Case Studies of Mental Health in General Practice(21)
——Alcohol Withdrawal Syndrome

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Similar to other cultural and ethnic groups,Chinese people accept ′having a drink′ as part of everyday life and it is often a part of building social relationships and interacting with friends or even work colleagues.While alcohol is often used in a relatively harmless manner by many in the community,alcohol over consumption is a major social problem as well as important risk factor for individuals′ health.

1 History

One morning,Tingting brought her father Mr Wang to your general practice clinic.He had arrived in Australia with his wife Hongmei,only two months earlier and was currently living with Tingting,a 22 year old university student.Mr Wang does not have fluent English and therefore Tingting translated the conversation between you and Mr Wang.

Mr Wang is 49 years old and originally came from Shandong in China.He is a man of large build and immediately you notice that he looks unhappy.During the early phase of consultation,the discussion is primarily a conversation between you and Tingting as she reports her father′s bad temper,and explains that he often argues with her and others with confused words (in Mandarin).She had also noticed that sometimes he would be shaking with emotion and also would work up a sweat.Two days ago,he told Tingting that he wants to see doctor for a script for treating his headache and feelings of faintness,shaking hands and stomach acid symptoms.

2 Further history

With the help of Tingting′s translation you obtain further information about Mr Wang.You discover that Mr Wang was a Chinese veteran,and that after retiring from the military force,he was allocated to the logistic department of local government.He explains that along with all the other fellows of Shandong,he became a ′capable drinker′ since he was 15 years old.In fact,he became a ′drinking champion′ during the time when he worked for local government.He is embarrassed to tell that finally he was sacked by his government supervisor as he was making "lots of trouble" after heavy drinking.

He tells you,via translation,that he was happy to be ′free′,because he could make more money in business.He found retired comrades-in-arms and opened a private company.′You might not know,business in China is a battlefield and alcohol is one of the weapons or tools′,he said.He explained that ′initially,I had to drink for my business,but eventually I found I cannot do without it′.

His ex-wife was a bank official.He describes that during their early stage of marriage,she thought that drinking must be an intrinsic feature of Shandong man.Even when Mr Wang had to leave his government job,she still thought that this was normal,acceptable and no surprise.However,she eventually could not put up with his drinking especially when he heavily engaged in drinking events.He often drank heavily,at least twice a week,and on these occasions,he bullied and argued with her and broke things at home.Mr Wang said he earned a lot money from the business during this time,which he attributed in part to ′the alcohol business culture′,but ultimately his wife divorced him.

Mr Wang re-married a year after and said he decided it was time to give a good life to his daughter and his new wife,and then sent them to Australia whilst he remained in China.He explains that he had more opportunity to be doing business and as part of that engage in heavy drinking.′Bai-Jiu (Chinese spirits) is my food′,he said.He preferred to drink over 50% alcohol Chinese liquor,two bottles a day,at least.Unfortunately,he was sent to the hospital emergency several times after nights of very heavy drinking.However,he said,′I need drink,for business and because I enjoy it′.Tingting worried for his health and safety,and suggested he come to Australia to be with his family.Mr Wang explained,"I really love my Tingting and so I listened to my daughter and agreed to come".However,Mr Wang found it difficult to find drinking companions and also found that being a businessman in Australia is not like in China.Also he found alcohol to be more expensive.

Tingting added that her father had tried several times to reduce his alcohol intake but had been unsuccessful.Even when he tried every week he found he′d go back on the bottle the week after.Sometimes,Tingting even found her father holding an ′invisible bottle and cup′,and seemed to be playing out a fantasy of drinking.She said her father had no significant physical illness apart from high blood pressure and a fatty liver and was otherwise fit and strong.

On further history Mr Wang reports nausea and a burning feeling in the stomach in the last month and ′less able to drink because he feels uncomfortable,′ he said.No vomiting reported and his stools were normal in colour.He has noticed that his cheeks have been very flushed and that his hands have been shaky.His daughter tells you that he is not himself and is often confused lately- in fact a few nights before he woke at night and was wandering around the house thinking he was back in China.

3 Examination

Mr Wang appears on edge during the examination.He was sweating and his hands were shaking,but no jaundice was evident.Looking at his eyes his sclera were white and his pupils were equal and reactive to light.His cheeks were flushed and his palms were red and he had spider naevi over his chest and abdomen.He had a swollen abdomen suggestive of ascites and some mild tenderness in the epigastric region.His balance on walking heel to toe was poor.No fever,BP 120/80 mm Hg(1 mm Hg=0.133 kPa),Pulse 66/min.No other significant physical findings.

He was orientated in time but he was not clear on who you are and where the practice was located.His short term memory was poor and he could only remember one of the 3 items you ask him to remember five minutes later.No hallucinations or perceptual abnormalities.No suicidal thoughts.

4 Questions

4.1 What is the probability diagnosis?

4.2 What other diagnoses should be considered?

4.3 What further investigations are required?

4.4 How should Mr Wang be treated?

5 Answers

5.1 What is the probability diagnosis? Alcohol Withdrawal Syndrome (AWS) is likely especially with the history of heavy drinking and the recent sudden cut back on drinking because of stomach pains.AWS is characterised by central nervous system hyperactivity that occurs when people suddenly stop or significantly reduces alcohol consumption.About half of alcohol-dependent patients develop withdrawal symptoms.The AWS includes three groups symptoms: autonomic hyperactivity (sweeting,hypertension,fever,etc.),gastrointestinal features (nausea,diarrhea,anorexia,vomiting,etc.) and cognitive and perceptual changes (anxiety,agitation,disturbed sleep,etc.)[1].Onset of the AWS is usually between six and 24 hours after the last drink or following reduction in alcohol drinking.In severe cases,alcohol withdrawal delirium or hallucinations or alcohol withdrawal seizures can occur.

Alcohol dependence is characterised by repeated alcohol use despite significant substance-related problems.Repeated drinking results in tolerance,withdrawal and compulsive drinking behaviour.Craving,a strong subjective to drink,is common.Tolerance,the need to use greatly increased amounts to achieve intoxication or the desired effects of drinking,is a key feature of alcohol dependence.

5.2 What other diagnoses should be considered? Because of the acute confusion there are a number of important diagnoses to consider as well as the possibility of alcohol withdrawal.It is likely that Mr Wang has some liver failure and hepatic encephalopathy and this too can present with confusion.Other important diagnoses to think of are infection (for example a chest or urine infection) and also the possibility of a subdural haematoma from a fall is not uncommon in the setting of excess alcohol use and a CT scan should be considered.There are a raft of other haematological and chemical imbalances that could cause confusion and should be checked for on a blood test (e.g.low glucose,anaemia and vitamin deficiencies) before assuming alcohol withdrawal is the only problem.The epigastic pain may be a peptic ulcer,but excess alcohol intake can also cause portal hypertension leading to oesophageal varicoses that can cause abdominal pain and also an acute severe bleeding so this needs to be considered too.

Looking back over Mr Wang′s history,the possibility of an underlying problem which he has self ′treated′ with alcohol should be considered.This is most commonly an anxiety disorder,and in particular social anxiety disorder and agoraphobia/panic disorder should be considered.Whilst this would not explain Mr Wang′s symptoms over the past month,it could be a significant contributor to his long-term alcohol dependence.

5.3 Further investigations? In light of the broad number of differential diagnoses to consider with this presentation it would be well worth doing a blood and urine test to check for things such as diabetes,infection or a thyroid abnormality.Importantly does he have evidence of liver failure on his blood tests? In someone with a history of alcohol abuse it would be important to make sure that there has not been a head injury and a suspicion of a subdural haematoma should prompt a CT scan of the head to exclude this.Ideally if available this patient needs a gastroscopy to further assess his epigastric pain to see if he has an ulcer or oesophageal varicoses.

5.4 Treatment and management? Once the acute clinical presentation has been sorted out there are a number of longer term issues to consider in Mr Wang′s care.A critical question to consider is if Mr Wang is actually ready to try withdrawing from alcohol! The Diclemente Stages of Change Model is very useful way to consider patients readiness to change in relation to an addiction such as alcohol[2].Many people are in the pre-contemplative stage,that is，they don′t really want to stop their addictive behaviour.However,eventually and usually prompted by a crisis or pressure from family,people move into what is termed the contemplative stage,that is,they are seriously thinking about giving up the alcohol.A GP can help a patient move to this stage by using an approach called motivational interviewing which encourages the patient to reflect on the benefits and costs of their addictive behaviour.Finally when the patient is in the ready to change stage,there is a great opportunity to help the patient with medical and social support services.Even after a successful withdrawal patients will need ongoing assistance to avoid and manage relapses.

The objective of alcohol withdrawal services include to interrupt pattern of heavy and regular alcohol use,to alleviate withdrawal symptoms,to prevent severe withdrawal complications,and to facilitate linkages to ongoing treatment[3].If possible,alcohol withdrawal management could occur in hospital,a patient′s home,a general practice,or an ambulatory service.Outpatient services are the most effective,safe and low-cost approach for a patient with mild to moderate symptoms.Community residential withdrawal is appropriate for moderate to severe withdrawal patients; while hospital (inpatient) treatment is suitable for severe withdrawal complications.This of course depends on the availability of services in any setting.Patients with a history of delirium tremens or withdrawal need high supervision care.For the case of Mr Wang - complex case and in reality given the liver signs and cognitive impairment as well as high risk for DTs-hospital admission could be advocated by the GP.

GPs are helpful for regularly monitoring patients who withdrawing from alcohol.GPs can provide pharmacological assistance.Often regular doses of benzodiazepines such as Valium are useful to minimise withdrawal symptoms and can be gradually tapered.Many alcoholic patients are nutritionally deficient and multi B vitamins and thiamine are given regularly.

Supportive counselling is also essential,such as patient information about the likely nature and course of alcohol withdrawal,and strategies to cope with common symptoms and cravings.Through education,Mr Wang can be helped to come to terms with the idea that he is alcohol dependent (alcoholic) and the only solution is to stop drinking.It is most helpful to view alcoholism and behaviour as due to a pathological reason instead of personal weakness or moral problem.Tingting and her Chinese friends can be of great assistance for Mr Wang.A quiet and peaceful environment will also helpful.In some countries,alcohol self-help groups or volunteer organisations can be found,such as Alcoholics Anonymous,where people share experience,strength and hope with each other and may help solve their common problems and help others to recover from alcoholism.

GPs can also help patients with long term rehabilitation.GPs are ideal person who help patient because it will be a long term process (at least three years) and require a long term and trustful relationship.The target of rehabilitation plan is to prevent relapse.If patient has psychiatric symptoms,the GP could refer the patient to a psychiatric service.For a patient who has medical conditions,closer monitoring is also important.

Cultural factors should also be considered for the case of Mr Wang.He may have defined himself as ′naturally a good drinker′ which could be an obstacle.He might also have a communication problem when sharing experiences with the doctor and their services and a professional interpreter or a doctor who can speak Mandarin would be preferable to using a family member as the translator.

1 National Health and Medical Research Council.Australian guidelines to reduce health risks from drinking alcohol[EB/OL].http://www.alcohol.gov.au/internet/alcohol/publishing.nsf/Content/guidelines.

2 Monhetit B.Gijsbers alcohol and other drug misuse in general practice psychiatry[M].McGraw Hill,2006.

3 Blashki G,Judd F,Piterman L.General practice psychiatry[M].McGraw Hill,2007.