case study on alcohol dependence syndrome slideshare

The alcohol dependence syndrome: a legacy of continuing clinical and scientific importance

Affiliation.

• 1 Department of Psychology, Centre for Addictions Research of British Columbia, University of Victoria, Victoria, Canada.
• PMID: 26042560
• DOI: 10.1111/add.12901

This paper offers some reflections on Griffith Edwards' continuing legacy with particular reference to his and Milton Gross's formulation of alcohol dependence as a 'provisional' clinical syndrome. The ideas and language from this seminal paper have heavily influenced international diagnostic classification systems. However, it is observed that there has also been significant (and increasing) divergence-in particular around the original proposal that dependence and negative alcohol-related consequences are independent, if inevitably inter-related dimensions. This is most apparent in the conflation of alcohol-related problems and dependence phenomena implicit in DSM-V. It is also argued that the alcohol dependence syndrome (ADS) has substantial continuing influence and relevance to current clinical practice. The hypothesis that degree of alcohol dependence is a useful indicator of the possibility of a return to controlled drinking continues to receive support, and underpins the widespread implementation of brief interventions for 'early stage' problem drinkers. It is suggested that the kind of careful clinical observations that underpinned the original concept of alcohol dependence have continuing relevance to the formulation of improved understanding, measurement instruments, diagnostic systems and clinical responses.

Keywords: Alcohol dependence syndrome; DSM V; Griffith Edwards; controlled drinking; craving; impaired control.

© 2015 Society for the Study of Addiction.

• Alcohol-Related Disorders / diagnosis
• Alcohol-Related Disorders / therapy
• Alcoholism / diagnosis
• Alcoholism / etiology*
• Alcoholism / therapy
• Clinical Decision-Making
• Patient Care Planning
• Treatment Outcome

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• v.7(1); 2010 Jan

Alcohol dependence syndrome in women: an Indian perspective

Chauhan ashutosh.

1 Department of Behavioral Science and Mental Health, Sahyadri Hospitals Ltd, Pune, Maharashtra, India email moc.liamtoh@nahuahchsotuhsa

Bapat Radhika

Tharoor hema.

2 Department of Psychiatry, Kasturba Medical College, Manipal, Karnataka, India

Sinha Mrigaya

3 Department of Clinical Psychology, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India

Chauhan Sudhindra

Sharma podilla satya venkata narsimha.

The estimated prevalence of alcohol misuse among Indian women is less than 5%. Misuse has been associated with the upper socio-economic classes, primitive tribal cultures and certain rural traditions. The problem of substance misuse in India has been underdiagnosed and underreported, but various health agencies and media reports suggest it is increasing.

The term ‘abuse’ has been used interchangeably in the literature for both dependence and harmful use; this is due to a lack of clarity in the diagnostic criteria used in most of the studies quoted in this article. However, the results of the current study are described only in terms of the ICD–10 criteria for dependence. In this paper we present findings which may contribute to our understanding of the prevalence of alcohol dependence in women in India.

Literature review

Indian studies that have looked at the prevalence of alcohol misuse in males (Mohan et al , 1978 ; Sethi & Trivedi, 1979 ; Agarwal, 2004 ) have reported rates ranging from 19% to 82.5% (the wide range might be attributable to cultural differences across geographical locations as well as differences in methods and definitions). There has, however, been little mention of use or misuse of alcohol among females (Murthy & Chand, 2005 ), although Neufeld et al ( 2004 ) reported that men were 9.7 times more likely than women to use alcohol regularly. Epidemiological surveys reported that the early 1980s saw negligible drug misuse (including of alcohol), which by the 1990s was a predominantly male phenomenon. Recent data from treatment centres show that only 1–3% of those seeking help are female (Murthy & Chand, 2005 ).

In a study conducted at the National Institute of Mental Health and Neurological Sciences, Bangalore, India, one of the largest addiction treatment centres in India, only 77 females qualifying for an ICD–9 diagnosis of alcohol dependence, with a mean (s.d.) age at onset of alcohol intake of 32 (9) years, sought treatment within a span of 11 years. The male:female ratio was 57:1. The majority of females were single and were from families of lower socio-economic status. The duration of dependent alcohol use before first contact with a treatment agency was 4.5 (3.8) years, and there were high rates of family (64.9%) and spousal (65.8%) alcohol dependence. Two-thirds were introduced to alcohol by friends or family. Psychiatric morbidity preceding alcohol dependence was present in 33.8% of the women – 28.6% had depression – and up to 68.7% had a concurrent physical disorder (Murthy & Benegal, 1995 ).

From 14 urban sites of the 1999 Rapid Assessment Survey (RAS) on substance misusers in the community, 371 women were identified, giving a prevalance rate of 8%. Alcohol was misused by 4.8% of the entire population. Separate data on alcohol misuse by women were not available (Ray, 2004 ). There was a trend for misuse to be seen more commonly in single, educated women (Murthy & Benegal, 1995 ).

A study from rural India indicated that most of these women were not formally educated, were engaged in unskilled work, started drinking because they liked the feeling of being drunk and drank at home (Kumar & Parthsarathy, 1995 ).

The Focused Thematic Study (FTS) on drug misuse in women had a sample of 75 women, and found that opiates, alcohol and minor tranquillisers were the main drugs of misuse. No specific alcohol-related data were obtained.

A global status report on alcohol misuse from the World Health Organization ( 2004 ) gave the rates of heavy and hazardous drinking among females as 0.4% and 1.4%, respectively ( n = 9540). There was a variable pattern in women’s drinking habits wherein two divergent patterns of drinking were seen: a ‘traditional’ pattern, in rural settings, featured bingeing and intoxication, usually not within social contexts; the other pattern, in affluent, educated, urban women, generally younger than the former group, featured drinking primarily in social settings.

The present study was conducted at Kasturba Medical College, Manipal, a university hospital that serves a catchment area with rural, suburban and urban populations as well as the university student population. The study was a retrospective chart review of females presenting to the Department of Psychiatry between September 1999 and September 2005 with an ICD–10 diagnosis of alcohol dependence syndrome (ADS). Those with both primary and secondary dependence were included. A total of 1539 charts were reviewed, of which 38 were women’s.

The male:female ratio was 39.5:1. Women presenting to the hospital with a diagnosis of ADS represented 2.5% ( n = 38) of all patient registrations for ADS. Their mean (s.d.) age at presentation to the hospital was 48.3 (12.9) years, mean age of initiation of alcohol use 30.7 (10.8) years, and mean duration of dependent alcohol use before their first contact with a treating agency 39.0 (11.1) years. Mean overall duration of alcohol use was 17.6 (11.6) years and mean duration of dependence 9.3 (7.6) years. The mean number of ICD–10 criteria fulfilled was 3.7 (0.8). Past psychiatric illnesses were seen in six women (16%).

A majority of the 38 women (22; 58%) were married; 30 (79%) were first-born children. Twenty-one (55%) were Hindus and the other 17 (45%) were Christians; none was from the Muslim community. Twenty-six (68%) had had some sort of formal education and 21 (55%) were classified as urban.

Twenty-eight (74%) had a family history of ADS and 4 (11%) a history of other psychiatric disorders; there was a history of spousal substance misuse in 21 of the 22 (95%) married women. Thirty-three (87%) had been introduced to the substance of misuse by a family member or spouse ( Table 1 ). Six (16%) had a history of psychiatric illness.

Symptoms of craving and tolerance were reported by all 38 women, withdrawal by 29 (76%), use despite knowing it would do harm by 24 (63%), loss of control by 8 (21%) and narrowing of repertoire by 2 (5%). Twenty-two (58%) had a diagnosable medical problem, with alcoholic liver disease (fatty liver disease, hepatitis or cirrhosis) in 23 (61%), hypertension in 9 (24%), anaemia in 5 (13%), diabetes mellitus in 4 (11%), peripheral neuropathy in 2 (5%), pancreatitis in 1 (3%) and migraine in 1 (3%).

A coexisting ICD–10 psychiatric syndrome was seen in 36 women (95%). A primary mood disorder was seen in 25 (66%), followed by other substance misuse in 18 (47%) ( Table 2 ). None qualified for a personality disorder; however, an abnormal personality trait – anankastic 9 (24%), anxious avoidant 3 (8%) or emotionally unstable 2 (5%) – was seen in 14 of the 38 women.

A factor precipitating the onset of alcohol use was identifiable in 24 (63%), and 30 (79%) women had an ongoing stressor in their life. The majority (37, 97%) had overlapping psychological (36, 95%), physical (30, 79%), social (13, 34%), financial (5, 13%) or legal (1, 3%) problems secondary to alcohol use/dependence.

The current study is one of the few of its sort conducted in India. Despite changing socio-economic conditions, the present study, with its limitations, might serve as a window to the important issue of alcohol dependence in women and its relation to a selection of variables. The biggest problem we faced was reviewing the scarce literature, which lacks clarity in definitions, with the terms ‘use’, ‘abuse’ and ‘dependence’ being used interchangeably.

The following causes can be suggested for the scarcity of reports: gender stereotypes manifesting in the attitudes of health professionals, leading to low identification rates in clinics; underreporting as a result of stigma; a lack of structured data entry; and overall low attendance rates of female clients in tertiary care centres in India. The figure of 38 females over 6 years is in stark contrast to the 1501 males seeking treatment for an addiction from the same centre, which is a reflection of gender role discrepancies.

Women with ADS had a later age at onset, presenting to the hospital around their 40s, with secondary alcohol dependence. The male:female ratio of individuals seeking help was 39.5:1, as against a comparable figure of 57:1 in the only other study in the Indian setting (Murthy & Benegal, 1995 ). The rate of 2.5% is in keeping with the figure reported by the World Health Organization ( 2004 ). The sociodemographic profiles of the study women are consistent with those in these two other reports (Murthy & Benegal, 1995 ; World Health Organization, 2004 ), but the family history of alcohol use was significantly higher than the figures quoted by Murthy & Benegal ( 1995 ).

Interestingly, a majority of the women with dependence belonged to a nuclear family set-up and contributed to the family income, and indeed a significant number (20, 53%) acted as head of family. This could be attributed either to their ‘single’ status, with the absence of a male member who might interfere with decision making, or to the matrilineal system of inheritance prevalent in the southern Indian states.

The striking presence of precipitating factors and stressors validates the importance of exogenous factors and corresponds with Indian literature (Ray, 2004 ) that has hinted at the importance of dysphoria-related craving and the self-medication hypothesis (Khantzian, 1985 ). A look at the nature of the stressors might have given us further important insights.

Dependence was seen only in Hindus and Christians. This demographic finding, along with the later age at onset of alcohol dependence, and later age of presentation to the hospital for help, is similar to the study done at the National Institute of Mental Health and Neurological Sciences (Murthy & Benegal, 1995 ) and points to a higher probability of late-onset secondary alcohol dependence in females, where exogenous non-genetic factors form an important link. We also saw a rural–urban divide. Despite the catchment area covering divergent populations, the primary urban representation was from the university, which suggests the possibility of stigma interfering with help-seeking in local urban dwellers, unlike in the rural population from the same catchment area. Future studies focusing on the causes of the postulated differences between the help-seeking behaviours of these communities might have some interesting findings. The above results to some extent validate the two divergent patterns of alcohol misuse proposed earlier for the Indian female population (World Health Organization, 2004 ).

Future research has to be planned with a few important factors in mind, including lack of uniformity in records, definitions used and most importantly the bias in collecting data. The current study gives, we believe, an underestimate of the actual problem and highlights the gender bias in the approach of healthcare professionals and society in general. Investigations into the reasons for fewer women seeking treatment, the pattern, course and outcome of misuse/dependence, comorbidities and stressors might help us to understand alcohol dependence in women in India.

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A case study of Person with Alcohol dependence Syndrome with Poor motivation

This article presents a case study of client with alcohol dependence syndrome with poor motivation. Psychiatric social work assessment and intervention was provided to the person with alcohol dependence syndrome, focusing on building motivation for change and strengthening commitment to change. The psycho social intervention was provided to the patients and his family members. Sessions on Admission counseling, Family intervention, Supportive therapy, Psycho education, Motivation enhancement therapy, Brief intervention, Relapse Prevention therapy, Pre discharge counseling, Discharge Counseling and Social Group Work was conducted. At the end of the therapy, the client improves knowledge regarding the illness and motivation level was enhanced to action phase and achieved the coping skills to recover from relapse.

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