RECURRENT DETOXIFICATIONS ARE ASSOCIATED WITH CRAVING IN PATIENTS CLASSIFIED AS TYPE 1 ACCORDING TO LESCH'S TYPOLOGY

Multidimensional alcoholism typologies: could they guide clinical practice? Results from a 3-month prospective study

OBJECTIVE

The current nosological classifications may describe a syndrome of "alcoholism" that is too heterogeneous to produce prognostic models for clinical management. Multidimensional alcoholism typologies (ATs) could represent a valuable paradigm in the search for targeted treatment. The main goal of this study was to evaluate the clinical implications of 3 empirically-validated ATs, focusing on various measures of clinical performance.

METHOD

This was a 3-month naturalistic study in which drinking status, and participation in the clinical protocol and group psychotherapy were recorded and used as indicators of treatment performance. The clinical profiles of the subtypes were also compared and graphically presented. Alcohol-dependent outpatients were classified according to the Cloninger, Lesch, and NETER typologies.

RESULTS

The results showed that the type II (Cloninger), type IV (Lesch), and sociopathic and addictopathic (NETER) subgroups showed a worse outcome in terms of abstinence rates and clinical healthcare resource use.

CONCLUSIONS

Our findings point to the need to differentiate multidimensional alcoholism subtypes before planning the clinical management of alcohol use disorders.

Sodium oxybate in maintaining alcohol abstinence in alcoholic patients according to Lesch typologies: a pilot study

Sodium oxybate (SO) is a γ-amino-butyric acid (GABA)-ergic drug currently used for the treatment of alcohol dependence (AD) in some European countries. The aim of this study was to describe the effect of SO administration in alcoholics classified according to Lesch alcoholism typology (LAT). Forty-eight patients were enrolled and classified into four groups according to LAT. All patients were treated with oral SO (50 mg/kg of body weight t.i.d.) for 12 weeks. All patients significantly reduced their alcohol intake (p<0.001). Alcohol abstinence during the 12 weeks of treatment did not differ between the four groups at the end of treatment. Craving for SO did not significantly differ amongst groups; cases of SO abuse were very limited and were observed in almost 10% of patients. In conclusion, our study showed an overall efficacy of SO in the treatment of AD irrespective of LAT categories. However, our results confirm that alcoholics with psychiatric co-morbidity, particularly with a borderline personality disorder of Axis II, are at a greater risk of developing craving for and abuse of the drug: until craving for alcohol and craving for SO are characterized in depth, SO should be used with caution in these patients.

Cognitive components of frontal lobe function in alcoholics classified according to Lesch's typology

AIMS

This study examined the frontal lobe cognitive function and the mental state among patients with different types of alcohol dependence according to Lesch's typology.

METHODS

The frontal assessment battery (FAB) and the mini-mental status examination (MMSE) were given to 170 patients with alcoholism from a Brazilian outpatient service classified by Lesch's typology and to 40 non-alcoholic controls matched for age, gender, socio-demographic characteristics and education.

RESULTS

Of the alcoholic sample, 21.2% were classified as Type I, 29.4% as Type II, 28.8% as Type III and 20.6% as Type IV. Alcoholics showed significantly lower overall scores on the MMSE and the FAB as compared to non-alcoholic subjects. Type IV alcoholics had lower MMSE and FAB overall scores as compared to non-alcoholic controls and also to all other types of alcoholic subjects. However, Type II and III subjects with alcoholism also had lower overall FAB scores, but not overall MMSE scores, as compared to non-alcoholic controls. The FAB subsets of motor programming, sensitivity to interference and inhibitory control were significantly reduced in Types II, III and IV alcoholics as compared to non-alcoholic subjects, but only motor programming remained impaired in Type IV alcoholics with preserved mental function.

CONCLUSIONS

Executive dysfunctions in alcohol dependence seem to vary depending upon the type of alcoholism. Therefore, the determination of clinical type of alcohol dependence by applying Lesch's typology, along with brief mental state and frontal function examinations, is of clinical relevance in the examination of alcoholics and provides significant clues for more directed forms of alcohol dependence treatment.

Hormones and drinking behaviour: new findings on ghrelin, insulin, leptin and volume-regulating hormones. An ESBRA Symposium report

There is growing evidence for a role of appetite-related peptides and volume-regulating hormones in alcoholism. In particular, recent evidence has suggested that hormones, such as ghrelin, insulin and leptin and volume-regulating hormones, could play a role in alcohol-seeking behaviour. The goal of this review is to discuss the results of recent preclinical and clinical investigations on this topic. The findings indicate that neuroendocrinological mechanisms are potentially involved in the neurobiology of alcohol craving. Accordingly, research on this topic could lead to possible development of new therapeutic approaches in the treatment of patients with alcohol problems.

Herp mRNA expression in patients classified according to Lesch's typology

Chronic alcoholism is associated with hyperhomocysteinemia. Herp (homocysteine-induced endoplasmic reticulum [ER] protein) levels are elevated as a response to ER stress prior to mitochondrial dysfunction and cell death. The Lesch classification system has been applied in many studies and has been found useful. This study was undertaken to assess Herp mRNA expression in actively drinking patients with alcoholism who were classified according to Lesch's typology. Herp mRNA expression levels were measured by quantitative PCR in the blood of 76 male alcoholic patients. Patients were classified according to Lesch's typology (type I-IV). With respect to Lesch's typology, a significant difference in Herp mRNA expression regarding the four subtypes could be shown (F[3,72]=2.83, P=.044). In a logistic regression model (dependent variable Herp dichotomized by a median-split; adjusted for age and homocysteine levels) the subtype II differed statistically significant from the others (odds ratio, 5.75; 95% confidence interval, 2.07-15.98; P=.001). Type II alcoholic patients had a statistically significant higher expression of Herp mRNA due to upregulation of the expression of this neuroprotective cell non-chaperone by toxic effects of ethanol. These findings might explain why type II patients do not express severe withdrawal symptomatology (i.e., withdrawal seizures). These findings may be useful in the understanding and treatment considerations of different subtypes of alcohol dependence.

NETER 1 alcoholic 5 subtypes: Validity with Lesch four evolutionary subtypes

Objective. To validate NAT (NETER's alcoholic typology), taking into account the differentiated distribution of the measures used as external criteria in alcohol-dependent sub-groups and its relationship with Lesch's alcoholic typology (LAT). Method. A sample of 133 alcohol-dependent patients integrated in the alcoholism unit of the Psychiatric Service of Santa Maria University Hospital were included in the study. Results and Conclusions. Convergent validity was assured by the agreement between the subtypes of the two typologies (NAT and Lesch), considering the same underlying model of alcoholism development: anxiopathic subtype of NAT and Type II (model of anxiety, alcohol as conflict solution) of Lesch and the tymopathic subtype of NAT and type III (model of depression, alcohol as antidepressant) of Lesch. Discriminant analysis (external criteria) showed significant differences between the subtypes in the following variables: gender; tobacco; beer and whisky consumption; daily average of drinks; clinical conditions such as delirium tremens, alcoholic blackouts and seizures; severity of alcohol-related problems; psychological dimensions such as psychological maturity and extroversion; and suicidal ideation during the alcohol consumption period. A more exhaustive description of alcoholic sub-groups may improve genetic studies of alcoholism and provide the alcoholic patient with an adequate specific therapeutic protocol.

Apolipoprotein E gene polymorphism and previous alcohol withdrawal seizures

Aim of this study was to investigate the possible association of apolipoprotein E (ApoE) gene polymorphism with a history of alcohol withdrawal seizures. We included 194 patients with alcohol dependence who were divided into patients with (SZ+) and without (SZ-) previous alcohol withdrawal seizures. ApoE genotypes were determined using PCR. For statistical analysis we examined the number of ApoE alleles (ApoE2: n=36; ApoE3: n=311; ApoE4: n=41). A significant positive association with a positive history of withdrawal seizures (SZ+) was found in the ApoE3 allele group (Fisher's exact test: p=0.006) while a significant negative association was observed in the ApoE2 allele group (Fisher's exact test: p=0.029). For the ApoE4 allele group no significant differences were found regarding a history of withdrawal seizures. Our findings suggest an association between the apolipoprotein E3 gene variant and an elevated risk of alcohol withdrawal seizures. These preliminary results must be validated in further studies.

Association of the long allele of the 5-HTTLPR polymorphism with compulsive craving in alcohol dependence

AIMS

Various studies have reported a role of the serotonin transporter-linked polymorphic region (5-HTTLPR) in alcoholism.

METHOD

The present study investigated an association of this polymorphism with obsessive-compulsive alcohol craving in 124 male patients admitted for alcohol detoxification treatment.

RESULTS

We found significantly higher compulsive craving in patients with the long allele of the 5-HTTLPR polymorphism [at admission: analysis of variance (ANOVA): F = 3.48, P = 0.034, general linear model: F = 3.92, P = 0.023; after 7 days: ANOVA: F = 3.12, P = 0.049].

CONCLUSIONS

Our results suggest that the long variant of the 5-HTTLPR polymorphism is associated with higher compulsive alcohol craving at the beginning of alcohol withdrawal.

Prolactin serum levels and alcohol craving - an analysis using Lesch's typology

BACKGROUND

Prolactin secretion is closely connected to dopaminergic transmission that is known to play a crucial role in mediating reinforcement and craving in alcoholism.

OBJECTIVES

The study was performed to analyze the association between prolactin serum levels and alcohol craving during withdrawal differentiating alcohol-dependent patients using Lesch's typology.

METHODS

We assessed 115 male patients with the Obsessive Compulsive Drinking Scale at early alcohol withdrawal. In addition, serum was obtained to measure prolactin concentration and the patients were classified according to Lesch's typology into one of four subgroups.

RESULTS

Correlation analysis showed a significant association between prolactin serum levels and the extent of craving in Lesch's type 2 patients (r=0.32, p=0.015; n=57); however, no association was found for any other subgroup. The results were confirmed comparing patients with low and high craving (Mann-Whitney U test: Z=-2.805, p=0.005).

CONCLUSIONS

In patients of Lesch's type 2, who are characterized to suffer from anxiety and to use alcohol because of its anxiolytic effects, prolactin is associated with craving during early alcohol withdrawal.

Subtypes of substance dependence and abuse: implications for diagnostic classification and empirical research

AIMS

To evaluate the relevance of a form of diagnostic classification called clinical subtyping in relation to possible revisions in the diagnostic criteria for substance abuse and dependence in psychiatric classification systems.

METHODS

A general rationale for subtyping is presented. To explore the implications for diagnostic classification, recent research on a variety of subtyping schemes is reviewed in terms of the development of new subtypes and the validation of established theories.

RESULTS

Subtypes of alcoholism and other psychiatric disorders have been proposed since the beginning of modern psychiatry. Recent subtyping research suggests that no consensus has emerged about the nature, much less the number, of subtypes that could be used to characterize the clinical heterogeneity assumed to be present in groups of people with substance use disorders. Although several relatively simple binary typologies have been developed (e.g. Cloninger's type I and type II; Babor et al.'s type A and type B), validation research has produced mixed results in terms of the construct, concurrent and predictive validity of these classifications.

CONCLUSIONS

The adoption of a subtyping scheme in the major psychiatric classification systems is not recommended until further international research is conducted.

GLUTAMIC ACID IN WITHDRAWAL AND WEANING IN PATIENTS CLASSIFIED ACCORDING TO CLONINGER'S AND LESCH'S TYPOLOGIES

AIMS

Though glutamic acid is well known as a working excitatory in the CNS, its impact on the modulation of alcohol withdrawal symptoms and withdrawal fits are not yet clear. The study has been undertaken to examine the levels of glutamic acid in chronic alcohol-dependent patients at different stages of alcohol withdrawal and weaning and to examine any existence of any differences according to Cloninger's and Lesch's typologies.

PATIENTS AND METHODS

One hundred and fifty-nine alcohol-dependent patients were assessed according to Cloninger's and Lesch's typologies and related to abstinence duration, age, and gender. Blood samples were taken for mean corpuscular volume (MCV), gamma-glutamyltransferase (GGT) and glutamic acid, in order to find primarily any differences in glutamic acid according to the typologies, age, abstinence duration, and liver damage.

RESULTS

There was no significant association between Cloninger's and Lesch's typologies. Cloninger's types 1 and 2 had an equal distribution of GGT and duration of abstinence, while Lesch's type I had more patients with high GGT, and more patients who were sober for a maximum of 2 days. Unlike in Lesch's types, glutamic acid levels did not differ according to Cloninger's types, as significantly higher glutamic acid values were found in Lesch's types I and IV. Glutamic acid values did not differ significantly in different age groups.

CONCLUSIONS

Our study findings of varying glutamic acid levels seen in Lesch's typology, higher in types I and IV than in types II and III, are of significant clinical value and can be interpreted differently, as in type I high levels of glutamic acid is seen as a kindling phenomenon, while in type IV elevated levels might be related to either compulsivity of frequent repetition of drinking or withdrawal.