MRCPsych Paper A1 Mock Examination 5: Questions
Melvyn WB Zhang, Cyrus SH Ho, Roger Ho, Ian H Treasaden, Basant K Puri in Get Through, 2016
A 25-year-old male has been seen by the addiction services and he has since been abstinent from alcohol for the past 3 months. However, he is still bothered by recurrent auditory hallucinations. Which of the following is the most likely clinical diagnosis? Alcohol withdrawalDelirium tremensAlcoholic hallucinosisDelusional disorderSchizophrenia
Intoxicants
Michael Y. Wang, Andrea L. Strayer, Odette A. Harris, Cathy M. Rosenberg, Praveen V. Mummaneni in Handbook of Neurosurgery, Neurology, and Spinal Medicine for Nurses and Advanced Practice Health Professionals, 2017
Alcoholic hallucinosis occurs in approximately 30% of patients experiencing alcohol withdrawal (Sarff and Gold, 2010, p. S495). Delirium tremens generally occur within 48–72 hours after the last drink in about 5% of alcoholics, but carry a mortality rate of 5%–15%, with early identification being key to increasing the effectiveness of therapies (Mehta, 2016, p. 29). Delirium tremens are characterized by fluctuating levels of consciousness, attention and cognitive deficits, confusion, hallucinations, and hypertension. If not managed effectively, delirium tremens can lead to cardiovascular and respiratory collapse, electrolyte imbalances, arrhythmias, dehydration, and multiorgan dysfunction (Sutton and Jutel, 2016, p. 30).
Barbiturates, Alcohol, And Tranquilizers
S.J. Mulé, Henry Brill in Chemical and Biological Aspects of Drug Dependence, 2019
Upon cessation of drinking, the alcoholics’ symptoms of intoxication subside over a period of six to eight hours. This is followed by the onset of a characteristic abstinence syndrome. The severity of acute withdrawal symptoms may be categorized in the following manner: i. mild to moderate: primarily neuromuscular and gastrointestinal symptoms. The patient displays anorexia, nausea, epigastric distress, tremulousness, sweating, apprehension, and insomnia;ii. severe or impending delirium tremens: diarrhea, vomiting, nightmares, and agitation occur in addition to those symptoms listed above. Autonomic hyperactivity is observed, as well, manifested as tachycardia, hyperpnea, and fever;iii. delirium tremens: in addition to all the above symptoms, psychotic manifestations are seen. Hallucinations (tactile, auditory or visual), delusions, muttering delirium, and paranoia occur.46 The hallucinations are usually of a threatening nature. A patient who exhibits only delusions and hallucinations, usually auditory, without signs of agitation, disorientation or autonomic hyperactivity, is usually described as exhibiting “alcoholic hallucinosis”.47 The patient displays incoordination, panic, disorientation, confusion, and clouded senses. Finally, grand mal seizures supervene, though occasionally they may be of the petit mal type.
Phenomenology and Course of Alcoholic Hallucinosis
Published in Journal of Dual Diagnosis, 2019
Venkata Lakshmi Narasimha, Rahul Patley, Lekhansh Shukla, Vivek Benegal, Arun Kandasamy
Third, this study helps inform the choice of treatment for alcoholic hallucinosis. We must note that there are two schools of thought regarding alcoholic hallucinosis—one that purports it to be a schizophrenia-like illness and another which views it to be akin of delirium tremens (Glass, 1989). As an extension, the choice of treatment is between agents that work on the gamma-amino-butyric-acid neurotransmission (e.g., BZD) or the dopaminergic system (e.g., antipsychotics). We observed that about 60% of patients had adequate symptom control with BZD itself. This is in contrast to a recent review that suggests antipsychotics as first-line treatment for AIPD (Masood et al., 2018). We believe that the most important reason for this is that our sample is dominated by “withdrawal hallucinosis.” We acknowledge that clinicians’ bias may have produced this finding. When you consider when a patient with ADS presents with new-onset hallucinations and mild alcohol withdrawal, one is inclined to start the treatment with BZDs as the first choice for two reasons. First, BZD will treat withdrawal syndrome and prevent seizures or delirium tremens. Second, if hallucinations respond well to BZD and do not recur, the clinician can be assured that the patient does not have a primary psychotic illness. Nevertheless, 40% of patients received an antipsychotic agent in addition to BZD, indicating that both the treatments should be considered for alcoholic hallucinosis. Fourth, we found an average gap of 14 years between the onset of dependence and the first episode of alcoholic hallucinosis. This is in line with earlier studies showing an early onset of dependence (20–25 years of age) and the development of psychotic symptoms in the late third decade of life (Jordaan et al., 2009). Jordaan and Emsley suggest that this gap between the onset of dependence and the appearance of psychosis distinguishes AIPD from a comorbid schizophrenic illness (Jordaan & Emsley, 2014).