Transition to alcohol dependence: clinical and neurobiological considerations.

The transition to alcohol dependence is supposed to occur during a critical period that begins with increased drinking and ends with a loss of control. This process may last about 3 to 4 years, and is modified by gender and accelerated by premorbid traits (e.g., novelty-seeking) and comorbid disorders (e.g., dissocial personality disorders according to ICD-10). Genetic disposition, environmental influences (e.g., stress), and sensitization by exposure are factors implicated in dependence that alter brain functions, some possibly in an irreversible way. Underlying neurobiological mechanisms that may have different time patterns are beginning to be characterized on a systemic, cellular, and molecular level. Repeated free choices of the rewarding compound seem to be necessary for the transition to dependence.

Serotonin transporter gene variants in alcohol-dependent subjects with dissocial personality disorder.

BACKGROUND: We tested the hypothesis that a functional biallelic repetitive element in the 5' regulatory region of the human serotonin transporter gene (SLC6A4) confers susceptibility to serotonin-related personality traits underlying alcohol dependence with dissocial behavior. METHODS: The association study was focused on 64 alcohol-dependent subjects with a dissocial personality disorder (according to ICD-10) who were derived from 315 German alcohol-dependent subjects. The Tridimensional Personality Questionnaire (TPQ) was applied to assess personality dimensions in 101 alcohol-dependent men, including 39 dissocial alcoholics. RESULTS: Our association analyses revealed a trend towards a higher frequency of the short (S) allele of the SLC6A4 polymorphism in dissocial alcoholics compared to 216 German controls (chi 2 = 2.81, df = 1, p = 0.094). Dissocial alcoholics carrying the S/S genotype exhibited significant lower scores of harm avoidance compared to those lacking it (U-test, p = 0.015). Significantly higher novelty seeking scores were obtained in dissocial alcoholics carrying the S allele relative to those lacking it (U-test, p = 0.021). CONCLUSIONS: Our tentative association findings in dissocial alcoholics suggest that the S allele of the 5' regulatory SLC6A4 polymorphism confers susceptibility to a temperamental profile of high novelty seeking and low harm avoidance that has been postulated to underlie dissocial (type-2) alcoholism according to Cloninger's neurogenetic theory of personality.

Quantitative EEG (QEEG) predicts relapse in patients with chronic alcoholism and points to a frontally pronounced cerebral disturbance.

The capability of predicting relapse in chronic alcoholism using quantitative EEG was investigated. For this purpose, 78 in-patients with alcoholism underwent EEG recordings (eyes closed) 7 days after the beginning of detoxification. Additionally, other clinical evaluations were carried out. After discharge from hospital, patients were regularly re-evaluated for the duration of 3 months in order to determine whether they relapsed or abstained from alcohol during this time. For classification of the two diagnostic subgroups (relapsers vs. abstainers), multivariate discriminant analysis as well as artificial neural network technology has been applied. Correct classification of patients' EEGs was achieved in 83-85% and thus outperformed classification with clinical variables considerably. Furthermore, artificial neural networks (ANN) improved classification results when compared with discriminant analysis. It was found that, in comparison to abstainers, relapsers had EEGs that were more desynchronized over frontal areas, which was interpreted as a functional disturbance of the prefrontal cortex.

Association analysis of a regulatory variation of the serotonin transporter gene with severe alcohol dependence.

The present study tested the hypothesis that the short, low activity variant of a biallelic polymorphism in the 5' regulatory region of the human serotonin transporter (5-HTT) gene confers susceptibility to severe alcohol dependence marked by severe withdrawal symptoms. Applying a phenotype-genotype strategy, our population-based association analysis included 216 German controls and an extreme sample of 103 severely affected alcoholics who were selected from 315 German alcohol-dependent subjects by a history of alcohol withdrawal seizure or delirium. The frequency of the short allele (S) was significantly increased in the severely affected alcoholics, compared with that in the controls (X2 = 3.87, df = 1, nominal p = 0.049). The post-hoc exploration indicated that this allelic association resulted exclusively from a significant excess of the S/S genotype in the severely affected alcoholics (p = 0.035), suggesting a recessively acting effect. Consistently, we found a weak but significant correlation (p = 0.013) between the frequency of the S/S genotype and severity of withdrawal symptoms (WDS): no WDS [18.3%, odds ratio (OR) = 1.16], vegetative WDS only (21.8%, OR = 1.44), and severe WDS with either withdrawal seizure only or delirium only (25.0%, OR = 1.69), and both withdrawal seizure and delirium (30.8%, OR = 2.30). Further studies are required to test whether the tentative genotype-phenotype relationship occurred by chance or reflects a real genotypic association between a recessively modifying effect of the short variant of the functional 5-HTT promoter polymorphism and alcohol withdrawal vulnerability.

Serotonergic dysfunction in addiction: effects of alcohol, cigarette smoking and heroin on platelet 5-HT content.

The impact of ethanol, cigarette smoking and heroin on serotonin function was evaluated, first in alcoholics during chronic ethanol intoxication and in opiate addicts after long-term heroin consumption, and secondly in both patient groups after detoxification treatment (i.e. a short-term abstinence of 8 days). Our results showed that the 5-hydroxytryptamine (5-HT) content in platelets was: (1) increased in the subgroup of anti-social alcoholics; (2) transiently and differently altered in alcoholics compared to opiate addicts; and (3) lowered in drinking alcoholics and normal in alcoholics who were drinking as well as smoking (that may occur via MAO-B inhibition by smoke). The findings indicate that alterations of the peripheral and possibly the central serotonin system may occur as predisposing factors for alcoholism in individuals with anti-social traits; they may also have some impact on the progression of alcoholism due to its lowered function during chronic ethanol intoxication that is substantially modified by smoking.

Dopamine D4 receptor exon III alleles and variation of novelty seeking in alcoholics.

A dysfunction of dopaminergic neurotansmission has been implicated in alcohol-seeking behavior. Recently, a significant association between the seven-repeat allele (DRD4*7R) of a 16 amino acid motif in the third exon of the dopamine D4 receptor gene (DRD4) and the personality trait of novelty seeking has been reported. Our population-based association study tested the hypothesis that the DRD4*7R variant predisposes to high levels of novelty seeking, which may underlie alcohol-seeking behavior. The genotypes of the expressed DRD4 exon III polymorphism were determined in 197 German controls and 252 German alcohol-dependent males, of whom 92 alcoholics completed the tridimensional personality questionnaire. We found no significant differences in the DRD4*7R frequencies between controls and alcoholics, including two subgroups (56 alcoholics with dissocial personality disorder according to ICD-10 and 89 alcoholics with severe withdrawal symptoms) with a high level of novelty seeking. The novelty-seeking scores did not differ significantly between alcoholics (including both subgroups) carrying long alleles with six or more repeats compared with those lacking long alleles. The present results do not provide evidence that the DRD4*7R allele contributes a common and relevant effect to alcohol-seeking behavior in our sample of alcoholics.

Influence of the dopamine D2 receptor (DRD2) genotype on neuroadaptive effects of alcohol and the clinical outcome of alcoholism.

The present study was performed to test the hypotheses that allelic variants at the human dopamine D2 receptor gene locus (DRD2) confer susceptibility to alcoholism or are associated with clinical subtypes of alcoholism. We investigated an A --> G substitution polymorphism in the 3'-untranslated region of exon 8 (E8) of DRD2 with allele frequencies of f(G) = 0.295 - 0.329. No significant association of the DRD2 genotype or allele frequencies with alcoholism was found in an association study including 283 alcoholics and 146 non-alcoholic controls. However, the frequent homozygous E8 A/A genotype with f(AA) = 0.47 - 0.48 was associated with increased anxiety and depression scores in alcoholics during the follow up after clinical detoxification treatment. In addition, E8 A/A was associated with increased suicide attempts and showed a tendency towards more severe withdrawal symptoms, early relapse and reduced responsiveness to the dopaminergic agonist apomorphine. Regression analysis revealed the DRD2 E8 genotype as the only significant factor determining withdrawal severity in female alcoholics. The findings suggest an influence of the DRD2 genotype on the neuropharmacological effects of chronic alcohol exposure and the clinical course of alcoholism.

Superiority of carbohydrate-deficient transferrin to gamma-glutamyltransferase in detecting relapse in alcoholism.

OBJECTIVE: The usefulness of carbohydrate-deficient transferrin is widely accepted in screening (male) population samples for heavy alcohol consumption, but its role in relapse detection is not convincingly established. The authors therefore compared the diagnostic value of carbohydrate-deficient transferrin with the commonly used gamma-glutamyltransferase in identifying relapsed alcoholics during outpatient aftercare. METHOD: The patients were 101 male alcoholics who entered a 6-month rehabilitation program after hospital detoxification. Drinking status was assessed by means of self- and collateral reports obtained during regular contacts with the rehabilitation team; relapse was defined as consumption of any alcohol. Visits occurred weekly during month 1, biweekly during month 2, and every 4 weeks during months 3-6. At every visit a blood sample was taken for measurement of carbohydrate-deficient transferrin and gamma-glutamyltransferase. RESULTS: The proportion of men who reported relapse was 25.6% per scheduled contact on average. Positive predictive values indicated that relapse was identified with a 76.2% probability by carbohydrate-deficient transferrin values above the upper normal limit, in contrast to a 32.9% chance with gamma-glutamyltransferase. Carbohydrate-deficient transferrin was especially useful in detecting early relapses during the initial rehabilitation phase, when gamma-glutamyltransferase values had not normalized. Because of the longer half-life of gamma-glutamyltransferase, it had some value with a 4-week monitoring schedule in detecting new drinking episodes in alcoholics whose previous results had been normal. CONCLUSIONS: Carbohydrate-deficient transferrin proved to be superior to gamma-glutamyltransferase in relapse detection in an outpatient care setting for alcoholics.

Antisocial tendencies in alcohol-dependent men and their relation to harman, salsolinol and dopamine.

Plasma dopamine, ß-carbolines (norharman, harman) and isoquinolines ((R)- and (S)-salsolinol) were examined for their relationship to antisocial tendencies in 138 drinking men with an alcohol dependence syndrome according to ICD-10 criteria. Antisociality was assessed according to the following criteria: delinquency, involvement in fist-fights and homelessness. The personality structure was documented by the Tridimensional Personality Questionnaire of Cloninger. An early age of onset of alcohol dependence and a high degree of 'novelty seeking' were associated with antisocial tendencies. Of the ß-carbolines and isoquinolines, harman and (S)-salsolinol were significantly decreased among antisocial alcoholics. Norharman, (R)-salsolinol and dopamine were not associated with antisocial personality. The contribution of endogenous alkaloids to the biological characterization of antisocial tendencies in alcoholics is described.

Psychopathological and behavioral correlates of dopaminergic sensitivity in alcohol-dependent patients.

OBJECTIVES: To explore 2 facets of dopamine receptor sensitivity in alcoholics: (1) whether reduced sensitivity of central dopamine receptors is correlated with anxiety, depression, or novelty seeking and (2) whether this reduction is associated with poor treatment outcome. METHOD: Sixty-four alcohol-dependent patients were assessed according to their clinical outcome, sensitivity of central dopamine receptors (apomorphine-induced growth hormone secretion), mood states, and personality traits before and after detoxification. RESULTS: Patients with poor treatment outcome displayed a blunted growth hormone response before, but not after, detoxification. Growth hormone response was not significantly correlated with novelty seeking. Relapsing patients tended to be less depressed than patients who remained abstinent during observation. CONCLUSION: This study did not support the hypothesis that reduced sensitivity of dopamine receptors is associated with anxiety, depressed mood, or high novelty seeking in alcoholism.

[Alcohol dependence in homeless men. Incidence, development and determinants]. / Alkoholabhängigkeit bei männlichen Wohnungslosen. Häufigkeit, Ausprägung und Determinanten.

Against the background of the complex relationship of alcoholism and homelessness, we investigated the question of whether homeless alcoholics and those with homes differed regarding biographical and clinical variables. Therefore, 49 of 72 (68.1%) homeless male visitors to a city kitchen in the center of Berlin, who had fulfilled the ICD-10 criteria for the alcohol-dependence syndrome, were compared with 141 outpatients of the addiction research unit of the Department of Psychiatry of the Free University of Berlin. It was found that homeless alcoholics had more psychosocial disadvantages than other alcoholics. They had been raised more frequently in families with an alcoholic father or mother and a higher number of children. The level of education and job qualification was lower in the homeless alcoholics. Early homelessness was predicted by a lack of sexual behavior (no partnership experienced) and a family history of alcoholism. In the interview, homeless alcoholics reported fewer symptoms of alcohol-dependence syndrome than other alcoholics; however, the first symptoms had been experienced earlier. Alcohol-related somatic and psychological consequences were reported more frequently in alcoholics with homes, whereas social problems were more common in the homeless subjects. The results are discussed in the light of methodological limitations and other reports on the topic.

Influence of dopaminergic transmission on severity of withdrawal syndrome in alcoholism.

OBJECTIVE: Dysfunction of dopaminergic transmission has been suggested as influencing withdrawal syndrome in alcohol-dependent patients. Therefore, dopamine levels and sensitivity of dopamine receptors were correlated with the severity of withdrawal syndrome in 40 alcoholics. METHOD: Dopamine blood plasma levels and apomorphine-induced Growth Hormone (GH) release were measured on the first day of detoxification (Day 1) and after 8 days of abstinence (Day 8). Severity of withdrawal syndrome was assessed daily by the Clinical Institute Withdrawal Assessment (CIWA) score. In the 22 patients (out of the 40) treated by chlormethiazole, severity of withdrawal was measured by the required chlormethiazole dose. RESULTS: A positive correlation was found between dopamine levels on Day 1 and the total CIWA score and necessary chlormethiazole dose, respectively. Correlation with the CIWA score was even stronger when the sensitivity of post-synaptic dopamine receptors was taken into account. No significant correlation between dopamine levels on Day 8 and withdrawal syndrome was found. CONCLUSIONS: Our findings indicate an influence of dopaminergic transmission on withdrawal syndrome during early withdrawal.

Lack of allelic association of dopamine D1 and D2 (TaqIA) receptor gene polymorphisms with reduced dopaminergic sensitivity to alcoholism.

Our study tested the hypothesis of whether the sensitivity of central dopamine receptors corresponds to the genotypic constitution of DNA-polymorphisms of the dopamine D1 and D2 receptor (DRD1, DRD2) genes and is associated with poor treatment outcome. Therefore, 97 alcohol-dependent patients were assessed according to their sensitivity of central dopamine receptors (apomorphine-induced secretion of growth hormone), clinical outcome during a 6-month observation period, and genotypic constitution of the TaqIA restriction fragment length polymorphism (RFLP) at the DRD2 locus and of the Bsp1286I RFLP at the DRD1 locus. On the 1st day of detoxification, dopamine receptor hyposensitivity was found in treatment nonresponders, but not in responders. Apomorphine-induced growth hormone release did not differ significantly in alcoholics with different genotypes of the DRD1 and DRD2 RFLPs. Neither did we find a significant allelic association with treatment response. Thus, we did not find evidence for a genetic determination of dopamine receptor hyposensitivity in alcoholics with poor treatment outcome.

No association of the structural dopamine D2 receptor (DRD2) variant 311Cys with alcoholism.

The human dopamine D2 receptor (DRD2) has been implied in the vulnerability for alcoholism and/or the modification of its severity. This is supported through animal experimental and pharmacological data. We analyzed the DRD2 311Ser/Cys polymorphism in 312 German alcoholics and 131 ethnically matched controls to investigate the association of genetic DRD2 variants with alcoholism or clinical characteristics of homogeneous subgroups of alcoholics. We observed no association between the 311Cys variant and alcoholism, and none of the clinical characteristics evaluated was significantly associated with 311Cys. The allele frequencies of the 311Cys variant were 0.026 and 0.031 in the alcoholics and controls, respectively. These are the highest reported 311Cys frequencies in Caucasians. The DRD2 TaqI A1/A2 restriction fragment length polymorphism was analyzed simultaneously in our samples. In most cases, the 311Cys allele is associated with the TaqI A2-allele. Data do not suggest a clinical relevance of the 311Cys variant in alcoholism. However, the relevance of this variant in other diseases or the existence of other DRD2 variants with altered receptor function or expression cannot be excluded.

Harman and norharman in alcoholism: correlations with psychopathology and long-term changes.

In the search for mechanisms specific for alcoholism, it has become evident that beta-carbolines (BCs; e.g., harman and norharman) are compounds that may act on brain reward systems, thereby mediating an increase in voluntary ethanol (ETOH) drinking in animals. This study was undertaken to analyze relationships between these compounds and clinical variables (e.g., family history, personality data, and affect) in alcoholics and to trace the time course of blood concentrations in subjects abstaining from alcohol for at least 6 months. Nonalcoholics were investigated during sober and ETOH-loading conditions (1 g ETOH/kg body weight). Levels of harman were elevated in the chronically intoxicated alcoholics and correlated with the scores on the self-rating depression (SDS) and the self-rating anxiety (SAS) scales. The group of alcoholics with at least one alcoholic parent had higher levels than the group without such a history. Levels remained elevated for 6 months. Norharman levels were only slightly elevated on the day of admission. They were correlated to high harm avoidance and SDS scores. A family history of alcoholism and the severity of alcoholism as assessed by the number of ICD-10 criteria fulfilled were correlated with norharman levels. Long-term observation revealed elevated levels of norharman after 3 months of abstinence, but not after 6 months. The association of harman levels with anxiety and depression demonstrated in the present study suggests that alcoholics with high harman levels use alcoholic beverages as self-medication in an attempt to overcome possible anxiogenic/depressiogenic actions of harman. Norharman levels are less strongly associated with these mood states, but significantly correlated to harm avoidance tendencies. It has been suggested that the activity of the indolergic neurons is relatively high in individuals with a high harm avoidance score. Biosynthesis of norharman might be stimulated under these conditions (tryptamine serves as precursor).

Dopaminergic responsivity in alcoholism: trait, state, or residual marker?

OBJECTIVE: In order to classify neuroendocrine abnormalities in alcohol-dependent patients as trait, state, or residual markers, growth hormone (GH) secretion was assessed longitudinally. METHOD: GH secretion, stimulated by the dopaminergic agonist apomorphine, was evaluated in 21 alcohol-dependent patients (16 men, five women) and 10 healthy comparison subjects (eight men, two women). The patients were tested during early withdrawal, after 8 days of abstinence, and after 3 months. RESULTS: Patients who relapsed within 3 months (N = 8) showed significantly less GH secretion in all neuroendocrine tests than did either the patients who abstained from ethanol consumption for 6 months (N = 13) or the healthy comparison subjects. The relapsers and abstainers did not differ significantly in any of their clinical or pathophysiological data, in the severity of their withdrawal symptoms, or in antecedent or concomitant illnesses associated with alcoholism. CONCLUSIONS: GH blunting appears to be a residual marker of clinical relevance in alcoholism.

Determination of (R)- and (S)-salsolinol sulfate and dopamine sulfate levels in plasma of nonalcoholics and alcoholics.

We have developed a new method to determine free as well as sulfoconjugated salsolinol (SAL), separated into both enantiomers, and free and sulfoconjugated dopamine in human blood plasma. Among the group of nonalcoholics (R)-SAL (mean +/- SEM: 0.24 +/- 0.07 ng/ml) was found in all blood samples and (S)-SAL in 1 out of 20 (0.08 ng/ml). Ethanol loading induced a rise of both enantiomers as well as of dopamine whereby (S)-SAL was detected in the plasma of 13 subjects only [(R)-SAL: 0.79 +/- 0.24 ng/ml; (S)-SAL: 0.49 +/- 0.15 ng/ml; DA: 8.84 +/- 0.75 ng/ml]. The later finding favors the notion of an enzymatic formation of (S)-SAL. In alcoholics, (R)-SAL and (S)-SAL were elevated at the day of admission for detoxification [(R)-SAL: 0.65 +/- 0.82 ng/ml; (S)-SAL: 0.35 +/- 0.05 ng/ml] and normalized after several months, suggesting intoxication marker characteristics [month 6: (R)-SAL: 0.24 +/- 0.14 ng/ml; (S)-SAL: 0.20 +/- 0.05 ng/ml]. Patients with alcoholic parents had lowered (R)-SAL and (S)-SAL levels compared with family history negative alcoholics, suggesting genetic association of disturbance of the SAL biosynthesis and alcoholism. Among the personality traits, suicidality was linked with low (R)-SAL and (S)-SAL concentrations in contrast to novelty seeking, impulsivity, and harm avoidance scores. The scores on the self-rating anxiety scale correlated positive with (R)-SAL. These findings suggest trait marker characteristics of salsolinol.

[Current aspects of pharmacotherapy of alcoholism]. / Perspektiven einer Pharmakotherapie der Alkoholabhängigkeit.

There is increasing evidence that "anticraving" drugs are promising agents in the treatment of alcoholics. Clinical studies indicate favorable effects of drugs with different pharmacological profiles (e.g., dopaminergic, serotonergic, anti-opioidergic, antiglutamatergic) on abnormal drinking behavior and relapse tendencies. Interactions with the limbic reward system seem to be involved. As several drugs will probably be registered in Germany, the need for integrating these drugs in a complex rehabilitation program is emphasized. Many clinical issues regarding the practical use of these drugs await further clarification.

Blunted growth hormone response is associated with early relapse in alcohol-dependent patients.

Growth hormone (GH) secretion, stimulated by the dopamine D1 and D2 receptor agonist apomorphine, was assessed in 55 alcohol-dependent patients before detoxification (on the day of admittance to hospital) and after 7 days of treatment on the ward (day 8). Patients who relapsed early (i.e., within 3 months after detoxification) showed significantly blunted GH secretion before detoxification, compared with both healthy controls and patients who abstained for 6 months. Among early relapsing patients, GH secretion was blunted whether or not patients were acutely intoxicated on the day of admittance to hospital. However, for patients who abstained during observation, a blunting effect of acute ethanol consumption on GH secretion was demonstrated. On day 8, a trend toward blunted GH secretion was found in early relapsing patients only when GH response over infusion time was assessed. Therefore, GH blunting, and no other variable indicating the clinical course of the disease, was associated with early relapse in alcohol-dependent patients. These findings are evidence of reduced dopamine receptor function in a subgroup of early relapsing alcohol-dependent patients during chronic intoxication.

Longitudinal observations of monoamine oxidase B in alcoholics: differentiation of marker characteristics.

The marker characteristics of monoamine oxidase B (MAO B) in human platelets were investigated in a clinical study of 59 alcoholics (diagnosed according to the criteria of ICD-10) observed over a period of 6 months. Demographic and family history were obtained by a structured interview, including the substance abuse section of CIDI (Composite International Diagnostic Interview). The patient's personality was assessed by Cloninger's Tridimensional Personality Questionnaire (TPQ). Blood samples were first drawn during chronic intoxication (day of admission to the hospital for detoxication), after short-term abstinence (8 days later), medium-term (3 months later), and long-term abstinence (6 months later). A group of 22 matched healthy nonalcoholics served as controls studied under sober conditions and during acute intoxication (4 hr after ingestion of 1 g ethanol/kg body weight). All platelet samples were investigated with 6 kynuramine concentrations as substrate (fluorometric assay) in the absence and presence of 200 mM ethanol (ETOH) in vitro. MAO B activity was significantly reduced in alcoholics during chronic intoxication (Vmax: 2.70 +/- 0.15 nmol/mg protein) compared with sober (Vmax: 3.25 +/- 0.23 nmol/min/mg protein) and acutely intoxicated controls that turned to normal during abstinence. However, MAO B activity obtained during medium- and long-term abstinence was significantly lowered in patients with high novelty-seeking and impulsiveness scores in the TPQ, a history of suicide attempts, or an alcoholic mother. The affinity of MAO B (Km values) was unchanged in alcoholics at any time investigated. Addition of ETOH in vitro reduced the affinity.(ABSTRACT TRUNCATED AT 250 WORDS)