Alkol ile İlişkili Bozukluklar
Özet
Alkol, tarihte anksiyete giderici etkileriyle keşfedilen ve dünya genelinde yaygın tüketilen psikoaktif bir maddedir. Alkol kullanımı bireyi, aileyi ve toplumu olumsuz etkilemekte, intiharların %22'si alkolle ilişkilendirilmektedir. Kan alkol düzeyi arttıkça motor yavaşlama, koordinasyon bozukluğu, konfüzyon, koma ve ölüm gibi klinik bulgular gelişebilir. DSM-5, alkol kötüye kullanımı ve bağımlılığı tanımlarını birleştirerek "Alkol Kullanım Bozukluğu" tanısını getirmiştir. Alkol intoksikasyonu; metabolik değişikliklere, taşikardiye, "tatil kalp sendromuna" ve ölümcül solunum depresyonuna yol açabilir. Alkolün uzun süreli kullanımı GABA ve NMDA reseptörlerinde değişimlere sebep olur; alkolün ani bırakılması ise otonomik aşırı aktiviteye ve deliryuma yol açan alkol yoksunluk sendromunu tetikler. Yoksunluk belirtileri 6-24 saatte başlar; %3-5 hastada konvülsiyon ve deliryum tremens gibi yaşamı tehdit eden komplikasyonlar görülebilir. Yoksunluk şiddeti CIWA-Ar ölçeğiyle değerlendirilir ve yönetiminde klordiazepoksit veya diazepam gibi uzun etkili benzodiazepinler temel ilaçlardır. Karaciğer bozukluğu olanlarda daha kısa etkili oksazepam veya lorazepam tercih edilir. Ayrıca alkol kullanım bozukluğu olan hastaların %37'sine duygudurum, anksiyete veya kişilik bozuklukları gibi psikiyatrik hastalıklar eşlik eder. Uzun süreli alkol kullanımı insomnia gibi uyku bozukluklarına ve cinsel işlev bozukluklarına yol açar. Tedavi; motivasyonel görüşmeler, bilişsel davranışçı terapiler ve farmakoterapiyi içeren çok disiplinli bir yaklaşıma dayanmalıdır.
Alcohol is a psychoactive substance discovered historically for its anxiety-relieving effects and is widely consumed globally. Alcohol consumption negatively impacts individuals, families, and society, with 22% of all suicides linked to alcohol. As blood alcohol levels increase, clinical findings such as motor slowing, coordination impairment, confusion, coma, and death can develop. DSM-5 combined the definitions of alcohol abuse and dependence into "Alcohol Use Disorder." Alcohol intoxication can cause metabolic changes, tachycardia, "holiday heart syndrome," and fatal respiratory depression. Prolonged alcohol use alters GABA and NMDA receptors; abrupt cessation triggers alcohol withdrawal syndrome, causing autonomic hyperactivity and delirium. Withdrawal symptoms begin within 6-24 hours, and 3-5% of patients may develop life-threatening complications like convulsions and delirium tremens. Withdrawal severity is evaluated using the CIWA-Ar scale, and long-acting benzodiazepines like chlordiazepoxide or diazepam are the primary medications for management. In patients with liver dysfunction, shorter-acting oxazepam or lorazepam are preferred. Additionally, 37% of patients with alcohol use disorder present with comorbid psychiatric conditions such as mood, anxiety, or personality disorders. Chronic alcohol use leads to sleep disturbances like insomnia and sexual dysfunction. Treatment must rely on a multidisciplinary approach combining motivational interviewing, cognitive behavioral therapies, and pharmacotherapy.
Referanslar
McKim MW. Drugs and Behavior. An Introduction to Behavioral Pharmacology. Forth Edition, Prentice-Hall, Inc., New Jersey, 2000.
Connor JP, Haber PS, Hall WD. Alcohol use disorders. Lancet. 2016;387:988-998.
Lasota D, Al-Wathinani A, Krajewski P, et al. Alcohol and the risk of railway suicide. Int J Environ Res Public Health.2020; 17(19): 7003.
Gülcan G. Alkol Madde Kullanım Bozuklukları Epidemiyolojisi, Evren C, Ögel K, Uluğ B (Ed.). Alkol Madde Bağımlılığı Tanı ve Tedavi El Kitabı 1. Baskı içinde. Ankara: Türkiye Psikiyatri Derneği Yayınları; 2012. p. 1-17
Substance Abuse and Mental Health Services Administration (2021). Key substance use and mental health indicators in the United States: Results from the 2020 National Survey on Drug Use and Health. HHS Publication No. PEP21-07-01-003, NSDUH Series H-56. Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. (22/09/2022tarihinde https://www.samhsa.gov/data/sites/default/files/reports/rpt35325/NSDUHFFRPDFWHTMLFiles2020/2020NSDUHFFR1PDFW102121.pdf adresinden ulaşılmıştır).
Mehmet V, Alkol raporu, Türkiye Yeşilay Cemiyeti, İstanbul, Mayıs 2011.
Brooks TL, Knight JR (2014) Screening and brief intervention for adolescents. The ASAM Principles of Addiction Medicine Fifth Edition. Ries RK, Fiellin DA, Miller SC, Saitz R eds. Wolters Kluwer Health-ASAM, China.
Simkin DR (2014) Neurobiology of addiction from a developmental perspective. The ASAM Principles of Addiction Medicine Fifth Edition. Ries RK, Fiellin DA, Miller SC, Saitz R eds. Wolters Kluwer Health-ASAM, China.
Şenol S (2008) Dikkat Eksikliği Hiperaktivite Bozukluğu. Çocuk ve Ergen Psikiyatrisi Temel Kitabı. Çocuk ve Gençlik Ruh Sağlığı Derneği. HYB Basım Yayın, Ankara
Biederman J. Pharmacotherapy for attention-deficit/hyperactivity disorder (ADHD) decreases the risk for substance abuse: findings from a longitudinal follow-up of youths with and without ADHD. J Clin Psychiatry 64:3-8.
American Psychiatric Association: Desk Reference to the Diagnostic Criteria From DSM-5. Arlington, VA, American Psychiatric Association, 2013.
Yost DA. Acute care for alcohol intoxication. Be prepared to consider clinical dilemmas. Postgrad Med 2002; 112: 14–6, 21–2, 25–6.
Marco CA, Kelen GD. Acute intoxication. Emerg Clin North Am 1990;8:731–48.
Ettinger PO, Wu CF, De La Cruz Jr C, Weisse AB, Ahmed SS, Regan TJ. Arrhythmias and the “Holiday Heart”: alcohol-associated cardiac rhythm disorders. Am Heart J 1978;95:555–62.
Lowenstein SR, Gabow PA, Cramer J, Oliva PB, Ratner K. The role of alcohol in new-onset atrial fibrillation. Arch Int Med 1983;143:1882 5.
Happel KI, Odden AR, Zhang P, Shellito JE, Bagby GJ, Nelson S. Acute alcohol intoxication suppresses the interleukin 23 response to Klebsiella pneumoniae infection. Alcohol Clin Exp Res 2006;30:1200–7.
Cem Ş. Alkol Madde Kullanım Bozuklukları Epidemiyolojisi, Evren C, Ögel K, Uluğ B (Ed.). Alkol Madde Bağımlılığı Tanı ve Tedavi El Kitabı 1. Baskı içinde. Ankara: Türkiye Psikiyatri Derneği Yayınları; 2012. p. 77-90
Krystal J. H., Staley J., Mason G., Petrakis I. L., Kaufman J., Harris R. A., et al. γ-Aminobutyric acid type a receptors and alcoholism: intoxication, dependence, vulnerability, and treatment. Arch Gen Psychiatry 2006; 63: 957– 968.
Krystal J. H., Petrakis I. L., Mason G., Trevisan L., D'Souza D. C. N-methyl-d-aspartate glutamate receptors and alcoholism: reward, dependence, treatment, and vulnerability. Pharmacol Ther.2003; 99: 79– 94.
Rogawski M. A. Update on the neurobiology of alcohol withdrawal seizures. Epilepsy Curr.2005; 5: 225– 230.
Cosgrove K. P., Krantzler E., Frohlich E. B., Stiklus S., Pittman B., Tamagnan G. D., et al. Dopamine and serotonin transporter availability during acute alcohol withdrawal: effects of comorbid tobacco smoking. Neuropsychopharmacology. 2009; 34: 2218– 2226.
Caputo F, Agabio R, Vignoli T, et al. Diagnosis and treatment of acute alcohol intoxication and alcohol withdrawal syndrome: position paper of the Italian Society on Alcohol. Intern Emerg Med. 2019;14(1):143-160. doi:10.1007/s11739-018-1933-8
Umut G, Evren C (2019) Alkol yoksunluğu ve deliryum tremens tedavi. Alkol ve Madde Kullanım Bozuklukları Temel Başvuru Kitabı’nda (Yayına hazırlayan: Cüneyt Evren), Türkiye Psikiyatri Derneği Yayınları, Ankara
Perry EC (2014) Inpatient management of acute alcohol withdrawal syndrome. CNS Drugs 28: 401–10.
Day E, Daly C. Clinical management of the alcohol withdrawal syndrome. Addiction.2022;117:804–814 doi:10.1111/add.15647
Stephens JR, Liles EA, Dancel R, et al. Who needs inpatient detox? Development and implementation of a hospitalist protocol for the evaluation of patients for alcohol detoxification. J Gen Intern Med 2014; 29: 587– 593.
Nadkarni A, Endsley P, Bhatia U, et al. Community detoxification for alcohol dependence: a systematic review. Drug Alcohol Rev 2017; 36: 389– 399
National Institute for Health and Clinical Excellence Alcohol-use disorders: Diagnosis and clinical management of alcohol-related physical complications (CG100). London: NICE; 2010
Minozzi S, Amato L, Vecchi S, Davoli M. Anticonvulsants for alcohol withdrawal. Cochrane Database Syst Rev. 2010;(3):CD005064. Published 2010 Mar 17. doi:10.1002/14651858.CD005064.pub3
NSW Department of Health (2008) Drug and Alcohol Withdrawal Clinical Practice Guidelines - NSW. Mental Health and Drug & Alcohol Office, NSW Department of Health, Sydney
Nadkarni A, Endsley P, Bhatia U, et al. Community detoxification for alcohol dependence: a systematic review. Drug Alcohol Rev 2017; 36: 389– 399.
National Collaborating Centre for Mental Health Alcohol-Use Disorders: The NICE Guideline on Diagnosis, Assessment and Management of Harmful Drinking and Alcohol Dependence. London: The British Psychological Society and The Royal College of Psychiatrists; 2011.
National Collaborating Centre for Mental Health Alcohol-Use Disorders: The NICE Guideline on Diagnosis, Assessment and Management of Harmful Drinking and Alcohol Dependence. London: The British Psychological Society and The Royal College of Psychiatrists; 2011.
National Institute for Health and Clinical Excellence Alcohol-use disorders: Diagnosis and clinical management of alcohol-related physical complications (CG100). London: NICE; 2010.
Schuckit M. A. Recognition and Management of Withdrawal Delirium (delirium tremens). New Engl J Med (NEJM) 2014; 371: 2109– 2113.
Palmstierna T. A model for predictng alcohol withdrawal delirium. Psychiatr Serv 2001; 52: 820– 823.
Khan A, Levy P, DeHorn S, et al. Predictors of mortality in patients with delirium tremens. Acad Emerg Med 2008; 15: 788– 790.
Bhat A, Hadley A. The management of alcohol withdrawal in pregnancy — case report, literature review and preliminary recommendations. Gen Hosp Psychiatry 2015; 37: 273.e271–273.e273.
Bellantuono C, Tofani S, Di Sciascio G, et al. Benzodiazepine exposure in pregnancy and risk of majör malformations: a critical overview. Gen Hosp Psychiatry 2013; 35: 3– 8.
Maldonado JR. Novel Algorithms for the Prophylaxis and Management of Alcohol Withdrawal Syndromes-Beyond Benzodiazepines. Crit Care Clin. 2017;33(3):559-599. doi:10.1016/j.ccc.2017.03.012
Krupitsky EM, Rudenko AA, Burakov AM, et al. Antiglutamatergic strategies for ethanol detoxification: comparison with placebo and diazepam. Alcohol Clin Exp Res. 2007;31(4):604-611. doi:10.1111/j.1530-0277.2007.00344.x
Bschor T, Henssler J, Müller M, Baethge C. Baclofen for alcohol use disorder-a systematic meta-analysis. Acta Psychiatr Scand. 2018;138(3):232-242. doi:10.1111/acps.12905
Marco CA, Kelen GD. Acute intoxication. Emerg Clin North Am 1990;8:731–48
Caputo F, Marchi B, Coralli B, et al. Symtomatic hypotonic hyponatremia in an alcoholic polydipsic patient: a favourable clinical outcome after sodium correction. Alcologia Eur J Alcohol Stud 2001;13:43–6.
Flensborg-Madsen T, Mortensen EL, Knop J, et al. Comorbidity and temporal ordering of alcohol use disorders and other psychiatric disorders: results from a Danish register-based study dual diagnosis: 15 years of progress. Comprehensive Psychiatry. 2009; 50: 307–314.
Tolliver BK, Anton RF, Assessment and treatment of mood disorders in the context of substance abuse. dialogues Clin Neurosci. 2015; 17: 181-90.
Regier DA, Farmer ME, Rae DS, et al. Comorbidity of Mental Disorders With Alcohol and Other Drug Abuse Results From the Epidemiologic Catchment Area (ECA) Study JAMA. 1990 Nov 21; 264: 2511-8.
Modesto-Lowe V, Kranzler HR. Diagnosis and treatment of alcohol-dependent patients with comorbid psychiatric disorders, Alcohol Res Health, 1999; 23: 144-149.
Nurmedov Serdar,(2010,11 Şubat). Madde Kullanımının Yol Açtığı Uyku Bozuklukları. www.e-psikiyatri.com
Cheng SH, Shih C-C, Lee IH, Hou Y-W, Chen KC, Chen K-T, Yang YK, Yang YC. A study on the sleep quality of incoming university students. Psychiatry research, 2012, 197: 270-274.
Brower KJ, Aldrich MS, Robinson EA, Zucker RA, Greden JF. Insomnia, self-medication, and relapse to alcoholism. Am J Psychiatry 2001;158(3): 399-404.
Thompson PM, Gillin JC, Golshan S, Irwin M. Polygraphic sleep measures differentiate alcoholics and stimulant abusers during short-term abstinence. Biol Psychiatry 1995; 38(12):831-6.
Robinson RW, White DP, Zwillich CW. Moderate alcohol ingestion increases upper airway resistance in normal subjects. Am Rev Respir Dis 1985;132(6):1238-41.
Aldrich MS, Shipley JE, Tandon R, Kroll PD, Brower KJ. Sleep-disordered breathing in alcoholics: association with age. Alcohol Clin Exp Res 1993;17(6):1179- 83.
Marc A, Schucklt, MD ; Alcohol-Related Disorders .. Kaplan HI, Sadock BJ (ed) : Comprehensive Textbook of Psychiatry I VIII, Williams and Wilkins, Baltimore, 2005
Caputo F, Vignoli T, Grignaschi A, et al. Pharmacological management of alcohol dependence: From mono-therapy to pharmacogenetics and beyond. Eur Neuropsychopharmacol. 2014;24:181-191
