History
The study of sexual deviancy began just before the turn of the 20th century as the taboo of discussing sexuality was beginning to lift. Early pioneers included Richard von Kraff-Ebing, Albert Moll, August Forel, Iwan Bloch, Magnus Hirschfield, Havelock Ellis, and Sigmund Freud. Their work was not well accepted, and they were regarded with disdain.
Several psychiatric concepts were prominent at this time. One of them was a constitutional predisposition of unknown origin called degeneration, which refers to an innate neurologic weakness that is transmitted with increased severity to future generations and produces deviations from the norm. Masturbation was blamed for a list of diseases including insanity, suicide, self-mutilation, and tuberculosis. The law of association of ideas suggests that when sex and another experience occur, one stimulus sets off the other.
Ellis worked against the prudish view of sex that existed at the time, and he advocated the decriminalization of homosexuality. Freud wrote on fetishism, masochism, and the theory of perversions. These early investigators of sexual deviation provide an important principal: "Not only must the act be studied, but also the person. The personal roots of deviance spring from an interaction of the individual's biological nature and his early life experiences."
Disorders of human behavior remain difficult to understand, identify, and treat. Few data are available, too much of our knowledge is based on speculation and unsupported theory, and societal stereotypes influence our perceptions. Good science-based research remains difficult, and monetary, ethical, and legal concerns complicate such research.
PARAP
Sexual deviation is a term applicable to a subclass of sexual disorders termed paraphilias. Paraphilias are associated with arousal in response to sexual objects or stimuli not associated with normal behavior patterns and that may interfere with the establishment of sexual relationships. In modern classification systems, the term paraphilia is preferable to sexual deviation because it clarifies the essential nature of this group of behaviors (ie, arousal in response to an inappropriate stimulus).
The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), the prevailing resource for diagnostic criteria of paraphilias, describes the essential feature of paraphilias as recurrent, intense, sexual urges and sexually arousing fantasies generally involving nonhuman objects, the suffering or humiliation of oneself or partner, or children or other nonconsenting persons. The DSM-IV-TR describes 8 of the more commonly observed paraphilias and makes reference to several other examples. People who experience one paraphilia may also experience other paraphilias, although the paraphilia may occur as an isolated event. Commonly, people who manifest paraphilias also exhibit personality disorders, substance abuse problems, or affective disorders.
Prevalence
Paraphilias are rarely diagnosed in clinical settings. Large commercial markets in paraphiliac pornography and paraphernalia are testaments that prevalence is high. Pedophilia, voyeurism, and exhibitionism are the most commonly observed behaviors in clinics that specialize in paraphilia treatment. Sexual masochism and sexual sadism are much less commonly observed. Approximately half of patients observed in clinics for treatment of paraphilias are married.
Differentials
Nonparaphiliacs may describe nonpathological use of sexual fantasies, behaviors, or objects as stimuli for sexual excitement.
In patients with mental retardation, paraphilia should be distinguished from dementia, personality change due to general medical condition, substance intoxication, manic episode, or schizophrenia in which judgment, social skills, or impulse control are compromised.
When appropriate, public urination should be distinguished from exhibitionism.
Exhibitionism
The DSM-IV-TR diagnostic criteria for exhibitionism are as follows:
The patient reports recurrent, intense, sexual urges and sexually arousing fantasies related to exposing the genitals to a stranger. Symptoms must be present for at least 6 months.
The patient experiences significant distress or impairment in social, occupational, or other important areas of functioning because of the fantasies, urges, or behaviors.
Generally, no attempt at further sexual activity with the stranger occurs, although a desire to shock the stranger sometimes exists or the exhibitionist may have a fantasy that the observer will become sexually aroused. Onset usually occurs in persons younger than 18 years but may occur later. The disorder causes significant stress or impairment in social, occupational, or other important areas of functioning. In 1975, Rooth classified 2 types of exhibitionism: Type I is the inhibited flaccid exposer, and type II is the sociopathic exposer who may have a history of other conduct. About half of adult women have witnessed indecent exposure sometime in their lives.
Exhibitionists, whether timid or brash, feel dominated by women and resent it. By exposing themselves, exhibitionists turn the table on women, dominating rather than being dominated. Exhibitionists view this act as making women their helpless victims, rather than being helpless before them. Some researchers have suggested that exhibitionists have a fragile sense of masculinity. Threats to masculinity are countered by demonstrations of manliness.
Exhibitionists have difficulty relating to women as whole people. Rather, women are present merely to provide both gratification and proof against castration. Many exhibitionists are very prudish with their wives. They go to great efforts to never look at their wives or be seen by them in the nude. Intercourse tends to be rigid and conventional.
Common to all exhibitionists is some abnormality in handling aggression and hostility. On the one hand, they must keep their anger under tight control, yet on the other hand they may become tyrannical with their family because they feel safe from retaliation.
Male genital exhibitionism is an indicator of future sexual offenses in some individuals. In a 1980 longitudinal study, Bluglass found that 7% of exhibitionists were later convicted of contact sexual offenses, including rape.
Genital exhibitionism is rare among women. This has been explained by the differences between the sexes in the development of the castration complex and the absence of a reassuring effect from showing a penis because of anatomic differences in women. Eber in a 1977 report and Kohut in a 1978 report view female exhibitionism as a disorder of bodily narcissism.
Presentation to physicians is common and may result from a sense of guilt and an inability to control the behavior. Sometimes the behavior is revealed as the result of a criminal offense. More serious underlying pathology is suggested when preferred scenes include defecation or small children.
Fetishism
The DSM-IV-TR lists the following diagnostic criteria for fetishism:
The patient experiences recurrent and intense sexual urges and sexually arousing fantasies involving the use of nonliving objects by themselves. Symptoms must be present for at least 6 months.
The patient experiences significant distress or impairment in social, occupational, or other important areas of functioning because of the fantasies, urges, or behaviors.
The fetishes are not limited to articles of female clothing used in cross-dressing (transvestic fetishism) or devices designed for genital stimulation (eg, vibrators).
Common fetishistic objects include female underwear; rubber, plastic, or leather garments; specific articles of clothing such as shoes or boots; and bodily items such as hair, odors, or feces. The disorder is more common among males than females. Prevalence is unknown. It can often be traced from adolescence and usually persists.
In the context of psychoanalytic theory, in a 1996 publication Greenacre associates fetishism with a severe castration complex in males and a more complicated and less readily recognized set of relational reactions in females. For men, the fetish serves a defensive function, a reinforcing adjunct for a penis of uncertain potency. The fetish serves to increase the efficiency of the penis, which does not perform well without it. In women, fetishism is less common, largely because of anatomic differences that allow women to conceal inadequate sexual response more readily than men. Women can develop symptoms more comparable to male fetishism when the illusion of having a phallus has gained sufficient strength to approach delusional proportions. This occurs in rare cases in which severe disturbances in the sense of reality exist.
Treatment of the specific condition (fetish), rather than the primary underlying disorder (eg, organic pathology, personality disorder) generally is unsuccessful. A variety of treatment approaches have been tried, such as aversive conditioning, cognitive therapy, and psychotherapy.
Frotteurism
The DSM-IV-TR lists the following diagnostic criteria for frotteurism:
The patient experiences intense, recurrent, sexual urges and sexually arousing fantasies involving touching and rubbing against a nonconsensual person. Symptoms must be present for at least 6 months.
The patient experiences significant distress or impairment in social, occupational, or other important areas of functioning because of the fantasies, urges, or behaviors, or the patient has acted on the sexual urges.
Frotteurs typically act out their fantasies in crowded places (eg, public transportation vehicles, busy sidewalks), which allows for escape; the frotteur can claim that the touching was accidental. The frotteur rubs his genital area against the (usually female) victim's thighs or buttocks, or the frotteur fondles a woman's genitalia or breasts with his hands. While committing the act, the offender typically fantasizes about an exclusive, caring relationship with the victim.
Most acts occur in perpetrators aged 15-25 years, after which frequency gradually declines. Frotteurism has been noted to be equally common among older, shy, inhibited individuals. Fantasies of frotteuristic behavior without action have been reported as a stimulant to sexual arousal.
Voyeurism
The term voyeurism, from the French word meaning to see, refers to the fairly common desire to view nudity and acts of coition. Differentiating innocent enjoyment of nudity from behavior that is similar but deviant in other circumstances can be difficult.
The DSM-IV-TR diagnostic criteria for voyeurism are as follows:
The patient has recurrent and intense sexual urges and sexually arousing fantasies involving the act of observing an unsuspecting person who is naked, in the process of disrobing, or engaging in sexual activity. Symptoms must be present for at least 6 months.
The patient experiences significant distress or impairment in social, occupational, or other important areas of functioning because of the fantasies, urges, or behaviors.
When severe, the act of peeping constitutes the exclusive form of sexual activity. Onset usually is in persons younger than 15 years, and the disorder tends to be chronic. The wide extent of voyeuristic tendencies in the general population is evidenced in the common desire to indulge in exploitative activities such as live shows and pornography.
Pedophilia
The essential features of this disorder as described by the DSM-IV-TR include the following:
The patient reports recurrent and intense sexually arousing fantasies, sexual urges, or behaviors involving sexual activity with a prepubescent child or children, generally aged 13 years or younger.
Pedophiles must be aged 16 years or older and be at least 5 years older than the victim.
The disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The clinician should specify if the person is attracted to males, females, or both; if the acts are limited to incest; and if the patient is attracted to children only (exclusive type) or both children and adults (nonexclusive type).
While female pedophiles are considered to be rare, discrepancies between the numbers of male and female offenders are tied to sexual stereotypes. Masculinity connotes sexual qualities, while femininity connotes maternal qualities and nurturance. When a female pets a child, she is nurturing. When a male pets a child, he is molesting. The majority of men who have had sexual contact with a woman when they were boys viewed it positively rather than negatively. Consequently, these acts were probably unreported. In one study, 16% of college males and 46% of prisoners reported having had sexual contact with older females, and half of the encounters involved intercourse. Mean age of males at the time of sexual contact was 12 years, and the females with whom they were involved were aged 20-30 years.
Many pedophiles have a personal history of unstable parent-child relationships as children and sexual abuse. The majority of pedophiles have a clear sexual preference. The undifferentiated or bisexual group accounts for only 5-25% of pedophiles. Most studies indicate that 60-90% of incidents of abuse involve girls.
Great variation exists among men who use children sexually. One third to one half prefer children as sexual partners. Others are attracted to children but act on their impulses only under stress. Some, who typically are younger than 30 years, are sociosexually underdeveloped, lack age-appropriate experience, and have feelings of shyness and inferiority. Unable to attain adult female contact, they continue prepubescent sexual patterns. Amoral delinquent youths (younger than pedophiles proper), lacking control when aroused, use whoever is close at hand. Patients with the situational type of pedophilia have no special preference for children, although they have sexual contact with children because of convenience or coincidence. Contact typically is brief and nonrecurrent. A residual category of offenders includes people with mental retardation, psychosis, alcoholism, senility, or dementia.
Approximately 37% of sexual assault victims reported to law enforcement agencies were juveniles ( <18 y); 34% of all victims were younger than 12 years. One in 7 victims is younger than 6 years. Forty percent of offenders who victimized children younger than 6 years were juveniles ( <18 y).
Sexual masochism
The essential features of this disorder as described by the DSM-IV-TR include the following:
The patient reports recurrent and intense sexual urges and sexually arousing fantasies involving the act (real, not simulated) of being humiliated, beaten, bound, or otherwise made to suffer. Symptoms must be present for at least 6 months.
The fantasies, urges, or behaviors cause significant distress or impairment in social, occupational, or other important areas of functioning.
Masochistic acts commonly involve a wide range of activities, such as restraint, blindfolding, beating, electrical shock, cutting, piercing, and humiliation (eg, being urinated or defecated on, forced to bark, verbally abused, forced to cross-dress). Some sexual masochists inflict pain through self-mutilation, and some engage in group activity or use services provided by prostitutes.
Hypoxyphilia is a dangerous form of masochism that involves sexual arousal by oxygen deprivation achieved by means of chest compression, noose, ligature, plastic bag, mask, or chemicals. Oxygen deprivation may be accomplished alone or with a partner. Data from the United States, England, Australia, and Canada indicate that 1-2 deaths per million population are reported each year.
Some sexually masochistic males also exhibit fetishism, transvestic fetishism, or sexual sadism. Masochistic sexual fantasies are likely present in childhood. Masochistic activities commonly begin by early adulthood, tend to be chronic, and the same act is generally repeated. Some individuals increase the severity of the act over time, which may lead to injury or death.
In 1926, Sadger observed a common association between homosexuality and masochism. In a 1977 report, Spengler found that 38% of exclusive homosexuals were sadomasochists, which provides some support for Sadger's observation.
Ritualized behavior is a noted feature of masochistic scenes; the slightest deviation from the script may result in failure to achieve the desired result. This feature is also viewed as a mechanism through which the masochist maintains control.
Sexual sadism
The DSM-IV-TR diagnostic criteria for sexual sadism are as follows:
The patient reports recurrent and intense sexual urges and sexually arousing fantasies involving the act (real, not simulated) in which the psychological or physical suffering (including humiliation) of one person is sexually arousing to another person. Symptoms must be present for at least 6 months.
The fantasies, urges, or behaviors cause significant distress or impairment in social, occupational, or other important areas of functioning.
Sadistic fantasies or acts may involve activities such as dominance, restraint, blindfolding, beating, pinching, burning, electrical shock, rape, cutting, stabbing, strangulation, torture, mutilation, or killing. Sadistic sexual fantasies are likely present in childhood. Onset of sadistic activities commonly occurs by early adulthood, and it tends to be chronic.
Some individuals do not increase the severity of their sadistic acts; however, severity of the sadistic acts does usually increase over time. When practiced with nonconsenting partners, the activity is likely to be repeated until the perpetrator is apprehended. When sexual sadism is severe and associated with antisocial personality disorder, victims may be seriously injured or killed.
No clear lines divide sexual sadism and sexual masochism, and the predispositions are often interchangeable. The conditions may coexist in the same individual, sometimes in association with other paraphilias. This relationship is supported by the finding that those who entertain masochistic fantasies also engage in sadistic fantasies. In the context of psychoanalytic theory, Panken in a 1973 publication does not find that the conditions coexist in an individual and claims that the dynamics are different.
Transvestic fetishism
Transvestic fetishism is defined by DSM-IV-TR diagnostic criteria as follows:
The patient is a heterosexual male who has recurrent, intense, sexually arousing fantasies, urges, or behaviors involving cross-dressing. Symptoms must be present for at least 6 months.
These fantasies, urges, or behaviors cause significant distress or impairment in social, occupational, or other important areas of functioning.
If gender dysphoria is present, it should be specified.
Fetishistic transvestism is essentially unheard of in females. Women may cross-dress, but no literature (English) describes cross-dressing females who become sexually excited by the activity.
Other paraphilias
Sexual arousal may be obtained from a wide array of additional behaviors. Some are provided with the assistance of prostitutes, others find willing partners when needed. Other paraphilias include the following:
Scatologia (obscene phone calls)
Necrophilia (corpses)
Partialism (exclusive focus on part of body)
Zoophilia (animals)
Coprophilia (feces)
Klismaphilia (enemas)
Urophilia (urine)
Read more HERE
Showing posts with label psychiatry. Show all posts
Showing posts with label psychiatry. Show all posts
Friday, 1 August 2008
Thursday, 26 June 2008
Cor pulmonale
Cor pulmonale is defined as an alteration in the structure and function of the right ventricle caused by a primary disorder of the respiratory system. Pulmonary hypertension is the common link between lung dysfunction and the heart in cor pulmonale. Right-sided ventricular disease caused by a primary abnormality of the left side of the heart or congenital heart disease is not considered cor pulmonale, but cor pulmonale can develop secondary to a wide variety of cardiopulmonary disease processes. Although cor pulmonale commonly has a chronic and slowly progressive course, acute onset or worsening cor pulmonale with life-threatening complications can occur.
Pathophysiology: Several different pathophysiologic mechanisms can lead to pulmonary hypertension and, subsequently, to cor pulmonale. These pathogenetic mechanisms include (1) pulmonary vasoconstriction due to alveolar hypoxia or blood acidemia; (2) anatomic compromise of the pulmonary vascular bed secondary to lung disorders, eg, emphysema, pulmonary thromboembolism, interstitial lung disease; (3) increased blood viscosity secondary to blood disorders, eg, polycythemia vera, sickle cell disease, macroglobulinemia; and (4) idiopathic primary pulmonary hypertension. The result is increased pulmonary arterial pressure.
The right ventricle (RV) is a thin-walled chamber that is more a volume pump than a pressure pump. It adapts better to changing preloads than afterloads. With an increase in afterload, the RV increases systolic pressure to keep the gradient. At a point, further increase in the degree of pulmonary arterial pressure brings significant RV dilation, an increase in RV end-diastolic pressure, and circulatory collapse. A decrease in RV output with a decrease in diastolic left ventricle (LV) volume results in decreased LV output. Since the right coronary artery, which supplies the RV free wall, originates from the aorta, decreased LV output diminishes blood pressure in the aorta and decreases right coronary blood flow. This is a vicious cycle between decreases in LV and RV output.
Right ventricular overload is associated with septal displacement toward the left ventricle. Septal displacement, which is seen in echocardiography, can be another factor that decreases LV volume and output in the setting of cor pulmonale and right ventricular enlargement. Several pulmonary diseases cause cor pulmonale, which may involve interstitial and alveolar tissues with a secondary effect on pulmonary vasculature or may primarily involve pulmonary vasculature. Chronic obstructive pulmonary disease (COPD) is the most common cause of cor pulmonale in the United States.
Cor pulmonale usually presents chronically, but 2 main conditions can cause acute cor pulmonale: massive pulmonary embolism (more common) and acute respiratory distress syndrome (ARDS). The underlying pathophysiology in massive pulmonary embolism causing cor pulmonale is the sudden increase in pulmonary resistance. In ARDS, 2 factors cause RV overload: the pathologic features of the syndrome itself and mechanical ventilation. Mechanical ventilation, especially higher tidal volume, requires a higher transpulmonary pressure. In chronic cor pulmonale, right ventricular hypertrophy (RVH) generally predominates. In acute cor pulmonale, right ventricular dilatation mainly occurs.
Frequency:
In the US: Cor pulmonale is estimated to account for 6-7% of all types of adult heart disease in the United States, with chronic obstructive pulmonary disease (COPD) due to chronic bronchitis or emphysema the causative factor in more than 50% of cases. Although the prevalence of COPD in the United States is about 15 million, the exact prevalence of cor pulmonale is difficult to determine because it does not occur in all cases of COPD and the physical examination and routine tests are relatively insensitive for the detection of pulmonary hypertension. In contrast, acute cor pulmonale usually is secondary to massive pulmonary embolism. Acute massive pulmonary thromboembolism is the most common cause of acute life-threatening cor pulmonale in adults. In the United States, 50,000 deaths are estimated to occur per year from pulmonary emboli and about half occur within the first hour due to acute right heart failure.
Internationally: Incidence of cor pulmonale varies among different countries depending on the prevalence of cigarette smoking, air pollution, and other risk factors for various lung diseases.
Mortality/Morbidity: Development of cor pulmonale as a result of a primary pulmonary disease usually heralds a poorer prognosis. For example, patients with COPD who develop cor pulmonale have a 30% chance of surviving 5 years. However, whether cor pulmonale carries an independent prognostic value or it is simply reflecting the severity of underlying COPD or other pulmonary disease is not clear. Prognosis in the acute setting due to massive pulmonary embolism or ARDS has not been shown to be dependent on presence or absence of cor pulmonale.
Pathophysiology: Several different pathophysiologic mechanisms can lead to pulmonary hypertension and, subsequently, to cor pulmonale. These pathogenetic mechanisms include (1) pulmonary vasoconstriction due to alveolar hypoxia or blood acidemia; (2) anatomic compromise of the pulmonary vascular bed secondary to lung disorders, eg, emphysema, pulmonary thromboembolism, interstitial lung disease; (3) increased blood viscosity secondary to blood disorders, eg, polycythemia vera, sickle cell disease, macroglobulinemia; and (4) idiopathic primary pulmonary hypertension. The result is increased pulmonary arterial pressure.
The right ventricle (RV) is a thin-walled chamber that is more a volume pump than a pressure pump. It adapts better to changing preloads than afterloads. With an increase in afterload, the RV increases systolic pressure to keep the gradient. At a point, further increase in the degree of pulmonary arterial pressure brings significant RV dilation, an increase in RV end-diastolic pressure, and circulatory collapse. A decrease in RV output with a decrease in diastolic left ventricle (LV) volume results in decreased LV output. Since the right coronary artery, which supplies the RV free wall, originates from the aorta, decreased LV output diminishes blood pressure in the aorta and decreases right coronary blood flow. This is a vicious cycle between decreases in LV and RV output.
Right ventricular overload is associated with septal displacement toward the left ventricle. Septal displacement, which is seen in echocardiography, can be another factor that decreases LV volume and output in the setting of cor pulmonale and right ventricular enlargement. Several pulmonary diseases cause cor pulmonale, which may involve interstitial and alveolar tissues with a secondary effect on pulmonary vasculature or may primarily involve pulmonary vasculature. Chronic obstructive pulmonary disease (COPD) is the most common cause of cor pulmonale in the United States.
Cor pulmonale usually presents chronically, but 2 main conditions can cause acute cor pulmonale: massive pulmonary embolism (more common) and acute respiratory distress syndrome (ARDS). The underlying pathophysiology in massive pulmonary embolism causing cor pulmonale is the sudden increase in pulmonary resistance. In ARDS, 2 factors cause RV overload: the pathologic features of the syndrome itself and mechanical ventilation. Mechanical ventilation, especially higher tidal volume, requires a higher transpulmonary pressure. In chronic cor pulmonale, right ventricular hypertrophy (RVH) generally predominates. In acute cor pulmonale, right ventricular dilatation mainly occurs.
Frequency:
In the US: Cor pulmonale is estimated to account for 6-7% of all types of adult heart disease in the United States, with chronic obstructive pulmonary disease (COPD) due to chronic bronchitis or emphysema the causative factor in more than 50% of cases. Although the prevalence of COPD in the United States is about 15 million, the exact prevalence of cor pulmonale is difficult to determine because it does not occur in all cases of COPD and the physical examination and routine tests are relatively insensitive for the detection of pulmonary hypertension. In contrast, acute cor pulmonale usually is secondary to massive pulmonary embolism. Acute massive pulmonary thromboembolism is the most common cause of acute life-threatening cor pulmonale in adults. In the United States, 50,000 deaths are estimated to occur per year from pulmonary emboli and about half occur within the first hour due to acute right heart failure.
Internationally: Incidence of cor pulmonale varies among different countries depending on the prevalence of cigarette smoking, air pollution, and other risk factors for various lung diseases.
Mortality/Morbidity: Development of cor pulmonale as a result of a primary pulmonary disease usually heralds a poorer prognosis. For example, patients with COPD who develop cor pulmonale have a 30% chance of surviving 5 years. However, whether cor pulmonale carries an independent prognostic value or it is simply reflecting the severity of underlying COPD or other pulmonary disease is not clear. Prognosis in the acute setting due to massive pulmonary embolism or ARDS has not been shown to be dependent on presence or absence of cor pulmonale.
Sunday, 1 June 2008
Alcoholism
Alcoholism is common, serious, and expensive. Physicians encounter alcohol-related cirrhosis, cardiomyopathy, pancreatitis, and gastrointestinal bleeding, as well as intoxication and alcohol addiction, on a daily basis. Alcoholism is also associated with many cancers. Wernicke encephalopathy and Korsakoff psychosis are also important causes of chronic disability as well as dementia. Fetal alcohol syndrome is a leading cause of mental retardation. In addition, accidents (especially automobile), depression, dementia, suicide, and homicide are important consequences of alcoholism.
Alcohol-related diseases are discussed in separate articles. The focus of this article is screening, diagnosis, treatment, and new research findings on the natural history and heritability of alcoholism.
Pathophysiology
Alcohol affects virtually every organ system in the body and, in high doses, can cause coma and death. It affects several neurotransmitter systems in the brain, including opiates, GABA, glutamate, serotonin, and dopamine. Increased opiate levels help explain the euphoric effect of alcohol, while its effects on GABA cause anxiolytic and sedative effects.
Alcohol inhibits the receptor for glutamate. Long-term ingestion results in the synthesis of more glutamate receptors. When alcohol is withdrawn, the central nervous system experiences increased excitability. Persons who abuse alcohol over the long term are more prone to alcohol withdrawal syndrome than persons who have been drinking for only short periods. Brain excitability caused by long-term alcohol ingestion can lead to cell death and cerebellar degeneration, Wernicke-Korsakoff syndrome, tremors, alcoholic hallucinosis, delirium tremens, and withdrawal seizures. Opiate receptors are increased in the brains of recently abstinent alcoholic patients, and the number of receptors correlates with cravings for alcohol.
Frequency
United States
These statistics are based on the US National Longitudinal Alcohol Epidemiologic Study. Alcoholism is prevalent in 20% of adult hospital inpatients. One in 6 patients in community-based primary care practices had problem drinking. The following apply to the US adult population:
Current drinkers - 44%
Former drinkers - 22%
Lifetime abstainers - 34%
Abuse and dependency in the past year - 7.5-9.5%
Lifetime prevalence - 13.5-23.5%
Alcoholism is slightly more common in lower income and less educated groups. Vaillant studied the natural history of alcoholism and the differences between college-educated and inner-city alcoholic persons. He followed 2 cohorts (over 400 patients) of alcoholic patients over many years.1
According to Vaillant's research, inner-city men began problem drinking approximately 10 years earlier than college graduates (age 25-30 y vs age 40-45 y). Inner-city men were more likely to be abstinent from alcohol consumption than college graduates (30% vs 10%) but more likely to die from drinking (30% vs 15%). A large percentage of college graduates alternated between controlled drinking and alcohol abuse for many years. Returning to controlled drinking from alcohol abuse is uncommon, no more than 10%; however, this figure is likely to be high because it was obtained from self-reported data. Mortality in both groups was related strongly to smoking. Abstinence for less than 5-6 years did not predict continued abstinence (41% of men abstinent for 2 y relapsed).
International
The World Health Organization examined mental disorders in primary care offices and found that alcohol dependence or harmful use was present in 6% of patients. In Britain, 1 in 3 patients in community-based primary care practices had at-risk drinking behavior. Alcoholism is more common in France than it is in Italy, despite virtually identical per capita alcohol consumption.
Mortality/Morbidity
Alcohol use is the third leading cause of preventable death in the United States (after smoking and obesity). Annually, 85,000 deaths are attributable to alcohol at a cost of $185 billion.2, 3 Almost half of these deaths are attributable to alcohol-related injury.
Four percent of the global burden of disease is attributable to alcohol. This figure rises to 7% in North America, Europe, Japan, and Australia and to 12% in Eastern Europe and Central Asia. Worldwide, alcohol is responsible for a percentage of a number of conditions, as follows:
Cirrhosis - 32%
Motor vehicle accidents - 20%
Mouth and oropharyngeal cancers - 19%
Esophageal cancer - 29%
Liver cancer - 25%
Breast cancer - 7%
Homicide - 24%
Suicide - 11%
Hemorrhagic stroke - 10%
Below are the statistically significant relative risks from a study by the American Cancer Society for men and women who consume 4 or more drinks daily. A drink is defined as one 12-oz beer, one 4- to 5-oz glass of wine, or one mixed drink containing 1.5 oz of spirits (80 proof). The relative risk for the noted maladies with consumption of 4 or more drinks daily is as follows:
Cirrhosis - For men, 7.5; for women, 4.8
Injuries - For men, 1.3
Ear, nose, and throat cancer; esophagus cancer; liver cancer - For men, 2.8; for women, 3
Moderate alcohol consumption (1-2 drinks/d) reduces the risk of cardiovascular disease in men and women by approximately 30%.4, 5, 6 The effect of heavy alcohol consumption on the risk of cardiovascular disease varies in different studies. The person's drinking pattern appears to have an effect on cardiovascular disease. Drinking with meals may reduce the risk, while binge drinking increases risk (even in otherwise moderate drinkers).
Moderate alcohol consumption appears to increase the risk of breast cancer in women. Total mortality is reduced with moderate alcohol consumption but not with heavy alcohol consumption; the cardiovascular benefit is offset by cirrhosis, cancer, and injuries. The amount of alcohol associated with the lowest mortality appears to be 2 drinks per day in men and 1 drink or fewer per day in women. Moderate alcohol consumption reduces the risk of developing diabetes, but heavy alcohol consumption may increase the risk. The cardiovascular benefit becomes important in men older than 40 years and in women older than 50 years. The risk of hypertension is increased with 3 or more drinks daily.
No benefits are noted in people at low risk for coronary disease (men <40 name="refsrc7">7 This effect was exacerbated by binge drinking.
Of men aged 18-25 years, 60% binge drink. (Binge drinking is defined as 5 alcoholic drinks for men [4 for women] in a row.) Binge drinking significantly increases the risk of injury and contracting sexually transmitted diseases. Women who binge drink at this age are at higher risk of becoming pregnant and potentially harming an unborn child. (Any amount of alcohol consumption during pregnancy is risky.)
More than three quarters of all foster children in the United States are children of alcohol- or drug-dependent parents. From 60-70% of reported domestic violence incidents involve alcohol. Half of all violent crime is alcohol or drug related.
Overall, morbidity and mortality are related strongly to smoking, and people who drink heavily are less likely to quit smoking. Additionally, persons who begin smoking early are more likely to develop problems with alcohol.
With regard to pregnancy, fetal alcohol syndrome is the leading known cause of mental retardation (1 in 1000 births). More than 2000 infants annually are born with this condition in the United States. Alcohol-related birth defects and neurodevelopmental problems are estimated to be 3 times higher. Even small amounts of alcohol consumption may be risky in pregnancy. A 2001 study by Sood et al reported that children aged 6-7 years whose mothers consumed alcohol even in small amounts had more behavioral problems.8 In a study from 2003, Baer et al showed that moderate alcohol consumption while pregnant resulted in a higher incidence of offspring problem drinking at age 21 years, even after controlling for family history and other environmental factors.9 All women who are pregnant or planning to become pregnant should avoid alcohol.
Race
The 2 largest studies, the US National Comorbidity Survey and the Epidemiologic Catchment Area Survey, both showed a lower prevalence of alcoholism in African Americans than in white Americans. The prevalence was equal or higher in Hispanic Americans compared with white Americans.
Studies of Native Americans and Asian Americans are smaller. These studies indicate the prevalence of alcoholism is higher in Native Americans and lower in Asian Americans when compared with white Americans.
Sex
Alcoholism is at least twice as prevalent in men as it is in women. In the National Comorbidity Survey, it was 2.5 times more prevalent in men than in women. The lifetime prevalence was 20% in men and 8% in women. For alcohol abuse or dependence in the past year, the rates were 10% for men and 4% for women.
Women do not metabolize alcohol as efficiently as men. Hazardous drinking (not alcoholism) is greater than 1 drink daily for women and greater than 2 drinks daily for men.
Problem drinking in women is much less common than it is in men, and the typical onset of problem drinking in females occurs later than in males. However, progression is more rapid, and females usually enter treatment earlier than males. Women more commonly combine alcohol with prescription drugs of abuse than do males. Women living with substance-abusing men are at high risk.
Alcohol problems are less likely to be recognized in women, and women with alcohol problems are less likely to be treated. This may be because women are less likely than men to have job, financial, or legal troubles as a result of drinking.
Age
The prevalence of alcoholism declines with increasing age. The prevalence in elderly populations is unclear but is probably approximately 3%. A study of the US Medicare population found that alcohol-related hospitalizations were as common as hospitalizations for myocardial infarction.
Among older patients with alcoholism, from one third to one half develop alcoholism after age 60 years. This group is harder to recognize. A recent population-based study found that problem drinking (>3 drinks/d) was observed in 9% of older men and in 2% of older women. Alcohol levels are higher in elderly patients for a given amount of alcohol consumed than in younger patients.
Read for more HERE
Alcohol-related diseases are discussed in separate articles. The focus of this article is screening, diagnosis, treatment, and new research findings on the natural history and heritability of alcoholism.
Pathophysiology
Alcohol affects virtually every organ system in the body and, in high doses, can cause coma and death. It affects several neurotransmitter systems in the brain, including opiates, GABA, glutamate, serotonin, and dopamine. Increased opiate levels help explain the euphoric effect of alcohol, while its effects on GABA cause anxiolytic and sedative effects.
Alcohol inhibits the receptor for glutamate. Long-term ingestion results in the synthesis of more glutamate receptors. When alcohol is withdrawn, the central nervous system experiences increased excitability. Persons who abuse alcohol over the long term are more prone to alcohol withdrawal syndrome than persons who have been drinking for only short periods. Brain excitability caused by long-term alcohol ingestion can lead to cell death and cerebellar degeneration, Wernicke-Korsakoff syndrome, tremors, alcoholic hallucinosis, delirium tremens, and withdrawal seizures. Opiate receptors are increased in the brains of recently abstinent alcoholic patients, and the number of receptors correlates with cravings for alcohol.
Frequency
United States
These statistics are based on the US National Longitudinal Alcohol Epidemiologic Study. Alcoholism is prevalent in 20% of adult hospital inpatients. One in 6 patients in community-based primary care practices had problem drinking. The following apply to the US adult population:
Current drinkers - 44%
Former drinkers - 22%
Lifetime abstainers - 34%
Abuse and dependency in the past year - 7.5-9.5%
Lifetime prevalence - 13.5-23.5%
Alcoholism is slightly more common in lower income and less educated groups. Vaillant studied the natural history of alcoholism and the differences between college-educated and inner-city alcoholic persons. He followed 2 cohorts (over 400 patients) of alcoholic patients over many years.1
According to Vaillant's research, inner-city men began problem drinking approximately 10 years earlier than college graduates (age 25-30 y vs age 40-45 y). Inner-city men were more likely to be abstinent from alcohol consumption than college graduates (30% vs 10%) but more likely to die from drinking (30% vs 15%). A large percentage of college graduates alternated between controlled drinking and alcohol abuse for many years. Returning to controlled drinking from alcohol abuse is uncommon, no more than 10%; however, this figure is likely to be high because it was obtained from self-reported data. Mortality in both groups was related strongly to smoking. Abstinence for less than 5-6 years did not predict continued abstinence (41% of men abstinent for 2 y relapsed).
International
The World Health Organization examined mental disorders in primary care offices and found that alcohol dependence or harmful use was present in 6% of patients. In Britain, 1 in 3 patients in community-based primary care practices had at-risk drinking behavior. Alcoholism is more common in France than it is in Italy, despite virtually identical per capita alcohol consumption.
Mortality/Morbidity
Alcohol use is the third leading cause of preventable death in the United States (after smoking and obesity). Annually, 85,000 deaths are attributable to alcohol at a cost of $185 billion.2, 3 Almost half of these deaths are attributable to alcohol-related injury.
Four percent of the global burden of disease is attributable to alcohol. This figure rises to 7% in North America, Europe, Japan, and Australia and to 12% in Eastern Europe and Central Asia. Worldwide, alcohol is responsible for a percentage of a number of conditions, as follows:
Cirrhosis - 32%
Motor vehicle accidents - 20%
Mouth and oropharyngeal cancers - 19%
Esophageal cancer - 29%
Liver cancer - 25%
Breast cancer - 7%
Homicide - 24%
Suicide - 11%
Hemorrhagic stroke - 10%
Below are the statistically significant relative risks from a study by the American Cancer Society for men and women who consume 4 or more drinks daily. A drink is defined as one 12-oz beer, one 4- to 5-oz glass of wine, or one mixed drink containing 1.5 oz of spirits (80 proof). The relative risk for the noted maladies with consumption of 4 or more drinks daily is as follows:
Cirrhosis - For men, 7.5; for women, 4.8
Injuries - For men, 1.3
Ear, nose, and throat cancer; esophagus cancer; liver cancer - For men, 2.8; for women, 3
Moderate alcohol consumption (1-2 drinks/d) reduces the risk of cardiovascular disease in men and women by approximately 30%.4, 5, 6 The effect of heavy alcohol consumption on the risk of cardiovascular disease varies in different studies. The person's drinking pattern appears to have an effect on cardiovascular disease. Drinking with meals may reduce the risk, while binge drinking increases risk (even in otherwise moderate drinkers).
Moderate alcohol consumption appears to increase the risk of breast cancer in women. Total mortality is reduced with moderate alcohol consumption but not with heavy alcohol consumption; the cardiovascular benefit is offset by cirrhosis, cancer, and injuries. The amount of alcohol associated with the lowest mortality appears to be 2 drinks per day in men and 1 drink or fewer per day in women. Moderate alcohol consumption reduces the risk of developing diabetes, but heavy alcohol consumption may increase the risk. The cardiovascular benefit becomes important in men older than 40 years and in women older than 50 years. The risk of hypertension is increased with 3 or more drinks daily.
No benefits are noted in people at low risk for coronary disease (men <40 name="refsrc7">7 This effect was exacerbated by binge drinking.
Of men aged 18-25 years, 60% binge drink. (Binge drinking is defined as 5 alcoholic drinks for men [4 for women] in a row.) Binge drinking significantly increases the risk of injury and contracting sexually transmitted diseases. Women who binge drink at this age are at higher risk of becoming pregnant and potentially harming an unborn child. (Any amount of alcohol consumption during pregnancy is risky.)
More than three quarters of all foster children in the United States are children of alcohol- or drug-dependent parents. From 60-70% of reported domestic violence incidents involve alcohol. Half of all violent crime is alcohol or drug related.
Overall, morbidity and mortality are related strongly to smoking, and people who drink heavily are less likely to quit smoking. Additionally, persons who begin smoking early are more likely to develop problems with alcohol.
With regard to pregnancy, fetal alcohol syndrome is the leading known cause of mental retardation (1 in 1000 births). More than 2000 infants annually are born with this condition in the United States. Alcohol-related birth defects and neurodevelopmental problems are estimated to be 3 times higher. Even small amounts of alcohol consumption may be risky in pregnancy. A 2001 study by Sood et al reported that children aged 6-7 years whose mothers consumed alcohol even in small amounts had more behavioral problems.8 In a study from 2003, Baer et al showed that moderate alcohol consumption while pregnant resulted in a higher incidence of offspring problem drinking at age 21 years, even after controlling for family history and other environmental factors.9 All women who are pregnant or planning to become pregnant should avoid alcohol.
Race
The 2 largest studies, the US National Comorbidity Survey and the Epidemiologic Catchment Area Survey, both showed a lower prevalence of alcoholism in African Americans than in white Americans. The prevalence was equal or higher in Hispanic Americans compared with white Americans.
Studies of Native Americans and Asian Americans are smaller. These studies indicate the prevalence of alcoholism is higher in Native Americans and lower in Asian Americans when compared with white Americans.
Sex
Alcoholism is at least twice as prevalent in men as it is in women. In the National Comorbidity Survey, it was 2.5 times more prevalent in men than in women. The lifetime prevalence was 20% in men and 8% in women. For alcohol abuse or dependence in the past year, the rates were 10% for men and 4% for women.
Women do not metabolize alcohol as efficiently as men. Hazardous drinking (not alcoholism) is greater than 1 drink daily for women and greater than 2 drinks daily for men.
Problem drinking in women is much less common than it is in men, and the typical onset of problem drinking in females occurs later than in males. However, progression is more rapid, and females usually enter treatment earlier than males. Women more commonly combine alcohol with prescription drugs of abuse than do males. Women living with substance-abusing men are at high risk.
Alcohol problems are less likely to be recognized in women, and women with alcohol problems are less likely to be treated. This may be because women are less likely than men to have job, financial, or legal troubles as a result of drinking.
Age
The prevalence of alcoholism declines with increasing age. The prevalence in elderly populations is unclear but is probably approximately 3%. A study of the US Medicare population found that alcohol-related hospitalizations were as common as hospitalizations for myocardial infarction.
Among older patients with alcoholism, from one third to one half develop alcoholism after age 60 years. This group is harder to recognize. A recent population-based study found that problem drinking (>3 drinks/d) was observed in 9% of older men and in 2% of older women. Alcohol levels are higher in elderly patients for a given amount of alcohol consumed than in younger patients.
Read for more HERE
Subscribe to:
Posts (Atom)
