Neuropsychiatric complications

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Delirium tremens (DTs), an indication of physical dependence, can be precipitated by abrupt withdrawal of alcohol in a heavy drinker, caused, for example, by the end of a drinking bout, efforts to give up drinking without professional advice, intercurrent illness, hospital admission, or arrest/imprisonment. Confusion, fever, visual or tactile hallucinations, and fits may occur. Delirium tremens is a medical emergency with an appreciable mortality, and should be treated by physicians. Treatment includes correction of any fluid or electrolyte imbalance, or hypoglycaemia, and a 5-day reducing course of a benzodiazepine, such as chlordiazepoxide, to counteract withdrawal symptoms by sedation and prevention of fits. These drugs have potential for dependence and abuse, and should not be continued after detoxification. Parenteral vitamins, thiamine being most important, are also given to prevent other neurological complications.

Wernicke's encephalopathy is an acute syndrome thought to result from deficiency of B1 (thiamine). Haemorrhages occur in the mammillary bodies, thalamus, and hypothalamus. Acute confusion is accompanied by nystagmus, diplopia, ataxia, and peripheral neuritis. The condition may be fatal unless promptly treated with thiamine.

Korsakov's syndrome, a more chronic disorder, is also believed to result from thiamine deficiency. It may be a sequel of delirium tremens or Wernicke's encephalopathy. Haemorrhage, necrosis, and gliosis are present in the mammil-lary bodies and hippocampus. A gross defect of short-term memory leads to disorientation, for which some patients attempt to compensate by confabulation. Peripheral neuropathy often co-exists.

Alcoholic dementia comprises global impairment of mental functioning, often accompanied by personality changes of the frontal lobe type. Brain scans show cerebral atrophy.

Epilepsy may be caused by direct toxicity of alcohol, especially if there is preexisting brain damage, alcohol withdrawal, over-hydration, or hypoglycaemia.

Peripheral neuropathy results from thiamine deficiency, and affects motor, sensory, and autonomic nerves. Presenting symptoms include impotence or burning pain in the feet.

Other neurological complications include cerebellar degeneration, central pontine myelinosis, degeneration of the corpus callosum, retrobulbar neuritis, and subdural haematoma following falls.

Alcoholic hallucinosis often starts during a phase of abstinence. Auditory hallucinations, usually voices, develop in clear consciousness. If insight is lacking, the voices may form the basis of a delusional system. It may recover spontaneously after a few months, but other cases become chronic and require treatment.

Alcoholic paranoia is the development of paranoid delusions in the absence of hallucinations. Morbid jealousy (see Chapter 8) of the sexual partner is a frequent theme, in which case dangerousness (see Chapter 21) must be assessed because of the risk of assault or even homicide.

Alcoholic hallucinosis and alcoholic paranoia can be helped by antipsychotic drugs, but abstinence is crucial.

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