Treatment of Alcohol-Induced Psychotic Disorder (Alcoholic Hallucinosis)-A Systematic Review.

AIMS: To evaluate the effectiveness of evidence based treatments for alcohol-induced psychotic disorder (AIPD) as described by ICD-10 and DSM-5, a condition that is distinct from schizophrenia and has a close relationship with alcohol withdrawal states. METHOD: Systematic review using PRISMA guidelines. RESULTS: Of 6205 abstracts found, fifteen studies and ten case reports met criteria and were examined. Larger studies examined the use of first-generation antipsychotic drugs, reporting full or partial remission in most patients. Newer case reports report similar results using second generation antipsychotic drugs. Novel treatments, such as those acting on GABA receptors reported low numbers of patients in remission. Some large studies report the successful use of standard alcohol withdrawal treatments. CONCLUSION: The findings of our systematic review are inconclusive. There was significant heterogeneity between and within studies. Significant publication bias is likely. Randomized control trials of more carefully delineated samples would produce evidence of greater clinical utility, for example, on differential effectiveness of antipsychotics and optimal length of standard alcohol withdrawal treatments. AIPD patients who show poor treatment responses should be studied in greater depth. SHORT SUMMARY: This systematic review of alcohol-induced psychotic disorder treatment found 15 studies and 10 case reports of relevance. Older studies of first-generation antipsychotics reported full or partial remission in most patients, as did newer studies with second-generation antipsychotics. Novel drugs reported low remission rates. Standard alcohol withdrawal treatments were successful.

Alcohol-induced psychotic disorder: brain perfusion and psychopathology--before and after anti-psychotic treatment.

Alcohol-induced psychotic disorder (AIPD) also known as alcohol hallucinosis is a rare complication of alcohol abuse. The pathogenesis and treatment of AIPD are still unclear. Few prospective treatment studies are available but case reports generally suggest that anti-psychotic treatment is effective. Brain imaging changes in relation to treatment response have also not been studied except for case reports. The aim of this study was to investigate the effect of anti-psychotic treatment on psychopathology and regional cerebral blood flow (rCBF) in patients with AIPD before and after 6 weeks of treatment. Nineteen patients with AIPD were assessed by the Positive and Negative Syndrome Scale (PANSS) and single photon emission computed tomography (SPECT) before and after 6-weeks of open-label treatment with a fixed dose of haloperidol (5 mg/day). Highly significant improvements were noted on the positive, general and total scores of the PANSS. Post-treatment increased rCBF to the left caudate and left frontal lobe was noted. Changes in frontal, temporal, parietal, occipital, thalamic and cerebellar rCBF showed significant negative correlations with the degree of symptom improvement, suggesting dysfunction of these areas in AIPD. Psychopathological and rCBF findings suggest reversible generalised cerebral dysfunction in AIPD.

[Psychotic experiences in the course of alcohol withdrawal symptoms: locus of control among patients with and without delirium and analysis of subjective experiences in delirium]. / Doznania psychotyczne w przebiegu alkoholowych zespolów abstynencyjnych: porównanie lokalizacji poczucia kontroli u osób z majaczeniem i bez majaczenia oraz analiza doznan w zespolach majaczeniowych.

AIM: The comparison of the locus of control in groups of patients hospitalised due to alcohol withdrawal with and without delirium and analysis of psychotic experiences of patients with delirium. METHODS: 25 patients with alcohol withdrawal with delirium and 25 without delirium took part in the study. They filled-in the Internal-External (I-E) Locus of Control Scale by Rotter; Multidimensional Health Locus of Control (MHLC) scale; the group with delirium also did the Psychopathological Symptoms Inventory, by Bizon et al. RESULTS: The mean score in I-E Locus of Control Scale in the group with delirium was more external than in the group without delirium (M = 13.28; SD = 2.762 versus M = 11.64; SD = 2.612; t(48) = -2.157; p = 0.036). Group with delirium had also lower mean score in the dimension of internal control in MHLC, than the group without delirium (M = 24.8; SD = 6.149 versus M = 26.8; SD = 4.648; t(48) = 1.99; p = 0.04). There were no statistically significant differences between the groups in the other subscales. The auditory and visual hallucinations were most common among patients with delirium (84%, 80% respectively, as well as delusions of taking part in not existing events (92%) and persecutory delusions (80%). Psychotic experiences influenced behaviour in nearly 50% of the cases. CONCLUSIONS: A more external locus of control may be one of the factors contributing to the development of alcohol delirium. The content of psychotic experiences seems to have impact on the behaviour of many patients with alcohol delirium.

Utility assessment in patients with mental disorders: validity and discriminative ability of the time trade-off method.

BACKGROUND: Preference-based health-state values, also referred to as utility scores, are considered an important measure of outcome in the evaluation of healthcare. A common approach to elicit utility scores is the use of the time trade-off (TTO) method; however, the data on TTO utility scores in patients with mental disorders are scarce. OBJECTIVE: To analyse the TTO method in patients with mental disorders in terms of discriminative ability, validity and the refusal to trade life time (zero trade). METHODS: In patients with affective (n = 172), schizophrenia spectrum (n = 166) and alcohol-related (n = 160) mental disorders, TTO utilities were administered through a standardized interview. Measures of quality of life (QOL) EQ-5D, WHOQOL-BREF, subjective (SCL-90R) and objective (CGI-S) psychopathology, and functioning (GAF, GARF, SOFAS, HoNOS) provided comparison. Discriminative ability was analysed by assessing frequency distributions of TTO utilities. Validity was analysed by assessing the correlation of TTO utilities with all other scores. The association of a patient's QOL, sociodemographic and disease-related variables with zero trade was analysed by logistic regression. RESULTS: Of patients with affective/schizophrenic/alcohol-related mental disorders, 153/143/145 (89/86/91%), respectively, completed the TTO elicitation; 29/43/28% of the respondents were zero traders. The mean TTO utility was 0.66/0.75/0.61 and the median was 0.85/0.95/0.75. TTO utility scores discriminated well among more impaired mental health states, but discrimination was limited among less impaired health states. In patients with affective and alcohol-related mental disorders, TTO utility scores were significantly correlated (mostly moderate: 0.3 < r < 0.5) with all other scores. However, in schizophrenic patients, TTO utility scores were only a little correlated with other subjective measures and not correlated with objective measures. QOL was significantly associated with zero trade; the influence of the other variables on zero trade was negligible. CONCLUSIONS: TTO utility scores in patients with affective or alcohol-related mental disorders were reasonably valid, but discriminative ability was compromised by a ceiling effect due to zero trade. In schizophrenic patients, validity of TTO utility scores was not demonstrated.

Alcohol withdrawal and prolonged hospital stay in a patient with neuroimaging abnormalities: a case report.

A hospital stay of 30 days was required in a 47-year-old woman with alcohol withdrawal. Magnetic resonance imaging (MRI) findings revealed a focal brain stem lesion and multiple focal supracortical abnormalities. Could asymptomatic neuroimaging abnormalities predict risk of complicated alcohol withdrawal? Future clinical observations and longitudinal studies may wish to address this potential risk factor.

Effects of alcohol on the offender's sanity-Issues of criminal law and psychiatry in light of findings of research.

The present report is the result of research on the causes of insanity or issuing opinions about the causes of insanity or diminished sanity perpetrators in criminal proceedings conducted in Poland (CEE). Research has shown the impact that has, in fact, use or abuse of alcohol and other alcoholic diseases on the status of the accused in criminal proceedings. This publication presents not only the results but also the basic regulations - valid in Poland and in other European countries - with respect to the responsibility of the perpetrators insane, with diminished sanity and being in a state of inebriation at the time of committing a criminal act.

Effective pharmacotherapy of alcoholic amnestic disorder with fluvoxamine. Preliminary findings.

Ten patients with alcoholic chronic organic brain disease were categorized as having alcohol amnestic disorder, or Korsakoff's psychosis (n = 6), dementia associated with alcoholism (n = 3), or compensated alcoholic liver disease (n = 1). All patients had severe deficits in memory for recently acquired information (episodic memory). Patients with alcohol dementia also showed global intellectual decline, including decreased performance on measures of semantic (knowledge) memory and reduction in levels of cerebrospinal fluid somatostatin. In a 4-week double-blind crossover design, the serotonin-uptake blocker fluvoxamine maleate (100 to 200 mg/d) was found to improve episodic memory in only the patients with alcohol amnestic disorder. These improvements in memory were significantly correlated with reductions in levels of cerebrospinal fluid 5-hydroxyindoleacetic acid, suggesting that facilitation of serotonergic neurotransmission may ameliorate the episodic memory failure in patients with alcohol amnestic disorder.

[A questionnaire survey on judgment of criminal responsibility].

The authors conducted questionnaire surveys utilizing model cases with the aim of investigating the current views of psychiatrists regarding criminal responsibility judgments in forensic psychiatric evaluations. Six model cases-injury by a person with acute schizophrenia, indecent assault by a person with chronic schizophrenia, attempted murder by a woman with depression, arson by an alcohol abuser, burglary by an amphetamine abuser, rape and indecent assault by a person with personality disorder-were presented to 345 psychiatrists, who were asked about criminal responsibility and appropriate treatment for each of the cases. One hundred eighty-five of the psychiatrists responded. In the case of acute schizophrenia with hallucination and delusion, the case of severe depression, and the personality disorder case, there was a high level of agreement between the evaluations of criminal responsibility made by the different respondents, but in the case of chronic schizophrenia, the case of alcohol-induced psychotic disorder, and the case of amphetamine abuse, there were variations in the evaluation of criminal responsibility, with many respondents emphasizing the patient's symptoms and condition at the time of the offense, and relatively few emphasizing whether the disorder was endogenous. Regarding the form of treatment, many of the respondents recommended compulsory hospitalization for the case of acute schizophrenia with hallucination and delusion, while at the same time recommending treatment in a prison environment for the personality disorder case. In contrast, for the case of chronic schizophrenia and the case of alcohol-induced psychotic disorder, opinion was divided as to whether the subject should be handled with a medical or a judicial approach. Regarding treatment for the case of alcohol-induced psychotic disorder and the case of amphetamine abuse, there was a tendency to make a judgment based on the subject's condition at the point of psychiatric evaluation, which was not necessarily linked to the criminal responsibility.

Altered NMDA glutamate receptor antagonist response in individuals with a family vulnerability to alcoholism.

OBJECTIVE: A family history of alcoholism is a risk factor for the development of ethanol dependence. Ethanol is an antagonist of the N-methyl-d-aspartate (NMDA) glutamate receptor, and alterations in NMDA receptor function are thought to be involved in ethanol abuse and dependence. The purpose of this study was to determine in healthy individuals with no ethanol dependence whether response to the NMDA receptor antagonist ketamine would differentiate those with a family history of ethanol dependence from those without such a family history. METHOD: Healthy subjects between the ages of 21 and 30 received 40-minute intravenous infusions of saline, low-dose ketamine (0.1 mg/kg), and high-dose ketamine (0.5 mg/kg) on three separate test days in a randomized order under double-blind conditions. The healthy individuals with at least one first-degree relative and another first- or second-degree relative with ethanol dependence (N=16) were compared with those who had no family history of ethanol dependence in any first- or second-degree relative (N=29). Outcome measures included the Brief Psychiatric Rating Scale, Clinician-Administered Dissociative States Scale, verbal fluency, Hopkins Verbal Learning Test, a biphasic alcohol effects scale, visual analog scales of mood states, and ketamine levels. RESULTS: During ketamine infusion, individuals with a family history of ethanol dependence showed an attenuated response in terms of perceptual alterations and dysphoric mood relative to those without such a family history. CONCLUSIONS: These data suggest that alterations in NMDA receptor function may contribute to subjective response to ethanol and therefore also to the risk of developing alcoholism.

Specific major mental disorders and criminality: a 26-year prospective study of the 1966 northern Finland birth cohort.

OBJECTIVE: The purpose of the study was to examine the quantitative risk of criminal behavior associated with specific mental disorders. METHOD: An unselected 1966 birth cohort (N = 12,058) in Northern Finland was prospectively studied until the end of 1992. The investigation started during the mothers' pregnancy, and the data on the subjects' family characteristics, mental and physical development, living habits, psychiatric morbidity, and criminal records were gathered at various times. RESULTS: The prevalence of offenses was the highest among males with alcohol-induced psychoses and male schizophrenic subjects with coexisting alcohol abuse, and more than half of the schizophrenic offenders also had problems with alcohol. Eleven (7%) of the 165 subjects who committed violent crimes were diagnosed as psychotic. Male schizophrenic subjects had a moderately high risk for violent offenses, but the risk for other types of crimes was not elevated significantly. Odds ratios for criminal behavior were adjusted according to the socioeconomic status of the childhood family and were the same as or slightly lower than the crude odds ratios for all disorders except schizophrenia and mood disorders with psychotic features. CONCLUSIONS: The results indicate that the risk of criminal behavior was significantly higher among subjects with psychotic disorders, even though the socioeconomic status of the childhood family was controlled. The higher risk for violent behavior was associated especially with alcohol-induced psychoses and with schizophrenia with coexisting substances abuse. The results suggest that schizophrenia without substance abuse may also be associated with a higher risk of offenses, but this finding is tentative and requires further investigation.

A three year follow-up of elderly alcoholics.

This a 3 year follow-up of the psychiatric status of 280 consecutive men age 65 and over who were admitted to the San Diego Veterans Administration Medical Center for medical or surgical problems. Eleven percent of the individuals were found to have active or remitted primary alcoholism. Over the 3 years only 20% of the surviving active alcoholics became abstinent. Most of the inactive alcoholics remained alcohol problem-free after 3 years. Affective disorder and dementia were common intercurrent psychiatric disorders arising during follow-up. The 3 year mortality rate was significantly higher for remitted alcoholics when compared to those without psychiatric illness.

Pathological intoxication--is there such an entity?

Pathological intoxication appears as a diagnostic term in DSM-II and DSM-III, is defined in a psychiatric dictionary and is described in several textbooks. Still, is there really such an entity? Is the small amount of alcohol inbibed incidental rather than causal? It should be borne in mind that alcohol is the popular explain-all of our culture and as such is used as an excuse for everything from sexual indiscretions to well-planned "impulsive" acts. It is likely--and evidence is presented for this conclusion--that so-called cases of pathological intoxication are really dissociative reactions. The existence of pathological intoxication as an entity must remain in doubt unless the disorder can be reproduced under controlled conditions.

The history of psychotic symptoms in alcoholics.

The history of psychotic symptomatology was reviewed in 220 consecutive male patients admitted to the San Diego Veterans Administration Center. Transient hallucinations and/or delusions were noted for 43% of the sample. A comparison of background variables in patients with and without histories of psychoses revealed that such symptoms are associated with less early life stability, higher levels of adult antisocial behavior, and a significant increase in use of most illegal drugs. The data indicated no association between a history of psychotic symptoms and a personal or familial history of schizophrenia.

The effects of antecedent substance abuse on the development of first-episode psychotic mania.

We examined associations of antecedent drug and alcohol abuse with age of onset of bipolar disorder and the time to hospitalization in a sample of 59 patients presenting with their first episode of psychotic mania. Patients with first-episode manic or mixed bipolar disorder with psychotic features were recruited from consecutive hospitalizations and evaluated using structured diagnostic instruments. Antecedent alcohol abuse was present in 12 patients (20%), and antecedent drug abuse in 19 (32%). Antecedent alcohol abuse was associated with a later age of onset of the bipolar disorder, although antecedent drug abuse was not associated with age of onset. Patients with antecedent drug or alcohol abuse required hospitalization sooner than those without. These preliminary findings suggest that patients with bipolar disorder and antecedent alcohol abuse may have a later onset of their affective illness, perhaps representing a subgroup of patients in whom previous alcohol abuse is necessary to precipitate an affective episode. Regardless, the presence of antecedent substance abuse leads to more rapid hospitalization in these patients. Our results should be considered preliminary, given the small sample size and the post-hoc design of the study. Additional prospective studies of patients with new onset bipolar disorder and antecedent substance abuse syndromes are needed to further clarify the complex relationships between substance abuse and bipolar disorder.

The discriminative stimulus properties of ethanol and acute ethanol withdrawal states in rats.

Twelve male Sprague-Dawley rats were trained in a standard two-choice Drug 1-Drug 2 discrimination task utilizing 3.0 mg/kg chlordiazepoxide (CDP, an anxiolytic drug) and 20 mg/kg pentylenetetrazol (PTZ, an anxiogenic drug) as discriminative stimuli under a VR 5-15 schedule of food reinforcement. Saline tests conducted at specific time points after acute high doses of ethanol (3.0 and 4.0 g/kg) indicated a delayed rebound effect, evidenced by a shift to PTZ-appropriate responding. Insofar as such a shift in lever selection indexes a delayed anxiety-like state, this acute 'withdrawal' reaction can be said to induce an affective state similar to that seen with chronic ethanol withdrawal states. Ethanol generalization tests: (1) resulted in a dose- and time-dependent biphasic generalization to CDP, (2) failed to block the PTZ stimulus and (3) failed to block the time- and dose-dependent elicitation of an ethanol-rebound effect. These data suggest that ethanol's anxiolytic effects are tenuous.

Delirium tremens and precipitous behavior. An analysis of two cases.

Alcoholism exists in alarming numbers of medical and surgical patients, often adding significant difficulties to their hospital management. Patient experiencing delirium tremens are known to exhibit irrational behavior, such as attempts to escape the hospital by any available means. Two cases of surgical patients at Rochester General Hospital who jumped from windows are discussed. These cases are reviewed closely, revealing deficiencies in history taking, errors in pharmacotherapy, and lapses in nurse-physician communication. The psychiatric consultant is alerted to a potential role in helping his medical and surgical colleagues avert disasters such as those described.

Successful treatment with captopril of an elderly man with polydipsia and hyponatremia.

A case of severe hyponatremia in a polydipsic 64-year-old man is described. He was unsuccessfully treated with both demeclocycline and lithium carbonate. However, low-dose captopril reversed the polydipsia and resulted in sustained normal serum sodium levels. We believe the antidipsogenic effect of captopril may benefit some patients with polydipsia and hyponatremia.

Alcohol-preferring rats in colonies show withdrawal, inactivity, and lowered dominance.

Rats with free access to water and 10% alcohol were raised in enriched, social colonies for prolonged periods of time. Then those animals which had developed extreme alcohol or water preferences were identified for further study. These selected animals were marked and returned to the colony. Both high and low alcohol consumers showed increased alcohol consumption just prior to feeding, but only the high consumers had a peak of alcohol consumption during the early morning hours. Compared to low consumers, high alcohol consumers ate less food, ran less in the activity wheel, spent more time in the burrows, and ranked low on several dominance measures. When access to alcohol was removed in the colony, these high alcohol consumers became more active but remained low in dominance. When tested in photocell cages, they showed a pattern of hyperactivity suggesting withdrawal effects. This sub-population of animals from rat colonies who voluntarily prefer alcohol to water represent a novel and social animal model of chronic alcohol consumption.

Alcoholic dementia.

At least four distinct cerebral diseases--Wernicke-Korsakoff, Marchiafava-Bignami, pellagrous encephalopathy, and acquired hepatocerebral degeneration--have a close association with chronic alcoholism. Each is characterized by a distinctive pathologic change and a reasonably well-established pathogenesis; in each the role of alcohol in the causation is secondary. The question posed in this review is whether there is, in addition to the established types of dementia associated with alcoholism, a persistent dementia attributable to the direct toxic effects of alcohol on the brain--i.e., a primary alcoholic dementia. The clinical, psychologic, radiologic, and pathologic evidence bearing on this question is critically reviewed. None of the evidence permits the clear delineation of such an entity. The most serious flaw in the argument for a primary alcoholic dementia is that it lacks a distinctive, well-defined pathology, and it must remain ambiguous until such time as its morphologic basis is established.

Self-reported effects of alcohol use on symptoms of schizophrenia.

Forty-two acute inpatients with schizophrenia, 23 of whom had a past or current alcohol use disorder, were given a structured interview that focused on reasons for alcohol use and changes in perceived effects of alcohol on psychiatric symptoms from the first episode of illness to the current episode. Drinking for sociability or celebration decreased over time, while drinking to relieve depression or problems increased. Subjects who experienced hallucinations, paranoia, or both significantly more often reported an increase in these symptoms after drinking. Subjects with an alcohol-related diagnosis were significantly more likely than those without such a diagnosis to cite relief of depression and problems or worries as a reason for alcohol use.