Alcohol dependence syndrome

Harmful use of alcohol
If the pattern of alcohol consumption has caused damage to the physical or mental health of the user, it is described as harmful use of alcohol. However this is not diagnosed if the patient is alcohol dependent. Those with the harmful use often have associated social problems, and are often criticized by others in their community about their level of alcohol use.

Alcohol dependence syndrome
This is a collection of physiological, behavioral and cognitive phenomena, in which the use of alcohol takes on a much higher priority for that individual, than other behaviors which once had greater value. The central characteristic of dependency is a strong desire or craving to take alcohol. A definite diagnosis of dependence should be made only if three or more ICD 10 criteria are present.

Features of acute alcohol withdrawal syndrome
Features of alcohol withdrawal occur with the fall in the blood alcohol levels. This could occur within hours of the last drink, and is commonest on waking from sleep and this is the reason why many dependent drinkers take an early morning drink or an eye opener to stave off withdrawal features on waking.

Common features of acute alcohol withdrawal syndrome:

• Tremor of hands, legs and trunk

• Restlessness, anxiety, easily startled, agitated and sweating

• Nausea, vomiting, retching, loss of appetite, and insomnia

• Tachycardia and systolic hypertension

Features of acute withdrawal syndrome can start within hours of the last drink and a peak in 24 to 48 hours; in most the symptoms are mild to moderate and disappear within 5 to 7 days. However 5% of dependent drinkers may develop delirium tremens which is a medical emergency.

Delirium tremens
In about 5% of dependent patients, the withdrawal syndrome becomes severe; 36 to 48 hours after the last drink they delirium tremens may develop.

Features of delirium tremens

• The patient Is disoriented/confused. He may be very agitated, and in his confusion may be of harm to himself and a disturbance to the patients in the ward.

• Objects may appear distorted in shape. Illusions, visual and auditory hallucinations may occur. There may be frightening in nature. Commonly described visual hallucinations include those of colorful animals, snakes etc. Auditory hallucinations may be disorganized voices, shouting or snatches of music. Paranoid ideation can also occur.

• Tachycardia and hypertension

• Fever

• Generalized fits her

Risk factors for development of delirium tremens and fits:

• Severe alcohol dependence or severe withdrawal features when presenting for treatment.

• Past history of long standing alcohol dependency with previous episodes of inpatient treatment for withdrawal features.

• Past experience of delirium tremens or fits.

• Older age and concomitant acute illness.

Types of delusions

Delusions have been classified in many different ways. One way is based on the content of the delusion. Some of the commoner types of delusions are described below.

Delusions of persecution
The patient has a deluded belief that others are trying to harm him. can present in different ways in different patients. Delusions of persecution are common, but may not be very helpful in diagnosis, because they can occur in many types of psychotic disorders for example severe mood disorders, schizophrenia and organic states. However the patient's attitudes to the delusion may point to the diagnosis. For example in depression the delusions of persecution is usually mood congruent for example accompanied by feelings of guilt and worthlessness; the patient may belief he is persecuted because he is wicked. Whereas in the schizophrenia, the patient often resents the "persecutions". It should be also recalled that in many cultures people often believe that their misfortunes are due to evil charms/malign activities of other people in their community. This is often culturally shared, culturally accepted belief and therefore is not a delusion.

Delusions of reference
With this delusion, the patient believes that other people's actions, and even other events have a special significance or reference to himself. For example when a schizophrenic patient sees his family members talking among themselves, he may deludedly believe that there are talking about him, plotting to harm him. Another patient may believe that the news telecast on television had special reference to him. Yet another patient might claim that political posters pasted on the wall outside the hospital are referring to him. Delusions of reference are very common, and may be seen in schizophrenia, delusional disorder and severe mood disorders. They often have persecutory associations, but may also relate to grandiose themes.

Delusions of jealousy
The patient firmly believes that his partner is unfaithful to him. This belief is not based on logical evidence. The patient may act on his delusion for example always check on the suspected partner or accuse the partner and physically abused the partner. Delusions of jealousy are dangerous because they could lead to violence towards the partner. Delusions of jealousy is again common, and may form part of the schizophrenic illness, delusional disorder or mood disorder. It should be noted that delusions of jealousy are also associated with alcohol dependency.

Grandiose delusions
The patient has a deluded belief that he has special abilities or that he is a special person. Grandiose delusions are common, often seen in mania with psychotic features. It is also seen in other situations such as schizophrenia (the the patient may have bizarre grandiose delusions) and also in some organic illnesses such as general paresis of the insane.

Obsessions and compulsions

An Obsession is a recurrent thought/image/impulse which the patient cannot get rid of. It occurs repeatedly, and dominates the patient's consciousness, although the patient realizes it is senseless and tries to resist it. There is a subjective sense of struggle -the patient resists the obsession, but it intrudes into his awareness. The patient is also aware that the obsession are his own thoughts. If the delusion and an obsession were compared, it is clear that unlike in a delusion, a patient with an obsession does not believe his thoughts is true; and unlike in a deluded patient, the patient with obsessions tries to resists his obsessive thoughts.

For example, a patient gets the recurrent obsessive thoughts that her skin will become dirty and leads to disease. She is aware that this is a senseless thought, and tries to resist it, but she gets this thought again and again and this causes her distress.

A compulsion can be described as an obsessional motor act. Here the patient carries out a stereotyped motor act repeatedly, and feels a strong urgent to do so. At the same time, he knows that the act is senseless, it causes him distress and he tries to resist it unsuccessfully. A compulsion might be secondary to an obsessive idea/image. For example the woman who has recurrent obsessive thoughts of becoming contaminated might also have a compulsion to wash.

Often these compulsions or motor acts are carried out in stereotypic ritualistic ways-hence they are often referred to as compulsive rituals. For example if the compulsion is to wash, the patient may have a ritualistic way of washing, such as pouring water five times, applying soap twice, and pouring water 15 times and so on. The ritual is usually individualistic to each patient. Compulsive acts are of many kinds; the commoner kinds are checking rituals, washing rituals, counting rituals and dressing rituals.

Obsessions and/or compulsions are the key feature of obsessive compulsive disorder. Obsessive phenomena may also form part of the symptomatology of other disorders such as depression, schizophrenia and some post encephalitic states. Obsessive traits are also often seen in healthy people where it does not account to a disorder.

Delusions

Delusions

This is a firmly held belief, which is not based on logic and not amenable to logical argument, which cannot be explained in terms of a patient's social or cultural background. A delusion is usually false. For example a person may claim his neighbor is sending rays to kill him. In order for this to be a delusion, the person should believe this very firmly, even though he had no logical evidence to support this belief; he might even act on this belie (for example he may take steps to protect himself). It is also not possible to change his belief by logical argument, and his belief is not shared by others in this community.

There are many different types of delusions, and delusions may be seen in many different types of psychotic disorders. Patients with severe mood disorders often have delusions that are mood congruent that is which match their mood. For example:
A manic patient may have delusions of grandiosity (for example he is the president of his country) or delusions of persecution (for example people are trying to kill him because he is so powerful).
A severely depressed patient too may have delusions, but these would be with negative themes; for example delusions of persecution(e.g. people are trying to kill him; and he deserves to die because he is wicked), or nihilistic delusions(for example his family is dead; he has lost everything).

Delusions are also seen in schizophrenia and delusional or disorder. Certain types of delusions are typical of schizophrenia, and are induced in Schneider's first rank symptoms of schizophrenia. They include delusions of control, delusional perception, thought insertion, thought withdrawal, thought broadcasting and thought echo.

Terms used to describe disorders of perception

Illusion
a stimulus from a perceived object is combined with a mental image to produce a false perception. They often occur in normal people. For example the normal person walking on lonely road in the dark may get frightened; he may see the shadows of the trees and interprets them as threatening people. Illusions could also occur in psychiatric illness for example severe depression, acute confusional and others.

Hallucinations
This Is a false perception; the perception occurs in the absence of an external stimulus. This appears in the patient's external objective space (that is seems to be situated outside the patient) and is clearly defined. Hallucinations are described as being independent of the person's will, i.e. they cannot be voluntarily recalled or changed.

Hallucinations can occur of the different sense modalities:

• Auditory hallucinations

• Visual hallucinations

• Olfactory hallucinations

• Gustatory hallucinations

• Tactile hallucinations

Auditory hallucinations are common. They could occur in normal people(for example when falling sleep/wakeing up). In patients they could be simple hallucinations (noises, catches of song) or complex(voices talking, arguing). Complex hallucinations can be further divided:

• Second person auditory hallucinations - the patient hears a voice talking to him. This is common, and could occur in mood disorders with the psychotic features or schizophrenia.

• Third person auditory hallucinations - the patient hears several voices, talking about him (among themselves). This type of hallucinations is usually but not always seen in schizophrenia.

Prominent visual hallucinations are often more commonly seen in organic disorders such as acute alcohol withdrawal, acute confusional state, certain types of dementias. Although visual hallucinations could occur in psychiatric disorders per sae, prominent visual hallucinations should always raise the suspicion of an underlying organic pathology.

Terms used to describe behavior and movement

Psychomotor retardation
this is seen in depression. The patient subjectively feels that all actions have become much more difficult to initiate and carry out. There is a slowing down of all motor acts and thoughts. With severe psychomotor retardation, the observer will notice that the patient's movements are slow and dragging. Psychomotor retardation has been compared to the uniform slowing down of a vehicle produced by the steady application of brake.

Agitation
a state of restlessness and motor overactivity. The patient is easily distracted, so he may be unable to carry through the complicated pattern of voluntary movements.

Apathy
A State of under activity with the reduced responsiveness to stimuli and inability to feel pleasure, which the observer has good reason to distribute to loss of interest or concern, rather than to any intrinsic difficultly in responding.

Tics
Brief, repeated contractions of a muscle or small group of muscles. For example repetitive blinking, distortions of the or nose, shrugging of the shoulders, sniffing, grunting, clearing the throat. It is thought to occur with stress, and is common during childhood. Tics could also occur after encephalitis, in Huntington's chorea, and in Gilles de la Tourette syndrome.

Rest tremor
In a tremor there is a constant rhythm,which produces a steady oscillation of the affected part of the body. The rest tremor is seen when the subject is at rest. Most commonly seen in the hands, but could also affect the trunk, and head. It could be a normal movement seen in anxious subject. Static tremor also occur in alcohol withdrawal, Parkinson's disease, thyrotoxicosis and as a familial condition in benign essential tremor. Even such organic tremor can vary in intensity from day to day and maybe worsened by emotional stress. Static tremor could also be entirely psychogenic in origin.

Action tremor
This is a tremor made worse by action.

Athetosis
Slow, twisting, sinus movements of arms and legs made more prominent when the patient attempts movement.May be seen in children with cerebral palsy.

Chorea
Sudden, rapid, involuntary, purposeless jerks of fragments of movements. They continually intrude into the patient's normal activity. In Huntington's chorea the face. upper trunk and arms are the most affected. During the early stage of this disease, the patient may try to disguise the choreoform movements by tuning them into a voluntary movement.

Terms used to describe changes in speech

Mutism
This is the complete loss of speech. It could occur in depression,schizophrenia, dissociative disorders, disturbed children and patient with coarse brain disease. For example, a severely depressed patient may be mute. Some children may have elective mutism - i.e. the child speaks in certain environments only. For example he speaks normally at home, but does not speak at all at the school.
In motor aphasia, the patient's use of words may be severely restricted, but he may not be completely mute, i.e. he may be able to use 1 to 2 words. In akinetic mutism the patient appears to be aware of their environment, but is mute.

Pressure of speech
A state where there is an increased flow of speech. This speech is difficult to interrupt or stop. Pressure of speech is common in mania, where it is often associated with flight of ideas. Pressure of speech may also be seen in schizophrenia.

Flight of ideas
Flight of ideas are changes in the flow of speech which is typically seen in mania. In flight of ideas, the patient's thoughts occur very fast. The patient is very distractible, and the thoughts change very quickly, but there is an understandable association or connection between one thought and the next. These rapidly changing thoughts are manifested in the way the patient speaks very rapidly, jumping from subject to subject.

Terms used to describe emotions

Mood
Strictly speaking, the term mood refers to the emotional state that prevails in a person at any given time. However in psychiatry the term mood is often used to describe the emotional state that has lasted for a period of time and which has colored much of the patient's recent experiences.

Diurnal variations of mood
This describes a variation of the mood which shows a consistent 24 hour cycle. For example in a depressed patient, the mood may be lowest in the early hours of the day and the patient may feel a little better towards the evenings. If this variation of mood is seen consistently everyday it is referred to as his diurnal variation of mood.

Elation
This is an abnormally elevated mood,which is persistent and not due to any obvious reason. An elevated mood is one of the main features of mania. These patients appear very cheerful,having a strong sense of well being and self confidence and they do not respond to external depressing influence. This elation of mood is often accompanied by over activity,pressure of speech and flight of ideas. The elevated mood in manic patients shows an infectious gaiety -i.e, the observer often gets caught up in the patient's gay mood.Elated mood can also occur in schizophrenia and certain organic states such as general paresis of the insane.

Euphoria
A state of unconcern and contentment which is not justified by circumstances. Unlike elation euphoria is not infectious. Euphoria may be seen in organic illnesses such as disseminated sclerosis, amnestic syndrome and frontal lobe lesions.

Lability of affect
Here the patient's emotions change rapidly. The patient has difficult in controlling his emotions.