Definition

Alcohol-related neurological disease represents a broad spectrum of conditions caused by

acute or chronic alcohol intake.
Description

Alcohol, or ethanol, is a poisonous chemical that has direct and toxic effects on nerve and
muscle cells. The effects can be profound, and symptoms can include incoordination,
weakness, seizures, memory loss, and sensory deficits. Alcohol has a profoundly negative
effect on both the central nervous system (i.e., the brain and spinal cord) and the peripheral
nervous system (i.e., nerves that send impulses to peripheral structures such as muscles and
organs). Alcohol can have negative effects on neurological centers that regulate body
temperature, sleep, and coordination.
Alcohol can significantly lower body temperature. It disrupts normal sleep patterns because it
decreases rapid eye movement (REM) during the dreaming stage of sleep. It also adversely
affects muscle coordination, causing imbalance and staggeringalcohol is a toxic insult to
the cerebellum, which is responsible for balance.
Additionally, the chronic use of alcohol can cause a broad spectrum of abnormalities in
mental functioning. Generally, persons exhibit poor attention, difficulty with abstraction and
problem solving, difficulty learning new materials, reduced visuospatial abilities (capacity to
discriminate between two-dimensional or three-dimensional space), and often require extra
time to integrate visual information. Other related problems include thiamine deficiency
(vitamin B-1) and liver disease (liver cirrhosis and possibly liver cancer).
Acute effects of alcohol

When alcohol is ingested, it moves from the bloodstream into every part of the body that
contains water, including the brain, lungs, kidneys, and heart. Alcohol distributes itself
equally both inside and outside cells. Ninety-five percent of alcohol is eliminated from the
body by breakdown in the liver, and 5% is eliminated through urine, sweat, and breath.
Alcohol is broken down (metabolized) in the liver by a complex process called zero-order
kinetics (broken down at a certain amount at a time). This means that alcohol is metabolized
at a rate of 0.3 oz (8.8 ml) of pure ethanol per hour. Within moments after ingestion, alcohol
reaches the brain and produces acute effects such as euphoria, sedation (calmness),
anesthesia, and a sleepy hypnotic state. Further effects include release of inhibitions and
judgment, blunting of sexual desire, aggressiveness, and mood changes. Physical effects of
intoxication (with continued consumption) include impairment of motor ability, muscle
function, eyesight, reaction time, night vision, and depth perception. Continued consumption
can be lethal because alcohol can depress heart and lung function, which can slow breathing
and circulation. Lethality occurs when levels are high enough to paralyze breathing.
However, death due to alcohol consumption is rare because body defenses tend to eliminate
the chemical by vomiting or the person becomes comatose. Alcohol "hangovers" usually
cause persons to have headache (due to dilation of blood vessels in the head), dehydration
(alcohol acts as a diuretic increasing urine output), and upset stomach (due to irritation of
stomach lining).
Specific neurological damage

The effects of alcohol can include damage or impairment to brain systems and to specific
regions in the brain. The limbic system, located deep inside the brain, has several functions,
including memory. Long-term users of alcohol often exhibit memory loss due to damage of
the limbic system structures called the amygdala and hippocampus, located in the temporal
lobes. Damage to other parts of the limbic system can produce symptoms such as
abnormalities in emotional functioning and in the ability to use one of the senses (e.g.,
eyesight or the sense of smell) or in the ability to learn using the senses (e.g., learning
through the sense of touch). Damage to the diencephalon (major relay station for nerve
signals moving within the brain, associated with memory functioning) occurs and is
associated with chronic usage and malnutrition (a late-onset condition). The cerebral cortex
(folded outer layer of the brain) is composed of nerve cells called gray matter, which
functions as the center of intelligent behavior and higher consciousness. Neuroimaging
studies reveal that there are definitive signs of morphological change such as cortical atrophy
(a decrease in size of the cerebral cortex). Cortical atrophy induced by alcoholism is
associated with deficits in spatial memory and visual associations, learning related to or
caused by touch, and problem solving. Alcoholic subjects also exhibit a decrease in blood
nourishing the frontal lobe (portion of the brain behind the forehead), whose functions
include planning, carrying out, and monitoring goal-directed and socially acceptable
behaviors.
Neurotransmitter deficits and the progression of alcoholism

Neurotransmitters are brain chemicals that allow nerve cells to communicate. These
chemicals are released and picked up by specialized structures (receptors) in a space between
nerve cells called a synapse. Alcohol can cause "up"-regulation or "down"-regulation effects
on neurotransmitters. Over prolonged periods of alcohol abuse, the levels of receptors
change. Genes that produce molecular copies of receptors may by turned off (decreasing
activity) or on (increasing activity). Levels of glutamate (an amino acid that is an excitatory
neurotransmitter in the brain) are abnormally altered. Glutamate is correlated with long-term
potentiation (mechanism vital for learning and memory) in the brain. Even minute amounts of
alcohol have profound effects on brain glutamate action. Interference with glutamate
chemistry in the brain can cause memory impairment and may account for the short-lived
condition called "blackouts." Because alcohol suppresses the excitatory effect of glutamate
on nerve cells, this can result in strokes and seizures.
Another neurochemical that is altered due to chronic intake of alcohol is gammaaminobutyric acid (GABA), a major inhibitory neurotransmitter in the brain. Initially, alcohol
increases the effects of GABA, which produces a state of mild sedation. Over time with
continued abuse, the GABA system is down regulated and, when alcohol is not present in the
system, the inhibitory effects are lost and overexcitation of the brain results.
Alcoholism is a chronic disease, with a natural history that progresses to death if the intake
does not completely stop. The progress consists of three stages. During the beginning stage,
the alcoholic becomes dependent on the mood-altering effects of alcohol. In the middle stage,
drinking starts earlier and there is tolerance (when more alcohol is needed to produce effects);
during this stage, alcohol consumption is out of control and alcoholics frequently exhibit
denial. Heavy consumption causes symptoms of anxiety, depression, fatigue, anger, rage, lack
of self-esteem, and self-loathing. Symptoms worsen as the disease progresses, and alcoholics
develop hand tremors and shaking (delirium tremens) and morning hangover. The final stages
of alcoholism progress to round-the-clock consumption despite extremely negative personal

and social consequences. The disease progresses with symptoms of intense guilt and remorse
(suppressed by more drinking), fear of crowds and public places, financial debt, legal
problems, and ill health (including malnutrition). Late-stage disease typically involves liver
degeneration (cirrhosis) and severe, even life-threatening, clinical signs (shakes and
convulsions) during withdrawal without treatment. Insanity due to brain damage or death
may occur during this stage.
Alcohol can cause thiamine deficiency (vitamin B-1). The Wernicke-Korsakoff syndrome is a
late complication due to vitamin B deficiency, resulting from malnutrition. These alcoholics
have a condition called hepatic encephalopathy, caused by diminished capacity of the liver to
metabolize and detoxify chemicals in the body. Symptoms of Wernicke-Korsakoff syndrome
include agitation, confusion, and altered personality. There is peripheral neuropathy (damage
to peripheral nerves), which is symmetrical and affects the lower extremities. If untreated,
this syndrome can further cause brain (cerebellum) degeneration, abnormal gait (walking),
memory deficits (retrograde amnesia), and difficulty with abstract thinking and the
acquisition of new learning (anterograde amnesia). Even if successfully treated with vitamin
therapy, patients may still have amnesia (a condition called Korsakoff Syndrome).
Fetal alcohol syndrome is a condition that occurs in infants born to alcoholic mothers.
Prenatal exposure to alcohol can impair and retard fetal development and growth. Affected
infants have a characteristic appearance that consists of a flat nose, flat mid face, small head
size, short stature, and a thin upper lip. Approximately 50% are mentally deficient and most
others exhibit intellectual deficits. Affected babies typically suffer from poor coordination,
decreased adipose (fat) tissue, cleft palate, attention deficit hyperactivity disorder (ADHD),
decreased muscle tone, heart defects, eye/ear defects, and smaller jaw.
Alcoholic myopathy (disorder affecting muscle tissue) can be either acute (rapid onset of
symptoms) or chronic (slower onset to develop symptoms). Acute alcoholic myopathy can
involve symptoms such as muscular cramps, weakness, swelling, and tenderness in affected
areas of muscle. Chronic alcoholic myopathy can be painless, but is associated with weakness
due to nerve atrophy.
Demographics

Alcoholism is a widespread and costly problem. Even though use has declined since 1981,
two of three American adults drink alcoholic beverages. Approximately 6.5% to 10% of the
total U.S. population are heavy drinkers and they consume 50% of all the alcohol ingested
annually. Alcohol is heavily implicated in tragic events and is involved in 50% of all crimes,
50% of all fatal car accidents, 33% of all boat/aviation deaths and drowning, and 50% of all
accidental death, suicides, and murder. Approximately 50% of alcoholics are not diagnosed,
because alcoholics rarely admit to excessive consumption. In approximately 50% of Chinese,
Japanese, and Koreans, an enzyme called aldehyde dehydrogenase is absent. This is the
enzyme that breaks down alcohol in the liver. Thus in populations who do not have the
enzyme, alcohol-related problems are less likely, because persons with this deficiency will
become sick (face flushing, racing heart rate) when they consume alcohol. Persons who
develop nerve damage as a result of chronic alcoholism have a greater mortality rate than the
general population. Fetal alcohol syndrome is estimated to occur in 5.2 per 10,000 live births
in the United States. Women are more likely to develop alcoholic myopathy more than men,
because women can develop the complication with 40% less consumption than males.

Causes and symptoms

Studies of adopted twins reveal that children of alcoholics have a greater propensity for
alcoholism even though they were adopted away from the alcoholic parents. Additionally,
research indicated that children of non-alcoholic parents are less likely to develop alcoholism
even when adopted into families with an alcoholic parent(s). Adopted children of alcoholic
parents have four times a greater risk of developing alcoholism than those born of
nonalcoholic parents. The cause is ultimately a combination of genetic and environmental
factors, and poor prevention programs among high-risk target populations.
Diagnosis

Diagnosis of neurologic disease is based on clinical signs and symptoms. Psychometric

testing, psychological evaluation, and appropriate medical tests (neuroimaging, blood
chemistry, liver profiles, differential cell count) can help establish the diagnosis. Alcoholics
can exhibit disorders in multiple organ systems, and careful, comprehensive examination is
necessary in order to stage the disease and execute an effective interventional treatment plan.
No single test can diagnose alcoholism. The diagnosis can be made once a careful evaluation
of all the clinical data is available. Criminal information related to drunk driving can also
help establish the diagnosis.
Treatment team

The treatment for medical-related disorders can include a psychiatrist, neurologist, and
members of an inpatient medical ward in a hospital or psychiatric unit. Professional
psychotherapist services are necessary to initiate an interventional treatment program.
Monitoring and follow-up care with primary care practitioners and specialists is part of a
well-integrated treatment program.
Treatment

Acute management of alcohol intoxication is supportive in nature, and patients are monitored
and treated if heart or lung problems develop. Patients may require intravenous fluid
replacement (due to fluid loss from sweating and fever). Agitation can be treated with
medications called benzodiazepines. Wernickes' syndrome can be reversed with IV thiamine
replacement, and withdrawal seizures can be treated with antiepileptic medication. Damage
to muscles (chronic alcoholic myopathy) can be treated by supplementation of deficient
vitamins and special diets. This initial management of detoxification usually requires
inpatient treatment ranging from three to 10 days. Patients must undergo intensive inpatient
or outpatient psychotherapy, and a long process of recovery and rehabilitation.
Recovery and rehabilitation

Involvement in nonprofessional community-centered support groups such as Alcoholics

Anonymous (AA) that utilize the "12-step" recovery approach is helpful for maintaining
sobriety. During early recovery, patients still exhibit mood swings and compulsions to drink.
Patients should attempt to receive positive support from family and friends, take rest and
good nutrition, and seek to share experiences with other alcoholics (e.g., through self-help
groups). Patients should also receive professional psychotherapy treatment from a clinician
with special certifications in addictions counseling, or from a specialist in forensic

psychotherapy. Typical treatment using psychological techniques include cognitive

behavioral therapy and motivational enhancement therapy.
Clinical trials

Clinical trials are currently recruiting patients for government-sponsored medical research
(National Institute on Alcohol Abuse and Alcoholics). Studies include the role of dopamine in
response to alcohol, and the effects of another neurotransmitter, serotonin, in alcoholism.
Prognosis

The prognosis depends on the motivation of the patient to stop drinking alcohol, and the
extent of organ damage, which varies with each case. The prognosis can be favorable in some
patients (with minimal organ damage) that successfully complete long-term intensive
psychotherapy and stop drinking.
Special concerns

Psychotherapy treatment may be long term and complicated. Frequently, there may be
psychological problems that occur within families who have an alcoholic. Alcoholics may
cause violence to or abuse of family members.