Vous êtes sur la page 1sur 58

DrSateesh R 26 Aug 2013

ALCOHOL WHAT IS IT ?
It is a fuel and a non essential nutrient It is a cellular toxin

WHAT DOES IT DO TO THE BRAIN

LT COL R SHASHIKUMAR

Burden of Disease Attributable to Alcohol Among the 10 Leading Risk Factors for Disease In Developed Countries

Tobacco Blood pressure Alcohol Cholesterol Overweight Low fruit and vegetable intake Physical inactivity Illicit drugs Unsafe sex Iron deficiency
0% 2% 4% 6% 8% 10% 12% 14%

% Total Number of Health Years Lost to Death/Disability

The World Health Report 2002: http://www.who.int/whr/2002/en/whr2002_annex14_16.pdf

Ethanol

CH3CH2OH Uncharged, highly lipid soluble Hydroxyl group formation of H bonds Lipophilic group interact with non-polar domains of macromolecules Pharmacologically active agent in alcoholic beverages

Alcohol by Volume
ABV (alcohol by volume) = % shown on the container which gives an indication of strength Approximate ABVs: Beer/Lager 4% Cider 5% Vodka 40% (but can be up to 70%)

Wine 9 to 13%
Rum - 42.8%

A convenient way of measuring alcohol intake is in units of alcohol. One unit is equivalent to 8g of pure ethanol.

PER CAPITA CONSUMPTION OF ALCOHOL (Min. Of Fin.,GOI,2001)

4 3 2 1 0 1951 1961 1971 1981 1991 2001

Metabolism of Ethanol
~90% rapidly metabolized in liver ~10% excreted unchanged in air and urine

Ethanol
Alcohol Dehydrogenase

Acetaldehyde
Aldehyde Dehydrogenase

Acetic Acid

Metabolism of Ethanol and Acetaldehyde in Hepatocyte


CYTOSOL
ADH ADH CH3CH2OH (mM) NAD+ CH3CHO (M)
NAD+ NADH

ALDH1 ALDH1 CH3COOH (mM)

NADH CH3COOH (mM) ALDH2 ALDH2 CH3CHO


NAD+ NADH

NADH Shuttle

CH3COOH
NAD+ NADH

TCA TCA CO2 H2O

electron electron transport transport Energy Yield: 7 Kcals/g

ATP

Substance Use Disorders (ICD- 10)


F10 Alcohol F11 Opioids F12 Cannabinoids F13 Sedatives F14 Cocaine F15 Stimulants including caffeine F16 Hullucinogens F17 Tobacco F18 Solvents F19 Others

FXX.1 Harmful Use FXX.2 Dependance Syndrome FXX.3 Withdrawal State FXX.4 Withdrawal With Delerium FXX.5 Psychotic Disorder FXX.6 Amnestic Disorder FXX.7 Residual State FXX.8 Others FXX,9 Unspecified

CLASSIFICATION OF ALCOHOL USE DISORDERS


Disorders due to Psychoactive Substance related disorders substance use (ICD 10) (DSM IV)
1. Acute intoxication 2. Harmful use 3. Dependence syndrome 4. Withdrawal state 5. Withdrawal state with delirium 6. Psychotic disorder 7. Amnestic syndrome 8. Residual and late-onset 9. Other mental and behavioral Disorders 10. Unspecified mental and behavioral disorder I. Substance use disorders II. Substance induced disorders 1. Intoxication 2. Withdrawal 3. Delirium 4. Persisting dementia 5. Persisting amnestic disorder 6. Psychotic disorder 7. Mood disorder 8. Anxiety disorder 9. Sexual dysfunction 10. Sleep disorders

Harmful Use Of Alcohol


ICD-10 Damage to physical or mental health

DSM-IV Failure to fulfill role obligations Physically hazardous use Legal consequences Social/interpersonal problems

Odds of Co-Occurrence of Alcohol Dependence and Selected Psychiatric Conditions

Anxiety Disorders Mood Disorders (especially Major Depression)

2.6x 4.1x

Personality Disorders Antisocial Personality Disorder


Drug Dependence Nicotine Dependence

4.0x 7.1x
36.9x 6.4x

NIAAA National Epidemiologic Survey on Alcohol and Related Conditions, 2004.

DIAGNOSIS OF ALCOHOL DEPENDENCE SYNDROME


ICD 10
(>=3 of the following)
1. Compulsion to drink 2. Difficulty to control 3. Withdrawal state 4. Neglect of alternative pleasures 5. Tolerance 6. Harmful consequences (Mental & physical)

DSM-IV
(>=3 of the following)
1. Tolerance 2. Withdrawal 3. Repeated attempts to give up/reduce interspaces with heavy drinks 4. Large time spent on procuring 5. Primacy over other activities 6. Continued use despite knowledge/ Presence of harmful consequences

ETIOLOGY AND PATHOPHYSIOLOGY


1. Genetics 2. Neurobiology

(a) Brain reward mechanisms (b) Neuroregulatory systems


* Gaba * Glutamate/ NMDA * Serotonin * Opioid (c) Craving (d) Membrane Studies 3. Psychodynamics

(a) Psychoanalytic theories (b) Defence mechanism


* Denial * Minimization * Rationalization * Projection 4. Socio cultural & family dynamics

Genetic Basis of Alcoholism


Alcohol dependence is a complex disorder Many pathways lead to the development of alcohol dependence Many genes are likely involved in the development of alcohol dependence

2002 Microsoft Corporation.

Genetic Basis of Alcoholism (contd)


The evidence of a genetic basis for alcohol dependence comes from a variety of sources:

Pedigree studies of large, multigenerational families Studies of adoptees Studies of identical (MZ) and fraternal (DZ) twins

Genetics of Alcoholism
Alcohol Dependence
-- Four Times Risk -- Adoption and Twin Studies

2 subtypes of alcoholics identified (Cloninger et al, 1986):


Type 1 (Non Familial type) Mainly women Later onset (>25 yrs) Type 2 (Familial type) Mainly male Earlier onset (<25 yrs)

No FH of alcoholism
Can abstain but binges Depressed/anxious Psychological dependence

FH of alcoholism
Impulsive a low 5HT function Antisocial Psychological dependence rare

Rate of Alcoholism as a Function of Family History Among Current Drinkers

40

Females Males

% alcoholic

30 20 10 0
FHN = no fam FHN= hxno FHP1 = 2 or 3 FHPZ = 1 only FHP2 = hx FHP1= only hx FHP3 = 1 + 2 FHP3 = hx or 3

fam hx of alcoholism
Source: Dawson et al., 1992

alcoholism 2nd or 3rd degree relatives only

alcoholism 1st degree relatives only.

alcoholism 1st degree relatives + either 2nd/3rd degree relatives

Estimated Rate of Alcoholism in Men Among Relatives of an Alcoholic


Percent Alcoholic

50 40 30 20 10 0
Po l a l pu io at n l ho ic r he t Fa s l ho ic r he t o M s er at n Tw l a in s tic n e Tw l a in s

e en G

So

ns

lc A f

s on

lc fA

Fr

Id

Alcoholism: A Common Complex Disease

1 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0

Genotype-Environment Interaction
Moderate genetic loading High environ. sensitivity

13

Low genetic loading Low environ. sensitivity

High genetic loading Low environ. sensitivity

Genetic Loading

Developmental Trajectory of AUD Initiation and Continuation of Drinking


Initiation of Drinking Progression Alcoholic Drinking

Extent of Influence

Environmental (familial and non familial) Personality/Temperament (Endophenotype) Pharmacological effects of ethanol (Intermediate Phenotypes)

Neurobiology Brain Reward Mechanisms Primary brain reward relevant portion appears to be a subset of the mesolimbic projections originating in the ventral tegmental area and terminating in the nucleus accumbens. Neuroregulator Systems Role of serotonin in alcohol reinforcement.

Craving Irresistible urge to use a substance that compels drug seeking behaviour. Changes in endorphin, serotonin levels linked to craving for alcohol. Hippocampus is one of the anatomical sites suggested for craving Kindling has also been proposed as a mechanism of craving Membrane Studies Glycine, NMDA, AMPA and kainate receptors have emerged as possible sites for alcohol action

Behavioural conditioning factors External and internal cues TV advertisement, drug using friend Depressed or anxious mood, anger

Psychodynamic theories Individuals seek self-regulation outside of themselves through alcohol Defence Mechanisms Denial, Minimalization, Rationalization and Projection Socio-cultural and Family Dynamics Availability Cultural Patterns Legal Control Semi structured Interviews

Blood Alcohol Concentration 20-30mg/dl 30-80mg/dl 80-200mg/dl 200-300mg/dl >300mg/dl

CNS Effects Slowed performance and decreased thinking ability Increase in motor and cognitive problems Increased in coordination and errors in judgement, mood lability and deterioration in cognition Nystagmus, marked slurring of speech and blackouts Impaired Vital Signs and possible Death

Long Term Consequences


Cardiovascular disorders Cardiomyopathy Hypertension Dysrhythmias Gastrointestinal disorders Dental caries Oesophagitis Gastritis & haematemesis Diarrhoea Hepatomegaly, cirrhosis Acute & chronic pancreatitis CNS Peripheral neuropathy Myopathy
Respiratory disorders Inhalation of vomit Tuberculosis) Cancer (mouth, tongue, pharynx, larynx, oesophagus, liver) Sexual problems Fetal alcohol syndrome Psychiatric Anxiety and depression Misuse of other substances Personality changes Dementia Wernicke-Korsakoff syndrome Cognitive changes

BOWEL UPSET

LT COL R SHASHIKUMAR

ULCERS

LT COL R SHASHIKUMAR

VITAMIN DEFICIENCY

LT COL R SHASHIKUMAR

VITAMIN DEFICIENCY

PELLAGRA

LT COL R SHASHIKUMAR

LT COL R SHASHIKUMAR

LT COL R SHASHIKUMAR

CANCER OF LARYNX

LT COL R SHASHIKUMAR

LT COL R SHASHIKUMAR

LT COL R SHASHIKUMAR

LT COL R SHASHIKUMAR

LT COL R SHASHIKUMAR

LT COL R SHASHIKUMAR

Alcohol withdrawal Autonomic hyperactivity Tremors Insomnia Nausea/vomiting Hallucinations Agitation Anxiety Seizures

Delirium Tremens
Alcohol withdrawal delirium Disorientation Impaired attention & concentration Psychomotor excitation Hallucinations vivid visual/auditory Fearfulness Delusions Other symptoms of withdrawal

Assessment
Barriers to assessment (related to pt) Denial of the problem Guilt about the substance use Feeling of shame Stigmatization of family and pt Dilemmas about physicians role and reaction Apprehension of possible legal consequences Barriers to assessment (related to clinician) Lack of correct scientific knowledge Judgemental attitude towards persons with substance abuse False opinion about therapeutic nihilism Fear of inability to manage substance use disorders

Remedies
Ensuring privacy and confidentiality Remaining non-judgemental Showing non-possessive warmth Expressing empathy and optimism Readiness to listen Avoiding ambiguous messages Being clear and firm regarding ones own role Introspective ability of the clinician

Purpose Setting Sources of Information Components of Assessment History Taking Examination Lab Investigation

History Taking
Chief complaints History of present illness Substance use pattern Onset, progression and recent use Complications of use Abstinence attempts Treatment history Past History Family History Personal History Early Childhood and development Adolescence Educational History Sexual History Marital History Occupational History

Premorbid Personality Physical Examination Vitals General Physical Exn Systemic Exn Signs of liver dysfunction Portal Hypertension Signs of neuro myopathy Signs of CNS dysfunction Signs of gastric dysfunction Mental State Examination

Biological Markers AST/ALT>2 highly suggestive GGT MCV Adenylate Cyclase CDT Erythrocyte Aldehyde Dehydrogenase Other Lab Parameters Screening Instruments and Rating scales
MAST, CAGE, AUDIT, CIWA-A

Thank You!!!

Vous aimerez peut-être aussi