Companion to psychiatric studies Book 1

Companion to Psychiatric Studies

impaired. Some die. High-dose vitamins should be given to all Table 13.6 Assessment of outcome after acute brain injury –
patients acutely and may also have some efficacy even after Glasgow Coma Scale
the acute phase has passed.
Scale score Injury
Transient amnesic syndromes
13–15 Mild

Transient amnesia can occur with several disorders: Transient 9–12 Moderate
global amnesia (TGA) is a distinctive benign disorder affecting 3–8 Severe
middle-aged or elderly subjects who become amnesic for
recent events, and unable to lay down new memories, for a (Table 13.6). It is highly predictive of both mortality and need
period of about 4 hours. Repetitive questioning by the patients for surgical intervention. However, it is less useful in predict-
of their companions is a characteristic feature. Episodes can be ing long-term outcomes, particularly when coma duration has
provoked by physical or emotional stress and are usually been brief. The length of post-traumatic amnesia (PTA) is
isolated. There is evidence that the disorder results from the other main predictor of severity of injury (Table 13.7).
reversible medial temporal lobe dysfunction, but the aetiology Studies in which both methods have been used find good
is uncertain. Temporal lobe epilepsy occasionally mimics TGA agreement but with a substantial number of discrepant cases.
(‘transient epileptic amnesia’), but episodes are typically
briefer, lasting less than an hour, recurrent (several/year) and Post-traumatic amnesia
often occur on waking. Other causes of transient amnesia
include transient cerebral ischaemia (usually accompanied The duration of post-traumatic amnesia is defined as the time
by other neurological symptoms and signs), migraine, drug from the moment of injury to the time of resumption of nor-
ingestion and head injury. mal continuous memory. The termination of PTA is often
abrupt except in cases where enduring memory difficulties
Acquired brain injury supervene. Brief islands of memory can punctuate the period
of PTA. Behaviour within the period of PTA can be normal
In industrialised countries advanced trauma and life support but more commonly there is defective memory and mental
techniques have led to a dramatic reduction in mortality rates confusion that is obvious to others. Studies of cognitive func-
from acquired brain injury (ABI), but an increasing number of tion during PTA are rare but illustrate that some procedural
survivors – the majority young adult males – have severely memory functions remain intact, while episodic memory is
damaged brains with multiple physical, cognitive and emo- impaired. Assessment of PTA at a time distant from the injury
tional disabilities. This has led to a silent epidemic of complex is not straightforward and often requires careful review of the
problems in a group who often lack a ‘home’ within healthcare patient’s medical record and careful analysis of behaviour in
systems as their problems straddle the increasing divide the immediate post-accident period.
between ‘mental’ and ‘physical’ health.
Retrograde amnesia
Epidemiology
Retrograde amnesia is defined as the time between the
The incidence in Scotland is 330/100 000 per year. Of these, moment of injury and the last clear memory from before the
approximately 80% are mild, 10% moderate and 10% severe. injury that the patient can recall. It can usually be indicated
Less than 20% of patients who survive a severe injury will have with reasonable precision. It is usually dense and much shorter
a good outcome. The consequent disability depends on both than PTA. It is of less predictive value, although in general
the severity and the nature of the injury, as well as on the pre- injury with a retrograde amnesia of less than 30 minutes to
morbid state of the patient. This latter issue is of considerable be associated with any significant cognitive impairment.
importance as people who have problems with substance or
alcohol abuse, violent tendencies or risk-taking traits in their Table 13.7 Assessment of outcome after acute brain injury –
personalities are much more likely to suffer brain injury. duration of post-traumatic amnesia

Severity of injury Duration of PTA Injury
<10 min Very mild
It cannot be overemphasised that the assessment of severity of 10–60 min Mild
an acquired brain injury should be made by examining the 1–24 h Moderate
peri-injury factors. Whilst there is no single definitive marker 1–7 days Severe
of severity three measures are of particular use: duration of >7 days Very severe
total loss of consciousness, the Glasgow Coma score and the
duration of post-traumatic amnesia. The Glasgow Coma Scale
has been a major advance in documenting the severity of coma

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Organic disorders CHAPTER 13

Mechanism of injury attention tend to be particularly sensitive to diffuse effects,
and patients will perform poorly on tests of oral or sequential
Penetrating injuries arithmetic.

Cognitive symptoms after a penetrating injury will correspond Sensory impairment
to the area of the brain that is damaged. They are also gener-
ally accompanied by impairment in memory and attention A loss of the sense of smell is frequently the result of damage
and general cognitive slowing reflecting associated diffuse to the olfactory nerve during a bruising injury to the frontal
damage. pole of the brain, although it can indicate damage to limbic
structures in the temporal lobe. Visual disturbance is common,
Closed head injury and its nature will be dependent on the nature of the damage
to optic pathways. Hearing and balance defects are common
Both primary and secondary injuries can occur, with the and may be associated with tinnitus.
secondary injury being more damaging. The primary injury is
the damage that occurs at the time of impact. There are three Language impairment
main mechanisms:
• the coup, which corresponds to damage to the cortex under Language impairment, particularly partial deficits in receptive
language, is particularly common after acquired brain injury.
the site of a direct blow, and the contrecoup, in which the It is often complicated by deficits in high-level concept forma-
brain sustains a bruise in the area opposite the injury; tion, complex reasoning and meta-cognition. The result is a
• bruising, which occurs as a result of rapid deceleration highly impaired communication in a patient who apparently
leading to the brain hitting the bony structures of the floor ‘talks’ normally. These deficits are possibly the commonest
of the skull; and cause of irritability and difficult behaviour after a brain injury.
• rotational injury which occurs when a moving head comes As a minimum a ‘bedside’ examination of receptive language,
to a rapid stop. This leads to a generalised disruption of the including comprehension of complex grammar, is essential in
internal cellular architecture of neurons, particularly at the all patients.
junction between grey and white matter, known as diffuse
axonal damage. Mild head injury

The secondary injury consists of the effects of the physiologi- Around 80% of injuries are mild. They are characterised by a
cal processes set in motion by the primary injury, and can short duration of loss of consciousness (<20 min), a Glasgow
often be the more destructive. Of major importance is an Coma Scale of between 13 and 15 and PTA of less than
increase in intracranial pressure (ICP) which results either 6 hours. In the immediate aftermath patients generally
from oedema in injured cerebral tissue or from secondary describe a triad of attention deficits, impaired verbal retrieval
haematomas. The control of intracranial pressure is conse- and emotional distress. The emotional distress is often
quently the most important consideration in acute care of accompanied by marked fatigue and concern over perceived
the head-injured patient. cognitive deficits. Headache, depersonalisation, dizziness and
photophobia/phonophobia are also common accompaniments.
Clinical features The effort needed to overcome perceived attentional deficits
is particularly distressing. It is notable that similar clusters
The immediate effect of a brain injury is concussion. This can of symptoms occur in association with other forms of trauma
be mild, without total loss of consciousness, and characterised such as orthopaedic injury and may not be the direct
by symptoms such as ‘seeing stars’, transient neurological dys- consequence of brain injury.
function, vomiting and disorientation, with or without amne-
sia. Or, it can be more severe with reversible coma at the The prognosis of such symptoms after a mild brain injury
instant of trauma, accompanied by neurological, cardiovascular has been a matter of considerable controversy. A recent com-
and pulmonary changes. prehensive systematic review by the World Health Organisa-
tion has been of considerable assistance to our understanding.
Cognitive effects of ABI They found substantive variation in prognosis depending on
where studies were conducted and in particular the legal
Coup and contrecoup lesions result in direct impairment of system of the country of interest. In general terms there
cortical function at the site of the lesion. Bruising tends to does appear to be an association with increased symptoms,
affect the frontal and temporal lobes and leads to problems including decreased attention, in the 3 months after an injury.
in control of behaviour, in conceptual thinking and problem However, such injuries are not associated with significant
solving and with various memory and learning tasks. Diffuse acquired dementia and they caution that the limited cognitive
damage from shearing reduces speed of processing, attentional symptoms that do occur are not the simple expression of neu-
functions, cognitive efficiency and high-level concept for- ronal damage. Instead they suggest that more complex models
mation and complex reasoning. This can be seen directly or involving the interplay of biological (in particular nociceptive
as irritability, fatigue and a general inability to do things as well pain), psychological and social factors may be more helpful in
as before the accident. Tasks requiring selective or divided understanding the phenomena. They conclude that any excess
symptomatology associated with mild injury will have resolved

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Companion to Psychiatric Studies

after 12 months. They also caution against the overinterpreta- This involves not just the cognitive ability itself but also the
tion of animal and postmortem studies, highlighting flawed ability to express it. Such patients frequently need external
methodology as a common problem. They note, for instance, cues for activity, and perseveration (repetition) of behaviours
that pathological features of diffuse axonal injury are encoun- is common.
tered at post mortem in around 1 in 10 non-brain-injured
fatalities anyway and have an association with opiate use. Both psychotic symptoms and major depressive disorders
occur. Early psychosis usually involves delusions of misidentifica-
In our clinical experience the apparent prognosis is not tion, and reduplicative paramnesias appear to be particularly
always as favourable; however, there are usually clear reasons associated with brain injury. In this striking disorder, the patient
for this. Most commonly the patient had pre-existent pro- believes himself to be in a different place despite all evidence to
blems with their health that have simply been re-interpreted the contrary. The majority remit spontaneously. Late presenta-
and ‘relabelled’ after a mild injury; often under the conscious tions of psychotic illness also occur, with a slight increased risk
or unconscious influence of litigation. For a smaller group of of a schizophreniform psychosis. Paranoid states, frequently
vulnerable patients the experience of physical symptoms in related to memory impairment, also occur and can be hidden
the aftermath of the injury appears to be the nidus on which by communication difficulties. These psychiatric syndromes
a complex somatoform disorder develops. should be treated in the usual way but with increased caution
about unwanted drug effects. The presentation and management
Moderate head injury of depressive disorders is discussed under stroke.

A patient with a Glasgow Coma Scale score of 9–12 and post- Agitation and aggression
traumatic amnesia of less than 6–24 hours is likely to be
classed as moderate. Headaches, memory problems and diffi- Agitation and aggression cause clinically significant problems in
culties with everyday life are the most common complaints. around 10% of brain-injured patients acutely. In the chronic
Many patients will not return to work although the reasons phase, such behaviours can be a major cause of disability and
behind disability are often complex and cannot usually be are one of the most frequent complaints of relatives and
solely ascribed to the effect of ABI. Most patients exhibit carers. Cognitive impairments, and in particular communica-
some evidence of frontal or temporal bruising. Impulsivity, tions disorders, are more likely to be the cause than psychotic
diminished initiative, affective muting and temper outbursts disorders or depression. Drug treatment is complicated and
are all common. Temporal lobe damage is displayed as a true almost always needs to be supplemented with behavioural
learning disorder with lateralisation for verbal and non-verbal interventions. The evidence is best for high-dose propranolol.
material. Carbamazepine, valproate, trazodone and atypical antipsy-
chotic drugs have all been advocated.

Severe head injury Prognosis

Although accounting for less than 10% of ABI cases, the com- This varies according to the severity of injury (Table 13.8).
plex rehabilitation and long-term care required make severe Recent outcome studies have highlighted a high rate of chronic
head injury a major problem for health services. The associated disability and failure to return to work (Thornhill et al 2000).
impairments are generally categorised as occurring in three However, the interpretation of such poor results must take
main areas: cognitive, emotional and executive. account of the squewed distribution of ABI in the popula-
tion and substantial over-representation of patients with pre-
Cognitive deficits are usually multiple, with individual existent problems; in the study cited, alcohol misuse was a
patterns unique – some neural functions being severely particular problem.
impaired and others functioning at near normal levels.
Attentional deficits are particularly common and when very In more severe injuries, following return to conscious-
severe can place barriers to any form of retraining. Memory ness, patients are generally delirious for a period of days to
impairment usually affects acquisition and retrieval of seman-
tic and episodic memory, with procedural and working Table 13.8 Disability 1 year after head injury
memories being relatively spared. Frontal lobe injuries can be
particularly handicapping and interfere with patients’ abilities Initial Severe Moderate Good
to use knowledge and skills appropriately. injury disability (%) disability (%) outcome (%)

Emotional disorders generally involve the exaggeration or Mild 20 28 45
muting of affective responses but, as well as reflecting the
nature of the organic damage, will also be influenced by pre- Moderate 22 24 38
morbid personality and mental state. Frontal lobe damage is
associated with either excitability, impulsivity and lability, or Severe 29 19 14
with apathetic, flat, uninterested and non-initiating responses.
Damage to temporal limbic structures tends to result in Reproduced from Thornhill et al (2000), with permission from BMJ Publishing Group
emotionalism with sudden temper outbursts or pathological Ltd.
crying.

Executive dysfunction involves impairment of self-
determination, self-direction and self-control and regulation.

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Organic disorders CHAPTER 13

weeks. In such states they usually display restlessness, agita- A Anterior cerebral
tion and incomprehension and are uncooperative. Over the Anterior Internal carotid
first 6–12 months many aspects of physical and cognitive func- communicating Middle cerebral
tion improve dramatically and then plateau – particularly those Anterior perforated Striate
relating to attention. Activities relating to new learning tend to substance
improve over a far longer period of time but seldom return Anterior choroidal
to premorbid levels. Improvements after the first 2 years Posterior Posterior
tend to be more related to the development of compensatory cerebral
strategies than to resolution of the underlying impairment. Basilar communicating

Litigation Anterior Superior
inferior cerebellar
Compensation claims are frequently made after accidental cerebellar
head injury and often involve considerable sums of money Pontine
reflecting long-term loss of earnings and a need for long-term Posterior inferior Labyrinthine
care. Specialist assessments are required. Studies have found cerebellar
little difference between those patients who seek compensa- Vertebral Anterior inferior
tion and those who do not, with the possible exception that cerebellar
the former may complain more of their impairments. B
Posterior inferior
Stroke cerebellar

Definition Anterior spinal

A cerebrovascular accident or stroke is ‘a rapidly developed Anterior cerebral artery
clinical sign of a focal disturbance of cerebral function of pre-
sumed vascular origin and of more than 24 hours duration’. Middle cerebral artery
One of two pathological processes can be responsible: cerebral
infarction or cerebral haemorrhage. Infarction may result Posterior cerebral artery
from thrombosis of vessels or emboli lodged within them.
Haemorrhage can be into either brain tissue directly or into Fig. 13.8 (A) The Circle of Willis and the arteries of the brainstem.
the subarachnoid space. Infarctions are four times more com- It should be noted that the arterial ‘circle’ lies in a horizontal plane
mon than haemorrhages and, as a result of a lower immediate and the basilar artery is vertical. (B) The lateral areas (left) and the
fatality rate, are a much greater source of enduring disability. medial areas (right) supplied by the cerebral arteries.

Epidemiology

Strokes are the third commonest cause of death in the West- may be expected whereas a non-dominant lesion will be
ern world. The Oxford community stroke project reported accompanied by neglect or perceptual disturbance.
an annual incidence of 2 per 1000 (Bamford et al 1988) for
first ever stroke. Stroke is more common in men, and a quarter Anterior cerebral artery occlusion leads to contralateral
of those affected are under 65 years of age. Psychiatrists are hemiparesis affecting the leg more severely than the arm.
not usually involved in the diagnosis of acute stroke but occa- A grasp reflex and motor dysphasia may be present. Cognitive
sionally can be in several of the less typical cerebral syndromes changes resembling a global dementia may occur and be
where altered mental state and cognitive function dominate accompanied by incontinence. Residual personality changes of
the clinical picture. a frontal type can occur.

Clinical features Posterior cerebral artery occlusion presents with a con-
tralateral hemianopia sometimes accompanied by visual hallu-
The clinical features depend largely on which area of the brain cinations, visual agnosias or spatial disorientation. Cognitive
is damaged, which in turn depends on which artery is affected disturbance can again predominate, with transient confusion
(Fig. 13.8). serving to obscure the detection of hemianopia. The vital
memory structures are supplied from the posterior cerebral
Middle cerebral artery occlusion produces a contralateral artery, and in a proportion of normal subjects both medial
hemiparesis and sensory loss of a cortical type. This is often thalamic areas are supplied by a single penetrating artery.
accompanied by a hemianopia if the optic radiation is affected. Dense amnestic symptoms occur if the hippocampus and
If the lesion is in the dominant hemisphere then dysphasia other limbic structures are involved bilaterally. Such disorders

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Companion to Psychiatric Studies

can be a particular diagnostic dilemma as early CT scan inves- for this hypothesis (Carson et al 2000). The disability caused
tigations are often negative, although subsequent MRI scans by the stroke is clearly a likely cause of depression in many
will show the bilateral lesions. cases but the association of depression and anasagnosial states
indicates that this is not the sole cause. There are disappoint-
Internal carotid artery occlusion may be entirely asymp- ingly few RCTs of treatments for depression after stroke.
tomatic but much depends on the efficiency of collateral cir- Both SSRI and tricyclic antidepressants have been shown to
culation and the Circle of Willis in particular. The clinical be effective, and although SSRI drugs are probably better
picture is often that of middle cerebral artery occlusion. How- tolerated (Andersen et al 1994), nortriptyline was superior to
ever, in some situations cognitive and behavioural symptoms fluoxetine in the only head to head trial. Certainly stroke
are predominant, with general slowing, decreased spontaneous patients who are prescribed antidepressants should be closely
activity and dyspraxia. In these situations it is important to pay monitored for both treatment effectiveness and for adverse
attention to the abruptness of onset of the symptoms. drug effects. The use of psychological treatments, in particular
cognitive-behavioural therapies, potentially offers a solution to
Vertebrobasilar strokes can be extremely varied in their this problem but has not been adequately evaluated and trials
manifestations. Total occlusion of the basilar artery is usually so far have been negative (Lincoln & Flannaghan 2003).
rapidly fatal. Partial occlusions can be very diverse but the
hallmark is brainstem involvement with a combination of Anxiety disorders are also common after stroke. They prob-
unilateral or bilateral pyramidal signs and ipsilateral cranial ably share the same risk factors as depression. Stroke is a
nerve palsies. One, thankfully rare, variant is the ‘locked in’ sudden and unpredictable life-threatening stressor, and post-
syndrome where total paralysis is accompanied by full wake- stroke anxiety states may be associated with fear of recur-
fulness and alertness. Occlusions of the rostral branches rence. This can lead to agoraphobia and to the patient’s
of the basilar artery can result in infarction of the midbrain, misinterpretation of somatic symptoms of anxiety as frighten-
thalamus and portions of the temporal and occipital lobes. ing evidence of recurrent stroke. Although there is a paucity of
evidence from RCTs the standard drug and psychological
Psychiatric manifestations and their therapies are probably effective.
management

Delirium and cognitive impairment Psychosis

Delirium affects 30–40% of patients in the first week after Psychosis and in particular mania are occasionally reported
stroke. It is important to distinguish delirium from focal cogni- following acute stroke. Old age and pre-existing degenerative
tive deficits affecting declarative memory. Although this can disease seem to increase the risk. Treatment is assumed to
often be complicated by the presence of an agitation, the dis- follow that of psychosis generally. Reduplicative paramnesias
turbance of attention and fluctuating pattern of impairment can occur and are usually short lived, although a small number
that accompany delirium are often absent in the latter. The of chronic cases have been reported.
presence of delirium after stroke is associated with poorer
prognosis, longer duration of hospitalisation and increased risk Parkinson’s disease
of subsequent dementia. Dementia following stoke is com-
mon, and approximately one-quarter of patients are found to Definition
be demented at 3 months after a stroke. This figure rises sig-
nificantly if focal cognitive impairments are also counted. Parkinson’s disease is a degenerative condition characterised
by the triad of tremor, rigidity and bradykinesia.
Emotional disorders
Epidemiology
Depression after stroke is also common, occurring in about a
quarter in the first year. Depressive disorder is usually defined The prevalence of Parkinson’s disease is 200–300 per 100 000.
according to standard DSM-IV or ICD-10 criteria. However, The prevalence rises with age and increases with distance from
these criteria may be hard to apply because of communication the equator.
problems and difficulties in deciding whether to attribute
symptoms such as sleep disturbance to the stroke or to the Aetiology
depression. Possible solutions are to use the accounts of infor-
mants and to place more weight on mood change and loss of The cause of Parkinson’s disease remains unknown. Genetic
interest than on somatic symptoms (see also Chapter 24). forms have been described, but account for a minority of
Most clinicians take a pragmatic approach and will treat cases. Similarly, environmental causes such as viral infec-
depression in patients who have suggestive symptoms, tion have been suggested, but no single exposure has been con-
although this is not without the risk of causing complications sistently replicated, with the exception of cases associated
such as delirium. There has been much controversy over the with the recreational drug MPTP. Cigarette smoking decreases
cause of depression after stroke. Much emphasis has been risk.
placed on the site of the stroke lesion, and in particular on
the hypothesis that damage to the left frontal area causes
depression. However, meta-analysis of data found no support

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Organic disorders CHAPTER 13

Clinical features Anxiety is also common in Parkinson’s disease. It tends to
occur with depression and is associated with the severity of
Rest tremor is the most characteristic feature of Parkinson’s motor symptoms. In particular, marked anticipatory anxiety
disease and is found in most patients. In the early stages of concerning freezing of gait is a common phenomenon. Treat-
disease it is described as ‘pill-rolling’. The rigidity manifests ment with antidepressant drugs and cognitive behavioural
as fixed abnormalities of posture and resistance to passive therapy, particularly if delivered in conjunction with an active
movement throughout the range of the joint. Concurrent physiotherapy programme, can be helpful. Benzodiazepines
tremor can give this a ‘cogwheel’ sensation. Bradykinesia may be required.
is usually of insidious onset and the most disabling feature.
Postural instability is a common additional feature, giving rise Medication-related impulse control disorders
to an increasing liability to falls as the disorder progresses.
Abnormal involuntary movements are common, both as a Over recent years there has been increased recognition of
result of the disease process and of dopaminergic replacement complex behavioural problems associated with dopamine
therapy. Freezing of gait is one of the most poorly understood receptor stimulation in Parkinson’s disease. They include path-
features of the disease but is one of the most disturbing to ological gambling, hypersexuality, punding (intense fascination
patients. Freezing to visual cues may be misinterpreted as with repetitive handling, examining, sorting and arranging of
voluntary behaviour. Non-motor manifestations are common objects), compulsive shopping and compulsive medication
and include autonomic (particularly orthostatic hypotension, use. These behaviours appear to affect up to 14% of patients
bladder and gastrointestinal disturbances), sensory (pain), with Parkinson’s disease.
cognitive and emotional symptoms.
Their aetiology is believed to be linked to dopamine agonist
Cognitive symptoms use although there is not a clear dose-related effect. It has
been postulated that neuronal sensitisation, particularly in
Approximately one-third of patients with Parkinson’s disease mesolimbic dopaminergic tracts, to the intermittent adminis-
have symptoms of dementia. Impairment of ‘frontal’ functions tration of dopamine agonists leads to an increased behavioural
is detectable from very early in the disease process; lexical response to similar levels of psychostimulation. This process
fluency is the most helpful bed-side test. Hallucinations and can be modified by genetic predisposition to risk taking (there
delusions are a common feature of dementia in Parkinson’s is a general association between PD and low risk-taking traits)
disease. Clinically it is important to distinguish between a and the environment. It is believed that lower age of onset,
delirium of acute onset with disorientation, impaired atten- right-sided onset and executive cognitive impairments can all
tion, perceptive and cognitive disturbance and alteration facilitate the process.
to the sleep–wake cycle, on the one hand, and an iatrogenic
dopaminomimetic psychosis, which is a subacute, gradually Management involves converting patients on dopamine ago-
progressive psychotic state without a primary deficit of atten- nists to L-dopa and, if possible, a reduction in total L-dopa load.
tion. The former state is often induced by dopamine agonists Some small trials have suggested some benefits from SSRI
(such as selegiline) or anticholinergic medication. Appropriate antidepressants and antiandrogens (in hypersexuality). In one
examination and laboratory tests should be performed to case series subthalamic deep brain stimulation showed very
detect underlying aetiological factors. For the latter a reduc- encouraging results; however, a recent meta-analysis cautioned
tion in the dose of dopaminomimetic drugs can be considered, that a history of impulse control disorders was a risk factor for
but is seldom successful, and antipsychotic drugs are often postoperative suicide.
required but may worsen motor function. Clozapine is the
agent of choice in terms of efficacy, but the associated pre- Epilepsy
scribing restrictions due to the risk of blood dyscrasias can be
problematic. Quetiapine remains a frequent first line agent Definition
although a recent small randomised controlled trial was not
favourable. Epilepsy is an episodic condition associated with cerebral sei-
zure activity. A seizure is a transient cerebral dysfunction
Emotional symptoms resulting from an excessive, abnormal electrical discharge of
neurons (Fig. 13.9). The clinical manifestations are numerous.
Depression is common in Parkinson’s disease, with a preva- As a result the psychiatrist commonly encounters epilepsy
lence of around 50% (Burn 2002). There is a bimodal distribu- both when considering whether epilepsy is the primary cause
tion with peaks at early and late stages of disease. Large-scale of paroxysmal psychiatric symptomatology and when treating
studies have demonstrated that depression is one of the major its significant psychiatric complications.
determinants of quality of life in Parkinson’s disease. The
degree to which it is neurogenic remains uncertain. Mood Epidemiology
changes can accompany the late-stage fluctuations to levodopa,
known as ‘on–off’ phenomena. Bipolar mood changes reflect- The prevalence of active epilepsy is around 7 per 1000 in the
ing the phases have been described. developed world. There is a higher incidence in developing
nations, probably as a result of increased rates of birth trauma

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Companion to Psychiatric Studies

Fig. 13.9 This EEG shows bursts of bilateral anteriorly dominant 2–3 Hz delta rhythmical EEG activity which corresponded with the patient
reporting a sense of ‘impending doom’. The focus of the seizures was deep in the frontal cortex.

and head injury. Most studies show a bimodal distribution of Tonic-clonic seizures are the most dramatic manifestation
the incidence with increased rates below 10 years and above of epilepsy and are characterised by motor activity and sudden
60 years old. It is twice as common in men. loss of consciousness. In a typical seizure a patient has no
warning with the possible exception of a couple of myoclonic
Aetiology jerks. The seizure begins with sudden loss of consciousness
and a tonic phase during which there is sustained muscle con-
In less than one-third of cases is a specific cause identified. traction lasting 10–20 seconds. This is followed by a clonic
These include perinatal disorders, learning disabilities, cerebral phase, of repetitive muscle contraction that lasts approxi-
palsy, head trauma, CNS infection, cerebrovascular disease, mately 30 seconds. A number of autonomic changes may also
brain tumours, Alzheimer’s disease and substance misuse. occur including an increase in pulse rate, apnoea, incontinence,
Many idiopathic seizures are likely to have a genetic basis. piloerection, cyanosis and perspiration. In the postictal period
the patient is drowsy and confused. Abnormal neurological
Clinical features signs are often elicited.

The key clinical distinction is between seizures with a focal Simple partial seizures have features that depend on the
or a generalised cerebral origin. The former are more likely brain region activated. Although the initial area is relatively
to be associated with a detectable and potentially remediable localised, it is common for the abnormal activity to spread to
cerebral lesion; the latter are more likely to start in childhood adjacent areas, producing progression of the seizure pattern.
or adolescence and to be familial. Despite the wide variety of If the activity originates in the motor cortex, there will be
possible seizure manifestations, an individual patient’s seizures jerking movements in the contralateral body part, which can
are usually stereotyped. Their clinical features result from a develop into progressive jerking in contiguous regions, known
recurrent pattern of cortical hyperactivity during the ictal as Jacksonian march; activity in the supplementary motor cor-
event followed by hypoactivity in the same area postictally tex causes head turning with arm extension on the same side.
(Fig. 13.10). This gives rise to a predictable set of symptoms Seizures originating in the parietal lobe can cause tingling
dependent upon the brain region affected (Fig. 13.11). or numbness in a bodily region or more complex sensory
experiences such as a sense of absence on one side of the
body, asomatognosia, or vertigo and disorientation in space.

346

Organic disorders CHAPTER 13

Fig. 13.10 SPET scans during epileptic seizures show hyperactivity in the region of onset at the time of the seizure, then hypoactivity
postictally in the same area. The symptoms seen during a fit will correspond to the brain regions affected.

Focal epilepsies Generalised epilepsy This is then followed by impairment of consciousness and a
seizure usually lasting 60–90 seconds. It may generalise into a
Focal seizure onsets Generalised tonic- Myoclonic tonic-clonic seizure. Automatisms may be present and can
Simple partial seizures clonic seizures seizures involve an extension of the patient’s actions prior to seizure
(consciousness retained) Clonic seizures Photosensitive onset. They commonly include chewing or swallowing,
Complex partial Tonic seizures seizures lip smacking, grimacing or automatisms of the extremities
(consciousness lost) Atonic seizures including fumbling with objects, walking or trying to stand
Secondary generalised Absences up. Postictal confusion is usually significant and would be
Focal status epilepticus Absence status expected to last for 10 minutes or longer. Complex partial sei-
epilepticus zures of frontal lobe origin tend to begin and end abruptly,
Convulsive status with minimal postictal confusion, and often occur in clusters.
epiliepticus The attacks are usually bizarre, with motor automatisms such
as bicycling, or sexual automatisms and vocalisations.
Fig. 13.11 A simplified version of the ILA classification of
Absence seizures are well-defined clinical and EEG events.
epilepsy. From Fuller et al (2000). The essential feature is an abrupt, brief episode of decreased
awareness without any warning, aura or postictal symptoms.
Seizures of the occipital lobe are associated with visual symp- At the onset there is a disruption of activity, and a simple
toms which are usually elementary, such as simple flashing absence seizure is characterised by only an alteration in con-
lights and in one visual field. However, if the seizure occurs sciousness. The patient remains mobile, breathing is unaf-
at the border with the temporal lobe more complex experi- fected, there is no cyanosis or pallor and no loss of postural
ences can occur, including micropsia and macropsia as well as tone or motor activity. The ending is abrupt and the patient
visual hallucinations of previously experienced imagery. resumes his previous activity immediately, often unaware that
a seizure has taken place. An attack usually lasts around 15 sec-
The temporal lobe is the most common site of onset onds. A complex absence seizure displays additional symptoms
accounting for 80% of partial seizures but can cause the most such as loss or increase of postural tone, minor clonic move-
diagnostic problems. Symptoms include auditory hallucina- ments, minor automatisms or autonomic symptoms such as
tions ranging from simple sounds to complex language. Mesial pallor, flushing or urinary incontinence.
temporal discharges lead to olfactory hallucinations, usually
involving unpleasant odours, and seizures in the sylvian fissure Violent behaviour of an undirected nature is incredibly rare
or operculum will cause gustatory sensations or epigastric but can occasionally arise from the emotional changes asso-
sensations such as nausea or emptiness. The well-known emo- ciated with temporal lobe seizures. However, in the over-
tional and psychic phenomena of temporal lobe seizure activity whelming majority of cases violence is in response to being
can occur in simple seizures but are more common in complex restrained during a seizure. We suggest that psychiatrists are
partial seizures. very cautious indeed before attributing other violent assaults
to a seizure. The following criteria should be considered before
Complex partial seizures usually begin with an aura at the making such a link.
onset of the seizure. The aura is, in fact, a simple partial
seizure lasting seconds to minutes. It should be distinguished • Has known epilepsy.
from a prodrome, which is not an ictal event, and can last
for hours or even days before a seizure. Prodromes usually • Clear evidence of a seizure at the time of the offence.
consist of a sense of nervousness or irritability. The content
of the aura will depend on the location of the abnormal dis- • The offender’s usual seizure phenomena might explain
charge within the brain. This can include hallucinations, behaviour at time of offence.
intense affective symptoms such as fear or depression or panic,
and cognitive symptoms such as aphasia or depersonalisation. • Behaviour at time of offence within range of known ictal/
Distortions of memory can include dreamy states, flashbacks postictal behaviours – in particular, no evidence of
and distortions of familiarity with events (d´ej`a vu or jamais vu).

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Companion to Psychiatric Studies

structured thought such as going to a specific drawer in a Box 13.12
different room to find a knife then returning to commit an
assault. Distinguishing NEAD from epilepsy
• No external motive for the offence.
More likely in NEAD
Differential diagnosis • Resistance to eye opening
• Eyes shut during attack
Documentation of the clinical features of the seizure is usually • Responsive during generalised shaking attack (or can interrupt
the key to diagnosis. As first-hand observation is seldom possible,
unless seizures are very frequent, the history of the episode, seizure)
including an eye-witness account (or a home video), is of para- • Memory of seizure
mount importance. The chief differential diagnosis of epilepsy • Weeping during or after a seizure
is from non-epileptic attack disorder and syncope. It also needs • Generalised attack lasting longer than 2–3 minutes
to be distinguished from other paroxysmal disorders, including
transient ischaemic attacks, panic attacks, hyperventilation Unhelpful in distinguishing NEAD from epilepsy
attacks, hypoglycaemia, migraine, transient global amnesia, • Aura or postictal confusion
cataplexy, paroxysmal movement disorders and paroxysmal • Tongue biting
symptoms in multiple sclerosis. Attacks during sleep can pose • Injury (carpet burns may indicate pseudoseizure)
particular difficulties as informant reports are often less reliable. • Incontinence
• Pelvic thrusting
Non-epileptic attack disorder (NEAD) previously referred • Attack during sleep
to as ‘pseudo-epilepsy’ or ‘psychogenic epilepsy’ is an impor- • ‘Status epilepticus’
tant differential diagnosis. It accounts for around 30% of • Patient alone during a seizure
patients attending clinics with suspected epilepsy. Some • Elevation of postictal prolactin — may be elevated in syncope
patients have both epilepsy and non-epileptic attacks, but
probably only around 10% of those with NEAD fall into this accompanied by myoclonic jerks which may be misinterpreted
category. Many of these patients are learning disabled and at as epileptic by both lay and medical onlookers. The occurrence
increased risk of both epilepsy and psychiatric disorders. The of more complex movements, eye deviation, eyelid flicker or
diagnosis of NEAD can often be made on the basis of a careful vocalisations can confuse the diagnosis further. Similarly, the
history and examination. Clinical clues include: majority of subjects recall aura symptoms including epigastric,
vertiginous, visual and somatosensory experiences.
• the presence of prior or current psychiatric disorders,
including somatoform disorders; Sleep disorders, including sleepwalking, night terrors and
confusional arousals, all of which occur from slow-wave sleep,
• atypical varieties of seizure, especially the occurrence of REM sleep behaviour disorder, and a variety of other parasom-
frequent and prolonged seizures in the face of normal nias including bruxism, rhythmic movement disorder and
interictal intellectual function and EEG; periodic limb movements, must all be distinguished from
epilepsy.
• a preponderance of seizures in public places, especially in
surgeries and hospitals; and Investigation of seizures

• behaviour during an apparently generalised seizure which Epilepsy is a clinical diagnosis, and the use and interpreta-
suggests preservation of awareness, for example resistance tion of investigations must reflect this. Routine blood tests
to attempted eye opening and persistent aversion of gaze should include full blood count, urea and electrolytes, liver
from the examiner. function tests, glucose and calcium. An ECG should always
be performed. An EEG is helpful if there is doubt about the
A history of childhood abuse is common but by no means uni- diagnosis, or a need to clarify the type of epilepsy (generalised
versal. In school age patients careful consideration should be or focal). However, the EEG is insensitive: a single inter-
given to possible bullying and in older patients health events ictal EEG will detect clearly epileptiform abnormalities in
and subsequent health anxiety is of particular importance. only about 30% of patients with epilepsy. Therefore a normal
There has been recent interest in conversational analysis as a EEG does not exclude epilepsy, just as minor non-specific
tool for separating epilepsy and NEAD. Patients with epilepsy abnormalities do not confirm it. Serial recordings, including
will talk in detail about the actual experience of the onset sleep-deprived recordings, increase the diagnostic yield to
of seizure whereas patients with NEAD tend to disclose no about 80%. Interpretation should be influenced by seizure fre-
information about the onset of the seizure but strongly empha- quency, such that a normal EEG in a patient with a seizure
sise the associated disability. Where doubt remains after care- every 3 months has different implications to a normal EEG
ful clinical assessment and standard investigations, the gold in a patient with daily seizures which would be strongly sug-
standard for diagnosis is the observation of attacks during gestive of NEAD. EEG can be supplemented with video
videotelemetry. A normal EEG during or immediately after recording to allow the correlation between clinical symptoms
an apparently generalised seizure provides strong evidence
against epilepsy (Box 13.12).

Syncope is due to temporary interruption of the blood
supply to the brain. It should be noted that it is often

348

Organic disorders CHAPTER 13

and EEG abnormality to be examined (videotelemetry). studies suggest associations with temporal lobe abnormalities.
Twenty-four-hour ambulatory monitoring is sometimes help- The impairment can be progressive although this is not inevita-
ful. Some form of neuroimaging should be performed to ble. Poor seizure control and cumulative effects of medication
exclude tumours and major structural abnormalities. Measure- appear to be risk factors for deterioration. The direct impair-
ment of serum prolactin is of limited value as false positives ments can be compounded by the indirect effects of epilepsy
and negatives occur. Additional cardiac investigations which on scholastic achievement.
may be helpful in selected cases include 24-hour ambulatory
ECG to identify cardiac dysrhythmias, echocardiography to Psychoses
identify structural cardiac abnormalities and tilt table testing
to help confirm the diagnosis of syncope. In population-based studies between 2% and 7% of patients
with epilepsy suffer from psychosis. In describing the psychia-
Treatment of seizures try of epilepsy, symptoms are usually related temporally to
seizure events. In ictal psychoses, i.e. generalised non convu-
The mainstay of management is with antiepileptic drugs. sive or partial complex status the symptoms are those of
A large number are available. The principles of drug treatment the epileptic discharge. Hallucinations and delusions occur
are: but altered consciousness is the core symptom. Epilepsy-
associated psychotic symptoms generally divide into transient
• Use a single drug whenever possible. postictal psychoses and chronic interictal psychoses. The for-
• Increase the dose slowly until either the seizures are mer often present with manic grandiosity, paranoid delusions
and hallucinations. A number of small studies have suggested
controlled or toxicity occurs. that such patients are more likely to have psychic auras, bilat-
• If a single drug does not control seizures without toxicity eral interictal spikes and nocturnal secondarily generalised
seizures than other epilepsy patients. In general, psychotic
then switch initially to another drug used alone. episodes do not start immediately after a seizure but follow a
• Drug level monitoring is generally unnecessary except in the lucid interval of 2–72 hours. In contrast, patients with chronic
interictal psychoses had a higher frequency of perceptual delu-
case of phenytoin, and is sometimes misleading: some sions and auditory hallucinations than patients with postictal
patients do well with drug levels below or above the psychoses. Risk factors include complex partial seizures,
‘therapeutic range’. refractory seizures and longer duration of seizures.
• Consider using two drugs only when monotherapy is
unsuccessful. Antiepileptic drugs may also contribute to the development
• Be aware that the ability to metabolise anticonvulsant of psychotic symptoms, especially newer agents. Vigabatrin, an
medication is different in the young, the elderly, pregnant irreversible inhibitor of GABA transaminase, has been shown
women and patients with chronic disease, particularly to precipitate psychotic and affective symptoms in 3–10% of
hepatic and renal, and be on the lookout for drug patients. This is more likely in patients with significant past
interactions. psychiatric histories.

Approximately 20–30% of patients do not achieve seizure con- Depression and anxiety
trol with drug treatment. In carefully selected cases surgery
can be effective. It is noteworthy that poor psychological out- It is well established that epilepsy is a significant risk factor
comes occasionally accompany good postoperative seizure con- for depressive illness. However, recent data from three
trol and some patients need considerable psychological help in population-based studies has shown that depression is asso-
adjusting to life without seizures. ciated with a four- to seven-fold increased risk for developing
epilepsy. This bi-directional relationship does not imply
Vagal nerve stimulation has been shown to reduce seizure causality but suggests common pathogenic mechanisms shared
frequency in some patients with refractory epilepsy, but prob- by both conditions including: abnormal CNS monoamine
ably no more so than the addition of the newer anticonvulsants activity; atrophy of temporal and frontal lobe structures;
to established therapy. decreased 5HT1A binding in mesial structures, raphe nuclei,
thalamus and cingulate; and disruption of the hypothalamic-
Psychiatric manifestations of seizures pituitary-adrenal axis (Kanner 2006). Depressive symptoms
and their management not only affect onset of epilepsy but are associated with poorer
response to treatment and poorer quality of life.
Studies have found greatly increased rates of psychiatric disor-
der in both men and women with epilepsy when compared Depressive disorders can be typical of their DSM-IV mood
with healthy controls, but not when compared with controls disorder description, can be characterised by their relationship
with a chronic medical condition. to the ictal event or can present as ‘interictal dysphoric disor-
der’. The latter concept was described originally by Kraeplin
Cognitive disorders and then Bleuler, describing a pleomorphic pattern of symp-
toms consisting of prominent irritability intermixed with
Cognitive disorders are commonly associated with epilepsy. euphoria, anxiety, anergia, insomnia and pain. It is said to have
Mild generalised cognitive deficits can be detected within a chronic relapsing remitting course but to respond well to
months of onset and, in children, academic records suggests
these deficits may predate onset. Quantative volumetric MRI

349

Companion to Psychiatric Studies

antidepressants. The treatment of depressive and anxiety Cognitive impairment
disorders follows the normal principles of treatment of anxiety
and depression in the medically unwell. Care needs to be Prevalence studies of cognitive impairment have consistently
taken not to exacerbate the epilepsy, as antidepressant agents reported rates of cognitive dysfunction ranging from 40%
can lower seizure threshold. However, this effect is often to 65%. There are a number of methodological concerns
exaggerated and, in general, under-treatment has caused far about how to define stages of the disease and how to define
more problems than over-treatment. cognitive dysfunction, but more importantly such studies use
predominantly cross-sectional methodologies which may not
Multiple sclerosis be adequate to answer the question – given the conceptual
framework of a primarily degenerative disease process will all
Multiple sclerosis (MS) is a demyelinating disease of the cen- patients develop cognitive impairment eventually?
tral nervous system which is associated with substantial neuro-
psychiatric morbidity particularly cognitive impairment and Impairment, when present, is generally a ‘subcortical
emotional disorders. dementia’ with impaired attention and speed of processing as
the hallmark signs. Executive deficits are common. Deficits
Epidemiology in working, semantic and episodic memory are reported but
procedural and implicit memory functions are generally pre-
The median age of onset is 24 but the condition can occur at served. Neuropsychological tests such as Paced Auditory Serial
any age. Woman are twice as likely as men to be affected. Addition Test (PASAT) appear most sensitive to changes.
Relapsing remitting disease tends to present earlier than At the bedside, tests such as verbal fluency are of most value.
primary progressive. The prevalence of the disorder rises In general terms speed of test completion is usually more
with increasing distance from the equator. Genetic factors impaired than accuracy. MRI correlates of cognitive impairment
influence susceptibility with a family history increasing the show associations with general atrophy but attempts to link spe-
risk by 30- to 50-fold. Epidemiological investigations have cific cognitive deficits with particular grey or white matter
suggested that an exogenous factor, possibly a viral infection, lesions have so far shown conflicting results. There is a paucity
plays a role. of well-designed studies looking at the effects of disease-
modifying agents (i.e. beta interferon) on cognition and little
Aetiology evidence as to the utility of acetylcholinesterase inhibitor drugs.
There is slightly more robust evidence showing the utility of
MS is characterised by multifocal areas of inflammatory treating comorbid depression when present.
demyelinating white matter lesions with glial scar formation
and, increasingly recognised, axonal loss. However, over Psychosis
recent years there has been increasing recognition of exten-
sive grey matter and subpial lesions. These cortical lesions A recent well-conducted population study has challenged the
show different pathology with a notable lack of T cell and B perceived orthodoxy that MS is not associated with increased
cell infiltration, microglia activation and astrogliosis. It has risk of psychosis (Patten et al 2005). The authors report
been suggested that they are a neurodegenerative process. It an increase in rate of psychosis to 2–3% with the highest
primarily affects cingulate, frontal and temporal structures. prevalence in the 15- to 24-year-old range of 4%.
It appears particularly relevant to the neuropsychiatric clini-
cal features of MS. There is a general theoretical shift Mood disorders
towards regarding MS as an inflammatory neurodegenerative
condition. Major depression is common in MS with almost half of
patients experiencing it during the course of their illness.
Clinical features Irritability, frustration and discouragement are often promi-
nent features as well as the more typical neurovegative
The onset of MS commonly includes optic neuritis (unilat- features. Depression has a significant effect on quality of life
eral, and often painful), ascending sensory loss and upper and suicide is a significant cause of mortality. MRI studies
motor neuron or cerebellar disorders. The deficits typically have suggested associations with hyperintense lesions in the
relapse and remit over the course of several weeks but tran- arcuate fasciculus, hypointense lesions in frontal and parietal
sient worsening of function lasting a matter of minutes can lobes and atrophy in anterior dominant temporal lobe. Psycho-
occur in partially demyelinated axons as a result of physiolog- logical active coping strategies seem more protective than
ical changes such as a rise in temperature, e.g. temporary avoidant ones. Recent systematic reviews do not associate
paralysis occurring during a hot shower. Positive symptoms depression with treatment with the interferons. Treatment
such as electric shock-like sensations on flexing the neck studies are notably lacking and treatment probably follows
(L’Hermitte’s phenomena) and trigeminal neuralgia are also general guidance for major depressive disorders. There have
described. been a number of studies of a variety of psychological
interventions. The Cochrane collaboration concluded that a
The initial presentation of MS can be to psychiatrists with number of forms of treatment may be helpful and although
changes in cognition, mood or personality. More commonly definitive recommendations could not be made there was
psychiatrists are involved in the assessment and treatment of reasonable evidence to support cognitive behavioural
neuropsychiatric complications in established cases. interventions.

350

Organic disorders CHAPTER 13

Bipolar disorder occurs at twice the general population normal and functional imaging data are contradictory at the
rate. Pseudobulbar affect, of pathological laughing and crying, current time.
is common and may respond to either SSRIs or dextrometho-
pram in combination with quinine. Euphoria is frequently Management
reported as occurring in 25% of patients, although our own
clinical experience suggests that this figure represents signifi- Management must address the educational, social and family
cant over-reporting with the exception of those patients consequences of the disorder. Dopamine antagonists remain
receiving intravenous steroids. It has been suggested that the mainstay of pharmacological management, with haloperi-
euphoria may be associated with reduction in global grey dol the most widely used. Pimozide has been shown to be
matter volume. superior in one of the few RCTs conducted, but the potential
cardiac side-effects limit its use.

Tic disorders Sydenham’s chorea and PANDAS

These are a type of movement disorder. Tics are sudden, Sydenham’s chorea is a movement disorder characterized by
rapid, repetitive, twitch-like movements. chorea (involuntary, purposeless, widespread, fidgety or danc-
ing movements) following infection with a beta-haemolytic
Gilles de la Tourette syndrome streptococcus which is thought to trigger an autoimmune
response against components of the basal ganglia. It occurs
Definition more commonly in girls, and is sometimes associated with
neuropsychiatric features including emotional lability, person-
This is an idiopathic condition in which multiple tics are ality change and obsessive-compulsive disorder. The term
associated with forced involuntary vocalisations which may ‘PANDAS’ syndrome (paediatric autoimmune neuropsychia-
take the form of obscenities (coprolalia). tric disorders associated with streptococcal infections) has
been used to refer to the spectrum of neuropsychiatric disor-
Clinical features ders occurring after streptococcal infection, associated with
basal ganglia antibodies. It has been suggested that Gilles de
The condition is characterised by a combination of multiple, la Tourette’s syndrome may sometimes occur as a result of a
waxing and waning motor and vocal tics. These vary from similar process. This is an area of active current research: the
simple twitches and grunts to complex stereotypies. Premoni- pathogenic significance of antibodies to the basal ganglia is
tory sensations in body parts that ‘need to tic’ are a common controversial.
feature and complicate the picture, as their temporary sup-
pressibility lends them a voluntary component. Other features Summary
are echolalia and coprophasia, particularly in severe cases. The
syndrome is strongly associated with obsessive–compulsive There is increasing recognition of the overlap between neuro-
disorder, but many claim that it is qualitatively different – logical and psychiatric practice. Many of the patients tradition-
with concern with symmetry, aggressive thoughts, forced ally seen by psychiatrists are increasingly recognised as having
touching and fear of harming self being prominent compared structural brain abnormalities, and many neurological patients
with typical symptom clusters of hygiene and cleanliness. have none (Martin 2002). It will be increasingly important
Depressive symptoms are commonplace, and attention deficit both for neurologists to be able to perform mental-state assess-
hyperactivity disorder has been described, but the issue of ments and for psychiatrists to be competent to perform basic
appropriate comparison groups has led to debate over its neurological assessments and to interpret neurological inves-
relevance. tigations. This is especially important for those psychiatric
disorders traditionally regarded as organic.
Epidemiology
Acknowledgements
The prevalence is around 5 per 10 000 with a 4:1 ratio of
males. The authors would like to thank Dr Rod Duncan, Consultant
Neurologist, Glasgow, for providing information on violence
Aetiology and epilepsy, and Dr Don Collie, Consultant Neuroradiologist,
Edinburgh, for providing the MRI scans.
Genetic studies have suggested a strong hereditary component
but without a specific pattern of inheritance. Recent interest
has concentrated on the role of anti-basal-ganglia antibodies
and streptococcal infections. Similarly the neurobiology
remains elusive, with dysfunctional dopaminergic basal ganglia
circuitry receiving most attention. Structural imaging is usually

351

Companion to Psychiatric Studies

Further reading Lishman, W.A., 1988. Physiogenesis and O’Brien, J., Ames, D., Burns, A., 2000.
psychogenesis in the postconcussional Dementia, second ed. Arnold, London.
Hodges, J.R., 2001. Early-onset dementia: a syndrome. Br. J. Psychiatry 153, 460–469.
multidisciplinary approach, Oxford
University Press, Oxford. Mayou, R., Sharpe, M., Carson, A.J., 2002. ABC
of psychological medicine. BMJ Press/
Lance, J.W., Goadsby, P.J., 1998. Mechanism Tavistock, London.
and management of headache, sixth ed.
Butterworth-Heinemann, Oxford.

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352

Misuse of, and dependence on, alcohol 14
and other drugs

Malcolm Bruce Jonathan Chick

Introduction 19th century. The chief opponent of drunkenness at that time
was the Temperance Movement. Initially it advocated moder-
It is hard to think of any country which does not rely on some ate consumption but later it championed total abstinence.
drug or other to facilitate social relations, mark festivals or Physicians such as Benjamin Rush in the USA and Thomas
enhance religious rituals. In Britain, alcohol has long been the Trotter in Scotland wrote empathically about the medical
most widely used and misused drug, but other forms of drug and psychological consequences of alcohol misuse, and out-
misuse are prevalent and are not new (Geikie 1904). In con- lined the contemporary concept of alcohol addiction.
sidering the consequences of drug use, it is helpful to differen-
tiate between the pharmacology of the drug, the hazards The Temperance Movement’s greatest victory was the 18th
inherent in the route of administration, the dose and fre- Amendment of the US Constitution, which prohibited the
quency of use, and the health and personality of the user. manufacture and sale of alcohol except for therapeutic or sac-
Finally, and perhaps more crucial, is consideration of the ramental purposes. However, as is well known, the Amend-
setting in which the drug is taken, the immediate surround- ment was difficult to enforce and led to gangsterism. It was
ings, the presence of friends, their attitudes and expectations, consequently repealed in 1933. (It is noteworthy mortality
the culture and folklore surrounding the drug as well as the from cirrhosis declined during the years of prohibition.) In
legal sanctions on its use. It is worth remembering that drugs the UK the Temperance Movement never attained the politi-
regarded as hazardous and illegal in one culture or time in his- cal strength it enjoyed in the USA or in some Scandinavian
tory have often been condoned, or even promoted, in another. countries. Nonetheless, by the end of the 19th century it
had become a considerable political force and facilitated the
Historical and cultural aspects of alcohol introduction of control measures which Lloyd George imposed
consumption during the First World War. Drinking habits in Britain have
continued to change dramatically over the last hundred years,
Ethyl alcohol is a natural product of the breakdown of carbo- most often in response to economic and social influences.
hydrates in plants. Its euphoriant and intoxicating properties The cycling between lower and higher consumption as controls
have been known from prehistoric times, and almost all are alternately tightened and relaxed have been evident in
cultures have had experience of its use. Early Egyptian and many countries.
Greek writings made references to alcohol and distinguished
its beneficial effects in moderation from the problem of Prevention of misuse
drunkenness. Throughout the 17th century in Britain drunken-
ness was widespread. In an effort to promote agriculture and General issues
also to obstruct competition from French brandies, positive
incentives were given to the production of cheap gin. This In the past, primary prevention of both drug and alcohol
policy succeeded so completely that by 1736 the consump- misuse focused principally either on controlling availability,
tion of spirits was approximately one gallon a head per annum or on strengthening the resistance of the individual by educa-
(Dillon 2002). Gradually, by means of licensing and taxation, tion and persuasion. However, the actual health and social
consumption was reduced, only to rise again during the costs of a substance have not necessarily been reflected in
the amount of effort invested in controlling its use. Tobacco,

ã 2010, Elsevier Ltd.
DOI: 10.1016/B978-0-7020-3137-3.00014-0

Companion to Psychiatric Studies

which is a more damaging drug in health terms, is still legally approaches are not mutually exclusive. There is considerable
available and advertised in many countries whereas other, scope for local actions such as may be achieved by licensing
arguably less harmful, drugs have been made illegal. practices (Ritson 1995). In some cases the task is to remove
drinking from certain contexts such as drinking and work,
Prevention of alcohol misuse sport such as swimming or driving.

For alcohol-related problems, prevention should be better than Controls of availability
cure. The mean per capita level of alcohol consumption in a
population and the prevalence of heavy drinking are closely Prohibition is an extreme form of control. It proved effective
correlated (r ¼ 0.97) (Rose & Day 1990). Thus a 10% decline in reducing mortality from liver cirrhosis in the USA in the
in consumption should reduce the number of heavy drinkers 1920s, but the public resented it, there was difficulty in
by a similar percentage. While the heaviest drinkers experi- enforcement, loss of tax revenue (which is, for the UK, cur-
ence many more alcohol-related problems than other drinkers, rently over £10 billion per annum), and the growth of crime
their contribution to the total of alcohol-related harm in a in the form of smuggling and illicit production of what were
community is smaller than that arising from the much larger sometimes lethal brews. Most countries now endeavour to
population of moderate drinkers. Consequently focusing a control rather than prohibit availability, an exception being
preventive strategy only on those at highest risk would have some Islamic societies.
less effect on the overall level of harm than could be achieved
with a population-based approach. This is the preventive Major restrictions on permitted hours of sale of alcohol in
paradox (Kreitman 1986). Britain were introduced by the Prime Minister Lloyd George
in 1915 in an effort to ensure that the workforce was suffi-
Prevention works best when a specified effect can be traced ciently sober to meet the demands required by the war effort.
to a cause which is readily amenable to influence. For example, Consumption dropped and remained low for more than
the association between drink-driving and road accidents is a decade. In the UK the enforcement of licensing laws and
clear-cut, and the 1967 legislation which imposed penalties permitted hours of opening is amenable to considerable local
on those driving in the UK with a raised blood alcohol level influence and can be seen as an example of the importance
had an immediate effect in reducing the number of road of local action in influencing the level of alcohol-related harm
fatalities by 15%, although the effect diminished as drivers in each community. Other examples are the designation
began to realise that the risk of detection was low. Introducing of zones where public drinking is banned and restrictions on
widespread targeted breath testing would lead to a further alcohol at sporting events; both have been shown to lead to
decline in alcohol-related accidents. an improvement in public order in the target areas.

Primary prevention Most countries impose a minimum age at which young peo-
ple are allowed to drink in public. In the USA and Canada
Primary prevention is aimed at reducing the prevalence of states or provinces which lowered the permitted age experi-
hazardous drinking, or in some cases reducing the hazards enced a rise in motor accidents and drink-driving offences
associated with drinking (for example by separating drink- amongst the young; the reverse took place in the USA in more
ing behaviour from driving) in the population. It relies on recent times following raising the permitted age for purchasing
three strategies: control of availability, education about sensi- alcohol to 21 (Babor et al 2003).
ble use and providing alternative pursuits (Table 14.1). These
While advertisers argue that they are simply concerned
with promoting or sustaining brand loyalty among drinkers,
research suggests that they also stimulate overall consumption.
The effects of advertising on the young are a particular
concern, and most counties have controls on advertising that
specifically seeks to attract youngsters.

Table 14.1 Primary prevention strategies

Strategy Method/target Aim Price

Controls Fiscal To reduce availability Over the past three hundred years, alcohol consumption in
Education Legislative Britain has shown marked fluctuations. Every time the price
of alcohol has fallen relative to disposable income, as it has
Provision of The general public To foster moderate done almost continuously since 1945, consumption has risen.
alternatives Young people and at-risk groups informed drinking and A 33% reduction in price resulting from taxation changes in
Key professionals; politicians promote awareness of Finland occurred early in 2004 coinciding with a reduction of
hazards limitations on importing alcohol. These changes were accom-
panied by an increase in alcohol-related mortality of 16%
Promoting alternative leisure To promote sensible among men and 31% among women; 82% of the increase was
activities, facilitating sensible drinking due to chronic causes, particularly liver diseases (Herttua
drinking, for instance with et al 2008a, 2008b). Meta-analysis of such data from many
meals, ensuring that inexpensive countries has found a clear inverse relationship between price
non- or low-alcohol beverages change and consumption (Wagenaar et al 2009). However
are readily available the health lobby is but one competing interest group in the

354

Misuse of, and dependence on, alcohol and other drugs CHAPTER 14

debate about controlling the availability and consumption of Box 14.1
alcohol. Others argue in favour of continuing growth in the
alcohol market. Current strategies in drug education

Education • Providing information (whether ‘scare’ or ‘balanced’)
• Seeking to remedy supposed deficits of moral values or living
Education needs to take into account the medium, the audi-
ence and the message. Target groups include the general public skills
or specific segments of the population such as schoolchildren, • Promoting decision-making skills in the context of anti-drug
the elderly or ethnic minorities, or particular high-risk groups
such as pregnant women, drivers or those in hazardous occupa- norms
tions. In the past, education for young people has often been • Providing alternatives to drug use through youth and community
woolly in focus and content, but even with carefully designed
and evaluated campaigns the lasting effect may be disappoint- participation
ingly small (Babor et al 2003). In the UK there is evidence that • Secondary prevention by harm minimisation
children know about alcohol from the age of 6 and that their • Peer-led approaches involving youth groups with facilitators
attitudes towards drinking become more positive between 11
and 14, as the peer group begins to exert more influence than Information-type programmes may slow the transition to
parents or teachers do. Information about the alcohol content heavier or hazardous use but do not stop experimentation.
of various alcoholic beverages, sensible drinking practices and A moral or living-skills approach has not been supported by
safe limits for consumption should be known by every young outcome studies. Promoting decision-making skills in the con-
person. It is easier to improve knowledge than to influence text of antidrug norms may reduce experimentation but may
attitudes and behaviour. also produce a polarised community, and more hazardous drug
use in those that use. Providing alternatives to drug use
Education can inform the public about alcohol problems as through youth and community participation also appears to
well as giving advice about where to seek help. Campaigns of be ineffective, but if linked to broader community initiatives,
this kind have been found not to influence drinking habits may have some value. Secondary prevention in the form of
but can increase uptake of treatment. Media programmes harm minimisation for those already using has shown sub-
aimed at ensuring that health issues are given a fair hearing stantial benefits. These are elaborated further on page 370,
in the public debate in combination with increased policing 371. Peer-led group approaches with facilitators has been
of road traffic laws can reduce drink-driving and other found to be effective, but can also have paradoxical effects
alcohol-related problems (Holder 2006). and lead to increased drug use when the selected peers use
the most drugs (Valente et al 2007).
Provision of alternatives
Prevention is not limited to stopping initial drug use but
Many communities are heavily dependent on drinking places may include detecting use at an earlier stage. This involves
as a principal source of entertainment. In the UK the ‘pub’ targeting parents and others to educate them about drugs
has a significant social role in its neighbourhood. Planners and solvents so that the thresholds for detection in their
should ensure that other leisure pursuits are encouraged and children are lowered (Health Publications Unit 2006). Drug
that other non-alcoholic beverages are also readily available. testing in schools has not been shown to help in reducing drug
The promotion of low-alcohol beers, especially if taxed to use (Yamaguchi et al 2003). The introduction of mandatory
advantage, has proved useful in some countries. drug testing in British prisons in 1995 may be having
unexpected results, such as the switching from cannabis to
Secondary prevention injectable shorter-acting drugs in order to avoid detection
(Boys et al 2002). Initiatives to achieve detection and early
Secondary prevention aims to prevent the further progression intervention in the workplace have also been made, not least
of a condition by identifying and treating cases at an early because of concerns about health and safety in the work place
stage. Symptom-free excessive drinkers see little reason to (Health & Safety Executive 2004).
change their habits. However, a primary-care worker, con-
sulted perhaps for some other reason, can take the opportunity Epidemiology
to educate and persuade an excessive drinker to cut down.
Detection and brief, early intervention for alcohol problems Epidemiology of drinking and alcohol-
are discussed in the section on Management. related harm

Prevention of misuse of drugs other The harm resulting from alcohol depends on the age, gender,
than alcohol setting, culture, genetic make-up and pattern of consumption
of the user, as well as on the amount of ethanol consumed.
Reducing the supply of drugs through customs and enforce- Nonetheless, guidelines for risk and alcohol consumption in
ment agencies is outwith the scope of this chapter. However, most countries, apart from those which deal with a specific
reducing demand through health promotion does justify situation such as driving, are based on amount. Amount is
consideration. Current strategies for drug education can be quantified in the UK by the unit system. One unit contains
divided into categories (Box 14.1).

355

Companion to Psychiatric Studies

8 g ethanol – roughly equivalent to the amount of alcohol in concentrated into fewer days of the week. Among males the
half a pint of 3.5% alcohol by volume beer, a small glass of highest weekly consumption is found in the North of England.
wine (125 ml) or a single pub measure of spirits. Different In Northern Ireland the proportion of abstainers is much
countries have different sizes for their standard drink, and so higher than elsewhere in the UK. In all parts of the UK there
in Spain and Australia for example their ‘drink’ contains is a close relationship between alcohol-related harm and social
10 g, and in the USA 13 g. deprivation.

The prevalence of alcohol-related problems in a population Ethnic and religious minorities
is linked to the alcohol consumption per person. There is a
close correlation between national consumption and mortality Islam, Hinduism, Sikhism, Seventh Day Adventism and the
from cirrhosis. Within countries, fluctuations in consumption Baptist Church oppose or prohibit consumption of alcohol.
over time are correlated with fluctuations in cirrhosis mortal- Nevertheless, heavy drinkers are to be found among people from
ity (Skog 1980). Changes which increase consumption, such India and Pakistan whether living in the UK or in South Asia.
as price, enhanced availability, more advertising or sales outlets
or greater social permissiveness, also contribute to rising Occupation
rates of alcohol problems. Of course, overall consumption is
not the only influence: different styles of drinking are linked There are various reasons for the association of heavy drinking
to different problems. In cultures where a bout pattern of with certain occupations: availability of alcohol at work (e.g.
drinking predominates, there is a higher level of social harm the licensed trade); social expectations (e.g. the business
than in areas where consumption is less episodic. lunch); separation from normal social and sexual relation-
ships (e.g. seamen, servicemen). Men in the drinks industry
Influences on consumption have the highest average per person consumption, while the
construction industry has the highest proportion of men who
Government revenue statistics are the usual source of infor- drink ‘heavily’ (over 50 units per week). Freedom from super-
mation about overall national alcohol consumption. The lowest vision, as well as high incomes, probably contributes to
point in per capita consumption of all forms of alcohol doctors, lawyers and senior executives having an increased risk
for three centuries occurred in the 1930s. In common with of being heavy consumers.
many other countries, consumption of alcohol in the UK rose
steadily from 1945 to 1980. Since then consumption has The prevalence of alcohol-related disorders
increased only slightly in many countries, with the UK being
an exception where drinking has increased particularly among For the year 2000, alcohol was estimated to be the fourth
teenagers and young women. In southern Europe alcohol con- most important worldwide cause of disability-adjusted life
sumption has declined in the past 40 years, due to a dramatic years, the first three causes being unsafe sex, blood pressure
fall in wine consumption only partially offset by an increased and tobacco (Ezzati et al 2002). Attempts to estimate the
popularity of beer and spirits. Death rates from cirrhosis of prevalence of ‘alcoholism’ are misleading, and epidemiologists
the liver fell in France and Italy over that period (Gual & now study the elements of this conglomerate concept, for
Colom 1997). In 1988 there were severe restrictions of official example breaking it down into identifiable components such
production and sales in Russia, and consumption declined, but as alcohol dependence and the adverse health and social con-
with the advent of free-market competition the 1990s saw a sequences of drinking. Data on the prevalence of physical
rise in alcohol use and alcohol-related problems. In the UK, damage from alcohol are available in mortality records (e.g.
and particularly Scotland, cirrhosis mortality has risen steeply Fig. 14.1) and hospital admissions statistics, both of which
in recent years. The rise in UK drinking is associated with have risen considerably in the UK in the past decade (Office
increased advertising and marketing, increasing numbers of of National Statistics 2007, 2009). Mortality from cirrhosis
outlets, extension of licensing hours and falling relative price.
20
Drinking by women Age-standardised rates per 100000 population
199118
There has been a great increase in consumption of alcohol by 1992
women since the middle of the 20th century. Changes in the 199316
woman’s role, with the result that she enters more male envir- 1994
onments and has more income, have contributed. Advertising 199514
directed specifically at women may have played a part too. 1996
In 1998, 24% of young women were drinking more than recom- 199712
mended limits, a rise from 18% in 1995. Although all age groups 1998
for women have shown a rise in excess drinking, younger age 199910
groups have shown the largest (Scottish Executive 2002). 2000
20018
Regional differences within the United Kingdom 2002
20036
Surveys show that, although the mean consumption and the 2004
proportion of drinkers who are heavy drinkers are similar in 20054
all parts of the UK, in Scotland drinking seems to be 2006
2 Males Females

0

Fig. 14.1 Alcohol-related death rates (alcohol specified) by gender,
United Kingdom, 1991–2006. Office of National Statistics (2007)

356

Misuse of, and dependence on, alcohol and other drugs CHAPTER 14

used to be greatest in the grape-growing countries of central for men and three units a day for women did not carry a signif-
and southern Europe, but an increase in cirrhosis deaths in icant health risk, but that intake above these levels was not
the UK since 1945, which is accounted for by an increase in advised. The proportion exceeding these daily benchmarks in
alcoholic cirrhosis, has meant that the UK, and particularly England was 41% of men and 34% of women in 2007 (Office
Scotland, has now overtaken many other European countries of National Statistics 2008).
(Leon & McCambridge 2006). During the past two decades
the USA and Canada also saw a decrease in deaths from It has been observed that those who report drinking
alcohol–related liver disease. 1–3 units of alcohol/day have a lower death rate than total
abstainers. Current evidence suggests that low to moderate
The general population survey permits a prevalence esti- consumption of alcohol may protect middle-aged men and
mate that is not subject to the vagaries of hospital admission post-menopausal women from developing coronary heart dis-
and referral policies or the defining processes of social agen- ease (Baglietto et al 2006; Connor 2006). However, in younger
cies. However, the door-to-door interviewer has difficulty in people, any benefits to mortality from cardiovascular disease
finding the heavy drinker at home, and when found at home are countered by the relationship between alcohol use and
he or she tends to under-report consumption and problems. death by trauma and suicide.
Estimates are very sensitive to alterations in the definition
of a case: for example, the number and severity of alcohol- Rehm et al (2008) determined the lifetime risk for chronic
related symptoms required to reach the criterion for inclusion, disease and for acute injury separately. Relative risk data for
and whether or not past as well as present symptoms are different levels of average consumption of alcohol were com-
counted. The rate of alcohol dependence in the UK is said to bined with age, sex and disease-specific risks of dying from
be 2% in women and 6% in men (Mason & Wilkinson 1996; an alcohol-attributable chronic disease. For injury, combina-
Department of Health 2005). tions of the number of drinks per occasion and frequency of
drinking occasions were combined to model lifetime risk of
Level of consumption and adverse consequences death for different drinking pattern scenarios. A lifetime risk
of injury-related death of 1 in 100 is reached for consumption
In order to estimate the risk to health of drinking at particular levels of about three drinks daily per week for women, and
levels we need to study community samples. It has been found three drinks five times a week for men. For chronic disease-
in France that the risk of cirrhosis increases logarithmically related death, lifetime risk increases by about 10% with each
with increasing consumption, starting at 6 units per day in 10-g (one drink) increase in daily average alcohol consumption,
women and 8 units per day in men. At 12 units per day the although risks are higher for women than men, particularly
risk in men is increased 14-fold. The risk for breast cancer at higher average consumption levels. Lifetime risks for
begins to increase at 2 units per day (e.g. Li et al 2009). injury and chronic disease combine to give overall risk of
Haemorrhagic and embolic stroke begins to increase above alcohol-attributable mortality. For a lifetime risk standard of
42 units per week (Dyer et al 1980). These findings are from 1 in 100 both men and women should not exceed a volume
longitudinal studies, or from case–control studies, and depend of two drinks a day for chronic disease mortality, and for
of course on the accuracy of what people admit to drinking. occasional drinking three or four drinks is tolerable.

One way of indicating the risk associated with consumption The risk of psychological and social harm also rises if a per-
is shown in Table 14.2. The UK Department of Health (1995) son takes five drinks or more per occasion (Room et al 1995).
considered that regular consumption of up to four units a day Many of the social costs associated with drinking impinge
on third parties such as the drinker’s partner, pedestrians,
Table 14.2 Alcohol consumption and risk bystanders or workmates. The Chief Medical Officer of
England in his Annual Report in 2009 made an analogy with
Risk Consumption passive smoking (Donaldson 2009).

Low risk – intake unlikely to be <21 units/week for men Patterns of illegal drug use and their
associated with the development of <14 units/week for women related problems
alcohol-related harm if taken over the
7 days The majority of drug users are not known and, as the beha-
viour is illegal, they wish it to remain hidden; anonymity and
Hazardous drinking – intake likely to 22–50 units/week for men confidentiality are essential in trying to access this population.
increase the risk of developing alcohol- 15–35 units/week for women Consequently assessing the pattern of drug use in Britain is
related harm (physical and/or like putting together a jigsaw with most of the pieces missing.
psychological) The British Crime Survey (BCS) now provides the best national
longitudinal estimate of drug misuse. It was carried out
Harmful drinking – a pattern of drinking >50 units/week for men every 2 years from 1992 and annually from 2000 (Hoare &
associated with the development of >35 units/week for women Flatley 2008). It is estimated that of the adult population,
alcohol-related harm 6% (2.8 million people) have tried illegal drugs and in any
one year at least 3% will take an illegal drug (Drugscope
In 1995 the Department of Health revised the previous low-risk drinking limits of 21 2002). In most cases the drug is cannabis, and most use it only
units for men and 14 for women per week to daily benchmarks of 3–4 units for men occasionally. Data from the BCS are shown in Table 14.3.
and 2–3 units for women and placed greater emphasis on pattern of drinking than
previously

357

Companion to Psychiatric Studies

Table 14.3 Population averages of drug use

(a) Prevalence for 16- to 59-year-olds, 1994–2008 (%)

Year of survey 1994 1996 1998 2000 2002 2004 2006 2008

Lifetime 28 29 32 34 34 36 35 36
9
Within the last year 10 10 11 11 12 12 11 5

Within the last month 6 6 6 6 7 7 6 2008

(b) Proportion of young adults who have used drugs for every 2 years from 1998 (%)

Age range 16–19 years 25–29 years

Year of survey 1998 2000 2002 2004 2006 2008 1998 2000 2002 2004 2006

Lifetime 49 42 – – – 36 45 50 – – – 51

Last year 31 27 29 28 25 21 19 20 18 21 19 16

Last month 22 15 – – – 12 11 12 – – – 9

(c) Proportion of 16–59 year olds who have used various drugs in the last year, for every 2 years from 1996 (%)

Year of survey 1996 1998 2000 2002 2004 2006 2008

Cannabis 9 10 11 11 11 9 7

Amphetamines 3 3 2 1.5 1.5 1 1

MDMA 2 1.5 2 2 2 2 1.5

LSD 1 1 1 <1 <1 <1 <1

Cocaine 0.5 1 2 2 3 3 2

Heroin <1 <1 <1 <1 <1 <1 <1

Source: Hoare & Flatley 2008.

The current trend (in adults above 15 years old) is that the longitudinal studies across Europe have shown similarities in
prevalence of drug use has been dropping since 2004. For that illicit drug use is dominated by use of marijuana or hash-
other drugs such as heroin and MDMA (‘Ecstasy’) use remains ish. Frequent use is mainly reported from countries in the cen-
unchanged. Cannabis, amphetamine and LSD use is falling, tral and western parts of Europe, where more than one-third
and cocaine use is rising. Other figures show a female:male of the students have used it. The high prevalence countries
sex ratio of 1:1.4 for lifetime use of any drug, increasing to include the Czech Republic, France, Ireland, Switzerland and
1:2.3 for use within the last month. Drug use does not vary the United Kingdom. However, significant variation also
by education, social class, employment or income, except for occurs and tranquillisers or sedatives can be used both as a
one drug, namely heroin. Heroin is six times more prevalent legally prescribed medicine and as an illicit drug. The use of
in the more socially deprived groups. such substances without prescription is most common in
Poland (17%) followed by Lithuania (14%), France and the
The longest-running longitudinal study of the knowledge Czech Republic (11–13%). The lowest prevalence rates are
and experience of drugs amongst young people (aged 14 and found in Austria, Bulgaria, Germany, Ireland, Ukraine and
15 years old) has run since 1969 in one English town. Over this the United Kingdom (2% each) (Hibell et al 2004).
period, the proportion of people who knew someone taking
drugs increased from 15% to 58% (peak 65% in 1994), and Heroin use is fairly stable across Europe, with a typical
the proportion who had been offered drugs increased from lifetime risk of around 2% and a male to female ratio of 2:1
5% to 48%. The major change occurred between 1989 and (Hartnoll 1994). Regular users of drugs may subsequently
1994. Stimulants were more commonly mentioned than opi- develop problems related to their drug use and may then
ates (Wright & Pearl 2000). More recent biannual surveys have present to the Criminal Justice System, the Health Service
been done in Scottish Schools since 1998 (SALSUS 2007). or other caring agencies outside the Health Service. National
These surveys show a plateau until 2002 and by 2006 a halving Statistics of numbers of drug users in contact with agencies
of drug use in the last month in 15 year olds from 24% to 13% are available in Scotland (Drug Misuse Statistics Scotland
and in 13 year olds from 8% to 4%. Cross-sectional and 2008). In 2007/08, 12 562 ‘new’ individuals were reported

358

Misuse of, and dependence on, alcohol and other drugs CHAPTER 14

to the Scottish Drugs Misuse database. This corresponds to a 1996 and 2000 to an average of 129 per year between 2003
rate of 259 per 100 000 of the population. Of those reporting and 2007 (Drug Misuse Statistics Scotland 2008).
illicit drug use, 69% used heroin. Over half (56%) of those
under the age of 25 reporting illicit drug use reported using Natural history of problem drinking
heroin. Twenty-nine percent reported that they had injected
in the month prior to seeking treatment. Forty-four per cent The problem drinker is not an individual irredeemably con-
reported that they had never injected. Nineteen percent of demned to addiction; many people move into and out of prob-
current injectors reported that they had shared needles/syrin- lem drinking. Surveys record low rates of drinking problems
ges in the previous month. Of current injectors, 68% reported after age 50. One-half to one-third of respondents in several
that they had been tested for hepatitis B, 69% for hepatitis C large USA surveys who reported a given ‘problem’ no longer
and 66% for HIV prior to seeking drug treatment. reported that problem when re-interviewed 4 years later.
Though some of these had developed a different alcohol-
Criminal statistics include a variety of data on drugs, includ- related problem instead, others had stopped or reduced their
ing the quantities, number of seizures by customs and by drinking. Positive changes in social circumstances such as job
police as well as a record of the number of offences against and personal relationships are important in the history of these
the 1971 Misuse of Drugs Act. Cannabis remains the most recovered individuals (see p. 374, 375). In a Swedish general
common drug seized making up 74% of cases in 2007. population cohort, re-interviewed after a 15-year interval,
Whereas overall drug seizures were falling until 2000, there 41% of the 71 alcoholics identified originally and still alive
has been a 85% increase since 2004, associated with cannabis were completely free of drinking problems (Ojesjo¨ 1981). A
warnings following the temporary reclassification of cannabis similar proportion (45%) of 120 problem drinkers from the
from B to C (reversed in January 2009). In Scotland however Boston inner-city sample (Vaillant 1995) followed over 20
(where a cannabis warning was not an option for the police) years were no longer in difficulties. However, 10% had died
cannabis seizures fell by 20%. Seizures of class A drugs and 40% continued to have drinking problems. At conscription
(heroin, cocaine, etc.) have continued to increase by 10% since to the Swedish armed forces, men who were drinking over 30
2005. The purity of drugs for the end user remains fairly units per week had three and a half times the expected death
stable, with amphetamines at around 10%, heroin 45% and rate in the following 15 years (Andreasson et al 1988).
cocaine at 40% and crack cocaine 50%. Typical retail prices
of drugs on the illicit market have tended to be stable since Natural history of drug taking
the early 1990s, suggesting that the supply and demand match
is relatively constant (Home Office Statistical Bulletin 2008). The vast majority of non-regular drug users do not become reg-
ular users. Non-regular users tend to use drugs to keep in with
Drug-related deaths continue to rise across the UK. Opiates their friends and to ‘act hard’. It is only when they begin to
were one of the most common groups associated with drug- use drugs to forget about problems, or to avoid boredom or
related deaths. In Scotland more than 23 heroin users were to get a ‘good feeling’ that they risk becoming regular users
killed by necrotising fasciitis in 2001. Among intravenous drug (Fast Forward Positive Lifestyles 1996). The natural history
users (IVDU) in the UK, HIV infection has remained low and tends to vary with culture, social setting, drug and route of
stable (at between 1% and 2%), but the transmission of hepa- use. For heroin, there is a tendency to move from smoking
titis C and B has become a major problem, with respective to injection. However the majority of smokers never moved
prevalence rates of approximately 30% and 5%. In Scotland to regular injecting, despite often using high doses for many
in 2007 there were 455 drug-related deaths, an increase from years (Gossop et al 2004). In a 22-year follow-up study of her-
317 in 2003 (deaths per year for the period: 1996 to 2000 was oin addicts from a London clinic, the mortality rate was 2%
260: 2003 to 2007 was 377). Men accounted for 86% of the annually, an excess mortality ratio of 12. No sex differences
deaths. Most deaths were in persons aged less than 45, with in mortality were demonstrated, but the excess mortality
20% in those aged under 25. Of the 94 cases aged under 25 years, was concentrated at younger ages. No prediction of survival
66% (62 cases) were attributed to ‘drug abuse’, 12% (11 cases) could be made on the length of heroin use or age at intake into
were accidental poisonings, 19% (18 cases) were undetermined the study (Oppenheimer et al 1994). In those that survived,
and 3% (3 cases) were intentional self-poisonings. The number two-thirds were not using opiates and had not transferred their
of deaths per year for the given period involving known or sus- dependence onto other substances, such as alcohol, but there
pected drug abusers is now at 246 for the years 2003 to 2007, was a high incidence of smoking.
an increase from 189 for the years 1996 to 2000. Deaths attrib-
uted to accidental poisoning have increased by 10% for the The natural history of cocaine use remains uncertain.
years 2003 to 2007. In 2007 heroin/morphine was recorded in A longitudinal study in Canada of 100 adult users in the com-
289 (64%), alcohol was recorded in 157 (35%), methadone munity in 1990, in which 54 were re-interviewed 1 year later,
was recorded in 114 (25%) and diazepam was recorded in found that the fear of adverse health, social and financial
79 (17%) of the deaths. The number of deaths involving heroin consequences cautioned users. Most had quit or reduced their
increased from an average of 128 per year between 1996 and use without professional help, suggesting that cocaine use is of
2000 to an average of 229 per year for 2003 and 2007. For a self-limiting phenomenon of relatively short duration as long
deaths involving cocaine, the number rose from an average of as dependence is not established (P G Erickson, unpublished
6 per year between1996 and 2000 to an average of 38 per year work 1993).
between 2003 and 2007. The number of deaths involving
alcohol increased from an average of 91 per year between

359

Companion to Psychiatric Studies

Definitions of dependence on phenomena. In the case of an initial psychiatric condition, this
psychoactive substances may have been precipitated in a vulnerable individual by drug
misuse, but may also reflect common risk factors between
The term ‘alcoholism’ still has currency. Though imprecise, psychiatric illness and substance misuse. Some suggest a pref-
the term carries the implication that the drinker is dependent erential use of particular drugs for ‘symptomatic relief’, others
and has incurred harm to himself or others. The ICD-10 that a sense of control is exerted by the use of drugs in some
categorises the mental and behavioural disorders due to psy- people who have psychotic phenomena.
choactive substance use by drug types. Within each drug
category, there is then the possibility of a number of clinical Drug-induced psychiatric states, their clinical relevance and
conditions (where ‘X’ refers to the drug type). The clinical their treatment has been reviewed by Schuckit (2006).
condition F1x.2 dependence syndrome has diagnostic guide-
lines based on the Edwards & Gross paper on the alcohol Comorbid mental disorders
dependence syndrome (1976); see Box 14.2.
Schizophrenia
A number of issues have been identified by the work groups
planning the ICD-11. Issues such as: do the same set of In schizophrenia, complications arising from comorbidity
criteria apply for all substances, for all age groups, for users include increased rates of violence, suicide, non-compliance
from all cultures?; do abuse and dependence represent one with treatment, earlier psychotic breakdown, exacerbation
spectrum?; should there be a mild, moderate or severe sub- of psychotic symptoms, relative neuroleptic refractoriness,
type, using number of criteria as a diagnostic approach?; might increased rates of hospitalisation, tardive dyskinesia, home-
certain risk factors, such as family history or a biomarker, be lessness and overall poor prognosis (Smith & Hucker 1994).
used to determine the certainty of a diagnosis?; and should However, if the substance misuse problem is dealt with,
there be a requirement for either tolerance or withdrawal, in the overall prognosis is better than for poor-prognosis schizo-
the dependence syndromes? (Saunders & Schuckit 2006). phrenia. Substance misuse is the most prevalent comorbid
condition associated with schizophrenia.
Comorbidity
In most cases, substance misuse occurs before the symptoms
Comorbidity has implications for aetiology, diagnosis, manage- of schizophrenia. The first psychotic episode may have an
ment and prognosis. For the purposes of this chapter, the term earlier onset, be more abrupt and with less negative symptoms
comorbidity (rather than dual diagnosis) will be used when of schizophrenia than in those who do not misuse substances.
one diagnosis is psychoactive substance use and the second a Typical drugs of abuse are cannabis and amphetamines, but
mental and behavioural disorder. Where 12% of the general many of the American studies have reported high rates of
population have been found to have a psychiatric diagnosis, cocaine use. An Australian study of self-reported substance
in those with alcohol dependence the rate of comorbidity rises misuse in patients with schizophrenia found that 40% of
to 30%, and to 45% in those with drug dependence (Farrell patients used cannabis and 8% used amphetamines, with 20%
et al 2001). using more than one substance. Despite associating their sub-
stance misuse with the initiation or exacerbation of their
In cases of comorbidity which condition occurred first? schizophrenic illness they continued to misuse. The continued
In the case of an initial substance misuse problem, intoxica- use in 80% of cases was because the drugs were perceived as
tion, withdrawal or chronic effects with or without continued relieving dysphoria or anxiety or enhancing social interaction
drug use can lead to psychiatric complications and long-term within their cultural subgroup. This may also contribute to
‘comorbidity’. However, drug-induced psychiatric states are the association between the denial of the diagnosis of schizo-
not true comorbidity and should rather be seen as secondary phrenia among substance-misusing patients and resistance to
follow-up attempts. Patients preferred activating drugs in the
Box 14.2 form of amphetamine, cannabis, hallucinogens or cocaine as
they were felt to relieve dysphoria and the negative symptoms
ICD-10 diagnostic guidelines for dependence syndrome of schizophrenia, even at the price of exacerbating positive
symptoms (Baigent et al 1995).
• A strong desire or sense of compulsion to take the substance
• Difficulties in controlling substance-taking behaviour in terms Relapse of schizophrenia is also associated with substance
misuse. In one study of compulsory admissions for ‘dangerous-
of its onset, termination or level of use ness’ in a mixed diagnostic group, patients with a positive
• A physiological withdrawal state when the substance use has urine result for drugs recovered more quickly over a 5-day
period than those without. The exception was when patients
ceased or been reduced had a history of personality disorder in addition to their severe
• Evidence of tolerance mental illness (Sanguineti & Samuel 1993). Others have
• Progressive neglect of alternative pleasures or interests reported higher readmission rates for abuse rather than for
• Persistence with substance use despite clear evidence of overtly dependence syndrome. The ‘natural history’ of comorbidity
in schizophrenia shows that, over a 7-year follow-up period
harmful consequences in 29 subjects, of those that abused substances, 46% still
continued to abuse substances at follow-up. In those that had
a dependence syndrome, 69% continued to abuse substances

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Misuse of, and dependence on, alcohol and other drugs CHAPTER 14

at follow-up. This suggests a chronic relapsing condition Neurotic and stress-related disorders
(Bartels et al 1995).
Alcohol disorders are associated with an increased prevalence
A study of the effects of substance misuse on treatment of neurotic and stress-related disorders. There are fewer
response in first episode schizophrenic patients found that data on the links with use of illicit substances however. One
higher rates of hallucinations, delusions and depressive symp- American study compared initial-onset anxiety disorder with
toms were associated with continued substance misuse, mostly initial-onset substance misuse disorder and looked for
cannabis (Harrison et al 2008). A review of pharmacotherapy substance-specific and diagnosis-specific interactions. They
suggested superior efficacy for second generation antipsy- found little support for the self-medication hypothesis but
chotic agents (aripiprazole, clozapine, olanzapine, quetiapine, did find an increased risk of opiate misuse in those with an ini-
risperidone) for improvement of distinct psychopathological tial diagnosis of post-traumatic stress disorder. Their strongest
symptoms, reduced craving and greater reduction of sub- finding was for an avoidance of stimulant drugs in those with a
stance use compared with orally administered conventional primary diagnosis of anxiety disorder. This was not found in
antipsychotics (Wobrock & Soyka 2008). those with a primary diagnosis of substance misuse disorder
(Goldenberg et al 1995). Although the use of psychotropic
Service delivery to patients with comorbidity has been medication for mental illness is encouraged, experts disagree
reviewed by Drake and colleagues (1996 and 2008). In their as to whether it is necessary to wait for abstinence before
earlier paper they identified nine key principles of treatment beginning pharmacotherapy (Watkins et al 2005).
for this group: assertiveness, close monitoring, integration,
comprehensiveness, stable living environment, flexibility in Obsessive–compulsive disorder
specialisation, stages of treatment, longitudinal perspective
and optimism. A study which selected patients from a substance misuse
setting found a rate four times that of the general population
Johnson (1997) in her review of the case for specialist (Fals-Stewart & Angarano 1994.) Accurate diagnosis of OCD
services outlined the need for integration. Psychiatric staff within substance misuse patients has been shown to be impor-
often lack training, expertise and confidence in the treatment tant (Fals-Stewart & Schafer 1992). An outcome study at
of substance misuse disorder, and only see these patients when 12-month follow-up found that patients with comorbidity
they are in crisis, i.e. when intoxicated or in withdrawal states. who received treatment for both their OCD and their sub-
This situation is perpetuated by the exclusion of patients with stance misuse stayed in treatment longer, showed greater
substance misuse disorder from some specialist psychiatric reduction in OCD symptom severity and higher overall absti-
units. As a result, staff do not gain experience in the man- nence. There have been no recent treatment outcome studies
agement of substance misusers who are not in crisis. Staff in this group.
working in substance misuse services have the converse prob-
lem with their experience of psychiatric illness. Substance Post-traumatic stress disorder
misuse treatment may be confrontational in a way that might
exacerbate schizophrenia. In the USA, dedicated teams for The course of symptoms in post-traumatic stress disorder
patients with comorbidity have been shown to decrease hospi- (PTSD) begins with hyperarousal, progresses to avoidance
talisation and improve outcome. However, Johnson argues behaviour and peaks with intrusive re-experiencing of the
that with the difference in training of staff in substance misuse trauma. Substance misuse tends to parallel the development
in the UK, such units may not be necessary. Options put of the PTSD supporting the hypothesis that substance misuse
forward are for increased training of respective staff in both in PTSD is a form of self-medication. In addition, there seems
services. In Scotland Government Policy has recommended to be a selective use of sedatives, primarily alcohol, cannabis,
this (Healthcare Policy and Strategy Directorate 2007). heroin and benzodiazepines, which would depress the hyper-
arousal and induce ‘numbing’ on exposure to stimuli specific
Mood disorders for the PTSD and also suppress or ‘forget’ re-experiences.
It has also been found that these patients avoid stimulants
Mood disorders are also associated with a four-fold increased such as cocaine and amphetamines (Bremner et al 1996).
risk of subsequent substance misuse if the mood dis- A review of evidence on effective treatments suggests that
order developed before the age of 20 (Burke et al 1994). the currently best tested psychological treatment (with consis-
The largest study of patients with bipolar disorder (BPD) tent positive findings in 16 studies including randomized
included 188 cases with a comorbidity rate of 35% (Feirnnan & controlled trials and multisite studies) is a present-focused
Dunner 1996). They analysed the data comparing three model that offers 25 topics to teach coping skills for PTSD
groups: bipolar affective disorder only; bipolar affective dis- with substance misuse in four domains: cognitive, beha-
order with late onset substance misuse; and initial substance vioural, interpersonal and case management. It has a variety
misuse disorder with later onset of bipolar affective disorder. of dissemination materials including a website (http://www.
The most common drugs abused by this group, in more than seekingsafety.org) and training videos (Schafer & Najavits 2007).
50% of cases, were stimulants, typically cocaine or amphet-
amine. Those who demonstrated mood changes rapidly over Eating disorders
a period of days or hours were patients with an initial diag-
nosis of substance misuse. Randomized, placebo-controlled An extensive review of the literature on eating disorders and
studies of BPD comorbid patients treated with carbamazepine, substance misuse has being carried out by Holderness and col-
lithium and valproate support the use of these agents (Vornik & leagues (1994). They present the three main theories of the
Brown 2006). association between substance misuse and eating disorders:

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eating disorders are a form of addiction; substance misuse is a Aetiology
form of self-medication; or the two disorders have a common
aetiology such as dysfunctional families. In all studies, bulimia Aetiology of alcohol dependence and
is found to be more strongly associated with substance misuse misuse
than is anorexia. The typical prevalence of substance misuse
in bulimic patients is 20%. The drugs misused were, in des- Availability of alcohol is a powerful determinant of level of
cending order, cannabis, amphetamine, benzodiazepines and consumption, and culture and tradition are potent influences
then other drugs. In clinical samples, subgroups of bulimics on the pattern and context, but many other factors play a
have been postulated with a ‘multi-impulsive’ disorder. These part in determining the individual development of harmful
finding have been confirmed in a community sample (Piran & drinking and dependence. For some problem drinkers the
Gadalla 2007). There have been no studies of treatment causes are to be found principally in their environment, for
however. The clinical implications of the comorbidity of eating others there is a major genetic contribution (see Chapter 8).
disorders and substance misuse therefore remain unexplored. On present evidence it seems likely that alcohol dependence
has many phenotypes which are genotypically different, and
Personality disorder to which the environmental contribution varies. There is good
epidemiological evidence that heavy drinking runs in families
Research has been mainly on antisocial personality disorder (Marshall & Murray 1991). A summary of factors influencing
(ASPD). The typical prevalence of ASPD is 5% of males and an individual’s disposition to use a drug or drink alcohol is
just less than 1% of females. In patients with a substance mis- shown in Fig. 14.2.
use disorder, the ASPD rate rises to 18% and as high as 44% in
intravenous drug users. When the diagnostic criteria ‘onset Personality
prior to the age of 15 with conduct disorder’ is removed (this
results in a diagnosis similar to antisocial personality disorder Patients with alcohol-related problems are more likely to have
used in the ICD-10) then the prevalence rises to near 70% personality deviations and early family disturbance than are
(Cottler et al 1995). Little is known about the effect of sub- the general population. This is partly to be expected since
stance abuse on the outcome of patients undergoing treatment clinics in the UK tend to be based in psychiatric services and
for their personality disorder as patients in this category are
often excluded from studies (van den Bosch & Verheul 2007).

ADHD Individual Social
Early influences Early influences
Attention deficit hyperactivity disorder (ADHD) (in ICD-10 • Key learning experiences
these patients would be classified as having hyperkinetic and early life • Peer group influences
disorders) is increasingly diagnosed. The research into ADHD • Genetic make-up • Family, parental drug use
and substance misuse is exclusively from the USA. The • Personality • Culture
hypothesis put forward by researchers is that ADHD in child-
hood progresses into adulthood in at least 50% of cases. In Immediate antecedents Immediate antecedents
adults, ADHD leads to comorbid substance misuse and self-
medication. Drugs used are typically stimulants. Therapeutic • Expectations • Social pressures/relationships
trials in adults have been shown to be effective with this group • Mood states • Availability
(Schubiner et al 1995). Pharmacotherapeutic treatment of • Withdrawal states • Demographic factors
ADHD in children reduces the risk for later cigarette smoking
and substance misuse in adulthood. In contrast, medication Avoidance Approach Avoidance
treatment alone of adults with ADHD and comorbidity is Disposition
inadequate for both ADHD and substance misuse. Stimulant
diversion continues to be of concern, particularly in older to use
adolescents and young adults (Wilens & Fusillo 2007). drug/
alcohol
Detection and management of comorbid
substance misuse Drug use

Doctors must have a low threshold for the detection of sub- Reinforcing consequences Aversive consequences
stance misuse in their patients. Typical figures for inpatient
psychiatric units are between 20% prior to drug screening • Mood enhancement • Toxic effects, illness
and 35% following drug screening, depending on the catch- • Psychosocial facilitation • Psychosocial dysfunction
ment area and the specific type of institution. Higher rates • Relief of withdrawals
of comorbidity can be found among young, male, urban,
lower-income groups and can be as high as 65%. Failure to Fig. 14.2 Factors influencing an individual’s drug/alcohol use.
recognise substance misuse results in incorrect diagnosis, poor
management and a worse prognosis.

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Misuse of, and dependence on, alcohol and other drugs CHAPTER 14

thus attract psychiatrically disturbed cases. In the general in secret, and associated with considerable shame and denial.
population, follow-up studies of young men show that the Whilst traditionally, women have been much more abstemious
impulsive, rebellious, more extrovert individual is somewhat than men, this has changed particularly amongst younger
more at risk of developing alcoholism, particularly alcohol- economically independent women who now pursue more male
related social problems. Childhood conduct disorder also pre- patterns of socialising and excessive drinking.
dicts alcohol-related problems, typically of early onset and
linked to criminality. A debate developed in the 1980s about Childhood experience of sexual abuse is more commonly
whether there is a type of male alcoholism, with early onset, reported in women alcoholics than in the general popula-
severe problems, especially social problems, a manner that tion. It is not yet known if it is more common than in other
is socially detached, distractible and confident, and also psychiatric disorders (Hurley 1991).
linked to a similar pattern in the biological father (‘Type 2’ –
Cloninger 1987), which contrasts with a more dependent, Female patients, whether presenting with dependence,
anxious, rigid, less aggressive, more guilty alcoholic (‘Type 1’) psychiatric or medical complaints, often give a shorter history
with either biological mother or father an alcoholic. Some have of excessive drinking than men and tend to report a lower
felt that Type 2 is best seen as alcoholism secondary to antiso- intake of ethanol, even after correction for body weight.
cial personality (ASP) (Schuckit & Irwin 1989). ASP greatly This may partly be explained by the greater stigma attached
increases the risk that a man or a woman will have an alcohol to women’s drinking, which might lead to their minimising
problem in longitudinal and cross-sectional community stud- their consumption. However, a given dose per kilogram body
ies. ASP and/or family history of alcoholism was found in weight of ethanol produces a higher peak blood level in
48% of male alcoholics and 63% of female alcoholics in a large a woman than in a man. This may be due in part to the female
community study (Lewis & Bucholz 1991). body having a lower ratio of water to fat than the male
body (alcohol dissolves more readily in water than in fat),
Drake & Vaillant (1988), in a 33-year longitudinal study of and to lower activity of alcohol dehydrogenase in the gastric
456 inner-city adolescent boys chosen as non-delinquent at mucosa.
that age, found that in this sample adolescent indicators of
personality disorder were good predictors of adult personality Role of marital relationships
disorder, but not of alcoholism. Having an alcoholic father
was the best predictor: 28% of sons developed alcoholism In an alcoholic’s marriage, hostility, mistrust and attempts by
compared with 12% of sons of non-alcoholic fathers. Apart one partner to control the other are common. Women prob-
from the severe disturbance associated with childhood con- lem drinkers sometimes have husbands whose energies are all
duct disorders and parental drinking habits, community stud- directed towards their work or their hobbies, or husbands
ies do not usually find evidence linking parenting styles to who make them feel worthless. It is difficult to disentangle
subsequent alcoholism (Vaillant 1995). As well as antisocial cause from effect, and adequate research which would need
personality disorder in the community, alcohol dependence is to be longitudinal has not yet been conducted. However, many
found to be associated with phobic disorder, anxiety disorder, marital problems undoubtedly improve when the drinking
other psychotropic substance misuse (notably tranquilliser ceases.
dependence) and (especially in women) depression (e.g.
Lewis & Bucholz 1991). Aetiology of drug use

Alcohol may be used to anaesthetise grief by the bereaved The aetiological factors vary, depending on what stage of drug
and may complicate pathological grief. Phobias, especially use one is considering. Factors determining initiation of
agoraphobia, are common in alcoholics attending psychiatric drug use may differ from those influencing continuation of
hospitals (Kushner 1996). Alcohol, because it is a short-acting drug use, the move into dependent use and from the causes
sedative causing rebound arousal, may exacerbate or even pre- of relapse. The aetiology of relapse is discussed later in
cipitate anxiety states. However, the phobia in some instances the chapter.
clearly predates the alcohol dependence. Bipolar disorder,
including the manic phase, may result in drinking to the point Initiation of drug use
of physical dependence.
Whether an individual will take a particular drug will depend
Psychological aspects of alcohol dependence on its availability, cost, legal status, alleged effects and risks
in women and, in some cases, the form of the drug. Why one particular
individual will chose to use a drug whereas another will not,
Women make up a third of alcoholics seen in psychiatric prac- given the same situation, is more complex. Personality traits,
tice. There is often a male heavy drinker either in the family such as rebelliousness and curiosity, are thought to contribute
history or the marriage. Women more often than men attri- to drug experimentation, as is a wish to express independence
bute the onset of problem drinking to a particular life-stress. or hostility. The wish to seek peer group approval may also
However, community surveys have not found that adverse life contribute. Individuals are also influenced by families and soci-
events predict an increase in drinking (Romelsjo et al 1991). ety, and here role models and group pressure may result in
Depression in middle life following the departure of the chil- some individuals taking drugs, whereas others do not. In some
dren (‘the empty nest’), or in the lonely spinster or widow, instances, initiation to drug use is iatrogenic: for example,
can lead to excessive drinking. Typically this is at home and treatment of severe pain.

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Companion to Psychiatric Studies

Continued use Individuals with high levels of anxiety will be conscious of
alcohol’s relaxing properties. At low doses alcohol has a eupho-
The factors involved in the initiation of use may play greater or riant effect for some individuals in some settings, and this is a
lesser importance in subsequent drug behaviour; however, potent reinforcer of continued drinking. Genetic factors may
additional factors come into play when people continue make some individuals experience euphoria or tension reduc-
to take drugs. For an individual drug to be continued, it must tion more intensely at this stage (Marshall & Murray 1991).
give positive effects and minimal negative effects. These It is also interesting that there is a greater concordance in
positive effects will be the beginning of the development of drinking style in monozygotic than in dizygotic twins, even
‘positive outcome expectancy’, which later with continued allowing for the greater social closeness of the former (Heath &
reinforcement develops into craving. With use, classical and Martin 1988).
other conditioned responses become more apparent. The phar-
macology of the drug determines much of what users then The main approaches of genetic studies have been by
chose to do. On the individual level, continued use is asso- linkage and association methods. The principal consistently
ciated with general nonconformity. Understanding of genetic reproduced finding has been the genetic transmission of
contributions to individual differences in sensitivity to drugs alcohol-metabolising genes in oriental populations. Orientals
and their influence on behaviour is not fully developed, have varying degrees of acetaldehyde dehydrogenase defi-
but will play a part in a future account of why some people ciency, and the consequent ‘flushing’ reaction to alcohol is a
move from experimental to recreational and then dependent deterrent to drinking for some (though alcohol dependence
use (Morse et al 1995). Individual distress or unrecognised does develop in some Orientals despite flushing).
psychiatric illness can lead on to self-medication and the
short-term alleviation of symptoms by continued use. Sons of alcoholics, identified both from among sons of clinic
attenders in a general population cohort and by questionnaire
Dependent use survey, for example in college students, have been compared
with controls on numerous measures (Pihl et al 1990). In sons
Once the dependence syndrome has developed, tolerance and of alcoholics, alcohol has a greater dampening effect on
withdrawal symptoms are frequently a feature of the condi- the physiological correlates of stress than is seen in controls.
tion, and the substance type primarily determines the quality Children of alcoholics, of school age, tend to be distractible,
and severity of withdrawals. Avoidance of withdrawal then quick to resort to aggression and often in trouble with author-
becomes a major factor in continued drug use. At the individ- ity. A twin study did not find cognitive impairment (nor corti-
ual level, personality traits in people dependent on drugs, cal atrophy) in the non-alcoholic MZ twins in discordant pairs,
particularly heroin addicts, are certainly different from those which also provides some evidence against the hypothesis
of normal controls. There is an increased incidence of: low that an inherited predisposing trait in alcoholism might be
self-esteem; submissiveness; dependence on others and a crav- cognitive impairment. It points to aspects, at least, of cognitive
ing of approval; lack of self-confidence; a learned helplessness; impairment being a result rather than a precursor of the
low expectations for the future; and a tendency to give up drinking (Gurling et al 1991).
easily. However, is this cause or an effect of the dependence
syndrome? This question has not been resolved by prospective Trait markers
studies. Much is said about individual denial of problems
related to drug use, or at least a lack of awareness. Dependent Longitudinal studies of the sons of alcoholics have shown that
drug users may chose to continue using because the benefits of a low response to alcohol in the laboratory, high externalis-
giving up are outweighed by the advantages of continued use. ing of behaviour and also the tendency to internalise related
An alternative theory of continued drug use in dependent to depression contribute to the development of alcohol
users is that they have not developed alternative coping dependence (Schuckit 2009).
mechanisms for dealing with problems, and that their use of
drugs is their main coping mechanism. A search is also being made for biochemical abnormalities
which occur in alcoholics and which can be demonstrated in
The psychobiology of alcohol their pre-drinking children. After drinking, alcohol levels of
prolactin are lower in those with a family history of alcoholism
dependence than in controls. The rise in cortisol and adrenocorticotrophin
(ACTH) following a drink of alcohol is less among those men
Initiation and reinforcement with a family history than those without. This is one of a num-
ber of illustrations of the way in which genetic predisposition
may in a variety of subtle ways make individuals more at risk
of drinking in a harmful way.

Initiation into drinking and other forms of drug taking is influ- Tolerance and withdrawal
enced by the setting, the company and expectancies about the
likely effects. All of these contribute as much or more than its As drinking becomes a regular habit, many drinkers find
pharmacological action to whether alcohol has a relaxing or that they have to take more to obtain the desired effect; this
euphoriant impact (Young et al 1990). is evidence that tolerance is increasing, and this may make
reduction in intake seem more difficult.
The consequences of drinking for the novice drinker
may well have an effect on his subsequent drinking career.

364

Misuse of, and dependence on, alcohol and other drugs CHAPTER 14

A behavioural explanation of tolerance and withdrawal is Relapse and reinstatement
that an organism ‘expects’ the drug because it is confronted
with signals that previously heralded the drug. ‘Drug compen- Some clinicians believe that there is a protracted physiological
satory conditional responses act to cancel the effect of the withdrawal state which outlasts the visible tremor, tachycar-
drug, producing tolerance if the drug is administered, or a dia, sweating and anxiety of the initial 3–10 days. Cognitive
‘withdrawal’ state if the drug is withheld. Thus animals may deficits are still improving several months after abstinence;
only display tolerance to alcohol in an environment where cerebral atrophy also resolves in some patients, and cerebral
the alcohol was initially administered and not in a novel blood flow improves. During this time, abnormalities in EEG
setting. Nonetheless, it seems probable that the development evoked response and sleep architecture, and complaints of
of neurophysiological tolerance is a key step along the way to insomnia persist; patients complain of anxiety and depressive
establishing dependence. The understanding of the neuro- symptoms, diminishing proportionately with the length of
chemical basis of the actions of alcohol is developing rapidly. abstinence; and there appears to be reduced suppression in
This has occurred because new neuroimaging techniques, pos- the dexamethasone-suppression test and blunted thyrotrophin
itron emission tomography (PET) and single photon emission response to thyrotrophin-releasing hormone (Garbutt et al
computed tomography (SPECT), have enhanced the capacity 1991). The indications are that GABA receptors, their chloride
to study and understand the biological basis of dependence. channels and perhaps up-regulation of N-methyl-D-aspartate
Prior to these developments much of the research was reliant (NMDA) receptors continue to be abnormal. (For further
on animal studies (Nutt 1999). discussion see Nutt 1996.)

Alcohol, in common with other neuroactive drugs, alters During this time, some patients feel an urge to drink and
brain transmitter function. It has several actions on different they struggle with craving. There are of course psychological
brain sites, including dopamine release in the nucleus accum- and social processes during this period, as well as neuro-
bens. When alcohol is stopped, dopamine release drops below chemical ones. These include a range of cues to drinking that
normal, which may account for the depressed mood asso- have been learnt over the years. Such cues may be environ-
ciated with early withdrawal. It is thought that overactivity mental: social situations, the pub or club. Cues may also be
of dopamine contributes to the excitability observed in delir- internal; for example, drinking may have become associated
ium tremens. Alcohol also appears to act through gamma- with feeling happy, sad, angry, tired, hungry or all of these.
aminobutyric acid (GABA) and excitatory amino acid recep-
tors; genetic influences on these systems and their response During these initial months some contend that further,
to alcohol may prove of critical importance in understanding even slight, use of alcohol may erode resolve about further
different propensities to develop tolerance and responsiveness consumption, and lead to relapse. Many alcoholism recovery
to pharmacotherapy. programmes recommend absolute abstinence. After tolerance
has been lost, five or six drinks may be sufficient to dissolve
There is evidence that endogenous opioid transmitters also one’s intention not to take a seventh. However, there seems
play a part in the effects of alcohol. It has also been shown that no obvious reason why that should lead to a return in the next
relapse in dependent alcoholics can be mitigated by opiate day or so to heavy harmful drinking, reinstatement of craving
antagonists (e.g. naltrexone). The activity of noradrenaline and withdrawal symptoms. There is no evidence that one
(norepinephrine) is decreased by opioids, and withdrawal drink sets off a neurophysiological tripwire, but disposition
symptoms are in part thought to be an expression of a rebound to drink in alcoholics (measured objectively as work done
of noradrenaline activity. to obtain alcohol or speed of drinking under standard con-
ditions) has been shown in laboratory settings to increase
Ion channels in the cell membrane are a particular target for after as little as three large measures of spirits. It seems as if
alcohol. Calcium homeostasis is critical to all cells, and several relapse occurs after a certain level of priming dose has been
different calcium channels control the passage of this ion across reached. Increased disposition to drink in abstinent alcoholics
cell membranes. Alcohol reduces entry through the channels. has also been demonstrated on the morning after a dose of
As a result they increase in number. One consequence of this is alcohol. Thus, in alcohol-dependent individuals who have been
that during withdrawal, calcium flux becomes excessive. Some abstinent for some time, the pattern of response to renewed
speculate that this intense calcium flux contributes to neuronal drinking is ‘carried over’ from their previous drinking period.
death (Nutt 1996). The varied actions may account for the Carry-over has been demonstrated in monkeys and in rats:
euphoriant and anxiety-reducing properties of the alcohol. physical dependence (tendency to withdrawal phenomena)
is more easily evoked in animals who have been previously
The original demonstration that ‘rum fits’ and delirium made physically dependent, even after 37 days’ abstinence.
tremens were withdrawal symptoms of alcohol dependence ‘Reinstatement’ is also used to describe the carry-over
was made by Isbell et al (1955). In this experiment, recovered phenomenon.
opiate addicts consumed between 1 and 11/2 bottles of spirits
(250–370 g ethanol) per day for 7 weeks. On cessation all As well as a learning theory/neurophysiological view of
had withdrawal symptoms, and some had fits or delirium. reinstatement a cognitive explanation has also been proposed.
Such a short history is unusual in clinical practice. Usually It is said that abstinent alcoholics who relapse on recommen-
the tendency to drink such large amounts over successive days cing drinking do so because they believe, as a result of treat-
takes years to develop. Nevertheless, traces of withdrawal ment or attendance at Alcoholics Anonymous, that one
phenomena (insomnia, restlessness, increased REM sleep) or two drinks necessarily leads to harmful drinking — ‘the
occur even after single large doses of a sedative such as alcohol.
Hangover is in part a mild withdrawal state.

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Companion to Psychiatric Studies

self-fulfilling prophecy’. Of course, having a drink can also be Usually these experiences are auditory and begin as fragmentary
seen as a stimulus with a long-ingrained conditional response – sounds. The sounds gradually become formed and voices are
taking another drink. This view has led some to advocate cue- heard, often making unpleasant remarks: ‘She ought to be
exposure, including exposure to drinking environments, as a ashamed of herself’, ‘He’s gay’, etc. The voices may give com-
way of reducing severity of relapse. This approach is not yet mands to do things against the subject’s will, and persecutory
been proven as a treatment method (Drummond et al 1990). delusions may develop. The experiences may be very compelling
and distressing, occasionally resulting in violence or suicide.
Psychiatric complications
In one series it was observed that men who developed
of alcohol misuse hallucinosis were significantly younger at the onset of alcohol
problems, consumed more alcohol per occasion, developed
Withdrawal states with delirium more alcohol-related life problems and had higher rates of
(ICD-10 F10.4) drug experimentation (Tsuang et al 1994). In two large series
of cases studied by Bendetti (1952) and Victor & Hope (1958)
The condition commonly known as delirium tremens (DTs) only a few cases (5–10%) continued to have symptoms for
is often taken as a hallmark of alcoholism but it is relatively 6 months or more if abstinence was maintained. Renewed drink-
rare, being reported by only about 5% of patients attending ing tended to bring about a return of hallucinations however.
specialist clinics. It occurs when an individual who is severely
dependent on alcohol stops or reduces drinking. Despite the close resemblance of the hallucinations to those
of acute schizophrenia, only a few go on to show typical
The full syndrome is characterised by marked tremor of the schizophrenic deterioration: 4 out of 76 in Victor & Hope’s
limbs, body and tongue, restlessness, loss of contact with real- series and 13 out of 113 in Bendetti’s series; but Cutting
ity, clouding of consciousness, disorientation and illusions (1978) observed 19%. In distinguishing this condition from
progressing to hallucinations, sometimes frightening, which schizophrenia, it is noteworthy that premorbid adjustment in
are most commonly visual, but may be auditory or tactile. the social and sexual spheres tends to be normal. A family
Delusions often of a paranoid kind may also occur, often asso- history of schizophrenia is usually absent except in the cases
ciated with the hallucinations. Sweating and tachycardia are where hallucinations persist and schizophrenic personality
pronounced. The disturbance usually develops out of milder deterioration occurs. There is no close relationship with gross
withdrawal symptoms 1 day after cessation of drinking and cognitive impairment. The basis of alcohol hallucinosis is pre-
rarely persists for more than 4 days. Symptoms are often sumably subtle alcohol-induced damage or dysfunction, per-
worse at night. There is a significant mortality (approximately haps of the temporal lobes, though this has not been proven.
10%), partly because it often complicates other medical emer-
gencies such as infections or injuries. The development of Management sometimes requires admission to hospital,
fever, dehydration and signs of shock are ominous prognostic withdrawal from alcohol and, if the hallucinations still con-
signs. Concomitant infection, Wernicke’s encephalopathy, meta- tinue, antipsychotics. It is usually possible to stop the antipsy-
bolic disturbance, hypoglycaemia or head injury may complicate chotics after 2 or 3 months. Thereafter the patient usually has
the clinical features and prognosis. Withdrawal fits may occur full insight into the illness.
at any time from the first to the 14th day (Isbell et al 1955).
The development of DTs and seizures can often be aborted by Pathological jealousy (Othello syndrome)
prompt and adequate sedation with a benzodiazepine. (F10.5)

Admission to hospital will usually be necessary. The patient’s Firmly held delusions of infidelity may occur in patients who
environment should be safe, uncluttered and uniformly lit to misuse alcohol. They may be precipitated by the patient’s feel-
avoid ambiguities. Parenteral multivitamin preparations are ing of inadequacy stemming from alcohol-induced impotence
given and haloperidol reduces the intensity of delusions and and further aggravated by the spouse’s growing indifference
hallucinations. Electrolytes and plasma glucose should be towards a drunken partner. The patient’s accusations become
checked. An oral benzodiazepine, such as chlordiazepoxide, repetitive, and aggressive demands for proof may be reinforced
commencing at 100–150 mg/day or diazepam 50–80 mg/day by violence. No amount of contrary evidence will dispel the
and reducing after the second or third day, will usually be suffi- delusion, and cases sometimes end tragically in assault or mur-
cient to contain the patient’s agitation and can be progressively der. Alcohol abuse is not the only cause of this syndrome (see
reduced and stopped by the end of 1, or at most, 2 weeks. Chapter 15, on schizophrenia). Treatment is of the underlying
condition. Sometimes the only feasible and safe solution is for
Psychotic disorder – alcoholic hallucinosis the couple to separate permanently.
(F10.5)
Depression and anxiety

In this condition hallucinations occur in clear consciousness. Symptoms of depression are common among excessive drin-
Sometimes these are a continuation of hallucinations first experi- kers. This is understandable considering the lifestyle of depen-
enced during withdrawal from alcohol. However, hallucinations dent drinkers, who frequently wake with a hangover facing a
may also commence de novo in a patient who is still drinking. day overshadowed by the problems caused by their drinking.

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Misuse of, and dependence on, alcohol and other drugs CHAPTER 14

Biological changes induced by excessive drinking may also thiamine deficiency; repeated head injury; and the conse-
contribute to depressed mood. quences of alcohol withdrawal fits. A spectrum of cognitive dis-
abilities has been observed extending from mild impairment to
Alcohol also releases inhibitions, which makes it easier to end-stage alcoholic dementia. That some of these deficits might
express feelings of sadness and to give way to self-destructive predate the heavy drinking has been discussed earlier.
impulses. It is therefore hardly surprising that alcohol figures
so prominently in studies of both attempted and successful Imaging has found cortical atrophy and ventricular enlarge-
suicide, in which associated risk factors are previous attempts, ment in 50–70% of patients admitted with alcohol dependence.
a history of depression, and significant physical and social There are modest correlations between atrophy and cognitive
problems. If secondary diagnoses of alcoholism are included, impairment. Magnetic resonance imaging (MRI) relaxation
the proportion of suicides affected ranges from 20% to 40% time and brain density measured during computerised tomo-
(or to 55% if only males are included) (Duffy & Kreitman graphy (CT) are altered in proportion to lifetime consump-
1993). The Scottish Government, reviewing data obtained by tion. The shrinkage is mainly in white matter (Sullivan &
the National Enquiry into Suicide and Homicide (University Pfefferbaum 2009) (see also Chapter 4 on Neuroimaging).
of Manchester 2008) regarding the events leading up to com- In liver cirrhosis hepatic encephalopathy is an additional factor.
pleted suicides in Scotland, recommended a review of the
availability of services for alcohol detoxification. In many cases impaired memory and attention improve
following withdrawal, and so formal cognitive assessment
Depression is a primary factor in a relatively small number would be premature during the first 3 weeks of abstinence.
of alcohol-dependent individuals, more commonly in women Improvements with abstinence can continue for a year or
than men. However, most depressive symptoms are probably more, so ideally the patient should be monitored at, say,
secondary to the alcohol intake: at presentation to an alcohol 3-monthly intervals. Impairments are commonly found in
treatment service 42% of men had significant depressive visuospatial tasks, planning and coordination; there is inflexibil-
symptoms but only 5% were depressed after 4 weeks of absti- ity in thinking, as shown in tests to show whether the patient
nence (Brown & Schuckit 1998). The clinician should discrim- can change his mental set, for example, in a test of how objects
inate between those patients whose alcohol misuse is or symbols are categorised. In common with all testing, the
symptomatic of depression and the much larger number who patient’s attentiveness and mood are confounding factors.
have become depressed because of their drinking. In the latter,
improvement usually follows cessation of drinking and appro- Reasonable social adjustment has been observed in abstinent
priate therapy, whereas the former may require antidepressant alcoholics despite significant impairment on formal testing
medication, combined with a period of abstinence. (Kopelman et al 2009). However, cognitive impairment is
overall a predictor of relapse to drinking.
Alcohol is often used as a means of lowering anxiety, partic-
ularly in stressful social situations. While alcohol may indeed Prompt administration of thiamine is believed to reduce the
relieve anxiety at low doses, greater quantities and chronic risk of cognitive impairment in malnourished heavy drinkers,
use generates anxiety symptoms, and a mild withdrawal state and it is prudent to give thiamine supplements for at least
mimics acute anxiety. It is important to avoid making a diagno- 4 months in newly abstinent cognitively impaired patients
sis of anxiety state until an alcohol-dependent patient has been (Kopelman et al 2009). Small bowel malabsorption, in addi-
abstinent for at least 3 weeks. In the majority of cases anxiety tion to poor intake and excessive utilisation, contributes to
and phobic symptoms will resolve, leaving about 10% of vitamin deficiency in alcoholics. Since this may take some
patients who have a primary anxiety disorder which will weeks to recover, parenteral administration is necessary initi-
require treatment in its own right. Care should be taken in ally, despite the very small risk of anaphylactic reaction.
prescribing anxiolytics to such patients because of the hazards The uses of cognitive testing are:
of substituting one dependence for another; behavioural
approaches are therefore preferable. • as an aid to diagnosis, when vascular or neoplastic causes
need to be considered and which can present with features
Cognitive impairment and brain damage that are not characteristic of alcohol brain damage, such as
diminished verbal skills or dyspraxia;
Some 50–60% of alcoholics attending specialist clinics perform
worse on cognitive testing than would be predicted from their • to provide a more formal judgement where there is clinical
verbal intelligence educational level and age. They commonly evidence of impairment; this is particularly helpful in
show: assessing whether the patient is likely to be able to use
cognitive behavioral techniques and make changes in his
• impairment of memory, visual more than verbal; way of life;
• narrowing and rigidity of thought processes, i.e. difficulty
• to provide a basis for feedback to the patient, who may
changing from one way of construing and categorising to need to know that drinking has affected his memory or
another; intellectual powers; this often proves a powerful motivating
• difficulty learning new material; and influence;
• impairment of visuospatial and visuoperceptive skills.
• monitoring progress, both for the clinician and patient;
A variety of factors may contribute to cognitive impairment
among excessive drinkers: the neurotoxic effect of alcohol; • to guide advice to employers, and draw attention to hazards in
occupations involving, for example, machinery or driving; and

• to assist the assessment of capacity, in the legal sense,
with a view to perhaps recommending guardianship under
the Incapacity Acts (see Chapter 26).

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Companion to Psychiatric Studies

Medical complications of excessive Korsakoff syndrome (KS)

drinking This late consequence of alcohol misuse is characterised by
impairment of short-term memory with a tendency to confab-
Cancer, cardiovascular disease, cirrhosis, pancreatic and gas- ulate. In most cases it will have been preceded by an episode
trointestinal disease, accidental death, suicide and greater of Wernicke’s encephalopathy, although this may not have
vulnerability to infection such as TB all contribute to the raised been documented or even witnessed. Neuropathology of KS
mortality amongst excessive drinkers. detectable with MRI has a different neuroradiological signa-
ture from the acute Wernicke’s encephalopathy stage and
Neurological complications can be observed as tissue shrinkage or atrophy of selective
brain structures, including the mammillary bodies and thala-
Wernicke’s encephalopathy mus and ventricular expansion, probably indicative of atrophy
of surrounding grey matter nuclei, and bilateral volume deficits
The triad of confusion, ataxia and ocular palsy was described in the hippocampus (Sullivan & Pfefferbaum 2009). Clinically,
by Wernicke in 1881. Patients dying of this condition show a wide range of other cognitive as well as memory defects may
haemorrhages in the brainstem and thalamus. In vivo MRI also be present. Total recovery, even after abstinence and
shows changes in the mammillary bodies, periaqueductal and treatment with thiamine, is rare, but significant functional
periventricular gray matter, collicular bodies and thalamus improvement is often observed over many months.
(Sullivan & Pfefferbaum 2009). Identical lesions have been
produced in thiamine-deficient animals. The condition Peripheral neuropathy
responds to urgent treatment with intravenous thiamine and
withdrawal of alcohol, but even with such measures there is Peripheral neuropathy, which may also be contributed to by
often a residual dementia or Korsakoff psychosis (Victor vitamin deficiency, is common in alcoholics in at least a mild
1962). This condition is often overlooked, and it is essential form, with asymptomatic absence of the ankle jerks, and calf
not to wait for the classical triad of symptoms before com- tenderness being early signs. In the established condition the
mencing therapy. Mental changes of confusion, drowsiness patient complains of muscular cramps and unpleasant para-
and pre-coma or coma are common and sometimes the only esthesiae in the feet and calves and unsteadiness of gait.
clinical findings. All forms of sensation are impaired in a stocking distribution.
Flaccid weakness in the limbs may progress to wrist drop.
Treatment of Wernicke’s encephalopathy should be in hos- The cranial nerves are spared.
pital and the patient given intravenous thiamine, for example
as Pabrinex 2 pairs of ampoules three times daily for 2–3 days Alcoholic myopathy
followed by daily Pabrinex for a further 3 days. Each ampoule
should be diluted in 50–100 ml N saline or 5% N/V glucose Alcoholic myopathy presents as chronic weakness with
and infused over 30 minutes. Because of a small risk of ana- wasting, punctuated by exacerbation during bouts of drinking.
phylaxis, facilities for treating anaphylactic shock should be
available. General and psychiatric hospitals should have agreed Gastrointestinal complications
protocols for the management of alcohol withdrawal including
delirium tremens and Wernicke’s encephalopathy. The merits Gastritis, presenting as upper abdominal pain and haema-
of continuing longer-term oral thiamine supplements are less temesis, perhaps accompanied by acute gastric erosions, is
clear, but in a poorly nourished and/or impaired patient it common in those who drink excessively. Peptic ulcer, though
seems a sensible preventative strategy. To prevent Wernicke’s it occurs in 10% of alcoholics, is as common in the general pop-
syndrome ensuing on admission to hospital (thought to occur ulation, so it is unlikely that alcohol is a cause. Alcohol never-
because of the stress of withdrawal or the first carbohydrate theless provokes the symptoms of an ulcer and probably delays
meal for some days, or the intercurrent illness precipitating healing. Severe diarrhoea sometimes occurs in excessive drin-
admission), it is common practice to give immediate parenteral kers, and small bowel damage leading to malabsorption exacer-
thiamine once or twice a day for 3 days to alcohol-dependent bates dietary vitamin deficiency. Chronic relapsing pancreatitis
patients who appear malnourished, who report recent severe is characterised by recurring acute abdominal pain with inflam-
vomiting or diarrhoea, who have an intercurrent illness, or mation, fibrosis and eventually calcification of the pancreas.
who have peripheral neuropathy. This should also apply to such It is usually associated with an alcohol intake of over 20 units
patients if they are undergoing outpatient detoxification. per day. A protein-deficient diet and hyperlipidaemia are
believed to contribute. Deaths from cancer of the mouth,
A disturbance of consciousness in the alcoholic must also pharynx, oesophagus, large bowel, breast and liver are elevated
raise the suspicion of traumatic subdural haematoma, though in heavy drinkers (Baan et al 2007).
unilateral signs will then probably be present. Hepatic enceph-
alopathy and hypoglycaemia should also be considered. Alcohol and liver disease
Occasionally, dementia is marked and accompanied initially
by incontinence, generalised weakness, tremor persisting long Over 90% of ingested alcohol is converted by an obligatory oxi-
after withdrawal from alcohol, slurred speech and ataxia. dative process in the hepatocytes to acetaldehyde, thence to
Alcoholic cerebellar degeneration presents as ataxia of stance acetate and finally to carbon dioxide and water. Fat deposition
and gait.

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Misuse of, and dependence on, alcohol and other drugs CHAPTER 14

in liver cells (steatosis) almost invariably accompanies heavy Alcohol is a cause of supraventricular arrhythmias, and of
drinking and may be present even though liver function tests cardiomyopathy leading to congestive cardiac failure. Arrhyth-
are normal. Less fortunate drinkers go on to develop hepatitis mias are prone to occur after bouts of excessive drinking and
or cirrhosis. Cirrhosis of the liver is nowadays among the excessive drinking is recognised as a cause of non-cardiac acute
five commonest causes of death in those under 60 in most chest pain.
industrial countries and is common in some developing
countries such as India and Sri Lanka. Sexual impairment

Obesity, also a cause of fatty liver worsens the risk. Cirrhosis Although alcohol may increase sexual arousal, high blood
can be induced in the individual who has drunk moderately for alcohol level can impair penile erection by a direct pharmaco-
years and then rapidly escalates consumption for 1 or 2 years. logical effect. Heavy drinkers who repeatedly fail to maintain
Women may be more vulnerable than men, and there are an erection become anxious about their sexual performance,
indications that progression to cirrhosis depends on immune which itself leads to further failure. Alcohol also has direct
responses and also, from studies of the human leucocyte antigen toxic effects on the Leydig cells of the testis, resulting in
system, that heredity contributes. reduced testosterone production, impaired spermatogenesis,
infertility and testicular atrophy. A significant improvement
Modern treatments do not appear to have been very in sperm count and fertility was noted in a sample of men
successful in reversing the complications of cirrhosis (variceal attending an infertility clinic when they reduced their alcohol
bleeding, ascites and primary liver cancer). However, before intake.
there is decompensation – that is, failure of synthetic activity
resulting in coagulopathy and low serum albumin, or portal Fetal alcohol syndrome
hypertension – with abstinence there can be a 90% 5-year
survival (Saunders et al 1981). Death from variceal haemor- Heavy drinking during pregnancy is associated with spon-
rhage or hepatic or renal failure may also result from alcoholic taneous abortion, intrauterine growth retardation and the
hepatitis in the absence of cirrhosis. fetal alcohol syndrome. This syndrome has been observed in
children born to mothers who have severe alcohol problems.
Alcoholics who are candidates for liver transplantation are It is characterised by developmental and growth retarda-
usually expected to demonstrate an ability to abstain and a tion and facial and neurological abnormalities. Impairment of
commitment to maintaining this after surgery. Despite this, a brain development (Guerri et al 2009) may occur after less
few revert to problematic drinking again, with past history severe drinking by the mother, leading to behavioural dif-
of depressive illness being a predictor of relapse (Kelly et al ficulties. It is also likely that the use of other drugs, particu-
2006). Nonetheless, patients transplanted for alcoholic liver larly smoking, are confounding factors. Although light and
disease appear to have a better survival than those with viral moderate drinking has not been proven to cause fetal damage
hepatitis. Liver transplant units should have the assistance of (Henderson et al 2007), most health authorities now advise
a liaison psychiatrist and alcohol specialist nurse to ensure women either to abstain or confine their drinking during preg-
detailed assessment of the patient’s drinking history and nancy to at most one or two drinks a week. Antenatal clinics
mental health and offer long-term follow-up with relapse should screen for hazardous drinking and alcohol-related
prevention therapy. problems.

Metabolic complications Alcohol and accidents

Life-threatening hypoglycaemia occasionally follows 6–8 hours Some studies in emergency departments found that alcohol is a
after heavy alcohol consumption in previously fasting indivi- factor in as many as one-third of all accidents. This is particu-
duals. It may follow imperceptibly from alcoholic stupor. larly the case among young men; road traffic accidents, drow-
Treatment is by urgent intravenous administration of glucose. nings, pedestrian deaths and accidents in the home are all
Insulin-dependent diabetics who ingest moderate to large common during intoxication. Because those who drink heavily
amounts of alcohol with little carbohydrate may become hypo- in single sessions tend to go on to develop further alcohol-
glycaemic, as may well-fed normal subjects who undertake related problems, the emergency department is a potential site
vigorous exercise in the cold. Chronic alcoholics may develop for screening and early intervention.
reactive hypoglycaemia following a carbohydrate-rich meal,
perhaps related to their known accelerated gastric emptying.

Acute renal failure after a beer-drinking binge has been
reported in Britain and several other countries.

Alcohol-related social harm

Cardiovascular disease

There is evidence that in the age group over 45 years drink- As alcohol comes to play an increasingly salient part in the
ing 1–3 units per day diminishes the risk of coronary disease, drinker’s life, he or she often experiences a number of distres-
but heavier consumption is related to increased morbidity sing social consequences. Frequently these have their first
and mortality from this cause. Drinking more than 6 units impact on family and work. Most of the social disabilities
per day can contribute to high blood pressure and risk of which arise are easier to list than quantify. They include the
haemorrhagic stroke. following:

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Companion to Psychiatric Studies

Disruption of family relationships approaches. In some countries, such as Finland, parts of
Canada and the USA, public drunkenness was decriminalised,
Alcohol misuse contributes to as many as one-third of while in Britain the approach has been to divert the habitual
divorces, and domestic suffering and violence are common- drunken offender out of the courts into a medico-social
place. Disappointments may lead to depression in the parent, system. The Criminal Justice Acts in both England & Wales
child or spouse, or to a numbed state in which the drinker is and Scotland now allow the police to take an individual
disowned. The children of problem drinkers are specifically charged with simple drunkenness to a ‘designated place’ for
at risk of developing behaviour problems and alcohol problems detoxification and rehabilitation. Very few of these places
later in life. They often show a facade of premature adult exist in Britain, and policy has moved away from detoxifi-
responsibility, losing the experiences of childhood in conse- cation towards police cautioning which takes no account of
quence. A fellowship of support groups formed for adult- rehabilitation. It has been shown in this population that severe
children of alcoholics has been prominent in the USA in recent withdrawal symptoms are surprisingly rare and that non-
years. medical detoxification is often sufficient, provided nursing
and medical help is available for the 5% who become seriously
Economic factors disturbed. An effective detoxification service can be used as
an entr´ee to a more stable lifestyle.
Alcohol is expensive, and the family budget suffers accord-
ingly. Earning power is usually reduced, which compounds Recognition and clinical management
the disability. The quality of accommodation which the heavy
drinker can sustain may decline, leading to homelessness. of alcohol-related problems

Employment problems Identification and assessment

Alcoholic employees usually develop a poor work record with The clinical manifestations of alcohol misuse are many and
frequent absences due to sickness, erratic time-keeping, low varied. Common ‘diagnoses’ seen on the sickness certificates
productivity and a greatly increased risk of accidents involving of people eventually diagnosed as alcohol-dependent include
themselves and others. The cost of all this to the employer has ‘stress’, anxiety states, depression, injuries, ‘gastritis’ and
prompted many companies to set up programmes to encourage ‘debility’. The general practitioner may have been aware of
employees with drinking problems to seek early treatment frequent absences from work for minor symptoms, or stress
(see below). symptoms in other members of the family, but the contribu-
tion of alcohol to these symptoms was overlooked or ignored.
Crime Patients rarely acknowledge alcohol as a problem at first
interview. They may be evasive because they are sensitised to
As many as 60% of prisoners report significant alcohol pro- criticism about their behaviour, and because admission of
blems. A quarter of young prisoners had been drinking when a drinking problem leads to the uncomfortable logic that
they committed their crime. Over 50% of male prisoners in something still enjoyed should be foresworn.
the UK were drinking hazardously in the year before coming
in to prison. Young offenders whose crimes are alcohol related Physicians should initially focus the interview on the
have been shown to benefit from attendance at alcohol educa- patient’s own current concerns and reasons for seeking help,
tion courses designed to promote sensible drinking practices and only later ask whether alcohol has been used to help that
(Baldwin 1991). symptom, or, on the other hand, has contributed to it. They
can then enquire about a recent period (e.g. the past 7 days)
Drink-driving offences are common among dependent drin- by asking in detail about work, leisure activities, the company
kers. One in three of all drivers killed have more than the legal kept, and the amount and type of beverage consumed. Spirits,
limit of alcohol in their blood. Offenders whose blood alcohol wines and beers should be enquired into separately.
is found to be exceptionally high (over 150 mg%), or who have
previous drink-driving convictions, are particularly likely to A basic principle for the clinician, whether psychiatrist,
be alcohol-dependent. Many drink-driving offenders have an physician, surgeon or general practitioner, is to bear in mind
elevated serum GGT indicating that they are regular heavy that alcohol can be a contributing factor for many presenting
drinkers. Drink-driving offences are also common in patients symptoms and to ask about alcohol use as part of routine his-
with other alcohol-related problems. tory taking. This simple step is often overlooked in acute and
psychiatric hospitals and general practice. Basic questions
Drunkenness offences should include:

The majority of men and women charged by the police • Do you find that alcohol helps your insomnia/ anxiety
with drunkenness offences have been shown to be alcohol- symptoms/ low mood/joint pains/etc. This helps convey
dependent, and 60% are homeless or living in hostels. The that the doctor realises that the patient may have many
Report on the habitual drunken offender (Home Office 1974) positive reasons for drinking, and is sometimes followed by
recognised that processing these people through the courts the patient defining the limitations of the positive aspects
was wasteful, and even dangerous as alcoholics sometimes died of the drinking.
in police custody. Concern has given rise to alternative
• How often do you take a drink? (¼ x)

370

Misuse of, and dependence on, alcohol and other drugs CHAPTER 14

• On a day when you drink, how many drinks would you A withdrawal fit may occur without other gross signs from
typically take? (¼ y) (Multiplying x and y together gives a any time between the first few hours of detoxification up till
rough estimate of number of units per week.) as late as 10 days.

• Have there been any days in the past month when you have The mean cell volume is raised (without anaemia) in 30–
had more than 10 units? 50% of patients, probably due to a direct toxic action of alco-
hol on the marrow. The gamma-glutamyl transferase (GGT)
• Have you had any problems from drinking in the past year? and/or other liver enzymes are elevated in 60–70% of patients,
due to enzyme induction and/or liver damage. They are
These questions should be asked of all newly admitted and markers of heavy drinking in the preceding 3–4 weeks. Other
referred patients. conditions such as liver disease or some medications can cause
similar elevations. Carbohydrate-deficient transferrin is a more
Brief questionnaires can be used in screening, such as specific but not more sensitive marker (not widely available in
AUDIT (Babor et al 1989) or the brief four-question FAST the UK). A reading on a portable breathalyser may help (or a
derived from AUDIT for use in accident & emergency depart- specimen for blood alcohol level). In a 70 kg man one unit
ments (Hodgson et al 2002), and CAGE (Ewing 1984). The (8 g) of ethanol produces a peak blood alcohol concentration
latter is more useful in identifying established serious drinking of about 15 mg% after about half an hour, and after about an
problems; the four questions for this are shown in Box 14.3. hour is no longer detectable in breath or blood. A patient
who appears sober at a blood alcohol concentration of
The English Screening and Intervention Programme for 200 mg% or above is highly tolerant and will almost certainly
Sensible Drinking (SIPS) has found adequate specificity and develop withdrawal symptoms on sudden cessation of drink-
sensitivity to employ, as a screening instrument, a single ing. On the other hand, the individual who appears drunk at
question ‘How often do you have X or more standard drinks 100 mg% or less lacks tolerance, and probably will not require
on one occasion?’ where X ¼ 6 for women and 8 for men, medication to control serious withdrawal symptoms. Chick &
with monthly or more frequently considered a positive Kemppainen (2007) have reviewed methods of recognising
screen. and estimating the severity of alcohol consumption and
dependence.
Severity of dependence is assessed as follows. Mildly
dependent patients will regularly notice restlessness at certain Assessment of brain damage, important in planning future
times of the day or in certain situations and at these times treatment, should be left until the patient has been free of
wish to have alcohol or seek out their drinking companions. alcohol for 3 weeks. If possible the spouse or partner or other
If they occasionally have very heavy sessions, they may relieve relatives should be interviewed, to add objectivity and to
the next morning’s hangover with a drink, but this will not be assess the quality of their relationship with the drinker. The
more than once or twice a week at most. More severely depen- spouse may feel angry or, less commonly guilty, and is reas-
dent patients report that the restlessness they feel without a sured when these feelings are acknowledged and understood.
drink is noticeable at times to colleagues or family, or prevents At this stage avoid reaching premature conclusions about
them from getting on with other activities. They organise ‘motivation’. A moment’s introspection shows that our own
their day to ensure that they are able to have a drink at times motivation to change familiar habits varies greatly from day
when they predict they will need one. There may be times to day. Problem drinkers are no exception. Clinicians have
when they feel unable to think of anything but getting a drink. to work with fluctuating levels of motivation. Probably the
Morning nausea, sweating and relief drinking may be reported psychiatrist’s most important first step is to acquire the trust
for periods of many days consecutively. Insomnia becomes of the patient and to establish an atmosphere in which frank-
frequent unless late evening intake relative to daytime drink- ness prevails and confrontation is seen as caring. Patients will
ing is very heavy. Wakefulness in the small hours of the night, then be able to start making decisions about themselves and
like daytime tenseness and anxiety in the dependent perhaps plan changes.
drinker, can be, of course, an effect of a falling blood alcohol
level. A widely used rating scale is the Severity of Alcohol Early intervention
Dependence Questionnaire (Stockwell et al 1979).
There are benefits of giving an intervention including advice
Tremor of the outstretched fingers or tongue, injected about ‘sensible drinking’ at an early stage in people’s drinking
conjunctivae and sclerae, stigmata of liver disease, excessive career when they are drinking in a hazardous way (i.e. drink-
facial skin capillarisation and alcohol on the breath indicate ing in a way which if sustained is likely to risk physical or
probable dependence. An epileptic fit for the first time in psychological harm) or have first experienced some pro-
an adult should raise the suspicion of alcohol dependence. blem related to their drinking. Simple focused advice given
in a primary healthcare or general hospital setting can be
Box 14.3 effective. The Cochrane review of studies in primary care by
Kaner et al (2009) found that participants who received a brief
CAGE questionnaire intervention reduced their alcohol consumption by a mean of
41 g/week more than participants in control groups, although
• Have you ever felt you should cut down on your drinking? there was substantial heterogeneity between trials. Subgroup
• Have people annoyed you by criticising your drinking?
• Have you ever felt bad or guilty about your drinking?
• Have you ever had a drink first thing in the morning to steady

your nerves and get rid of a hangover (eye-opener)?

371

Companion to Psychiatric Studies

analysis indicated that the benefit occurred in men but not ReRlaeplaspese Pre-contemplation
in women. Further studies are underway, particularly of Pre-contemplation
‘effectiveness’, that is, the assessment of the effects of brief
intervention when implemented in routine practice. Contemplation
Contemplation
Helping patients change their drinking
habits MMainatinetneannacnece ReaRdyeafodryafoctrioanction

Helping patients change their habits requires a considered and Action
phased approach. A person’s initial decision to seek help is
often fleeting and characterised by ambivalence about change. Action
The clinician can help by clarifying reasons for changing: for
example, by asking the patient to draw up a balance sheet of Fig. 14.3 Stages of change. (After Prochaska & Di Clemente 1992.)
the benefits versus the harms of continuing to drink in this
way. It is often helpful to explain the physiology of symptoms about making change. They also recognised a ‘readiness for
that may be due to physical dependence, and the role of action’ stage when they would be willing to accept positive
alcohol in other presenting symptoms, be it sleep disturbance, advice for change. The circle was completed by a period of
tension, depression or family disharmony. The status and role relapse or faltering of resolutions, indicating the need for
of a physician is a powerful persuasive force. The majority maintenance (Fig. 14.3).
of early intervention strategies aim to achieve a return to
problem-free drinking rather than total abstinence. Bien et al Other strategies for helping to achieve change
(1993) summarised the essential components of brief inter-
vention in the acronym FRAMES (Box 14.4). • Set goals – Goals should be defined by the patients and be
specific, attainable, short-term, immediately rewarding.
Motivational interviewing For example: no alcohol for 4 weeks; rewards: better
physical health, better family atmosphere. Abstinence is
While a significant number of patients seen in primary health- often immediately rewarding and is an easier target for
care and in hospital settings will respond to simple advice, many than partial reduction of drinking. However, some see
others will require more help to make a commitment to abstinence as totally inappropriate (though they may well
change. Patients tend to respond well to an interview style revise that if repeated attempts to control drinking fail).
which starts from the patient’s own concerns and uses open- For them an initial goal might be: reduce intake by half;
ended questions. These are aspects of the approach known or, reduce GGT to below 50 units/L, when the reward is
as motivational interviewing (Miller & Rollnick 2002). Motiva- the satisfaction of watching this measure of liver ‘strain’
tional interviewing is a technique which helps patients argue improve over the months.
their own case for a change, and reach their own decision
about what they wish to change. • Involve the family – Family distress is common, and advice
on being firm with the drinker, not entering into fruitless
Prochaska & Di Clemente (1992) observed that patients struggles, but remaining caring and positive, is often
came to see clinicians at different stages of readiness to make beneficial. Without information from those near at hand,
changes and that motivation was not a fixed and unchanging the clinician may not get the full picture from the patient.
entity, but fluctuated from day to day and in different cir-
cumstances. They divided patients into those who came at a • Enhance self-esteem – Often patients feel powerless to
precontemplative stage, that is before they had even recog- change their lives. The doctor should convey hope and
nised that alcohol was contributing to their problems, and encourage patients to believe in their own ability to
those at a contemplative stage where they were beginning to change things.
recognise that drinking was a problem but were ambivalent
• Review impediments to change such as former cues and
Box 14.4 triggers to drinking. Such cues may be subjective, for
instance the feelings of anxiety or depression which
FRAMES acronym experience suggests will be relieved by a drink; or external,
like the atmosphere among friends in the pub. The barriers
• Feedback about personal risk or impairment to change are varied (Box 14.5). Encourage substitute
• Responsibility — emphasis on personal responsibility for change activities: alternatives to drinking. For some, physical
• Advice to cut down or, if indicated because of severe dependence and the experience of withdrawal symptoms
will be a significant impediment necessitating detoxification
dependence or harm, to abstain as the initial step.
• Menu of alternative options for changing drinking pattern
• Empathic interviewing • Identify associated conditions such as depressive illness or
• Self efficacy – an interview style which enhances this phobias that might respond to specific treatment, but bear
in mind that many will be secondary to the drinking.

• Consider other agencies Alcoholics Anonymous (see below);
voluntary ‘Councils on Alcohol’ which may provide a

372

Misuse of, and dependence on, alcohol and other drugs CHAPTER 14

Box 14.5 pills found that medical (i.e. physician) management when
characterised by unwavering, optimism-instilling confidence
Barriers to change of habits in the treatment allied with flexibility in its application
improved outcomes, even after taking patient characteristics
• Dependence into account (Ernst et al 2008).
—Physical
—Psychological Pharmacotherapy and alcohol
dependence
• Stress
—Intrapsychic Detoxification
—Interpersonal
Medication to minimise withdrawal symptoms makes stopp-
• Environment ing drinking easier, and in very heavy drinkers, helps prevent
• Illness seizures and delirium. Hospital admission is only essential
when delirium threatens, and/or there is a history of fits or a
—Psychiatric current medical or psychiatric illness. A long-acting benzodiaz-
—Physical epine such as chlordiazepoxide (starting at 60–80 mg/day and
• Influence of others reducing to nil over 5–7 days) is usually adequate for commu-
• Stereotypes nity detoxification. Larger doses may be needed in hospital to
• Expectations control agitation and offset the likelihood of confusional states.
The final dose should be determined by regular clinical moni-
counselling service or a social programme; supportive toring, but the maximum dose should not exceed 400 mg
accommodation specifically for substance misusers. chlordiazepoxide in 24 hours (SIGN 2003). It should not be
• Follow-up – Active follow-up is one of the ingredients of continued for more than 10 days. If there is a history of fits,
successful treatment. Relapse is common in the first year greater initial doses of the benzodiazepine should be given.
after treatment. Brief but regular appointments help to In any circumstance the final dose should be determined by
remind the patient of goals and to provide an opportunity regular monitoring. Chlormethiazole effectively controls the
perhaps to repeat mean corpuscular volume or serum GGT withdrawal syndrome, but is not safe for outpatient use,
or breath alcohol measure. It is important to be prepared to because alcohol/chlormethiazole interactions cause respiratory
confront patients when necessary and risk anger. The depression and deaths have occurred. Major tranquillisers are
spouse or partner should usually be encouraged to attend less effective and may increase the risk of withdrawal fits
follow-up sessions. Relapse, if and when it occurs, should be (Mayo-Smith 1997), but are required if psychotic symptoms
viewed as an opportunity for further learning, not as an develop.
irrevocable catastrophe.
When the patient is reasonably well-intentioned and there
Close study of the factors that precipitate relapse shows that is someone at home, or a nurse or family doctor who can
they have a lot in common across a range of addictions. Marlatt visit, and where there is no history of fits and no confusion,
& Gordon (1984) analysed 311 relapses among patients with a withdrawal can be undertaken at home or at a community out-
variety of addictive behaviours (problem drinking, smoking, patient centre. The patient should be advised to take time off
heroin addiction, gambling and overeating). They identified work, to rest and to drink fruit juices and other soft drinks,
three high-risk situations which accounted for three-quarters but avoid caffeine-containing tea and coffee. In more severe
of all relapses: negative emotional states, interpersonal con- withdrawal it is sensible to check serum urea and electrolytes
flicts and environmental triggers. In therapy, the patient and aim to maintain an oral fluid intake of 2–21/2 litres daily.
should learn to identify cues to relapse and develop strategies
for handling them. In view of the frequency of cognitive impairment in heavy
drinkers and its probable relation to vitamin depletion, vitamin
Faith, hope and empathy supplements should be given to most patients, particularly
those who are poorly nourished, and if there is any evidence
Faith in the therapist, faith in the treatment, and the warmth, of cognitive impairment or neuropathy, they should be given
empathy and authenticity displayed by the therapist have orally for several months.
often been termed non-specific ingredients of therapy, but
they have a major influence on efficacy. In a 2-year follow- Deterrent medication
up study of outpatient treatment of problem drinkers, low-
empathy therapists were associated with the same or even Disulfiram (Antabuse) interferes with one step in ethanol
a worse outcome compared with giving patients a booklet breakdown, acetaldehyde dehydrogenase, so that once disul-
only, while high-empathy therapists significantly improved on firam has been taken for several days, absorption of alcohol
the booklet-only outcome (Miller & Baca 1983). Non-specific leads to a sudden rise in blood acetaldehyde and an unpleasant
factors in therapy need to be transformed into clearly defined reaction with flushing, headache, nausea, tachycardia, laboured
specifics. The COBINE study of 1383 patients randomly allo- breathing and hypotension. Disulfiram is a useful adjunct in
cated to ‘medical management’ by a physician, or a sophisticated the follow-up phase of treatment until a new lifestyle has
cognitive-behavioural package, and medications/placebo/no developed. In patients who have been taking disulfiram

373

Companion to Psychiatric Studies

regularly, the aversive interaction with ethanol lasts for several Sleep
days.
Poor sleep post detoxification is one among many factors
Disulfiram can be started when the blood/breath alcohol identified as predictors of relapse. The patient can be warned
level is zero. The patient and partner should be fully informed that sleep may take some weeks of abstinence to normalise,
about the mode of action of the drug and its hazards. With the and be encouraged to use sleep hygiene rather than medica-
recommended dose of 200 mg daily, the only frequent tions. Trazodone, widely used by GPs and psychiatrists
unwanted effects are tiredness (about 1 in 10 patients) and because of its short-term benefit on perceived sleep quality,
perhaps halitosis. Some patients prefer to take the drug at when compared to placebo for sleep complaints in the post
night. Reversible neuropathies and confusional states have also detoxification period, was found to be associated with
been reported. It should not be given to patients with recent increased drinking, when stopped after a few weeks (Friedman
heart disease, suicidal intentions or who take hypotensive et al 2008).
drugs. It should be avoided when there is active liver disease
(Chick 1999). To ensure success, the patient should be Emerging pharmacotherapy
encouraged to nominate a supervisor, for example, the spouse,
a general practice, a pharmacist, the clinic itself or an occupa- Baclofen is a GABAB agonist used for many years as a muscle
tional health nurse in cases with employment problems. The relaxant. Initial studies have found that it can reduce relapse
supervisor ensures that the compound is dispersed in water in alcohol dependence (Addolorato et al 2007) Although
and swallowed. These measures improve compliance which it has some antianxiety effects it appears to have low abuse
greatly improves efficacy. Disulfiram, when dispensed by a liability. It appears not to exacerbate psychomotor impairment
spouse as part of a contract, or by a clinic as part of an arrange- due to alcohol when given in combination with intoxicating
ment with the patient’s employer, is of proven efficacy in doses of alcohol in the laboratory (Evans & Bisaga 2009).
maintaining abstinence for substantial periods (Chick et al
1992), has been superior in several studies to naltrexone and Psychological treatments
acamprosate (e.g. Laaksonen et al 2008), helps to reduce
absenteeism at work (Robichaud et al 1979) and can assist Social skills training
even with socially deteriorated patients (Bourne et al 1966).
One clinic, where supervised disulfiram was the major plank Many excessive drinkers are influenced by social cues, and
for the first year of outpatient treatment and was continued many report that they feel deficient in social skills. Refusing
by some patients for much longer, reported a 7-year abstinence drinks, buying non-alcoholic drinks, applying for jobs, being
rate of 50% (Krampe et al 2006). firm with subordinates, expressing affection to loved ones
and expressing annoyance without being insulting are some of
Other drug treatments the items of interpersonal behaviour that alcoholics find it
useful to role-play in social skills training groups. In one of
There has been understandable resistance to the use of psy- the best-known methodological analyses of controlled trials
chotropic drugs in the treatment of alcohol problems because for treatments for alcohol disorders, social skills therapy was
of the risk of precipitating a further addiction. Drugs which one of the most consistently highly rated of the psychological
have specific effects on neurotransmitters have been shown treatments (Miller & Wilbourne 2002).
to reduce alcohol consumption in animal experiments. Several
studies have suggested that the frequency and severity of Group therapy
relapse can be reduced by use of the opiate antagonist naltrex-
one; others have shown benefits from acamprosate, which is a Participating in treatment in a group facilitates identification
GABA agonist and glutamate antagonist (Bouza et al 2004). and enhances self-esteem. Fellow problem drinkers are quick
Both have demonstrable effectiveness when combined with to expose the rationalisations and self-deception of their peers,
psychosocial interventions and, roughly, improve drinking out- but often do so sympathetically and with great tolerance. The
comes in one-third of patients compared with one-quarter in importance of Alcoholics Anonymous in the recovery of many
placebo-controls. At present most follow-up periods have been alcoholics is one indication of the value of the group process
less than 2 years. Acamprosate is established in the UK and and the fellowship this provides.
the rest of Europe, but appears less successful in the USA
(Anton et al 2006). Naltrexone is not licensed in the UK. Conjoint and family therapy

Antidepressant and antipsychotic medications can benefit Cohesiveness of marriage and family life is a predictor of
drinkers who have psychiatric disorders. However, it is impor- recovery. Family interviews enable members to have their
tant to remember that most symptoms of anxiety and depres- views heard, without the discussion spiralling into denials,
sion resolve after 2–3 weeks of abstinence without treatment. accusations and counter accusation. The patient can be helped
Studies of fluoxetine and fluvoxamine in alcohol dependence to see that family members are bound to feel hesitant at first
have suggested that patients whose drinking was problematic but that this need not imply that they do not care or appreci-
from before age 25 tend to drink more if prescribed SSRIs ate the efforts that are being made. The man who has opted
(Kranzler et al 1996; Chick et al 2004), and harmful effects out of married and family life, or who has gradually been
have also been shown for antipsychotic drugs (Guardia et al extruded because of his drinking, may suddenly want to
2004; Wiesbeck et al 2001).

374

Misuse of, and dependence on, alcohol and other drugs CHAPTER 14

resume his roles of husband and father, ignoring the fact and patient can work out appropriate strategies together
that others in the family now have their own way of doing (Fig. 14.4):
things.
• stick to drinks that are low in alcohol (e.g. low-strength
Other members of the family sometimes fear that the ther- beers rather than those that are extra strong);
apist is going to blame them for the patient’s drinking. The
psychiatrist’s invitation to them might be ‘to hear their views • avoid buying rounds;
of how things have been, and to have their opinions on how • intersperse drinks with non-alcoholic drinks;
X can best be helped’. Involving a partner or relative in therapy • go to the pub at 9.30 p.m. instead of 7.00 p.m.;
improves outcome and should be part of both assessment and • sip rather than gulp;
treatment whenever possible (Edwards & Steinglass 1995). • no lunch-time drinking;
(O’Farrell 1998). • eat while drinking;
• completely avoid situations or company where heavy
Community reinforcement approach: social
behaviour and network therapy drinking is likely; and
• set a limit (e.g. never more than 6 units per day).
One of the strongest predictors of improvement is a beneficial
change in the patient’s social network. Therapies have Keeping a daily record of consumption can help monitor prog-
emerged which structure the process of social skills acquisi- ress and review goals. Controlled studies on clinic attenders
tion and specifically engage family, friends and other contacts aimed at demonstrating the efficacy of controlled drinking
in the patient’s social network to reward positive changes in remain few and need replication (Heather & Robertson 1997).
behaviour and develop strategies for dealing with crises.
In contrast with family therapy, in this approach network Specialist services
members are part of the therapist’s working team, not subjects
of treatment (Galanter 1999; Meyers et al 2003; UKATT Units for the treatment of alcohol problems
Research Team 2005a).
These units offer a specialised service in most regions of
To drink or not to drink Britain. They have a responsibility for treatment, training and
research, and facilities of a similar kind are to be found in
Abstinence is the safest goal, particularly for those who have many parts of the industrial world. Traditionally they offered
sustained physical damage from alcohol or who have been inpatient treatment of 6 to 8 weeks’ duration with an emphasis
physically dependent, and for patients aged 40 and over. How- on group therapies. In recent years there has been a shift away
ever, in young people, particularly those who have not been from this devotion to inpatient treatment towards outpatient
severely physically dependent, return to limited drinking after therapy combined with brief inpatient or day-patient treat-
a few month’s abstinence is sometimes appropriate. Therapist ment. In response to evaluation studies which have cast doubts
on the importance of very intensive forms of therapy,
these units have become more flexible, offering a range of

PROBLEM Physical damage ENCOURAGE
DRINKING or history of severe ABSTINENCE

dependence

ENCOURAGE INITIAL Initial Physician and No physical damage. Further loss of
ABSTINENCE abstinence spouse agree to No history of control or
achieved limited drinking
(e.g. 3 MONTHS) severe dependence gradual escalation

Failed CONSIDER FURTHER FIX AMOUNT OF ALCOHOL Repeated loss of CHANGE DRINKING
abstinence PSYCHOLOGICAL AND PATTERN (e.g. 2–3 control or PATTERN, LOCATION
THERAPY AND/ DRINKS TWICE A WEEK)
OR ACAMPROSATE AND KEEP gradual escalation AND/OR DRINKING
OR SUPERVISED DIARY OF DRINKING COMPANIONS
DISULFIRAM
Limited drinking
RETURN TO NORMAL DRINKING Limited drinking maintained
Only 5–10% of problem drinkers who attend clinics seem eventually maintained
to re-establish problem-free drinking. It is not yet possible to identify Monitor blood
them in advance. Probably those who succeed are socially stable, tests and keep
younger, more conscientious individuals who have not been physically in touch with
dependent. They are also likely to be single or have spouses who are happy
to tolerate limited drinking and support their partners in achieving this relatives

Fig. 14.4 Advice to patients who have found total abstinence difficult. 375

Companion to Psychiatric Studies

approaches, including behaviour therapy, marital and family AA usually offers to meet a new affiliate personally and
therapy as well as more familiar but unproven group and facilitate an introduction to a group, though they will also
individual psychotherapy. warmly welcome anyone who simply turns up at a local
meeting. Records of outcomes are not kept and all members
Glaser (1980) has criticised the tendency for specialist ser- are anonymous, but observation shows that AA helps large
vices to act as if the alcoholic population were homogeneous numbers of regular attenders (Robinson 1979). Those most
and to offer a single form of treatment for all. This is clearly likely to adhere to AA tend to have suffered much harm from
inappropriate, and a careful assessment of each patient’s needs their drinking, but this is by no means always the case.
and matching of these to a range of treatment options is
required (US Department of Health and Human Services 1990). In the large US treatment outcome study, Project MATCH
(1998), patients who had been randomly allocated to a spe-
Councils on alcohol and alcohol advice centres cific method to help them understand the AA approach and
engage with AA (Twelve Step Facilitation) were more likely
Many countries now have counselling services separate from to achieve complete abstinence at 1 year than patients allo-
psychiatric or medical clinics. Problem drinkers or their cated to cognitive behavioural therapy or to a (less frequent)
families may initiate the contact, and referrals will be accepted motivational interviewing therapy. The advantage of the
from doctors. AA-facilitation was most marked in those patients who lived
or worked in an environment where there were other drin-
Alcohol-related offences are commonplace, and some courts kers (Longabough et al 1998). Vaillant (1995) followed
now have access to programmes which help offenders learn to 100 patients at regular intervals for 8 years. Of the 39 men
drink sensibly and break the link between crime and alcohol. attaining stable abstinence, two-thirds did so through AA.
Similar strategies have been used in rehabilitating persistent In the same city, 120 problem drinkers identified in the com-
drink driving offenders. munity and not at clinics, and who were followed for between
10 and 30 years, yielded 34% who became stable abstainers.
Employment policies Of those, a third were regular AA attenders and many had
commenced abstinence through that route.
Many employers hold an alcohol in employment policy arranged
between management and the trade unions so that those who For the 12-step method as offered by clinics, as opposed to
are drinking where it affects work performance can be helped facilitating attendance at AA meetings themselves, randomised
while safety and productivity at work is ensured. If drinking controlled trials have been conducted but it has proved diffi-
leads to a breach of work regulations, the employee may be cult to establish a distinct advantage. For example, Gr nbaek
offered the opportunity of attending a treatment service rather and Nielsen(2007) found that 12 months after onset of treat-
than facing disciplinary proceedings. The outcome of problem ment, patients allocated to a private 12-step based ‘Minnesota
drinkers identified and treated in the work context tends to be model’ day clinic treatment were total abstainers for a slightly
good. longer average period than patients allocated to a much cheaper
‘standard’ public treatment. However, other parameters of suc-
Safety-critical jobs include medicine and other health pro- cess were not significantly better for the ‘Minnesota’ treatment.
fessions. Alcohol misuse accounts for the largest single health
issue dealt with by the UK General Medical Council fitness Al-Anon is a fellowship which offers mutual support and
to practise section. With appropriate help, doctors can make understanding following the 12-step philosophy as applied to
sustained recovery and continue to practise, and employers the families and spouses of alcoholics. Attenders begin to learn
are encouraged to identify problems at an early stage. they are ‘powerless’ over the other’s addictive illness and can
learn to detach from the struggle with the drinking, but with-
Alcoholics Anonymous out withdrawing support for sober behaviour. An affiliated
body is Al-Ateen, for the teenage children of alcoholics.
Since the meeting of its two founder members, Dr Bob and
Bill W in Akron, Ohio, in 1935, Alcoholics Anonymous (AA) Services for the homeless alcoholic
has spread to most countries of the world and now is believed
to have 2 million members worldwide. It grew particularly in The homeless alcoholic usually finds abstinence unattainable
the 1960s and 1970s in the USA and the UK, and is currently unless he can be helped out of the environment of street
growing at a rate of 15% per annum. Members meet regularly drinking, lodging houses or sleeping in the open. Engaging
and share a common belief that as alcoholics they are power- such individuals in treatment is often difficult, and outreach
less where alcohol is concerned and that total abstinence is services have been developed working with the homeless, to
the only route to recovery. maintain contact and encourage them to utilise services.

The principles on which AA was founded are open self- Hostels that require abstinence as a condition of residence
scrutiny, the giving of aid to others and fellowship. The AA can help in rehabilitation especially if they provide a therapeu-
programme offers hope and clear, simple advice (e.g. avoid tic programme in which the residents help each other to find
the first drink; attend meetings; take life one day at a time; a new lifestyle. After a residence of up to 1 year, many find
stay sober for yourself). A prayer is said at every meeting, the transition to independent life extremely difficult, and
but potential affiliates need not be put off by AA’s spiritual some provide half-way houses and supported accommodation
language. Hedblom (2007) offers a helpful socio-psychological as the next stage. In some cities there is accommodation for
analysis of the AA recovery process and the meaning of alcoholics who continue to drink. These ‘wet houses’ provide
spirituality in that context.

376

Misuse of, and dependence on, alcohol and other drugs CHAPTER 14

some shelter and support, and perhaps a dialogue to open the replacing the receiver, having offered an appointment in
way to longer-term rehabilitation. the near future ‘when sober’, and ‘not continuing the discus-
sion until you sound less intoxicated’ is often appropriate.
The intoxicated patient Acknowledgement of negative or even suicidal thoughts, with-
out condoning them, and an offer of assessment within, say,
When to undertake a mental state 48 hours may help to terminate the call.
examination?
Management of drug misuse

A definitive mental state examination can only be conducted Assessment and management of clinical
when the patient is sober or at least behaving in a sober fashion conditions associated with drug use
(which if the patient is highly tolerant to alcohol could
be when they still have alcohol on the breath). However, if Every doctor is now likely to see patients who misuse drugs,
suicide or homicidal risk is intimated, we are bound to make be it a member of staff in the accident & emergency depart-
an assessment of the degree of risk. It is common for intoxi- ment dealing with an acutely intoxicated patient, the general
cated patients to portray such risk more graphically than they practitioner confronted with concerns around the harmful
would if sober, even when intent is not great. For suicidal use of various substances, the obstetrician faced with a preg-
threats, a relatively safe intervention will often be a recognition nant patient whose drug use has been disclosed because of
that ’perhaps you see suicide as a solution to your current dif- concerns about the child, the police surgeon attending a
ficulties’ with a suggestion that ‘there may be other solutions patient in the cells with a drug-induced psychosis, the house
that could be discussed with you if you attend sober tomorrow officer in the general hospital confronted with a patient under-
morning’. For homicidal threat a cooling period in the emer- going withdrawal from drugs, the psychiatrist having to dif-
gency setting, perhaps with police present, often permits ferentiate drug-induced psychopathology from other causes
retraction of the threat. or the specialist drug service trying to help patients with a
dependence syndrome who have already failed to give up the
Is it likely that withdrawal might lead substance by themselves. Prior to assessment, a low index of
to delirium or seizures? suspicion of drug misuse is required; early detection is pre-
ferable to the subsequent management of the dependence
If the patient is intoxicated when seen, a breath alcohol level syndrome. Assessment is based on standard clinical skills of
will help. If the level is equivalent to, say, over 350 mg% in history, examination and investigation. However, emphasis is
blood (1.60 mcg/litre in breath), then he is likely to be given to:
severely dependent, and might begin to show withdrawal signs
when the level has dropped to 100 mg%. However, someone • drug use and previous treatment;
appearing intoxicated at 150 mg% is probably not severely • objective signs of withdrawal;
dependent. • needle marks;
• toxicology;
If a patient has had delirium or seizures in the past couple • mental state;
of years after sudden cessation of drinking, then they should • comorbid, physical and mental conditions, e.g. HIV,
be advised not to stop drinking suddenly without medication
cover. They could, however, be advised to attempt gradually hepatitis B or C;
cutting down alcohol intake over 1–2 weeks. • areas of conflict: relationships, jobs, debt, the law; and
• support structure.
How intoxicated? Subjective versus
objective assessment During the late 1980s and early 1990s, much of the funding
and impetus for the setting up of services for drug use and
Breathalysers should be readily available in all hospitals (and its associated problems was driven by concern about HIV. This
primary care health centres too, in our opinion). That is the is now less of an issue among drug users as injecting has
correct way to assess level of alcoholisation. Neurophysiologic declined and knowledge exists within the drug-using subcul-
intoxication shows as emotional lability, disinhibited (i.e. over- ture about the risks of spread of HIV and hepatitis B and C.
familiar) interactions with others, slurred speech, unsteady That said, knowledge in itself does not change behaviour, and
gait and slow responses to questions (slow mentation). the incidence of sharing among those that inject continues to
be high. As a result, detailed questioning may be required if
injecting is practised.

The intoxicated phone caller Acute intoxication (ICD-10 F1X.0)

Psychiatrists and their teams receive emotionally loaded, ram- This may require the medical or surgical management of injuries
bling, drunken phone calls from alcohol-dependent patients, occurring secondary to the intoxication. It may also require
sometimes with threats of self-harm. Experience shows that observation of any head injuries. Life support may be required

377

Companion to Psychiatric Studies

in the event of coma and in some instances (e.g. opiates) antago- withdrawal and the drugs that may be used are discussed later
nists may be available and given to reverse drug effects. Offensive under the individual drug types.
or dangerous disinhibited behaviour may require containment
until drug effects decline. Acute intoxication is a transient phe- Psychotic disorder (F1X.5)
nomenon, and recovery is therefore complete.
This requires management as any other psychotic disorder, but
Harmful use (F1X.1) the aetiology is drug induced. The disorder typically resolves at
least partially within 1 month and fully within 6 months and,
A patient may be recovered from intoxication or be presenting as long as the patient remains drug-free, is unlikely to reoccur.
with some other medical condition and has raised drug use as a
personal concern. Education is required around the dangers Residual and late-onset psychotic disorders
of drug use and the options explained about how to change (F1X.7)
that behaviour. Some patients may not see their drug use as
a problem, and the concepts of Prochaska & Di Clemente Here a variety of conditions may be present which have been
(1992) are helpful (see Fig. 14.2). If patients are experiencing caused by drug use but are now persisting despite termination
harmful use but are in a precontemplative phase (i.e. do of drug use. These conditions include flashback phenomena
not recognise their drug problem), then efforts to encourage (F1X.70), personality or behavioural disorder (F1X.71), resid-
abstinence will fail. In this case, the process of motivational ual affective disorder (F1X.72), dementia (F1X.73), other
interviewing (see p. 372) can be used to effect change in the persisting problems of impairment (F1X.74) and late-onset
direction of awareness and a wish to move away from harmful psychotic disorders (F1X.75). The management of these
drug use (Miller & Rollnick 1991). conditions is symptomatic.

Dependence syndrome (F1X.2) Goals of treatment

Once this has developed, management will depend on the The rationale for this heading may seem obscure, because
patient, drug and the patient’s environment (Department of surely the goal of treatment must be recovery. However,
Health 1999). If the patient is continuing to use (F1X.24), recovery has been associated with abstinence and as this is
management is as outlined above for harmful use. Alterna- rarely achieved in the dependent patient therapeutic nihilism
tively, if abstinent and in the community (F1X.20), then the may develop. To avoid this, it is important to elaborate
focus should be on relapse prevention techniques which are on the goals of treatment. Most clinical conditions are self-
discussed later in the chapter (p. 381). Other alternative cate- limiting and only require supportive management. A few resid-
gories within the dependence syndrome include the patient ual states exist where the management is no longer directed at
being abstinent but in a protected environment (F1X.21). drug use but at helping people live with their changed state.
These treatment settings may be divided into four groups: The difficulty comes when one is confronted with people who
rehabilitation houses; religious units; community crisis reha- continue to use drugs, or are dependent on drugs, and require
bilitation units; and residential 12-step programmes. The help in gaining awareness of the problems that their drug use
essential elements of management within these units are to is causing them. The hierarchy of goals and harm reduction
provide a safe drug-free environment, to address pre-existing for intravenous drug users and others is given in Box 14.6.
causes, solve current problems and equip patients with greater
personal resources for their discharge back to the community. Health professionals tend to focus on health. However, it
Another category concerns the patient who is abstinent but needs to be accepted that, in cost–benefit terms, preventing
receiving treatment with antagonist drugs (F1X.23) (e.g. opi- drug-related crime is today more the driving force behind
ate dependence, receiving naltrexone). Management in this the provision of services for drug users than is the fear of an
instance usually involves a partner supervising daily consumption HIV epidemic. It is estimated that class A drug use incurs
at the start of a period of abstinence, and the provision of some crime and health costs of £15.4 billion annually in the
chemical support while relapse prevention techniques are
acquired. The final category is that of the patient in a clini- Box 14.6
cally supervised maintenance or replacement regimen (con-
trolled dependence) (F1X.22). In maintenance programmes, Hierarchy of therapeutic goals for intravenous drug
chaotic illegal dependence is replaced with controlled legal users
dependence. Once established, the management is similar to
that of those who are in protected environments. 1. Reduction of sharing of injecting equipment
2. Reduction in injecting
Withdrawal state, with (F1X.3) or without 3. Reduction in street drug use
delirium (F1X.4) 4. Stabilisation on substitute prescribing
5. Management of features associated with dependence syndrome
Withdrawal states may be managed by acute abstinence 6. Reduction in substitute prescribing
and symptomatic supportive measures or, more commonly, 7. Maintenance of abstinence from psychoactive drugs
the initiation of substitute medication and then a graduated,
more humane withdrawal over a period of time. The types of

378

Misuse of, and dependence on, alcohol and other drugs CHAPTER 14

UK (2007 costs). The cost to the Government to deliver its Inpatient detoxification prior to transfer to a rehabilitation
strategy for dealing with drug users is similarly substantial, programme may improve retention rates, as there is often a
in excess of £940 million (for the year 2007/8). Diversion high dropout if patients go direct to drug-free rehabs while
from the criminal justice system into healthcare has become still using.
more important with the development of drug testing on
arrest, with drug worker assessments and rapid access to crim- The majority of patients with opiate drug dependence
inal justice supported treatment. A similar approach is being syndrome receive a maintenance programme. This is probably
taken with parents whose drug use may put their children at the most extensively evaluated treatment within this field, and
risk, with increased testing and child and family social work repeated reviews of the literature have confirmed that compli-
supported treatment (HM Government Drug Strategy 2008). ance with the treatment is good and that it reduces illicit drug
use (Mattick et al 2008). There is less robust evidence that
Specific drugs and treatment options methadone reduces criminal activity, lowers risk of serocon-
version for HIV, hepatitis B and hepatitis C, and improves
Opiates re-socialisation (Farrell et al 1994). It needs to be remem-
bered, however, that methadone itself is not the treatment,
Acute intoxication with opiates can result in respiratory and needs to be given in conjunction with a full package of
depression and sometimes death. This is not an uncommon care, with contingent management being shown to be most
event. An Australian study of heroin users indicated that effective (Dutra et al 2008). The research on maintenance pre-
two-thirds had had a drug overdose, and a third had had one scribing is chiefly with oral methadone and buprenorphine.
within the past year (Darke et al 1995). One reason for this Doses in the UK were primarily aimed at the minimum dose
may be that the purity of heroin varies so that the dose being to avoid withdrawal symptoms, but if the goal is the reduc-
taken is unpredictable. Alternatively, a dose of drug that takes tion of illicit drug use then a higher dose is usually needed.
the user near to the edge of death may maximise the euphoric A typical dose of methadone may be in the region of 60–
effect. An increasing presentation of opiate intoxication is 120 mg methadone mixture, 1 mg/ml, per day. Doses of
methadone overdose (Hickman et al 2007). The reasons for 50 mg and above have been associated with death in naive drug
this are complex, but undoubtedly more users are presenting users. In addition, approximately 10% of substitute metha-
to services with methadone as their route into opiate depen- done prescribing in Britain is in an injectable form, a practice
dence rather than heroin. Methadone overdose can be difficult which used to be exclusive to the UK and has some research
to control and follows an unpredictable course in non-tolerant support for its use (Strang et al 2000), but the case for inject-
patients, who are at risk of sudden death. Clinical management able substitute prescribing is by no means made (Zador 2001).
of opiate overdose follows general guidelines. The opiate The remaining 10% of methadone prescriptions are for the
antagonist naloxone may be used in a dose of 0.4 mg i.v. to tablet form, which is readily acknowledged as being easy to
reverse respiratory depression, but as it is short-acting, and reconstitute for injection and therefore is specifically now
the overdose may be of a long-acting drug such as methadone, contraindicated in dependent opiate users (Department
subsequent infusion may be required. Concern about the of Health 1999). In the UK there is greater provision of
mortality of accidental opiate overdose has made some advo- ‘take-home’ medication than in the USA or Australia, where
cate the ‘take-home’ of naloxone by opiate addicts (Strang the majority of medication is dispensed on a daily basis and
et al 2006). often with supervised consumption at the point of collec-
tion. In the UK, opiate substitution is still dominated by
Patients with an opiate dependence syndrome tradition- methadone (83%), with an average daily dose of 56.3 mg,
ally constitute the bulk of specialist drug services work. Their with some buprenorphine (16%). There are more frequent
management depends on their pattern of use. If still using, and daily dispensing instalments (60%), more supervised con-
not prepared to move towards abstinence from street drugs, sumption (36%) and fewer methadone tablets (1.8%) than
then harm reduction strategies are employed as described 10 years ago, all in line with best practice (Strang et al
above. Some may be abstinent and concentrating their therapy 2007). Buprenorphine is also an effective intervention for use
on relapse prevention techniques. Some may be abstinent and in the maintenance treatment of opiate dependence, but it
supplementing their relapse prevention techniques with a trial is not more effective than methadone at adequate dosages
of naltrexone at a dose of 50 mg a day. This is an opiate antag- (Mattick et al 2008).
onist similar to naloxone but can be administered orally and
lasts for over 24 hours. A comprehensive review has been car- The opiate withdrawal syndrome can be characterised by
ried out by Kirchmayer and colleagues (2002). However, most nausea, vomiting, muscle aches, lacrimation, rhinorrhoea,
abstinent drug users chose not to carry on with naltrexone. pupillary dilatation, piloerection, sweating, diarrhoea, yawning,
There has been some promising work using naltrexone as a fever and insomnia. The severity and length of withdrawal
condition of treatment for people who repeatedly offend to is dependent on the drug of abuse, shorter-acting drugs
finance their drug habit. The best results with naltrexone tending to have more severe withdrawal over shorter periods
treatment have been reported in studies with certain target than do longer-acting drugs. Some describe withdrawal as a
groups (particularly people who are highly motivated, e.g. ‘flu-like’ illness but others demonstratively have a severe reac-
doctors) who have developed a drug dependence syndrome tion. This may in part be due to expectation, but the level
on opiates (Washton et al 1984). A select group of patients of tolerance and dependence on the drug also contribute.
may elect to go into drug-free rehabilitation programmes. The withdrawal is managed with substitution of the opiate,
usually methadone, and a gradual reduction is then carried

379

Companion to Psychiatric Studies

out over a period of time. The shortest period advocated is improvement throughout the withdrawal period. There is no
24 hours (Carreno et al 2002) – this needs to be carried specific symptomatic treatment, and the majority of stimulant
out in an intensive care unit and involves naltrexone-induced users end their dependence without resorting to medical
withdrawal, with heavy sedation. More typical withdrawal support.
periods are of 10–21 days on an inpatient basis. Symptomatic
treatment may be given with, for example, a2 adrenergic Sedatives and hypnotics
agonists such as clonidine or lofexidine, but these drugs have
no effect on the insomnia, craving and muscle aches associated Illicit use of drugs in this group is now almost exclusively of
with withdrawal (McCambridge et al 2007). Longer out- benzodiazepines, although historically barbiturates have been
patient maintenance to abstinence programmes are also used important. The management of benzodiazepine acute intoxica-
(Farrell 1994). tion follows general principles, and the benzodiazepine antago-
nist flumazenil may be used to reverse the onset of respiratory
The medical management of opiate withdrawal is not com- depression and coma. Sedatives and hypnotics are also com-
plicated other than in the very short procedures. The difficulty monly used in conjunction with other drugs, particularly
is in achieving continued abstinence, and this is discussed stimulants and alcohol. There is extensive harmful use of this
further under ‘Relapse prevention’. However, approaches that class of drugs, the harm including increased risk behaviour by
might increase compliance with subsequent naltrexone main- intravenous drug users (Strang et al 1994), an increased associ-
tenance treatment, such as antagonist-induced regimens, ation with accidents (Currie et al 1995), aggression (Bond et al
require further research to confirm their relative effectiveness, 1995), deterioration in performance (Kerr et al 1992) and
as well as variables influencing the severity of withdrawal and amnesic effects which can be used medically to good purpose
adverse effects (Gowing et al 2002). in surgical premedication (Hindmarch et al 1993). Iatrogenic
initiation of benzodiazepines, with subsequent dependence,
Stimulants remains a concern (Surendrakumar et al 1992), despite the
recommendations from the Committee on Safety of Medicines
Intoxication with stimulants appears to be less common than (1988) to limit treatment to short courses only. Medical negli-
with opiates, possibly because there is a loss of pleasurable gence may be claimed in these cases, and long-term use
effect at high doses, the mental state becomes associated with requires careful consideration (Hallstrom 1990). Iatrogenic
paranoia and psychosis, and convulsions may result. Treatment benzodiazepine drug dependence is more common than high-
is symptomatic. Patients with a stimulant dependence syn- dose illicit benzodiazepine drug dependence (usually in the
drome in the UK usually abuse amphetamines, but increasingly context of multiple drug use). The latter group poses a sig-
there are cases of dependence on cocaine and ‘crack’ cocaine. nificant clinical challenge, but has been studied the least.
If patients continue to use, then harm reduction advice is As to the former, the clinical management has been reviewed
essential as with any other substance. However, treatment (Higgitt et al 1985) and guidelines have been issued (Sub-
options are few and abstinence orientated, with the majority stance Abuse Committee of the Mental Health Foundation
involving residential settings (Schuckit 1994). Therefore, the 1992). The best outcome in this group is associated with youn-
main focus is on relapse prevention. Various drugs have been ger patients, fewer withdrawal symptoms and at 6 months
suggested as being useful in the stimulant dependence syn- post-withdrawal less personality disturbance and longer dura-
drome, including bromocryptine, which theoretically should tion of use prior to withdrawal (Holton et al 1992). In high-
alleviate the hypothesised dopamine depletion of chronic dose illicit use, management of a dependence syndrome may
stimulant abuse. Other drugs which boost dopamine activity be different. One finding is that drug users prefer high-dose
include mazindol, flupenthixol and amantadine. Unfortunately, short-acting compounds and are more likely to seek these
research results do not justify their use as part of a standard out (Griffiths & Wolff 1990). There is no research support
therapy for stimulant-dependent individuals. Antidepressant for maintenance prescribing.
medication has been used in view of the mood swings expe-
rienced following stimulant abstinence. Again, while theo- The withdrawal state has features which are clinically
retically sound, the research does not provide support for similar and sometimes indistinguishable from anxiety states.
antidepressant use in day-to-day practice (Lima et al 2002). Additional features include hypersensitivity in all senses,
There are limited randomized controlled trials published on de-realisation and depersonalisation. Late presentations of
substitute prescribing for stimulant dependence syndrome, withdrawal include psychotic states and convulsions. The man-
suggesting that dexamphetamine and modafinil may play a agement of withdrawal involves substitute prescribing of
future role (Castells et al 2007). a long-acting benzodiazepine (e.g. diazepam). Then gradual
controlled withdrawal with the cooperation of the patient
Stimulant withdrawal has been suggested by some to be a can take place over a period of months. Rapid inpatient detox-
triphasic state with a ‘crash’, ‘withdrawal’ and ‘extinction’ ification may be unsafe (Denis et al 2006). Associated features
phase. The crash typically occurs within 30 minutes and may of withdrawal are managed symptomatically as they arise, as
last up to 40 hours. The withdrawal phase tends to peak at outlined above in the treatment of iatrogenic dependence.
2–4 days and various depressive symptoms last for several
weeks after that, including hypersomnia, fatigue, anhedonia, There is increasing abuse of gamma-hydroxybutyrate (GHB)
sadness, suicidal ideation and general malaise (Lago & Kosten and gamma-butyrolactone (GBL) in the UK. The risk of
1994). However, this description of stimulant withdrawal psychosis during withdrawal can be managed using inpatient
has not been repeated by others, who find a persistent, gradual high-dose benzodiazepines (McDonough et al 2004).

380

Misuse of, and dependence on, alcohol and other drugs CHAPTER 14

Hallucinogens Little evidence has been found (Ashton 2001) of long-term
negative consequences for chronic users, but marijuana smoke
There is a large variety of hallucinogens. These include psilocy- contains the same carcinogens as tobacco smoke, usually in
bin and mescaline (primarily found in fungicides), lysergic acid somewhat higher concentration, and therefore long-term phys-
diethylamide (LSD), 3,4-methylenedioxymethamphetamine ical health may well be damaged. Cannabis has been made
(MDMA) and many other compounds with botanical origin available on prescription in two American states. This is for
(De Smet 1996). The drugs that most commonly present clin- symptomatic treatment of various conditions, including
ically are LSD and MDMA. Hallucinogenic intoxication usu- cancer, chronic pain and spasticity. Randomised controlled
ally only presents when there is a ‘bad trip’, the occurrence trials have shown some promise (Wade et al 2006).
of which is mainly determined by the mental set and environ-
ment of the user. If the user is not relaxed, or is feeling under Solvents
pressure of time, or had a recent argument, or holding major
resentments, this may lead to a bad trip. In addition, solitary Acute intoxication with solvents can produce coma and death.
experimentation in an over-stimulated environment can also In addition, there are quite specific problems of sudden death,
precipitate bad experiences. These experiences usually wear usually related to cardiac arrhythmia, or vasovagal inhibition
off before medical intervention is sought. However, treatment resulting in cardiac arrest. There is no place for harm reduc-
should be directed at preventing the patient from physically tion in solvent misuse, and the sole goal is abstinence. There
harming themselves, or others. Reducing external stimulation is limited evidence that a dependence syndrome with spe-
and focusing on a single individual, preferably a friend, may cific withdrawal occurs. Residual states due to long-term use
be used to help the user calm down. The somatic (dizziness, can occur, as there is extensive multiple organ damage with
paraesthesiae, weakness and tremor), perceptual (altered real- protracted use. Treatment is symptomatic. The main focus
ity) and psychic (labile mood, dreams, altered time sense and for solvents is prevention, early detection and abstinence
depersonalisation) symptoms may be so severe as to require (Advisory Council on the Misuse of Drugs 1995).
antipsychotic medication, such as chlorpromazine. Some of
the adverse reactions that occur after LSD are not due to the Relapse prevention
drug but to contaminants, such as phencyclidine (PCP). There
appears to be no significant dependence syndrome or with- Once a former user is abstinent from the substance, the pro-
drawal state for the hallucinogenic group. There is some con- cess of keeping him drug-free is described as relapse preven-
cern over the hallucinogenic residual state of flash-backs, tion. The psychological and psychobiological models of this
which occurs in a small proportion. Over time, their intensity, process are well developed (Connors et al 1996). However,
frequency and duration diminish (Frankel 1994). There is no there has been limited outcome research to support the model
evidence of any neurotoxic effect of LSD, but this is not for addictions other than to alcohol. Substance misuse needs
the case for MDMA. to be seen as a chronic relapsing disorder. Progress in the area
is hampered by variation in the definition of relapse itself.
Acute intoxication with MDMA can produce a syndrome Reported outcomes can vary between studies depending on
similar to the serotonergic syndrome and neuroleptic malignant whether they report on a continuous basis along a dimension,
syndrome (Demirkiran et al 1996). This condition is managed or just for short periods repeatedly throughout that dimension.
in the same way as the neuroleptic malignant syndrome. Also, is relapse focused just on the substance misused or is
Harmful use of MDMA occurs as a result of tolerance, where there a more comprehensive assessment, including other areas
users may increase the dose to achieve the original effect, of physical psychological and social functioning? In addition,
and this may result in neurotoxicity. This toxicity consists of the threshold at which a drug is being used and what constitu-
residual alterations of serotonergic transmission, although at tes a relapse need to be defined. Does any use constitute
least partial restitution may occur after long-term abstinence, a relapse or may it just be seen as a lapse which is rapidly
with functional sequelae persisting even after longer periods followed by reinstatement of abstinence? The inclusion of
of abstinence. To date, the most consistent findings associate assessments of whether there is transfer to another substance
subtle cognitive, particularly memory, impairments with heavy or behaviour of dependence, and issues around verification
ecstasy use (Gouzoulis-Mayfrank & Daumann 2006). and the importance placed on this, are also undecided and
make analysis across studies difficult. The continued develop-
Cannabis ment and harmonisation of accepted standards of outcome
measures makes it more likely that, in the future, studies of
As with hallucinogens, the premorbid state and setting are individual groups can be generalised beyond the setting
influential in determining bad reactions to acute ingestion. of the research. Miller and colleagues in 1996 conducted an
In a dose–response manner, acute intoxication with cannabis analysis of alcohol relapse that could be extended to other sub-
can result in disturbances of perception and, in severe cases, stances. In addition to pretreatment characteristics, they iden-
psychotic states (Ghodse 1986; Thomas 1993; Johns 2001). tified five factors mediating tendency to relapse (Box 14.7).
A dependence syndrome for cannabis occurs in a small minor-
ity of users; treatment tends to be aimed at reduced consump- The practical process of applying relapse prevention
tion and abstinence. Withdrawal from cannabis is also reported involves various key themes outlined by Daley & Marlatt
for high-dose chronic users, but the literature is poor and (1992) (Box 14.8).
unclear as to what the withdrawal features are (Smith 2002).

381

Companion to Psychiatric Studies

Box 14.7 acute conditions, and rarely as a chronic condition such as
chronic medical illnesses such as diabetes, hypertension and
Factors mediating tendency to relapse asthma (McLellan 2002). However, of the various treatments
discussed in this chapter, methadone maintenance has been
• Negative life events most evaluated. There is an extensive review of the literature
• Cognitive appraisal, including self-efficacy, expectancy and by Ward and colleagues (1998). In the UK numbers of
patients receiving substitute prescriptions (mainly methadone)
motivation for change have increased from 85 000 in 1998 to 195 000 by 2006/07.
• Client coping resources Research shows increased compliance with treatment, reduc-
• Craving experiences tion in crime by 50% year on year, reductions in illicit drug
• Affective/mood status use, reductions in sharing and improvements in psychosocial
functioning. Inpatient detoxification is also advocated within
Miller et al (1996). the UK, and outcome studies do show abstinence rates near
50% at 6-month follow-up (Johns 1994). As for other treat-
Box 14.8 ments in substance misuse, not all treatments work on all
patients. The attempts in alcohol research to match patients
Themes important in relapse prevention to particular treatments will no doubt be duplicated in other
drugs.
• Help patients identify their high-risk relapse factors and develop
strategies to deal with them An evaluation of treatments in the opiate dependence syn-
drome was carried out by The National Treatment Outcome
• Help patients understand relapse as a process and as an event Research Study. This involved 1110 people who entered treat-
• Help patients understand and deal with substance cues as well ment in 1995, who were in residential programmes, inpatient
units, methadone maintenance or methadone reduction
as actual cravings programmes. The findings after 5 years (National Treatment
• Help patients understand and deal with social pressures to use Outcome Research Study 2001) show reductions in:

drugs • heroin and other drug use (at 5 years abstinence rates for
• Help patients to develop a supportive relapse prevention opiates were 47% in the residential settings and 35% for
those previously taking methadone; continued daily opiate
network use was about 20% for both groups, and 40% were still
• Help patients develop methods of coping with negative using heroin at least once a week);

emotional states • injecting (60% falling to 37% in both groups);
• Help patients learn methods to cope with cognitive distortions • sharing injecting equipment (falling from 14% to 5% in the
• Help patients work towards a balanced lifestyle
• Help patients develop a plan to interrupt a lapse or relapse 5 years);
• physical and psychological ill health (improved but still
Some specific work has been done with opiate addicts to
assess whether they can predict their own relapse (Powell with an annual mortality rate of 1.2% – much higher than
et al 1993). In this study, 43 opiate addicts who had under- age-matched peers); and
gone inpatient detoxification were followed-up at 6 months. • criminal activity (reduced by 50% at 1 year and then largely
Those with lower self-esteem and higher positive expectancies dependent on whether heroin use continued).
were using less often. Latency to first lapse was longer in sub-
jects with higher anxiety and neuroticism score. It is suggested An economic evaluation of treatment showed that for every £1
that greater awareness of personal vulnerability may promote spent on treatment £3 was saved in the criminal justice
effective coping strategies. Experimental models have also system. However, the more important results addressing ques-
been used with this population to examine mood effects tions such as the relationship between client characteristics
(euphoria, depression, anxiety and anger). This showed that and treatment outcome, or the relationship between treatment
induced depression increased drug craving, and tended to structure, process and outcome, will follow in the coming
increase opiate withdrawal symptoms. Other trends were years.
also outlined and a suggestion was made that these may
become a conditioned stimulus to trigger a relapse (Childress Evaluation of treatment for alcohol misuse
et al 1994).
There is considerable instability in the drinking status of
Evaluation of treatments samples of patients followed up in the first 2–4 years after
commencing treatment (Polich et al 1981). Ten studies are
Evaluation of treatments for drug misuse published where follow-up was at least 8 years and objective
as well as subjective data are available on outcome. A fifth of
Prior to addressing the research into the evaluation of sub- subjects died (a mortality rate two to three times greater than
stance misuse treatments it is worth reflecting on the percep- expected). Of the survivors, half to two-thirds were still in
tion that addiction treatments are evaluated on the basis of some difficulty with their drinking. Of those who were well,
most were abstainers. Some 5–10% had been drinking without

382

Misuse of, and dependence on, alcohol and other drugs CHAPTER 14

problems for a year or more. It is clear, however, from follow- Box 14.9
ing problem drinkers identified in the community that many
change their habits without professional help. Levels of intervention relevant to an effective response
to alcohol problems
Systematic reviews of treatment for alcohol dependence
include Slattery et al (2003), Berglund et al (2003) and Level 1 The drinker, the family and friends
Raistrick et al (2006). The overall picture is that approxi- Level 2 Employers, work colleagues, police, bartenders,
mately two-thirds of individuals receiving treatment show social welfare
improvement and that treatment is significantly better than Level 3 Primary healthcare, accident & emergency services,
no treatment. Considering the costs to society of alcohol pro- hospitals, social work, probation, counsellors
blems, there is good evidence of the cost benefits of providing Level 4 Alcoholics Anonymous, councils on alcohol,
treatment to individuals with alcohol problems (Holder & specialist alcohol treatment services
Blose 2000; UKATT Research Team 2005b).
Level 1: Awareness of hazardous drinking can lead to ‘spontaneous’ improvement,
Organisation of services influenced by health promotion and the attitude of the family. Level 2: Although
care is not their primary responsibility, these agencies are well placed to initiate an
effective intervention. Level 3: Primary-level caring agencies can be effective with
sufficient training and support. Level 4: Specialist services (responsible for direct
care as well as giving consultation and support to levels 2 and 3).

Alcohol

Alcohol-related problems are common and protean in their specialist service. A joint plan for each district should be
clinical manifestations. It is estimated that about one in twenty concerned with both prevention and treatment and will
patients seen by a general practitioner will have an alcohol involve multiagency cooperation perhaps in the form of an
problem, and a further 10–20% will be drinking amounts alcohol (or ‘drug and alcohol’) action team to take forward
which increase their risk of future problems. In general medi- the local plan (e.g. Scottish Executive 2002). In the mean-
cal and general psychiatric wards approximately 20% of men time, the Department of Health (2005) estimates that in
and 12% of women will be found to be drinking at levels that England specialist treatment (tier 3 and 4) is accessed by
are potentially damaging to their health. 5.6% per annum or 1 in 18 of the in-need alcohol-dependent
population. The greatest relative lack of services was in the
The manifestations extend from hazardous drinking pat- north of England.
terns which may prove harmful in the future or in certain con-
texts to complex and severe problems including dependency There have been repeated exhortations from Health
and physical and psychological harm. It is therefore unrealistic Departments in many countries that primary care workers
to expect one single therapeutic strategy to meet all these should do more to recognise and intervene early in problem
needs. A framework of health and social services is required drinking and who and where to refer for specialist care.
which takes into account this range of problems. This should While at the time of writing the English Department of
extend from services that provide identification and assess- Health is evaluating the cost effectiveness of implementing
ment often coupled with brief intervention, commonly screening and brief advice in primary care, the Scottish
provided by generalists, to more specialist services that cater Government has decided to make payment available to
for patients who have complex needs including comorbidity GPs to do this, albeit limiting the screening exercise to
or have proved unresponsive to simpler approaches. Any patients with some of the higher risk clinical presentations
framework of services should ensure that help is readily acces- (high blood pressure, trauma, depression, anxiety, etc.)
sible, non-stigmatising and equitably available. This ‘stepped (Health Scotland 2009).
care approach’ ensures that patients receive the least intrusive
and most cost-effective intervention and only draws specialist Within the general hospital a specialist alcohol nurse well
services into direct service provision when necessary (National integrated into the ward’s culture can improve detection of
Treatment Agency 2006). alcohol problems by nursing and medical staff and help to
ensure that protocols are followed for preventing and manag-
There is an opportunity for change inherent in each crisis, ing alcohol withdrawal syndrome and Wernicke’s encephalop-
provided the problem is recognised and the primary-level athy. They can be called on to offer brief advice to less
agency has received adequate training and feels competent in severely affected drinkers. Such brief advice has been shown
coping with the problem and giving advice. The different to be effective in psychiatric outpatient populations too
layers of increasingly specialised intervention are illustrated (Eberhardt et al 2009).
in Box 14.9.
Drugs
Front-line services will require support from agencies,
such as councils on alcohol, Alcoholics Anonymous and With specific reference to drugs, three early documents
specialised treatment units. The majority of alcohol problems formed the basis of the current organisation of services: one
can be managed in the community, while a smaller number produced by The Advisory Council on the Misuse of Drugs
require some initial inpatient treatment and/or residential (1993), the second the result of the establishment by the
hostel care. Community nurses specialised in alcohol pro- Secretary of State for Scotland of a ministerial drugs task force
blems provide the backbone of the specialist services in many
areas of the UK and may be based in primary care, or within a

383

Companion to Psychiatric Studies

(Ministerial Drugs Task Force 1994) and thirdly the English Box 14.11
Task Force to Review Services for Drug Misusers (1996). This
last task force made 12 recommendations that would greatly Health Advisory Service (2001) suggested approach
improve the effectiveness of drug services (Box 14.10). to services
The report by the Advisory Council on the Misuse of Drugs
made 33 similar recommendations but, in addition, included • Tier 1: Universal-generic primary services
a recommendation to expand outreach to try and contact • Tier 2: Youth-orientated services offered by practitioners with
hidden populations of drug users.
some drug and alcohol experience and youth specialist
It is clear that there are many similarities in the problems knowledge
experienced by those who misuse alcohol or other drugs, and • Tier 3: Services provided by specialist teams. Such teams would
multiple drug misuse is commonplace. Nonetheless, difference entail collaboration between mental health, paediatrics and
of age, life-style and the legal status of the drugs involved results addiction workers, alongside education and social services
in many agencies retaining some separation in the treatment • Tier 4: Very specialised services – these would work in
systems for individuals who misuse alcohol or other drugs while continuity with Tier 3, often providing short periods of
working closely together when this is advantageous. residential care including detoxification at times of crisis.
They would be concerned with adolescents with very complex
Services for young people needs

Among young people alcohol and drug misuse is often asso- As with all services, emphasis should be placed on early
ciated with increased dropout from school, poor scholastic recognition with particular attention to screening among vul-
attainment, delinquency, early pregnancy, family difficulties nerable groups such as: young offenders; runaway homeless
and mental health problems. The evidence on optimal organi- children; all those in the ‘looked-after’ system or in contact
sation of services for young people is limited and principally with social services; children with behavioural or learning
from the USA. The Health Advisory Service (Gilvarry 2001) problems at school; those subject to family disturbance; and
in England reviewed the available evidence and proposed a attenders at accident & emergency departments with trauma
tiered approach to services, emphasising the need to integrate or self harm. While many young people mature out of alcohol
drugs, alcohol and other child care services (Box 14.11). or drug misuse, a significant minority progress to greater harm.

Box 14.10 Any framework for services needs to recognise that some
groups find it difficult to access or utilize mainstream adult
Recommendations to improve the effectiveness of drug services. These groups include women (see p. 363), ethnic
services minorities, the homeless, the elderly (in whom alcohol pro-
blems are commonly overlooked or misdiagnosed) and young
• A shared-care model between specialist services and general people.
practice. (However, the General Medical Services Committee
has defined shared-care arrangements with regard to treatment Websites
in drug dependence as non-core services. It seems that unless
funding is available to support GPs in this extra work, resistance The following websites give up-to-date information:
may occur regarding GP involvement.)
• National guidelines for the management of drug misuse –
• Opportunities should be taken when drug misusers present to full text: http://www.nta.nhs.uk/publications/documents/
the criminal justice system. Treatment within the prison service clinical_guidelines_2007.pdf
and on release should be continuous with treatments in the
community • Drug misuse in Scotland: http://www.drugmisuse.
isdscotland.org
• Maintenance of syringe exchange facilities
• Basic health checks at first point of contact with drug users • UK government policy and research on drug misuse: http://
• Hepatitis B vaccination being made available to injectors drugs.homeoffice.gov.uk/
• Counselling and support services as co-components of
• European Monitoring Center for Drugs and Drug Addiction
treatment (EMCDDA): http://www.emcdda.org
• Availability of: methadone reduction programmes; oral
• American drug information & research: http://www.nida.
methadone maintenance programmes; residential rehabilitation nih.gov
programmes; specialist inpatient drug dependency units
• An end to the prescribing of methadone tablets to drug users • Systematic reviews: http://www.cochrane.org
• A limitation to the licence to prescribe injectable drugs to drug • UK drug resource centre: http://www.drugscope.org.uk
misusers • Society for the Study of Addiction with excellent links
• Maximum waiting times
• Flexible opening times reflecting needs of drug users page to many countries’ drug databases: http://www.
• Monitoring of key indicators of treatment organisations and addiction-ssa.org/links.htm
outcomes • Alcohol use and misuse in Scotland: National Plan:
http://www.scotland.gov.uk/Resource/Doc/166474/
From Task Force to Review Services for Drug Misusers (1996). 0045367.pdf

384

Misuse of, and dependence on, alcohol and other drugs CHAPTER 14

• UK alcohol resource centre: http://www.alcoholconcern. • Medical information about alcohol: http://www.
org.uk/servlets/home medicouncilalcol.demon.co.uk

• Alcohol review of relapse prevention: http://www. • American alcohol information and research: http://www.
nhshealthquality.org/nhsqis/controller?p_service¼Content. niaaa.nih.gov
show&p_applic¼CCC&pContentID¼441

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