Complicated alcohol withdrawal presenting as self mutilation

Alcohol Withdrawal Presenting with Cut Throat Injury during COVID-19 Lockdown: Case Reports from Nepal

Background

The relationship between alcohol dependence and suicidal tendency is well recognized. Self-harm by cut throat is an uncommon but is potentially life-threatening when attempted. We present a description and discussion of a series of three cases of alcohol dependence syndrome who presented with self-inflicted cut throat wounds during the lockdown period from 24th March to 7th July 2020 due to the COVID-19 pandemic at the largest tertiary care hospital in Nepal. Case description. During the three and a half months of COVID-19 lockdown, we had three cases of alcohol dependence syndrome presenting to emergency services with a self-inflicted cut throat injury. Two cases were diagnosed as having alcohol withdrawal delirium and one case as alcohol-induced psychotic disorder (alcoholic hallucinosis) as per the international classification of mental and behavioral disorders diagnostic criteria for research. All three cases were alcohol dependent for more than a decade, but with no prior self-harm attempts. Necessary surgical interventions were done by the Department of Otorhinolaryngology, and in liaison with the Department of Psychiatry, appropriate psychiatric management was done. All three cases had uneventful outcomes in regard to wound care and mental disorder.

Conclusion

Suicidal precautions should be taken in alcohol dependence during phases of consumption and abstinence. Screening for alcohol dependence and withdrawal should be a standard process in all self-harm cases that present to the emergency department during a crisis.

Pharmacologic hyperreactivity of kappa opioid receptors in periaqueductal gray matter during alcohol withdrawal syndrome in rats

BACKGROUND

Periaqueductal gray matter (PAG) is a brain region rich in kappa-opioid receptors (KOR). KOR in PAG mediates behavioral responses related to pain integration, and panic response, among others. Its participation in the addiction phenomena has been poorly studied. Hence, this preliminary study explored the pharmacological effects of KOR stimulation/blockade in dorsal-PAG (D-PAG) during alcohol withdrawal on anxiety-type behaviors and alcohol intake/preference.

METHODS

Juvenile male Wistar rats were unexposed (A-naïve group) or exposed to alcohol for 5 weeks and then restricted (A-withdrawal group). Posteriorly, animals received intra D-PAG injections of vehicle (10% DMSO), salvinorin A (SAL-A; a selective KOR agonist), or 2-Methyl-N-((2'-(pyrrolidin-1-ylsulfonyl)biphenyl-4-yl)methyl)propan-1-amine (PF-04455242; a highly selective KOR-antagonist). Subsequently, the defensive burying behavior (DBB) and alcohol intake/preference paradigms were evaluated.

RESULTS

SAL-A markedly increased burying time, the height of bedding, and alcohol consumption/preference in A-withdrawal, while slightly increased the height of bedding in A-näive rats. PF-04455242 decreased both burying and immobility duration, whereas increases latency to burying, frequency of rearing, and the number of stretches attempts with no action on alcohol intake/preference in A-withdrawal rats.

CONCLUSIONS

In general, stimulation/blockade of KOR in A-withdrawal animals exert higher responses compared to A-naïve ones. SAL-A produced anxiety-like behaviors and increased alcohol consumption/preference, especially/solely in the alcohol-withdrawal condition, while PF-04455242 augmented exploration with no effects on alcohol intake/preference. Our findings suggest a possible pharmacologic hyperreactivity of the KOR in PAG during alcohol withdrawal.

Phenomenology and Course of Alcoholic Hallucinosis

Objective: The objective of the study was to examine the correlates, phenomenology, and short-term treatment response to benzodiazepines and antipsychotics in an inpatient sample with alcohol-induced psychotic disorder, predominant hallucinations i.e., F10.52. Methods: We reviewed the charts of the patients admitted in a tertiary care addiction treatment center between 2010 and 2016 with the diagnosis of alcoholic hallucinosis. Results: Among 6,493 patients admitted with alcohol dependence during the study period, 61 patients (0.9%) had alcoholic hallucinosis. Among them, 41 (67.2%) had alcoholic hallucinosis in the past; 26 (42.6%) had a family history of psychosis. Only auditory hallucinations were found in 46 patients (75.4%), only visual hallucinations in 3 patients (5%), and both auditory and visual hallucinations in 12 (19.7%). Thirty-four (55.7%) had delusions, which were secondary to hallucinations. Suicidality which includes suicidal ideas and attempts was noted in 12 (19.7%) patients. Fifty-three (86.9%) patients had hallucinations exclusively during alcohol withdrawal, while 8 (13.1%) had them during withdrawal as well as while consuming alcohol. At the end of six months, 13.1% of the patients had an independent psychotic disorder diagnosed. The primary mode of management was treatment with only benzodiazepines (n = 37, 60.7%) or benzodiazepines and antipsychotics (n = 24, 39.3%). The reasons for starting antipsychotics were the presence of florid psychotic symptoms (26.2%) and incomplete symptom resolution with benzodiazepines (9.8%). The median duration of response was four days, with 25th to 75th quartile range at two to seven days. Conclusions: Alcoholic hallucinosis is an acute short-lasting psychotic disorder which lasts for less than a week when treated. Suicidality is high in this group, which needs attention. Benzodiazepines as part of withdrawal management may be sufficient for a majority of cases. Antipsychotics may be required in selected cases. A high degree of recurrence and morbidity indicates a need to intervene early with an abstinence-oriented management goal.

Self-disembowelment during delirium tremens: why early diagnosis is vital

Delirium tremens is a serious yet treatable complication of alcohol withdrawal. Timely diagnosis is critical as there are well-established treatment regimens that provide symptomatic relief within hours to days. We report the case of a 34-year-old man with an undisclosed history of alcohol dependency. He presented with paranoid beliefs and was transferred to a psychiatric inpatient unit with suspected schizophrenia. Classic features of delirium tremens such as sympathetic overdrive and visual hallucinations were not salient features of his presentation. Within 24 hours of admission, he sustained major self-inflicted abdominal stab wounds and extracted a metre of small bowel as a result of command hallucinations. The possibility of delirium tremens was raised by the receiving trauma team and he responded rapidly to benzodiazepines. Emergency jejunal reanastomosis was successful. This case highlights the fact that delirium tremens may present atypically and that associated command hallucinations can confer grave risks.

Are Alcohol Anti-relapsing and Alcohol Withdrawal Drugs Useful in Cannabinoid Users?

Cannabinoids are still classified as illegal psychoactive drugs despite their broad and increasingly acknowledged therapeutic potential. These substances are most famous for their wide recreational use, particularly among young adults to either alter the state of consciousness, intensify pleasure induced by other psychoactive substances or as an alternative to the previously abused drugs. It is important to emphasize that cannabinoids are often taken together with a variety of medications intended for the treatment of alcohol use disorder (AUD) or alcohol withdrawal syndrome (AWS). These medications include disulfiram, acamprosate, and naltrexone. In this paper, we summarize recent advances in the knowledge of possible beneficial effects and interactions between cannabinoids and drugs commonly used for treatment of AUD and AWS either comorbid or existing as a separate disorder.

Non-suicidal self-injury and other self-directed violent behaviors in India: A review of definitions and research

The interpersonal theory of suicide suggests that most forms of self-directed violent behaviors lie on a continuum, with each behavior successively increasing the capability of committing suicide. There is increasing evidence to suggest that the continuum may begin with Non-Suicidal Self-Injury (NSSI). This theory can be important in developing interventions for suicide prevention. However, in India, consistent usage of definitions of various forms of self-directed violent behaviors is lacking. In the present study, we reviewed definitions of various forms of self-directed violent behaviors that have been investigated in India. Further, we compared the usage of these definitions with the usage by WHO. Additionally, we reviewed NSSI research in India. Thirty-eight publications were identified by a comprehensive electronic search undertaken in Indian psychiatry, psychology, and mental health-related databases. Inconsistent definitions of eight self-directed violent behaviors were observed in Indian literature. Agreement on consistent definitions of various forms of self-directed behaviors is essential. Based on the findings of the current review, it can be suggested that culturally relevant large-scale research on NSSI in India is required to confirm the limited evidence that suggests high prevalence of NSSI in India.