ALCOHOL

Introduction:
• Mankind has lived with the use and abuse
of Alcoholic beverages for along, long time.
• It plays an important role in the social and
religious life of many communities.

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 Adverse effects documentation
• Were done many centuries before Christ.
• Knowledge prompted the Buddhists to
prohibit its use in 6th Century B.C.
• And followers of Islam in the 7th century
B.C.

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 Current situation
• Approximately 20% in patients admissions
in acute psychiatric admissions are due to
alcohol.

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 The nature of alcohol
• Varieties of alcohol are many.
• Ethyl alcohol or ethanol or the ‘alcohol’ used
as beverage is only one of these.
• It is a natural product of fermentation-when
sugars,as in fruits or grains, are converted
into alcohol through the action of yeast which
is abundant in nature or added by man.

Alcohol 4
 Cont’d
• Alcohol boils at temperatures lower than
water hence it is possible to make stronger
beverages from weaker ones.
• Alcohol is name coined from Persian name
of powder distillable known as ‘al kohl’.
• Pure alcohol is colourless and mixes readily
with water.

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Categories of alcoholic beverages
• Wines and Ciders
Are products of direct fermentation of fruit
sugars by natural yeast.
• Beers and Ales
Starch of grain is converted into sugars by the
process called ‘malting’. The sugars are then
fermented by yeasts.
• Spirits
Distilled from malted beverages or wines.
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 Metabolism
• Alcohol is rapidly absorbed and distributed
throughout all the tissues.
• Solubility in water is 30 times greater than
it is in fat.
• 90% is metabolised in liver
• Two to five per cent is eliminated
unchanged through lungs and in urine.

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 Cont;d
• Amount of alcohol breathed out the
concentration in the blood.
• Food can retard absorption of alcohol
• Breakdown of alcohol occurs at a set rate.

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Acute or short term effects of alcohol

• Alcohol reaches most organs within minutes.

• Subjective effects are felt within 15 to 30
minutes.
• Effects are basically governed by the level of
alcohol in the body and the strength of the
drink.

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 Cont’d
• Concentrated drinks rather than diluted
ones.
• Quick drinking rather than sipping drinks
slowly.
• Drinking on an empty stomach lead to
stronger and speedier effects.

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 Alcohol
• Progressively depresses many parts of the
brain.
• Conspicuous effects are reflected in changes in
– Mood
– Judgement; and
– Behaviour.

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 Cont’d
• Alcohol is not a stimulant
• General effects include:lowering of
temperature
• Impaired concentration, co-ordination,
memory and judgement.
• these may result in accidents and risk taking
behaviour

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 Cont’d
• Dehydration
• Irritation of stomach and increased secretion
of acid in the stomach
• Fall in blood sugar increased, leading to
fainting.

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 Cont’d

• It may also cause rise in blood sugar

• Potentiating effect on tranquillizers
• Sexual desires are increased but
performance is decreased

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 Effects of long term abuse
Terminology used:
• Alcoholism
• Alcohol addiction
• Alcohol dependence
• Problem drinking.

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 Cont’d
• The first three terms (Alcoholism, Alcoholic
addiction, Alcoholic Dependence) are old and
established and they are often used
interchangeably.
• They all suggest that the condition is chronic.
• The term alcoholic is overinclusive and vague
but is preferred by Alcoholics Anonymous
(A.A).

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 Cont’d
• Alcoholic addiction is claimed to imply moral and
social judgements.
• Dependence is said to be too narrow and clinical.
• Furthermore all these three terms (Alcoholism,
Alcoholic addiction, Alcohol dependence) accepts
that alcohol is a disease.

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 Cont’d
• The vast majority of drinkers who experience
problems or difficulties are not dependent on
or addicted to alcohol.
• They do not show signs of illness or
experience continued craving.
• They resent the label of being an “alcoholic”

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 Cont’d
• A relatively new term “ Problem drinking” is
being used to overcome the difficulties of
(Alcoholism, Alcoholic addiction, Alcohol
dependence)
• A problem drinker is any one who suffers
from harm or causes harm to others due to
the abuse of alcohol.

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 Cont’d
• Alcoholics, Alcoholic addicts and alcohol
dependents have all experienced harm to
themselves or caused to harm others.
• “Drinking problem” simply means that
there is a problem which is directly linked
with the pattern of drinking.

Alcohol 20
 Cont’d
• Problems may be varied; they may be acute,
Chronic; they may also vary in the type of
harm or difficulty such as social difficulties,
Criminality or disease of the liver.
• They can be identified as distinct entities
• One need not to be chronic abuser to
experience problems.

Alcohol 21
 Cont’d
• A one-off incident has results in both acute
& long term problems for anyone who is not
an addict or dependent.
• Chronic excess may lead to chronic
problems(addiction) as well as acute ones
such as acute inflammation of pancreas.

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 Cont’d
• Patients find the term “drinking problems”
more acceptable and especially young
people who are in a phase of abuse of
alcohol.

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Increased Tolerance and Dependence
• Repeated excessive drinking leads to increased
tolerance and dependence.
• Increased tolerance is shown by the ability to
handle the effects of large amounts of alcohol
without obvious signs of intoxication & need
to drink more to experience desired effects.

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 Cont’d
• The following are some of the more
commonly observed indicators of dependence:
– Fear of losing control
– Inability to feel “normal” without a certain
amount of alcohol in the blood.
– Increasing preoccupation with and craving
for the effects of alcohol and ensuring
adequate supplies

Alcohol 25
 Cont’d
– Realisation of loss of control
– Repeated minor withdrawals symptoms
put right by use of alcohol, such as
irritability, feeling shaky or anxious etc.
– Increased episodes of not remembering
events during drinking (lapses of
memory)

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 Cont’d
• Unfortunately the process of the dependent
state insidious and may take years to
develop although it may take place more
rapidly in women and in some young men,
in a matter of 4 to 5years.

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Withdrawal or Abstinence Syndrome
• The severity of the syndrome will vary with the
degree of the dependence and from person to
person.
• In its severe form it can be life threatening and
10% or more may die if untreated.
• Its main feature is marked excitation of the brain,
and these symptoms begin to be evident from the
third or fourth day of sudden abstinence.
• They are all more severe if the person is debilitated
or has an acute infection.
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 Cont’d
• The Main features are:
– Increasing in restlessness and agitation
– Visible tremor of hands, especially when
trying to use them
– Marked apprehension
– He looks frightened

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 Cont’d
– Feeling of being persecuted and chased
– Seeing frightening creatures esp in the
dark
– Confusion interspersed with short periods
of lucidity
– Unpredictable mood – may be violent or
suicidal.
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 Cont’d
– Raised temperature
– Profuse sweating
– Loss of fluids
– Feels sick and unable to eat
– Epileptic fits

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 Assessment of alcohol abuse
• Features that comprise the alcohol
dependence syndrome may form a basis for
assessment:
– Narrowing of Repertoire
– Silence of drinking

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 Cont’d
– Increased tolerance
– Repeated withdrawal symptoms
– Drinking to avoid or relieve withdrawal
symptoms
– Subjective compulsion to drink
– Reinstatement after abstinence

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 Abstinence Syndrome
• Features of Delirium Tremens:
– Tremor
– Autonomic overarousal
– Clouding of Consciousness
– Disorientation
– Altered motor activity

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 Cont’d
– Disorientation
– Mood Instability
– Illusions
– Delusions
– Convulsions

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ALCOHOLIC HALLUCINOSIS
• Condition is characterized by a prolonged
state of: auditory hallucinations and
delusions:
– Preservation or slight clouding of
consciousness
– Absence of distinct schizophrenic features such
as thought disorder

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 Cont’d
– Hallucinations are in third person
– Delusions are secondary
– The syndrome does not have a clear link
with alcohol withdrawal

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 ALCOHOLIC PARANOIA
• Distinctive feature is the combination of paranoid
delusions with high alcohol consumption.
• Auditory hallucinations my be present
• Personality is well preserved
• Impotence is common in male alcoholics both as an
immediate effect of alcohol intake and as a long-term
result of hypogonadism, hence morbid jealousy.

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 Cont’d
• Heavy use of alcohol affects production and
metabolism of testosterone – testicular
atrophy, oligospermia and erectile impotence.
• Gynaecomastia from excess oestrogens.
• Opioids reduce the release from the brain of
gonadotrophic hormones in other sexes –
reduction of sexual drive and in women of
reproduction functions.

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 CEREBRAL DAMAGE
• Cognitive deficits are common among of
substances other than alcohol.
• Prolonged use of benzodiazepines may impair
memory

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 CEREBRAL DAMAGE IN
ALCOHOLISM
• Brain shrinkage – due to alteration with
ventricular dilation of white matter.
• Neuronal damage in the cerebral cortex
• Subcortial dementia due to damage of
nucleus basalis of Meynert hence cognitive
impairment of alcoholism.
• Psychometric anomalies e.g impaired
abstracting and problem-solving functions.

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 Cont’d
• Reduced visual-spatial performance
• Defective memory for recent events
• 3 cortical areas are predominantly involved:
a) The frontal areas – features of frontal damage
b) Parietal lobe on the non-dominant side since
vision-spatial deficits point to that region
c) Overall cortical damage not concentrated to a
specific area.
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 Wernicke-Korsakoff Syndrome
• Lesions are located in the medical areas of the
base of the brain around the third ventricle,
sylvian aqueduct and brain stem nuclei.
• Mamillary bodies are always affected. Medial
dorsal of nucleus of the thalamus is also
involved when memory loss occurs

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 Cont’d
• Features include:
– Mental changes
– Cerebellar ataxia
– Ophthalmoplegia

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 Cont’d
• Psychological:
– Drowsiness
– Disorientation
– Amnesia
– Stupor or come Ataxia is trunk type

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 Cont’d
• Occulomotor palsies involves the sixth
cranial nerve leading to weakness or
paralysis of the lateral rectus muscle.
• Paralysis of gaze also occur.

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 Korsakoff’s
• Features: memory loss

– Condition follows as a long-standing sequel of

Wernicke’s disorder

– Amnesia of events occurring before and after the

onset of illness

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 Cont’d

– Patients tend to conceal forgetfulness by

confabulations
– Thiamine supplements are proposed as a
preventive means for the Wernicke’s
Korsakoff’s syndrome

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 Subdural Haematoma
• Alcoholics are liable to develop subdural
haematoma from head injury when intoxicated
– Headache
– Memory Impairment
– Drowsiness and impairment of consciousness
develop often in fluctuating manner
– Papilloedema can be absent

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 Investigative Developments
• New techniques for investigations of cerebral
structure and functions hold promise to
deepen understanding of brain damage in
alcoholism – e.g. magnetic resonance
imaging (MRI) reveals atrophy of the
mammilary bodies in Wernicke’s disease.

Alcohol 50
 Cont’d
• Changes in the water content of the brain
especially of the matter , are shown by M & I C.
• Positron Emmission Tomography (PET) and
Single Photon Emisson Tomography (SPET)
allow evaluation cerebral metabolism, cerebral
blood flow and neuroceptor system.

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 Magnetic Resonance
Spectroscopy(MRS)
• Potential powerful non-evasive exploration of
tissue chemistry in vivo.
– An integrated examination using RI and
MR & S unifies the anatomical and
biochemical identification of abnormalities

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 Disorders of Mood
• Substance misusers are prone to mood
disturbances of depression and anxiety.
• Comorbidity of depression and alcoholism
is commoner in women than in men.

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Reasons for Coexistence of Alcoholic
Dependence and Depression
• Loss of social supports, unemployment due to
drink secondary alcoholism
• Pharmacological effects of alcohol
• Primary depressive disorder (but secondary
alcoholism may then have its own course)
• Alcohol misusers more likely to attend clinics
if depressed
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 Cont’d
• Fall in blood sugar > leading to fainting.
• It may also cause rise in blood sugar.
• Potentiating effect on tranquillizers.
• Sexual desires are increased but performance
is decreased.

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 Cont’d
• Some genetic components are common-
possibly
• Both secondary to other conditions of
antisocial personality disorder
• Drug misuse, characterological depression

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MEDICAL ASPECTS OF DRUG
AND ALCOHOL MISUSE
Disorders of every bodily system have been
associated with alcohol misuse.
These include:
– Gastritis
– Liver disorders
– Pancreatitis
– Cardiomyopathy: amythmias
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 Cont’d
– Carcinoma: Oropharnyx, larynx,
oesophagus and liver
– Peripheral neurophathy
– Cerebral ataxia is reversible and benign

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 Cont’d
• Some patients with longstanding cirrhosis
develop liver cancer. The stigmata of
chronic liver diseases are:
– Telangiectasia
– Palmar erythema
– Hypogonadism and feminisation in men

Alcohol 59
 Cont’d
• In fatty liver hepatic function is preserved.
• Alcohol hepatisis is characterized by
leucocytosis, elevated ALT and in severe
cases by prolonged prothrombrin time and
renal failure.

Alcohol 60
 Cont’d
Clinical features of chronic pancreatitis:
– “Jack-Knife” pain –patient assumes a stooped
position
– Nausea and Vomiting
– Weight loss
– Steatorrhoea
– Diabetes
– Jaundice (in later stages)
Ultrasound and CT scanning are main diagnostic aids

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 OTHER NEUROLOGICAL
DISORDERS
• Peripheral Neuropathy
• Sensorimotor Neuropathy
– It begins as weakness diminished reflexes, pain and
numbness in the lower limbs
– Walking downstairs may become particularly
difficult, as proprioception is lost. Foot drop may
develop.

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 Cont’d
• Histology in alcoholic neuropathy shows
destruction of the myelin sheath and axon.
• This neuropathy improves with abstinence and
thiamine, but worsens even with vitamin
therapy if the patient continues to drink
• Recovery is slowly and may not be complete in
severe cases, the patient may need a wheelchair

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 CEREBELLAR ATROPHY
• Presents as gait axatia and nystagmus is
rarely seen. The gait is wide-based and the
patient may look drunk as he walks. CT Scan
shows atrophy, which can be present before
clinical signs.
• Treatment is abstinence from alcohol and
vitamin supplements. Once established the
syndrome is largely irreversible.

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 Skin & Skeletal Complications
• Psoriasis is worsened by heavy alcohol
consumption
• Alcohol may play a part in the development
discoid eczema. The coin-shaped patches of
eczema occurring particularly on the shins
of middle-aged men.

Alcohol 65
 Cont’d
• Some genetic components are common-
possibly
• Both secondary to other conditions of
antisocial personality disorder
• Drug misuse, characterological depression

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MEDICAL ASPECTS OF DRUG
AND ALCOHOL MISUSE
• Disorders of every bodily system have been
associated with alcohol misuse.
• These include:
– Gastritis
– Liver disorders
– Pancreatitis
– Cardiomyopathy: amythmias

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 Cont’d
– Carcinoma: Oropharnyx, larnyx, oesophagus
and liver
– Peripheral neurophathy
– Cerebral ataxia is reversible and benign

Alcohol 68
 Cont’d
• Alcoholic hepatitis (degeneration of hepatocytes),
inflammatory infiltration and “mallory’s hyaline”
– can lead to liver failure with jaundice,
hepatomegally and severe coagulopathy: cirrhosis
(widespread fibrosis connecting the portal triads
and central veins and degenerative nodules
leading to architectural disruptions) – complicated
by portal hypertension, ascites, hepatic encephalo-
phathy or renal failure

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 Cont’d
• Some patients with longstanding cirrhosis
develop liver cancer. The stigmata of
chronic liver diseases are:
– Telangiectasia
– Palmar erythema
– Hypogonadism and feminisation in men

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