Alcohol Dependence Correlated to Mental Health Diagnosis - Report Example

ALCOHOL DEPENDENCE CORRELATED TO MENTAL HEALTH DIAGNOSIS ACCORDING TO DSM IV TR CRITERIA INTRODUCTION Substance dependence has an old and complexrelation with human civilization, with a wide variety of intoxicants, narcotics and other plant products introduced and experimented for therapeutic, ritualistic and recreational purposes by different cultures. Alcohol is one of the substances that have been used for many social and cultural purposes with significant economic contributions as well as substantial harms. Damages as a consequence of alcohol have been reported by Babor and associates to result as a consequence of toxicity, intoxication and dependence (Room et al., 2005). American Psychiatric association (APA, 2000) defines dependence as substance use leading to psychological and physical symptoms of tolerance, withdrawal and the specific pattern of compulsive substance taking behavior; causing preoccupation of the individual with ensuring substance availability and use despite the repeated negative consequences of its use. Abuse on the other hand refers to pattern of substance use resulting in repeated and substantial harms as a consequence of substance use causing an adverse impact on interpersonal relationships, illegal activities, and inability to fulfill one’s responsibilities. Alcohol dependence has been known to result in severe illnesses and death due to psychological as well as physical effects. The present paper aims to present a comprehensive account of the psychological effects of alcohol dependence based on the DSM IV TR criteria and the diagnostic and treatment modalities followed for the psychological symptoms (APA, 2000). 2. DSM IV CRITERIA FOR ALCOHOL ABUSE American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 4th edition (DSM-IV) provides list of criteria for the diagnosis of alcohol related disorders (APA, 2000). It identifies two categories of disorders, alcohol dependence or alcohol abuse disorders, and alcohol induced disorders such as withdrawal, dementia, intoxication etc. Table 1 presents the DSM-IV criteria for alcohol dependence and abuse (Hasin, 2003). Table 1: DSM-IV Criteria for Alcohol Dependence and Alcohol Abuse (Hasin, 2003) Alcohol Dependence Manifested as any three of the following criteria occurring at any time during a continuous 12 month period 1. Drinking in amounts larger than or for longer duration than intended 2. Continuous but unsuccessful efforts or desire to cut down or control drinking 3. Time spent in obtaining and drinking 4. Giving up or reduction of important social, recreational and occupational activities for drinking 5. Continued drinking despite knowledge of the same leading or aggravating persistent or recurrent physical or psychological problem 6. Requirement of significantly increasing amounts of alcohol for desired effect or for achieving levels of intoxication; or reduced impact with continued use of same amount of alcohol Specify if: 1. With physiological dependence: evidence of tolerance or withdrawal 2. Without physiological dependence: no evidence of tolerance or withdrawal Alcohol Abuse Manifested as any one or more of the following criteria occurring at any time during a continuous 12 month period 1. Continued drinking despite persistent and recurring interpersonal and social problems caused or aggravated as a consequence of impact of drinking 2. Recurrent drinking in situations where the same can be physically hazardous 3. Recurrent drinking resulting in failure to fulfill one’s major role obligations 4. Recurrent alcohol related quarrels 3. EPIDEMIOLOGY OF MENTAL ILLNESS AND ALCOHOL ABUSERS Alcohol has been attributed with increased incidences of various diseases and aggravation of disease condition. The relationship between health and alcohol abuse is complex and multidimensional. Approximately 60 different diseases have been related to alcohol use at different levels and at least some have been found to exhibit a positive relationship. For those related adversely such as cancers of mouth, liver and breast; epilepsy, cardiovascular diseases etc, the disease condition aggravates with increasing uptake (Room et al., 2005). Further psychiatric problems have been found to be more frequently associated with alcohol abuse that can either be alcohol induced, alcohol related or comorbid conditions (Shivani et al., 2002). The commonly reported psychiatric disorders include mood disorders such as depression, anxiety disorders and antisocial personality disorder (ASPD); with each of these having further clinical implications (Modesto-Lowe & Kranzler, 1999). The National Comorbidity Survey (NCS), on the basis of its investigations of the comorbid psychiatric conditions associated with alcoholism in 8000 respondents from general population, provide extensive epidemiological data for occurrence of mental illnesses in alcoholics. Of the women, 72.4% of the alcohol abusers and 86.0% of the alcohol dependent were reported to have a comorbid lifetime mental illness or drug use disorder. Similar condition was reported for 56.8% of the male alcohol abusers and 78.3% of the male alcohol dependents. Anxiety and mood disorders were the most frequently reported women, while among men; drug use disorder and ASPD were most common. The levels of correlation between the mental illnesses and alcoholism in both sexes were found to be much higher than the levels encountered in general population. In clinical settings too lifetime mental illnesses have been frequently reported to be associated with alcohol dependence and abuse (Modesto-Lowe & Kranzler, 1999). 4. DIFFERENTIAL DIAGNOSIS OF MENTAL ILLNESS WITH ALCOHOL ABUSE DIAGNOSIS Diagnosis of mental illnesses with alcohol abuse is a complex process that needs constant repetition. For differential diagnoses it is imperative to treat the abuse followed by abstinence for at least a week. Usually this is interrupted as a consequence of the mental condition such as depressive symptoms of the addict. Certain psychiatric symptoms may also appear to be mood disorders, one of the most prominent being addiction. This disorder often remains either undiagnosed or is misdiagnosed. Mood disorders can also be manifested in most personality disorders such as those of the antisocial, narcissistic and borderline types. During addiction many or all of these disorders may coexist. Further the symptoms of all these being fluid, they may not remain persistent and are therefore very difficult to diagnose (Ries, 2005). A basic approach to differential diagnosis of psychiatric problems in patients with alcohol dependence or abuse is presented in figure 1. Figure 1: (Anthenelli, 1997) 5. MEDICATIONS USED TO TREAT ALCOHOL ABUSE WITH MENTAL ILLNESS: USAGE AND SIDE EFFECTS Treatment of alcohol abuse or dependence focuses on detoxification and strategies for ensuring abstinence. This approach is however, complicated in presence of a comorbid mental disorder (Modesto-Lowe & Kranzler, 1999). The researches too have investigated and provided treatment modalities for either of the alcohol abuse or related psychiatric disorder rather than for dual diagnosis. During the last two decades, as a consequence of realization of frequent co-occurrence of the two conditions and their mutual impact, researches have been oriented for treatment modalities addressing the dual diagnosis. Use of traditional or self help techniques in dual diagnosis is prevented due to paranoia & negativism; while reduced thinking ability slows down involvement in cognitive therapies. Hence compared to these medications have been found to be of advantage in such cases (Petrakis et al., 2002). Some of the common medications investigated and found to be useful for dual diagnosis include: Disulfram: U.S. Food and Drug Administration (FDA) approved, has been found to cause complete abstinence by working with body’s normal breakdown of alcohol leading to formation of acetaldehyde, a highly toxic compound. The completely aversive reaction to disulfram causes most people to stop taking alcohol, but in some cases they also choose to stop taking the drug; which forms the greatest weakness of this drug. Disulfram has also been clinically shown to control several psychiatric symptoms such as depression, delirium, anxiety etc (Petrakis et al., 2002). Naltrexone: Another FDA approved drug for alcoholism treatment, naltrexone is an opioid antagonist. Unlike disulfram it does not cause aversive action but has shown to have a modest impact on psychiatric symptoms. Researchers have also shown positive clinical response in cases of related psychiatric disorders such as schizophrenia, bipolar disorders etc (Maxwell & Shinderman, 2000). Medication for comorbid alcohol dependence and mood disorders The two medications commonly used for the treatment of depression in alcoholics are tricyclic antidepressants (TCAs) and selective serotonin uptake inhibitors (SSRIs). TCAs such as impramine and desipramine have been found to be effective but the risk of lethal overdose remains a major drawback of these medications. SSRIs in contrast have a better safety profile. Fluoxetine is effective antidepressant as well as reduces drinking behavior. Sertraline has also been reported to be effective antidepressive agent for alcoholics. Non-SSRI antidepressants nefazodone has also been reported to effective though without any impact on alcohol intake in alcoholics (Modesto-Lowe & Kranzler, 1999). Medication for comorbid alcohol dependence and anxiety disorder Buspirone, a nonbenzodiazepine has been found to be effective drug for anxiety disorders in alcoholics, with added advantage of being non-addictive. The major drawback of this drug is that it exhibits positive effects only after a continuous medication of at least 2 weeks (Modesto-Lowe & Kranzler, 1999). Medication for comorbid alcohol dependence and ASPD Medications have found limited use in treatment of ASPD though a three month course of lithium has been found to be effective for control of symptoms of aggression and impulsivity. But it has no effect on other behavioral traits associated with ASPD. SSRI fluoxetine has also been reported to be effective for treating personality disorders (Modesto-Lowe & Kranzler, 1999). 6. OTHER MEDICATIONS USED TO TREAT DISORDERS Other medications investigated for treatment of alcohol related psychiatric disorders are acamprostate and antipsychotic drugs (Petrakis et al., 2002). Acamprostate interacts with N-methyl-D-aspartate (NMDA) receptor for neurotransmitter glutamate. Widely used in European countries, its effects on aiding alcohol abstinence are known and those on psychiatric comorbidities are being studied (Mason & Ownby, 2000) A diagnosis of psychological disorder related to alcohol abuse requires thorough consideration of individual case history, family and socioeconomic status etc. Based on these considerations clinical decisions regarding the nature, type and setting of interventions are taken (Rooms et al., 2005). 7. SUMMARY AND CONCLUSIONS Exhaustive psychiatric assessment of patients with alcohol dependence and abuse is essential considering the high rates of co-occurrence of mental illnesses with alcohol abuse. The diagnostic procedures however; find limited use and are complicated due to multifocal impact of drinking behavior on psychiatric problems as well as impact of psychiatric problems on drinking behavior. Treatment of the dual disorder is also rendered complicated due to the aforementioned complications. Added to this is the addictive potential of the drugs used. It is important to diagnose and find effective cures for total control of mental illnesses associated with alcohol dependence and abuse, since treatment of dependence and abuse in rendered ineffective in presence of untreated mental illnesses. The risk for relapse is high and with it is associated the mortality and morbidity resulting as a consequence of alcohol dependence and abuse. It is therefore important to find and test diagnostic strategies and effective treatment approaches for the mental illnesses associated with alcohol dependence and abuse. REFERENCES 1. Antheneli, R. M. (1997). A basic clinical approach to diagnosis in aptients with comorbid psychiatric and substance use disorders. In N. S. Miller, Principles and practice of addictions in psychiatry (pp. 119-26). Philadelphia: W. B. Sanders. 2. APA. (2000). Diagnostic and Statistical Manual of Mental Disorders (4th ed. text revision). Washington D. C.: American Psychiatric Association. 3. Hasin, D. (2003). Classification of Alcohol Use Disorders. Retrieved December 2011, from National Institute of alcohol abuse and alcoholism: http://pubs.niaaa.nih.gov/publications/arh27-1/5-17.htm 4. Mason, B. J., & Ownby, R. L. (2000). Acamposate for the treatment of alcohol dependence: a review of double blind, placebo controlled trials. CNS spectrums , 58-69. 5. Maxwell, S., & Shinderman, M. S. (2000). Use of naltrexone in the treatment of alcohol use disorders in patients with concomitant major mental illness. Journal of addictive diseases , 61-9. 6. Modesto-Lowe, V., & Kranzler, H. R. (1999). Diagnosis and treatment of alcohol dependent patients with comorbid psychiatric disorders. Alcohol research and health , 144-9. 7. Petrakis, I. L., Gonzalez, G., Rosenheck, R., & Krystal, J. H. (2002). Comorbidity of alcoholism and psychiatric disorders. Alcohol research and health , 81-9. 8. Ries, R. (1996). Tretament of patients with coexisting mental illness and alcohol and other drug abuse. Rockville, U.S.: DIANE Publishing. 9. Room, R., Babor, T., & Rehm, J. (2005). Alcohol and public health. Lancet , 519-30. 10. Shivani, R., Goldsmith, J., & Anthenelli, R. M. (2002). Alcoholism and psychiatric disorders: diagnostic challanges. Alcohol research and health , 90-8. Read More