Category Archives: Psychological Medicine

Molluscum Contagiosum

AETIOLOGY 

This infection is usually grouped with other diseases caused by the poxviruses, but the virus is antigenically different. Atopic individuals appear to be especially prone to infection and in such persons lesions may be more numerous and difficult to eradicate.

CLINICAL FEATURES

Flesh-coloured, umbilicated papules are seen. They are usually not more than 5 mm in diameter, but the size may vary. Children are most commonly infected and flexural surfaces are the areas of skin most frequently involved. In adults, spread often occurs with sexual contact.

Irritation over the surrounding skin may induce scratching and further spread. Single lesions may occur and become quite large and inflammatory and then the diagnosis may not be easy.

TREATMENT

The papules need only to be opened and the contents expressed; this often occurs with scratching although a sterile needle can be used. Silver nitrate or phenol may be applied or electrocautery or a Hyfrecator (which seals blood vessels using a small charge of electricity but without heat) may be used, or cryosurgery. Associated changes in the skin, such as eczema, need to be treated in order to prevent scratching and further spread of lesions.

Warts 

AETIOLOGY 

The human papillomavirus (HPV) is a member of the papovavirus family, which includes other species-specific viruses that infect domestic animals such as dogs, rabbits, horses or cattle. It has long been recognized that tumours induced in animals by this group of viruses may undergo malignant transformation, and the oncogenic potential for humans is of increasing concern.

Types of virus

DNA hybridization techniques have demonstrated more than 50 different virus types, and immunocytochemical methods have identified virus particles in human tumours.

Previously warts have been classified according to the clinical appearance or anatomical site that they infect. It is now recognized that one or several viral types can be found in each of the clinically different lesions, e.g. plantar warts are caused by HPV-l and HPV-4. The genus is divided into types according to the homology of the

DNA pattern. 

PATHOGENESIS 

Viral DNA can be isolated from the basal cells of the epidermis, but the fully infective virion is only evident in more superficial epidermal cells. Cytology or histology shows gross disruption of the cells of the granular layer and below, which have intranuclear and cytoplasmic eosinophilic inclusions. Gross hyperkeratosis and parakeratosis are also associated with viral infection.

CLINICAL FEATURES

Common warts

Common warts are individual papular lesions with a coarse or roughened surface that are seen on the palmar aspect of the fingers and on the knees; other sites are less commonly affected. Children between the ages of 11 and 16 years are principally affected. Spread is associated with trauma. Many periungal warts are seen in nail biters, who may also have warts on or around their lips.

Plantar warts (verrucae)

These lesions are often solitary and are distributed over contact areas of the foot. When they overlie a bony prominence and are associated with marked hyperkeratosis, pain and tenderness when pressure is applied may be severe. Squeezing a plantar wart or verruca may more readily induce pain than pressing on the lesion and this is a useful test in differentiating a verruca from a callosity. Paring down the skin over a verruca will demonstrate a pit in the skin at which the surface markings come to an abrupt halt; they are, however, continuous over a callus. Maceration of the skin associated with sweating may induce many superficial lesions that form a mosaic wart.

Single filiform warts

These lesions occur on the face and at the nasal vestibule or around the mouth; they may also be seen over the face or neck of older patients.

Plane warts

Plane warts are flat-topped and slightly rough on the surface, which is often pigmented. They are usually 2-3 mm in diameter and may require incidental lighting to discern their outline. The face, around the mouth and chin are the sites most commonly involved, and the hyperpigmentation may give children an unwashed appearance.

Young women are also affected and lesions may persist for years. The dorsa of the hands and knees are sometimes involved and trauma may demonstrate the Koebner phenomenon at these sites.

TREATMENT

Spontaneous resolution is common and this makes it difficult to assess the value of therapy. Keratolytics containing salicylic or lactic acid may lessen the unsightly appearance of common warts, which is peculiarly loathsome to so many patients.

Drying preparations may speed resolution if maceration of the skin over the hands and feet is associated with excessive sweating. Glutaraldehyde 10% w/v may be applied twice daily with a brush to individual lesions or wiped over the surface of mosaic warts. Soaks include formaldehyde as a formalin solution at concentrations of between 2 and 5%, or potassium permanganate 0.01%. Too strong solutions or too frequent applications may induce cracking or fissuring over areas of the skin such as the toe-clefts.

Destructive methods may hasten resolution by producing local inflammatory changes and enhancing immune reactions. These include chemical cautery, electrocautery and cryo urgery.

On some occasions curettage may prompt the resolution of painful verrucae but any scarring that accompanies such procedures may give rise to chronic pain, particularly when situated over pressure points.

Viral infections

Herpes simplex

There are two types  of herpes simplex virus (HSV) infection-HSV types I and II.

CLINICAL FEATURES

Primary herpes gingivostomatitis (HSV-1) may be asymptomatic in children, but others can experience severe stomatitis associated with buccal ulceration, marked local lymph node enlargement and systemic features. Trauma to the skin may introduce the virus, as in glad iatoral or ‘scrumpox’. Damage to the skin over a finger may produce a herpetic whitlow especially in nursing personnel.

Type 2 genital infection may not cause symptoms in females if it is intravaginal. Vulvovaginitis causes burning irritation, dysuria and lymph node enlargement. Extragenital infection on the thigh or buttock can cause myalgia, and dysaesthesiae of the affected overlying skin. Recurrent disease may induce systemic upset with fever, headaches and meningeal irritation associated with the spread of the virus into the eNS. There is local dysaesthesiae followed by vesiculation, weeping and crusting; less commonly local erythema and papule formation occur but no blistering. Depending on the degree of secondary bacterial infection, attacks clear in 10-14 days, with separation of the crust.

COMPLICATIONS 

Ocular complications 

More serious and chronic disease can occur when the eye is the site of primary herpes infection or of recurrent attacks. Ulceration may give rise to marked local pain and oedema and produce keratitis, scarring and visual impairment.

Cutaneous complications

Recurrent HSV-1 infection is probably the most common cause of erythema multiforme, which occurs 10-14 days following vesiculation over the lips, face or mucous membranes.

Typical target or iris lesions appear usually over acral skin on the fingers, toes, palms or soles.

Eczema herpeticum

Atopic individuals can develop widespread disseminated viral infection at any time. This does not only occur when their eczema is in an active phase, nor does it occur on every occasion of contact. Nurses and parents with active cold sores should avoid nursing children with atopic eczema.

DIAGNOSIS

This is usually clinical. Rarely the virus may need to be cultured from the vesicles and differentiated immunologically from varicella zoster virus.

TREATMENT AND MANAGEMENT

Local drying agents such as ether or surgical spirit will promote crusting and diminish pain and discomfort. Povidone-iodine has a mild antiviral action and is available in an alcoholic solution or paint form (10% w/v). The astringent effect is a useful adjunct to treatment and secondary infection may not occur so readily following its use.

Specific measures include the use of idoxuridine or acyclovir. Infection of the eye is improved by the use of local application of eyedrops containing 0.1% idoxuridine or an ointment containing 0.5% idoxuridine. Idoxuridine 5-20% is applied to the skin in a vehicle such as dimethyl sulphoxide (DMSO), which aids the absorption of the active ingredient into the skin. The local applications need to be made at the onset of discomfort and for the ensuing few days.

Acyclovir, a thymidine analogue, is activated in the presence of HSV thymidine kinase. Toxicity to normal tissues is therefore reduced and treatment with this agent in severe local infection or disseminated disease in neonates, atopic individuals or those with immune deficiency may greatly reduce morbidity and mortality. The compound is available for local use as a 5% cream. In tablet form, acyclovir 200 mg five times daily for 5 days is a normal dosage for type 1 infection. This may need to be
increased or doubled when treating type 2 disease. Parenteral forms of the drug are also available for severely ill patients and for disseminated disease.

Women with genital herpes should undergo cervical screening as there may be a link with carcinoma of the cervix. This should always be performed if their sexual partners have recurrent disease.

Varicella (chickenpox)

This is a common infectious disease of childhood occurring in the winter and spring and caused by the varicella zoster virus (VZV).

Herpes zoster (shingles)

This infection usually represents the re-emergence of VZV from posterior nerve roots in the spinal cord or cranial nerves into the skin .

AETIOLOGY

This disease affects patients in their middle years or old age. Factors that cause the re-emergence of the virus are often unknown and probably represent changes in the immune state of the host. The induction of an attack by local spinal disease or an occult concomitant malignancy is unusual.

CLINICAL FEATURES

The prodromal symptoms of pain, tingling and dysaesthesia may precede by days the re-emergence of the virus into the skin. It then produces characteristic vesicles, papules or bullous lesions throughout the dermatome.

Unusual sites of involvement such as sacral nerve disease may give rise to visceral changes and lead to, for example, bladder dysfunction

COMPLICATIONS

Secondary infection increases discomfort, and in an elderly person intractable post-herpetic neuralgia may follow an attack of shingles. Trophic ulcers are sometimes seen over the face in association with cranial nerve involvement. Trigeminal nerve disease (ophthalmic division) can lead to infection of the eye. Signs that include swelling of the eyelid, conjunctivitis or blistering at the side of the nose require an ophthalmic opinion.

TREATMENT

DRYING SOLUTIONS such as calamine cream or lotion are soothing.

ANTISEPTIC POWDERS containing povidone-iodine or hexachlorophane may help to limit secondary
infection.
IDOXURIDINE 20-40% in DMSO may be applied where practical to the affected dermatome on dressings that are kept moist with the compound for the first 3-4 days of infection. This treatment should be limited to immunocompromised or elderly patients with severe disease.

ACYCLOVIR 800 mg orally five times daily for 7 days is recommended for all patients with shingles. Famciclovir is also effective and given three times a day. Acyclovir cream 5% may be applied for less severe attacks.
PREDNISOLONE in doses of 40-60 mg decreasing over 3 weeks can prevent post-herpetic neuralgia in those over 60 years of age. Dissemination of disease is not seen with systemic steroids.
MANAGEMENT OF POST-HERPETIC NEURALGIA is discussed on p. 928.

Orf

 This disease is due to a poxvirus infection that commonly affects young sheep, producing a pustular dermatitis. Vesiculopustular lesions appear around the mouth or feet of lambs, and persons coming into contact with the fluid from these may develop papular lesions on traumatized skin. Veterinary surgeons, farmers or their families and butchers are among those principally at risk.

Milker’s nodes are produced by a poxvirus that is morphologically identical to that of orf. Lesions are seen in farm workers handling the mouths or teats of cattle, and the organism may be carried by domestic cats.

CLINICAL FEATURES

Hands are usually affected. The lesions consist of redlblue papules, 1-2 em in diameter, with a grey edge and surrounding erythema. Misguided incision of such a swelling may release antigen and produce erythema multiforme. Lesions settle in 6-8 weeks and immunity appears to be lifelong.

Psychiatry and the Law

At the heart of the relationship between psychiatry and the law is the issue of responsibility. Mental disorder, by virtue of its severity and/or quality, may impair individuals’ responsibility for their thinking and actions. The law in most Western countries provides for the compulsory admission and/or treatment of mentally disordered persons for their own protection and/or the protection of others and for mitigation in the case of mentally disordered individuals who commit a criminal offence.

In England and Wales the law relating to the care and control of the mentally ill has evolved out of common law. The Act of Parliament that is crucially involved is the Mental Health Act of 1983. This Act is concerned not merely with provisions governing the compulsory admission and treatment of mentally disordered persons, but also with patients’ rights, appeals tribunals and the overall supervision of the use of compulsory powers. The Act is divided into a number of sections, each of which deals with a different aspect of the process. The Mental Health (Scotland) Act 1984 and the Mental Health (Northern Ireland) Order 1986 contain clauses broadly similar to those in England and Wales.

Apart from one provision of the National Assistance Act 1948, the Mental Health Act 1983 is the only method whereby individuals can legally be deprived of their liberty without having committed a crime or being suspected of comrruttmg a crime. It is, therefore, very important that doctors understand the seriousness of their responsibility and the details of the legislation.

There are three conditions that need to be met before an appropriate compulsory section form is signed. The patient must be:

1 Suffering from a defined mental disorder
2 At risk to his/her and/or other people’s health or safety
3 Unwilling to accept hospitalization voluntarily

The reasons why there is no alternative approach to the treatment suggested for the patient should be outlined.

Important sections of the Mental Health Act 1983.

Important sections of the Mental Health Act 1983.

Sexual deviance or alcohol or drug dependence are not mental disorders, but otherwise the definition of mental disorder is broad and includes:

• Mental illness
• Mental impairment
• Severe mental impairment
• Psychopathy

Any registered medical practitioner may sign a medical recommendation under the Act, but the added signature of a specialist psychiatrist approved under Section 12 is needed for compulsory orders lasting for more than 72 hours. Unless the patient is already in hospital, the nearest relative or an approved mental health social worker is also required to sign the application form. Important sections of the Act are detailed. Sections 4, 5(2), 5(4) and 136 cannot be extended by repetition.

They must be converted to a Section 2 or 3 if prolonged detention is necessary. Likewise, Section 2 should be converted to a Section 3 if required. Patients on the longer orders (2 and 3) can appeal to a Mental Health Review Tribunal. The Act also deals with consent to treatment, guardianship, mentally abnormal offenders and hazardous treatments. A Mental Health Act Commission supervises the Act, provides second opinions and regularly visits hospitals. Although much of the process of detention against one’s will is formalized, there is no liability for a doctor who acts in good faith with a patient’s best interests at heart. Clearly written medical notes, accepted forms of treatment and common sense remain the basis of good practice.

Gender Role Disorders

Transsexualism involves a disturbance in sexual identity. The criteria for establishing sexual identity are described .

In transsexualism, there is no evidence as yet of abnormality in the chromosomal or phenotypic sex; social sex conforms to biological sex. There is, however, a severe disturbance in psychosexual differentiation. A person’s gender identity refers to the individual’s sense of masculinity or femininity as distinct from sex. It is thought to arise from a biological component (prenatal endocrine influences), psychological imprinting and social conditioning.

Disturbances in these three areas have variously been blamed for the cause of transsexualism. The four
key features of transsexualism are:

I A sense of belonging to the opposite sex and of having een born into the wrong sex
2 A sense of estrangement from one’s own body; all manifestations of anatomical sexual identification are regarded as repugnant
3 A strong desire to resemble physically the opposite sex and seek treatment, including surgery, towards this end
4 A wish to be accepted in the community as belonging to the opposite sex

For males, treatment includes hormonal administration (oestrogen is used to produce some breast enlargement and fat deposition around hips and thighs) and, if surgery is to be recommended, a period of living as a woman as a trial beforehand. In the case of female transsexuals treatment involves surgery and the use of methyltestosterone.

Psychosexual Disorders

Sexual disorders can be divided into sexual dysfunctions, sexual deviations and gender role disorders .

Sexual dysfunctions

Sexual dysfunction in men refers to repeated inability to achieve normal sexual intercourse, whereas in women it refers to a repeatedly unsatisfactory quality of sexual satisfaction.

Problems of sexual dysfunction can usefully be classified into those affecting sexual desire, those affecting sexual arousal and those affecting orgasm. Among men presenting for treatment of sexual dysfunction, impotence is the most frequent complaint. The prevalence of prema  ture ejaculation is low, while ejaculatory failure is rare.

Sexual drive is affected by constitutional factors, ignorance of sexual technique, anxiety about sexual performance, medical conditions and certain drugs .

The treatment of sexual dysfunction involves careful assessment, the participation (where appropriate) of the patient’s partner, and specific therapeutic techniques, including relaxation, behavioural training and supportive counselling

Sexual dysfunction

Affecting sexual desire
Low libido

Impaired sexual arousal
Erectile impotence
Failure of arousal in women

Affecting orgasm
Premature ejaculation
Retarded ejaculation
Orgasmic dysfunction in women

Sexual deviations

Variations of the sexual ‘object’
Fetishism
Transvestism
Paedophilia
Bestiality
Necrophilia

Variations of the sexual act
Exhibitionism
Voyeurism
Sadism
Masochism
Frotteurism

Disorders of the gender role
Transsexualism

Classification of sexual disorders

Medical conditions affecting sexual performance.

Medical conditions affecting sexual performance.

Drugs adversely affecting sexual arousal.

Drugs adversely affecting sexual arousal.

Sexual deviations

Nowadays, sexual deviations are more likely to be regarded as unusual forms of behaviour than as illnesses and doctors are only likely to be involved when the behaviour involves breaking the law (e.g. paedophilia or bestiality) and when there is a question of an associated mental or physical disorder. Homosexuality was formerly classified as an illness but it is now an accepted alternative sexual life-style.

Transvestism is a form of sexual deviation in which individuals, usually men, dress in clothes of the opposite sex. The cross-dressing may either be a symptom of some other sexual deviation or may be employed as a means of fetishistic sexual excitement. It usually begins at about puberty and the transvestite experiences sexual excitement and may masturbate when indulging in this behaviour.

The overwhelming majority of cross-dressers believe that they are of the correct gender, in contrast to transsexuals .

COURSE AND PROGNOSIS

The condition runs a fluctuating course, with exacerbations and partial remissions. Long-term follow-up suggests that about two-thirds of patients maintain normal weight and that the remaining one-third are split between those who are moderately underweight and those who are seriously underweight. Indicators of a poor outcome include:

• A long initial illness
• Severe weight loss
• Bulimia, vomiting or purging
• Difficulties in relationships

Suicide has been reported in 2-5% of patients with chronic anorexia nervosa. More than one-third have
recurrent affective illness, and various family, genetic and endocrine studies have found associations between eating disorders and depression.

TREATMENT

Treatment can be conducted on an outpatient basis, but if the weight loss is severe it is accompanied by marked physical symptoms of lassitude, dizziness and weakness and/or electrolyte and vitamin disturbances; hospital admission may then be unavoidable. Rarely, the patient’s weight loss may be so severe as to be life-threatening. If the patient cannot be persuaded to enter hospital, compulsory admission may have to be used.

Treatment goals include:

• Establishing a good relationship with the patient
• Restoring the weight to a level between the ideal body weight and the patient’s idea of what her weight
should be
• The provision of a balanced diet of at least 3000 calories in three to four meals per day
• The elimination of purgative and/or laxative use and vomiting

Treatment can be conducted on behavioural or dynamic psychotherapeutic lines or on a combination of both. The usual behavioural approach is to remove privileges on the patient’s admission and to restore them gradually as rewards for weight gain. Intense psychoanalyticallyderived psychotherapy is not helpful. Family therapy, involving the exploration of problems in family relationships and their modification through counselling, is used; however, evidence that it is superior to simple supportive
psychotherapy is lacking.

Bulimia nervosa 

This refers to episodes of uncontrolled excessive eating, which are also termed binges. There is a preoccupation with food and a habitual adoption of certain behaviours that can be understood as the patient’s attempts to avoid the fattening effects of periodic binges.

These behaviours include:

• Self-induced vomiting
• Laxative abuse
• Misuse of drugs-diuretics, thyroid extract or anorectics

Additional clinical features include:

1 Physical complications of vomiting:

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2 Associated psychiatric disorders:
(a) Depression in reaction to vomiting
(b) Alcohol dependence
3 Fluctuations in body weight
4 Menstrual function-periods irregular but amenorrhoea rare
5 Personality-neurotic traits present premorbidly

The prevalence of bulimia in community studies is high; it affects between 5 and 30% of girls attending high schools, colleges or universities in the USA. Bulimia is often associated with anorexia nervosa. The prognosis is uncertain.

TREATMENT

It is not yet clear what is the most effective form of treatment. Admission to hospital with careful control over eating has been advocated, while a behavioural approach involving careful diary-keeping regarding eating and making patients responsible for control is under extensive study. In this approach, patients attempt to identify and avoid any environmental stimuli or emotional changes that regularly precede the desire to binge. Results of this approach are promising.

Eating Disorders

Obesity

The majority of cases of obesity are caused by a combination of constitutional and social factors that encourage overeating. It is relatively infrequent for psychological causes to be involved. However, even when obesity is not due to definite psychological causes, it may itself produce a psychological reaction of depression and tension, particularly if attempts by the patient to lose weight are repeatedly ineffective.

TREATMENT

Behavioural methods of treatment that make use of positive rewards for weight loss or for behaviour likely to lead to a reduction of weight have been attempted, but their efficacy is doubtful.

Anorexia nervosa

The main clinical criteria for diagnosis are:

• A body weight more than 25% below the standard weight
• An intense wish to be thin
• A morbid fear of fatness
• Amenorrhoea in women

Clinical features may include:

• Onset usually in adolescence
• A previous history of chubbiness or fatness
• A relentless pursuit of low body weight
• Usually a distorted image of own body size
• The patient generally eats little
• Particular avoidance of carbohydrates
• Vomiting, excessive exercise and purging
• Amenorrhoea-an early symptom; in 20% it precedes weight loss
• Binge eating
• Usually a marked lack of sexual interest
• Lanugo

The physical consequences of anorexia include sensitivity to cold, constipation, hypotension and bradycardia. In most cases, amenorrhoea is secondary to the weight loss. Vomiting and abuse of purgatives may lead to hypokalaemia and alkalosis.

PREVALENCE

Case register data suggest a rate ranging from 1 to 10 per 100000 females aged between 15 and 34 years. Surveys have suggested a prevalence rate of 1-2% among schoolgirls and university students. However, many more young women have amenorrhea accompanied by less weight loss than the 25% required for the diagnosis. The condition is much less common among men. The onset in women is usually between 16 and 17 years of age and it seldom occurs after 30 years.

AETIOLOGY

Biological factors

GENETIC. Six to ten per cent of siblings of affected girls suffer from anorexia nervosa; there is an increased concordance amongst monozygotic twins suggesting a genetic predisposition.

HORMONAL. There could be a disturbance of hypothalamic function in that:

• Amenorrhoea can precede weight loss in 20% of sufferers.
• Hormonal disturbances include low luteinizing hormone levels with impaired response to luteinizing hormone releasing hormone and to clomiphene. However, such findings could be due to the effect of prolonged fasting as they resolve after weight gain. Psychological factors

INDIVIDUAL. Patients usually have:

• A disturbance of body image
• Dietary problems in early life

Anorexia is seen as an escape from the emotional problems of adolescence and a regression into childhood.

FAMILY. The specific pattern of relationships described is characterized by:

• Overprotectiveness
• Rigidity
• Lack of conflict resolution

Anorexia serves to prevent dissension in families. However, evidence in favour of such patterns is conflicting.

Social factors

There is a higher prevalence in higher social classes, and a high rate in certain occupational groups (e.g. ballet students and nurses) and in societies where cultural value is placed on thinness.

Amphetamines and Related Substances

These have temporary stimulant and euphoriant effects that are followed by depression, anxiety and irritability. Psychological rather than true physical dependence is the rule. In addition to restlessness, over-talkativeness and overactivity, amphetamines can produce a paranoid psychosis indistinguishable from acute paranoid schizophrenia. Ecstasy is another amphetamine derivative (see below).

Cocaine

Cocaine is a eNS stimulant (with similar effects to amphetamines) derived from Erythroxylon coca trees grown in the Andes. In purified form it may be taken by mouth, sniffed or injected. If cocaine hydrochloride is converted to its base (crack) it can be smoked. This is an effective way of obtaining an intense stimulating effect and free-basing has become common. Compulsive use and dependence are thought to occur more frequently amongst users who are free-basing. Dependent users take large doses and alternate between the withdrawal phenomena of depression, tremor and muscle pains, and the hyperarousal produced by increasing doses. Prolonged use of high doses produces irritability, restlessness, paranoid ideation and occasionally convulsions. Persistent sniffing of the drug can cause perforation of the nasal septum.

Hallucinogenic drugs

Hallucinogenic drugs such as lysergic acid diethylamide (LSD), cannabis and mescaline produce distortions and intensifications of sensory perceptions as well as frank hallucinations.

Cannabis

A widely used drug in some subcultures is cannabis, derived from the plant Cannabis sativa. It is not thought to cause physical dependence. The drug, when smoked, seems to exaggerate the pre-existing mood, be it depression, euphoria or anxiety. There is no definite withdrawal syndrome or tolerance. There is disagreement over whether it can produce a psychosis.

Ecstasy

‘Ecstasy’ is the street name for 3,4-methylenedioxymethamphetamine (MDMA), a psychoactive phenylisopropylamine, synthesized in Germany early in this century. It is a psychodelic drug which is often used as a ‘dance’ drug. It has a brief duration of action (4-6 hours) and is usually ingested in a dose of 75-150 mg orally. There is anxiety concerning the possibility of MDMA causing permanent brain damage and deaths have been reported from hyperpyrexia, collapse, acute renal and liver failure.

Hypnotics

Other drugs of dependence include barbiturates and benzodiazepines. Discontinuing treatment with benzodiazepines may cause withdrawal symptoms such as anxiety, restlessness, tachycardia and sensory disturbances for this reason, withdrawal should be supervised and gradual.

Narcotics

Physical dependence occurs with morphine, heroin and codeine as well as with synthetic and semi-synthetic narcotic analgesics such as methadone and pethidine. These substances display cross-tolerance-the withdrawal effects of one are reduced by administration of one of the others. The psychological effect of such substances is of a calm, slightly euphoric mood associated with freedom from physical discomfort and a flattening of emotional response. This is believed to be due to the attachment of morphine and its analogues to receptor sites in the eNS normally occupied by endorphins. Tolerance to this group of drugs is rapidly developed and marked. Following abstinence it is rapidly lost. The abstinence syndrome consists of a constellation of signs and symptoms that reach peak intensity on the second or third day after the last dose of the opiate. These rapidly subside over the next 7 days. Withdrawal is dangerous in patients with heart disease, tuberculosis or other chronic debilitating conditions.

Narcotic addicts are reported to have a high mortality rate due to acute illness associated with drug abuse. Heart disease (including infective endocarditis), tuberculosis and glomerulonephritis are common causes of death, while tetanus, malaria and acute viral hepatitis B are also causally related to addiction.

Narcotic abstinence syndrome.

Narcotic abstinence syndrome.

TREATMENT

The treatment of a narcotic drug overdose requires immediate action. If opioid overdose is suspected, naloxone given intravenously (see p.755) can be lifesaving and diagnostic. There should be an immediate recovery of consciousness or a lightening of the comatose state if the offending agent is an opioid. Care must be taken, however, as opiate antagonists can precipitate violent abstinence symptoms. A constant infusion of naloxone hydrochloride may be required in methadone overdose.

The treatment of chronic dependence is usually directed towards helping the addict to live without drugs. Some who cannot manage such a regimen may be maintained on oral methadone. In the UK, only specially licensed doctors may legally prescribe heroin and cocaine to an addict for maintenance treatment of addiction.

Causes of drug dependence

There is no single cause of drug dependence. Three factors appear important:

1 Availability of drugs
2 A vulnerable personality
3 Social, particularly peer, pressures

Once regular drug taking is established, pharmacological factors are particularly important in determining dependence.

Drug Abuse and Dependence

In addition to alcohol and nicotine, there are a number of psychotropic substances that are used for their effects on mood and other mental functions .

Solvents

Adolescents engage in glue-sniffing for the intoxicating effects produced by the solvents inhaled. The glue is sniffed directly from tubes, plastic bags or smears on pieces of cloth. Tolerance develops over weeks or months.

Intoxication is characterized by:

• Euphoria
• Excitement
• A floating sensation
• Dizziness
• Slurred speech
• Ataxia

Acute intoxication can cause amnesia and visual hallucinations. The habit is dangerous because:

• Inhaled vomit can lead to asphyxiation.
• There is a risk of tissue damage, including damage to bone marrow, brain, liver and kidneys. Death can occur.
• Acute intoxication can also result in aggressive and impulsive behaviour.

Commonly used drugs of abuse and dependence.

Commonly used drugs of abuse and dependence.

Alcohol Dependence Syndrome

The alcohol dependence syndrome is usually very much easier to identify than problem-related drinking. Figure 19.3 outlines the main characteristics of the syndrome but these do not necessarily present in any particular order. Symptoms of alcohol dependence in a typical order of occurrence are shown in Table 19.27.

Unable to keep to a drink limit
Difficulty in avoiding getting drunk
Spending a considerable time drinking
Missing meals
Memory lapses, blackouts
Restless without drink
Organizing day around drink
Trembling after drinking the day before
Morning retching and vomiting
Sweating excessively at night
Withdrawal fits
Morning drinking
Decreased tolerance
Hallucinations, frank delirium tremens

Symptoms of alcohol dependence.

COURSE

The course of the alcohol dependence syndrome comprises three linked stages. The first stage is heavy social drinking, i.e. the ingestion of three to five standard drinks (units) of alcohol a day for several years. This stage can continue asymptomatically for a lifetime or, because of a change of circumstances or peer group, it can revert to a more moderate pattern of drinking or can progress to the second stage of alcohol abuse. This stage is usually associated with frequent ingestion of more than eight drinks a day and there are associated medical, legal, social and/or occupational complications. About half of such abusers either return to asymptomatic (controlled) drinking or achieve stable abstinence. In a small number of cases, such alcohol abuse can persist intermittently for decades with minor morbidity and become milder with time. About 25% of all cases of alcohol abuse will lead to chronic alcohol dependence, withdrawal symptoms and the eventual need for detoxification. This last stage most commonly ends in social incapacity and death or abstinence.

Evidence suggests that alcohol-dependent drinkers do not develop their dependence after a few drinks but that the disorder requires up to 10 years of heavy drinking to evolve (3-4 years in women). In some individuals who use alcohol to alter consciousness, obliterate conscience and defy social canons, dependence and apparent loss of control may appear in only a few months to a few years.

Withdrawal symptoms

Mild tremor, headache, nausea and general malaise are characteristic of the hangover. Patients who are chronically alcohol dependent often do not have these symptoms, partly because they are tolerant to alcohol and tend to continue to consume alcohol on the next day. Withdrawal from alcohol causes:

• Prominent tremor
• Insomnia
• Agitation
• Fits
• Delirium tremens (DTs)

Delirium tremens is the most serious withdrawal state and occurs 1-5 days after alcohol (or barbiturate) withdrawal. Patients are disorientated, agitated, and have a marked tremor and visual hallucinations (e.g. ‘pink elephants’).

Signs include sweating, tachycardia, tachypnoea and pyrexia. Additional signs include dehydration, infection, hepatic disease or the Wernicke-Korsakoff syndrome. If delirium tremens is not treated promptly, death can occur.

CAUSES 

Genetic factors 

Sons of alcohol-dependent people who are adopted by other families are four times more likely to develop drinking problems than the adopted sons of nonalcohol abusers.

Environmental factors

A Boston follow-up study showed that one in ten boys who grew up in a household where neither parent abused alcohol subsequently became alcohol dependent compared with one in four of those reared by alcohol-abusing fathers and one in three of those reared by alcoholabusing mothers.

Biochemical factors

Several factors have been suggested, including abnormalities in alcohol dehydrogenase, neurotransmitter substances and brain amino acids, such as GABA, but, to date, there is no conclusive evidence that these or other biochemical factors playa causal role.

Personality

Follow-up studies have failed to identify any trait or tendency that significantly distinguishes those who subsequently abuse alcohol from those who do not.

Psychiatric illness 

This is not a common cause of addictive drinking but it is a treatable one. Some depressed patients drink excessively in the hope of raising their mood. Patients with anxiety states or phobias are also at risk.

Excess consumption in society

The idea has grown that rates of alcohol dependence and alcohol-related problems correspond to the general level of alcohol consumption in society and, in turn, to factors that may control overall consumption, including price, licensing laws, the number and nature of sales outlets, and the customs and moral beliefs of society concerning the use and abuse of alcohol.

TREATMENT 

Psychological treatment 

Successful identification at an early stage constitutes an important treatment in its own right. It should lead to:

• The provision of information concerning safe drinking levels
• A recommendation to cut down where indicated
• Simple support and advice concerning associated problems

Such an approach has been found to be as effective as more expensive and specialized forms of psychotherapy in the treatment of moderate to heavy non-addictive drinking. With addictive drinking, the most favoured psychological treatment is group therapy, which involves identification, confession, emotional arousal, the implantation of new ideas, and the long-term support by fellowmembers of the group. Family and marital therapy involving both the alcohol abuser and spouse may also be important.

Behaviour therapies involving teaching patients how to drink in a more controlled way are the subject of much study.

Physical treatment

Addicted drinkers often experience considerable difficulty when they attempt to reduce or stop their drinking. Withdrawal symptoms are a particular problem and delirium tremens needs urgent treatment (Table 19.28). Drugs that show cross-tolerance for alcohol, such as diazepam or chlorrnethiazole, may be used in a regimen that involves a steady reduction over 5-7 days. A useful chlormethiazole regimen is 9-12 capsules for 1 day, 6-8 for day 2 and 4-6 for day 3. However, long-term treatment with drugs should not be prescribed in those patients who continue to abuse alcohol. Many alcohol abusers add dependence on diazepam or chlorrnethiazole to their problems.

Drugs such as disulfiram (Antabuse) react with alcohol to cause very unpleasant acetaldehyde intoxication and histamine release. A daily maintenance dose of such a drug means that an alcohol-dependent drinker must wait until the disulfiram is eliminated from the body before drinking safely. Such drugs, therefore, can provide a ‘chemical fence’ around the drinker for at least 24 hours. Disulfiram implants have been developed that have a treatment life of 6 months. As yet there is doubt as to whether their benefit is psychological rather than pharmacological.

OUTCOME
Whereas in the case of non-dependent heavy drinkers the goal of normal drinking within safe limits can be a very reasonable one, the alcohol-dependent drinker must be persuaded to abstain. Abstention, particularly after many years of drinking, is a difficult goal and not surprisingly many fail in the attempt. Research suggests that between 40 and 50% of alcohol-dependent drinkers are abstinent or drinking very much less up to 2 years following intervention.

Specialized treatment units, psychiatric treatment, group therapy and attendance at meetings of Alcoholics Anonymous-the self-help organization that provides members with a social structure to fill the gap previously occupied by drinking are all potential elements in the attempt to keep the alcohol-dependent  individual abstinent and healthy. To date, however, there is little convincing evidence that highly expensive, time-consuming and specialized modes of treatment are superior in their efficacy to straightforward advice, support, encouragement and monitoring.

The patient should be hospitalized
Chlormethiazole’ S-12 capsules (each capsule contains
192 mg) for 24 hours, then reduced over 5 days, or
diazepam 4-100 mg for 2 days then reduced
Any dehydration should be corrected
Any electrolyte imbalance should be corrected
Any systemic infection should be treated
B vitamins should be given parenterally
ai.v. should be avoided, if possible.

Management of delirium tremens.