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Key Features

Essentials of Diagnosis

  • Major criteria

    • Physiologic dependence as evidenced by withdrawal when intake is interrupted

    • Tolerance to the effects of alcohol

    • Evidence of alcohol-associated illnesses, such as alcoholic liver disease, cerebellar degeneration

    • Continued drinking despite strong medical and social contraindications and life disruption

    • Impairment in social and occupational functioning

    • Depression

    • Blackouts

  • Other signs

    • Alcohol odor on breath

    • Alcoholic facies

    • Flushed face

    • Scleral injection

    • Tremor

    • Ecchymoses

    • Peripheral neuropathy

    • Surreptitious drinking

    • Unexplained work absences

    • Frequent accidents, falls, or injuries

    • In smokers, cigarette burns on hands or chest

    • Laboratory tests: elevated values of mean corpuscular volume, serum liver biochemical tests, uric acid, and triglycerides

General Considerations

  • The two-phase syndrome includes at-risk drinking and moderate to severe alcohol misuse

  • At-risk drinking is the repetitive use of alcohol, often to alleviate anxiety or solve other emotional problems

    • For men, at-risk drinking is defined as > 4 drinks per day or 14 drinks per week

    • For women, at-risk drinking is defined as > 3 drinks per day or 7 drinks per week

  • Moderate to severe alcoholism is similar to that which occurs following the repeated use of other sedative-hypnotics; characterized by

    • Recurrent use of alcohol despite disruption in social roles (family and work)

    • Alcohol-related legal problems

    • Taking safety risks by oneself and with others

  • Alcoholism is associated with a high prevalence of lifetime psychiatric disorders, especially depression

Demographics

  • Alcohol is responsible for about 88,000 deaths in the United States each year

  • Most suicides and intrafamily homicides involve alcohol

  • Major factor in rapes and other assaults

  • Male-to-female ratios of 4:1 are converging

  • Adoption and twin studies indicate some genetic influence

  • Forty percent of Japanese have aldehyde dehydrogenase deficiency, which increases susceptibility to the effects of alcohol

Clinical Findings

Symptoms and Signs
Acute intoxication

  • Drowsiness, errors of commission, disinhibition, dysarthria, ataxia, and nystagmus

  • Ataxia, dysarthria, and vomiting indicate a blood level > 150 mg/dL

  • Lethal blood levels: 350–900 mg/dL

  • Severe intoxication: respiratory depression, stupor, seizures, shock syndrome, coma, and death

  • Serious overdoses often include other sedatives combined with alcohol

Withdrawal

  • Categorized as mild, moderate, or severe withdrawal, withdrawal seizures, and delirium tremens (DTs)

  • Symptoms of mild withdrawal

    • Tremor, anxiety, tachycardia, nausea and vomiting, insomnia

    • Begin about 6 hours after the last drink and end by day 2

  • Symptoms of moderate withdrawal signs and symptoms fall between those of mild and severe

  • Symptoms of severe withdrawal

    • Disorientation, agitation, diaphoresis, whole body tremor, vomiting, hypertension, and hallucinations (visual>tactile>auditory)

    • Occurs 48–96 hours after the last drink

    • Usually preceded by prolonged heavy alcohol use

  • Withdrawal seizures

    • Occur as early as 8 hours after last drink

    • Do not manifest more than 48 hours after alcohol cessation

    • More prevalent in persons who have a history of withdrawal syndromes

    • These seizures are generalized tonic-clonic seizures, are brief in duration, ...

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