ALCOHOLISM
Alcoholism is a chronic mental illness caused by alcohol abuse, characterized by a pathological craving for alcohol and the associated physical and mental consequences of alcohol intoxication of increasing severity.
The primary link in the development of alcoholism is acute alcohol intoxication with its characteristic clinical manifestations of intoxication, which predispose to the development of the disease.
Alcoholism, like any human disease, arises and develops as a result of a combination of environmental and genetic factors, representing a violation of the adaptation of the body and personality to the social environment, associated with certain pathobiological mechanisms.
Pathological attraction to alcohol has pronounced dominant properties, prevailing over other motivations in human behavior. As a result, alcohol is consumed not so much for the sake of anything, but in spite of many negative consequences, including disruption of family, friendship, work and other social ties, conflicts with the law, signs of deteriorating health, and regularly occurring painful hangovers. Continued systematic consumption of alcohol, despite all these circumstances, is the surest diagnostic criterion for pathological craving for alcohol. This criterion is used by modern clinicians as a key sign of alcoholism in general, which indicates the exceptional importance of pathological craving for alcohol in the pathogenesis and clinical picture of the disease.
"Alcohol Dependence Syndrome."
In ICD-10, all alcohol-related disorders are concentrated in section V “Mental and behavioral disorders”. They form the subsection “Mental and behavioral disorders due to the use of psychoactive substances”
(headings F10 - F11).
Syndromedependenciesfromalcoholincludes: 1) a strong desire to take alcohol or an urgent need for alcohol;2) impaired ability to control its consumption;3) the emergence of a tendency to drink alcohol equally both on weekdays and on weekends, despite social deterrents (“narrowing of the repertoire” of consumption); 4) progressive neglect of alternative pleasures and interests; 5) continued drinking despite obvious harmful consequences; 6) withdrawal syndrome;7) hangover;8) increasing tolerance to alcohol.
Diagnosis of alcoholism must be based on criteria that are both sufficiently sensitive and specific. Such criteria are best served by clinical syndromes and the sequence of their changes during the course of the disease.
PREVALENCE
Generally accepted statistical indicators of morbidity and morbidity from alcoholism do not reflect the real situation, since the number of identified and registered patients largely depends on the activity of the drug treatment service. This has been especially noticeable in recent years (since 1990), when the rigid system of compulsory dispensary registration, active identification and semi-compulsory involvement of patients with alcoholism in treatment ceased to operate. Therefore, to assess the drug situation, a number of indirect indicators are used: the dynamics of alcohol consumption in a particular region, mortality from liver cirrhosis, the incidence of alcoholic psychosis, crime, transport accidents, injuries, the number of divorces, etc. Each of these indicators separately, of course, ambiguous and debatable, but taken together they are quite informative.
CLASSIFICATION OF ALCOHOL MENTAL DISORDERS
Mental disorders caused by alcohol consumption are usually divided into groups depending on the duration of its use: those arising after single or episodic use and those resulting from repeated use over a significant period of time (chronic use), as well as depending on the presence and absence of psychotic disorders.
Groups of alcohol disorders:
I. Acute alcohol intoxication:
simple alcohol intoxication;
modified forms of simple alcohol intoxication;
pathological intoxication. P. Chronic alcoholism;
III. Alcoholic (metal-alcoholic) psychoses.
Like any other classification of human diseases, the above division of alcoholic pathology is somewhat schematic and conditional. In clinical practice, other diagnostic classifications are used, which will be given when considering chronic alcoholism.
ACUTE ALCOHOL INTOXICATION
According to ICD-10, acute alcohol intoxication is a transient condition that occurs following the consumption of alcohol, which causes disturbances or changes in physiological, psychological or behavioral functions and reactions.
If all the cerebral functions affected by alcohol are conditionally divided into mental, neurological and vegetative, then even more conditionally we can assume that a mild degree of alcohol intoxication is manifested mainly by mental disorders, a moderate degree - by the occurrence, in addition to them, of obvious neurological disorders, severe degree - violations of vital autonomic functions with the actual cessation of mental activity and deep depression of motor and reflex activity. Strictly speaking, any degree of alcoholic intoxication is characterized by the impact of alcohol on all three named areas of function, but since mental functions are impaired earlier and more strongly than others, these disorders should be considered leading.
Simple alcohol intoxication
Alcohol intoxication can be defined as a psychopathological syndrome, the structure of which depends on the dose of alcohol taken, the time that has elapsed from that moment, and on the biological and psychological characteristics of the person exposed to alcohol intoxication. The degrees of alcohol intoxication are the stages of the dynamics of this psychopathological syndrome.
Although simple alcohol intoxication is a mental pathology in a clinical sense, in a legal sense it is not such and does not relieve a person of responsibility.
The given narrow clinical definition of alcohol intoxication as a psychopathological syndrome is opposed to its broad interpretation as inadequate: behavior or as a condition in which “normal reactions to the external environment change. In this understanding, the assessment of behavior and the degree of its adequacy depend largely on specific environmental conditions, their routine or extreme. For example, with a blood alcohol concentration of 0.4 mmol/l, when there are no clinical signs of intoxication, the skill of transport drivers drops by 32%. situations. On the contrary, in the habitual and leisurely activity of a person, it is difficult to detect any deviations in reactions when he drinks, for example, a glass of beer.
Thus, the clinical diagnosis of simple alcohol intoxication does not have universal significance - it is used only when the appropriate need arises. In other cases, diagnosis is limited to special tests and departmental instructions are applied.
Degrees of alcohol intoxication. As already noted, the symptoms of alcohol intoxication are determined primarily by the concentration of alcohol in the blood. At low concentrations in the blood, the stimulating effect predominates.
A mild degree of alcohol intoxication, in which the blood alcohol concentration ranges from 20 to 100 mmol/l (20-100 mg of alcohol per 100 ml of blood), is usually characterized by increased mood, verbosity, accelerated associations, increased amplitude of emotional reactions, decreased self-criticism, instability attention, impatience and other signs of the predominance of mental excitation over inhibition. In this case, some neurological (impaired coordination of fine movements, nystagmus) and autonomic (facial hyperemia, increased heart rate and breathing, hypersalivation) disorders can be observed.
If you are moderately intoxicated (alcohol concentration e blood from 100 to 250 mmol/l) mental reactions lose their vivacity, thinking becomes slow, unproductive, judgments become trivial and flat, speech becomes perseverative and blurred. Understanding and correct assessment of the environment become very difficult. Emotional reactions become coarser, acquire a brutal character, the mood tends towards gloominess, anger or dull indifference.
Neurological disorders during moderate intoxication are manifested in ataxia, lack of coordination of movements, dysarthria, weakening of pain and temperature sensitivity. Facial hyperemia gives way to cyanotic color and pallor, and nausea and vomiting often occur.
Severe alcohol intoxication (with a blood alcohol concentration of 250 to 400 mmol/l) is expressed by depression of consciousness - from stupor and somnolence to coma. Sometimes epileptiform seizures occur. At higher blood alcohol concentrations (up to 700 mmol/l), death from respiratory paralysis may occur.
The maximum tolerated alcohol concentration is variable. A case is described where a person remained awake and could participate in a conversation with a blood alcohol concentration of over 780 mg%.
The duration of alcohol intoxication depends on many factors (gender, age, racial characteristics, addiction to alcohol), but most of all - on the amount of alcohol consumed and its metabolic transformation in the body.
After moderate and especially severe alcohol intoxication, post-intoxication symptoms remain for several hours the next day - headache, thirst, poor appetite, weakness, weakness, nausea, vomiting, dizziness, tremor. Of great practical importance is a decrease in performance, the severity of which depends on both the “alcoholic” factor and the individual characteristics of the drinker. It is largely determined by the nature of work. For example, even experienced pilots, after being slightly intoxicated for 14 hours, experience a decrease in professional skills.
With age, as well as in the process of systematic alcohol abuse, the time required to fully restore a normal state increases, and the disorders become more severe and varied. With continued systematic alcohol abuse, a “symptom of decompensation of well-being” is formed. In these cases, the state of health remains poor for 1-2 days after drinking. The next stage may be the development of post-intoxication syndrome into alcohol withdrawal syndrome.
The symptoms of acute alcohol intoxication largely depend on the “soil” on which alcohol affects. The presence of such soil (consequences of previously suffered diseases, injuries, as well as emerging pathology) leads to the emergence of altered forms of alcohol intoxication. Among them are the following:
The dysphoric version of intoxication is a state when, instead of the euphoria characteristic of simple alcoholic intoxication, a gloomy mood with irritability, anger, conflict, and a tendency to aggression arises from the very beginning. In other words, a mild degree of intoxication in its emotional background resembles a medium degree, i.e. as if it carries within itself the beginning of a more serious condition. Such features of alcohol intoxication are often observed in patients with chronic alcoholism, as well as in various types of organic brain failure.
The paranoid version of intoxication is characterized by the appearance of suspicion, touchiness, pickiness, and a tendency to interpret the words and actions of others as a desire to humiliate, deceive, ridicule, or gain the upper hand in competition; jealous feelings and associated aggression are possible. Similar behavioral traits when intoxicated are found in some psychopathic individuals - epileptoid, paranoid, primitive (especially if they are suffering from chronic alcoholism).
Alcohol intoxication with hebephrenic features is manifested by foolishness, stereotypies, antics, chaotic rowdyness, monotonous onomatopoeia, and senseless rioting. Such pictures can be observed in the presence of a latent schizophrenic process, as well as in adolescents and young men.
Alcohol intoxication with hysterical traits - in the presence of appropriate personal prerequisites (egocentrism, desire to be the center of attention, a tendency to “exploit” the sympathy of others, the desire to make a bright impression, excess of ambition over abilities), alcohol intoxication brings to life hysterical mechanisms, which most often manifest themselves demonstratively suicidal attempts, theatricalized grief, violent scenes of despair, “madness”, etc.
The term “pathological intoxication” does not accurately reflect the essence of this phenomenon: it is not so much the result of alcohol intoxication as an expression of a peculiar idiosyncrasy to alcohol, which can occur with a certain combination of a number of factors (overwork, forced insomnia, psychogenia, organic cerebral insufficiency, etc. .). The picture of pathological intoxication and outwardly bears little resemblance to alcoholic intoxication, since there are no disturbances in statics and coordination of movements, as well as pantomimic features characteristic of the appearance of an intoxicated person.
Essentially, pathological intoxication is a transient psychosis, and in syndromological terms it is a twilight state of consciousness. There are two forms of it - epileptoid and paranoid, which differ in the predominance of certain disorders
In the epileptoid form, painful symptoms are expressed in the form of total disorientation, lack of any contact with the surrounding reality, sharp motor agitation with an affect of fear, anger, malice, with silent, senseless and cruel aggression, which sometimes has the character of automatic and stereotypical actions.
In the paranoid form, the patient's behavior reflects delusional and hallucinatory experiences of frightening content. The same is evidenced by individual words, shouts, commands, threats, although in general the patient’s speech production is scarce and incomprehensible. Motor activity is relatively orderly in nature and takes the form of complex and purposeful actions (escape using transport, defense, attack, carried out with great force).
Pathological intoxication occurs suddenly and ends just as suddenly, often ending in deep sleep. It lasts from several minutes to several hours, leaving behind asthenia, headache, total or partial amnesia. Complete amnesia is more typical for the epileptoid form, partial amnesia - with fragmentary, sometimes very colorful, memories - for the paranoid form.
CLINICAL MANIFESTATIONS AND PATTERNS OF COURSE
The clinical picture of alcoholism is based on three syndromes - pathological craving for alcohol, alcohol withdrawal syndrome and alcoholic personality degradation.
These basic syndromes refer to common features that unite all clinical variants of alcoholism. They are consistently formed during the development of the disease. Let's look at each of the main syndromes.
Sometimes the state of mild and moderate alcoholic intoxication is accompanied by significant deviations from the described pictures of typical intoxication of the corresponding degrees. Unlike typical intoxication, with altered forms, any one group of symptoms characteristic of intoxication sharply intensifies, the sequence of their appearance is disrupted, or disorders arise that are not at all characteristic of intoxication.
1. Intoxication with explosiveness. After a short period of euphoria or without it, suddenly (sometimes for a minor reason) irritation arises with dissatisfaction, hostility, even anger and a corresponding change in behavior and statements. Such states are short-lived, replaced by relative calm and even complacency, but during intoxication they can be repeated several times.
2. Intoxication with hysterical features. A tendency to loud phrases, posturing with sharp transitions from one extreme to another, for example, self-praise followed by self-flagellation. Mild self-harm and imitation of suicide are possible. There are primitive motor reactions such as astasia-abasia, motor storm, hysterical attack, “imaginary death reflex”.
3. Intoxication with depressive affect. Depressed mood has various shades - with a predominance of gloomy moodiness, a dysphoric component, anxiety, hopelessness, and in some cases with a feeling of acute melancholy. Ideomotor retardation is usually mild. The possibility of suicide is quite high.
4. Intoxication with paranoid mood. In some cases, these are expressed, predominantly catatically conditioned ideas of jealousy, condemnation, and diffuse suspicion of others. In others, unsystematic ideas of relation and persecution appear. Verbal illusions and elementary auditory hallucinations may also occur.
5. Intoxication with pronounced speech motor arousal and increased affect- agitated, manic-like form of intoxication. Foolishness with antics, clowning, childish behavior, with a tendency to inappropriate jokes and witticisms, unmotivated laughter. Sexual desire often increases. With altered forms of simple alcoholic intoxication, as a rule, not only the auto- and allopsychic orientation is preserved, but also the experiences and behavior of the drunk are associated with actual events. However, memories of the period of intoxication are more fragmentary here compared to ordinary intoxication. Atypical forms of simple intoxication are found in persons suffering from chronic alcoholism, in psychopathic individuals, mental retardation patients, with residual phenomena of organic damage to the central nervous system, and in erased forms of mental illness. In some cases, the toxic effect of alcohol increases with the simultaneous use of alcoholic beverages and various medications.
54. Pathological alcohol intoxication: criteria, options and clinical manifestations.
Pathological alcohol intoxication is a psychotic form of alcohol intoxication with severe disturbances of consciousness and the absence of physical signs of intoxication. There are 2 forms: 1. delirious (paranoid). 2. epileptoid. Pathological intoxication is an acute transient psychosis in the form of twilight stupefaction. Soon after taking small and, much less often, large doses of alcohol, deep confusion of consciousness suddenly develops. It is accompanied by pronounced affective disorders, mainly in the form of anxiety, fear, anger or frenzied rage, and only occasionally in the form of elevated mood. Delusions and hallucinations arise, reflecting the prevailing affect. Motor excitement develops. Usually, two main tendencies can be identified in the actions of patients - defense with attack and violent destructive actions and the desire to avoid danger. Motor excitation can be chaotic, often in the form of stereotypically repetitive actions. Much more often, behavior outwardly retains expediency and purposefulness with rather complex actions, sometimes requiring not only good coordination of movements, but also great strength and dexterity. More often there is silent motor excitation. Less often, patients utter individual words, short phrases, or make inarticulate screams. If movement disorders predominate in the clinical picture, then they speak of epileptoid form pathological intoxication, and with severe delirium and hallucinations - delirious. The duration of pathological intoxication ranges from several minutes to several hours. Usually it ends in deep sleep and then either complete amnesia or leaves a vague memory of individual fragments of mental disorders. Pathological intoxication can also develop in healthy individuals, but more often occurs in people with various organic diseases of the central nervous system, including those suffering from alcoholism, with sluggish or latent epilepsy, and in psychopathic individuals. The emergence of pathological intoxication is facilitated by various debilitating factors - forced insomnia, mental or physical fatigue, psychogenia, malnutrition, affective disorders in the form of dysphoria.
55. Criteria and options for alcoholic personality degradation.
Diagnosis of alcohol intoxication carried out through clinical research and biochemical tests. The main clinical signs of alcohol intoxication are the smell of alcohol on the breath, the behavior of the subject, the characteristics of his speech and motor skills, and vegetative-vascular symptoms. Biochemical methods for detecting alcohol vapor in exhaled air are based on its ability to oxidize various reagents with a change in their color - potassium permanganate (Rappoport test) and chromic anhydride (Mokhov-Shinkarenko test). For the quantitative determination of alcohol in blood, urine, exhaled air, and stomach contents, gas chromatographic and spectrographic methods are used.
Diagnosis of alcoholism is based on physical and laboratory signs, as well as on the use of special tests (questionnaires). Physical signs include: obesity or weight loss, arterial hypertension, hand tremors, impaired sensitivity of the limbs and movement disorders, muscle wasting, sweating, enlarged parotid glands, redness of the face, spider veins, traces of injuries, burns, tattoos, enlarged mammary glands and a number of others signs. A combination of 6 or more signs indicates regular alcohol consumption. Laboratory indicators include the detection of high concentrations of alcohol in the blood (or other fluids - saliva, urine, sweat, tears) in the absence of external signs of intoxication. Alcoholism develops: liver damage (hepatitis, cirrhosis), acute renal failure, heart damage (tachycardia, heart failure), blood system (mild anemia with macrocytosis, folate deficiency, thrombocytopenia, granulocytopenia, abnormal liver function tests (including increased levels of y-glutamyltransferase), hyperuricemia, hypertriglyceridemia, decreased levels of K, Mg, Zn and P in serum), chronic gastritis, pancreatitis, peripheral nerve damage, sexual disorders, memory disorders, etc. A feature of alcoholic damage to internal organs is the possibility of significant improvement in the patient’s condition when abstaining from alcohol (even without medication) and rapid deterioration after resuming its use.
Treatment of chronic alcoholism is carried out in stages. At the first stage (symptomatic treatment), binge drinking and hangover disorders are relieved, and the patient’s somatic condition is normalized. In the second stage (active treatment), the glorious task is to permanently suppress the desire for alcohol. At the third stage, supportive therapy is carried out, consolidation and further development of attitudes toward a teetotal lifestyle are carried out. Throughout complex anti-alcohol treatment, in addition to medications, it is necessary to use psychotherapy.
Symptomatic treatment stage carry out the following measures: 1) detoxification using thiol drugs - 15-20 ml of 30% sodium thiosulfate solution intramuscularly or intravenously 2) vitamin therapy - B vitamins, ascorbic acid, nicotinic acid 3) psychotropic drugs are prescribed for a pronounced mental component of the hangover syndrome; tranquilizers are used - diazepam (seduxen), phenazepam. 4) sleeping pills - eunoctin (radedorm), adaline. 5) anticholinergic drugs, primarily amizil and metamizil 6) insulin therapy from 2 to 8 units of insulin daily. The diet should be dominated by foods rich in mineral salts.
On stage of active treatment conditioned reflex and sensitizing methods are used. Conditioned reflex method is based on the development of a negative reflex (vomiting) to the smell and taste of alcohol. For this purpose, the effect of emetics (apomorphine, emetine) is combined with a small (30-50 ml) amount of alcohol consumed by the patient. Sensitization method- the goal of this type of therapy is not only to permanently suppress the desire for alcohol, but also to make it physically impossible to take it. With the resumption of drunkenness, various, very painful, and often life-threatening somatic disorders appear. The most widely used are Antabuse (Teturam), less commonly cyamide (Temposil), metronidazole (Flagyl), and furazolidone. Antabuse is prescribed daily at 0.5 g in the morning, and for severe asthenia - 0.15-0.25 g in the evening. In a week, tests begin. On the day of the test, 0.75-1 g of Antabuse is given in the morning. The test is carried out in an outpatient setting at the end of the working day, i.e. approximately 8-9 hours after taking Antabuse. First, give 30-50 ml of vodka, subsequently you can give up to 100 ml. The antabuse-alcohol reaction begins after 5-15 minutes, manifests itself in a variety of autonomic disorders and lasts from 1 to 2 hours. Psychotherapy begins with the first visit to the doctor. Methods and types of psychotherapy for alcoholism are largely determined by the personal attitudes of the doctor.
Maintenance therapy takes at least 5 years, of which the first 3 years the patient is on active registration, and the next 2 years (in the absence of relapse) on passive registration. The patient must always visit a narcologist accompanied by a close relative, preferably the same one. This relative should monitor the fulfillment of the Vra's prescriptions at home. The frequency of doctor visits varies, for example, in the first 6 months - 1-2 times a month, in the next 6 months - at least once every 2 months, then - at least twice a year. Therapy at this stage includes the use of medications that prevent the resumption of alcoholism, normalization of the mental state, various general somatic treatment and psychotherapy.
57. Clinic and course of alcoholic delirium.
Metal-alcohol psychoses- protracted and chronic disorders of mental activity in the form of exogenous, endoform and psychoorganic disorders that arise in the II and III stages of the development of alcoholism. There are: delirium, hallucinosis, delusional psychoses.
Delirium (delirium tremens). The first episode of delirium is usually preceded by prolonged drinking. In the prodrome, which lasts days, weeks and even months, sleep disorders predominate with nightmares, fears, frequent awakenings and vegetative symptoms, and during the day asthenic phenomena and changeable affect in the form of fearfulness and anxiety. Delirium develops most often 2-4 days after stopping drinking, against the background of severe hangover disorders or with their reverse development. The development of delirium is preceded by single or multiple convulsive seizures; Episodes of verbal illusions or figurative delusions are possible. Delirium begins with influxes of figurative ideas and memories that appear in the evening and intensify at night; visual illusions are not uncommon, in some cases visual hallucinations lacking three-dimensionality - “movies on the wall” with the preservation of a critical attitude towards them, transient disorientation or incomplete orientation in place and time. In the advanced stage, complete insomnia appears, illusions become more complex or are replaced by pareidolia, and true visual hallucinations arise. Multiple and moving micropsychic hallucinations predominate - insects, small animals, fish, snakes, as well as threads, wires, cobwebs; less often, patients see large, including fantastic animals, people, humanoid creatures - “wandering dead”. As delirium deepens, auditory and among them verbal, as well as olfactory, thermal and tactile hallucinations appear, including those localized in the oral cavity. The behavior, affect and themes of delusional statements correspond to the content of hallucinations. Motor excitement with fussy efficiency predominates. Speech consists of a few, fragmentary short phrases or words. Attention is over-distracted. Predominant are figurative delusions of persecution or physical destruction, less often delusional ideas of other content. The patient feels a sharply slowed down or, on the contrary, accelerated passage of time. Patients are highly suggestible. Periodically and briefly, the symptoms of psychosis spontaneously weaken and even almost completely disappear - the so-called lucid intervals. Psychosis intensifies in the evening and at night. Even without treatment, symptoms of delirium disappear within 3-5 days. Recovery occurs critically - after deep, long sleep. The lytic ending of psychosis occurs more often in women. Delirium is often replaced by various intermediate syndromes. In men, asthenic, mild hypomanic and delusional disorders are usually found; Depression predominates in women. Delirium is always accompanied by neurological and somatic, primarily somatovegetative disorders: hyperemia of the skin, primarily the face, tachycardia, fluctuations in blood pressure, tachypnea, enlarged liver, yellowness of the sclera. Variants of delirium. Hypnagogic delirium limited to numerous, vivid, in some cases, scene-like dreams or visual hallucinations when falling asleep and when closing the eyes. Visual hallucinations disappear when you open your eyes. Delirium without delirium - Fussy excitement with pronounced tremors and sweating predominates. Sensory and delusional disorders are absent or rudimentary. Abortive delirium - is determined by the development of sparse, and in some cases, isolated visual illusions and micropsychic hallucinations that do not create the impression of certain, but
especially complete situations, as with expanded forms of de-
Lyria. Systematized delirium - multiple, scene-like (with a sequentially developing plot or in the form of individual situations) visual hallucinations predominate. Their content is determined mainly by various scenes of pursuit, often opportunistic, with flight or pursuit, in which routes and types of transport and shelter change. Delirium with severe verbal hallucinations- verbal hallucinatory disorders have a frightening or life-threatening content for the patient. Ideas of physical destruction predominate in delusional statements. Unlike systematized nonsense, which always has a system of evidence, with this option, delusional statements are not supported by arguments. It is possible to identify distinct symptoms of figurative delusion (confusion, delusional ideas of staging, a symptom of a positive double, spreading to many surrounding people). The depth of clouding of consciousness, despite the abundance of productive disorders, is insignificant. Delirium with mental automatisms - mental automatisms arise with the complication of typical or at the height of systematized delirium when delirium is combined with pronounced verbal hallucinations. All main variants of mental automatism can occur - ideationary, sensory, motor, but all three never occur at the same time. Motor automatism occurs against the background of oneiric clouding of consciousness and is manifested primarily by objective sensations of transformations occurring in the patient’s body or its parts (limbs, internal organs disappear or change, etc.). At the same time, patients not only feel the effect, but also see its results. Delirium with occupational delirium (occupational delirium, delirium with occupational delirium)- psychosis can begin as a typical delirium with subsequent transformation of the clinical picture. Typically, there is a predominance of relatively simple motor acts of stereotypical content that occur in a limited space, reflecting individual everyday actions - dressing and undressing, collecting or laying out bed linen, counting money, lighting matches, individual movements during drinking, etc., actions are observed less frequently reflecting some episode related to professional activity. In the initial period of delirium with occupational delirium, there are multiple variable false recognitions. Psychosis is accompanied by complete amnesia. Delirium with muttering (mussing, "mumbling" delirium)- replaces other delpriotic syndromes. Delirium is characterized by a combination of deep confusion and special motor and speech disorders with severe neurological and somatic symptoms. Patients do not react at all to their surroundings; verbal communication with them is impossible. Motor excitation occurs in an extremely limited space - “within the bed” (palpating, smoothing, grasping, pulling or, on the contrary, pulling a blanket or sheet, the so-called picking - carfology, fingering), i.e. it manifests itself in rudimentary movements without the simplest solid motor acts. Speech stimulation is a set of either the same or different syllables, interjections, and individual sounds.
At times, both motor and speech stimulation disappear. Upon recovery, the entire period of illness is completely amnesic.
There are two variants of the formation of a psychopathic form of alcohol intoxication. In the first case, in a state of intoxication, there is a sharpening of the personal characteristics inherent in the subject, the emergence of ways of responding that are usually restrained outside of intoxication, the development of which in a state of acute intoxication becomes possible as a result of the weakening of volitional control and the influence of intensifying emotions that occur during intoxication. This manifests itself in paranoid, hysterical, with delusional fantasies and elements of eidetism (which is characteristic of persons with hysterical radicalism and traits of mental infantilism) variants of intoxication. By the same mechanism, variants of acute alcohol intoxication with a disorder of desires and with sexual disinhibition develop, which are not realized in the normal state and appear only in conditions of “washing away” the moral and ethical barrier due to alcohol intoxication.
In the second option, emotional-volitional disorders that develop within the framework of chronic alcoholism and (or) organic mental disorder take part in the formation of a psychopathic-like form of intoxication. If at the first stage of alcoholism psychopathic-like disorders are observed only in a state of alcoholic intoxication, then subsequently they become an integral part of the “mental appearance” as a whole. The first pathogenetic variant of the formation of psychopathic-like forms of intoxication eventually transforms into the second, which practically no longer depends on the initial characterological traits and is expressed in the development of explosive and dysphoric pictures of alcoholic intoxication. At the same time, the explosive version of alcohol intoxication can transform into dysphoric over time due to the increase in affective rigidity.
Affective disorders during alcohol intoxication are usually observed in persons with a hyposthenic personality structure who have a hereditary burden of mental illness; that is, constitutional features in this case take precedence over exogenous influences.
Along with this, affective forms of alcohol intoxication can develop in persons with an organic mental disorder of traumatic origin. According to the literature, a traumatic illness can occur with a predominance of affective pathology, and a certain sequence of development of symptoms is noted. First, cerebrasthenic disorders are formed, and as they deepen, asthenodepressive syndrome is formed. With the progressive course of organic mental disorder, post-traumatic fear reactions appear in the clinical picture (Fairbank J.A., De Good, Jenkins C.W., 1981). At first, they arise only against the background of acute alcohol intoxication, which is like a “catalyst” and “indicator”, revealing hidden, previously compensated ways of reacting to subjectively difficult situations.
Hallucinatory and delirious variants of alcohol intoxication usually develop in persons with alcohol dependence.
The dysphoric variant, as one of the varieties of psychopathic forms of alcohol intoxication, is characterized by gloomy malice, aggressiveness, and dissatisfaction with others. With an increase in the affective component, the development of twilight stupefaction is possible. This form of alcohol intoxication is characterized by a general pattern of development of symptoms from milder to gradually worsening.
This is consistent with the observations described in the literature that relate directly to the state of acute intoxication. Acute poisoning, regardless of etiology, begins with a psychovegetative syndrome, followed by hallucinatory, epileptic, and hyperkinetic. In addition, in patients with alcoholism, before the formation of hyperkinetic syndrome, delirious or hallucinatory-delusional syndrome may develop. As the stupor deepens, hallucinatory-delusional symptoms are leveled out due to edema and hypoxia of the brain, and hyperkinetic manifestations (myoclonus, hyperkinesis, tonic convulsions) begin to come to the fore. Hyperkinetic disorders that develop after delirious stupefaction indicate an unfavorable prognosis. Exit from the state of intoxication occurs in reverse syndromic dynamics. Some patients, at the stage of emerging from a comatose state, experience pathological drowsy states, accompanied by complete disorientation (Churkin E.A., 1985, 1989; Bolotova E.V., 1990).
F.F. Detenhof (1963) defined the following syndromenogenesis of psychotic states within the framework of acute alcohol intoxication: first, delirious stupefaction develops, regarded by many as the prognostically most favorable form of disorder of consciousness, then, as the level of damage to mental activity deepens, hallucinosis, paranoid and schizophrenia-like psychoses develop successively.
The difference between atypical psychotic forms of intoxication in persons with alcohol dependence and alcoholic psychoses is that the latter are not caused by the direct effect of alcohol on the brain, as in atypical alcohol intoxication, but by metabolic and neurovegetative processes as manifestations of metabolic disorders as a result of chronic alcohol intoxication.
However, in practice, differentiating these conditions can be difficult. As noted above, in the anamnesis of patients with alcoholic psychoses, psychotic forms of alcohol intoxication may be observed. As alcoholic illness progresses, quantitative rather than qualitative changes occur in the clinical picture of acute intoxication. Moreover, the longer the binge that precedes psychotic disorders, the more reason to regard them as alcoholic psychosis.
In persons with an organic mental disorder, the clinical picture of alcoholic psychosis often differs from the classical description. Therefore, it seems more successful in this case to qualify it as “exogenous psychosis.”
With the development of exogenous psychosis (including alcoholic psychosis), in contrast to atypical psychotic intoxication, a prodromal period is observed in the form of a feeling of general physical ill-being, increased fatigue, irritability, sleep disturbance, decreased mood, and a final stage in the form of asthenic syndrome, against the background of which possible residual delusions, perceptual deceptions in the evening, incomplete criticism of psychotic experiences. The psychotic version of intoxication is limited to the period of intoxication; the beginning and end of psychotic symptoms are quite clear.
The development of motor disorders during intoxication is based on deep damage to the brain (permanent soil factor) under the influence of a subjectively increased dose of alcohol (temporary soil factor). A comparison of the role of permanent and temporary factors with certain forms of acute alcohol intoxication with an atypical clinical picture showed that the less pronounced the signs of an organic mental disorder, the greater the importance of additional exogenous harms immediately preceding atypical intoxication, with psychogenics being the main factor of the temporary condition. With a pronounced depth of organic disorders, an increasing influence of internal biological mechanisms was observed with a decreasing proportion of the influence of temporary factors, primarily psychogenic. This pattern was previously described in psychopathic individuals (Kusakin V.A., 1992).
Thus, in accordance with the teachings of J.H. Jackson (1864) about the “layer-by-layer” construction of mental activity and, by analogy with the ideas of A.V. Snezhnevsky (1983) about “enlarged monoqualitative syndromes” and the depth of damage to the mental sphere, all identified forms of alcohol intoxication can be arranged in a certain sequence from the least pathological to the most pathological as follows: psychopathic, affective, psychotic and forms of intoxication with movement disorders. Personality disorders are the axis on which those identified by A.V. are “strung” as the lesion deepens. Snezhnevsky "monoqualitative syndromes". Personal characteristics themselves also change dynamically under the influence of endogenous and exogenous factors. Psychopathic-like forms of atypical alcohol intoxication, thus, reflect the involvement of only the characterological “core” in the pathological process, which is the easiest option. This principle corresponds to the position of O.N. Arnold and N. Hoff (1961) that the effect of various psychotropic drugs on the psyche of healthy individuals has its own characteristics - low doses cause personal psychoreactive manifestations, and large doses cause exogenous types of reactions. These relationships are shown in the figure.
Rice. Clinical and dynamic relationships
various forms of atypical alcohol intoxication
Based on the above, the division of the entire population of those examined into groups, taking into account the forms of atypical alcoholic intoxication identified in them, can be done according to the following principle. Persons who had movement disorders in the structure of acute alcohol intoxication were allocated to one group, regardless of the presence of other atypical forms of intoxication. The second group included subjects who experienced psychotic phenomena while intoxicated. The third group consisted of people with affective disorders. The fourth group included those examined who had only psychopathic-like disorders. Thus, in persons with a deeper level of mental damage, which is reflected in the form of atypical alcohol intoxication, there are disorders related both to this level and to more “superficial” ones.
Factors predisposing to the development of atypical forms of simple alcohol intoxication are different. These may be residual organic brain damage, early age of onset of alcohol consumption, combined intake of various types of alcoholic beverages, simultaneous intake of alcohol and medications, somatic illness accompanied by asthenia, lack of sleep, malnutrition, overwork, psychogenic disorders. In this case, there is an excessive strengthening or weakening of the disorders accompanying intoxication, or a change in their dynamics, as well as the appearance of symptoms that are not characteristic of intoxication. The mental signs of simple intoxication undergo the greatest changes.
Dysphoric form of alcohol intoxication.
Instead of euphoria, anger, irritability, anger, and a gloomy mood appear, leading to conflict, etc. The intoxicated person experiences a feeling of discomfort and hyperesthesia appears. Anger spreads to everything around it, accompanied by pickiness, causticism, and a search for reasons for quarrels. This condition may persist for several days. This form of intoxication usually develops with organic pathology of the brain.
Paranoid form of alcohol intoxication.
Characterized by the appearance of suspicion, touchiness, and pickiness. Those who are intoxicated inadequately evaluate the words and actions of others as an attempt to humiliate, deceive, and ridicule. Motor and speech excitement increases, drunk people shout out individual phrases or words indicating danger that threatens them. This form of intoxication is often accompanied by aggression towards others, regardless of their words and actions. The paranoid form of intoxication develops in primitive individuals, paranoid and epileptoid psychopaths.
Hysterical form of simple alcoholic intoxication .
The behavior of a drunken person is designed for an audience. The movements are theatrical (stormy scenes of despair, throwing, wringing of hands) sometimes with an element of puerilism. Statements are pathetic with various accusations against others, self-praise or exaggerated self-reproach. Demonstrative acts are often performed. This form of intoxication usually develops in individuals with hysterical character traits.
A depressive form of simple alcohol intoxication.
Instead of euphoria, a depressed mood prevails. Tearfulness, unpleasant memories, self-pity, feelings of sadness, ideas of self-blame and suicidal thoughts appear. The risk of suicide attempts in this case is high.
Manic form of simple alcoholic intoxication.
An elevated mood with carelessness and complacency prevails, accompanied by inappropriate jokes and various “mischievous” actions. The behavior of some intoxicated people is manifested by foolishness, stereotypies, antics, and echolalia. Such forms are typical for teenagers and young men.
Epileptoid form of simple alcohol intoxication.
It is characterized by motor agitation with irritability, which increases with opposition from others. Intoxicated people are initially aggressive towards those who reprimand them or try to calm them down, and then the aggression spreads to everyone who happens to be nearby. However, even at the height of the episode, there is no complete separation from reality. are reduced critically with subsequent sleep. Often the period of excitement is amnesic.
A doubtful form of simple alcoholic intoxication.
After a short euphoria, soon after drinking alcohol, deep sleep sets in, sometimes turning into stupor or coma.
An explosive form of simple alcoholic intoxication.
The state of euphoria under the influence of minor external factors is replaced by severe discontent, irritability, and anger. These outbreaks are usually short-lived, alternating with periods of rest, but are repeated repeatedly against the background of intoxication.
Simple alcohol intoxication, including its atypical forms, retains the main signs of acute alcohol intoxication, while productive (psychotic) forms of consciousness disorder do not occur. The various actions and statements of a drunken person have a selective focus. The presence of persons capable of resisting with unpleasant consequences for the drunk influences his behavior. Those who are intoxicated always retain the possibility of contact with others.
An atypical picture of intoxication develops in certain types of psychopathy (personality disorders), after past traumatic brain injury, brain infections, neurointoxication, in mental illness, and in some chronic somatic diseases. Atypical intoxication is facilitated by forced insomnia, severe emotional stress, as well as a combination of alcohol with other toxic and medicinal drugs.
Dysphoric intoxication. Occurs in explosive and epileptoid psychopathy and character accentuations, after traumatic brain injury, in epilepsy with personality changes. A persistent state of tension prevails, accompanied by dissatisfaction, sullenness, hostility or anger. In almost all cases, a low-sad affect can be identified. Hostility and anger spread to everything visible and audible: an intoxicated person becomes picky, sarcastic, quarrelsome, looking for reasons for quarrels. A feeling of somatic discomfort and hyperesthesia are often detected. The above violations can be observed for several days after alcohol excess.
Depressive intoxication. Characterized by a depressed mood, feelings of hopelessness, and self-flagellation. As a rule, the euphoria of the initial period is either absent or short-lived. In relatively mild cases, there is a subdepressive affect with tearfulness, unpleasant memories, and self-pity. In more severe cases - melancholy, a feeling of hopelessness, anxiety, which are accompanied by self-reproach and suicidal thoughts. Due to the lack of motor inhibition in this state, the likelihood of suicide attempts is high. Typically, this form of intoxication is an expression of psychogenic or endogenous depression and exposes existing affective disorders.
Doubtful intoxication. It occurs in asthenic and weakened subjects, with rapid absorption of alcohol when used in combination with carbonated drinks, as well as when combined with tranquilizers or clonidine. After a short and mild period of euphoria, a state of drowsiness occurs, quickly turning into sleep. Its depth and duration depend on the degree of intoxication; transition to coma is possible.
Hysterical intoxication. Occurs in individuals with hysterical character traits. The behavior of a drunken person is always designed for the viewer. Noteworthy are the demonstrative and theatrical behavior, the desire to arouse the sympathy or admiration of others by resorting to stories about various episodes of one’s life. Often, statements characterized by pathos are dominated by various accusations against others, self-praise or, on the contrary, exaggerated self-reproaches, and fantasy is often observed. Demonstrative suicide attempts may occur.
Explosive variant of modified simple alcoholic intoxication. The state of euphoria is expressed weakly and easily spontaneously or under the influence of external minor circumstances by transient outbursts of sharp dissatisfaction, irritation or anger. The content of statements and behavior change accordingly. Usually these outbursts are short-lived, alternating with relative calm and even complacency, but during intoxication they are repeated several times.
Modified simple intoxication with impulsive actions, as a rule, is observed in patients with schizophrenia and is usually accompanied by sexual perversions - homosexual acts, exhibitionism, flagellation. Pyromania and kleptomania are much less common.
Manic intoxication. It manifests itself as an elevated mood with carelessness and complacency, short bursts of irritation, various “mischievous” actions, annoying pestering, inappropriate jokes, loud laughter, and increased responsiveness to the environment. The picture of intoxication may resemble a manic state of organic origin, or, less commonly, hebephrenic agitation.
With all of the listed forms of altered simple alcoholic intoxication, symptoms of ordinary intoxication expressed to varying degrees are always observed: deterioration of motor skills, articulation, changes in behavior depending on environmental conditions, preserved orientation.
Pathological intoxication
Pathological intoxication is a hyperacute transient psychosis caused by alcohol intake.
The criteria for diagnosing pathological intoxication are:
Sudden onset and sudden end of a psychotic state;
The onset of a psychotic state shortly after drinking alcohol in the range of 10-15 minutes. Up to 1 hour, regardless of the dose of alcohol consumed;
Duration from several minutes to several hours;
No external signs of intoxication;
Total or partial amnesia after recovery from pathological intoxication against the background of residual asthenia.
Predisposing factors are: brain injuries, latent epilepsy, vascular disease of the brain, previous infections and intoxications. Provoking moments can be severe excitement, fear, fear, anger, insomnia and overwork.
Twilight pathological intoxication (epileptoid variant). After drinking a relatively small amount of alcohol, twilight stupefaction suddenly develops. Detachment from the environment occurs, accompanied by disorientation of all kinds, but habitual automated behaviors are preserved, in particular the ability to move on foot or by transport.
The transformation of the clinical picture is determined by rapidly increasing motor agitation with affects of irritation or anger towards others. The condition deepens under the influence of opposition and is complicated by aggressive and violent actions. Initially, aggression is usually selective and directed at persons directly related to the behavior of the intoxicated. As motor excitement increases, aggressive behavior spreads to everyone nearby. Previously observed violations of motor coordination usually decrease or completely disappear. At the height of excitement, movement disorders and statements may become stereotypical, but a semantic connection with the situation of the initial period of intoxication is always maintained. Moreover, the intensity of speech motor excitation and associated aggressive actions is subject to certain fluctuations, depending on the verbal reactions of others. At the height of the episode, there is no complete separation of the drunken person from the real situation. Mental disturbances disappear critically, followed by drowsiness or sleep. Quite often there is amnesia during periods of pronounced arousal.
This type of pathological intoxication most often occurs in people who have suffered traumatic brain injuries, patients with epilepsy or epileptoid psychopathy.
Paranoid pathological intoxication. It is distinguished by a sudden, like insight, delusional interpretation of what is happening around. It may be associated with illusions, and less commonly, auditory and visual hallucinations. Fear usually predominates: they believe that they are surrounded by bandits, terrorists, that they want to kill them, etc. Less often, delusions of attitude or influence predominate. The content of delusional experiences is often associated with something previously seen or heard from someone that made a great impression. Aggressive actions are usually differentiated, carried out taking into account the situation, and change depending on the words and actions of others. Characterized by a decrease and even disappearance of motor coordination disorders and dysarthria. The statements of intoxicated people are usually connected in one way or another with specific events occurring around them; they do not reflect the internal state and therefore it is more correct to label them as delusional. Mental symptoms of intoxication usually disappear lytically, in 2/3 of cases amnesia of intoxication is observed.
Forensic psychiatric examination qualifies pathological intoxication as a state of insanity, and therefore persons who commit socially dangerous acts in this state are exempt from criminal liability.
