Psychiatry - H.T. Sonnyk 2003

Alcoholism and alcoholic psychoses

Alcoholism is a chronic, progressive disease caused by systematic alcohol abuse and accompanied by The Development of psychological and physical dependence on it.

This disorder is classified as a mental illness because, firstly, the pathological craving for alcohol is rooted in profound psychopathological changes in personality, and secondly, prolonged abuse leads to mental impairment, personality deterioration, and the development of alcoholic psychoses.

Historical Background.

The scientific study of alcoholism began in 1857 when M. Huss described A number of its symptoms in his book Chronic Alcoholism, or Chronic Alcohol Disease and coined the term "chronic alcoholism." This research was further advanced by Marcé (1862), K. Bonhoeffer (1906), S.S. Korsakoff (1901), F.E. Rybakov (1914), and S.A. Sukhanov (1914).

In the second half of the twentieth century, the development of addictology was based on The Study of its clinical, biological, and social manifestations. Thus, S.G. Zhislin (1931) was the first to describe and investigate alcohol withdrawal in detail, while I.V. Strelchuk (1959), A.A. Portnov, and I.N. Pyatnitskaya (1971) continued developing S.S. Korsakoff's Concept of the transition from functional mental disorders to organic ones, formulated THE PRINCIPLE OF the progressive Nature of the condition, and divided it into three stages.

PREVALENCE.

According to estimates by E.A. Babayan, M.Kh. Eonopolsky (1987), and H.I. Kaplan and B.J. Sadock (1996), the prevalence of alcoholism ranges on average from 6.2% to 14.8% of the adult population.

Studying the Epidemiology of alcoholism encounters serious difficulties due to the high prevalence of so-called "hidden alcoholism" ("home drinkers"). A fairly reliable criterion for the prevalence of alcohol dependence is the annual per capita consumption of absolute ethanol. For instance, in 1995 this figure was 18.6 liters in France and 20 liters in Russia. According to WHO data, it is precisely in these countries that the highest rates of alcoholism within the population were recorded.

Etiology.

Among the Factors Determining the development of alcoholism as a disease, the following should be highlighted: genetic, physiological, psychological, and social.

Genetic factors. Since ancient times, people believed that parents suffering from alcoholism often gave birth to children with various physical defects, intellectual disabilities, and seizures, who subsequently developed alcoholism themselves.

The Role of genetic factors in the development of alcoholism is also confirmed by comparing monozygotic and dizygotic twins, with a significantly higher concordance rate observed in monozygotic pairs. In patients with a positive family history, an irresistible craving for alcohol appears much earlier, and the progression of alcoholism is accelerated compared to patients without a family METABOLISM/13.html">History of the disease.

Some scientists believe that alcohol alters the metabolism within the fetus, which subsequently causes a heightened susceptibility to it.

Physiological factors. Metabolic Disorders are considered to be of great importance in the origins of alcoholism. In particular, this concerns imbalances in B-complex Vitamins and Vitamin C. An important role is also recognized for disturbances in the Blood chlorine-to-sodium ratio. Given that individuals who abuse alcohol frequently experience mood swings,

it is believed that an imbalance between adrenaline and adrenochrome plays a significant role in the etiology of alcoholism.

Psychological factors are important in the development of alcoholism because the short-term stimulating effect of alcohol reduces anxiety, tension, and fear. A person's temperament and personality traits also play a certain role.

Some people easily socialize and enjoy company, while others, conversely, strive to remain alone; yet both types can suffer from alcoholism, although their motivation for drinking differs—some seek socialization, while others attempt to alleviate loneliness. Alcohol promotes a sense of pleasure, euphoria, relaxation, and relief. The former drives a specific group of people to use alcohol as a means for pleasure and easy entertainment. These tend to be primitive individuals with limited interests who lack hobbies or are accustomed to easy, accessible gratification. In other cases, we are dealing with individuals who, faced with difficult life situations they cannot cope with, find a sense of peace and escapism in alcohol, at least for a short time.

Personality formation is of great importance, including the upbringing received within the family and at school. In some cases, a personality that demands instant gratification is fostered. In others, it is a personality that requires excessive protection and is unable to cope with life's adversities. Some individuals mistakenly blame their professional activities in the production, storage, or sale of alcoholic beverages as the actual cause of their illness.

In a number of cases, alcoholism in children and adolescents stems from a desire to appear adult. Sometimes drinking is a protest against an uninteresting, mundane life.

Social factors represent a complex of conditions that contribute to alcohol abuse, including specific upbringing, education, marital status, financial security, the individual's position in society, the state's attitude toward Structure/149.html">The problem of alcoholism, etc.

It has been proven that the majority of alcoholics are single, independent, or divorced individuals. Financial status plays a role in the Cytology/cytology/16.html">Early stages of alcoholism; later, as the disease progresses, the individual experiences a shift in social standing and a drop in social status with a loss or reduction of income, yet alcohol consumption does not decrease.

State policy largely depends on national traditions and religious doctrines. For example, alcohol consumption is prohibited among Muslims and Protestants. Social factors also include—and may be one of the most prominent among them—the easy availability of alcoholic beverages and millennia-old traditions of consuming alcohol in A wide variety of situations.

The combination of these factors contributes to the spread of everyday heavy drinking, which subsequently develops into chronic alcoholism. It must be emphasized that the boundaries between heavy drinking and chronic alcoholism are blurred.

Pathogenesis.

Under conditions of chronic alcohol abuse, enzymatic processes and the metabolism of biogenic amines (norepinephrine, serotonin) are disrupted, particularly in the Brain and Hypothalamus.

Certain significance in the pathogenesis of alcoholism is attributed to disorders of vitamin metabolism (B1); fluctuations in blood sugar levels (hyper- and hypoglycemia), which induce a peculiar "craving," particularly for ethanol, and contribute to recurrent alcohol consumption. Due attention is also paid to the state of the Autonomic Nervous system, characterized by the alternating dominance of its sympathetic and parasympathetic divisions.

An important role in the pathogenesis of alcoholism is assigned to factors of natural and acquired Immunity. An increased production of morphine-like substances is noted, which may potentially lead to the development of physical

dependence on alcohol.

Classification OF Mental disorders in ALCOHOLISM

I. Acute alcohol intoxication

1. Simple alcohol intoxication:

✵ mild degree;

✵ moderate degree;

✵ severe degree.

2. Pathological intoxication.

II. Chronic alcohol intoxication

1. Social (habitual) drinking.

2. Alcoholism:

✵ Stage I (asthenic);

✵ Stage II (narcomanic);

✵ Stage III (encephalopathic).

3. Dipsomania.

4. Alcoholic psychoses:

✵ acute alcoholic psychoses — delirium tremens, acute alcoholic hallucinosis, acute alcoholic paranoid;

✵ chronic alcoholic psychoses — chronic alcoholic hallucinosis, alcoholic jealousy paranoia, Korsakoff's psychosis, alcoholic pseudoparalysis.

ACUTE ALCOHOL INTOXICATION.

Mild intoxication is characterized by excitation, elevated mood, vigor, and a sense of well-being. Real-world circumstances and interpersonal relationships are assessed inadequately. Anxiety and fear are suppressed, indicating the tranquilizing effect of alcohol. Motor disinhibition and impaired coordination of movements are observed. The pace of thinking accelerates, behavior is driven by the dominant affect, and The ability to critically evaluate one's own actions diminishes.

Consequently, an intoxicated individual often cannot refuse requests, becoming excessively amiable, generous, and prone to making numerous promises. Such individuals tend to be overly communicative, easily initiate acquaintances, exhibit talkativeness, and recount their experiences with significant exaggeration. A sense of tact and personal boundaries is lost, personal capabilities are overestimated, leading to boasting and recklessness.

Affective instability is frequently observed — euphoria gives way to irritability, aggression, and tearfulness. Feelings of sympathy easily turn into antipathy and hostility. At this stage, vital drives become disinhibited: appetite, libido, and primitive emotionality increase.

Overall, the described clinical picture can be designated as the euphoric form of intoxication. Dysphoric forms also exist, characterized by a prevailing low mood, conflict behavior, aggressiveness, fault-finding, as well as suicidal ideation and attempts.

Alcohol impairs intellectual and mnemonic Functions; it has been experimentally proven that 10–15 grams of pure alcohol disrupt the performance of psychological tests, impair the comprehension of instructions, memory, and calculation skills. Intoxication is accompanied by a decline in arithmetic Processing capacity, a weakening of combinatorial associative processes, impaired visual and auditory perception, and slowed reaction times.

Autonomic-vascular changes manifest as facial hyperemia, a sensation of warmth, peripheral vasodilation, tachycardia, increased blood pressure, accelerated Respiration followed by subsequent bradypnea. The secretion of salivary and digestive glands increases, peristalsis is accelerated, and diuresis is enhanced.

Moderate alcohol intoxication is primarily characterized by the inhibition of the higher Divisions of the CNS. This is accompanied by general lethargy, a slowed pace of thinking, and gait disturbances. The speech of an intoxicated person becomes dysarthric and repetitive. Impairment of orientation in the environment may develop, accompanied by a loss of control over one's own behavior. Consequently, cynical remarks, loss of modesty, overt sexuality, and the relief of physiological needs in the presence of others may occur.

Severe intoxication. This is a state characterized by varying depths of consciousness disorders, up to and including coma. Involuntary urination and defecation, as well as epileptic seizures, may occur.

Muscular hypotonia and hypothermia frequently occur, Reflexes are suppressed, and mydriasis, horizontal nystagmus, and hypoesthesia—ranging to complete loss of Pain Sensation—are observed. The Skin becomes pale and cold. Occasionally, pyramidal signs and symptoms of oral automatism appear, the latter being characteristic of alcohol-induced coma. Death may result from the suppression of vital functions due to the paralysis of bulbar centers.

Individuals who have undergone severe states of intoxication retain no memory of the events, and long remain asthenic and adynamic, presenting with phenomena of ataxia, dysarthria, and autonomic disorders.

The period of simple alcohol intoxication lasts, on average, from 6–7 to 12 hours following the ingestion of a large amount of alcohol. Severe intoxication is followed by amnesia—such as "alcoholic palimpsests" or "patchwork memory"—alongside asthenia, headache, subdepression, nystagmus, decreased corneal sensitivity, and sluggish pupillary light reactions. Hypoesthesia and analgesia are possible. Gustatory perception, thermal and cold sensitivity, and Olfaction are diminished, and the adaptation period is prolonged, among other symptoms.

Pathological intoxication. This is an acute, short-lived, and rare psychotic state characterized by the sudden onset of profound clouded consciousness, resembling a twilight state of consciousness.

Pathological intoxication develops after the ingestion of a small amount of alcohol, or less frequently, against the background of moderate intoxication.

In this state, the external signs of intoxication disappear. Gait and speech remain unchanged, while behavior is driven by internal psychotic, impulsive motives, and feelings of anxiety and fear, which may alternate with motiveless anger and rage. These reactions can arise on The basis of delusional and hallucinatory experiences.

Sometimes, during a state of pathological intoxication, the actions of patients lack purposeful direction and manifest as senseless acts of attack, defense, or flight, leading to severe antisocial behavior. Such actions are accompanied either by shouting, the stereotypical repetition of the same words, or silent concentration.

Depending on the clinical course features, the following forms of pathological intoxication are distinguished: twilight, delirious, hallucinatory-paranoid, and manic.

If individuals commit criminal acts while in a state of pathological intoxication, they are deemed not guilty by reason of insanity (non compos mentis).

Methods FOR EXAMINING ALCOHOL INTOXICATION.

Outpatient examination involves questioning about the dose and type of alcoholic beverage consumed, assessing Complaints, appearance, behavior, gait, speech, and other objective criteria of neurological and mental status, as well as the condition of Internal Organs.

Rapoport's test: 2 ml of distilled Water is poured into each of two test tubes; the examined individual is asked to blow into one of them through a long Glass tube for 15 seconds. Then, 15 drops of pure sulfuric acid and 1 drop of a 0.5% potassium permanganate solution are added to both test tubes. If alcohol is present in the exhaled air, a color change of the potassium permanganate occurs, whereas the control tube retains its light pink color.

Mokhov and Shinkarenko's method: the subject is asked to blow through a special tube. If alcohol vapor is present in the exhaled air, the dry reagent inside the tube changes color from yellow to green or blue.

CHRONIC ALCOHOLISM.

Chronic alcoholism is a disease resulting from the systematic consumption of alcoholic beverages, characterized by a pathological craving for them, and leading to mental and somatic disorders, as well as the disruption of an individual's social relationships.

The leading syndrome of the disease is the addiction or dependence syndrome, which exhibits the following features:

✵ a morbid, irresistible craving for alcohol and loss of control over alcohol consumption ("psychic dependence");

✵ the development of withdrawal syndrome—the appearance of psychological and somatoneurological disease symptoms upon abstinence from alcohol (Sleep disturbances, nightmares, tremor, anxiety, hypnagogic hallucinations, painful sensations in internal organs, etc.)—"physical dependence";

✵ altered tolerance—an increase or decrease in individual sensitivity to alcohol;

✵ psychotoxic action—impairment of mental activity following single doses and personality changes with prolonged use;

✵ alterations in somatic and neurological functions.

Alcoholism develops gradually, imperceptibly to others and to the future alcoholic alike. This period is known as social or habitual drinking. At this stage, alcohol is consumed occasionally, but in large quantities. Intoxication is typically accompanied by vomiting; however, the vomiting reflex becomes suppressed over time, which serves as one of the early signs of the disease.

Social drinking lasts, on average, from 5 to 10 years. In men, it usually begins between the ages of 20 and 30, while in women it starts between 25 and 35.

Alcoholism is classified into three stages:

Stage I – initial, mild, neurasthenic;

Stage II – moderate (narcomanic);

Stage III – terminal, severe, encephalopathic.

The general dynamic characteristics of alcoholism include the development of a craving for alcohol, the onset and progression of physical dependence, changes in alcohol tolerance, impaired mental activity, and pathological Changes in the somatic and neurological spheres.

First stage of alcoholism.

This stage is characterized by the following signs:

1. Psychological dependence on alcohol manifested as an obsessive syndrome.

2. Absence of physical craving for alcohol.

3. Increasing tolerance (resistance to alcoholic beverages).

4. Altered patterns of intoxication.

5. Transition from episodic to systematic alcohol consumption.

6. Development of a neurasthenic syndrome with early manifestations of mental disorders.

7. Somatic manifestations – appetite disturbances, short-term digestive disorders, discomfort and pain in specific organs.

8. Nervous system manifestations – peripheral local neuritis, hyperactive tendon and periosteal reflexes, hyperhidrosis.

Most often, triggers for activating the craving for alcohol include situational and domestic factors (family quarrels, trouble at work, grief, etc.) or mood fluctuations. There is no physical craving for alcohol yet at this stage of the disease.

By the end of this stage, the dose of alcohol required to achieve intoxication increases by 3 to 5 times. At the same time, control over the amount consumed diminishes.

Neurasthenic syndrome manifests as vegetative-vascular disorders, neurasthenic and asthenic symptoms, insomnia, and a certain accentuation of personality traits that eventually lead to psychopatization.

Second Stage of alcoholism.

The second stage of alcoholism is characterized by:

1. Psychological dependence on alcoholic beverages of an obsessive nature, accompanied by the loss of quantitative control over alcohol consumption and a drive for physical comfort while intoxicated.

2. Physical dependence in the form of a compulsive craving for alcohol.

3. Altered reactivity to alcohol, manifested by maximum tolerance levels, blackouts (amnesias), systematic drinking, and pseudo-binge episodes.

4. Gradual development of psychopathic-like syndrome (asthenic, hysterical, explosive, or apathetic types).

5. Dysfunction of internal organs (gastritis, hepatitis) and systems (cardiovascular, respiratory, urogenital, etc.).

6. Nervous system: autonomic disorders, polyneuropathy, cerebellar and other cerebral syndromes.

One of the main criteria of the second stage is The Emergence of physical dependence, which involves a constant need to supply the body with new portions of alcoholic beverages. Otherwise, a severe withdrawal syndrome occurs, manifested by Disorders of the cardiovascular and autonomic systems, the gastrointestinal tract, etc.

Patients complain of tachycardia or bradycardia, vomiting, diarrhea, headache, weakness, tremors in the extremities, hyperhidrosis, and fever.

Similar disorders occur in the morning after consuming large amounts of alcohol and are known as hangover syndrome. Its manifestations can be alleviated by non-specific remedies (kefir, tomato juice, pickle brine) or tonic Procedures (shower, bath).

Withdrawal syndrome is highly persistent. Treatment can completely eliminate or reduce it, but upon resumption of drinking, it reappears, even after prolonged periods of abstinence from alcohol.

In the second stage of alcoholism, alcoholic (metalcoholic) psychoses may occur.

Third Stage of alcoholism.

It develops 8-10 years after the onset of alcohol abuse and has the following main features:

1. Psychological craving for alcohol is driven by The Need for a specific mental comfort and is compulsive in nature.

2. Pronounced physical dependence with withdrawal syndrome.

3. The body's reactivity continues to change: tolerance decreases, and true or systematic heavy drinking appears alongside pseudo-bouts, characterized by low tolerance and lack of situational control.

4. Further personality degradation with noticeable impairment of intellectual and mnemonic functions. Dementia obliterates individual personality traits.

5. Alcoholic (metalcoholic) psychoses.

6. Damage to organs and systems, in some cases with irreversible changes (Liver cirrhosis, cardiovascular failure, etc.).

7. Exacerbation of neurological symptoms.

The syndrome of psychological craving for alcohol is replaced by profound physical dependence. Alcohol consumption takes the form of true bouts (binges): 3-4 days of continuous drinking followed by 10-15 days of the so-called clear interval. A binge always begins with a compulsive craving, and tolerance decreases, especially daily tolerance.

The alcoholic consumes beverages to regain physical comfort, or at least to get rid of a general sense of weakness, malaise, and guilt. The patient gets drunk quickly, reaching a state of severe intoxication. Surrogates are most commonly used because they produce a more pronounced intoxication effect in relatively small doses.

Further intellectual and mnemonic disorders occur: patients lose interest in public life, work matters no longer concern them, they typically lose their jobs, begin to lead a parasitic lifestyle, and the family falls apart.

The patients' personality is obliterated, sharp psychopathic manifestations are smoothed out, which makes most patients in stage III resemble one another—emptied, indifferent to their surroundings, with interests narrowed down to satisfying the need for alcohol (alcoholic dementia).

There are two types of alcoholic dementia:

Erectile type - initially resembles the explosive form of psychopathy, characterized by excitability, aggressiveness, angry outbursts without significant reason against a background of recklessness and lack of restraint, accompanied by emotional incontinence, increased talkativeness, and flat humor.

Torpid type - characterized by lethargy, apathy, indifference, and sometimes a euphoric attitude toward the environment.

In Stage III of the disease, prominent organic symptoms of dementia include impaired memory and critical judgment. In 13% of cases, alcoholic psychoses are observed. A general decline in the body's resistance is revealed, As a result of which these individuals most often die from various intercurrent diseases (Influenza, Pneumonia, etc.). Disorders of internal organs and systems are chronic and largely irreversible (Stomach ulcers, liver cirrhosis, myocardial infarction, etc.).

More pronounced nervous system disorders are observed in the form of movement incoordination, strokes, cerebral vessel thrombosis, and vascular crises followed by paresis and paralysis.

ALCOHOLIC PSYCHOSES.

Chronic alcoholism leads to the development of alcoholic psychoses in approximately 10% of cases, most commonly alcohol delirium (delirium tremens), which accounts for up to 90% of all alcoholic psychoses.

ACUTE ALCOHOLIC PSYCHOSES.

Acute alcohol delirium is a psychosis that typically develops against the background of a prolonged, severe alcohol withdrawal syndrome.

As noted earlier, the withdrawal syndrome is characterized by insomnia with terrifying dreams. As the withdrawal syndrome worsens, these dreams become increasingly horrific, taking on an adventurous and detective-like nature (fights, murders, chases, jumping over abysses, etc.). They are then partially populated with zoological elements, such as various small animals. Finally, the patient practically does not sleep at night, and during this night, their terrifying dreams seem to be projected outward. Various visual hallucinations arise, which can fill the entire surrounding space. Patients lack orientation in time (it seems to them that time passes faster) and in surrounding reality, but their orientation regarding their own personality remains intact.

A sweeping tremor of the entire body is observed, hence the name of this condition - delirium tremens (shaking delirium). Patients feel as though they are in hell, in prison, etc. They experience a continuous stream of vivid, scene-like visual hallucinations, most often of a threatening nature. They see corpses, frightening faces, small animals: rodents, amphibians, etc., but always in miniature (microzoopsia); A large number of insects and devils, all revolving around the patient in an endless round dance. Auditory hallucinations may also occur, though less frequently, such as screams, whistling, etc.; tactile ones, such as the sensation of threads in the Mouth or a flow of water; and olfactory ones, such as the smell of sulfur, among others.

A characteristic combination of the terrifying and the ridiculous is observed. For example, devils leap around threatening the patient while simultaneously offering them a small glass of vodka and laughing. All of this is reflected in the patients' behavior as they alternately brush away insects, hide under the bed, or laugh.

The psychotic state reaches its peak intensity during alcohol delirium at night. By morning, the hallucinations disappear and the patient's agitation subsides; however, the psychosis intensifies again the following night.

On average, the duration of delirium is 5–7 days. It is dangerous primarily because patients, driven by fear, may commit aggressive acts against others or attempt suicide. Furthermore, prolonged agitation and severe intoxication can in some cases lead to death resulting from Heart Failure, pneumonia, or pulmonary edema.

An unfavorable course is also characteristic of such variants of delirium as professional (where the patient simulates their professional activity during the psychosis) and murmuring delirium (manifested by incoherence of thought and chaotic motor activity).

In some cases, following an episode of delirium tremens, patients may develop Korsakoff's psychosis (loss of memory for immediate current events, amnestic disorientation, pseudoreminiscences, and confabulations combined with polyneuritis).

Acute alcohol paranoid is a psychotic state characterized by a mildly altered state of consciousness, vivid and affectively charged delusions of reference and persecution, accompanied by fear, anxiety, and episodic illusions and hallucinations. The patients' behavior is dictated by the plot of the delusions. The duration of acute alcohol paranoid ranges from several days to a month.

Acute alcoholic hallucinosis is a psychosis that also develops acutely, but unlike delirium, firstly, it occurs with a clear state of consciousness and preserved complete orientation in time, place, and one's own personality; and secondly, it is characterized exclusively by auditory hallucinations. Furthermore, acute alcoholic hallucinosis can manifest both during the withdrawal period and at the peak of alcohol abuse.

The patient continuously hears voices that either address them or discuss them among themselves. The content of these statements is related to the patient's heavy drinking. The voices threaten them, calling them a drunkard and a good-for-nothing. Aggressive actions toward others or patient suicide are also possible in these cases. The duration of acute alcoholic hallucinosis averages 2–3 weeks.

CHRONIC ALCOHOLIC PSYCHOSES.

Chronic alcoholic hallucinosis. This is very rare. Patients hear voices almost continuously for a number of years, grow accustomed to them, and cease to pay attention to them. Emotional flattening sets in. Most researchers classify chronic alcoholic hallucinosis as Schizophrenia combined with alcoholism.

Alcoholic jealousy delusion. This psychosis most commonly manifests as unmotivated, absurd ideas of jealousy directed at one's spouse. Such patients can be socially dangerous and may commit the murder of a spouse, children, or a perceived lover.

With many years of alcohol abuse, dementia caused by organic brain damage may develop in stage III of the disease. At this stage, so-called encephalopathic psychoses are observed, which include Korsakoff's psychosis, Wernicke-Korsakoff syndrome (Wernicke's encephalopathy), and others.

Korsakoff's psychosis is characterized by severe memory and consciousness impairments (fixation amnesia, confabulations, and amnestic disorientation), depressed mood in patients, and polyneuritis.

Wernicke's alcoholic encephalopathy is a very severe condition accompanied by symptoms of acute intoxication and various neurological disorders. Patients are in a state of stupor that can gradually progress to sopor or coma. The prognosis is unfavorable.

TREATMENT.

Medical care for severe alcohol intoxication:

✵ Inducing artificial vomiting and gastric lavage. Vomiting can be induced by subcutaneous administration of 0.25–0.5 ml of a 1% apomorphine hydrochloride solution (which simultaneously relieves agitation).

✵ Urinary catheterization (in case of urinary retention).

✵ Administration of 5-10 drops of ammonia solution in 1/2 glass of water.

✵ In case of cardiac impairment and comatose state - subcutaneous administration of 1-2 ml of 10% caffeine sodium benzoate solution, subcutaneous or intravenous injection of 1-3 ml of 10% corazole (can be repeated every 1-2 hours), 1 ml of cordiamin, 1-3 ml of 0.1% strychnine nitrate solution, intravenous administration of 200-300 ml of saline or 5% glucose solution with 15 IU of Insulin.

✵ Inhalation of a gas mixture containing 90% oxygen and 10% carbon dioxide.

✵ In case of asphyxia - oxygen inhalation, artificial respiration, subcutaneous injection of 1 ml of 1% lobeline solution, intramuscular or intravenous administration of 1 ml of cytiton, general and local warming.

Treatment of patients with chronic alcoholism.

This treatment is carried out in several stages:

At stage I, detoxification therapy is performed via intravenous administration of a 5% glucose solution with vitamins C and B-group, along with intramuscular injections of magnesium sulfate.

At stage II, conditioned reflex therapy is applied, meaning a negative conditioned reflex to alcoholic beverages is established using emetics. For this purpose (preferably during group sessions), after an injection of apomorphine or the ingestion of clubmoss (Barнец) decoction, the patient is given a small dose of alcohol. Thus, a vomiting reflex to alcohol is gradually developed, which subsequently manifests even without apomorphine injections—simply upon smelling or even mentioning alcohol. This reflex, however, requires reinforcement every few months.

Another approach used at the second stage is the sensitization method. Patients are given tablets of teturam (antabuse), phthalazole, or trichopol, which are incompatible with alcohol.

Teturam is primarily used in the form of implantable Esperal tablets, the action of which is based on blocking Alcohol dehydrogenase, leading to acetaldehyde intoxication even after the intake of small doses of alcohol. The teturam-alcohol reaction causes severe autonomic disorders, forcing patients to abstain from alcohol consumption. Esperal is implanted subfascially, usually under the shoulder blade, and its effect lasts for 8-12 months. In the event of an alcoholic relapse during this period, the preparation must be immediately removed surgically, followed by massive detoxification.

An important method in treating chronic alcoholism is psychotherapy. Suggestive measures (hypnosis, emotional-stress therapy) are applied. Rational therapy can be conducted either individually with each patient or in a group Setting.

Since the pathological craving for alcohol generally does not completely cease, comprehensive treatment of alcoholism must include maintenance (anti-relapse) therapy, which involves prescribing additional courses of conditioned reflex or sensitizing therapy at regular intervals.

Treatment for alcoholism is most effective when patients have a positive mindset toward quitting alcohol.

Treatment of alcohol psychoses.

In the treatment of mild to moderate delirium tremens without a pronounced somatic component, patients are prescribed hypnotics for 7-10 days (5-10 ml of a 5% barbamil solution), Popov's mixture, Ravkin's mixture, 0.5% seduxen 4.0-8.0 ml intramuscularly or intravenously with 10-15 ml of 40% glucose, and neuroleptics: tizercin or chlorpromazine 2-3 ml of 2.5% 2-3 times a day by intravenous drip with 500 ml of 5% glucose, haloperidol 1-2 ml of 0.5% intramuscularly, clopixol-acuphase 200 mg, or flupenthixol injections of 20 mg per day.

In cases of severe alcoholic delirium or other acute alcohol psychoses, the primary focus is directed toward intensive detoxification, restoration of acid-base balance, and the Prevention of Hypoxia and cerebral edema.

EXPERT ASSESSMENT.

Medical-labor evaluation. A state of intoxication or a regular hangover is not grounds for issuing a sick leave certificate. Only in cases requiring the interruption of severe binges and withdrawal symptoms accompanied by seizures, suicidal tendencies, or alcohol psychoses are patients treated under a sick leave certificate on an outpatient or inpatient basis. Patients with Korsakoff's psychosis, alcoholic pseudoparalysis, and chronic alcoholic hallucinosis are assigned disability group II, and in the first two cases, if custodial care is required, group III (Note: translated naturally as group I as per medical context, but kept strictly true to the text meaning). For the paranoid form of prolonged alcohol psychoses, patients may go without disability assignment for many years, although the paraphrenic variant indicates disability group III, and intensifying hallucinations indicate group II. Disability group II is also indicated in cases of severe alcoholic dementia.

Military-medical evaluation. Patients with alcoholism (except for cases of alcoholic dementia), even with a history of acute alcohol psychoses, are deemed fit for military service. In cases of prolonged alcohol psychoses (even in remission) or alcoholic dementia, patients are declared unfit for military service and are deregistered.

Forensic-psychiatric evaluation. Individuals suffering from alcoholism who commit illegal acts are recognized as sane and bear full responsibility for their actions; committing a crime while intoxicated only aggravates the offender's guilt. Exceptions include cases of overt alcoholic dementia. The legal capacity of patients with alcoholism can be restricted by a court verdict in some cases, for example, they may be deprived of the right to receive their own salary.

An important aspect of forensic-psychiatric evaluation is the differentiation between complicated and pathological intoxication. Both share pronounced psychomotor and affective agitation. In addition, The structure of pathological intoxication includes signs of impaired consciousness—disorientation, impaired objective contact with the environment, and incoherence of thinking combined with hallucinations and fragmentary sensory delusions, which determines the status of insanity (not guilty by reason of insanity) for such patients. The structure of complicated intoxication is entirely free of psychopathology, which leads to the Conclusion of full legal responsibility for one's actions.

Patients who committed illegal acts in a psychotic state are recognized as insane and bear no criminal liability. Compulsory treatment is prescribed even in cases where, by the time of the trial, the patients have already emerged from the psychotic state but still require treatment for alcoholism.

CONTROL QUESTIONS.

1. ETIOLOGY AND PATHOGENESIS of chronic alcoholism.

2. Clinical manifestations of ordinary alcohol intoxication.

3. Clinical manifestations of pathological alcohol intoxication.

4. Methods for examining alcohol intoxication.

5. Define everyday heavy drinking (social/habitual drinking).

6. Definition and Classification of the stages of chronic alcoholism.

7. Provide a clinical description of stage I chronic alcoholism.

8. Provide a clinical description of stage II chronic alcoholism.

9. Provide a clinical description of stage III chronic alcoholism.

10. Classification of alcoholic psychoses.

11. Acute alcoholic delirium (delirium tremens).

12. Acute alcoholic hallucinosis and acute alcoholic paranoid state.

13. Chronic alcoholic psychoses and their Clinical Features.

14. Encephalopathic alcoholic psychoses.

15. First aid for acute Alcohol poisoning.

16. Principles and primary methods of treating alcoholism.

17. Conditioned reflex therapy and sensitizing therapy, and their specific features.