Alcohol and Tobacco (eBook)

Otto Michael Lesch, MD is currently President of the Austrian Society of Addiction Medicine, Head of the Alcohol Research Group of the Medical University of Vienna, Department of Psychiatry and Psychotherapy. Since 1972 he is responsible for longterm studies in alcohol dependence. He organized many international clinical trials and basic research in alcohol and tobacco dependence. He served 12 years as secretary of ESBRA and organized European networks for alcohol research. He always bridged the gap between basic and clinical research and developed clinical used tools to define subgroups of addiction for better treatment approaches. His assessment tools are now available in many different languages (www.LAT-online.at). Henriette Walter, MD, is University Professor at the Dept. of Psychiatry and Psychotherapy.  She is a member of the Senate and of many commissions of the Medical University, Vienna. Dr. Walter is working in the field of alcoholism since more than 20 years, both, practically and scientifically, with over 200 publications. She is secretary of the ‘AUSAM, the Austrian Society of Addiction Medicine and an ESBRA board member. She is associate editor of the Journal “Hypnose”, a field in which she takes an active scientific interest since 1982. With the “theory of frontalisation” as the neuro-equivalent for the hypnotic state, she contributed to the neuroimaging research in this field. She gives regular training courses in medical hypnosis. Christian Wetschka, PhD.is socialpedagogue, working in diverse socialtherapeutic and pastoral fields, supervisor, founder of Verein Struktur, which provides commune-flats for alcohol dependent persons Michie N Hesselbrock, PhD is Professor Emeritus at the School of Social Work, and Professor of Psychiatry at the School of Medicine, University of Connecticut.  She held the Zach’s Chair,  and was the founder and director of the PhD program at the School of Social Work before her retirement.   She has served on several NIH study sections and VA Merit review committees as a regular member and as an ad hoc reviewer.   Her research interests include epidemiology, behavior genetics, and health disparities of alcoholism and treatment Victor Hesselbrock, PhD  is currently Professor and Interim Chairman, Department of Psychiatry, University of Connecticut School of Medicine.  He holds the Physicians Health Services endowed chair in Addiction Studies.  Dr. Hesselbrock is the Principal Investigator and Scientific Director of the University of Connecticut’s NIH/NIAAA funded Alcohol Research Center and is co-PI of the NIH funded national Collaborative Study on the Genetics of Alcoholism (COGA).  He is a past President of the Research Society on Alcoholism (RSA).  Dr. Hesselbrock is Associate Editor of Alcoholism: Clinical and Experimental Research, a Review Editor for Addiction, and a member of the editorial board of the Journal of Studies on Alcohol and Drugs.  His research interests include: the genetic epidemiology of alcoholism; co-morbid psychiatric conditions and substance dependence; and psychosocial, cognitive, and genetic risk factors for developing alcohol dependence and alcohol-related problems.

Alcohol and Tobacco 2
Acknowledgements 4
Foreword 5
Foreword 7
Statement 8
Table of contents 9
1 Information about the origination of this book 16
1.1 Aims of this book 17
1.2 Personal reasons for the rstauthor writing this book 18
2 Addiction – a short overview of a widespread disease 20
2.1 Introduction 20
2.2 Prevention 21
2.3 The Diagnosis addiction 21
2.4 Aetiology of addiction 22
2.5 Secondary disorders andaddiction 23
2.6 Secondary diseases and brainfunctions 24
2.7 Subgroups of addicts 24
2.8 Motivation of addicts 24
2.9 The path from motivation totherapy 25
2.10 Addiction and relapse 25
2.11 Specific groups of addicts 26
2.11.1 Co-morbidity of tobacco andalcohol-addiction 26
2.11.2 Overweight, eating disorders 26
2.11.3 Gender 27
2.12 Addiction and the homeless 27
2.13 Polytoxicomania 27
2.14 Non-substance dependence 28
3 Aetiology of addiction 29
3.1 The psycho-socio-biologicalmodel 29
3.2 Psychological theories 29
3.2.1 Behavioural approaches 30
3.2.2 Models of depth psychology 31
3.2.3 Depth psychological approach 32
3.2.4 Ego-psychological approaches 32
3.2.5 The psychological model of objectrelations 33
3.2.6 Theoretical approach of Narcissism 33
3.2.7 Explanation models according tofamily psychotherapy 34
3.3 Social explanation approaches 34
3.4 Biological theories about theaetiology of tobacco and alcoholaddiction 36
3.4.1 Important ndings about tobaccoand alcohol use from basic research 36
3.4.2 Aspects of alcohol and tobaccometabolism 37
3.4.3 Maternal tobacco and alcohol useduring pregnancy: a risk factor for the offspring? 39
3.5 Aetiological aspects of tobaccoand alcohol dependence from anepidemiological perspective 44
3.6 Aetiology of addiction from apsychiatric perspective 47
4 Prevention strategies 50
4.1 Attitudes towards addictivedrugs 50
4.1.1 Attitudes towards alcohol consumption 50
4.1.2 Attitudes towards tobaccoconsumption 52
4.2 Primary prevention of tobaccoand alcohol addiction 53
4.3 Secondary prevention: earlydiagnosis and intervention 55
4.3.1 Conclusions for secondaryprevention 56
4.4 Tertiary prevention(see chapter 9) 59
5 Diagnosis of abuse and addiction 60
5.1 Problems concerningpsychiatric diagnoses 60
5.2 Development of the term“addiction” 61
5.3 Substance related diagnoses inthe ICD-10 62
5.3.1 Harmful use (ICD 10 F10.1, F 17.1) 63
5.3.2 Dependence syndrome(ICD 10 F10.2, F 17.2 ) 63
5.3.3 Withdrawal state (ICD 10 F10.3) 64
5.4 Substance-related diagnosisin DSM-IV (American PsychiatricAssociation. 1994) 65
5.4.1 DSM-IV and the multidimensionaldiagnostic in ve axes 65
5.4.2 Diagnosis according to DSM-IV axis I 65
5.4.3. Speci ers de ning subgroups ofdependence 67
5.4.4 Therapeutic approach 68
5.4.5 Withdrawal symptoms of tobaccoand alcohol 68
5.5 Commonalities and differencesof ICD-10 and DSM-IV 69
5.6 Implication of theseclassi cation systems for therapyand research 69
5.6.1 Alcohol 69
5.6.2 Tobacco 74
6 Types, dimensions and aetiology 76
6.1 Alcohol addiction 76
6.1.1 Development of typology research 76
6.1.2 Important typologies for researchand practice 77
6.1.3 Assessment of severity in differentdimensions 82
6.2 Tobacco addiction 84
6.2.1 Smoking typology according toSchoberberger and Kunze 84
6.2.2 Smoking Typology according toFagerstroem 84
6.2.3 European smoking classi cationsystem 86
6.3 Alcohol addiction –Lesch’s typology 87
6.3.1 Framework for the de nition ofLesch’s typology 87
6.3.2 Alcohol addiction from a longitudinalperspective 1976–1982–1995 88
6.3.3 The “Burgenland Modell” 88
6.3.4 Methodology of the longitudinalstudy on alcohol dependent patients(according to DSM-III and ICD-9), used forthe development of Lesch’s typology 90
6.3.5 Stability in the longitudinal course 92
6.3.6 The four long-term illness coursesused for Lesch’s typology 95
6.3.7 Results of studies using the Leschtypology 97
6.3.8 Lesch’s typology from an internationalcomparative perspective 104
6.4 The relationship betweenalcohol dependent patients accordingto Lesch’s typology and theseverity of tobacco addiction 105
7 Motives for alcohol-and/or tobacco addicted patients to seekmedical help 108
7.1 Tobacco addiction 108
7.2 Alcohol addiction 108
7.3 Sequelae that bring patientsinto therapy 110
7.3.1 Tobacco and sequelae 110
7.3.2 Alcohol and sequelae 112
8 Detection of alcoholand tobacco addiction 132
8.1 Recommendations for the rstcontact 132
8.2 Assessment of drinking behaviourby using biological markers 135
8.2.1 Trait markers 135
8.2.2 State markers 135
8.2.3 Associated markers 136
8.2.4 Practical suggestions for the use ofbiological markers for forensic purposes 136
8.3 The clinical dialogue intobacco addiction 142
9 Therapeutic strategies in alcoholand tobacco addiction 144
9.1 Motivation for therapy indifferent settings 144
9.1.1 Motivational interviewing at thegeneral practitioner’s 144
9.1.2 Motivational interviewing in internalmedicine 145
9.1.3 Motivational interviewing duringpregnancy 145
9.1.4 Motivational interviewing inpsychiatric settings 145
9.2 Pharmacotherapy of alcoholand tobacco addiction 147
9.2.1 Alcohol addiction 147
9.2.2 Tobacco addiction 151
9.3 Pharmacotherapy of alcoholwithdrawal 154
9.3.1 Withdrawal syndrome 154
9.3.2 Therapy of withdrawal states 154
9.3.3 Therapy of the withdrawal syndromesaccording to Lesch’s typology 158
9.3.4 Complications in alcohol withdrawal 164
9.4 Alternatives to withdrawal 166
9.4.1 Gradual reduction of drinkingamount, “ Cut down drinking”,method according to David Sinclair 167
9.4.2 Case study: “Cut down drinking” 168
9.5 Pharmacotherapy of tobaccowithdrawal syndrome 169
9.5.1 Symptoms of the tobaccowithdrawal syndrome 170
9.5.2 Therapy of the tobacco withdrawalsyndrome 171
9.6 Medical strategies for relapseprevention 172
9.6.1 General guidelines for relapseprevention 172
9.6.2 Goals for relapse prevention 173
9.6.3 Medication against so-called“ positive” craving (= desire forpleasurable, rewarding effects of theaddictive substance) 174
9.6.4 Pharmacotherapy against theso-called “ negative” craving (= desire foraddictive substances to relieve negativemood and anxiety) 175
9.6.5 Pharmacotherapy in relapseprevention in dependent patients 176
9.6.6 Relapse prevention according toLesch’s typology 177
9.6.7 Treatment of relapses according toLesch’s typology 182
9.6.8 Pharmacotherapy of relapse preventionin tobacco dependents 183
10 Sociotherapy of alcohol-andtobacco dependents with regardsto Lesch’s typology 191
10.1 Alcohol and Tobacco 191
10.2 The sociotherapeutic1 mission 192
10.3 Classification Psychotherapy-Sociotherapy 197
10.4 Sociogenesis andsociotherapeuic chances 201
10.4.1 Primary, secondary and tertiarysociogenesis 201
10.4.2 Sociological factors ona macro-level4 202
10.4.3 Co-morbidity and marginal groupidentity 207
10.4.4 The link between social relationships(factors on a social micro level),group coherence and resilience 209
10.4.5 Analogy to Gerontology: an atrophyof the “ social atom” 211
10.5 Sociotherapy in the context oftherapeutic phases 214
10.5.1 Socio therapy location(s)(Schwendter 2000) 214
10.5.2 Therapeutic phases and settings 215
10.6 State of the Art: overlappingperspectives for sociotherapeutichousing and support projects foralcohol dependents 219
10.6.1 Standard categories 220
10.6.2 Excursus: supported housingprojects – worlds of their own 227
10.7 Motivation – a challenge forwhom? 235
10.7.1 Ambivalent functions of motivation 235
10.7.2 The relationship betweendependence and motivation systems 238
10.8 Sociotherapy as networkpromoter 240
10.8.1 Micro and meso levels ofnetworking 241
10.8.2 Macro levels of networking 247
10.9 Sociotherapy with alcohol dependents in the context of Lesch’s typology 248
10.9.1 The critical relationship between psychiatry and sociotherapy 248
10.9.2 Application of the typology in sociotherapeutic contexts 249
10.9.3 The relationship between type and self-regulation 251
10.9.4 Types and aims of therapy 255
10.9.5 Sociotherapeutic aspects oftherapy with alcohol dependents whoare fundamentally impaired in theirperformance 258
Appendix 1 Lesch Alcoholism Typology –Questionnaire 284
Appendix 2 Lesch European Smoker Classification 293
Index 356
About the Authors 362