Jooholism is one of the mast costly diseases a toring. The eenmstances that lead to compulsive include psychosocial, environmental, genet, and neuro jology has made tremendous advances on the brain, Hewever, key questions regarding the precise sites of Alcohol action remain unanswered. Notable discoveries are that alcohol, ike other drugs ff abuse, increases the fring and dopamine release of ventral tegmental area (VTA) ins. This action is key critical for the reinfaeing aspects of alcohol, but GGABA,), sci and nicotinic acetylcholine (ACh) receptors, have emerged as likely sites of alcohol ‘ction, However, Tis evident that aleolism is nots homogeneous disease but consists of subtypes, ‘each with varying degrees of blologie and psychosocial antecedents. Standardized homenclatures, such asthe Diagnastic and Statistical Manuai of Mental Disorders, 4th tediion, txt revision (DSMGIV-TR), define the core features of alcoholism, which encom pass the concepts of tolerance, withdrawal, and reinsttement after period of abst- hence, The DSNHIV-TR is widely used throughout the world, and the term aleohot dependinee is used in favor of alzohotism to remove emphasis on the individual but instead focus on the concent of disease. Epidemiology Alcoholism is a major cause of morbidity and morality in the United Staves and word wide Globally, the disease impact of alcoholism is greatest in regions with the highest 20 Chapter 2 Alco! 21 per capita consumption, such as Latin America, and is smallest in regions ike th ‘Middle East where dbinking levels are relatively low. Inthe United States, there at Excessive and binge drinking episodes inerease the risk of a multitude of injurie ‘that can occur from the operation of heavy machinery, vehicle accidents, fires, at In general, mortality rates increase when drinking levels rise. Inverestingly, ther ‘appears to be 4 protective effect of light or moderate drinking on the development © coronary heart disease; hence, morality rates for abstainers approach those of hoav, dsinkers Drinking through the Ages and Natural History In recent times, there has been no improvement in the: drinking, even though there appears to have been a. ‘surmption among those older than age 12 years from 72.9% in 197% to 68.7% in 2001, From the 2000 National Household Survey on Drug Abuse repor, it can be seen tha te average age st which drinking starts asong those between 12 years and 20 year the delay of drinking unt adujhoo Nevertheless, not al eases of earlyalcohol problems does this have prior behavioral, ‘appears that the symap- 1e age of 50 years tend to {Con aleahol continnes to rise reen ethnic and loves, followed ‘Jews, Bpiscopalians, ant lependence when comp: + Alectol 23 (eg, working asa bartender), and the progression to heavier easily noticed. Increased tolerance to aleo {ain the same pharmacologic effect. ‘Once the bouts of drinking to sntarication become an exibedded behavioral pat ter, the likelihood thatthe individual will develop alcohol-related problems tends to Increase. Typically, there are increasing days of Sck leave taken from work, interper- ss pattems is not rive aise in consumption to main Features Detectable by Physical Exam or Laboratory Tests, Skin and Muscle ‘Many skin conditions are exacerbated by heavy’ alcohol consumption. Exposure to san shine leading to erythematous eruptions without bistering may be a sign of erythropoi- tic protoparphiyria. Psoriasis vulgaris and aene rosacea (ted nose) are also corunonly ound, Rarely, hepatic porphyrias can be tiggered by alcohol and result in skin erup- tons—porphyria cutanea tarda —which are characterized by ‘ng, crusting, and searred healing with ityperpigiencaiion or depign tw the face, side ofthe neck, and back ofthe hancls, Palmar erythema (red palin) ray be sean, and with the onsot of aleoholic liver disease, there way be spider nevi (angiomas ‘of interlaced red blood vessels). Myopathy can be a rare complication of alcoholism. Eyes ‘Arens senils may be present as a result of increased blood lipid levels in heavy drinkers. However, this sign is so ubiquitous 28 to be not of much diagnostic wse. Rarely, prominent eye signs, such as ophthalmoplegia and nystagmus, which are {features of Wernicke encephalopathy, ean be manifested in individuals with ehronie2A Section Ile Substances of Abuse severe alcoholism, However, patients with this condition are unlikely to present in general practice, Limbs Sometimes, indi [Excessive drinkers may present with hypertension. Although the etiology of most avy drinking may be involved he vomiting of frank olyps and rectal cancer palpated under the right Endocrine System Heavy alcohol consumption ean exacerbate hypoactiity of a number of endocrine 1 should be considered as Cpter2 + Aleobol 25 ‘Therefore, drinkers tend to experience a ‘such as systeanle Inpus eryvemato- , however, precipitate attacks of ns of osteoporosis and myopathy. Hes fetions cansed by an increase in the CDECDS I to distinguish from other conditions that may gout, and less commonly there may be Erythropoiesis Anemia are common and should be examined for clinically by inspecting the lower eye- ‘Mammary Glands Chronically heavy-deinkking women are at increased risk of breast cancer Central Nervous System cognitive function is & associated with chronic heavy alcohol consum Fetal Development Alcohol andl is metabolite ac fetus. High levels of aleoto ition in pregnant: mothers ean produce spanta- ‘latzoned nasal bridge, an Laboratory Tests Laboratory tests may pfovide evidence that inereases the physician's suspicion about carbohydrate deficient transferrin (CDT) level, a carier protein, was approvedby the