Pharmacological Treatment of Alcohol Hallucinosis

Abstract

We read with interest and sympathy the recent paper of Aliyev and Aliyev (2008) reporting results of a double-blind placebocontrolled study in 40 patients with acute alcohol hallucinosis indicating valproate to be effective in reducing verbal hallucinations. This is the first placebo-controlled study in this rare disorder, a widely neglected subject of research. The pathophysiology of alcohol hallucinosis is not clear (Soyka, 1995;Soyka et al., 2000a). There is no evidence for a common genetic basis for alcohol psychosis and schizophrenia (Glass, 1989a). An impaired dopaminergic neurotransmission and hyperdopaminergic state has not been shown in alcohol hallucinosis (Soyka et al. 2000b). Recent PET findings indicate a hypofunction of the thalamus in patients with alcohol psychosis that may resolve on clinical improvement (Soyka et al., 2000(Soyka et al., , 2005Kitabayashi et al., 2007).With respect to pharmacological treatment, no standard therapy has been established yet . To date there are only a few predominant case series and reports, mostly uncited in the Aliyev paper, which may indicate a rather good prognosis in patients treated with neuroleptics (Soyka et al., 1992(Soyka et al., , 1997(Soyka et al., , 2007de Millas and Haasen, 2007). Therefore, it is surprising to read the results of this study. A few specific questions on this study raise some concern:1. Epidemiology: There is broad consensus that alcohol hallucinosis is a rare disorder (Tsuang et al., 1994). In the Psychiatric Hospital of the University of Munich (200 inpatients) over a 10-year episode we only saw 13 cases (Soyka et al., 2007). Recent data from official German hospital statistics indicate a prevalence of 0.6-0.7% in alcoholics (Soyka, 2008). We therefore wonder how a single centre is able to include 40 patients in an unreported period of time. This may either be explained by a much higher rate of alcohol hallucinosis in this area, as we understand a predominantly Islamic state compared to elsewhere, or schizophrenic patients with secondary alcoholism were included, a frequent diagnostic dilemma (Surawicz, 1980). Psychopathology is only briefly described in the Aliyev paper, but we wonder how these patients were excluded. 2. Methodology: There also is broad consensus that alcohol hallucinosis is a very acute disorder that deserves treatment. We wonder about the 2-week washout phasefrom what drugs? In our experience, most alcoholics with acute hallucinosis are admitted as emergency patients, free of medication and require acute treatment. In addition, none of the 40 patients recovered spontaneously within the 2 weeks although the prognosis is usually good (Glass, 1989b). This may again raise the question whether some patients with schizophrenia might have been included. 3. Outcome: Aliyev and Aliyev (2008) reported rating for verbal hallucinations of the PANSS scale as outcome. It is unclear from the paper how many patients were actually symptom free at the end of treatment. In the larger case series with neuroleptics, >90% were no l...

Acute Alcoholic Hallucinosis: A Review

“…The clinical features of acute alcoholic hallucinosis (such as psychomotor agitation accompanied by the feeling of fear and an influx of frightening hallucinations, as well as a high frequency of suicide attempts and sudden manifestations of aggression) often necessitate hospital treatment [39, 48]. Patients with acute alcoholic hallucinosis typically benefit from antipsychotic medication, sometimes in combination with sedatives [48, 49]. Moreover, given that the use of antipsychotics in the context of alcohol withdrawal could precipitate convulsions, the administration of benzodiazepines should be mandatory [50].…”

“…The transition of acute alcoholic hallucinosis to the advanced stage is accompanied by the development of advanced verbal and auditory hallucinosis, which is often combined with delusion. These voices, in most cases, come from the real surroundings of the patient and have a condemning character [34,40]. A distinctive feature of verbal hallucinations is a reference by voices to the patient in the third person that makes him an involuntary listener, forced to be present when discussing his actions and behavior (occurring, as a rule, in a negative way and often cynical in nature) [39,40].…”

“…These voices, in most cases, come from the real surroundings of the patient and have a condemning character [34,40]. A distinctive feature of verbal hallucinations is a reference by voices to the patient in the third person that makes him an involuntary listener, forced to be present when discussing his actions and behavior (occurring, as a rule, in a negative way and often cynical in nature) [39,40]. It is not uncommon that some voices judge the patient, scold him, and make mocking remarks, while others, on the contrary, are friendly to him, protect him, and justify him and, as a result, he listens to a whole discussion about himself [34].…”

Psychotische Störungen durch Alkohol

“…Eine Therapie mit Neuroleptika gegebenenfalls in Kombination mit Sedativa ist meist notwendig. Kontrollierte klinische Studien zur Frage der Therapie der Alkoholhalluzinose fehlen weit-gehend (36,48), was angesichts der relativen Seltenheit des Krankheitsbildes und der guten Prognose verständlich ist. Von den meisten Autoren wird eine Therapie mit Neuroleptika wegen der meist lebhaften paranoidhalluzinatorischen Symptomatik und der erkennbaren Selbst-und Fremdgefährdung für notwendig gehalten.…”

Προσδιορισμός της μεταβολής των κυτταροκινών IL-7, IL-10 και GCSF (Granulocyte Colony Stimulating Factor) σε ασθενείς εξαρτημένους από την αλκοόλη χωρίς ηπατική ανεπάρκεια, κατά τη διάρκεια της θεραπείας απεξάρτησης

“…Ενώ ενδιαφέρον έχει ότι μπορεί σε άλλους ασθενείς να υποχωρήσει αυτόματα από μόνη της. Στους ασθενείς χρειάζεται να γίνει άμεση διαφορική διάγνωση με αντίστοιχο εργαστηριακό έλεγχο, ώστε και να αποκλειστούν και άλλες επείγουσες καταστάσεις όπως η ανάπτυξη Τρομώδες Παραλήρημα, τραυματισμών.Ακόμα, λόγω του υψηλού κινδύνου απαιτείται η έναρξη κατάλληλης θεραπείας με τη χρήση κυρίως βενζοδιαζεπινών και αντιψυχωσικών[19,28,182,183].Η προκαλούμενη από το αλκοόλ ψυχωσική διαταραχή με παραλήρημα ονομάζεται αλλιώς και αλκοολική παράνοια. Μπορεί να εκδηλωθεί τόσο κατά τη διάρκεια αλκοολικής τοξίκωσης, όσο και κατά τη διακοπή χρήσης του αλκοόλ.…”