mental and behavioural disturbances due to use of alcohol with simple withdrwal

MENTAL AND BEHAVIOURAL DISTURBANCES DUE TO USE OF

ALCOHOL WITH SIMPLE WITHDRAWL.

AKHIL JOSEPHREG.NO: 13Q0402

INTRODUCTION

Alcohol dependence is a previous psychiatric diagnosis in which an individual is physically or psychologically dependent upon drinking alcohol.

Alcohol withdrawal syndrome is a set of symptoms that can occur following a reduction in alcohol use after a period of excessive use. Symptoms typically include anxiety, shakiness, sweating, vomiting, fast heart rate, and a mild fever. More severe symptoms may include seizures, seeing or hearing things that others do not, and delirium tremens (DTs). Symptoms typically begin around six hours following the last drink, are worst at 24 to 72 hours, and improve by seven days.

PATHOPHYSIOLOGY Alcohol is considered as a membrane disruptor with a

generalized effect all over the brain, as the small molecule can freely diffuse across the blood–brain barrier. There are particular cells in the brain that alcohol targets by binding certain hydrophobic pockets on their surface receptors. The gamma-aminobutyric acid (GABA) receptor is one of these. "Alcohol is an indirect GABA agonist,“GABA is the major inhibitory neurotransmitter in the brain. Alcohol is believed to mimic GABA's effect in the brain, binding to GABA receptors and inhibiting neuronal signaling. When ethanol links to the GABA receptor it promotes a facilitating action of GABA inhibition. The result is a further inhibitory effect upon the brain, leading to relaxation and sedation of the organism. Several parts of the brain are affected by the sedative effect of alcohol such as those responsible for movement, memory, reasoning, respiration and so on.

Alcohol also inhibits the major excitatory neurotransmitter, glutamate, particularly at the N-methyl-d-aspartate (NMDA) glutamate receptor. And it releases other inhibitors, such as dopamine and serotonin. Dopamine is a neurotransmitter associated with the pleasure centers of the brain. It is responsible for feelings related to love, joy, pleasure, reward and motivation. Serotonin is also a neurotransmitter and helps to regulate mood, irritability, impulse, obsession and memory. Consumption of even small amounts of alcohol increases the amount of dopamine in the nucleus accumbens area of the brain—one of the so-called "reward centers." However, it is most likely that the GABA and glutamate receptors in some of the reward centers of the basal forebrain—particularly the nucleus accumbens and the amygdala—create a system of positive reinforcement. In fact, multiple neurotransmitters in various parts of the brain combine to make the consumption of small doses of alcohol enjoyable.

Dependence to alcohol is linked to the interaction of alcohol with the brain's stress system, which alcohol activates. The major component of the brain stress system is the corticotrophin-releasing factor (CRF) in the amygdala and related areas, which activates sympathetic and behavioral responses to stress. A normal stress response sees CRF recruiting other parts of the brain to help adapt the mind and body to deal with the physical and mental "stressors" that challenge it. Alcohol interacts in such a way as to acutely reduce CRF levels in the brain; chronic alcoholism does the opposite. Unfortunately, CRF and the stress system adjust to the alcohol. CRF is hypothesized to persist at artificially high levels in the brain while reward neurotransmitters are compromised. In the absence of alcohol, the alcoholic feels ill because his or her body cannot easily reverse these artificial levels (for example, high CRF and low reward neurotransmission).

Demographic Details Name : XYZ

Sex : Male

DOA : 13-02-2017

Age : 35

Dept : Psychiatry

DOD : 21-02-2017

Reason for admission

C/O alcohol intake since 13 years. C/O tobacco chewing 6-8 packs/day since 13

years. C/O nausea and abdominal pain.

Past medical history

H/O similar complaints 8 years back and had taken medication for it.

No H/O of difficulty in sleeping. No H/O of shaking of hands on not having

alcohol. No h/o DM, HTN, Asthma.

History of present illness

Pt was apparently alright 13 years back. In 2004 he started working, where he started having alcohol along with his friends, every Sunday around 30-60ml of beer which gradually increased to 6-12 units of alcohol every 3 days, but patient doesn’t had any difficulty in sleeping and there were no incidents of shaking of hands on not having alcohol, but would feel like having alcohol whenever there are quarrels at home. Till 2009 he continued with this. Then consulted a psychiatrist and was treated with tablets and he remained abstinent for 9 months. After which because of construction work in home, the quarrels also increased. Patient says because of this he started alcohol again but once in a month or so.

Later in 2012 he got married but he doesn’t like his wife because she was from village and not well educated and the inter personal relationship issues at home went on increasing. Due to which patient would have 12-15 units of alcohol once in every 2-3 days. After the birth of his first child, patient tried to remain abstinent for 5 months without any medication. But again because of loan problems and quarrels at home, patient started alcohol again around 12-13 units every 3-4 days.

He also had H/O tobacco chewing , 6-8 packs per day. Last intake of alcohol; yesterday : 6 units.

Family history

Joint family.

First of birth order.

No h/o alcohol intake in family.

Married life : 4 years, initially after marriage he had issues with wife as she was not well educated and from a low social economic status and village life.

Habits

Alcohol consumption.

Tobacco chewing.

General physical examination

Pt is conscious and cooperative. PR : 84 bpm BP : 110/70mmHg Temp : afebrile

- - - - - -P I C K L E

SYSTEMIC EXAMINATION

CVS : S1S2 HEARED, NO MURMUR.

CNS : Soft , non-tender.

RS : B/L AE +, NVBS +

P/A : no focal neurological deficits.

MENTAL STATUS EXAMINATION

G A B : moderately built and nourished, well dressed and kempt. Eyecontact – maintained, rapport – poorly established, PMA – normal.

CONSCIOUSNESS : pt is conscious. ORIENTATION : well oriented to time, place and person. ATTENTION AND CONCENTRATION : aroused and

ill sustained. MEMORY : Immediate Recent intact, DST – DF: 4, DB: 3 Remote

SPEECH : tone, tempo and volume – normal, relevant and coherent.

THOUGHT : denies craving for alcohol, craving for tobacco present.

LOC – external LOM - precontemplation MOOD : S: says calm, O: annoyed/irritable, communicability

+ PERCEPTION : no disturbances JUDGEMENT : impaired personal and social judgement. INSIGHT : Grade III

Provisonal diagnosis ?

MENTAL AND BEHAVIOURAL DISTURBANCES DUE TO USE OF ALCOHOL WITH SIMPLE WITHDRAWL.

LABORATORY FINDINGS

HB : 14.5 g/dl ( 13.5- 17.5 g/dl )

WBC: 6400 cells/µl. RBC: 4.87Million/µl. PLT: 2,02,000 cells/comm. DLC: polymorphs: 55% basophils: 00% eosinophils : 02% lymphocytes: 43% monocytes: 00%RBS : 100 mg/dl ( 60-140mg/dl)HBsAg : negative

RFT

Sr. Urea : 32 Creatinine : 0.7

LFT

ALT : 21 U/L (6-38) AST : 26 U/L ( 6-40) ALP : 78 U/L ( 35-140)

BILIRUBIN T : 1.0 MG% ( 0.2 – 1.0) D : 0.4 MG% ( 0.1 - 0.4 ) I : 0.6 MG % ( 0.1 – 0.6)Total protien : 6.5 gm ( 6.4-8.3 gm/dl)Albumin : 3.4 gm ( 3.5 – 5 gm/dl ) Globulin : 3.1 gm ( 2.3 – 3.5 gm/dl) A/G ratio : 1:1

TREATMENT CHARTBRAND NAME GENERIC NAME DOSE ROUTE FREQUENCY

DAY 1

DAY 2

DAY 3

DAY 4

DAY 5

DAY 6

DAY 7

DAY 8

IVF NS WITH 1 AMP OPTINEURON

1 PINT IV 1-0-1√ √ √ √ √

INJ. PAN PANTOPRAZOLE 40MG IV 1-0-0 √ √ √ √ √

TAB. BETACAP TR

PROPRANOLOL 40MG P/O 1-0-0 √ √ √ √ √ √ √ √

TAB. LIBRIUM CHLORDIAZEPOXIDE

25MG P/O 1-0-2 √ √ 0-0-2

0-0-1.5

0-0-1

0-0-1/2

0-0-1/2

0-0-1/2

TAB. NODICT NALTREXONE 50MG P/O 0-0-1 0-0-1/2

0-0-1/2

√ √ √ √

TAB. NUHENZ mecobalamin,alpha lipoic acid

benfotiamine folic acid chromium

polynicotinatemyo-inositol

pyridoxine hydrochloride .

1500 mcg200MG200MG1.5MG200MG

100MG3MG

0-1-0 √ √ √ √ √ √

NICOTEX CHEWING

GUM

NICOTINE 4MG P/O SOS SOS

SOS

SOS

SOS

SOS

SOS

TAB. DISULFIRAM

DISULFIRAM 250MG P/O 0-0-1 √ √ √ √ √ √

FOLLOW UPDAY 1




P/A : no focal neurological deficits. BP : 120/78 mmHg.

PR : 84bpm.

Slept well yesterday night. Appetite : normal DC/PC : good Thought : denies craving for alcohol, craving for tobacco present. Patient was told about the ill effects of alcohol. Patient was made

to interact with other alcohol dependence patients, who told about the ill effects what they faced due to alcohol.

PSYCHOLOGIST : Motivational enhancement therapy done. Explained about the problem. Plan for aversion therapy, behavioural therapy and family therapy for IPR issues .

DAY 2




P/A : no focal neurological deficits. BP : 120/80 mmHg

PR : 90bpm

No fresh complaints. Slept well yesterday night. Appetite : normal DC/PC : good Bowel/ Bladder : regular Thought : denies craving for alcohol, craving for tobacco present. Explained regarding how to cop up with conditions like quarrel

with family, parties with friends and lifestyle of wife.

PSYCHOLOGIST : counselling done to patient, aversion therapy done, plan for family therapy.

DAY 3





PR : 82bpm

C/O burning of vision.Ophthalmologist review : simple myopia.Advice : Use glasses. Slept well yesterday night. Appetite : normal DC/PC : good Bowel/ Bladder : regular Thought : denies craving for alcohol, craving for

tobacco present.

DAY 4





PR : 86bpm

C/O pain in right hand because of injury 1 month back. Ortho review : Advice : physiotherapy for right hand, crepe bandage for 2 weeks. Appetite : normal DC/PC : good Bowel/ Bladder : regular Thought : denies craving for alcohol, craving for tobacco present.

PSYCHOLOGIST : counselling done to patient and family members, explained about the behavioural issues and self skill training, psychoeducation done to family members.

DAY 5





PR : 88 bpm

No fresh complaints. Slept well yesterday night. Appetite : normal DC/PC : good Bowel/ Bladder : regular Thought : denies craving for alcohol, craving for tobacco

present.

PSYCHOLOGIST : individual and family counselling done . Psychoeducation done.

DAY 6





PR : 82 bpm

No fresh complaints. Slept well yesterday night. Appetite : normal DC/PC : good Bowel/ Bladder : regular Thought : denies craving for alcohol, craving for

tobacco present.

DAY 7





PR : 84 bpm

No fresh complaints. Slept well yesterday night. Appetite : normal DC/PC : good Bowel/ Bladder : regular Thought : denies craving for alcohol, craving for tobacco

present.

PSYCHOLOGIST : psychoeducation done to family members, motivational therapy for patient.

FINAL DIAGNOSIS

MENTAL AND BEHAVIOURAL DISTURBANCES DUE TO USE OF ALCOHOL WITH SIMPLE WITHDRAWL.

TREATMENT CHART

BRAND NAME GENERIC NAME DOSE ROUTE FREQUENCY DURATION

TAB. LIBRIUM CHLORDIAZEPOXIDE 25MG P/O 0-0-1/2 15 DAYS

TAB. NODICT NALTREXONE 50MG P/O 0-0-1 15 DAYS

TAB. NUHENZ mecobalamin,alpha lipoic acid

benfotiamine folic acid

chromium polynicotinatemyo-inositol

pyridoxine hydrochloride .

1500 mcg200MG200MG1.5MG200MG

100MG3MG

0-1-0 30 DAYS

NICOTEX CHEWING GUM

NICOTINE 4MG P/O SOS 30 DAYS

TAB. DISULFIRAM

DISULFIRAM 250MG P/O 0-0-1 30 DAYS

REVIEW : REVIEW ON PSYCHIATRY OPD ON MONDAY’S AFTER 15 DAYS.

PHARMACEUTICAL CARE PLAN

SUBJECTIVE EVIDENCES

C/O alcohol intake since 13 years. C/O tobacco chewing 6-8 packs/day since 13

years. C/O nausea and abdominal pain. H/O similar complaints 8 years back.

OBJECTIVE EVIDENCES

MENTAL STATUS EXAMINATION

GAB : rapport – poorly established. ATTENTION AND CONCENTRATION : aroused and ill sustained. THOUGHT : denies craving for alcohol, craving for tobacco present. LOC – external LOM - precontemplation MOOD : S: says calm, O: annoyed/irritable, communicability + JUDGEMENT : impaired personal and social judgement. INSIGHT : Grade III

ASSESSMENT

BY OBERSVING THE SUBJECTIVE AND OBJECTIVE EVIDENCES THE PATIENT WAS DIAGNOSED AS MENTAL AND BEHAVIOURAL DISTURBANCES DUE TO USE OF ALCOHOL WITH SIMPLE WITHDRAWL.

PLANNINGGOALS TO BE ACHIEVED

Reduction or elimination of ALCOHOL abuse. To improve patient quality of life. To solve or reduce the Inter Personal Relationship issues of

the patient. To provide psychoeducation to patient and family members. Understanding of underlying co-occurring mental health

issues. Development of healthy stress-management techniques. Connection with family to encourage patient.

GOALS ACHIEVED

Reduction of ALCOHOL abuse achieved with de-addiction. Patient quality of life improved. Counseling done to solve the Inter Personal Relationship

issues of the patient. Psychoeducation given to patient and family members. Explained about the underlying co-occurring mental health

issues and ill effects of ALCOHOL. Explained to cop up with different conditions.

PHARMACIST INTERVENTIONDRUG INTERACTIONS

Propranolol - Chlordiazepoxide : Moderate

Propranolol and chlordiazePOXIDE may have additive effects in lowering your blood pressure. You may experience headache, dizziness, lightheadedness, fainting, and/or changes in pulse or heart rate.

Chlordiazepoxide - Disulfiram : Moderate

Disulfiram may increase the blood levels and effects of chlordiazePOXIDE. This can increase the risk of side effects including excessive drowsiness and breathing difficulties.

Disulfiram - Naltrexone : Moderate

Naltrexone may cause liver problems, and using it with other medications that can also affect the liver such as disulfiram may increase that risk. You should avoid or limit the use of alcohol while being treated with these medications.

ABOUT DISEASE

Alcohol dependence is a previous psychiatric diagnosis in which an individual is physically or psychologically dependent upon drinking alcohol.

Alcohol withdrawal syndrome is a set of symptoms that can occur following a reduction in alcohol use after a period of excessive use. Symptoms typically include anxiety, shakiness, sweating, vomiting, fast heart rate, and a mild fever. More severe symptoms may include seizures, seeing or hearing things that others do not, and delirium tremens (DTs). Symptoms typically begin around six hours following the last drink, are worst at 24 to 72 hours, and improve by seven days.

ABOUT MEDICATION

Take medications on time. Don’t skip the medication. T.BETACAP TR : must be taken 1hr before 2 hr

after meal. T.DISULFIRAM : Patients who stop therapy

should be advised to wait at least 1 week before taking alcohol and that reactions with alcohol may occur for up to 3 weeks after terminating therapy.

Patient must be warned that a disulfiram-alcohol reaction is potentially dangerous.

LIFE STYLE MODIFICATION

Identify potential relapse triggers and develop coping strategies for difficult situations that pop up at work or home

Avoid reaching for a drink when stressed or upset. Learn stress reduction or relaxation techniques. Consider starting a regular exercise program.

Tell friends and family about your intentions. They can help you with your goals.

Find ways to socialize without alcohol. Avoid going to bars or other places associated with drinking. Keep alcohol out of the home or office. Make new, nondrinking friends. Do fun things that do not involve alcohol. Eat a healthful diet.

MEDICATIONS FOR ALCOHOLISMFDA Approved

Medications Treatment Use Target Neurotransmitters Effect

Benzodiazepines (Valium® and Xanax®)

Treating alcohol withdrawal

GABA (γ-aminobutyric acid)

Increases GABA activity, curbing the brain’s

“excitability” during its withdrawal from alcohol,

allowing the brain to restore its natural balance.

Disulfiram (Antabuse®) Preventing alcohol consumption

Main effect on alcohol metabolism rather than in

the brain

Increases the concentration of acetaldehyde, a toxic

byproduct that occurs when alcohol is broken down (i.e.,

metabolized) in the body. Excess amounts of this

byproduct cause unpleasant symptoms, such as nausea and flushing of the skin.

Naltrexone (ReVia®, Vivitrol®, Naltrel®)

Reducing/stopping drinking Opioids Blocks opioid receptors involved in the pleasant

sensations associated with drinking.

Acamprosate (Campral®) Enhancing abstinence Glutamate Thought to dampen glutamate activity and may reduce some of the hyper

excitability associated with alcohol withdrawal.

‘’Quitting ALCOHOL is ROUGH and TOUGH but its WORTH ENOUGH’’ – THANK YOU

mental and behavioural disturbances due to use of alcohol with simple withdrwal

Education