument that has been a large role in the aetiology of most de-
strongly criticised). pendences, general information about
The sociocultural theory of Bales the patient’s health are of interest.
(1991, 1946), who investigates the so-
cial conditions of a dependence devel- Children
opment, also belongs to the categories Child mortality and disorders are more
mentioned above. He differentiates be- frequent among children from lower
tween abstinence cultures (prohibi-
tion of any alcohol consumption), am- 5 “Even if medical care improves disease progression
bivalence cultures (conflict between and life expectancy in some acute diseases, the so-
cial and economic conditions, which make people
values towards alcohol consumption), ill and in need of care, are by far more important for
permissive cultures (allowing alcohol the health of the total population”. WHO

192
Sociogenesis and sociotherapeutic chances

socioeconomic classes. For example, also influenced by the family’s prosper-


the frequency of stillbirths in mothers ity and the parent’s occupational sta-
who went to special school is much tus. Students from general secondary
higher than in other mothers. Also, in- schools smoke three times more than
fant and child mortality rate is extreme- students from grammar schools.
ly high in low status groups.
Children from lower socioeco- Adults
nomic backgrounds, show relatively The disease and mortality rate is higher
poor health behaviour. Their nutrition in the lower classes than in the higher
is worse and they exercise less, com- ones. For example, there are more dis-
pared to children that are better off. eases and higher early mortality rates
Also, children from lower classes take in working class families than in em-
part in fewer medical check-ups. ployed, self-employed or civil servant
The standard of dental care, and families. Social differences have an im-
with it dental health, also continuously pact on health behaviour, such as the
decreases with class (from upper to utilization of medical care services.
lower classes). Members of lower status populations
Children with parents of lower smoke significantly more often and
socioeconomic status are involved in more heavily and alcohol consumption
more accidents than others. Kersting- is clearly higher in men (women show
Duerrwaechter and Mielck (2001) found different results) (Lampert and Burger
that children from lower class families 2004).
have a 24 % higher risk of having an ac- Almost two thirds of men, aged 20
cident than preschool children from to 59, who are in short- and long-term
higher social classes. This also applies unemployment, smoke, whereas only
to the severity of accidents (lasting 40 % of employed men smoke. Men
damage), an association that is reflect- who are unemployed for up to a year,
ed by the aetiology of type IV depend- smoke twice as much as employed
ents. men. Men, who have been unemployed
for more than a year, smoke three times
Adolescents as much (Dauer 1999).
Trends that were displayed in child- Differences can also be found in
hood continue in adolescence: socially eating behaviour, personal hygiene and
disadvantaged adolescents are more physical activity. Lower status groups
often ill than those from higher social go to the doctor, particularly the spe-
classes. Children attending general sec- cialist, less frequently.
ondary school are more often ill than Higher levels of education and a
children attending grammar school. more favourable economical situation
Nutritional behaviour also decreases influence all age groups, even age-re-
with socioeconomic status. Conse- lated dementia is more prevalent in
quently, adolescents from the lower lower social classes.
classes are more frequently overweight. In, Austria the following data has
There are clear social differences been published in 2007: the population
in consumption of psychoactive sub- below the poverty level has three times
stances. Girls’ smoking behaviour is worse health conditions (11 %) than

193
10 Sociotherapy of alcohol-and tobacco dependents with regards to Lesch’s typology

those with a high income (4 %) and is cular diseases and dependences are
twice as often ill than those on a medi- more frequent in those who are socially
um income (7 %). In regard to educa- isolated.
tional certificates, graduates from gen- In conclusion, the following can
eral secondary schools are twice as be suggested: poverty and isolation (lack
often (20 %) affected by a chronic dis- of resources) promotes disorders. Peo-
ease, than A-level graduates (11 %). ple from lower socioeconomic classes
90 % of employees with higher or ad- (lower income, lower occupational sta-
ministrative jobs describe their health tus, lower educational level, long-term
as “good”, whereas only 76 % of labour- unemployment, single parents, families
ers feel this way. The rich live between with many children, migrants, homeless
five and seven years longer than the people, prisoners) need a greater de-
poor (Statistic Austria 2007). gree of health care promotion, to bal-
Furthermore, lonely and socially ance their social conditions and state
isolated people are more likely to get ill. of health. Health costs are highest in
They lack a network to help and sup- this population group.
port them. The elderly especially are af- No less important are the serious
fected and migrants and homosexuals socio-political and sociological chang-
also represent risk groups. Cardiovas- es in postmodern society, which are es-

Fig. 105 Nicotine consumption and educational status

Proportion of regular smokers according


to type of school
Richter and Hurrelmann 2004
25
Boys
Girls
18.5 19.2
20

15

9.5
10 8.5

0
Grammar School Intermediate Secondary School
(Realschule) or
General Secondary School
(Hauptschule)

194
Sociogenesis and sociotherapeutic chances

Fig. 106 Health/diseases and socioeconomic diagnoses

Low socioeconomic status High socioeconomic status


Health behaviour
– Malnutrition – Alcohol abuse in women
– Poor nutritional rhythm
– Lack of exercise
– Lack of bodily hygiene
– Cigarette consumption
– Alcohol abuse in men
– Consumption of illegal substances
– Violent behaviour
– Few medical check-ups
– Few early diagnosis check-ups

Diseases
– Cardiovascular diseases – Few allergies
– Diabetes mellitus – Bronchitis (in children)
– Stomach cancer – Few skin diseases, e. g. neurodermitis
– Bowel cancer – Myopia and hypermetropia
– Lung cancer
– Kidney-/bladder cancer
– Leukemia
– Stomach diseases
– Teeth diseases
– Bronchitis (in adults)
– Intervertebral disk degeneration
– Overweight/ adipositas
– Rheumatism/ gout
– Accidents (in children and adolescents)
– Mental illness
– Multi-morbidity
Scientific findings in regards to the socioeconomic status, health behaviour and diseases (Hurrelmann 2006

pecially characterised by the dissolving networks (self-help groups, sport clubs,


of traditional social networks (Beck religious communities etc.)
2003), and should be pointed out. The
trend towards a single life and the de-
nial of the processes which promote 10.4.3 Co-morbidity and marginal group
solidarity in society and especially in identity
the cities, make education, the mainte-
nance of a social network and, increas- Fichter (2001) carried out an epidemio-
ingly, the integration of marginal groups logic study which examined a homeless
more difficult. The lack of alternative population in Munich from a socio-psy-
social networks following the termina- chiatric perspective by using represent-
tion of withdrawal therapy is one of the ative samples (n = 265). Results showed
biggest problems for the stabilisation a high degree of co-morbidity (90 %)
of patients with addictions, consider- and social deprivation. For example,
ing that only a small percentage of pa- the extent of social deficits can be illus-
tients manage to join artificial social trated by the predictor “family status”.

195
10 Sociotherapy of alcohol-and tobacco dependents with regards to Lesch’s typology

Fig. 107 Homelessness and marital status

Homeless: marital status: Normal population Germany


n = 265 n = 178
53,4 % single 43,4 %
0,0 % married 49,7 % (!!!)
6,0 % separated –
3,9 % widowed 2,5 %
35,1 % divorced 10,1 %
Fichter 2001

In regard to psychological disor- and values is of importance for socio-


ders, substance dependence, especially logical discourse. If it is not possible to
alcohol dependence, was very preva- meet these norms, individual suffers
lent with 72.7 % (vs. 15.2 % in the nor- from unbearable pressure, which can
mal population). only be handled by assuming an anom-
It can’t be denied that “social ic attitude, or “apathy” as Merton (Rein-
factors” are very significant for the de- hardt 2005) has described it.
velopment and progression of a depend- The relationship between co-mor-
ence (and other psychological disor- bidity, alcohol dependence and home-
ders). This pretty much constitutes basic lessness is one of the most difficult sce-
socio-psychiatric knowledge. Within narios to manage when treating groups
this context, the population group’s at- of multiply and chronically impaired
titude towards socially accepted norms dependents. This can only be handled

Fig. 108 Homelessness and psychiatric diagnoses

80
70
60
50
40
30
20
10
0
Psychosis Affective Substance Alcohol Anxiety
disorders abuse dependence disorder

Homeless Normal population

196
Sociogenesis and sociotherapeutic chances

if social work and psychiatry cooperate social and a number of organic and psy-
in an effective way. The threshold of chological functions can be demonstrat-
most traditional addiction support in- ed. These range from the regulation of
stitutions, specialised hospitals, coun- stress hormones via childhood influ-
selling centres and self-help groups is ences to the regulation of the immune
too high to provide assistance for home- system through the quality of social re-
less clients (Reker and Wehn 2001). In lationships. Psychosomatic medicine
this case, the availability especially of and various psychotherapeutic schools
short-term psychiatric help could be of thought have been making use of
very helpful. this knowledge for some time. Social
causes have always been considered in
10.4.4 The link between social relations- cases of dependence (e. g. examination
hips (factors on a social micro level), of family background of alcohol de-
group coherence and resilience pendents), although they are still un-
dervalued in biologically based models.
In line with Coleman (2006), we can in- There is no doubt that the formation of
deed speak of a “new science”, if one neuronal networks depends on the qual-
looks at the multitude of data and hy- ity of interpersonal relationships, even
pothesis from fifteen years of neurosci- to a greater extent than has been sup-
entific research. Imaging techniques for posed. This applies for both children
exploring brain functioning have been and adolescents, who have high brain
introduced and relationships between plasticity (social control patterns are

Fig. 109 Relapse and social integration

Social Network
Havassy et al. 1991

90
80 90
70
% o f relapses

60
50 61
54
40
30
20
10
0
high middle low

Degree of social integration


Havassy et. al. 1991

197
10 Sociotherapy of alcohol-and tobacco dependents with regards to Lesch’s typology

formed up until age 25), but also for all Further support for the healing
persons beyond the age of 25, in whom potential of social relationships and in-
neuronal networks are still formed, yet tegration comes from resilience research
to a lesser extent and at a slower rate. that examined which social and indi-
The importance of social relation- vidual factors contribute towards a pos-
ships is represented by the therapeutic itive coping with crises (Welter-Ender-
effectiveness of group experiences. The lin and Hildenbrand 2006). These are:
integration into a stable group is un-
doubtedly a highly effective therapeutic  growing up in one’s own family
factor and the goal of group therapy. In and a relationship to at least one
his textbook, Yalom (1999) rates “group stable attachment figure (who does
cohesion” as one of the most important not necessarily have to belong to
healing factors. the family),
Another eminent finding is the re-  the ability and opportunity to ex-
lationship between social integration, press one’s feelings
utilization of therapy and therapy suc-  the integration into a stable, active
cess. Further, it is uncontested that community (youth group, church
broken social networks increase the risk community, self-help group, sport
for a relapse in dependents (Havassy club etc)
et al. 1991). Havassy (1991) found that  a completed professional or school
those dependents who relapsed after education
twelve weeks of therapy, were badly or  a stable marriage or partnership
not at all socially integrated (e. g. living
alone, no or few close friend or rela- The above factors above are, next to in-
tives, no association to groups etc.). dividual personality traits like intelli-
The quality of social relationships, gence, interests, positive philosophy of
the number of important attachment life, flexibility etc., fundamental long-
figures and the extent of social con- term factors for protection6.
tacts, especially to people that are not
6 Emmy E. Werner’s long-term study counts to the
linked to institutions, and friends are fundamental works of resilience research. On the
crucial for the stability of a successful Hawaiian island Kaunai, she observed 698 chil-
dren, born in 1955, for 40 years. Around 30 % (210
therapy (Roehrle et al. 1998). children) grew up in poor conditions: birth compli-
Result from neurobiological re- cations, stress in the family, parental psycho-
pathologies, divorce. Two thirds of these 210 chil-
search supports this by showing that dren developed learning and behaviour problems,
motivation primarily depends on social turned delinquent or/and mentally ill. Yet, despite
these adverse conditions, one third of the children
impulses (see according paragraph in turned into competent, confident and caring adults
this text) (Bauer 2006, 2007) and that who successfully completed school and coped well
with societal norms. By age 40, none of these per-
psychological and physical health to a sons was unemployed or had problems with the
great extent depends on social integra- law. Divorce rate, mortality and the number of
chronic health problems were average when com-
tion or disintegration. Social interac- pared with the normal population. Certain person-
tions and physical activity, for example ality traits that were already present in childhood
turned out to be resilience factors. These were e. g.
group activities, have a stress-reducing certain active behavioural patterns already appar-
effect and therefore have a positive ef- ent during babyhood, later, a relationship to at
least one stable attachment figure, mostly from
fect on psychological and physiological within the family, the children’s ability to recruit a
disorders (Unger et al. 1997). substitution for parents, integration in groups (e. g.

198
Sociogenesis and sociotherapeutic chances

“Social support” also determines (1) the stimuli that arise from the in-
whether resiliencies are being activated ternal and external environment
or whether new resiliencies can be throughout life, are predictable
formed (Mueller and Petzold 2004)7. In and explainable;
summary, this implies that a human (2) resources, to cope with the de-
being is another human being’s best mands that these stimuli request,
medicine. The establishment and culti- are available;
vation of stable relationships, especial- (3) these demands are challenges,
ly the integration into a collective, has a which are worth the effort and
very high protective and healing poten- engagement” (Antonovsky 1997,
tial. This is especially interesting as re- p. 36).
sults from resilience research have sug-
gested that psychotherapy only assists This sense of coherence is formed by
the stabilisation process to a subordi- specific life experiences, which allow
nate extent8. the person to be largely in control and
In his theory of salutogenesis, the which don’t over or under challenge the
Israeli stress researcher, Antonovsky, person. A precondition of this is the
has outlined a similar perspective: not availability of general resistance re-
only pathogenetic factors determine sources like physical factors, intelli-
the development and the progression gence, coping strategies, social support,
of diseases, but the availability or lack cultural stability etc., are available.
of resistance resources in the person. If the sense of coherence and, as a
Whether resources are used or not de- result, the effect of the resistance re-
pends on the manifestation of a sense sources, are too weak, a state of stress
of coherence (“SOC”= sense of coher- sets in, which affects existing vulnera-
ence). bilities (e. g. tendency for substance
“The SOC (sense of coherence) is abuse)9.
a global orientation that demonstrates In regard to the resource-oriented
to what extent one experiences a per- approach of salutogenesis, the patho-
vasive, enduring, but yet dynamic feel- genic diagnosis, which assesses deficits
ing of confidence, that and impairments, is opposed to a salu-
togenic diagnosis, which assesses dif-
ferent resistance resources. For this,
church). A crucial result was also that adult sub- data from resilience research can di-
jects experienced a fundamental improvement in
their ability to succeed in life between age 32 and rectly be transferred.
40. This often manifested in “turning points”, espe-
cially where chances came up that they could bet-
ter take advantage of at this age. Of eminent impor- 10.4.5 Analogy to Gerontology: an atrophy
tance for the effective use of turning points was the of the “social atom”
successful coping with crises (e. g. recovery from a
life-threatening disease or accident). Werner 2006
7 The questionnaire developed by Petzold and Muel- The atrophy of the “social atom” (Jakob
ler (PMFR) to assess resilience and protective fac- Moreno) represents an undeniable anal-
tors, can be recommended for social work.
8 In the case of the Kaunai-study cited, only 5 % of
ogy with chronic alcoholism at ad-
the group, which showed the strongest resilience,
were in psychotherapeutic treatment. They were 9 For information about the application of the salu-
better educated and rather introverted (Werner togenesis approach in addiction research, see
2006) Franke et al. 1998.

199
10 Sociotherapy of alcohol-and tobacco dependents with regards to Lesch’s typology

Fig. 110 Pathogenesis vs. salutogenesis

Pathogenic diagnosis: Salutogenic diagnosis:


– alcohol and medication abuse – social skills (ability to communicate
– major depression disorder and sleep with all kinds of different people,
disorder dependable, sensitive)
– dependant personality disorder – ability to carry out certain
organisational tasks
– stamina, discipline
– used to doing different sports
(and still interested)
– humour (sometimes cynicism)
– several long-term relationships
– likes to read (e. g. newspapers)
– acceptance of disease
– fond of animals (used to have dogs
before)

vanced stage, which is always accom- ity due to dependence on (home) care,
panied by chronic tobacco abuse and stigmatisation due to long-term unem-
geriatric problems. Moreno, the found- ployment, admissions to psychiatric
er of psychodrama, was one of the first hospitals, homelessness, old age, social
to suggest that social relationships are deficits etc.), and this consequently
part of one’s identity (Petzold 1985, leads to a permanently destabilised
200410)11. The collapse of the social sys- identity. It has been shown that the de-
tem is caused by the loss of important terioration of the social network is
attachment persons. These can’t be re- linked to suffering, diseases, accelerat-
placed due to individual or social cir- ed aging processes and even higher
cumstances (disease, restricted mobil- rates of mortality (Petzold and Bubolz
1979, Bauer 2006/2007).
10 “The role of the group in therapy with the elderly –
With regards to aging, “social
concepts for an “integrative intervention” death”, with the decay of the “social
11 “The consistency of the social atoms changes when atom”, takes place prior to physical
we get older, especially the possibility of replacing
lost family members or friends. The social atom
death. This applies for alcohol depend-
changes intermittently when we are young and full ents, especially the type IV group, ac-
of resources. When a single member is gone, an-
other individual can take his place by playing a
cording to Lesch, whose social inte-
similar role. A friend is lost and quickly replaced by gration is very precarious and shows
someone else. This social repair seems to take
place almost automatically ... When we get older it
deficits. Apart from the instability of
is more difficult to replace people we have lost, just the “social atom”, the alcohol depend-
like it becomes more difficult for our body to repair
itself with increasing age. This describes precisely
ent, who usually lives among other al-
the phenomena of the “social” death: not in terms cohol dependents, is often confronted
of the mind and how we are dying internally, but
how we are dying externally ... When we live longer
by the early death of attachment per-
than those we love or hate, a small part of us dies sons. The mortality rate in alcohol de-
with them, by seeing how the shadow of death
strides from one person to the next in our social
pendents is extremely high, with 12 to
atom.” (Moreno 1960 [1947], S. 63 f.) 23 years lesser life expectancy in com-

200
Sociogenesis and sociotherapeutic chances

parison to the normal population. This ing with one’s own age and death need
often depends on aetiology, progres- to be emphasised in the training and
sion (type) and treatment history (Le- supervision of care workers.
sch et al. 1990). Without treatment, type
IV patients don’t live longer than 60 Example:
years, implying that they don’t reach Mr W. has been living in a commu-
senior age. It is not exaggerated to as- nity flat for three years, to which he
sume that alcohol dependents who moved by the help of political
have actively consumed alcohol for friends from his “old” life after being
years, especially those without any pro- evicted from his house. After insol-
longed periods of abstinence which al- vency, he lost his petrol station, the
low the organism to recover, are affect- cafe and the house in which his
ed by premature aging. In particular, family was living. He and his wife
cerebral degeneration (cerebellar atro- became virtually homeless. The
phy, frontal lobe syndrome, organic reason for this was his sustained
psycho-syndrome), which has been alcoholism and the repression of
sufficiently described in the literature, threatening reality. Since the evic-
stimulates or accelerates the develop- tion from his house and the sepa-
ment of a dementia similar to old age ration from his wife and family, he
dementia. This also applies for social has no contact to his family or
conditions, where isolation and aliena- friends. His “social atom” has col-
tion, related to a reduction or loss of an lapsed from one day to the next.
intact social environment, can lead to At present Mr W. is living off social
enormous deprivation. welfare. After falling down the
In regard to premature aging, ger- stairs in an intoxicated state, he
ontological, geragogical and even thana- became handicapped and suffers
tological therapeutic aspects may be from permanent pain. He is epi-
suitable for the support of alcohol de- sodically depressed and thinks
pendents in confronting behavioural that he will die soon anyway. After
restrictions and the presence of the his 60th birthday, the depressive
topic, “death”. Clearly, this needs to be thoughts increased. Despite re-
considered in academic training, self- peated recommendations, he has
awareness and supervision (Petzold rejected medical treatment. Fur-
1985). As affected patients or clients are thermore, he needs to undergo a
normally older than the carer and de- cataract operation, but he con-
velop deep attachments and a need for stantly makes up excuses because
attention, child-parents dynamics of- he is too afraid. He rejects all of-
ten result via transferences and coun- fers of support. Neither has with-
tertransferences. Here, the personnel drawal therapy been successful in
might set harsh boundaries and behave the long-term. Brain atrophies that
in a patronizing way. have been detected by a computer
Topics like the death of someone tomography, cause loss of energy
close (especially one’s parents), dealing and forgetfulness and the therapy
with the need for closeness (e. g. with centre advises a custodianship.
regressive defiance and protest), deal- Yet, this has not been approved by

201
10 Sociotherapy of alcohol-and tobacco dependents with regards to Lesch’s typology

the Court, as Mr W. is categorized tres, parenting, pregnancy and


as a “borderline case”. motherhood advisory services,
What kind of reorientation is pos- school psychological services,
sible in this context? probation and judicial support
How can Mr W. establish a new so- services, psychosocial support so-
cial environment? cieties, organisations for commu-
As Mr W. is in contact with a po- nity-based work, extramural initi-
litical group, he has tried to build atives.
new, stable and non alcohol-relat-  Semi-public in-patient institu-
ed contacts with the help of this tions:
group and has managed to do this Day and night hospitals, transi-
to a certain extent. Furthermore, tional institutions, sociotherapeu-
he has managed to get in touch tic residential homes, open pris-
with his children again. The con- ons, probation homes, special
tact with his family and his “politi- daycare facilities for children …
cal party” improve his affective As a result of decades of experi-
state episodically but not perma- ence, Petzold suggests “collective
nently. Two to three times a week, living facilities” as alternatives to
he visits the political party’s office residential homes or single apart-
in order to get some things done ments for certain groups. Assisted
(ironing, running errands, copy- residential homes have become
ing …), tasks in which his OPS-re- common for both old and handi-
lated forgetfulness plays a consid- capped persons. For alcohol de-
erable role. He has learned to pendents and certain subgroups,
write down all his appointments permanent or temporary housing
and is not alone anymore during in collective living facilities seem
festivities. to be a sensible option. These
have emerged from the atrophy of
10.5 Sociotherapy in the context of the “social atom” as mentioned
above. All forms of collective liv-
therapeutic phases
ing mentioned by Petzold can be
10.5.1 Socio therapy location(s) found in sociotherapeutic prac-
(Schwendter 2000) tice: residential homes, housing
groups, therapeutic communities,
In contrast to psychotherapeutic con- therapeutic residential homes
texts, sociotherapy is determined by the and therapeutic housing groups
location, function and aim of the socio- (Petzold 1985). Some are limited
therapeutic intervention. Sociotherapy in time and context by withdrawal
is often about genuinely participating therapy, while others are long
and “exploring” character and assisting term and represent rather less re-
the affected in their life environment. stricted forms of collective living.
Sociotherapy can take place in:  Closed institutions like approved
schools, mental institutions, closed
 Open outpatient institutions: mar- prisons etc. However, these insti-
riage and family counselling cen- tutions usually inhibit develop-

202
Sociotherapy in the context of therapeutic phases

Fig. 111 Motivational stages

Motivational stages according to Prochaska & DiClemente


I. No intentions
II. Development of intentions
III. Preparation stage
IV. Action Stage
V. Maintenance
VI. Relapse

ment and are therefore anti-ther- tion of therapy is an everyday require-


apeutic. ment, which often becomes the respon-
sibility of sociotherapeutic workers.
10.5.2 Therapeutic phases and settings People, who are chronically impaired,
often face precarious housing provi-
In line with international standards, sion, homelessness and co-morbidities.
the treatment of alcohol dependents The situation requires the close coop-
can be divided into four groups. A eration of social work and psychiatry,
“closed therapeutic chain” is only effec- which actually makes therapy possi-
tive if adequate tenders for healthcare ble. High threshold settings with high
services for all four phases are provid- normative requirements often prevent
ed. The requirements for treatment integration into a support system. Be-
setting and sociotherapy depend on sides in-patient and outpatient options
whether treatment is carried out on an for healthcare services, explorative con-
outpatient, semi-inpatient, or in-pa- cepts are needed for subgroups with
tient level. The structural approaches multi-morbidity and high social vulner-
of the setting are influenced by the pa- abilities/pressure.
tient’s phases of motivation. The mod- Generally, the initiation of therapy
el of Prochaska and DiClemente (1992) takes place in an outpatient setting. If
has established itself in practices and the patient has no insight into his dis-
also applies for the therapy of nicotine ease, the first aim is to establish a trust-
dependents. There are six phases of ing relationship, so that the patient can
motivation and actual therapy is not re- be made aware of his substance de-
alized until phase four. Insight into the pendence. These conversations should
disease and a readiness to deal with the take place in a quite atmosphere (no
dependence, increase with every phase. disturbance, no telephone calls), also
sufficient time should be granted (at
Therapeutic phases least 35 minutes for the initial meet-
ing). The method used in Millner´s and
1. Phase: initial contact, initiation of therapy
Rollnick’s12 motivational interviewing
In sociotherapeutic settings like day
12 Miller ER, S.Rollnik Miller WR and Rollnick S (2002).
centres for the elderly or homeless, or A sound description of this method for practical use
assisted living institutions, the initia- has been offered by Koerkel, Kruse 1997, chapter 15

203
10 Sociotherapy of alcohol-and tobacco dependents with regards to Lesch’s typology

serves as a standard and can be used as An outpatient treatment is viable if


a guideline for this context. A prema- the patient is socially integrated (fami-
ture confrontation with a “diagnosis” ly, occupation, friends, daily structure a
should be avoided. By asking open ques- high GAF score) and if his health condi-
tions, the patient should gradually be- tion is good. The institution in charge
come ready to confront his alcohol de- needs to assure the continuity of treat-
pendence. ment. It is crucial that the therapist and
patient have a positive relationship
Open questions: (transference), because otherwise the
“You are saying that alcohol relationship is likely to be terminated
helps you to switch off? How should I in times of crisis.
picture this?” In the case of poor health, severe
withdrawal symptoms, co-morbidity
“You are saying that you couldn’t (typology) and an unsupportive social
endure stressful situations without environment, an inpatient admission
any cigarettes – what would happen if is indicated. In this case, the principle
you do not smoke?” of low threshold should be demanded,
that is, the patients should not be prom-
“You have mentioned that alco- ised a later admission in order to allow
hol has helped you to cope with dif- them time to “clarify their motivation”,
ficult situations? What kind of situa- but should immediately be admitted.
tions were these? And what were the Once more it must be emphasised that
effects of alcohol?” a dependence is a life threatening dis-
ease, which requires very prompt inter-
In the first phase, objective informa- vention.
tion, similar to that sought in medical Further, it should be advised that
examinations (e. g. elevated liver tests, the cooperation between sociothera-
blackouts, lung functioning tests etc) peutic institutions and the withdrawal
should be gathered. “Suggestions” for setting should be optimally coordinat-
changing drinking habits that are for- ed so that necessary in-patient admis-
mulated too early, can be counterpro- sions can be carried out quickly and
ductive. The highlighting of discrep- smoothly.
ancies (contrasting advantages with
disadvantages) in phases of indecisive- 2. Phase: withdrawal treatment
ness is recommended. Therapy can (around 14 days)
only be initiated with the patient’s agree-
ment. The therapy setting or the out- In this phase, sociotherapy is usually
patient counselling centre then arrang- secondary, while the treatment of with-
es an initial or admission meeting. Here drawal syndromes is predominant.
it needs to be decided whether in- (The nicotine withdrawal syndrome
patient admission or outpatient treat- lasts longer, around 1 month, with most
ment13 is more suitable. symptoms manifesting in the second
week [Lesch 2007].)
13 There is almost no available therapeutic provision
for tobacco withdrawal therapy in regard to inpa-
Many therapy institutions tend to
tient withdrawal or cessation. confine or control the dependent’s cur-

204
Sociotherapy in the context of therapeutic phases

few. Occupational therapy is limited in phase the patient starts to properly


its possibilities, as patients tend to be confront reality. All catamnesis studies
psycho-motorically impaired, as a re- have shown that aftercare, subsequent
sult of high doses of medications. Soci- to an in-patient therapy, acts as a sta-
otherapy raises the question about how bilising factor (Koerkel 1992). This also
to maintain a minimum daily routine applies for self-help groups. Therapy
for clients. options that are offered by institutions
are often insufficient which confirms
3. Phase: withdrawal treatment the impression that aftercare is seen as
(around 1–2 months) little more than an appendage to in-
patient therapy.
On the one hand, the dependent’s con- It is certain that the vulnerability
frontation with his own dependence to dependence, e. g. spontaneous re-
now becomes the focal point, whilst on currences of withdrawal symptoms,
the other hand, his physical and psy- cravings etc., is heightened during the
chological well-being (e. g. capacity to first two years and, with this, the risk of
experience, recovery, sleep etc) should a relapse (Scholz 1996). During this pe-
be supported by health-promoting riod of time, stable contact with the
measures. Motivational crises and pro- therapy institution, preferably with the
tracted withdrawal symptoms might therapist-in-charge, and the availabili-
set in (according to Scholz, motivation- ty of instant crisis interventions, should
al crises become more frequent in be provided.
weeks 7–9 of therapy). A night hospital is a valid alterna-
The ambulant therapy setting is tive for transferring the patient from the
limited to one to two contacts per week therapeutic environment to his “old”
at the maximum. The correlation be- world: patients are able to work during
tween therapy success and frequency the day, are in touch with their social
of contacts has been documented by environment, but stay in the hospital
research. overnight during the week. This option
The in-patient setting usually can be offered for up to two months.
combines a variety of therapeutic ap- Interval therapy, another concept
proaches, with medical, sociothera- that seeks to counteract the increased
peutic, psycho-educative and psycho- relapse rates of certain subgroups, per-
therapeutic approaches overlapping. mits patients several short-term stays
Parallel to these, the social worker as- (lasting two to four weeks) which are
sists in clarifying occupational and fi- spaced over a year. Patients are allowed
nancial issues and organising subse- to come by, regardless of whether or
quent housing arrangements. not they are suffering a relapse. In this
way, the therapy institution protects
4. Phase: aftercare, crisis intervention patients during particular relapse-vul-
(1–2 years) nerable phases, like birthdays or Christ-
mas. This form of provision practically
From a sociotherapeutic perspective, anticipates crises interventions and
this phase is the most important one in helps to maintain the patient’s contact
combating dependence because in this with the therapy institution.

205
10 Sociotherapy of alcohol-and tobacco dependents with regards to Lesch’s typology

The sociotherapeutic contribu- An example from practice should


tion towards aftercare within this ther- illustrate this:
apy setting, is distinguished by net- Mr B., 52 years old, looks back on
working efforts. These assist the patient a long history of counselling. Af-
in making and maintaining contact ter his mother’s suicide, the tragic
with the institution responsible for af- death of his brother and sister
tercare. In this, sociotherapeutic coun- and the loss of two fingers due to
sellors are often restricted by institu- a workplace accident, he is suf-
tional borders, e. g. when the amount fering from acute, recurring de-
of therapy hours are cut down due to pression. Over the years, he has
economic measures, when “crisis in- developed an alcohol depend-
tervention” is misinterpreted as being ence. Extreme drinking phases
mere breathalyzer tests or if “aftercare” are always linked to depression.
is no more than a series of short Whether his delinquency in early
3-minute meetings stretched out over adulthood and subsequent im-
14 days. prisonments are related to the
Often sociotherapeutic helpers depression, has never been ex-
are personally affected by the defence amined. Several long-term with-
mechanisms of an overstrained psychi- drawal therapies in Germany and
atric system. Suddenly the institutions Austria have not improved the re-
in charge (admission pavilions, detoxi- lapse rate. After several months
fication clinics, counselling centres) of abstinence, he usually relaps-
demand rituals designed to prop up es, which lasts for weeks and dur-
motivation from the severely censured, ing which suicidal ideations are
relapse patients (“Attend the breatha- dominant. Two previous suicide
lyzer check-up twice a day, then we will attempts have been documented.
proceed”) or appointments can only be He barely eats when he is in a de-
arranged in far in advance, not to speak pressive phase.
of waiting lists. At the “other end” of the In the meantime, Mr B. has moved
“closed therapy chain”, the psychiatric to a council flat in Vienna and re-
world shows a very different picture, ceives social welfare. He finds it
which has nothing to do with “motiva- more and more difficult to endure
tional talks”, “empathy” and “under- the loneliness in the flat and con-
standing”. The “verification of motiva- siders abandoning his flat to move
tion” argument is often used in this out to live on the street.
context. Indeed, with these separate During the last crisis, Mr B. again
mechanisms, the psychiatric system’s decides to “really end it all”. He
precarious role in the medical system hasn’t eaten for three weeks and
becomes visible: shortness of resourc- bloody sputum indicates a stom-
es, permanent confrontation with men- ach inflammation. A visiting carer
tally ill patients, difficult patients, a lack finds him in a weak condition and
of acceptance and other critical factors immediately calls emergency, but
create a system, in which many em- Mr B. resists and, as a consequence,
ployees are at risk of “burn-out” (Helt- he is not being picked up. He in-
zel 2000, Fengler 2004). sists: “I want to die now”.

206
State of the Art: overlapping perspectives for sociotherapeutic housing
and support projects for alcohol dependents

The next day he changes his mind Only after the carer, who has to
and calls his helper asking for come to the hospital, intervenes,
help. At one o’clock the next day does the psychiatrist offer to see
the carer meets with Mr B. at the Mr B. Mr B. is admitted the next
local hospital pavilion. Mr B. has day.
dark circles around the eyes, is
just skin and bones and can hard- Apart from the occasional task of net-
ly stand upright. working, sociotherapy is responsible
When the psychiatrist in charge for structuring the patient’s daily life
appears, she passes the waiting as part of aftercare. This means, sup-
clients without saying a word and porting the maintenance of a daily,
avoids eye contact as she disap- monthly, or yearly structure and the
pears into her office. A little later, development of a (mentally) stabilising
Mr B. enters her office. It is decid- environment. Methods available de-
ed that he will not be admitted. pend on the setting, the available facili-
He should come back four days ties and the options open to sociother-
later for an admission interview at apists but are usually determined by
9 o’clock sharp. Mr B. says that he the individual’s situation. Some exam-
won’t be able to manage this. The ples of this are as follows:
psychiatrist replies, “Then you
have to make an effort!”  crisis intervention, relapse support
The carer points out Mr B.’s sui-  supporting job-seeking, cooper-
cidal tendency and problematic ating with employment centres
health condition, but he is ignored.  searching for suitable work or
Four days later, still not having projects that structure daily life,
eaten anything, Mr B. drags him- e. g. day centres for seniors etc.
self to the hospital pavilion, but he  recreational activities in groups
is half an hour late. He is told to (swimming, bowling, playing
wait four more days because he cards, …)
was late.  organizing festivities
Following this, Mr B. seeks out his  arranging furniture in a new room
former therapy unit in the same  cleaning up the flat together
hospital, but even after having  regulating debt
spoken to his former doctor, he  stabilising health (establishing ad-
still has to wait four days for an ap- equate contact with doctors, nu-
pointment with the psychiatrist. tritional advice ...)
On the advice of his carer, Mr B.
drags himself to another hospital 10.6 State of the Art: overlapping
with a psychiatric unit. In the perspectives for sociotherapeutic
meantime, he has developed acute housing and support projects for
withdrawal symptoms. The out-
patient department immediately
alcohol dependents
sends him away due to his condi- Analyses of the experiences of different
tion. Mr B. breaks down in the care facilities in Austria and Germany
hospital foyer. over many years, have provided very

207
10 Sociotherapy of alcohol-and tobacco dependents with regards to Lesch’s typology

helpful structures and approaches to – gender (e. g. male and female


improving the course of the disease of houses)
chronic alcohol dependents14. They re- – age (minimum and maximum age,
flect the institutions’ therapeutic and e. g. houses for the seniors or for
pedagogic orientations. The “concept” adolescents)
reflects the accumulation of practical – nature of substance (separating al-
and reflected experience and usually cohol dependents from drug de-
documents a lengthy learning process. pendents)
It allows assumptions to be made about
the current position of care facilities or The terms “high-threshold” and “low-
how concepts develop. The tension be- threshold” are further ways of differen-
tween the ideal and the reality, that is, tiating certain aspects. The institution’s
between the concept and daily life it- differentiation and specialisation may
self, is always present and may serve as promote a “high threshold”, which
a yardstick for improvement. An essen- means that clients have to meet certain
tial characteristic of social facilities is criteria15. Care facilities tend to select
that they adapt to changing situations according to “motivation” and “com-
(trends, political climate, situations, petency”. These factors are generally
changes in clients etc.) and that they difficult to assess as they always de-
connect marginal groups with society. pend on the phase in which an alcohol
Furthermore, local solutions, that is, dependence is diagnosed (it must be
procedures that conform to local con- borne in mind that the regeneration
ditions, are more efficient than general process takes several months). Therapy
concepts (e. g. procedures in rural areas places are expensive and scarce and this
are different to the ones in cities). is why the system supports those in
The following formulates overlap- whom an investment “pays off”. This is
ping perspectives which are based on how the terms “motivation” and “com-
different concepts of aftercare facilities petence” become criteria for the alloca-
and the practical implementation of tion of financial and personal resourc-
their work. These are “standards” which es.
are largely valid today and can be found There is a danger of losing “low-
in various forms in most aftercare insti- threshold” as a value, especially in terms
tutions for alcohol dependents. of therapy and the support of alcohol
dependents. If alcohol dependence is
10.6.1 Standard categories considered a disease, a low-threshold
approach which serves the clients’ needs,
1. The differentiation of (a) patient should be employed.
group(s) Apart from these general assess-
The most established differentiation ment criteria (age, gender, lifetime his-
criteria are tory of drug consumption, motivation

14 The Vinzenz House of the Caritas in Vienna, ALOA


and GOA in Upper Austria, Aloisianum in Graz, the 15 In most cases, the care institutions for alcohol de-
alcoholics housing community in Feldkirch, SOALP pendents have developed from housing projects
in Salzburg, the residential home in Schillerstrasse, for the homeless, in which the specialisation on the
Berlin, Hans-Scherer House in Munich, Type IV group of alcohol dependents has resulted in high-
housing community in Vienna. er-threshold therapy offers.

208
State of the Art: overlapping perspectives for sociotherapeutic housing
and support projects for alcohol dependents

and competence), any further differen- may not stabilise or help certain
tiations, and their realisation in prac- subgroups.
tice, become more difficult. Require- – Differentiations promote the trans-
ments are: parent handling of house rules,
– Clear conceptions, which have concept-based rules and especially
been theoretically and practically the management of “exceptions” to
considered, about which patient these rules, which are made in
group will, and can, be treated in practice at times; for example, in
the respective care facility. As a relapse assessment, a differentia-
rule, the facilities’ written concept tion is made between “hidden and
plan will already contain the core visible relapses” or different levels
of this differentiation as long as of motivation (= cooperation,
it has been developed in tandem “compliance”) (e. g. sanctions for
with the learning and adjustment extending admission).
processes, which is generally the
case, if one considers the history 2. The written concept plan as a sign
of the institution and its relation- of an institutional learning and matu-
ship to the concept plan. ration process
– The differentiation does not im- – The concept plan grows along with
ply that only one group (types) the institution and is representa-
should be allocated to one institu- tive of the institution’s different
tion, but special emphasis should maturation and learning phases
certainly be given to one particu- because it is regularly adapted in
lar target group. An example of line with any institutional chang-
such a differentiation is the thera- es.
peutic programme according to – The concept plan is usually avail-
Lesch’s typology at the Humboldt able in written form and serves as
University of Berlin, which does a basis for orientation for employ-
not permit type IV patients into ees in training.
the normal programme. Admis- – The concept plan is important for
sion criteria like “autonomy” and decision processes in the team.
“social competencies” are often That is, it is more than a “dead pa-
used in differentiations. per”, which is never referred to, but
– Differentiations are made in struc- rather a description of the team’s
tured and focused admission in- values and reasoning.
terviews or procedures, which are
mostly conducted by specially 3. House rules/user agreement
trained and experienced workers. – The house rules (or user agree-
– Differentiations also lead to non- ment) show the client who has
admissions and rejections. The moved in, which care strategies
team is likely to develop the atti- and therapeutic mindset are be-
tude “that they can’t help all alco- ing used. It reflects the facilities’
hol dependents” and that the re- concept plan.
spective institution has strengths – The house rules can be seen as a
and weaknesses, which may or therapeutic instrument in them-

209
10 Sociotherapy of alcohol-and tobacco dependents with regards to Lesch’s typology

selves as, when adhered to, they – More or less explicit knowledge
regulate daily procedures for liv- about alcohol, that is, more knowl-
ing together. edge about disease-specific proc-
– The house rules are signed at the esses and symptoms, e. g.
time of admission. • Knowledge about the dangers
– House rules may need to be re- of withdrawal symptoms, with-
vised, in accordance with changes drawal epilepsies and delirium
in daily life, as required. tremens
• Knowledge about organic se-
4. Practice quelae (fatty liver, liver cir-
Practice is not only implemented “in- rhosis, gastrointestinal diseas-
tuitively”, but is based on specific theo- es etc)
retic/scientific systems of thought which • Knowledge about the relation-
distinguish between different levels of ship between depression/anxi-
reflection (a continuum ranging from ety and alcohol consumption
very general to very specific levels) (tree as an attempt to treat oneself
of science). etc.

– Principally, any action is, or can be, – More specific practical standards
linked to professional discourse. are:
This is manifested in the ways in • Legal foundations for occupa-
which field-related topics are ex- tional activity (social welfare
amined. law, immigrant laws etc)
– Knowledge about the following