CASE REPORT

• A 16-year-old adolescent male with a normal birth history and developmental milestones and belonging to
low socioeconomic status; was brought to the outpatient department by his mother who permitted and
consented along with the child in writing the report, complained that the child was smelling a rubber based
adhesive using a handkerchief since the last 3 years. There was significant family history of alcohol
dependence in father. There was no history of fever, head injury, seizure or attention deficit hyperactive
disorder. There was no history of stress, tension or depressive thoughts. The toluene based substance abuse
began gradually from 5ml/day and picked up to 20 ml each per day gradually over a span of 1 year which
remained relatively stable during the presentation to the outpatient. After acute ingestion of Polychloroprene
based solvent; the adolescent complained of tinnitus, slurring of speech, restlessness tremors, dizziness
and ataxia. During the phase of withdrawal, there was coprolalia with assaultive and abusive behaviour,
increasing fights, maladaptive behaviour and headache. These symptoms increased in severity; which
compelled the parent to seek help. In addition, excessive tearing in the morning, headaches, decreased
cognitive ability were the prominent symptoms in the morning; due to withdrawal.

• After obtaining detailed history, it was found that there was no confusion, visual hallucinations and/or
seizure. Alcohol abuse began approximately 6 months after the volatile substance abuse, on detailed
questioning child was asked whether he needed to cut down on the drinking behaviour, his annoyance, guilty
and use of alcohol eye opener in the morning the response was positive for ¾ of the questions. He further
added that the alcohol abuse began when the patient’s friends circle changed to include more people of
higher age group. The patient used to steal money from his house in order to fetch the abused substance. The
child was a school drop out as he faced inability to concentrate and low scores at school. Moreover, he often
was involved in assaultive behaviour at school. The alcohol consumption increased from initially 20-40 ml of
local alcohol average per day to approx 60-120 ml per day ; later during the span of last 2 months before
presentation to the outpatient department. The child abused glue more than the alcohol due to its easy
availability.
• During times of the day when no glue was consumed; alcohol abuse was noted along with the peers of elder age. During the
phase of acute alcohol intoxication alone; the adolescent complained of nausea, headache, dizziness and excessive somnolence
however when combined with glue sniffing; disorientation and ataxia, restless, diaphoresis and nystagmus were
complained of, in addition. The child also developed blurring of vision and inability to perceive numbers and letters in the
central visual field and fixed hearing deficits to increased frequency sound was noted; more prominent during the last 2
months, during which period combined abuse was done and dose of alcohol was increased to about 60-120 ml of (42.8%
w/v) alcohol per day. A progressively increasing tendency of violence, disorientation, restlessness was noticed by the mother
and his family in the form of anger outbursts, abusive and assaultive behaviour in the last two months during which alcohol
intake was accelerated.

• The child presented to the clinic in a state of withdrawal since the mother had not let the child consume any substances since the
last 2 days. The child tried to abstain from glue and alcohol a few times; but each episode of abstinence was followed by increase
in the use. During the phase of abstinence; the child complained of increasing slurring of speech, difficulty hearing voices and
sleep disturbances. The central nervous examination exhibited symptoms of withdrawal including combativeness, irritability,
aggressiveness, an impaired long term recall on minimental status examination with a score of 20. 

• The psychometric tests scored low on aptitude and skills. IQ assessment was done using Seguin Form board, Malin’s intelligence
scale for Indian child. The test score indicated to a below average intelligence in the child. On the Family Environmental Scale;
there was a low score in all subgroups like personal, relationship, and system maintenance. The areas of behaviour control,
problem solving, communication, affective response scored low.
 Addiction
• Addiction is a state of psychological or physical dependence (or both) on the use of alcohol
or other drugs. The term is often used as an equivalent term for substance dependence
and sometimes applied to behavioural disorders such as sexual, internet and gambling
addictions(Adapted from APA Dictionary of Psychology)
• Substane dependence : An addictive disorder that describes continued use of drugs or
alcohol, even when significant problems related to their use have developed. Signs include
an increased tolerance—that is, the need for increased amounts of the substance to attain
the desired effect; withdrawal symptoms with decreased use; unsuccessful efforts to
decrease use; increased time spent in activities to obtain the substance; withdrawal from
social and recreational activities; and continued use of the substance even with awareness
of the physical or psychological problems encountered by the extent of substance use.
• Substance abuse : Substance abuse, as a disorder, refers to the abuse of illegal substances
or the abusive use of legal substances. It is an addictive disorder that describes a pattern of
substance (usually drug or alcohol) use leading to significant problems or distress, such as
failure to attend school, substance use in dangerous situations (like driving a car),
substance-related legal problems or continued substance use that interferes with
friendships and/or family relationships. Alcohol is the most common legal drug to be
abused.
• Substance use behaviour is a complex and multidimensional phenomenon having
biological, psychological and social factors acting as the cause and consequence of
the same (Sinha, 2008). It is often marked by initial use of substance for its
rewarding and pleasurable effects gradually escalating to maladaptive use of same.
The development of substance use behaviour can be explained using the three
major components of addiction cycle (Koob & Volkow, 2016):
• 1.Binge/intoxication: the stage in which individual consumes substances for its
positive rewarding effects.
• 2.Withdrawal/negative affect: the stage in which individual experiences negative
affect in the absence of substance.
• 3.Preoccupation/Anticipation: the stage where individual seeks substances post
abstinence.
WHO Psychosocial Model
Figure 3.1 : Modification
of the WHO model. This
figure is a modification
of Figure 3 that
emphasizes that
processes that subserve
the urge to use drugs can
be distinct from
processes that subserve
cognitive risk-benefit
analysis and that both
can be influenced by
distinct factors. Note
consequences of
alternative drug-use or
no drug-use decisions
and variety of factors
shown by recent
research to influence
mood, urge to use drugs,
and capacity (coping
skills) to avoid drug use.
Figure 3.2 : Model of drug use
and dependence including
amelioration influences. This
figure is a modification of
Figure 2.2 that deletes (for
visual clarity) some
relationships shown in Figures
3.1 and 3.2 and introduces some
of the multiple influences
(including treatment) that can
ameliorate patterns of harmful
drug use (including
dependence).
• Alcohol dependence and harmful alcohol use are recognised as mental health
disorders by the World Health Organization (WHO, 1992; see Section 2.2)

• The definition of harmful alcohol use in this guideline is that of WHOs International
Classification of Diseases, 10th Revision (The ICD–10 Classification of Mental and
Behavioural Disorders) (ICD–10; WHO, 1992):

• A pattern of psychoactive substance use that is causing damage to health. The

damage may be physical (e.g. hepatitis) or mental (e.g. depressive episodes
secondary to heavy alcohol intake). Harmful use commonly, but not invariably, has
adverse social consequences; social consequences in themselves, however, are not
sufficient to justify a diagnosis of harmful use.
• Although alcohol dependence is defined in ICD–10 and DSM–IV in categorical terms for
diagnostic and statistical purposes as being either present or absent, in reality dependence exists on
a continuum of severity. Therefore, it is helpful from a clinical perspective to subdivide
dependence into categories of mild, moderate and severe.
• People with mild dependence (those scoring 15 or less on the Severity of Alcohol Dependence
Questionnaire [SADQ]) usually do not need assisted alcohol withdrawal.
• People with moderate dependence (with an SADQ score of between 15 and 30) usually need
assisted alcohol withdrawal, which can typically be managed in a community setting unless there
are other risks.
• People who are severely alcohol dependent (with an SADQ score of 31 or more) will need assisted
alcohol withdrawal, typically in an inpatient or residential setting. In this guideline these
definitions of severity are used to guide the selection of appropriate interventions
• Several terms including ‘alcoholism’, ‘alcohol addiction’, ‘alcohol abuse’ and
‘problem drinking’ have been used in the past to describe disorders related
to alcohol consumption. However, ‘alcohol dependence’ and ‘harmful
alcohol use’ are used as per guideline consistent with WHO's International
Classification of Mental Disorders, 10th Revision (WHO, 1992).
• Defined as scoring 8 or more on the Alcohol Use Disorders Identification
Test (AUDIT). (Harmful alcohol use)
• Defined as scoring 16 or more on the AUDIT. (Alcohol addiction or
dependence)
.
• The etiology of alcohol use behaviour is multifactorial.

• Addictive disorders are caused by multiple factors, including genetic vulnerability,

environmental stressors, social pressures, individual personality characteristics and
psychiatric problems.

• From a neurological standpoint, addictive disorders arise when a substance changes

the way the user’s brain feels pleasure. Addictive substances alter the brain’s ability
to send and receive chemicals called neurotransmitters, which cause pleasure. The
addictive substances can prevent nerves in the brain (called neurons) from receiving
these neurotransmitters, meaning the drug user relies on the drug, rather than his or
her natural brain chemicals, for feelings of pleasure.