Clinical Neuropsychology of Alcoholism

Robert G Knight, Barry E. Longmore

• Publisher: Psychology Press
• Year: 2013
• ISBN:
  9781134833771
• Edition: 1
• Topic: Psychologie
• Subtopic: Histoire et théorie en psychologie

Alcohol abuse is a major health problem in most parts of the world. This book focuses on the way in which alcohol affects the brain, with the aim of describing advances in the neuropsychology of alcoholism in a way that makes this work accessible to clinicians from a variety of backgrounds who treat people with alcohol-related problems.; The book is divided into four parts. Part One provides an introduction to the medical and neurological conditions that can result from alcoholism, and to the process of neuropsychological assessment. The problems involved in conducting research in this area are also considered. In Part Two, research that focuses directly on changes to the nervous system is surveyed. This includes studies of both the short-term and the chronic neurological changes in the brain caused by alcohol. In Part Three, studies of the neuropsychological effects of acute intoxication, social drinking and alcohol abuse are described. Finally, in Part Four, the implications of neuropsychological research for the assessment and management of patients with alcohol problems are considered.
The objective of this book is to collate the range of research work that is relevant to understanding how alcohol affects the brain. This includes both the acute and the chronic effects, at both the biological and physiological levels.

CHAPTER ONE

Introduction

On this planet, ethanol is probably almost as old as life itself but in the universe it is probably much older. Large amounts have recently been detected adrift in the constellation Sagittarius.

Lieber (1982, p. xi)

The history of alcohol use extends back thousands of years. There is no record of where or how fermented drinks were first made, but few of the preliterate peoples did not discover or encounter alcohol at some stage of their development. Indeed only the indigenous peoples of Tierra del Fuego, the aboriginal tribes of Australia, and groups of Eskimos, did not learn about alcohol. In Europe, it is likely that mead made from honey was the earliest form of alcoholic drink. No doubt, however, ethanol was produced from whatever was available—fruit, berries, cacti, and tubers. With its ability to induce a sense of transcendent euphoria, alcohol came to be associated with times of celebration. Thus drinking came to be an integral part of ceremonies associated with rites of passage, the making of magic, the promotion of fertility, and preparations for war.

The ancient civilizations of the Middle East, the Babylonians, Hebrews, Sumerians, and Egyptians, left behind written inscriptions and frescoes providing us with evidence of a flourishing trade in wine and of their knowledge of the consequences of drunkenness. The benefits that flowed from drinking were lauded; the troubles that it provoked lamented. Alcohol has been a part of the Judaeo-Christian culture since the earliest times and there are numerous references to it in the Bible. In Genesis, one of Noah's first acts on alighting from the Ark was to till the ground and plant a vineyard. He was, however, innocent of some of the properties of the grape, which left him naked and drunk in his tent, to be discovered by his sons. Also to be found in Genesis is the story of how the daughters of Lot used wine to render their father senseless, before they lay with him to preserve his line. In the Old Testament we see both the beneficent and evil effects of alcohol. In Proverbs (31:6–7) the power of alcohol to provide solace is recorded: “Give strong drink to them that are sad: and wine to them that are grieved in the mind: Let them drink, and forget their want, and remember their sorrow no more”. There are also dire warnings: “Look not upon the wine when it is yellow, when the colour thereof shineth in the glass: it goeth in pleasantly. But in the end it will bite like a snake, and will spread abroad poison like a basilisk” (Proverbs 23: 31–35). It is also apparent that the Hebrews knew of the toxic effect of alcohol. The woman Hannah is observed moving her mouth in prayer without uttering words, and mistaken for a drunkard hallucinating.

In the world of the ancient Greeks, both mead and wine were well known. According to legend it was Dionysus, sometimes known as Bacchus, who brought them wine. The votaries of Dionysus were given to rituals of frantic ecstasy, in which alcohol played a part, giving them a sense of being at one with the god. Dionysus is often represented in opposition to Apollo, who exemplified the qualities of discipline, rationality, and purity. Drunkenness features on occasion in Greek writings. Antipater of Thessalonica writes, for example, of the cunningness of the habitual inebriate. Paton (1916, p. 455) quotes Antipater telling of the woman Bacchylis, known as “the sponge of Bacchus”, who once addressed the goddess Demeter in this manner:

“If I can escape from the wave of this pernicious fever, for the space of a hundred suns I will drink but fresh water and avoid Bacchus and wine”. But when she was quit of her illness on the very first day she devised this dodge. She took a sieve, and looking through its close meshes, saw even more than a hundred suns.

Elsewhere, this dedication is recorded: “Xenophon, the toper, dedicates his empty cask to thee Bacchus. Receive it kindly for it is all he has” (Paton, 1916, p. 341). Drunkards were artful in the pursuit of their addiction and left impecunious as a result. In addition to the psychosocial effects, the Greek physician Hippocrates also recorded the medical consequences. Amongst his Aphorisms he states that “If a drunk man suddenly becomes speechless in a fit, he will die after convulsions unless a fever ensues or unless, upon recovering from his hangover, he regain his voice” (Lloyd, 1978, p. 222). Elsewhere he teaches, with considerable justification, that “A shivering fit and delerium following excessive drinking are bad” (Lloyd, 1978, p. 231).

Viticulture was known to the Romans from the time of the founding of the city (Jellinek, 1976). Wine was celebrated by the Latin poets, and an evocative picture of the extravagant banqueting and drinking habits of rich freedmen is to be found in the Satyricon of Petronius. Seneca (p. 273) rails against the drinking bouts of his time in his Epistle on Drunkenness:

What glory is there in carrying too much liquor? When you have won the prize, and the other banqueters, sprawling asleep or vomiting, have declined your challenge to still other toasts; when you are the last survivor of the revels; when you have vanquished everyone by your magnificent show of prowess and there is no man who has proved himself of so great capacity as you—you are vanquished by the cask.

Many of the most prominent citizens of that time were notable drunkards, including the general Sulla, Mark Anthony, and Tiberius Claudius Nero. Of Anthony, Seneca (p. 273) wrote:

Mark Anthony was a great man, a man of distinguished ability; but what ruined him and drove him into foreign habits and un-Roman vices if it was not drunkenness and—no less potent that wine—the love of Cleopatra?

The Romans spread their knowledge and practice of viticulture both East, to the regions that were to form the Byzantine empire, and West through Europe. Cultivation of the grape occurred throughout Gaul and the Rhone valley, eventually crossing the channel to Britain (Sournia, 1990). To the North, the Germanic people brewed and consumed in great quantities beer made from barley and mead. Throughout the Middle Ages, wine drinking became increasingly popular in Europe. Wine was prescribed by doctors for its medicinal properties and cultivated extensively by the Church. The glories of wine were celebrated; the medical perils of excessive consumption were largely unknown. Typical of the medieval Latin lyrics exalting the pleasures of drinking are those found in the Carmina Burana, an anthology of such songs, thought to have been compiled at the monastery of Benedictbeureu, during the thirteenth century.

By the thirteenth century the Arabs had learned to distil ethanol from wine, which acquired the Latin name spiritus or aqua vitae. From the beginning of the sixteenth century, knowledge of the distillation of alcohol became widespread, and with it the opportunity to drink alcohol in the strength of 50% by volume, as compared with the strength of wine, which varied from 10–15%. The Dutch learned to make gin from grain and juniper berries and exported this skill and the product to England. Each nation distilled a preferred spirit: whisky in Scotland, vodka in Russia, arak in the Mediterranean countries, and schnapps in Germany. By the beginning of the eighteenth century the scale of drunkenness caused by gin and other spirits in England was becoming a matter of grave concern. Gin was blamed for the evils of poverty, disease, criminality, and chaos in family life. London was populated with numerous gin houses and there was widespread drunkenness among the poor and the rich. A compelling image of the time is Hogarth's “Gin Lane” with its debauched woman and abused child. With the advent of the industrial revolution came a greater concern for the physical effects of alcohol on productivity; no longer was drinking considered to be a way of enhancing the performance of the manual labourer. The tremors associated with inebriation, which Hippocrates and Galen had observed, were now labelled delerium tremens by Sutton, who, in 1813, observed this symptom in the sailors he ministered to, although he was unaware that the cause was alcohol abuse.

In response to the pervasive drunkenness and the associated civil problems in the early part of the nineteenth century, several temperance organisations were founded. The medical profession became increasingly aware of the damage that alcohol caused; the relationship between alcohol abuse and liver disease was established, and descriptions of the medical consequences of alcohol entered the literature. Benjamin Rush, often regarded as the father of American psychiatry, inveighed against alcohol, which he saw as undermining the fabric of colonial America. In 1784 he published a monograph entitled An Inquiry into the Effects of Ardent Spirits on the Human Mind and Body, drawing the attention of his colleagues to the ubiquitous social and organic damage caused by drunkenness. The public concern with inebriety is highlighted by the title of a pamphlet circulated at the time, which described America “as becoming a nation of drunkards” (Sournia, 1990).

The diagnosis of alcoholism was first used by the Swedish physician Magnus Huss, in his Alcoholismus chronicus, published simultaneously in Sweden and Germany in 1849. He lectured extensively on the threat that alcohol posed to the human body and to traditional Swedish values, based on his extensive clinical experience and travels throughout Europe. He characterised alcoholism as being both a mental and a physical disorder, and recognised the widespread organ damage caused by ethanol. Throughout the nineteenth century a scattering of medical and scientific publications described the chronic effects of alcohol abuse, but not until the latter part of the century was the body of work sufficient for the scientific study of the consequences of alcohol to be regarded as clearly established (Keller, 1966). By that time, the effect of chronic alcoholism on cognition was widely recognised (Blandford, 1884, pp. 67–68):

After years of habitual drinking, drinking which may hardly have amounted to intoxication, far less to delerium tremens, we may perceive the mind weakening, memory failing, and the dotage of premature age coming on; and not infrequently with the decrepitude of mental power, we notice some amount of body paralysis, which slowly advances at the same time ...

The concern of this book is with the changes in the brain caused by alcohol and the consequent changes in neuropsychological functioning that come with these lesions. The research we will be concerned with dates from the time in the late nineteenth century when Wernicke and Korsakoff first described the brain lesions they found in the brains of their chronic alcoholic patients. Wernicke's encephalopathy has come to be solely associated with alcoholism, although the first of the cases he described in 1881 was of a 20-year-old seamstress, who developed symptoms of ophthalmoplegia, ataxia, and drowsiness as a consequence of sulphuric acid poisoning. His other cases, however, involved chronic alcoholism. One was a woman who was admitted with delerium, hallucinations, and ophthalmoplegia, who died after 6 days in hospital. On autopsy, lesions were identified in the periventricular area and Wernicke (1881, p. 48) described her neurological condition as “an independent, inflammatory, acute nuclear disease in the region of the optic nerves”.

In 1887, Korsakoff provided the first detailed account of patients with an irreversible amnesic disorder associated with alcoholic peripheral nerve disease, which he called polyneuritic psychosis (Korsakoff, 1955). He identified the disorder in both alcoholic and non-alcoholic subjects and surmised that a common pathology and aetiology caused the disease. Many reports of memory disorder in alcoholism predated those of Korsakoff, a fact which he himself acknowledged, citing Magnus Huss as one such forerunner. However, the comprehensive nature of Korsakoff's description has ensured that there has been no challenge to his primary position in recognising this condition (Victor, Adams, & Collins, 1971). Korsakoff's view was that the amnesia was principally the result of cortical atrophy, and neither he nor Wernicke recognised the link between the two disorders they had identified. The history of the clinical description of chronic amnesia in alcoholism from the 1880s features the gradual appreciation of the link between Wernicke's encephalopathy and Korsakoff's amnesia and the discussion of the possible aetiological basis.

In formulating a cause for the aetiology of Wernicke's disease, and by implication, Korsakoff's syndrome, nutritional insufficiency was soon seen to have an important role. The study of beriberi in the 1880s, led to the identification of vitamin B₁ (thiamine) deficiency as the root cause. In 1886, the Japanese navy succeeded in eradicating beriberi by adding fresh foods, fish, and vegetables to their sailors’ diet of polished rice. Experimental studies with pigeons showed that thiamine deficiency caused neural degeneration, and research with human volunteers showed that diets depleted of thiamine caused reversible confusion and memory loss (Spillane, 1947). An increasing body of clinical and experimental evidence pointed to thiamine deficiency as causing alcoholic encephalopathy. This association was strengthened by DeWardener and Lennox's (1947) report on 52 cases of encephalopathy occurring in malnourished prisoners held in Singapore from 1942 to 1945. No less than 70% of their cases also had the classic physical symptoms of beriberi; these symptoms, and the mental confusion, were banished by injections of thiamine. DeWardener and Lennox described the condition as “cerebral beriberi”.

By the turn of the century, medical practitioners had come to appreciate that alcohol caused a variety of medical disorders. These included gastritis, cirrhosis and degeneration of the liver, pancreatitis, hypertension, cardiomyopathy, and an increased risk of certain cancers, as well as damage to the central nervous system. Concern at the considerable menace posed by alcohol to public health, as well as to the social fabric, led to a variety of legislative experiments designed to enforce abstinence. In the United States, prohibition won legislative approval with the addition in 1920 of the eighteenth amendment to the Constitution. Prohibition, however, proved a failure from the outset and by 1933 it was clear that this attempt at legislating abstinence had failed. Only unambiguous religious teaching, as in the Koran or the Buddhist lay ethic, seems sufficient to motivate sobriety, at least amongst believers.

With establishment of psychology as a laboratory science in the 1890s came the first attempts to study the changes in cognition caused by alcohol using the methods of experimental psychology. In 1896 Kraepelin studied the perceptual processes of amnesic alcoholics using the tachistoscope. Talland (1965) describes a variety of experimental studies carried out during the period 1900 to 1915 by Brodmann, Ranschburgh, Schneider, and others. In an early report, Wechsler (1917) described results from a study of five amnesic alcoholics using the procedures that were later to be the basis for his well-known memory battery. He found that chronic amnesics performed normally on the Digit Span test, but were grossly impaired on measures of paired-associate learning; he characterised amnesia in terms of a failure to form new associations.

THE STRUCTURE OF THE BOOK

This book is divided into four Parts.

Part 1

In Part 1 we describe the medical and neurological conditions that result from alcohol abuse, and neuropsychological approaches to assessing deficits in alcohol-impaired clients. As we have already seen, there has been a gradually increasing awareness of the toxic effects of alcohol. Alcoholism has been seen to promote a range of serious physical conditions, as a consequence not only of the toxicity of ethanol, but also the inadequate diet of patients dependent on alcohol. This organic damage contributes to the pattern of cognitive impairment in alcoholics and is an important factor in documenting the clinical consequences of alcoholism.

In Chapter 3 we consider the problems implicit in measuring cognitive deficits and in quantifying drinking practices. Study of the neurological deficits of alcoholics is limited by our inability to determine accurately the amounts of alcohol that subjects have been exposed to and the way in which their physical condition has changed with time. This lack of experimental control means that the study of alcoholics involves primarily correlational methods, with one set of variables, individual differences in drinking history, being extremely difficult to quantify.

Part 2

In Part 2 we review research that has focused directly on damage to the nervous system. The morphological abnormalities that were identified by Wernicke, Korsakoff, and others at post-mortem have been studied more recently in vivo with an increasingly sophisticated range of brain imaging techniques. Advances in neuroradiology during the last two decades have greatly facilitated our understanding of the effects of alcohol on brain structure and functioning, and led to the modification of the concepts that were previously applied. Chapter 5 considers the findings from neuroradiological studies, and Chapter 6 reviews the findings from post-mortem studies of the brains of alcohol-dependent patients. Stud...

Table of contents

• Front Cover
• Title Page
• Copyright
• Dedication
• Contents
• Series Preface
• Preface
• 1. Introduction
• PART 1: DIAGNOSTIC AND MEASUREMENT ISSUES
• PART 2: ALCOHOL AND THE NERVOUS SYSTEM
• PART 3: NEUROPSYCHOLOGICAL RESEARCH
• PART 4: IMPLICATIONS FOR PRACTICE
• References
• Glossary of Abbreviations
• Author Index
• Subject Index