Alcoholism is a disease as a result of alcohol abuse in such doses and with such frequency that lead to loss of effectiveness in work and disruption of family relationships and social life and to physical and mental health disorders. Alcoholism in the social sense is the excessive consumption of alcohol, which has a harmful effect on the health, life, work and welfare of society.
Alcoholism is a form of substance abuse, characterized by addiction to the use of substances containing ethyl alcohol, the development of mental and physical dependence, withdrawal symptoms, mental, physical and social degradation of the person. Like any other disease, alcoholism does not occur suddenly, but has its preclinical manifestations - domestic drunkenness.
Alcoholism differs from domestic alcoholism by clearly defined and biologically determined symptoms, although domestic alcoholism always precedes alcoholism. Household drunkenness, habitual abuse of alcohol - this is always a violation by a person of social and ethical rules. As a result, measures of an administrative-legal and educational nature are crucial in the prevention of alcoholism. Unlike drunkenness, alcoholism is a disease that always requires the use of active medical measures, a set of therapeutic and rehabilitation measures.
The effect of alcohol on the human body
The word "alcohol" comes from the Arabic "al kegol", which means stupefying. People got acquainted with alcohol as an intoxicant many centuries ago. Apparently, they learned how to make it since they began to grow cereals and grapes.
Get alcohol through the fermentation of various sugary products (cereals, vegetables, fruits, honey, etc.), as well as a synthetic method from waste wood. Alcohol is part of all alcoholic beverages - vodka, cognac, wines, liquors, beer, etc., the strength of which depends on the content of ethyl alcohol. In addition to ethyl, there are other alcohols that are extremely harmful to the body. The most life-threatening methyl, or wood, alcohol. People who accidentally took 50-100 g of methyl alcohol die or become blind permanently. Dry grape wines, beer are weak alcoholic beverages, but in large quantities they are also toxic. It is curious that in countries with a hot climate, where they drink mainly natural grape wines with a lower concentration of alcohol, the number of cases of chronic alcoholism is less than in countries where the use of strong alcoholic beverages, including surrogates, is common.
In the action of alcohol on the body, two features can be distinguished - its direct effect, causing a state of intoxication, and systematic abuse, leading to a disease - alcoholism.
The main effect of alcohol is intoxicating. The result of the action of alcohol is determined not only by the absolute dose of the alcohol taken, but also by its strength. Under the influence of such strong drinks as vodka, the maximum concentration of alcohol in the blood is reached within an hour. In this case, intoxication develops quickly and more pronounced.
Alcohol does not have an exciting effect on higher nervous activity. On the contrary, it inhibits both basic processes - both inhibitory and irritable. But the impact on the first is stronger and ahead of its influence on the second. Hence the picture of alcoholic excitement. Already small doses of alcohol inhibit the inhibitory process, and this leads to the fact that the ratio between it and the irritant process is violated in favor of the latter. Thus, the observed excitation is the result of the removal of the brakes, and not stimulation in the literal sense of the word.
Alcohol is alien to the body, therefore, the biochemical mechanisms of man, of course, are not “tuned” to its assimilation, and the negative reaction to alcohol is more pronounced at the first doses of alcohol - nausea, a feeling of lightheadedness, vomiting, etc. Over time, after "meetings" with alcohol in the liver, a specific enzyme is formed - alcohol dehydrogenesis, which neutralizes alcohol, breaking it down to water and carbon dioxide. Interestingly, such a function is not characteristic of the liver of children and adolescents. That is why at this age, alcohol is especially toxic and causes irreversible changes in the internal organs. Alcohol abusers develop cirrhotic degeneration of the liver over time, in which the production of the alcohol dehydrogenase enzyme decreases sharply. Associated with etm is their rapid intoxication from small doses of alcohol.
The state of intoxication is characterized primarily by a slowdown in the course of associations, which is beginning to acquire a more superficial character, which entails a decrease in the quality of intellectual work. With an increase in the dose of alcohol taken, the mood rises, the picture of drunken excitement begins to increase both in mental and motor activity. The characteristic manifestations of this condition, which is still attributable to slight intoxication, are an elevated, euphoric mood background with a general feeling of carelessness, complacency, fun, swagger, a tendency to buffoonery and tomfoolery. At the same time, drunks often show mischief, the desire to show off. Increased conceit, boastfulness, the desire to show oneself as a special person, having great merits, called to subordinate and command, often lead drunk people to conflicts with others. This is facilitated by the appearing increased touchiness and, as a consequence of it, arrogance and pugnacity. For many drunks, this condition leads to disinhibition in sexual manifestations. Observed flat jokes, cynical remarks, swearing. In a state of intoxication, a person very often insults with the word and action of others, which is the main reason for all kinds of scandals, fights and hooligan acts. With further intensification of intoxication, aggressive tendencies turn into drunken violence, which can entail serious crimes up to murder.
When intoxication, a number of somatic, neurological and mental disorders are observed, the manifestations of which vary depending on the degree of intoxication. In forensic psychiatric practice, it is customary to distinguish between simple alcoholic intoxication, which is distinguished from pathological intoxication. It is customary to distinguish between mild, moderate and severe degrees of simple intoxication.
With a mild degree:
- typically lowering the threshold of perception;
- intellectual processes are disturbed: attention is frustrated, reactions are slowed down, thinking becomes less logical, associations in harmony are noted;
- comprehension of the environment is difficult, criticism is reduced;
- the mood is unstable, often increased, but there may be short temper, irritability and viciousness;
- coordination of movements is impaired, mild speech impairment is noted.
With an average degree:
- attention is sharply disturbed, it becomes distracted;
- lack of clarity and differentiation of perception;
- intellectual processes proceed at a slower pace, thinking is determined by random associations;
- revived primitive drives, especially sexual ones;
- persons in a state of the middle stage are often angry, aggressive;
- coordination of movements is significantly impaired, gait becomes shaky, speech - dysarthria.
Severe intoxication is expressed by the clinical picture of increasing stunning. In the future, a deep sleep occurs: a drunken person falls asleep in an uncomfortable position and in inappropriate places, involuntary urination and defecation, sometimes convulsive muscle twitches can be observed. Memories of a period of intoxication, as a rule, are available, but sometimes they are fragmentary.
In a coma that occurs with severe alcohol intoxication, urgent measures are needed aimed at the most rapid removal of alcohol from the body (gastric lavage, maintaining cardiovascular and respiratory functions).
Particularly severe forms of alcohol poisoning occur when alcohol substitutes are consumed. These include alcoholic beverages made by the artisanal method (moonshine, chacha, etc.), cosmetics (cologne, lotion, elixirs) and medicines (tinctures, rubbing, etc.). In case of poisoning by surrogates, severe forms of intoxication develop, which are accompanied by a disturbance of consciousness, a sharp respiratory failure of the cardiovascular system.
There are frequent cases when both alcoholic drinks and medicines are consumed. As a result, serious disorders of the cardiovascular system and severe complications arise, up to the death.
To establish the fact of alcohol intoxication, indicator tubes are widely used. These tubes contain a dry reagent - a solution of chromic anhydride in concentrated sulfuric acid impregnating cotton wool. Exhaled vapors of alcohol change the yellow color of the indicator to green or blue, which is an indicator of the presence of alcohol in the exhaled air.
In many cases, despite the pronounced signs of alcohol intoxication, drunks, as a rule, are able to be aware of and direct their actions. In the same cases of especially severe intoxication, when the ability to report in one’s actions is obviously lost, one should speak of sanity because no matter how heavy alcohol intoxication is with simple intoxication, it does not lead to twilight consciousness disorder, to hallucinatory and delusional experiences and other psychotic states. In addition, intoxication as alcohol poisoning is a pathological condition arbitrarily caused, and its severity is arbitrarily caused, completely determined by the amount of alcohol consumed, taken for very specific reasons - to raise one’s mood, to obtain pleasant sensations.
Pathological intoxication belongs to the group of acute short-term occurring mental disorders. This is a psychotic condition with a peculiar symptom that occurs as a result of drinking alcohol. Pathological intoxication is characterized by a sudden onset of a change in consciousness such as twilight disorder, in the clinical picture of which signs of twilight dizziness and hallucinatory-delusional experiences are combined, resulting in a distorted perception and delusional interpretation of the environment. Usually pronounced affective tension is noted - unaccountable fear, anxiety, confusion, anger. Patients' actions are divorced from the real situation and are completely determined by the plot of painful experiences. The defining sign for distinguishing between simply alcoholic intoxication and pathological intoxication is the establishment of the nature of impaired consciousness, which qualitatively differs from being stunned with simple intoxication.
Socially dangerous acts committed in a state of pathological intoxication are not a reaction to any real events. They are based on painful impulses, impulses, ideas. In patients in this state, neuropsychic mechanisms that regulate complex automated skills and balance are not disturbed, so people with pathological intoxication can make rather dexterous and complex movements aimed at implementing painful socially dangerous actions. They retain the ability to perform complex purposeful acts, use transport, correctly find the way to the house, etc. Pathological intoxication ends, as a rule, all of a sudden, just as it begins, sometimes it goes into sleep, after which there is complete amnesia or fragmentary memories of what has been experienced are preserved.
Pathological intoxication in forensic psychiatric practice is regarded as psychosis. Persons who have committed an unlawful act in a pathological intoxication are recognized as insane.
Chronic alcoholism is a serious neuropsychiatric disease in which a person develops a painful craving for alcohol, which eventually takes on an obsessive nature, and there is an acute “need” to get hangover. The need for hangover in such patients is so acute that if they are not satisfied in this, they are able to not only work, but generally move.
Chronic drinking destroys the entire body of the drinker. Almost all vital organs, such as the liver, heart, kidneys, digestive organs, etc., suffer. All this inevitably leads to the transformation of a chronic alcoholic into a somatic patient. But predominantly, the harmful effect of alcohol affects the central nervous system and, first of all, its higher section - the cerebral cortex. This leads to the degradation of the whole personality and to the emergence of special alcoholic psychoses. The destructive effect of alcohol on a drunk person affects primarily the emotional sphere. A certain coarsening of the personality takes place: callousness, selfishness, indifference develops not only towards others, but also to the sufferings of one's family. Emotional instability is manifested in the ability to quickly move from complacency and fun to sadness and anger. A chronic alcoholic does not tolerate any objection. The slightest resistance to his harassment causes him a sense of rage. At the same time, often the general background of mood bears the imprint of euphoria with an uncritical attitude to one’s position. There is a tendency to buffoonery, joker, and the content of this humor is precisely what a healthy person can not cause laughter. An alcoholic makes a joke of his own fall, as well as all the chagrin and pain that he inflicts on his family. This kind of humor is a fairly typical phenomenon for the reduced intelligence of a chronic alcoholic.
It is clear that all these mental properties of chronic alcoholics extremely often lead to a violation of the law. Hooligan acts, insults with words and actions, sexual offenses, theft, direct gang crimes - this is the main list of offenses committed by a chronic alcoholic. Forensic psychiatric assessment of this condition, as a rule, is not particularly difficult. Although there are certain personality changes, but basically they come down to a change in character that does not deprive the alcoholic of the ability to give an account of and direct their actions. So in relation to the offenses committed, chronic alcoholics are overwhelmingly recognized as sane. Rare exceptions are only those cases when there is a picture of severe dementia. It should be noted that this is more often observed already at an older age and, as a rule, is accompanied by severe arteriosclerosis of the brain. In those cases when these organic destructive disorders already indicate a mental illness, sanity for the deed, of course, is excluded.
Clinical manifestations of alcoholism
Addiction syndrome consists of the symptoms of a pathological craving for alcohol, loss of self-control, and withdrawal symptoms.
The pathological craving for alcohol is one of the earliest manifestations of the disease. There are 2 types of attraction: obsessive and compulsive. The first type is an expression of an obsessive desire for alcohol, arises at the very beginning of the disease and determines the formation of mental dependence. Compulsive attraction develops later, in terms of severity reaches a degree of physiological need (like a feeling of thirst and hunger) and determines the physical dependence on alcohol.
Loss of self-control and control over the amount of alcohol consumed is also an early symptom of alcoholism. Under the influence of the inhibitory effect of even small doses of alcohol in patients, there is a need to take it in even larger quantities, which usually grows to such an extent that the severity of intoxication makes it physically impossible to further absorb alcohol.
Alcohol withdrawal syndrome is the most convincing sign of addiction. It usually occurs the day after a drink and means the need for the alcoholic to form in the body to maintain a constant concentration of ethanol in the blood. That is why taking the next dose of alcohol relieves withdrawal symptoms and improves well-being for a while.
The most common division of alcoholism into three stages: primary, secondary and final. Each stage is characterized by its typical symptoms - symptoms and syndromes.
Initial (neurasthenic) stage
Signs of the initial stage of alcoholism distinguish alcoholism from domestic drinking.
In the vast majority of patients, the first stage of alcoholism is formed before the age of 25 years.
One of the earliest and most significant signs of the initial stage of alcoholism is a pathological attraction to alcohol, which is obsessive, a sign of a decrease, and then loss of control over the amount of alcohol consumed.
In contrast to domestic drinking, mental dependence on alcohol is expressed in the form of an obsessive drive. Patients not only do not miss any reason to drink (various celebrations, holidays and the like), but they themselves try to create a situation in which a drink would be appropriate. Increased attraction is manifested in the activity, the initiative with which patients take on the organization of a feast. At the same time, a positive background of mood, disinhibition, pleasant memories associated with previous drinks arise.
At the stage of domestic drinking, it remains possible to control the amount of alcohol consumed - "drink in moderation." The restraining motives are, on the one hand, the idea of the consequences of an overdose (nausea, vomiting), which reflects the initial level of tolerance, and on the other, reasonable fears of making an undesirable impression on others, being “out of shape” the next day. The decrease in quantitative control in stage I of alcoholism is determined by changes both in the biological sphere (increasing tolerance) and in the sphere of mental functioning (volitional decline, reduction in criticism, etc.).
At stage I of the disease, the state of intoxication is always pleasant for the patient, which is not necessary for a non-alcoholic, but in order to achieve it, an intensive increase in the dose of alcohol is necessary. Outwardly, this manifests itself in the fact that patients are impatient at the beginning of a feast, rush to toasts, are illegible regarding the quality of alcoholic beverages, tend to necessarily drink all purchased and, if possible, add more.
The initial symptom of alcoholism is the loss of a protective vomiting reflex - the disappearance of vomiting in case of an overdose of alcohol. Alcohol tolerance is changing - there is an increase in it, the ability to take more and more large doses of alcohol.
Already in the initial stage of alcoholism, palimpsests can occur - symptoms of a memory disorder consisting in the inability of patients to reproduce individual details and events that occurred during alcohol intoxication.
In some patients, the character changes - they become spiteful, intrusive, touchy, often suspicious.
All these symptoms of psychopathological disorders of the initial stage of alcoholism arise and exist against the background of increasing and deepening asthenic syndrome. Its main manifestations are weakness, lethargy, fatigue, impaired attention, exhaustion of intellectual processes and headaches. All this leads to the fact that in patients the quality of work is deteriorating. They have early sleep disorders. They do not fall asleep for a long time, the dream is superficial, intermittent, with frequent dreams, often frightening in nature. After sleep, there is no feeling of vigor. Irritability and causeless temper, conflicts with others appear and become permanent.
The duration of the first stage of alcoholism is on average from 1 year to 5 years, depending on the intensity of alcohol abuse. Already at the initial stage of alcoholism, there are functional somatoneurological disorders: vegetovascular dystonia, esophagitis, gastritis, colitis, impaired liver function, initial symptoms of hepatitis, pancreatitis.
At this stage, a transition is made from episodic drunkenness to systematic.
Middle stage (withdrawal)
The middle stage of alcoholism is characterized by an increase in the pathological attraction to alcohol, which takes on the character of irresistibility and violence. The patient is no longer trying to fight the urge to drink, but passively submits to him.
The pathological attraction to alcohol in stage II is uncontrollable, compulsive in nature. If the desire to drink alcohol in patients in the initial stage is dictated by the desire to enjoy or overcome the psychological costs of a stressful situation, then the motive for taking alcohol in stage II is the need to experience a sense of physical comfort, to alleviate one's condition.
The symptoms characteristic of the initial stage of alcoholism do not disappear, but these or those changes are amplified or undergo during the formation of the middle stage of alcoholism. The most characteristic is withdrawal syndrome (hangover syndrome). It occurs in a patient several hours or days after the cessation of prolonged alcohol intoxication. The severity of its severity may be different, however, as the disease develops, clinical manifestations tend to be heavier. The most mild cases are characterized by a picture of asthenovegetative disorders (sweating, tachycardia, decreased appetite). Although with difficulty, patients can still cope with the desire to hang out or delay it until a more suitable moment - after work, in the evening. The worsening of the clinical manifestations of withdrawal is expressed in cardiac arrhythmias, fluctuations in blood pressure. The coordination of movements is disturbed, tremor occurs, tendon reflexes become uneven. The desire to hang out is characterized by irresistibility and is realized, despite the difficulties of the socio-ethical order. The most severe withdrawal symptoms are accompanied by mental disorders. Decreased mood, a sense of anxiety, tension, pathological ideas of attitude, guilt, suicidal thoughts are noted. Sleep disorders are accompanied by nightmares, feelings of falling, suffocation, fear. These phenomena are observed for several days, forcing the patient to a constant desire to get hangover.
Tolerance to alcohol in the middle stage rises and reaches its height and may not change for years. The daily dose of consumption reaches 1.5-2 liters of vodka. A further change in the pattern of intoxication is noted. The mood in a state of intoxication becomes more and more irritated and spiteful with a tendency to aggression in relation to others. Loss of control over the amount of alcohol consumed occurs after taking the smallest doses of alcohol.
The combination of an irresistible craving for alcohol with the loss of quantitative control and withdrawal syndrome causes a change in the form of drunkenness. Most often, at this stage, patients drink alcohol almost daily in doses that cause a state of severe intoxication, or drink heavily from several days to several weeks with breaks of several weeks between hard drinking.
In the middle stage of alcoholism, pseudo-bouts are special manifestations of the course of the disease. Binges, the frequency of which is associated not with biological, but with purely external situational reasons, are called pseudo-bouts (false or situational). Such binges can be found at the end of the week, upon receipt of a salary, after going on vacation, on the occasion of family celebrations or any troubles. External causes - administrative punishment, family conflict - determine their termination. Pseudo bells have no periodicity. Usually they are much longer than true ones and last from several days to several weeks. In the intervals between binges, patients usually do not drink alcohol.
Almost every drunkenness ends with amnesia of its final stage.
All these disorders exist amid an increasingly dramatic change, the degradation of personality. Become coarser characteristic of the initial stage of the patient’s personality changes, egoism is growing. To receive funds for a drink, the interests of the family, team, and society are ignored. Mnestic-intellectual disorders intensify, cynicism and flat humor appear. Attention and memory are getting worse. Thinking is becoming more monotonous, concrete, with superficial associations that come down to alcohol.
Willful processes are grossly violated: oaths, promises to stop drunkenness are immediately forgotten. There is no feeling of guilt in front of others. All previous interests are lost, the dominant need is alcoholic beverages.
At this stage of alcoholism, acute alcoholic psychoses often arise. The duration of this stage is on average 3-5 years.
Final (encephalopathic) stage
This stage is characterized by further modification and aggravation of the symptoms of the previous stages of alcoholism and the manifestation of new symptoms.
Stage III is formed at the remote stages of the course of alcoholic disease. The greatest number of patients falls on the age of 35 - 45 years, although in some cases with a malignant course, alcoholism can be observed at the age of over 50 years. Such cases are extremely rare due to the shortening of the average life expectancy of patients with alcoholism.
Attraction to alcohol acquires a more moderate character, loses a painful character, becomes less intrusive. A violent attraction to alcohol arises as a result of unexpressed, psychogenic factors that are small in significance. Together with these even a small dose of alcohol leads to uncontrolled alcohol addiction.
Alcohol tolerance is reduced, i.e. intoxication occurs from lower doses of alcohol compared with the initial and middle stages of the disease; physical dependence on alcohol prevails compared with mental. Patients cease to feel a sense of joy, pleasure when drinking alcohol. At the same time, due to the aggravation of withdrawal symptoms, the physical attraction to alcohol becomes completely irresistible. Finally, the situation control is lost, and in trying to get the next portion of alcohol, the patients do not stop at nothing. Often they resort to the use of surrogates, various liquids sold in pharmacies, perfume stores. The craving for alcohol can be so strong that patients are ready to use any, even obviously poisonous substances, if they contain a negligible percentage of alcohol.
The encephalopathic stage of alcoholism is characterized by daily abuse of fractional doses of alcohol (up to 150 ml after a few hours) or true binges when patients drink for several days. At the same time, with the duration of binge, the patient's tolerance to alcohol progressively decreases. If the doses reach 1 liter of vodka in the first days of binge, then at the end of binge they decrease to 100-150 ml per day. Such binge due to physical intolerance to alcohol ends due to vomiting or emerging collaptoid states. True binges are cyclical. The light intervals between binges, when the patient does not drink alcohol, range from several days to several weeks.
At this stage of alcoholism, the manifestations of alcohol degradation of the personality are most pronounced. Patients lose moral and ethical standards of behavior. Their interest in the environment disappears. Mnestic-intellectual disorders that form at the middle stage of alcoholism are growing and deepening. There is a depletion of all mental activity. Efficiency decreases, patients can only do unskilled work, go down, do not monitor their appearance, go dirty, carelessly dressed. Often commit offenses.
At this stage, ideas of jealousy often take on a painful nature. During the period of intoxication, these ideas take possession of the sick so much that they can be socially dangerous, make aggressive actions. Patients often become helpless, eat poorly, lose weight significantly. The final stage of alcoholism is characterized by chronic alcoholic psychoses. The most common alcoholic psychosis is delirium tremens (delirium tremens), which usually occurs against the background of withdrawal symptoms in the evening or at night and is accompanied by disorientation in time and space, bright imaginative visual hallucinations (snakes, mice, devils, etc.), psychomotor agitation, feeling fear, vegetative manifestations (sweating) and severe tremor of the hands.
For the purposes of criminological research, it is worth highlighting such features of alcoholics as suspicion, incredulity, increased suspiciousness, and a willingness to painfully fix erroneous statements. In the motivational sphere, the content of needs changes and the hierarchy of motives is rebuilt. Alcohol becomes a measure for assessing the success of actions in order to satisfy the need for it, for one or another attitude to an ever greater part of the surrounding reality. Over time, the assessment of what surrounds the patient begins to more or less depend on whether or not this item, action, person helps meet the need for alcohol. Alcohol is becoming a leading motive for behavior.
The restructuring of the motive system is accompanied by an increase in mental dependence on alcohol and a violation of the structure of activity, which is increasingly subordinated to the need to purchase alcoholic beverages. The need for alcohol becomes dominant in the motivational sphere. Distant motives disappear, and behavior is regulated by neighbors, among which the main and semantic - alcohol. Violations of mediation of the need for alcohol develop, in connection with which immediate drinking becomes necessary. This pushes the alcoholic to obtain the necessary material resources by all means available to him, including illegal ones.
Recently, alcoholism among women has become more common. Female alcoholism has a number of features. Alcoholism in women develops at a faster rate and is more severe in its manifestations than in men. However, there are conflicting data indicating a milder course of alcoholism, which does not allow evaluating female alcoholism as malignant. Unlike men, a pathological attraction to alcohol in women is formed in the first 1-2 years of alcohol abuse, and during the same time, physical dependence on alcohol, i.e., withdrawal symptoms, is revealed. Alcoholic personality changes in women are detected more rapidly, accompanied by sexual licentiousness, social degradation.
Despite different points of view, most authors currently view dipsomania as a manifestation of alcoholism. True dipsomania (binge) is a rare disease. It must be clearly distinguished from the so-called pseudo-dipsomania or false binge - one of the usual types of chronic alcoholism, in which the habitual use of alcoholic beverages is uneven due to external circumstances. True dipsomania has no dependence on such circumstances. It is characterized by periodically occurring insurmountable attacks of a painful craving for alcohol. Most often, a state of binge is preceded by a sleep disorder, a feeling of anxiety, they become embittered, irritable. They have a complete loss of interest in work, communication with friends and relatives. Often there is a feeling of some kind of unaccountable excitement and fear.
One of the characteristic precursors of a dipsomatic attack can be olfactory hallucinations in the form of the smell of vodka and alcohol.
It is interesting to note that after binge, patients do not experience the slightest attraction to alcohol. Rather, the opposite can be noted - alcoholic drinks arouse a sense of disgust in them, they lead a sober lifestyle, sincerely repent of their alcoholic excesses, condemn their behavior, and are sure that this will not happen again. But after a few weeks, months, sometimes even years, the above conditions again arise, irresistibly attracting the patient to alcohol. During a drunken attack lasting several days, sometimes weeks, alcohol is absorbed in huge quantities, up to several liters per day. Patients eat almost nothing, live in the full sense of one vodka. If there is no money to purchase it, they don’t stop at anything, go for deception, stealing, drink various surrogates, including denatured alcohol and varnish. An attack usually ends abruptly with a sudden onset of disgust for alcohol, which also differs from the false binges of chronic alcoholics, in whom there is a gradual decrease in the number of drinks consumed - a kind of gradual attenuation of binge.
Dipsomania treatment requires persistence and duration. An attack should be broken off in stationary conditions, where patients should undergo a thorough examination in connection with the possibility of the presence of other diseases, in particular epilepsy and circular depression. In such cases, in addition to anti-alcohol therapy, appropriate treatment should be carried out aimed at combating these diseases.
Forensic psychiatric assessment of dipsomania should take into account the severity and irresistibility of the attraction to alcohol, the dependence of this attraction on the general change in mood and mental state, on the possibility of attributing this attack to the circle of depressive experiences of circular psychosis or dysphoria of epileptic genesis; in cases of the establishment of such a relationship, it is natural to make an exclamatory decision and referral to compulsory treatment. Outside of a fit of binge, dipsoman should be considered sane.
Alcoholic psychoses are psychoses, the occurrence and development of which are associated with alcoholism, and the clinical picture is expressed in an exogenous type of reaction, with gross violations of the reflection of reality and psycho-organic disorders.
Alcoholic psychoses are various in clinical manifestations and course of mental disorders occurring in stages II and III of alcoholism. Alcoholic psychosis develops not in connection with the direct action of alcohol, but under the influence of its decay products and products of impaired metabolism. In particular, the most common psychoses - delirium and hallucinosis - usually occur not during the period of hard drinking, i.e. at the height of alcohol intoxication, and during withdrawal, when the alcohol content in the blood decreases sharply. In people who do not suffer from alcoholism, alcoholic psychoses do not appear even with exceptionally large doses of alcohol (milks). Often the onset of psychosis is preceded by additional harmful effects - injuries, acute infectious diseases, mental stresses that contribute to the development of a psychotic reaction from the altered central nervous system of patients with alcoholism.
Delirium tremens (alcoholic delirium)
Delirium tremens is the most common acute alcoholic psychosis that occurs in chronic alcoholics as a result of prolonged abuse of alcohol. The frequency of delirium development increases with age, which is associated both with the somatic state of patients and with the duration of the disease. With the greatest constancy, delirium occurs in the 7-10 year of alcoholism. Significantly more often in comparison with female alcoholism, this form of psychosis is observed in men.
In the etiology of this disease, in addition to alcohol itself, it seems that those painful disorders in the human body as a whole and primarily in the liver that are the result of prolonged alcohol intoxication are of great importance. The development of delirium tremens can be promoted by various additional harmful effects, such as trauma, infections and mental shocks. 39
Alcoholic delirium is a hallucinatory stupor of consciousness. This form of psychosis is characterized by:
- the prevalence of true visual hallucinations, illusions and pareidolia;
- pronounced motor excitement in combination with a strenuous affect of fear and figurative delirium;
- disorientation in time, place along with the preservation of self-consciousness.
The duration of delirium tremens is generally from 2 to 8 days.
Delirium tremens usually begins with a period of precursors, usually short-term. The precursors of psychosis are insomnia, nightmares, awakening from which the patient can not really perceive the environment for a long time. Separate images of dreams in the form of visual and auditory deceptions of feelings invade reality, scare and confuse it. Characteristic of such conditions is an increase in limb tremor present in chronic alcoholics. It is interesting to note that sometimes during such a pre-hot condition, the desire for wine and the need for it completely disappear in patients. They stop drinking, as alcohol begins to cause them disgust. The attack of delirium tremens itself occurs suddenly, sharply, usually at night, by a massive influx of hallucinatory experiences, primarily visual ones. In most cases, various small animals are seen: spiders, rats, snakes, mice, cockroaches, etc., that run around the patient, climb on it, bite, sting. Frightening faces of some people appear: robbers, stalkers, freaks. Sometimes these figures and faces are absolutely fantastic: then they are very small, then, on the contrary, they are prohibitively large, distorted, reminiscent of monsters. They threaten the patient with various terrible tools: knives, saws, axes, send pistols and guns at him. Blood is seen all around. Most often, such experiences are accompanied by auditory and tactile hallucinations. The patient hears screams for help, screams, threats, curses. Insects fly around it with a characteristic buzz, mice squeak, snakes hiss, etc. mosquitoes and spiders bite him, climb into his nose, mouth, ears. He tries to shake them off, clearly sensing how they fit on him, feeling the rough touch of their legs, painful injections of their stings. There are also such white-hot experiences in which the main action is played out somewhere outside the window of the room, behind the door in the corridor. Although the patient does not see, he clearly feels that something terrible is happening there: his children are being killed, his wife is raped and slaughtered, etc. He hears their cries for help and at the same time knows that they will now burst here, to him. In a hurry, he frantically arming himself with anything and everything and waiting for the attack of his tormentors or rushing to meet the shouting - to save his relatives. Sometimes delirium tremens occurs on the road, in the train. Then the patients begin to rush from wagon to wagon. In all they see enemies who want to kill them, throw them out of the car under the very wheels. In desperation, they jump on the move from the train or do any other meaningless and dangerous actions.
If we take into account that all the experiences described above are felt by patients with complete reality, then the great danger posed to those around them by a person in this state becomes clear. Any household item in his hands turns into an instrument of aggression. Protecting himself from imaginary danger and imaginary enemies, he himself becomes the perpetrator of various offenses, among which in the first place are serious injuries and even murders. The picture of delirium tremens is so vivid and obvious that there can hardly be any doubt about the presence of a mental illness when conducting an examination about committed illegal actions, and naturally, the responsibility of patients is completely removed and such persons are recognized insane at the time of the crime.
Alcoholic hallucinosis accounts for 5-11% of the total number of alcoholic psychoses, ranking second after prevalence after delirium. Alcoholic hallucinosis is much more common in women with alcoholism. Like delirium tremens, alcoholic hallucinosis is a disease that occurs in chronic alcoholics as a result of prolonged long-term abuse of alcohol.
The main symptom of alcoholic hallucinosis that distinguishes it from delirium tremens is that it proceeds against the background of a clear consciousness and intact orientation. In the clinical picture, a clear predominance of auditory hallucinations is noted, while with delirium tremens, visual impairment in the form of illusory and hallucinatory experiences is in the first place. Auditory hallucinations are mainly perceived in the form of voices - male, female, children's. Their reality is complete. Most often, not addressing directly to the patient, they conduct a conversation among themselves about him, scolding him, insulting and threatening the most severe reprisals and punishments. Phrases like the following are constantly heard: “drunkard, thief, get to you”, “he won’t leave us - it’s all the same to him”, “we will cut into pieces”, etc. Sometimes voices are accepted to argue about the patient: one proves the need for immediate and most cruel reprisals against him, others tend to defend him, offering to mitigate the punishment and reduce him. In some cases, voices, listing all the details of the patient's life, begin to mock him. Becoming mocking, they ironically evil over certain events of the past and thereby lead the patient into a rage. Often, threats are directed not at the patient himself, but about his family and relatives. Voices threaten to kill, mutilate, rape. At the same time, and as if to confirm this, the patient hears cries for help from his wife, children, relatives. In these cases, visual illusions in the form of bloodied corpses, some ominous images, armed people brandishing knives, etc. can also join. but such hallucinations are less vivid than the white-hot ones, and arise only in special conditions - in the dark and with eyes closed.
Hallucinatory experiences with alcoholic hallucinosis contribute to the formation of persecution ideas that turn into direct delusional experiences. The patient begins to believe that a gang of some enemies and intruders arranges surveillance of him and his family. Some “spies” and “bandits” want to kill and rob them. In accordance with this, general anxiety, fear develops. The patient's actions fully reflect these experiences and fears. He runs away, hides, does things incomprehensible to those who watch him from the outside: he hides valuable things, buries them, and stores them; invites relatives to immediately go somewhere far away, to hide, etc. Naturally, such experiences can lead the patient to commit a wide variety of offenses.
Unlike alcohol delirium in hallucinosis, consciousness is not clouded - patients are correctly oriented in place and time, are accessible to contact, retain memories of their experiences and behavior in a psychotic state.
Treatment of chronic alcoholic hallucinosis, especially with a long course, does not lead to the desired results. However, persistent therapy, subject to complete abstinence from wine, can free some patients from hallucinatory experiences.
Alcoholic paranoid is an acute or chronically occurring psychosis with systematic delusions, in the clinical picture of which there are ideas of persecution, jealousy, poisoning, etc. Here, however, such a variety of delusional experiences that occurs in schizophrenia is not noted, and the picture of persecution or, more often, jealousy comes to the fore. In the clinical picture of the state of chronic alcoholics expressing crazy ideas of jealousy, there is always a general delusional assessment of the reality and a delusional attitude towards most of the people they have to deal with. This delusional assessment takes a wide variety of clinical forms: here are delusional ideas of persecution, and attitudes, and poisoning, and significance, and sometimes even greatness. It is characteristic that alcoholic paranoid arises more likely as primary delirium, independent of hallucinations, and the structure of its occurrence and development proceeds more often according to the paranoid type, with a known dependence on external psychogenic motives. However, there are paintings and definitely paranoid structures, when much depends on hallucinatory experiences, which further contribute to the formation of crazy ideas and give them one or another specific form and fill them with a certain content.
In those cases when the experiences of a chronic alcoholic are limited to ideas of jealousy, there are only certain characterological features that are sharpened by the specific influence of prolonged alcohol intoxication in this regard. Naturally, the forensic psychiatric assessment of this condition does not go beyond the general provisions that exist during the examination of offenses committed by a chronic alcoholic, i.e. persons are recognized as responsible and responsible for their offenses. In alcoholics with psychopathic traits of character traits in a certain real situation, the emergence of overvalued ideas of jealousy and paranoiac development with a predominance of experiences associated with the ideas of jealousy.
Fundamentally, things change when ideas of jealousy begin to take on a delusional character, i.e. the formation of alcoholic paranoid as a disease begins. We are talking about the formation of an alcoholic paranoid, and not the alcoholic delirium of jealousy because in this case the transition of ideas of jealousy into a delusional form does not occur in the form of a quantitative increase and increase in the intensity of painful experiences, but as a qualitative change in them. Now the circle of painful experiences is not closed by one idea of jealousy. If it plays a leading role, it is still accompanied by a number of delirious experiences: ideas of persecution, attitude, poisoning, etc., i.e. gives a framed picture of the paranoid syndrome as a whole.
Korsakovsky psychosis (Korsakov’s disease) is a disease that occurs in people who have been abusing alcohol for a long time, especially from those who drink various kinds of surrogates (crude alcohol, moonshine, etc.). Korsakovsky psychosis develops mainly at the final stage of alcoholism.
In the picture of mental disorders, characteristic memory disorders come to the fore. The ability to remember is significantly impaired. The patient is not able to answer the simplest questions, namely, did he have dinner or not, did someone just come to him, etc. He greets the doctor or sister many times, as soon as they leave the room, he no longer remembers whether he saw them or not, and therefore those who entered her again after a few minutes are first seen for him. In a conversation, he instantly forgets what he said and heard from others, and because of this he is able to repeatedly ask about the same thing and repeat what has been said. Memory gaps are filled up with pseudo-reminiscences and confabulations. A characteristic feature of these symptoms in Korsakov’s disease, in contrast to progressive paralysis or other organic psychoses, is the absence of an element of fantasticness and unreality in them. The patient tells about events that, perhaps, did not take place in his life in the form that he reports about them, but, taking into account his position and lifestyle before the illness, it is entirely possible to assume that they occurred. Most often, what was reported to the patient actually happened to him several months or years ago before the illness, for example, a patient who has been in the hospital for a long time tells the doctor that he returned from a business trip or from a rest house yesterday, that he had a meeting, was at an exhibition or in a theater.
Disorders of memory on current events explain sharply expressed orientations in space and time in those suffering from Korsakov psychosis. But, despite severe memory impairment, the perception and thinking of such patients is much less altered, and therefore the core of the personality remains intact.
In treatment, immediate and complete cessation of alcohol consumption comes first. One fulfillment of this prerequisite may lead to the reverse development of the symptoms of the disease.
The forensic psychiatric significance of Korsakov’s disease is small, firstly, because this nosological form itself is very rare. The question of exclusion is only in those cases when it is possible to prove with certainty that criminal actions were the result of painful memory impairments, if there are memory defects with which the patient has learned to cope to a certain extent, and his personality as a whole is sufficiently preserved, sanity is the crime is not in doubt.
Like Korsakov’s psychosis, alcohol pseudo-paralysis develops in individuals who have long been abusing alcoholic substitutes. A predisposing moment to its development is a sharp eating disorder with metabolic disturbance, observed to a particularly high degree in some alcoholics, accompanied by vitamin deficiency phenomena. In the mental sphere of such patients, the phenomena of intellectual degradation come to the fore. The patient does not realize his inferiority, does not notice the committed miscalculations and errors. The mood background is dominated by a complacent, euphoric. At the same time, a reappraisal of his personality begins to develop, which takes on the form of an absurd delirium of greatness in the expressed stages of the disease. Further development of the disease leads to a certain decrease in mental activity, which is why productive symptoms in the form of hallucinatory and delusional experiences fade, lose their character of system, and patients are in a state of lethargy and indifference to the environment.
On the neurological side, with alcoholic pseudo-paralysis, a sluggish reaction of the pupils to light, some dysarthria of speech, pain in the limbs are noted. With milder forms, pupil reflexes may not suffer, and only disturbances in tendon reflexes, pronounced tremor of the fingers, polyneuritic phenomena are observed.
The disease is very rare and its forensic psychiatric significance is extremely small. Naturally, in all those cases when during the period of criminal acts the psychotic symptoms in the form of hallucinatory and delusional experiences and the degree of intellectual decline and degradation made it possible to diagnose pseudo-paralysis, the expert came to recognize such a subject as insane.
Treatment and prevention of alcoholism
The treatment of patients with alcoholism is closely related to their rehabilitation and rehabilitation.
Alcoholism is a disease from which the patient himself, his relatives, relatives and society suffer. Treatment of suffering from alcoholism, taking into account the alcoholic changes in the psyche, degradation should be carried out even if the patient has no desire to be treated. The physician should use his best efforts to convince himself of the need for voluntary treatment and absolute subsequent abstinence from drinking alcohol. Treatment should be started as soon as possible.
Treatment of a patient with alcoholism should be comprehensive (taking into account the methods of treatment used), individual (based on personality traits, stage of alcoholism), long and continuous. Treatment of the patient should be aimed at the patient's awareness of his illness, the restructuring of his attitude to the previous environment, and sometimes changes in the whole way of life, completely eliminating the use of alcohol. This is achieved by various methods of psychotherapy and a change in the microsocial environment.
Drug therapy is aimed at restructuring the pathogenetic mechanisms that support the craving for alcohol. This is achieved by the use of calcium salts, glycerophosphate, magnesium sulfate. All this not only normalizes salt metabolism, but also reduces emotional stress, causes a sedative effect. At the same time, it is necessary to regulate mental processes, which, along with psychotherapy, is achieved by the appointment of small tranquilizers: seduxen, tazepam, grandoxin, which reduce tension, sadness, anxiety. Treatment is prescribed that contributes to the normalization of impaired functions of internal organs and the restoration of the vitamin composition in the body, especially B vitamins.
Actually, anti-alcohol drug therapy is aimed at developing an aversion to alcohol, sensitizing the body to it. Aversion to alcohol is caused by the development of conditioned reflexes. Most often, a nausea-emetic reaction to alcohol is produced by apomorphine therapy. From 0.2 to 1.5 ml of a 1% solution of apomorphine is injected subcutaneously to the patient before inducing vomiting. When approaching the onset of vomiting, the patient is given 50 ml of an alcoholic drink. Treatment is carried out until the conditioned reflex emetic reaction to alcohol is firmly established.
For the prevention of alcoholism, a complex of social and medical measures is used. All work on the organization of the identification and treatment of alcohol abusers should be carried out against the background of a widely organized anti-alcohol education of the population.
There are 3 stages of prevention:
- primary prevention - the prevention of drunkenness and the occurrence of alcoholism;
- secondary prevention - comprehensive treatment with subsequent courses of anti-relapse therapy;
- tertiary - social rehabilitation and rehabilitation of patients.
The most effective measure to prevent alcoholism is the anti-alcohol education of the younger generation. Great importance should be attached to sanitary-educational work, the purpose of which is to familiarize the population with the effect of alcohol on the body, including its small doses, with the risk of the formation of alcoholism as a disease.
In the fight against alcoholism, it is important to overcome centuries-old traditions associated with lifestyle, social psychology of a person. Today, not everyone understands and soberly assesses the complexity of the work ahead. Campaigning only compromises the fight against alcoholism. In studying the social causes of drunkenness and alcoholism, new approaches are required in conjunction with the problems of hygienic education of the population, taking into account the psychology of modern man.
Forensic Psychiatric Examination
Persons suffering from alcoholism who commit unlawful acts are at high risk — more often, offenses are committed while intoxicated.
Forensic psychiatric assessment of people with alcoholism, as a rule, does not present significant difficulties. Given the presence of a number of mental disorders in this disease and at the same time the absence of gross changes in perception, thinking, consciousness of the motor-volitional sphere of facial tone, criticism, they are not deprived of the ability to be aware of and direct their actions, therefore, as a rule, they are recognized sane.
When examining the person who committed the offense while intoxicated, all the features of the clinical picture of intoxication are taken into account, for which investigative data are very important, as well as anamestic and clinical data obtained during forensic psychiatric examination, which can either confirm the diagnosis of this condition or exclude, which is especially important in cases of road traffic offenses.
The offending behavior of alcoholics is usually characterized by passivity and is not the result of thoughtful decisions, a form of meaningful, mature views, clear positions. Many offenders of this type, especially from among the many times convicted persons of older ages, are inactive and inert, indifferent to themselves and others.
A patient with alcoholism is recognized insane only when he has persistent dementia, which excludes the patient's ability to recognize the factual nature and social danger of his actions and to direct them. By the decision of the court, medical measures may be applied to this person.
In accordance with the Criminal Law of the Republic of Latvia, a person who has committed a crime while intoxicated is subject to criminal liability. If it is established that a person suffers from alcoholism and needs compulsory treatment, then the convict, along with the punishment, may order compulsory treatment at the place of deprivation of liberty.
Another type of clinical picture of pathological intoxication is paranoid or hallucinatory-delusional syndrome, which is characterized by the appearance of delirium, stereotypic motor and speech excitement against the background of twilight dizziness. The difference between pathological intoxication is the inability of a person in this state to contact with others, to joint actions. His actions do not follow from the environment, but at the same time they often represent outwardly ordered actions.
During forensic psychiatric examination, it is important to obtain data on the events that the subject remembers and compare to what extent they coincide with reality. When detaining people in pathological intoxication after an offense, they, unlike people in simple alcoholic intoxication, do not show aggression, excitement, but passively submit to those who detained him. The examination of the perpetrators of the offense while intoxicated is the most frequent and at the same time complicated, because the sanity of a person depends on the solution of the question in which state of intoxication the offense is committed.
Examination of legal capacity in chronic alcoholism and other drug addictions occupies a significant place in forensic psychiatric examination in the civil process. Peculiarities of the psyche of chronic alcoholics with their inherent general moral coarsening, callousness, selfishness, creating an intolerable atmosphere in the family, their attraction to alcohol, for which all money is drunk, taken out of the house, things are sold and exchanged in the most unfavorable way, and obviously flawed transactions are made, they can often give rise to determining the legal capacity of such persons and their right to conclude property transactions, raise children, be married, etc. It is clear that these issues must be addressed in a strictly individual order, taking into account the totality of the subject’s behavior, his general mental state, and the degree of moral and intellectual degradation. In addition, the question may be dealt with that a chronic alcoholic could be at the time of his civil act in a prepsychotic, postpsychotic or even psychotic state. Of particular note is the question of assessing the condition of a test subject under the influence of alcohol, during which property transactions or other civil law relations can often occur.
In cases where alcohol abuse, reaching a degree of chronic alcoholism, occurs in people suffering from some kind of mental illness, for example, schizophrenia, epilepsy, syphilitic psychosis, etc., and these patients commit an offense or civil law actions, in respect of which their sanity or legal capacity should be determined, the question is decided depending on the state of their underlying disease.
The problem of alcoholism is one of the most important socio-medical problems. This is due to the fact that as a result of the widespread use of alcohol among the population and an increase in the number of alcohol abusers, enormous harm is done to the health of the population and society as a whole. The harm caused to society by alcohol abusers is manifested in the large volume of offenses that these people commit while intoxicated.