Alcoholism What is alcohol? Ethyl alcohol, or ethanol, is an intoxicating ingredient found in beer, wine, and liquor.

. Alcohol is produced by the fermentation of yeast, sugars, and starches How does alcohol affect a person Alcohol affects every organ in the body. It is a central nervous system depressant that is rapidly absorbed from the stomach and small intestine into the bloodstream. Alcohol is metabolized in the liver by enzymes; however, the liver can only metabolize a small amount of alcohol at a time, leaving the excess alcohol to circulate throughout the body. The intensity of the effect of alcohol on the body is directly related to the amount consumed. Difference between alcoholism and alcohol abuse: Alcohol abuse is a pattern of drinking that results in harm to ones health, interpersonal relationships, or ability to work. Dependency on alcohol, also known as alcohol addiction and alcoholism, is a chronic disease. The signs and symptoms of alcohol dependence include: 1. A strong craving for alcohol. 2. Continued use despite repeated physical, psychological, or interpersonal problems. 3. The inability to limit drinking. Immediate effects: 1. Unintentional injuries, including traffic injuries, falls, drownings, burns, and unintentional firearm injuries. 2. Violence, including intimate partner violence and child maltreatment. 3. Risky sexual behaviors, including unprotected sex, sex with multiple partners, and increased risk of sexual assault. These behaviors can result in unintended pregnancy or sexually transmitted diseases. 4. Miscarriage and stillbirth among pregnant women, and a combination of physical and mental birth defects among children that last throughout life. 5. Alcohol poisoning, a medical emergency that results from high blood alcohol levels that suppress the central nervous system and can cause loss of consciousness, low blood pressure and body temperature, coma, respiratory depression, or death. Alcoholic Beverages Malted Liquors: Fermentation of germinating cereals (malts) mostly Barley Beers (3-6%) Wines: fermentation of Natural Sugars grapes, apples and other fruits No distillation, <15% Fortified (port) up to 22% Champagne 12-16% (effervescent wine) Spirits Rum, Whisky, Brandy and Gin 40 - 55% v/v Standard 42.8% v/v or 37% w/w Sources: Whiskey - distilled grain Rum - distilled molasses Gin any sugar source Brandy Distilled wine (Grapes) Vodka fermentation of any of grain, rye, wheat, potatoes, grapes, sugar beet or mollases Alcohol Percentage Calculations Alcohol content of beverages: specific gravity of alcohol is 79 Therefore, 1 litre alcohol weighs 790g Percent may be by weight or by volume By volume: 1 litre alcohol add 1 litre water = 50% (vol) By weight: 1 litre alcohol (790g), add 790g water = 50% (weight) 40% alcohol by weight = 50% by volume

Effects of alcohol consumption - Acute CNS: depressant dose dependent manner Kidney: Diuresis increased water ingestion and inhibition of ADH Uterus: Relaxation of uterine muscles Endocrine: Low dose Adrenaline release and hyperglycemia High dose Hypoglycemia Sex - Aphrodisiac Absorption Rapidly absorbed from small intestine, and colon but slowly from stomach First pass metabolism in stomach and liver Maximal blood concentration within 30 to 90 minutes Can be absorbed through the lungs Can be absorbed through skin Distribution Uniformly distributed throughout tissues and body fluids Readily crosses placenta, to exposure fetus Crosses BBB readily Elimination Urinary Excretion Exhalation Metabolism Adverse Effects of Alcohol Acute Effects Nausea, Vomiting, hangover and traffic accidents CNS Depressant Depression of inhibitory control Vasodilatation, warm, flushed, reddish skin Emotional outbursts Decreased memory & concentration Poor judgment Decreased reflexes Decreased sexual response Acute Alcohol Intoxication: Estimated ED50: 150 mg/100 ml and LD50 = 500 mg/100ml Therapeutic index about 3.5 Hypotension, hypoglycemia, respiratory depression coma and death Death due to respiratory depression or inhaled vomit Treatment: Gastric lavage Endotracheal intubations Fluid and electrolyte balance Glucose infusion Thiamine injection 100 mg in 500 ml of glucose IV Haemodialysis Consequences of acute Alcohol intoxication

Vomiting Driving accidents Loss of inhibitions Hangover Toxic Effects - Chronic Alcoholism GIT: Gastritis and damage to the mucosa anaemia Intestinal damage: Lack of absorption - Deficiency of water soluble vitamins and amino acids (protein deficiency) Less or no food intake (enough calorie) - Vitamin and Protein deficiency (Q. Is Alcohol a total food ? Answer: No - Lacking in total food value) Chronic Alcoholism Liver cirrhosis scarring of liver Usually fatal if drinking is not stopped Fatty infiltration (excess in NADH) Oxidative stress and cellular necrosis Damage to hepatocytes and inflammation aldehyde Glutathione depletion Microsomal enzyme induction Neurological: Polyneuritis, pellagra, tremors, seizures, loss of brain mass, Korsakoff`s psychosis and Warnicke`s encephalopathy CVS: Hypertension, cardiomyopathy, CHF arrhythmias and stroke Hormonal: Impotence, gynaecomastia and infertility Acute pancreatitis Reproduction Alcohol is a teratogen, it causes birth defects. Fetal Alcohol Syndrome (FAS) or Fetal Alcohol Effects (FAE), or Alcohol-Related Birth Defects (ARBD) Symptoms include retardation, poor coordination, loss of muscle tone, low birth weight, slow growth, malformation of internal organs and peculiar facial characteristics Fetal Alcohol Syndrome (FAS) Characteristics Growth retardation Facial malformations Small head Greatly reduce intelligence Chronic Alcoholism - features Craving: A strong need, or compulsion, to drink Loss of control: The inability to limit ones drinking on any given occasion Tolerance: The need to drink greater amounts of alcohol in order to get high pharmacokinetic or cellular tolerance Physical dependence: Withdrawal symptoms, such as nausea, sweating, shakiness, sleep impairment, hallucinations, delirium tremens and anxiety, occur when alcohol use is stopped after a period of heavy drinking Withdrawal syndromes: long acting BZDs like chlordizepoxide and diazepam Naltrexone (50 mg) Summary Alcohol is a neuronal depressant Long term exposure to alcohol brings about adaptive changes in the neuronal system Chronic alcoholism causes toxic effects on all the organs especially liver Withdrawal syndrome in alcoholics are treated by BZDs and Naltrexone Antabuse/disulfiram is the drug use as aversion technique in chronic alcoholics Ethanol is used as antidote in Methanol Poisoning

PATERNITY AND FILIATION PATERNITY Is the civil status of the father with respect to the child begotten by him FILIATION Is the civil status of the child in relation to its father or mother Legal Importance of Paternity and Filiations For succession For enforcement of Naturalization and Immigration laws PRESUMPTION of LEGITIMACY Art. 255, NC Children born after 180 days following the celebration of the marriage, and before 300 days following its dissolution or the separation of the spouses shall be PRESUMED TO BE LEGITIMATE. Against this presumption, no evidence shall be admitted other than that of the physical improbability of the husbands having access to his wife within the first 120 days of the 300 which preceded the birth of the child. Physical Improbability Causes: Impotence Husband and wife living separately Serious illness of the husband impossibility of access Presumption of Legitimacy based on ETHNIC REASONS Art. 257, NCC - Should the wife commit adultery - Although there was no physical improbability - Child is presumed to be illegitimate - It it appears highly improbable, for ethnic reasons Duty of a woman after annulment of marriage when she becomes a widow and pregnant If after a judgment annulling a marriage, the former wife should believe herself to be pregnant by the former husband, she shall within thirty days from the time she became aware of her pregnancy, notify the former husband or his heirs of that fact. He or his heirs may ask the court to take measures to prevent a simulation of birth. The same obligation shall devolve upon a widow or a separated wife. Marriage of women within 300 days following death of husband or marital dissolution: Art. 84, CC No marriage license shall be issued to a widow till after 300 days following the death of her husband, unless in the meantime she has given birth to a child Art. 351, RPC A widow who shall marry within 301 days from the date of death of her husband, or before having delivered if she had been pregnant at the time of his death Art. 259, CC: Presumptive legitimacy if the widow marries within 300 days ff. death GOVERNING RULES: 1. A child born within 180 days after a subsequent marriage is disputably presumed to have been conceived during the former marriage, provided it be born within 300 days after the husbands death. 2. A child born after 180 days ff. the celebration of a subsequent marriage is prima facie presumed to have been conceived during such marriage even though it be born within 300 days after the death of the former husband. Evidence of Paternity and Filiations Parental likeness - Heredity transmits traits and characteristics but it should be gross manifestations General features Manner of gesture Peculiarities/Deformities Color of the eyes General built and size Hair color and texture Gait, and speech Movement Blood Grouping Test

Evidence from the Mother Proofs of previous delivery Proofs of physical potency and fertility Proof of capacity to have access with the husband Evidence from the Father Proof of physical potency and fertility Tumescence test Semenology Congenital anomalies Proof of access NON-MEDICAL EVIDENCE Record of birth In the Civil Registry By an authentic document Final judgment Continuous possession of the status of a legitimate child As allowed by the Rules of Court and Special Laws ARTIFICIAL INSEMINATION 1. Artificial insemination from husband- legitimate 2. Artificial insemination from donor- if done without consent illegitimate 3. Artificial insemination from husband and donor- legitimate a. Husbands consent constitutes waiver b. So as subsequent adoption In vitro fertilization TEST TUBE BABY -GONADOTROPIN -OOCYTES removed by laparoscopy -Petri dish containing growth medium simulating mothers millieu -Fertilization with donors sperm -Blastocyst stage -Embryo returned at the proper time of the menstrual cycle Situations and Comments on IN VITRO Fallopian tube defects Genetic screening Third party Sperm donor Ovum donor-Husband Sperm to Wifes uterus Sperm donor Ovum donor Recipient uterus Single woman Parental donors to Host or Surrogate uterus Wifes ovum Sperm donor Surrogate uterus Legality of IN VITRO Art III, Sec.1, Constitution Liberty The right of privacy Procreation rights Right of marital privacy Freedom to decide Right to self-determination Other methods of procreation: 1. Artificial inovulation 2. Embryo transplants 3. Parthenogenesis (virgin birth) 4. Cloning

ABNORMAL PSYCHOLOGY, PSYCHOPATHOLOGY & PSYCHOTHERAPY What should be labeled deviant? What psychiatrists, clinical psychologists or other trained professionals label deviant? (DSM-IV) Or, Only organically based behavioral disorders (Szaz). Treating Insanity Hippocrates recognized depression and epilepsy as medical problem. Middle ages deviant people were locked up Bedlam (Bethlehem hospital, London) Reform movement Pinel (1790) Dorothea Dix (1850) Medical Model (late 19th century) Trephination Exorcizing the Devil to alleviate madness An old-fashioned straight-jacket St. Marys of Bethlehem Hospital (Bedlam) Dorothea Dix Medical Model of Mental Illness Psychiatry an offshoot of neurology (Charcot (1860), Breuer & Freud (1896), Bleuler (1911). Freud: Too little was known about the brain; opted for psychoanalysis. Classified mental illness into two major categories: neuroses and psychoses. General paresis discovered by Krafft-Ebbing to have a physical cause in 1905 (syphilis). Pavlov (1904). Concept of conditioning and experimental neurosis that was mediated by specific brain circuits. Reactions to the Medical Model Harry Stack Sullivan (broke with psychoanalytic tradition). Clinical (lay) psychologists allowed to treat patients with mental disorders. Carl Rogers, Ph.D. Published first transcript of a therapeutic session. Behavior Therapy (Wolpe, Lazarus). Began in 50s. Cognitive Therapy (Seligman). Began in 60s. Thomas Szaz: Mental illness should only refer to behavioral deviations that have a well defined organic basis. Other deviant behaviors the product of problems of living. DSM-III (1983) & IV (1994) What is a normal personality? Least deviant? What is deviant? Statistical (does 1/10 of population have mental illness?) Adaptive sublimation? Self-actualization? Quantitative vs. qualitative differences between normal and abnormal Sheldons Body Types

Types of Personality Tests Objective- MMPI (Minnesota Multi Phasic Inventory) Projective- TAT (Thematic Apperception Test) Rorschach Test

MMPI CATEGORIES

Interpretation of Sample MMPI Score Overly self-critical Personality disorder Poor social adjustment Unusual thinking and behavior High level of anxiety

*DSM III (1983) Disorders first evident in childhood (e.g., mental retardation, hyperactivity). Organic mental disorders: symptoms directly related to injury to brain or to abnormality (syphilis, Alzheimers disease, extreme alcoholism, brain tumor). Substance use disorders. Schizophrenic disorders. Paranoid disorders. Affective disorders (manic and/or depressed moods). Somatoform disorders (hysteria, hypochodriasis). Dissociative disorders (amnesia, multiple personalities). Psychosexual disorders (transsexualism, frigidity, exhibitionism, sadism, homosexuality only if individual is unhappy). Personality disorders (anti-social behavior, narcissistic personality). Anxiety disorders (generalized anxiety or panic, phobias, posttraumatic stress disorder, obsessive-compulsive disorder). Leftovers (marital problems, family therapy). *DSM-IV (1994) Anxiety disorders. Mood disorders. Somatoform disorders. Dissociative disorders. Schizophrenia and other psychotic disordcrs (delusional). Substance-related disorders Eating disorders (aneroxia nervosa, bulimia nervosa). Sleep disorders. Impulse control disorders (kleptomania, pyromania, pathological gambling) Personality disorders (anti-social behavior, narcissistic personality). Disorders first evident in childhood (e.g., mental retardation, hyperactivity). Delerium, dementia, amnestic and other cognitive disorders. Adjustment disorder (Maladaptive, excessive emotional reaction to a stressful event within previous 6 months). Psychoanalysis Based on Freuds theory of personality Many varieties, e.g., Jung, Adler, Sullivan M.D. usually required; Ph.D. in clinical psychology now acceptable (lay analysts) Training performed by certified institutes in three stages: -formal courses -personal analysis with an institute analyst -control analyses supervised by a training analyst. Patients: usually brighter than average; in most cases neurotic. Typically excluded are homosexuals, alcoholics, psychotics, patients with character disorders. Conditions for Psychoanalysis MD originally required No psychotics, alcoholics, homosexuals, sociopaths Time commitment: ~ 5 years Financial commitment: $150 x 4; $600/week; $27,000/year. Life decisions placed on hold. No marriage, divorce, moving, changing jobs without consulting analyst. Psychoanalytic Method (freuds courch) Treatment consists of three to five 50 minute sessions per week . Patient is instructed to free associate. He does this while lying on a couch that is facing away from the analyst. - less fatiguing to the analyst than face-to-face relationships -facilitated free association. Basic goal is to have awareness of ones motives and memories. Dream interpretation Transference Goals of Psychoanalysis Genetic progression - bring the patient from his point of fixation in the psychosexual development to the genital stage. Structural - the ego should be strengthened in satisfactory relationships with the super ego. Dynamic - direct energy from the defense mechanism to more productive outlets. Topographic - makes the unconscious conscious - specifically, the defense mechanisms.

Client-centered Therapy Does not assume medical model (client vs. patient; counsellor vs. therapist/doctor Brief duration (~ 10 vsits) Non-directive Counselor reflects rather than interprets No dream analysis No specific retracing of psychosexual history PROCESS OF CLIENT-CENTERED THERAPY 1. Rigidity - little desire to change. Little recognition of feelings. 2. Perception of problems, externally dispassionate display of feeling. Little recognition of contradictory feelings... 3. Free expression of feelings. Source of feelings considered. Increased awareness of the real me. Awareness of contradictions. 4. Immediacy of feelings. Real direct experience. High self-regard. Less intellectualization about self. 5. Acceptance of self and problem. BEHAVIOR THERAPISTS INSTRUCTIONS Let all your muscles go loose and heavy. Just settle back quietly and comfortably. Wrinkle up your forehead now; wrinkle it tighter....And now stop wrinkling your forehead, relax and smooth it out. Picture the entire forehead and scalp becoming smoother as the relaxation increases.... Now frown and crease your brows and study the tension....Let go of the tension again. Smooth out the forehead once more....Now, close your eyes tighter and tighter...feel the tension...and relax your eyes. Keep your eyes closed, gently, comfortably, and notice the relaxation .... Now clench your jaws, bite your teeth together; study the tension throughout the jaws....Relax your jaws now. Let your lips part slightly....Appreciate the relaxation.... Now press your tongue hard against the roof of your mouth. Look for the tension....All right, let your tongue return to a comfortable and relaxed position .... Now purse your lips, press your lips together tighter and tighter....Relax your lips. Note the contrast between tension and relaxation. Feel the relaxation all over your face, all over your forehead and scalp, eyes, jaws, lips, tongue and throat. The relaxation progresses further and further.... [from Wolpe and Lazarus (1966), p. 178] Sensitization -behavioral therapy treatment of phobia Comparisons of Different Approaches to Psychotherapy Behavior Modification Psychoanalysis Learned behavior Symptoms Deliberate None - minimal Active Indirect Direct Passive Scientific Intuitive Real Goal directed Training Present behavior Heights Flying Public places Sharp pointed objects Spiders Thunder-storms Closed spaces Insects Blood Symbolic General restructuring Insight Past behavior Monophobia Mysophobia Nyctophobia Ophidiophobia Parthenophobia Porphyrophobia Triskaidekaphobia Xenophobia Zoophobia Being alone Dirt & Germs Darkness Snakes Virgins The color purple #13 Strangers Animals

What is to be modified? Role of therapist:

Philosophy of treatment: Interpretation of behavior: Aim: Basis of change: What is dealt with: Acrophobia Aerophobia Agoraphobia Aichmophobia Arachnophobia Brontophobia Claustrophobia Entomophobia Hematophobia

POISONING Poison Any substance that is harmful to the body When ingested, inhaled, injected, or absorbed through the skin Does not include adverse reactions to medications taken correctly Classification Intentional poisoning: A person taking or giving a substance with the intention of causing harm, e.g. Suicide and Assault Unintentional poisoning: If the person taking or giving a substance did not mean to cause harm, e.g. For recreational such as in an Overdose or Accidentally taken by a toddler Undetermined: When the distinction between intentional and unintentional is unclear *Top Poisons (Those 19 Years and Below) 1. Methamphetamine 2. Multiple drugs 3. Mixed pesticide 4. Ethanol 5. Isoniazid 6. Marijuana 7. Salicylic Acid (Salicylates) 8. Malathion (Organophosphates) 9. Paracetamol (Acetaminophen) 10. Caustic Substances Acute Poisoning Pharmaceuticals: sedatives, analgesics, contraceptives, cardiovascular drugs Household products: bleaches, detergents, solvents, kerosene Cosmetics: perfumes, shampoo, nail products Substances of abuse: alcohol, tobacco, illicit drugs Pesticides: insecticides, rodenticides, herbicides Plants and mushrooms: berries, seeds, leaves Seafood Poisoning: paralytic shellfish poisoning, fish poisoning Venomous bites and stings: snake, scorpions, bees, jellyfishes, spiders Chronic Poisoning Metals Lead Mercury Pesticides in food or fields Organophosphates Carbamates Warfarins Organochlorines: Persistent Organic Pollutants (POPs), has potential developmental neurobehavioral and endocrine effects, e. g. DDT Prevention 1. Primary: to prevent occurrence a) Discard old prescriptions b) Have only few tablets per bottle at a time c) Use child-proof packaging d) Keep medicines in high locked cabinets e) Keep potentially dangerous substances properly labeled and stored in places not easily accessible to toddlers 2. Secondary: to lessen injury after exposure a) Create poison control centers IS YOUR HOME POISON PROOF? 1. Remove the risk, put poisons right away. 2. Discard old prescriptions 3. Have only few tablets per bottle at a time 4. Keep potentially dangerous substances properly labeled 5. Keep medicines in high locked cabinets 6. Use child-proof packaging

7. Keep potentially dangerous substances properly labeled and stores in places not easily accessible to toddlers. Exposure to Lead in Children Preventing Absorption Emesis: Syrup of Ipecac, 15-30 ml followed by water results in vomiting in > 95% less than 5 yr Contraindications: 1) When there is significant risk of aspiration 2) A comatose or convulsing patient 3) Ingestion of strong acids or bases About 8-30% recovery of ingested substance Lavage: Warm saline or warm tap water Complication is esophageal perforation Used to remove fragments of tablets & capsules Charcoal: Activated charcoal most effective and safest to prevent absorption given as water slurry, 15-30 gm in a child and 30-100 gm in adolescent; repeat 20 gm q 2 hr until charcoal in stool Cathartic: Sorbitol max 1 gm/kg, MgSO4 max 250 mg/kg, sodium citrate max 250 mg/kg, or phosphosoda max 250 mg/kg Used to hasten emptying of GIT Requiring Simultaneous Antagonist and Life Support Carbon Monoxide Oxygen 100% ASAP to reduce concentration of CO in the blood Those with high toxin levels may need hyperbaric oxygen therapy Opiates Naloxone minimum of 0.4 mg to any patient irregardless of age or weight If unresponsive, up to 2.0 mg given IV rapidly to larger children and adolescents and may be repeated as needed Newborns to 6-month-old infants should be given a dose of 10-100 mg/kg Cyanide Oxygen immediately then antidote Antidote kit: Amyl nitrite inhalers broken under nose for 30 sec/min while sodium nitrite solution being readied Sodium nitrite 3% solution 0.33 ml/kg (10 mg/kg) to maximum 10 ml/patient with normal hemoglobin Sodium thiosulfate 25% solution given next at 1.65 ml/kg to maximum of whole ampule Hydroxocobalamine-thiosulfate mixture in doses of 4-10 g, an alternative These antidotes produce methemoglobin that help remove cyanide by competition for the cytochrome Substances Causing Methemoglobinemia (Aniline Dyes, Nitrobenzene, Azo Compounds & Nitrites) Unresponsive to oxygen If there is at least 20% methemoglobinemia, patients drop of blood will be relatively brown when dried on filter paper Methylene blue at 0.1-0.2 ml/kg (1-2 mg/kg)/dose of 1% solution is therapeutic Exchange transfusion may be needed if two doses failed Cholinergic Agents (Organophosphates & Carbamates) Manifestations are salivation, lacrimation, urination, defecation and fasciculations Atropine 0.05 mg/kg to maximum initial dose of 2-5 mg to be given while patient decontaminated with soap and water If unresponsive, repeated doses of atropine may be necessary Pralidoxime, a cholinesterase regenerator, may be given when cholinesterase level falls to 25% of normal or lower, at a dose of 25-50 mg/kg over 30 min IV every 8-12 hr in young children to maximum of 1 g/dose in older children Everything is poison, there is poison in everything. Only the dose makes a thing not a poison. --Paracelsus, Father of Toxicology