Psychiatry · Year 3 · from Psychiatry

Case 1: Alcohol Use Disorder with Complicated Withdrawal

Patient Demographics

  • Age: 52 years old
  • Sex: Male
  • Occupation: Construction foreman (currently on disability leave)

Chief Complaint

"I've been shaking and seeing things since I stopped drinking two days ago."

History of Present Illness

The patient is a 52-year-old male presenting to the emergency department with tremors, diaphoresis, and visual hallucinations that began 48 hours after his last drink. He has a 30-year history of heavy alcohol use, currently drinking approximately one liter of vodka daily. He attempted to quit "cold turkey" after his wife threatened to leave him. Within 12 hours of his last drink, he developed hand tremors, anxiety, and nausea. Over the past 24 hours, symptoms have progressed to include visual hallucinations of insects crawling on the walls, which he recognizes are not real. He has not slept since stopping drinking. He denies seizure history but reports a prior hospitalization 5 years ago for alcohol withdrawal that required ICU admission. He has had multiple failed attempts at sobriety, with his longest period of abstinence being 3 months. He reports drinking to manage stress and to avoid withdrawal symptoms.

Mental Status Examination

Appearance: Diaphoretic middle-aged man, tremulous, flushed face with telangiectasias, appears older than stated age

Behavior: Restless, picking at bedsheets, frequent position changes, visible coarse tremor of hands

Speech: Normal rate, slightly slurred, coherent

Mood: "Terrified"

Affect: Anxious, fearful, appropriate to content

Thought Process: Linear but with intermittent confusion and difficulty maintaining focus

Thought Content: Preoccupied with withdrawal symptoms, fear of seizures, regret about drinking; denies suicidal ideation; insight that visual disturbances are not real

Perceptions:

  • Visual hallucinations: Seeing insects on walls (recognized as not real)
  • Tactile hallucinations: Intermittent sensation of bugs crawling on skin
  • No auditory hallucinations

Cognition: Alert but disoriented to date; attention impaired; short-term memory impaired; oriented to person and place

Insight: Fair - recognizes alcohol problem and need for treatment

Judgment: Fair - sought help appropriately when symptoms worsened

Physical Examination

Vital Signs:

  • Blood pressure: 168/102 mmHg
  • Heart rate: 112 bpm
  • Temperature: 100.4°F (38°C)
  • Respiratory rate: 22

Pertinent Findings:

  • Diaphoresis
  • Coarse bilateral hand tremor
  • Hepatomegaly
  • Spider angiomata on chest
  • Palmar erythema
  • CIWA-Ar score: 24 (severe withdrawal)

Psychiatric and Medical Workup

Screening Tools:

  • CIWA-Ar: 24 (indicates high risk for complicated withdrawal)
  • AUDIT: 32 (severe alcohol use disorder)

Laboratory Studies:

  • Blood alcohol level: 0 mg/dL (abstinent 48 hours)
  • Urine drug screen: Positive for alcohol metabolites only
  • CBC: WBC 11.2, MCV 108 fL (macrocytosis), platelets 98,000
  • CMP: AST 186, ALT 92 (AST:ALT ratio >2:1 classic for alcohol), albumin 2.8 g/dL, glucose 68 mg/dL
  • GGT: 342 U/L (elevated)
  • INR: 1.4
  • Ammonia: 68 mcg/dL (elevated)
  • Magnesium: 1.2 mg/dL (low)
  • Phosphorus: 2.0 mg/dL (low)

Diagnosis

Primary Diagnosis:

  1. Alcohol Use Disorder, Severe (F10.20)
  2. Alcohol Withdrawal with Perceptual Disturbances (F10.232)

DSM-5 Criteria for Alcohol Use Disorder - Severe (6+ criteria met):

  • Alcohol taken in larger amounts/longer than intended
  • Persistent desire or unsuccessful efforts to cut down
  • Great deal of time spent obtaining, using, or recovering from alcohol
  • Craving
  • Continued use despite social/interpersonal problems
  • Important activities given up due to alcohol
  • Continued use despite physical health problems (liver disease)
  • Tolerance
  • Withdrawal

Risk Factors for Complicated Withdrawal (Delirium Tremens):

  • Prior complicated withdrawal
  • Current severe withdrawal (CIWA-Ar >15)
  • Age >40
  • Concurrent medical illness (liver disease)
  • Heavy, prolonged drinking
  • Elevated vital signs

Treatment Plan

Acute Management - Medical Admission:

  • ICU monitoring given high risk for delirium tremens
  • Symptom-triggered benzodiazepine protocol (lorazepam preferred given liver disease)
  • CIWA-Ar monitoring every 1-2 hours
  • IV fluids with dextrose (after thiamine)
  • Thiamine 500 mg IV x 3 days, then 100 mg daily (Wernicke prophylaxis)
  • Folate 1 mg daily
  • Multivitamin
  • Electrolyte repletion (magnesium, phosphorus, potassium)

Pharmacotherapy for Withdrawal:

  • Lorazepam 2-4 mg IV/PO for CIWA-Ar >10
  • Maximum: lorazepam 8 mg/hour for severe withdrawal
  • If refractory, consider phenobarbital loading

Post-Withdrawal Treatment:

  • Naltrexone 50 mg daily OR Acamprosate 666 mg TID (choose based on liver function)
  • Consider disulfiram if highly motivated
  • Gabapentin 300 mg TID for residual symptoms and craving

Psychosocial Interventions:

  • Motivational interviewing during hospitalization
  • Referral to inpatient rehabilitation (28-day program recommended)
  • Alcoholics Anonymous introduction
  • Family therapy referral
  • Social work consultation for occupational and financial concerns

Follow-up:

  • Addiction psychiatry within 1 week of discharge
  • Primary care for liver disease monitoring
  • Consider hepatology referral

All cases for this lecture as Markdown