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Tales From the Clinic: The Art of Psychiatry

, we examine the case of alcohol use disorder with difficult relapses. AUDs are known to be 1 of the most prevalent mental health disorders worldwide. This discussion examines comorbidities and barriers to treatment.

“Ms Frank” is a young woman with a history of 

 (PTSD), and bipolar disorder who is currently receiving psychiatric care at an outpatient program. She has a severe trauma history that has never been fully discussed with a therapist or psychiatrist, despite years of treatment. She has chronic suicidal thoughts after multiple previous attempts by overdose. 

 is increased in times of intoxication, and suicidal thoughts have never completely gone away even with the switch to lithium. She has failed over 15 medications and is often sensitive to adverse effects.

After a significant suicide attempt and inpatient rehabilitation for 90 days, Ms Frank achieved and maintained sobriety for almost 2 years prior to being put into a supervisory role at her sober living facility. Some of her duties in this included expelling people who had relapsed, including people she had gotten to know as friends. She felt that “everyone relapses anyway” and “there’s no point,” and subsequently relapsed herself with successive suicide attempts and psychiatric hospitalizations. She has since regained sobriety and gone to another 30-day 

. She continues to struggle with persistent suicidal thoughts and difficulty engaging with therapy; however, she has managed to again achieve and maintain sobriety for over a month with a medication regimen including naltrexone monthly injectable, which has reportedly helped with her cravings. She has previously tried and failed naltrexone by mouth, acamprosate, and disulfiram due to 

. She regularly attends Alcoholics Anonymous meetings and therapy.

Ms Frank’s history is significant for a pervasive pattern of instability in personal relationships; impulsivity; affective instability; difficulty controlling anger; and recurrent suicidal behavior, gestures, and threats concerning for an underlying cluster B personality disorder. While she deals with these issues, she does maintain a close circle of friends and is able to maintain a consistent job.

AUDs are known to be 1 of the most prevalent mental health disorders worldwide. As seen in 

, according to the 2019 National Survey on Drug Use and Health (NSDUH), 7.6% of men and 4.1% of women aged 18 and older suffer from AUD.

 As the prevalence of AUDs has continued to rise, various methods of detection have been recommended. The Alcohol Use Disorder Identification Test (AUDIT) is recommended by the World Health Organization as a screening tool to detect alcohol problems. Different AUDIT scoring thresholds are required for men and women, as research has shown that AUDs in women have distinctive social and biological characteristics.

, women develop a higher blood alcohol concentration than men. Therefore, the Centers for Disease Control and Prevention (CDC) provides distinctive cutoffs for alcohol use and binge drinking in women vs men, as seen in 

. Women are also more susceptible to the toxic effects of alcohol such as cognitive disorders, 

, and liver cirrhosis. Women also differ in their approach to the health care system, which may influence their performance on self-reported screening tests.

 Women also often display a shorter trajectory from onset of alcohol use to the diagnosis of AUD. The prevalence of AUD in women has steadily increased in women, resulting in a narrower gender gap in AUD diagnoses.

 These are a few of the many reasons it is imperative to utilize a lower screening threshold when assessing female patients for AUDs.

Despite the increasing prevalence of AUDs and the multitude of services available, national surveys consistently demonstrate low utilization of treatments, as seen in 

 Gender disparities in the utilization of treatment are long-standing and significant. Women have about one-third to one-half the odds of utilizing any alcohol use treatment when compared to men.

 and beliefs that treatment is ineffective seem to play a large role across the board. In a recent study, women were found to be more likely than men to report attitudinal barriers to treatment. These barriers consisted of shame, fear of others finding out, belief that no one can help, and the belief that the problem is not serious enough.

 Several gender-specific factors have been identified as reasons women are less likely to seek help, further warranting the need for tailored interventions.

Although underutilized, effective and safe treatment for AUD is available through psychosocial and pharmacological interventions.

 The combination of pharmacotherapy and psychotherapy (

, individual and group drug counseling, motivational enhancement therapy, etc) has been found to enhance outcomes for AUD. Currently, the Federal Drug Administration (FDA)-approved drugs for AUD include disulfiram, acamprosate, and naltrexone. Disulfiram, commonly known as Antabuse, acts by blocking the metabolism of alcohol leading to an accumulation of acetaldehyde, a toxic substance that results in tachycardia, 

, nausea, and vomiting after an individual consumes alcohol. Acamprosate has been associated with decreased craving and consumption of alcohol through agonist activity at GABA receptors and inhibitory activity at NMDA receptors. Naltrexone, available in oral formulation as well as long-acting injectable form, has been shown to decrease cravings and help prevent relapse through its action as an opioid antagonist.

Advances in addiction neurobiology have led to the development of the FDA-approved medications previously mentioned; however, 

 retail medication sales remain relatively small when considering the size of the population that could benefit. According to the 2019 NSDUH, only about 7.3% of adults aged 18 and older with AUD received any treatment in the past year. As seen in 

, less than 4% of patients with AUD were prescribed an FDA-approved medication for AUD.

Individuals struggling with AUD are unlikely to initially seek help from specialty providers. The best chance of identifying AUD usually occurs within the primary care setting; however, the recognition of AUD remains low in such settings.

 Studies have identified reasons such as limited time, limited organizational capacity, fear of losing patients, and feelings of incompetency regarding treatment of AUD as 

 regarding identification of AUD in primary care.

 Within primary care settings, there is evidence to support the effectiveness of AUD screening, brief interventions, and referral to specialized treatment (SBIRT). However, the implementation of models for identifying and treating AUD in primary care remain inadequate.

 Effective treatment may be more widely utilized if measures are taken to increase primary care participation, destigmatize AUD, and address inaccurate attitudes about treatment efficacy.

Not only are AUDs associated with many physical illnesses, but they also often cooccur with other mental health disorders. Significant associations exist with other substance use disorders, major depressive disorder, generalized anxiety disorder, panic disorder, PTSD, 

, specific phobias, and antisocial and borderline personality disorders. 

 in patients with AUD tend to lead to increased risk of suicide, lower rates of treatment retention, shorter period before relapse, greater number of hospital admissions, and overall poorer clinical course.

When formulating treatment plans for patients with cooccurring disorders, it is imperative to determine the chronology of onset of the diseases. The clinical course tends to be determined by the primary diagnosis. Comorbidity has particularly important clinical implications in cases where psychiatric symptoms increase the 

. AUD in patients with depressive disorder is associated with increased suicidality.

 Personality traits that are often associated with increased risk for alcohol abuse, impulsivity, negative emotionality, and antagonism are also characteristics of 

(BPD) and antisocial personality disorder.

Although these disorders are highly comorbid and result in poorer prognosis when they occur together, there are limited treatments that target the symptoms of both BPD and AUD. There is promising evidence that some anticonvulsants (topiramate, lamotrigine)and second-generation 

 (aripiprazole, olanzapine) may reduce the anger, impulsivity, and mood lability present in BPD. There are also studies suggesting that these same medications may also reduce alcohol craving and consumption.

 It should be noted that these medications are not FDA approved for BPD or AUD. Modified psychotherapies have been developed for the treatment of comorbid AUD and BPD (dynamic deconstructive therapy, dialectical behavior therapy, and dual focus schema therapy); however, there is limited evidence to support the efficacy of these modalities on treating symptoms of both disorders concurrently. Only dynamic deconstructive psychotherapy has been specifically tested on patients with both AUD and BPD. Evidence shows that although this therapy may be successful in treating symptoms of BPD, its efficacy in reducing alcohol consumption may not be sustained long-term.

The efficacy of the other 2 models in the treatment of AUD has not yet been established.

 Due to the lack of sufficient evidence, psychotherapies for antisocial personality disorder (ASPD) are limited.

 Although there is sparse evidence to support pharmacotherapy for ASPD, medications can be used to treat symptoms of the disease, such as aggression and impulsivity.

Alcohol use disorders are known to be one of the most prevalent mental health disorders in the world. In order to effectively treat these disorders, an awareness and utilization of evidence based treatment options is imperative. Furthermore, barriers to seeking care in this particular population require special consideration when formulating treatment plans.

is a PGY 3 general psychiatry resident at Menninger Department of Psychiatry & Behavioral Sciences at the Baylor College of Medicine. She plans to pursue a fellowship in forensic psychiatry after graduation. 

is a psychiatry resident at Baylor College of Medicine. 

is an addiction psychiatrist at Baylor College of Medicine and the Director of the Consult Liaison Psychiatry service at the Ben Taub General Hospital- Harris Health System- Houston, Texas.

1. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. 2019 NationalSurvey on Drug Use and Health. Table 5.4B – Alcohol Use Disorder in Past Year amongPersons Aged 12 or Older, by Age Group and Demographic Characteristics: Percentages,2018 and 2019. Accessed January 5, 2022. 

https://www.samhsa.gov/data/sites/default/files/reports/rpt29394/NSDUHDetailedTabs2019/NSDUHDetTabsSect5pe2019.htm

2. Neumann T, Neuner B, Gentilello LM, et al. 

Gender differences in the performance of a computerized version of the alcohol use disorders identification test in subcritically injured patients who are admitted to the emergency department.

3. McHugh RK, Votaw VR, Sugarman DE, Greenfield SF. 

Sex and gender differences in substance use disorder.

4. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. 2019 NationalSurvey on Drug Use and Health. Table 5.11B – Received Alcohol Use Treatment in PastYear among Persons Aged 12 or Older, by Age Group and Demographic Characteristics:Percentages, 2018 and 2019. Accessed January 5, 2022. 

Gender differences in use of alcohol treatment services and reasons for nonuse in a national sample.

Influence of gender and race/ethnicity on perceived barriers to help-seeking for alcohol or drug problems.

Advances in the science and treatment of alcohol use disorder.

8. National Institute on Alcohol Abuse and Alcoholism. Alcohol facts and statistics. Updated June 2021. Accessed January 5, 2022. 

https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/alcohol-facts-and-statistics

9. Rombouts SA, Conigrave J, Louie E, et al. 

Evidence-based models of care forthe treatment of alcohol use disorder in primary health care settings: protocol for systematic review.

10. Storholm ED, Ober AJ, Hunter SB, et al. 

Barriers to integrating the continuum of care for opioid and alcohol use disorders in primary care: a qualitative longitudinal study.

Dual diagnosis: alcoholism and co-morbid psychiatric disorders.

12. Helle AC, Watts AL, Trull TJ, Sher KJ. 

Alcohol use disorder and antisocial and borderline personality disorders.

13. Gianoli MO, Jane JS, O'Brien E, Ralevski E. 

Treatment for comorbid borderline personality disorder and alcohol use disorders: a review of the evidence and future recommendations.

14. Khalifa N, Duggan C, Stoffers J, et al. 

Pharmacological interventions for antisocial personality disorder.

15. Centers for Disease Control and Prevention. Alcohol Use Basics. Updated December 30, 2019. Accessed January 5, 2022. 

https://www.cdc.gov/alcohol/fact-sheets.htm

Approximately 7.6% of men and 4.1% of women aged 18 and older suffer from AUD, but national surveys consistently demonstrate low utilization of treatments. 

Everyone Relapses Anyway. Or Do They?

Researchers from Syracuse University contributed a poster presentation discussing their research on the relationship between attention-deficit/hyperactivity disorder (ADHD) diagnosis, sexual health, and substance use among college students at the 2022 American Professional Society of ADHD and Related Disorders (APSARD) virtual conference.

In the poster presentation, “Sex, Drugs, and ADHD: Sexual Health and Moderators of Risk in College Students,” Ashley Rohacek, study coauthor, reviewed previous research suggesting links between ADHD diagnosis with earlier and more frequent sexual activity, and with increased likelihood of using alcohol and cannabis, as well as links between alcohol and cannabis use with more frequent sexual activity among the general population. As not much is known about the sexual health of college students with ADHD specifically, Rohacek stated that she and her coauthors aimed to learn more about it, as well as to consider alcohol and cannabis use as potential moderators of the ADHD-sexual health relationship among college students.

Rohacek et al conducted a secondary data analysis of the National College Health Assessment III. They asked sexually active undergraduate students (N=36,236) to report on their sexual activity (ie, number of sexual partners in the past year, condom use, etc), sexual health outcomes (ie, unplanned pregnancy, sexually transmitted illness [STI] diagnoses, etc), and substance use habits. The investigators used logistic regression models to compare sexual activity and health outcomes in students with ADHD with those of students without ADHD, using substance use as a risk moderator. Results showed that college students with ADHD reported more past-year sexual partners, lower rates of condom use, and higher rates of condom-less sex while drinking, thus significantly raising the risk among students with ADHD for STI diagnoses, unplanned pregnancy, and emergency contraception use.

According to Rohacek, these findings show that substance use is a significant moderator between ADHD and sexual health, and that college students with ADHD are differently impacted by substance use in ways that make them a more vulnerable population to poor sexual health outcomes. The findings also suggest that sexual health prevention strategies should specifically target individuals with ADHD who report substance use, and that future research should consider the impact of ADHD’s common comorbidity with other disorders associated with risky sexual activity.

The study’s additional coauthors included Madison Firkey, MS; Sarah E. Woolf-King, PhD; and Kevin M. Antshel, PhD, ABPP, all affiliated with Syracuse University.

1. Rohacek A, Firkey M, Woolf-King S, Antshel K. Sex, drugs, and ADHD: sexual health and moderators of risk in college students. Presented at 2022 APSARD Conference. January 15, 2022.

What is the connection between ADHD diagnosis with sexual activity and substance use among college students?

Sex, Drugs, and ADHD

The juxtaposition of 2 recent research reports should give us pause for concern. In September, the National Institute on Drug Abuse reported that 

 use among college students reached 44% in 2020, a significant increase from 38% in 2015 and at its highest level since the 1980s.

 currently available is more potent than that used in the past. This follows a July report from researchers in Denmark who claim that the increasing use of cannabis is a likely cause of increasing incidence of schizophrenia noted in that country over the past 2 decades.

 An increasing incidence of schizophrenia, or psychosis in general, has also been reported in England, Switzerland, and Canada, especially among young people.

 Since 19 US states have already legalized the recreational use of cannabis and other states are considering doing so, a possible relationship between cannabis use and increasing 

 is potentially very important and needs to be confirmed.

The National Institute of Mental Health (NIMH) website describes itself as “the lead federal agency for research on mental disorders.” Schizophrenia is generally considered to be the most disabling mental disorder and in 2013 was estimated to cost the US $155.

 One would therefore expect NIMH to have accurate information on the incidence and prevalence of schizophrenia and some idea whether they are increasing, decreasing, or constant over time. However, when a health reporter asked NIMH for its reaction to the report on cannabis and 

 from Denmark, a NIMH spokesperson had little to offer other than to say that “it’s hard to obtain accurate estimates of the prevalence of schizophrenia because diagnosis is complex and it overlaps with other disorders.”

In fact, NIMH says that it does not know the prevalence of schizophrenia in the US other than within broad limits.

 For the last 4 years, the NIMH website has combined schizophrenia with other “related psychotic disorders” and claimed that together, their prevalence is “between 0.25% and 0.64%” of the population, which translates to between 772,000 and 2.0 million individuals. For every other mental disorder, except schizophrenia, NIMH provides a precise prevalence number.

Part of the problem is that NIMH has not undertaken a serious study of the incidence or prevalence of 

 or other major mental illnesses in 40 years. At that time, it reported the 1-year prevalence of schizophrenia among adults in the US to be 1.1%, equivalent to 2.6 million adults based on 2010 census data.

 NIMH used that percentage as its official estimate for the prevalence of schizophrenia until 2017. At that time, for reasons it has yet to explain, NIMH declared that the true prevalence of adult schizophrenia was really only 0.3%, or 704,000 individuals. As justification for this new number, NIMH cited a study from 2005that only counted people with schizophrenia who were living at home (including college students); those residing elsewhere—including hospitals, group homes, 

 Since NIMH had effectively made 2 million people with schizophrenia disappear without justification, the number was publicly ridiculed.

 NIMH’s response was to acknowledge that it really does not know the prevalence and to offer the range of numbers cited above.

In order to ascertain whether any disease is increasing or decreasing over time, one needs a reliable baseline number as well as repeated surveys. Since NIMH has never repeated the prevalence survey for the 40-year-old study or established another reliable baseline number, it has no way to tell whether schizophrenia is increasing or decreasing. In fact, since the 1990s, there are suggestions that it may be increasing. The number of seriously mentally ill individuals who are homeless or incarcerated has appeared to increase in recent years, and schizophrenia is a significant part of that population. Schizophrenia is a major, and apparently increasing, contributor to the cost of the Medicaid and Medicare programs. And the “mental disorders” diagnostic category has been 1 of the fastest-growing parts of the Supplemental Security Income and Social Security Disability Income programs.

It is an embarrassment to American medicine that NIMH has so little to contribute on such an important question. At a minimum, NIMH should issue a request for proposals to try and confirm the Danish study in another country which has appropriate data so that we will have a definitive answer to this question.

is the founder of the Treatment Advocacy Center and the author of 

American Psychosis: How the Federal Government Destroyed the Mental Illness Treatment System

1. Marijuana use at historic high among college-aged adults in 2020. National Institute on Drug Abuse. September 8, 2021. Accessed December 22, 2021. 

https://www.drugabuse.gov/news-events/news-releases/2021/09/marijuana-use-at-historic-high-among-college-aged-adults-in-2020

2. Hjorthøj C, Posselt CM, Nordentoft M. 

Development over time of the population-attributable risk fraction for cannabis use disorder in schizophrenia in Denmark.

3. Boydell J, Van Os J, Lambri M, et al. 

Incidence of schizophrenia in southeast London between 1965 and 1997.

4. Ajdacic-Gross V, Lauber C, Warnke I, et al. 

Changing incidence of psychotic disorders among the young in Zurich.

Increase in schizophrenia incidence rates: findings in a Canadian cohort born 1975-1985.

6. Cloutier M, Aigbogun MS, Guren A, et al. 

The economic burden of schizophrenia in the United States in 2013.

7. Hunt K. Schizophrenia linked to marijuana use disorder is on the rise, study finds. CNN Health. July 22, 2021. Accessed December 22, 2021. 

https://www.cnn.com/2021/07/22/health/marijuana-schizophrenia-study-wellness/index.html

8. Gordon JA. On the prevalence of schizophrenia-and transforming care through research. 

https://www.psychiatrictimes.com/view/prevalence-schizophrenia-and-transforming-care-through-research

9. Gordon JA. Letter to Senator Bernard Sanders. February 6, 2019.

10. Regier DA, Narrow WE, Rae ES, et al. 

The de-facto US mental and addictive disorder system. Epidemiologic Catchement Area retrospective 1-year prevalence rates of disorders and services.

11. Kessler RC, Birnbum H, Demler O, et al. 

The prevalence and correlates of nonaffective psychosis in the National Co-Morbidity Survey Replication (NCS-R).

12. Torrey EF, Sinclair E. Hocus pocus: how the NIMH made 2 million people with schizophrenia disappear. 

https://www.psychiatrictimes.com/view/hocus-pocus-how-nimh-made-2-million-people-schizophrenia-disappear

13. Torrey EF, Simmons W. Where did the schizophrenics go? 

. March 26, 2019. Accessed December 22, 2021. 

https://www.wsj.com/articles/where-did-the-schizophrenics-go-11553640973

14. Torrey EF. Severe psychiatric disorders appear to be increasing. 

https://www.psychiatrictimes.com/view/severe-psychiatric-disorders-may-be-increasing

Is cannabis’ effect on schizophrenia being downplayed? 

Is Cannabis Use Increasing Schizophrenia? 

A version of this quiz originally appeared in our sister publication, 

Test your knowledge of holiday drinking habits.

10 Questions on Holiday Spirits

The US Food and Drug Administration (FDA) authorized marketing for “VLN King” and “VLN Menthol King” combusted, filtered cigarettes as modified risk tobacco products (MRTPs). MRTPs help reduce exposure to, and consumption of, nicotine for smokers who use them. These are the first combusted cigarettes to be authorized as MRTPs.

“Our mission is to find ways to stop tobacco-related disease and death. We know that 3 out of 4 adult smokers want to quit and the data on these products show they can help addicted adult smokers transition away from highly addictive combusted cigarettes,” said Mitch Zeller, JD, director of the FDA’s Center for Tobacco Products.

These combusted, filtered cigarettes are also the second tobacco products overall to receive “exposure modification” orders. This allows them to be marketed as having a reduced level of, or presenting a reduced exposure to, a substance. The orders specifically authorize “VLN King” and “VLN Menthol King” manufacturers to market the products with reduced exposure claims regarding nicotine.

-“Helps reduce your nicotine consumption.”

-“...Greatly reduces your nicotine consumption.”

The company must include “Helps you smoke less,” when using any of the reduced exposure claims in the product label, labeling, or advertising. Additionally, the FDA recommends the labeling and advertising state that, “Nicotine is addictive. Less nicotine does NOT mean safer. All cigarettes can cause disease and death.”

The company must request and receive authorization from the FDA to continue marketing the products with the same modified exposure information after the initial exposure modification orders expire in 5 years.

“Having options like these products authorized today, which contain less nicotine and are reasonably likely to reduce nicotine dependence, may help adult smokers. If adult smokers were less addicted to combusted cigarettes, they would likely smoke less and may be exposed to fewer harmful chemicals that cause tobacco-related disease and death,” Zeller said further.

1. FDA authorizes marketing of tobacco products that help reduce exposure to and consumption of nicotine for smokers who use them. US Food and Drug Administration. News release. December 23, 2021. 

https://www.fda.gov/news-events/press-announcements/fda-authorizes-marketing-tobacco-products-help-reduce-exposure-and-consumption-nicotine-smokers-who?utm_medium=email&utm_source=govdelivery

The FDA authorized the marketing of these tobacco products that help reduce exposure to and consumption of nicotine for smokers. 

“Helps You Smoke Less”: First Combusted Cigarettes Authorized as Modified Risk Tobacco Products 

Like hotshot detectives from Scotland Yard, psychiatrists are often asked to make sense of mysterious situations. In the case described here, a young man was admitted to the hospital with perplexing psychiatric and neurologic symptoms. (The identifying details of the patient have been changed to protect the patient’s identity.) Since symptoms of medical disorders can mimic neuropsychiatric disorders, it would take careful interviewing and some detective work to arrive at the right diagnosis.

“Roger,” a Hispanic male, aged 34 years, residing alone, presented to the emergency department with severe depression, marked by difficulty getting up in the morning for work, crying spells, chronic insomnia, and passive suicidal ideation—all worsening over the past 6 weeks. He complained of auditory and visual hallucinations, reporting that he “often heard voices muttering in the background,” although he could not decipher what they were saying. He also “sometimes saw shadows in the corner of the room.” He further noted that he was concerned about “missing a lot of work and forgetting things.”

According to Roger, he had been well until approximately 3 years ago when he began experiencing depression. He already had 2 prior psychiatric admissions at another hospital, about 2 months apart, with each hospitalization lasting 2 weeks. After the second discharge, about 6 weeks prior, he was referred back to his therapist in their outpatient clinic.

Roger was prescribed fluoxetine 20 mg by mouth (po) every morning (qAM), risperidone 1 mg po twice daily (BID), and benztropine 0.5 mg po BID. He admitted he was not as careful as he should be with medication adherence, noting that he takes the medications “some of the time. Sometimes I forget.” He complained that the fluoxetine had sexual adverse effects, reducing frequency of erections, and it “also interrupted my sleep.” He complained of ongoing fatigue and memory lapses.

He reported that he did not like the outpatient clinician, saying, “I never really felt comfortable with her.” He admitted missing a number of follow-up appointments at the mental health clinic. When the symptoms persisted, the patient “decided to try another hospital” and was admitted to our psychiatry unit.

The patient presented with severe depression with insomnia, decreased appetite, anhedonia, and increasing social withdrawal. Roger denied any suicidal plans, but he admitted to having passive thoughts of “not living anymore.” He firmly denied any history of suicide attempts and had no intention of harming himself. Roger also denied any history of violence.

Roger was particularly troubled by his decreased appetite, but he denied dieting or having any kind of eating disorder. He noted that he “didn’t enjoy cooking,” and his diet consisted mainly of take-out and fast food. Roger acknowledged that he should eat better and said he was not taking any vitamins or supplements.

Roger also complained of worsening memory loss and confusion: “A year or so ago, I started misplacing things: my phone, my house keys…I have trouble concentrating. I even forgot my mother’s birthday. That’s never happened before. I forgot the rent was due and had to pay a late fee.” He also noted that he was having trouble walking, which worsened over the past year or so. He denied any physical trauma. He noted that his legs “felt weaker” and his balance was “off.” He had fallen at home a few times. The patient also presented with vertical nystagmus, which was present for the past year.

Roger was pleasant upon approach. He said he was glad he had sought admission and was “less lonely now.” He had a fresh-faced look, with good hygiene, and he maintained good eye contact. He said his mood was depressed: “a 7 or 8 on a scale of 1 to 10.” The mental status exam was normal except for some difficulty with short-term memory. He scored 22 of 30 on the mini-mental state examination, which is consistent with mild cognitive impairment. On the Montreal Cognitive Assessment Test for Dementia, Roger scored 18 of 30, which is consistent with mild dementia. The score can be influenced by factors like fatigue or sedating medications. His long-term memory was adequate.

In ascertaining his substance use history, Roger said he was a social drinker but “had managed to stop entirely over the past year.” He also noted that, up until a year ago, he drank to help with his sleeping problem, saying he “would take a couple of shots of tequila or vodka to knock me out.” He felt this strategy was “necessary to cope.” He stopped alcohol use when he had memory issues and fell at home a few times.

Insomnia, however, was still an issue. He noted that he had tried over-the-counter sleep aids, which “did nothing for me.” He volunteered that he had experimented with mushrooms while in college, which he had enjoyed, but he denied using them since then. He denied using cannabis or any other street drugs. His urine toxicology on admission was negative.

The Inpatient Unit: The Triad Comes to Light

Basic admission bloodwork results were normal. Thyroid function tests were normal. Chest X-ray was negative.

Roger was initially placed on risperidone 1 mg po BID, benztropine 0.5 mg po BID, and bupropion 75 mg po daily. He was started on desyrel 50 mg po (qHS), as needed, for the insomnia, which he said helped him sleep. He participated in many activities and groups on the unit. He was observed chatting with peers in a friendly way.

To further explore the diagnostic differential, a neurology consult was completed. The neurologist found no physical explanation for the nystagmus and ataxic gait. He concluded that both symptoms were psychogenic.

Since Roger believed he had a computed tomography (CT) scan during a prior hospitalization without any reports of abnormalities, one was not immediately completed on admission. The team requested records for the 2 prior psychiatric hospitalizations and, to be thorough, ordered a CT scan.

Similarly, an ophthalmology consult was ordered. It revealed normal healthy eyes except for the vertical nystagmus.

This triad—the combination of an eye disorder (in this case, vertical nystagmus, but it could be another ocular disturbance); a broad-based, ataxic gait; and a context of memory decrease along with mood and psychotic symptoms—was suggestive of Wernicke encephalopathy (WE) or Korsakoff psychosis.

 Interestingly, this syndrome usually occurs in the context of heavy alcohol consumption, and Roger noted upon admission that he was merely a social drinker. Upon physical examination, he had no signs of chronic or advanced alcohol use, eg, broken facial capillaries (“gin blossoms”), palmar erythema, or jaundice. The liver function tests on his admission chemistry labs were elevated, but they were still within normal limits. While on the unit, he showed no signs of alcohol withdrawal.

To further explore the possibility of WE, the team chatted again with Roger about his alcohol use to ascertain more details. For instance, Roger now noted that for his long history of sleep issues, he had drunk “several glasses”—not shots—“of vodka or tequila nightly since about the age of 22 or 23.” He was now 34. Clarification of the term “several” was also pursued. Roger explained that meant “4 or 5 regular glasses; it takes that much to calm me down so I can finally sleep. I drink a lot of coffee during the day.”

Roger also admitted that this was his nightly routine, not just an occasional thing. He denied ever having any blackouts or withdrawal tremors. He explained, “I’ve always had a high tolerance for booze. It runs in my family.” He did not share these insights regarding alcohol intake at the initial interview.

He further noted, again, that he decided to stop drinking about a year ago: “I was forgetting too much stuff, oversleeping sometimes, falling at home. I didn’t want to get fired.” Roger said he “had stopped on his own,” without going to an inpatient detoxification or rehabilitation facility, and he denied any withdrawal seizures. He said he attended a few Alcoholics Anonymous meetings but did not like the vibe and stopped.

The head CT with contrast showed changes in the thalamus consistent with WE. There were abnormalities noted in the cerebellum consistent with ataxia. Perhaps the head CTs at the prior hospital had not been interpreted properly.

 We ordered a serum thiamine (vitamin B1) level, which showed that he was severely deficient in thiamine. Based on these new findings, the criteria for WE diagnosis were met.

His loss of appetite and eating habits suggested the possibility of other vitamin deficiencies. We tested for serum vitamin B12 and vitamin D; he was severely deficient in both. This may well have contributed to his depressed mood.

To correct these vitamin deficiencies, the patient was transferred to a medicine inpatient unit. He received an intravenous (IV) bolus infusion of thiamine 500 mg 3 times daily for 2 days, then 250 mg IV daily for 5 days.

 In addition, Roger was started on vitamin B12 injections and high-dose vitamin D tablets. Within about 2 weeks, all of his vitamin levels were restored to the normal range.

His vertical nystagmus stopped completely. His ataxic gait resolved. The depression lessened considerably, and his hallucinations ended.

Roger was discharged on the same psychotropic medications that he received as an inpatient: bupropion, 75 mg po qAM; risperidone, 1 mg po BID; benztropine, 0.5 mg po BID; and desyrel, 50 mg po qHS as needed for insomnia. He was also prescribed vitamin supplements of thiamine, vitamin B12, and vitamin D, as well as a therapeutic multivitamin. Finally, he received a consult with a nutritionist to address his eating habits and was referred for supportive psychotherapy to help address his depression and family issues.

In general, WE is reversible with thiamine infusions. However, failure to diagnose WE can lead to a serious amnestic syndrome (Korsakoff syndrome). Korsakoff psychosis is generally irreversible. Therefore, it is extremely important that patients are diagnosed and treated as promptly as possible.

When a patient admits to social drinking, it is helpful to pinpoint the exact extent of alcohol use in terms of type of alcohol, quantity, and frequency.

 An assessment of a patient’s eating habits and nutritional intake (or lack thereof) can also contribute to the diagnosis and treatment of common psychiatric disorders.

A variety of evidence-based cognitive rating scales exist for WE.

 Heirene et al compared the neuropsychological tests used to assess alcohol-related cognitive impairment with tests that screen for alcohol-related dementia and Korsakoff syndrome (

 They concluded that there is a heterogeneity in presentation and suggested using the more broad and inclusive diagnostic conceptualizations of alcohol-related cognitive impairment instead of the discrete diagnoses of Korsakoff syndrome and alcohol-related dementia.

Meanwhile, Sgouros et al have pursued the development of a Thiamine Deficiency Questionnaire (TDQ) to assess thiamine deficiency in patients with severe alcohol dependence.

 Unfortunately, they concluded that further refinement and evaluation were needed before endorsing TDQ’s validity.

Alcohol use (as well as the use of other nonprescribed drugs) is often underreported by patients.

 According to Livingston and Callinan, “population surveys typically produce underestimates of alcohol consumption of approximately 40% to 50%.”

 Thus, it is essential in the initial patient interview to receive answers that are as specific as possible regarding what kind of alcohol is being consumed, how much is consumed in a drinking session, and how often the sessions occur. If the patient admits to “a couple of beers,” ask if those are 12-ounce, 16-ounce, or 24-ounce drinks. Ask about the drinking pattern: Do they drink more on weekends than on weeknights when they have to get to work the next day? Listen for words like 

lonely, isolated, homesick, bored, trouble sleeping, frustration

, as these can be common triggers for high levels of alcohol consumption.

Alcohol use disorder is not the only cause of WE; the culprit can be any condition that compromises the body’s access to vitamin B1 (thiamine) (

 But those are cases for another day. This one is closed.

is a board-certified psychiatrist. She is on the staff of Manhattan Psychiatric Center and works in its mental health outpatient clinic. Her new book

1. Chandrakumar A, Bhardwaj A, ’t Jong GW. 

Alcohol use is often underreported by patients. This case demonstrates the importance of obtaining the most accurate information possible in the initial patient interview.

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