A case illustration of severe withdrawal with alcohol hallucinosis from prolonged alcohol use
Case Study
A case illustration of severe withdrawal with alcohol hallucinosis from prolonged alcohol use
Shauryaa Sharma,1 Shagufta Nasir2
1Assistant Professor, Jagannath Institute of Management, Rohini, Delhi
2Assistant Professor, Amity Institute of Clinical Psychology, Amity University Rajasthan Address for Correspondence: Email: snasir@jpr.amity.edu
ABSTRACT
Objective: Alcohol Withdrawal Syndrome (AWS) is experienced by most individuals who have a history of long-term and heavy alcohol consumption. Alcohol hallucinosis and delirium tremens are other symptoms of alcohol withdrawal found in some severe cases. Early identification and prevention can aid in mitigating the progression of withdrawal symptoms and planning interventions to reduce the dependence. Method: In the present case, a 34-year-old-male, educated till 12th grade, working as a bus conductor, presented with the chief complaints of restlessness, tingling sensation in the body, tremors in hands, frequent breaking into a sweat, aggressive outbursts and bizarre talk that have been present for 4-5 days. With the longstanding history of excessive use of alcohol over the past 12 years, the symptoms of withdrawal started on the second day of not consuming alcohol, as he was on medication for jaundice. Results and Conclusion: Brief Opportunistic Intervention and Cognitive Behavioural Therapy were found to be helpful in the patient’s preparedness to change, building insight, and setting goals for the treatment. A few techniques of Cognitive Behavioural Therapy were used to deal with the cognitive distortions associated with alcohol dependence.
Keywords: Alcohol Withdrawal Syndrome, Alcohol Hallucinosis, Brief Opportunistic Intervention, Cognitive Behavioural Therapy.
INTRODUCTION
Problematic use of Alcohol is a widespread issue with an ever-increasing count in the world’s population. Disorders related to alcohol impact 5-10% of the world’s population and account for around 2% of the global burden of diseases (World Health Report, 1993). The global alcohol consumption rate is higher in developing countries. The Indian Council of Medical Research Bulletin (2008) estimates that there are around 62 million individuals in our country who are alcoholics. Alcohol Withdrawal Syndrome (AWS) is a common phenomenon that is seen in alcohol-dependent individuals after cessation or reduction in heavy and prolonged alcohol use. The clinical manifestations of it range from night- mares, restlessness, tremors, insomnia, vivid dreams, hypervigilance, tachycardia, paroxysmal sweating, loss of appetite, headaches, vomiting or nausea (Cuttshall, 1965; De Witte et. al., 2003; Hall & Zador, 1997; Koob et. al., 1995). Alco- holic hallucinosis (AH) is another symptom of alcohol withdrawal that is observed in some cases. AH was first discussed by Bleuler (1916) and is characterized by an acute onset, hallu- cinations that are predominantly auditory, but may also be sensory or tactile, with intact sen- sorium, absence of thought disorder and complete resolution of symptoms within a few weeks (Glass, 1989; Jordaan & Emsley, 2014).
Very few individuals with AWS may also develop Alcohol Withdrawal Delirium, commonly referred to as Delirium tremens (DT) (Mayo-Smith et. al., 2004). DT is characterized by a decrease in the level of consciousness, impaired recent memory, disruption in the sleep- wake cycle, disorientation, transient perceptual disturbances, symptoms getting worse in the eve- nings, variable agitation and tremors in the limbs (Schuckit et. al., 1995; Lee et. al., 2005).
The present case mentions a severe condition of alcohol withdrawal characterized by restless- ness, tremors and tingling sensation in the body followed by symptoms of visual hallucinations and bizarre talk along with aggressive outbursts that started on day two of cessation of alcohol use. The role of early identification followed by intervention and the subsequent symptom con- trol is also observed in the discussed case as the treatment the patient received immediately post the episode, prevented the withdrawal symptoms from getting more severe. The present case also highlighted the role of the psychotherapist in mitigating the progression of the stages of withdrawal.
Case Description
The patient was a 34-year-old male with a higher secondary education, married, working as a bus conductor and belonging to a lower socio- economic status. He was admitted to the psychi- atric ward of the hospital with complaints of restlessness, tingling sensations in the body, ex- cessive shivering and sweat outbreaks over the past 4-5 days. The informant also reported symptoms of bizarre talk, seeing things and aggressive outbursts in the patient from the past 2 days that prompted the hospital admission with the precipitating factor being a complete ces- sation of the patient’s consumption of alcohol as he was on treatment for jaundice. He had a longstanding history of excessive alcohol use that started at the age of 20 years and gradually kept on increasing. At present, he would consume around 2 bottles (Around 500 ml) of country liquor every day and would show up to work intoxicated on most days. He also got into several brawls with passengers at work and his home. His interpersonal relationships with his family were also strained because of his excessive alcohol use. A family history of alcohol use and dependence was also reported as the patient’s father also consumed alcohol in high quantities and died several years ago from a longstanding liver condition. On detailed questioning the Patient was asked whether he needed to cut down on his drinking behaviour, felt annoyance on being criticized for his drinking pattern, guilty over alcohol use, and used alcohol in the morn- ing. The response was positive for 2 out of 4 of the questions.
His physical examinations revealed his SGPT and SGOT values were 162 U/L and 169 U/L respectively which were higher than the refereed range. His medication on admission included Tablet Lopez (2 mg) which was given to control the symptoms that resembled autono- mic over- activity. Tablet Serenance (0.5 mg) was prescribed for relief from the symptoms of visual hallucinations. Microliv Forte and Uristop (300mg) were given for his liver function. Apoliv DS, Deuphalac (SOS), and Tablet Tim (100 mg) were prescribed for stomach-related issues.
The mental status examination revealed psychomotor activity being decreased, low tone of speech, increased reaction time, anxious preoccupations about physical health, dysphoric mood, difficulties sustaining attention, not oriented to time, inadequate recent, abstract ability at the functional level and Grade 3 Insight.
Psychological assessments were conducted across psychotherapy sessions with the clinical psychologist. A score of 32 on AUDIT indicated mild to severe alcohol use and possible alcohol dependence. A score of 21 on the Clinical Institute Withdrawal Assessment of Alcohol Scale, revised (CIWA-Ar) was indicative that he was in severe withdrawal (impending delirium tremens). Based on the findings of the clinical interview and the assessments, the patient was diagnosed with F10.30: Mental and behavioural disorders due to the use of alcohol – withdrawal state, accord- ing to ICD-10. After two days of being on the prescribed medications, most of his symptoms subsided, but he continued to feel restless and cravings for the substance persisted. Further assessments were conducted, and the Patient was assessed to have mild cognitive impairment, according to Montreal Cognitive Assessment (MoCA).
Psychological Intervention focused on individual and family counselling. The long- standing use of alcohol could be accounted for by the observed findings. The short-term goals were identified to provide care and support while the 5 withdrawal symptoms persisted and to educate the patient and the family about the negative impacts of alcohol dependence. The long-term goals were helping the patient build insight into alcohol dependence, identifying triggers to problematic behaviour and developing the skills required to curb it, restoring his socio- occupational functioning and preventing relapse. Initially, Brief Opportunistic Psychotherapy was delivered. Psycho-educating the patient and the family members about the harmful consequences of alcohol use was also done. Motivational inter- viewing was used to work with readiness, ambivalence and resistance to change. To work on rigid core beliefs that contribute to alcohol consumption, techniques of Cognitive Behaviour Therapy were used. The patient repeatedly ex- pressed that ‘I can never get myself together without drinking alcohol’ and ‘I will always need alcohol in small amounts to be able to work.’ Such cognitive distortions were targeted during psychotherapy sessions. The patient improved significantly during the course of treatment with continuous use of medication and regular psychotherapy sessions and was then discharged after 6 days of admission. A follow-up session after a period of 1 month was planned, in incase the patient needed further assistance.
Details of The Therapy Sessions
In the initial phase, the psychotherapy sessions with the patients began after clinical interviewing and several assessments. As previously discussed, the psychotherapy sessions with the clinical psychologist began with Brief Opportunistic Psychotherapy. A total number of three sessions of 30 minutes in the beginning along with the screening and assessments were carried out to ascertain the patient’s preparedness to change, help him build insight and set goals for treatment. It was observed through the psychotherapy sessions that the patient did not see his alcohol use and dependence as proble- matic and grossly underreported his behaviour. He was hence identified to be in the pre-contem- plation stage (Prochaska et al., 1992). The education-clarification approach was used while the therapist encouraged the Patient to review his drinking behaviour and post detailed discussions and proceeded to educate the client about the health risk associated with it (Sitharthan et al., 2001). Brief opportunistic psychotherapy found to be helpful because the Patient’s attendance was gauged on his symptoms and disease conditions rather than on the con- sumption of alcohol. This approach also helped to establish a therapeutic alliance with the Patient. The Patient’s alcohol abstinence self- efficacy was low however, a strong working alliance was established to some degree which helped in continuing sessions with him.
The reports of the physical examination, his deteriorating liver condition, and the life-threat- ening consequences that it can pose were also discussed. The Patient gradually accepted his behaviour to be problematic and expressed thoughts about quitting. His desire to quit, however, was expressed with a lot of ambivalence and he reiterated his inability to abstain and continue with life without consuming alcohol. In the middle phase of the therapy, a few techniques of motivational interviewing that were used next helped the patient build intrinsic motivation for change. The therapist helped the Patient work on his self-efficacy and deal with the innate resistance to change (Rollnick & Miller, 1995). Over a course of the next 3-4 sessions, improvement was observed, and the Patient was seen to be innately motivated for abstinence.
Cognitive behaviour therapy was then used to work on cognitive distortion observed in the Patient. In the last phase of the sessions, the Patient and the Clinician worked to identify po- tential high-risk situations in his environment and develop the necessary interpersonal and intra- personal skills to handle such situations. Skills training in refusing invitations to drink with friends, avoiding situations at work that encourage drinking behaviour, social settings where drinking gets triggered, and management of craving were discussed and practiced through role-play.
The present case also reiterated the impor- tance of family and social support in motivating a patient with alcohol dependence toward abstinence and relapse prevention. The role of sociocultural factors and family environment during childhood was also clearly seen. The Patient grew up in a household where drinking was a common sight among the men in their house. Consequently, he was desensitized to it from a very young age. A dual role of ‘nature & nurture’ was also observed in the present case. Both the family history and environmental factors contributed to his alcohol consumption, rendering him unable to see the maladaptive behaviour. Therefore, his immediate family was also involved as much as possible in the sessions. Relapse prevention was introduced next and discussed with the Patient and the family.
The discussed psychotherapy techniques are individually known to be a fairly common module while dealing with patients with alcohol withdrawal and the various complications it may have. However, in the discussed case the associa- ted health complications, the resistance to change and the interpersonal issues of the Patient required the clinician to bring out an eclectic ap- proach to address the wide range of issues that he had. Addressing several aspects of the pa- tient’s life simultaneously was vital so that the acquired behavioural changes were also sus- tained and the chances of relapse were reduced. While the role of medication was known to be paramount in lessening the aggravated with- drawal symptoms and preventing the situation from worsening, the psychotherapist had a major role to play to help the patient understand the source of the problem and acquire the required skills to abstain. The psychotherapist role in assessments and psychotherapy, can be best used to establish programs that facilitate early recogni- tion and management of such problems.
Early identification was considered to be a key feature in the discussed case that acted as a good prognostic factor. The patient had a very severe case of alcoholic hallucinosis when he was bought to the hospital. The condition could have advanced to a state of delirium tremens ending in profound confusion, autonomic hyperactivity or even cardiovascular collapse (Rahman & Paul, 2022) if immediate medical attention would not be provided.
CONCLUSION
The present case helped to understand the progression of symptomatology and the process of lessening the severity of symptoms with the help of early identification and intervention. Early identification is a potent factor which helped to alleviate symptoms. An amalgamation of a few techniques from Brief Opportunistic Therapy and Cognitive Behavioural Therapy was found to be beneficial in this case, especially, in building therapeutic alliance, preparedness for change, identifying high-risk situations and health condi- tions and dealing with faulty cognitive misrepre- sentations. As a part of the intervention, an education-clarification approach with the patient and family members was found to be effective.
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