Alcoholic psychoses (Greek psychz — soul, state of mind + - osis) — the disorders of mental activity developing as a result of long-term abuse of alcoholic drinks. Several years prior to emergence And. items at the patient appear all or almost all manifestations of a syndrome of narkomanichesky dependence — the changed tolerance, a syndrome of a hangover, etc. (see. Alcoholism , alcoholism , Drug addiction ) and very often characteristic changes of the personality. To emergence And. the item are promoted by somatic diseases, injuries, avitaminosis. As And. items, as a rule, do not arise in an ebrietas, treat them as metalkogolny psychoses.
Distinguish the following groups of alcoholic psychoses: tremens; alcoholic hallucinosis; alcoholic crazy psychoses; structurally difficult and atypical And. item; alcoholic encephalopathies (see). Besides, to And. items carry alcoholic epilepsy, an alcoholic depression, a dipsomania and pathological intoxication. K A. the item can carry and those mixed cases at which symptomatology And. the item arises against the background of other mental diseases.
- 1 The historical sketch
- 2 The clinical picture
- 2.1 the Tremens
- 2.2 Alcoholic hallucinosis
- 2.3 Alcoholic crazy psychoses
- 2.4 Structurally difficult alcoholic psychoses
- 2.5 Atypical alcoholic psychoses
- 2.6 The alcoholic psychoses arising at a combination of alcoholism to other mental diseases
- 2.7 An alcoholic depression
- 2.8 Alcoholic epilepsy
- 2.9 Alcoholic encephalopathies
- 2.10 Pathological intoxication
- 2.11 A dipsomania
- 3 The pathogeny and pathological anatomy
- 4 The diagnosis and the differential diagnosis
- 5 Forecast
- 6 Treatment
- 7 Prevention
- 8 Value of alcoholic psychoses in forensic-psychiatric practice
- 9 Bibliography
The historical sketch
the Tremens under the name delirium tremens is for the first time described by Sutton (T. Sutton) in 1813. The alcoholic etiology of psychosis was established to Rayer in 1818. Patterns of development of a tremens, its symptomatology and the main forms were studied by V. Magnan, Laseg (S. Lasegue), Rose, Bongeffer (To, Bonhoeffer), Krepelin (E. Kraepelin), S. S. Korsakov.
The French psychiatrists use the term «delirium tremens» for from designation of the most serious conditions which are followed by a considerable hyperthermia, and easy and moderately severe deliriums designate as attacks confusingly-snovidnogo stupefactions. In domestic and German literature under the name delirium tremens (delirium tremens, a tremens) are described various on weight and complexity of symptomatology And. the items which are followed by the expressed stupefaction.
Alcoholic hallucinosis is described in 1847 by Marseille (Marcel). The term «alcoholic hallucinosis» accepted in the German and domestic psychiatry was offered in 1900 Mr. of Vernike (S. to Wernicke). The clinic of acute and chronic alcoholic gallyutsinoz received the fullest reflection in Bongeffer, F. Meggendorfer, Krepelin, S. A. Sukhanov, I. N. Vvedensky and S. G. Zhislin's works. The delirium tremens of prosecution (acute alcoholic paranoid) under the name a delirium tremens was described by N. P. Tyapugiiy in 1914 who noted lack of illusions and hallucinations, communication of psychosis with the termination of hard drinking. Since 1949 psychosis was described by M. O. Gurevich and other domestic psychiatrists.
The clinical picture
the Tremens (delirium tremens, delirium tremens) usually develops in the first days or even in the next few hours after the termination of multi-day alcohol intake. To the first attack of a delirium (see. Delirious syndrome ), as a rule, the long period of an alcohol abuse precedes, repeated psychoses can arise also after shorter hard drinkings. A stage of harbingers of delirium tremens is the syndrome of a hangover weighted in the manifestations (see. alcoholism ). Most often psychosis develops at height of a hangover, is more rare at a stage of its involution.
In the beginning there is a fussiness, haste of movements, variability of mood. The attention at the patient unstable, it easily distracts, orientation in time, a situation, a situation is broken from time to time. There are flows of thoughts, figurative memoirs, then illusions and hallucinations. Delirium tremens can begin one or a series of convulsive attacks, flow acoustical about hallucinations, a figurative persecution complex. At the beginning of development of a delirium visual hallucinations, sometimes scenic, can be combined with safe orientation in a situation. During the deepening of a delirium there is a false orientation in a situation, but orientation in the personality remains. The behavior of the patient depends on the content of deception of perception: patients expel from the room of rats, cats, devils, trample down snakes, catch and find the hidden dwarfs somewhere. Emergence of images is followed by bright affects of surprise, a protest, curiosity. The combination of fear to rough humour is characteristic. In certain cases acoustical join visual hallucinations, there is a sensual persecution complex, sorcery, jealousy. With development of a delirium of a hallucination become various (in addition to visual, there are auditory, thermal, vestibular, tactile hallucinations, including and hallucinations of an oral cavity and the general feeling), there are paresthesias, disturbances of the scheme bodies (see).
At abundance of hallucinations patients shake from themselves threads, pull something from a mouth, dump from a body of insects and animals, complain of the flowing water or the sand pouring in eyes, wave away from the attacking animals.
At concentration the interlocutor of attention of patients, e.g. on their biographic data, hallucinations for a while disappear. Patients easily respond to the content of the conversation which is conducted at their presence, insert the notes. Appropriate questions easily possible to cause false recognitions and to inspire deception of feelings. So, having heard the offer to read, the patient sees the printed words (Reykhardt's symptom) on the clean sheet of paper; vividly speaks «by phone» if to give the receiver (a symptom of Ashaffenburga) which is switched-off from the device in hands; during the pressing on the closed eyes and provocative questions «sees» animals, people, insects (Lipmann's symptom). People around patients take for the acquaintances, answer questions quickly, hasty, without noticing inconsistency and rough contradictions in the statements, many of which differ in extreme absurd. Own answers and the fact of a conversation very quickly forget. From time to time the abundance of deception of perception decreases, into the forefront false orientation in the place and time, fussy or hyperkinetic excitement acts. Patients are busy with something all the time, fuss, aim to go somewhere, make orders, appeal, agree with imaginary interlocutors about a meeting, alcohol intake, «load goods», count «money» (a professional delirium).
Duration of a delirium seldom exceeds 3 — 4 days. Deception of perception and disturbance of orientation most often disappear after an hours-long dream. The maintenance of a delirium amnezirutsya partially. After clearing of consciousness the short-term period of an adynamy is noted. Sometimes within several days there is no critical relation to a part of delirious frustration (residual nonsense).
The following somatoneurologic symptomatology is typical for a tremens: absolute sleeplessness, perspiration, tachycardia, fluctuations of arterial pressure, tremor of hands, heads, all body, ataxy, hypomyotonia, hyperreflexia, reflexes of oral automatism, sometimes horizontal nystagmus, weakness of convergence of eyeglobes.
In time a delirium at the patient often find the following somatic frustration: increase in a liver, a dark brown fur, quite often easy yellowness of scleras, increase in blood of bilirubin and cholesterol, a leukocytosis and shift in a leykogramma to the left, acceleration of ROE, hypochromia anemia; subfebrile temperature is characteristic.
Except the described classical picture, distinguish some more options of delirium tremens.
The abortal delirium lasts several hours, emergence of hallucinations is not followed by disturbance of orientation.
At gipnagogichesky (arising during the backfilling) deliriums the maintenance of dreams reminds a delirium (participation of animals, adventurous and adventure subject of scenes of prosecution, a pursuit, rescue). After awakening critical evaluation of dreams appears not at once, and during nek-ry time the wrong behavior is noted. Sometimes the gipnagogichesky delirium precedes for several days to the developed picture of delirium tremens.
«The delirium without delirium» [A. Dollken] proceeds without deception of perception and nonsense, but with a disorientation and fussy excitement. The state reminds that, a cut is observed at usual Deliriums when deception of perception for a while disappears.
At systematized deliriums prevail the stsenopodobny visual hallucinations forming content of consistently developing, dangerous or amusing, but deprived of scale events. Usually it is scenes of prosecution, flight, pleasant events are much more rare. Depth of stupefaction insignificant, quite often remains partial orientation in the place and time. After clearing of consciousness the residual nonsense can keep several days.
The combination of the systematized hallucinatory nonsense to the expressed disorder of consciousness is characteristic of a delirium with dominance of auditory hallucinations. Depth of stupefaction constantly fluctuates, from time to time the state approaches hallucinosis. Looking alike the last is especially considerable at the beginning of psychosis and in a stage of its involution.
Hard proceeding tremens usually begins as classical, then within the first days there is an accruing oglushennost. The professional delirium is replaced by a hyperkinetic delirium or mussitans (the patient muffledly mutters something, makes the uniform elementary movements by hands, something pulls, twists, feels, «is gathered»; it is not possible to come into contact with it). On 4 — the 5th day of a disease emergence of a hyper thermal coma from the death as a result of the collapse caused by wet brain or paralysis of breath is possible. At a favorable current the oglushennost gradually decreases, consciousness every day clears up more and more. Nevertheless very often after the periods of clear consciousness the delirious symptomatology appears again. Development of a heavy tremens is often preceded by months-long hard drinkings, convulsive attacks with a loss of consciousness, repeated attacks of vomiting. At height of psychosis the following neurologic symptomatology is characteristic: a rough ataxy, a dysarthtia, twang, muscular dystonia, various hyperkinesias, pathological reflexes, reflexes of oral automatism, eye symptoms (a miosis, a nystagmus, weakness of convergence), vegetative disturbances (a hyperhidrosis with dehydration, falling of arterial pressure, a hyperthermia to t ° 42 °, absolute sleeplessness). The current is long, sometimes with aggravations, the termination of psychosis gradual, with full amnesia of a delirium and a long asthenic phase. Repeated psychoses at renewed an alcohol abuse regarding cases keep a form primary (it is characteristic of heavy deliriums). However very often they take the form of atypical, fantastic deliriums or gallyutsinoz.
An atypical delirium — the symptomatology includes these or those manifestations of a syndrome of Kandinsky — Klerambo. Usually psychosis proceeds in the form of the systematized delirium or a delirium with dominance of auditory hallucinations in the beginning. At height of development of a disease there are various senestopathetic, ideatorny and even motive avtomatizm, sensual nonsense of influence, a metamorphosis, obsession (see. Nonsense , Kandinsky — Klerambo a syndrome ). The sensual persecution complex dominates, to-ryi it is combined with the ideas of poisoning, hypnotic influence, jealousy. Affect of fear, alarm, despair prevails. It becomes very frequent the maintenance of an atypical delirium a subject of death and revival. It seems to patients that in various ways persecutors, without hurting, cut off them legs and hands, pierce heart, subject to influence of current, gas, a radiant energy. They feel how heart stops, hands grow cold and legs, see then themselves at the cemetery, in a coffin, hear messages on own death and consider themselves the dead. Then there is «revival». The atypical delirium is followed by rather deep stupefaction expressed by motive and speech excitement. At height of psychosis it is difficult to come into contact with patients, their speech is abrupt and inconsistent. Clearing of consciousness with recovery of orientation in surrounding comes after a long dream; in several days the critical relation to the postponed psychosis appears. The current of an atypical delirium can be long, especially when the specific weight of auditory hallucinations is big.
The fantastic delirium (alcoholic oneiroid) arises at height of development of the atypical or systematized delirium, and also at height of acute hallucinosis. The fantastic delirium, as a rule, is not the first in life psychosis. At most of patients it is noted before slightly typical or atypical acute alcoholic psychoses. The stage of dreams, fantastic on contents, can precede emergence of a fantastic delirium. Transition from the systematized delirium to oneiroid (see. Oneiric syndrome ) it is made suddenly or gradually. There is a confusion, illusiveness of perception surrounding amplifies. Then there is a double crazy orientation in surrounding, excitement accrues or there is a block reaching degree of a substupor with the phenomena of wax flexibility, a passive podchinyaemost (see. Catatonic syndrome ). Feature of the stage which is directly preceding oneiroid is existence of acute sensual delirium, nonsense of a performance with false recognitions, verbal (verbal) hallucinations, various mental avtomatizm. At height of oneiroid there is a full disorientation, scenic visual hallucinations of fantastic contents, the acute fantastic delirium which is combined with various manifestations of a syndrome of Kandinsky — Klerambo (see. Kandinsky-Klerambo syndrome ), disturbances of a body scheme, depersonalizatsioiny frustration (see. Depersonalization ). The fear, alarm, melancholy and despair are combined with depressive megalomaniac nonsense (see. Nonsense ); affect of joy, delight is characteristic of expansive oneiroid. With development of fantastic nonsense excitement is replaced by motive block. If the fantastic delirium develops at height of hallucinosis, it is preceded by emergence of double orientation, nonsense, a performance, mental avtomatizm.
As well as at other forms of a delirium, involution of symptomatology usually begins after the long hours-long dream coming after reception of hypnotic drugs or introduction of neuroleptics. In the beginning senesthopathias (unpleasant feelings in different parts of a body), then manifestations of mental automatism (nonsense of influence, pseudohallucination) disappear. Most longer auditory hallucinations keep. The critical relation to the postponed psychosis can appear only in several days after clearing of consciousness.
Alcoholic hallucinosis (hallucinatory insanity of drunkards, alcoholic hallucinatory nonsense, alcoholic paranoia) develops as a result of a long-term alcohol abuse and proceeds in the form of acute, long or hron. psychosis.
Acute hallucinosis arises crapulent, a cut often proceeds heavier, than usually. Psychosis can begin with delirious disorders, elementary deception of perception, but most often with suddenly developing verbal hallucinations. In the beginning the patient hears changeably sounding voices of one-two people. While their contents directly does not concern the patient, his behavior obviously does not change. At the same time there is an affect of curiosity, discontent, indignation, surprise or bewilderment, aspiration to find those persons whose voices are heard. At height of psychosis verbal hallucinosis is combined with more or less systematized nonsense. Affect of fear, alarming and intense expectation, melancholy and despair prevails. Orientation in time and a situation is not broken. Scenic verbal hallucinations differ in the sensual brightness, a various tonality, plurality, the commenting character, repeatability of words and phrases. Voices comment on feelings and the movements of patients, their past and present acts, intentions and thoughts, sometimes appear visual and tactile hallucinations. The patient often hears emotionally rich dialogues with mentioning of it in the third party. The maintenance of voices comes down to threats, humiliating comments and notes, charges, orders, predictions. Charges of alcoholism, commission of immoral acts alternate with threats to kill, cripple, dismiss about robots, to dishonor, commit to prison. At the same time the patient hears and the protecting and justifying voices.
The sensual nonsense is closely connected with hallucinations, it is almost always wider than simple processing of the last. Most often there is a persecution complex, tool observation, sorcery, physical and mental impact. The combination of nonsense of influence to true hallucinations and various pathological feelings is typical. Primary phenomena of alienation — representation, feelings and affects with direct feeling of perfection (see. Kandinsky-Klerambo syndrome ) are observed extremely seldom. The behavior reflects the specific maintenance of nonsense, hallucinations and feature of affect: patients flee from prosecution, also medical institutions ask for the help in militia, take measures of self-defense (barricade the apartment, arm with heavy objects for defense against persecutors).
Suicide attempts are made at height of affect of despair. In such way patients try to avoid the most painful punishment which is allegedly threatening to them. Aggression against people around is rare. During flow of hallucinations patients aloud ask questions and answer imaginary interlocutors, they are entirely absorbed by the maintenance of hallucinations. From time to time there is a condition of hallucinatory detachment with the motive block reaching a full obezdvizhennost. The abundance of deception of perception is followed by emergence of the easy disturbances of consciousness which are expressed in disorders of attention, associative processes and partial amnesia of real events. Disappearance of symptomatology happens gradually or extremely quickly after an hours-long dream. In the beginning the affective sphere is normalized, then hallucinations, pathological feelings and nonsense disappear. Duration of acute hallucinosis does not exceed 3 — 4 weeks.
To abortal alcoholic hallucinosis carry psychoses duration about one days at which the nonsense and hallucinosis do not reach full development. Hallucinosis with dominance of paranoid frustration is characterized by sharply arising persecution complex; verbal hallucinations are not numerous, but contents them corresponds to subject of nonsense. Atypical gallyutsinoza are followed by emergence of a short-term stupor or the expressed depression. The stupor with catalepsy lasts only several hours, the further course of psychosis usual. At the expressed depressive symptomatology motive and ideatorny block, depressive nonsense, the accusing and condemning maintenance of hallucinations, melancholy with feeling of a hopelessness is noted. The syndrome of verbal hallucinosis remains not developed. The combination of symptomatology of a delirium and hallucinosis is expressed in alternation of those and other manifestations, change of hallucinosis by a delirium or fantastic delirium, in emergence of the last at height of hallucinosis.
Clinical picture listed And. the item it is sometimes very difficult, and reference of a disease to a delirium or hallucinosis is very conditional. Repeated gallyutsinoza develop as a result of resuming of an alcohol abuse. Lack of delirious inclusions, emergence of long and atypical forms is characteristic of them.
To long (protragirovanny) alcoholic hallucinosis carry the psychoses lasting from a month to one year. They differ from acute in the frequency of emergence of depressive frustration and atypical symptomatology. The last is expressed in emergence of true avtomatizm (ideatorny, senestopathetic and motor), a paraphrenic syndrome and visual hallucinosis. At some long gallyutsinoza, especially repeated, the partial or full criticism to hallucinations, unpleasant on contents, remains.
Chronic alcoholic hallucinosis meets seldom. Verbal hallucinations often arise after the period of alarming and timid mood.
The initial symptomatology is sometimes close to a delirium to plentiful acoustical deception or to an atypical delirium. Allocate stationary and progreduated forms. At the first in a clinical picture verbal hallucinations dominate, and the nonsense is reduced. At the second organic weak-mindedness slowly accrues and the systematized nonsense, various avtomatizm (the true touch, ideatorny, motor, inspired feelings and dreams), paraphrenic symptomatology forms. Aggravations are caused by an alcohol abuse, the postponed infectious diseases. The symptomatology reminds them acute hallucinosis or hallucinosis with delirious inclusions (i.e. with the symptoms characteristic of a delirium — visual hallucinations, stupefaction, etc.). Out of aggravations the behavior remains arranged. Some patients, despite long-term existence of hallucinosis, keep working capacity.
Alcoholic crazy psychoses
Alcoholic crazy psychoses. Allocate a delirium tremens of prosecution and a delirium tremens of jealousy.
The delirium tremens of prosecution (alcoholic paranoid) suddenly develops crapulent. The figurative nonsense of physical destruction, prosecution is combined with verbal illusions and the sharpest affect of fear or intense expectation. Patients notice persecutors everywhere, in a crazy way interpret the speech, a mimicry, gestures and behavior of people around, ask for the help in militia, in medical institutions, escape from «death». They are convinced that they are wanted to be killed to use their money or from revenge. If there are single auditory hallucinations, then at the very beginning of psychosis, contents them does not match subject of nonsense. Psychosis lasts up to 10 — 14 days. At long forms of the idea of prosecution and the relation are combined with alarming and sad affect. Recurrent paranoid proceeds in the form of the acute or long psychoses arising every time after hard drinkings.
The delirium tremens of jealousy (nonsense of marital infidelity) most often develops at persons with psychopathic traits of character or signs of alcoholic deterioration. In the beginning jealous fears express in intoxication or in a hangover, they are unstable and corrections give in. Gradually the systematized nonsense of jealousy forms. Emergence of the ideas of poisoning and prosecution is possible. The patient begins to claim that the wife, wishing to meet with the lover, intends to poison him or to kill. The accidental facts are estimated as the proof of treason and the prepared punishment. At advanced age confabulations are often observed, retrospective crazy assessment of the remote past, nonsense of jealousy gains defective character. The ideas of jealousy can arise for the first time in deliriums or hallucinosis, they are not exposed to correction and become a basis for formation of the systematized nonsense.
Structurally difficult alcoholic psychoses
Structurally difficult alcoholic psychoses proceed in the form of alternation of states, typical for alcoholism. So, psychosis is defined by a syndrome of acute paranoid, then the verbal hallucinosis which is replaced by a delirium develops. Alternation of verbal hallucinosis and a delirium is most often observed. E.g., hallucinosis is replaced by a delirium, then consciousness clears up and again the symptomatology of hallucinosis prevails.
Atypical alcoholic psychoses
In a clinical picture the symptomatology characteristic of hl is observed. obr. for endogenous psychoses. Are atypical a delirium with manifestations of a syndrome of Kandinsky — Klerambo, including and a fantastic delirium (see above); the acute gallyutsinoza which are followed by a short-term stupor with catalepsy or the expressed depression (see above); long and chronic gallyutsinoza with true mental avtomatizm, paraphrenic symptomatology; visual hallucinosis. Emergence of atypical psychoses after typical speaks about increase of encephalopathic changes. Further deepening of encephalopathy can lead to disappearance of atypical symptomatology and emergence of a pathopsyhosis (e.g., to development of a pseudoparalytic syndrome instead of paraphrenic).
The alcoholic psychoses arising at a combination of alcoholism to other mental diseases
Alcoholic psychoses, arising at a combination of alcoholism to other mental diseases can have some differences from a typical picture. Organic diseases of a brain (vascular, infectious, allergic) often alter symptomatology of a delirium, causing a deep water of stupefaction or emergence of mental avtomatizm, extending the period of existence of residual nonsense. The residual phenomena of organic lesion of a brain, including and traumatic, epilepsy with rare attacks, maniac-depressive psychosis, being combined with alcoholism, in itself do not conduct to an atipization of alcoholic psychoses.
In 1909 V. Graeter described the patients abusing alcohol who had psychoses similar with alcoholic in the beginning, and typical schizophrenic frustration were found later. Further studying showed that alcoholism is combined with optimum proceeding forms of schizophrenia. Its influence on schizophrenic symptomatology is expressed more if development of schizophrenia is preceded by a long-term drunkenness. Least of all influence of alcoholism affects symptomatology of pristupoobrazno-progreduated and periodic schizophrenia, much more — in an initial stage paranoid p at slow schizophrenia. The combination of alcoholism to inertly current process or superficial defect after an attack of schizophrenia excludes development of classical delirium tremens (psychoses with stupefaction arise seldom and proceed in the form of gallyutsinoz with delirantny inclusions or oneiroids). Usually gallyutsinoza or acute paranoids which duration, as well as alcoholic, does not exceed 2 — 3 weeks develop, and the symptomatology often includes depressive and paranoid, catatonic frustration and true mental avtomatizm. In an initial stage of paranoid schizophrenia the two-phase psychoses reminding alcoholic only in the first phase can be observed. At inertly current schizophrenia after hard drinkings the gallyutsinoza indistinguishable from alcoholic sometimes develop, however repeated psychoses lose communication with alcoholic. Development of paranoid and pristupoobrazno-progreduated schizophrenia can lead to reduction of weight of alcoholism and even to complete cessation of the use of alcohol.
An alcoholic depression
the Alcoholic depression — the concept serving for designation of various depressions at patients hron. alcoholism. In narrow sense the alcoholic depression is a syndrome of a hangover with melancholy, the ideas of self-accusation, superficial ideatorny and motive block. Refer also situationally caused depressive reactions amplifying crapulent to an alcoholic depression. Emergence in hard drinking and after its termination of the expressed melancholy can be connected with constitutional features — tendency to tsiklotimny frustration: moods.
Alcoholic epilepsy — a convulsive syndrome in the third stage of an alcoholism. Single or serial attacks with a loss of consciousness, tonic and clonic spasms, tongue biting, an incontience of urine can repeatedly arise in the first days after the termination of hard drinking, before a delirium or at the beginning of an acute form of encephalopathy of Gayet — Vernike (see. Alcoholic encephalopathies ). The combination of alcoholism to residual organic (traumatic) lesions of a brain facilitates approach of attacks. During the interepileptic period on the electroencephalogram there are no changes, characteristic of epilepsy. Emergence in an ebrietas of attacks like petit mal or big convulsive attacks is not characteristic of alcoholic epilepsy. Changes of the personality are characteristic of alcoholism.
Alcoholic encephalopathies — one of groups of the metalkogolny psychoses developing at And. items of which the combination of mental disorders to the system somatic and neurologic disturbances which are quite often dominating in a clinical picture is characteristic (it is detailed — see. Alcoholic encephalopathies ).
Pathological intoxication — the twilight stupefaction arising after the use of insignificant doses of alcohol less often after high doses of alcohol. Pathological intoxication develops not only at patients with an alcoholism and does not belong to actually alcoholic psychoses. Its approach is promoted by exhaustion, a sleep debt, emotional pressure.
At epileptoidny (epileptiform) option the state suddenly changes: orientation is lost, the situation is perceived not clearly and incorrectly, deception of perception and the sketchy crazy ideas appear. Sharp excitement with affects of anger and rage is followed by chaotic aggression, aspiration to destruction. The behavior can have character of automatic unaccountable actions.
At paranoid option the distorted crazy perception of a situation and behavior of people around is combined with deception of perception, affect of fear, alarms, the approaching danger. Patients arm for defense, attack imaginary enemies, run away from danger.
Pathological intoxication differs from simple intoxication in suddenness of the beginning, lack of external signs of intoxication, safe coordination of movements. It lasts of several minutes till several o'clock and quite often comes to an end with a deep and long sleep. At paranoid option partial memories of the postponed state remain, at epileptiform — there comes full or almost full amnesia.
the Dipsomania — one of types of periodically coming hard drinkings. Before hard drinking appear in depression - the angry mood, concern, fussiness, a physical indisposition, sleeplessness, loss of appetite, sometimes headaches, perspiration and a tremor. Working capacity decreases or lost. If the attack of a dipsomania develops in an initial stage hron. alcoholism, it begins in connection with a strong inclination to alcohol and 7 — 14 days last. Patients drink alcohol day and night, feeling an uncontrollable attraction to alcohol and trying to get rid in the small portions of vodka or wine of quickly appearing hardest manifestations abstinences (see). To the termination of hard drinking endurance to alcohol falls, weakness, an ataxy, a tremor, short wind, tachycardia amplify, almost full sleeplessness develops. Appetite is absent, in the mornings there is vomiting. The inclination to alcohol weakens or disappears, without being found to the following hard drinking. If the dipsomanichesky attack arises at psychopathic persons or at the erased forms of a cyclotymia, epilepsy, schizophrenia, physical and mental manifestations of intoxication can be insignificant, despite receptions of high doses of alcohol (to 1 l and more in days), and the suppressed mood remains. The termination of hard drinking usually sudden, is followed by disappearance of need for alcohol, sometimes disgust for it. After hard drinking there can be an increased mood accompanied with tireless and productive activity.
The pathogeny and pathological anatomy
In a pathogeny of a tremens is of great importance strengthening of all exchange and neurovegetative disturbances inherent hron. to alcoholism. At deliriums the main role is played by changes in a diencephalon with disturbance neuro vegetativioy regulation and functions of pituitary and adrenal system. An important role in disturbance of a homeostasis is played by accumulation in blood of products of incomplete combustion of alcohol and the subsequent sharp termination of reception of alcoholic drinks. Neurovegetative dysregulation is aggravated with a vitamin deficiency of B1, B6, B12, PP and folic to - you, disturbance of functions of a liver. In a result in of blood ketonic acids collect, there is acidosis, the level of bilirubin, cholesterol increases, ion concentration of magnesium and potassium falls, develops hyper in the beginning - then a gipoadrenergiya. Toxicosis and brain hypoxia cause a hyperpermeability of a vascular wall and wet brain which in turn strengthens vegetative dysregulation. Development of a syndrome of a delirium is connected first of all with oppression of a phase of a paradoxical dream.
The pathogeny of other alcoholic psychoses is studied insufficiently. At acute psychoses of change, probably, are close to those which are available at deliriums. In a pathogeny long, hron. gallyutsinoz and nonsense of jealousy significance is attached to encephalopathic changes and associated diseases.
Morphological changes at alcoholic deliriums, in addition to characteristic of alcoholism, are expressed in the strengthened krovenapolneniye of a brain, a trichangiectasia, perivascular hypostasis, different types of a degeneration of nervous cells. Changes in a hypothalamus, in area III of a ventricle, at the bottom of the IV ventricle, but without Gayet, characteristic of alcoholic encephalopathy — Vernike of zone limitation prevail.
The diagnosis and the differential diagnosis
the Tremens differs from not alcoholic delirious states in typical psychopathological symptomatology (a combination of fear to euphoria, an otklikayemost, alcoholic subject of hallucinatory scenes) and characteristic neurologic signs (a tremor, an ataxy, a hyperreflexia, a hypomyotonia, reflexes of oral automatism, a hyperhidrosis). At a heavy hangover, unlike a delirium, there are no disturbances of consciousness with a disorientation, hallucinations develop only during the closing of eyes or in a drowsy state (gipnagogichesky hallucinations).
Acute alcoholic hallucinosis differs from a tremens in dominance of auditory hallucinations and nonsense, safety of orientation.
The delirium tremens of prosecution and situational paranoid arising at the alcoholic in the unusual or concealing in itself danger situation — identical states; their distinction of hl. obr. in the conditions of emergence. Acute alcoholic paranoid, unlike acute alcoholic hallucinosis, proceeds without deception of perception; if there are auditory hallucinations, they are short-term, poor and contents them does not match subject of nonsense.
Difference long and hron. gallyutsinoz at organic diseases from alcoholic it is expressed in other neurologic symptomatology, type of decrease in intelligence, uncharacteristic for alcoholism, bigger monotony of hallucinations.
The delirium tremens of jealousy is delimited from similar paranoiac states at progreduated diseases on the basis of its constructive simplicity, proximity of motives of pathological jealousy to usual, existence of signs of alcoholic deterioration.
To differentiate the psychoses arising at a combination of schizophrenia to alcoholism, to alcoholic psychoses very difficult since alcoholism is combined with optimum current forms of schizophrenia at which defect is not expressed. Nevertheless in most cases it is possible to reveal the changes of thinking of N of the emotional and strong-willed sphere, characteristic of inertly current or pristupoobrazny schizophrenia, which arose long before acute psychosis. Besides, at acute alcoholic gallyutsinoza and paranoids there is no depressive and paranoid, catatonic symptomatology and confusion with true mental avtomatizm (see. Kandinsky-Klerambo syndrome ). Depressive and paranoid and catatonic frustration are not observed at long and hron. alcoholic gallyutsinoza are also very characteristic of the schizophrenia which is combined with alcoholism.
Alcoholic epilepsy differs from an epileptic disease in approach of attacks in a hangover, neurologic symptoms of encephalopathy, disappearance of convulsive paroxysms at abstention from alcohol, lack of specific changes on the electroencephalogram.
Forecast acute And. the item is favorable; at timely hospitalization they come to an end with recovery. Hazard to life is posed by only hard proceeding delirium. Repeated and frequent developing of acute psychoses, confirming deepening of encephalopathy, is followed by decrease in intelligence. At chronic and protragirovanny gallyutsinoza approach of temporary or constant disability is possible.
Treatment And. by the item it has to be carried out in a hospital. Therapeutic tactics is defined by a form of psychosis, its duration and weight. At all forms of a delirium, except heavy, appointment odpy of the following means is effective: a combination of 0,5 — 0,7 g of barbamyl from 90 — 100 ml of 40% of alcohol, 50 — 100 mg of aminazine or Tisercinum intramusculary or intravenously, 20 — 40 mg of Seduxenum intramusculary, 10 — 15 mg of a haloperidol intravenously, 250 — 500 mg of a hlormetiazol inside or intravenously. The daily dosage of each of means is defined by speed of approach of a dream, its duration and completeness of disappearance of symptomatology of a delirium after awakening. In addition appoint cardiacs (Cordiaminum, korglyukon), B1, C, PP, B6, B12 vitamins, folic to - that, intramusculary 20 ml of 25% of solution of magnesium sulfate.
At heavy deliriums aminazine and Tisercinum can be entered only into stages of the increased arterial pressure. Excitement is eliminated with barbamyl with alcohol, hlormetiazoly, Elenium, Seduxenum, hydroxybutyrate of sodium. Approach of a collapse is prevented purpose of 60 — 120 mg of Prednisolonum inside or parenterally, intravenously enter 400 ml of Polyglucinum with a phenylephine hydrochloride or noradrenaline. Wet brain is eliminated with drop injection of 60 — 90 g of urea intravenously, a cut immediately stopped if it causes an aggravation of symptoms. Purpose of high doses of B1 vitamin — to 1000 — 1500 mg a day from which 500 — 600 mg enter intravenously is obligatory.
Duration of the specified therapy is defined by speed of approach of a dream, disappearance of neurologic symptomatology and clearing of consciousness.
Thanks to modern therapy And. the item sharply reduced mortality at deliriums. Introduction to therapy of Seduxenum, hydroxybutyrate of sodium, urea led to reduction of duration of heavy deliriums, disappearance of waviness and long drowsiness, the critical termination of psychosis.
At acute gallyutsinoza and paranoids the most effectively intramuscular introduction of 50 — 150 mg of aminazine of a pla of Tisercinum, and also a combination of one of these drugs administered intramusculary from 5 — 10 mg of a haloperidol or 20 — 40 mg of Triphtazinum. At long gallyutsinoza lack of effect of Triphtazinum (to 60 mg), an etaperazina (to 80 — 100 mg), a haloperidol (to 30 mg) or the trisedpla (to 10 mg) forces to begin an insulin therapy in combination with one of the specified drugs. Aggravations at hron. gallyutsinoza are stopped as acute gallyutsinoza.
At nonsense of jealousy an insulin therapy, Triphtazinum (to 60 mg), a haloperidol (15 — 25 mg), Metherazinum are most effective (to 150 mg).
Prevention — fight against alcoholism, prevention and early treatment hron. alcoholism, performing active antialcoholic therapy by that who transferred a psychotic state once.
Value of alcoholic psychoses in forensic-psychiatric practice
Forensic-psychiatric value A. the item it is very big. On the frequency and weight of commission of socially dangerous acts first place is won by patients with alcoholic crazy psychoses. Social danger of such patients decides by the crazy ideas of prosecution, characteristic of them, on affect of fear and alarm or the crazy ideas of jealousy; development of the last constitutes the greatest danger. The second place is taken by patients with a tremens. They are dangerous to the persons surrounding them and to themselves especially in the initial period of a disease, in Krom intensive affects of fear and alarm, confusion of consciousness appear.
Patients with alcoholic hallucinosis most often make dangerous acts in cases of an aggravation and especially at accession to verbal hallucinosis of separate visual deception and the crazy ideas. Existence of a delirium, hallucinosis or pathological intoxication excludes sanity.
The twilight disorders of consciousness of a traumatic etiology arising against the background of intoxication also exclude sanity.
The persons who made socially dangerous actions is able And. to the item and recognized deranged, for the purpose of prevention of repetition of psychotic states it is necessary to direct to compulsory treatment in insane hospitals. Persons, at which And. the item arose after an offense, it is necessary to direct to treatment in insane hospitals; after escaping of disease state return in the order of investigating authorities of a pla of court. Persons, at which And. items accept a long current, exempt from criminal liability and direct to compulsory treatment.
At examination of the persons, in the past who transferred And. the item and made responsible on any offense, it is necessary to consider their aspiration to metasimulation — conscious target reproduction of the psychotic symptoms endured by them earlier.
Banshchikov V. M. and Korolenko Ts. P. Alcoholism and alcoholic psychoses, M., 1968, bibliogr.; Bathhouse attendants V. M., Korolenko Ts. P. and Korolenko of T. A. Intoksikatsionnye psychoses, page 60, M., 1968, bibliogr.; Gulyamov M. G. Syndrome of mental automatism, Dushanbe, 1965, bibliogr.; Zhislin S. G. Sketches of clinical psychiatry, M., 1965, bibliogr.; A pathogeny and clinic of alcoholic diseases, under the editorship of. I. I. Lukomsky, M., 1970; Bonhoeffer K. Die akuten Geisteskrankheiten dcr Gewohnheitstrinker, Jena, 1901, Bibliogr.; Boudin G. et Lauras A. Le delirium tremens, P., 1960; Kraepelin E. u. Lange J. Psychiatric, Bd 2, Lpz., 1927.
Value A. the item in forensic-psychiatric practice
Vvedensky I. N. Problema of exclusive states in forensic-psychiatric clinic, in book: Probl. court. psikhiat., under the editorship of Ts. M. Feynberg, t. 6, page 331, M., 1947; Zatulovsky M. I. About pathological intoxication and its diagnosis in forensic-psychiatric practice, in book: Vopr. court. - psikhiat. examinations, under the editorship of A. N. Buneev, etc., page 104, M., 1955; Kachayev of A. K. Otgranicheniye of irregular shapes of simple alcoholic intoxication from pathological intoxication, in book: Probl. court. psikhiat., under the editorship of G. V. Morozov, century 18, page 77, M., 1967; Rozhnov V. E. Alcoholism and other drug addiction, in book: Court. psikhiat., under the editorship of G. V. Morozov, page 277, M., 1965, bibliogr.
A. G. Hoffman; A. K. Kachayev (court. psikhiat.).