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3. Alcohol


NATURAL HISTORY OF ALCOHOL DEPENDENCE

Progression
At-risk groups and social factors
Recovery
Pregnancy
Alcohol and physical disease

Fundamentally, 'alcohol dependence' is a longitudinal development, a series of events (problems) correlated with the consumption of alcohol and associated with the phenomena of tolerance, loss of control and dependency.

The natural history of alcohol dependence is therefore a continuum, evolving from hazardous to harmful patterns of drinking, causing a series of alcohol-related disorders or problems, and the development of a dependency on the use of alcohol.

Progression

At-risk groups and social factors

The presence of positive outcome indicators need to be considered when planning treatment programs. Examples may include:

Recovery

Pregnancy

Any drinking is potentially deleterious to the foetus but major abnormalities are the sequel of heavy drinking (five or more drinks in a day). Women should be advised not to consume alcohol during pregnancy. Very early pregnancy (less than 6-8 weeks) and late pregnancy (third trimester) appear to be times of greatest foetal risk.

Alcohol and physical disease

PHYSICAL COMPLICATIONS

Certain diseases and conditions may be present which are not specific or consistently diagnostic of heavy alcohol consumption. However, suspicion should be raised particularly when more than one is present.

Note: They usually appear later than the social and psychological complications.

* = common; E = early (may also be late); L = late


Cardiovascular

Respiratory

Gastrointestinal

Haematological

Neurological

Alcohol should be included in the differential diagnosis of all acute, confusional and coma states.

Chronic disorders

(These may coexist.)

Nutritional

Metabolic

Endocrine

Skin

Facial

Musculoskeletal

Traumatic and accidental (*E)

PSYCHOLOGICAL COMPLICATIONS

General

The alcoholic personality as such does not exist. There is no difference between the mental health and pre-morbid personality of the alcohol-dependent person and the non-dependent person. Most, but not all, psychological problems in alcohol-dependent people are secondary to the effects of drinking. In some a psychiatric disorder (eg affective disorder, antisocial personality disorder) is primary and precedes the abnormal drinking behaviour.

There are almost no psychological symptoms or syndromes which cannot be caused or exacerbated by alcohol and other drug misuse. These must be considered in every psychological presentation. The diagnostic possibilities cover the whole field of psychiatry and only the most common can be listed here.

Common psychological presentations

Cognitive and memory defects

It is important to consider alcohol use every time a tranquilliser, antidepressant or hypnotic is prescribed.

Sexual problems

SOCIAL COMPLICATIONS

Social disorders are usually the earliest and most frequent complications of alcohol misuse. A complete range of these can be produced by, or associated with, alcohol misuse.

General

At work

Common effects of excessive alcohol consumption within the family

The alcohol-dependent person:

The spouse or partner:

The children

The children have an increased risk of developing alcohol dependency themselves. They may:

EARLY RECOGNITION OF ALCOHOL-RELATED PROBLEMS

Early indicators

Psychosocial factors

Investigation factors

Clinical symptoms and signs

BLOOD TESTS WHEN ALCOHOL dependence IS SUSPECTED


Routine                      Specific



* MCV Red cell count            * WBC Diff., platelet count ESR



  - MCV must be included in       - if MCV raised, anaemia liver

    blood count                     pathology or acute infection

                                    present



                                * CPK



                                  - if myopathy suspected



* Liver function tests          * Prothrombin time



  - must include GGT, ALP,        - if liver pathology suspected

    ALT, AST



* Blood alcohol level           * Amylase



  - if any indication of          - if abdominal symptoms

    current alcohol ingestion



* Lipids                       * Folate



  - fasting                      - if anaemia, macrocytosis

                                   or poor nutrition present



* Uric acid                    * Transketolase (thiamine assay)



                                 - if poor nutrition, neuropathy,

                                   cardiomyopathy or CNS changes



                               * Urea, Electrolytes, Mg, Ca, Glucose,

                                 pH, Osmolarity



                                 - if acutely ill

                               * Hepatitis B surface antigen,

                                 hepatitis C and HIV antibody



                                 - if liver pathology confirmed or

                                   illicit drug use suspected


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