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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