Reference no: EM133509905

Case Study: 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 (42.6% w/v) average per day to approx 60-120 ml per day (42.6%w/v); 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. General physical examination revealed a rash over the nostrils and nasolabial folds; a low BMI for age and a debilitated adolescent, with conjunctival pallor and a resting pulse of 92/min, and blood pressure of 110/80 mmHg. 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. Cranial nerve examination showed normal pupillary reflexes and mild pallor of both optic discs on fundus examination, hearing loss of sensorineural type on both sides of moderate type. The child had a normal motor examination and sensory examination and flexor plantar response. Cerebellar examination revealed ataxic gait with a wide base and a moderate dyssmetria was observed on finger nose test; abdominal examination revealed hepatomegaly with liver margin 2 cm below costal margin and a span of 12 cm chest and cardiovascular examination was normal. The haematological workup revealed mild anaemia with Hb of 8gm% with MCV of 104 fl/cell, hypersegmented polymorphs and macrocytosis and were noted on the peripheral smear. The vitamin B12 levels were low 12pg/dl (nl200-900pg/dl) and liver function tests had transaminases 3 times the upper limit. (ALT-152U/l, ASt-200U/L, ALP-160U/L). A grade I fatty liver was noticed on abdominal sonogram. Audiometery results demonstrated moderate sensorineural hearing loss. Urine drug screen for alcohol was found to be negative. Urine for heavy metal screen was found to be negative. Renal Function tests, serum electrolyte, glucose, serologic tests for syphilis, urinalysis and chest radiograph were normal. Urine EEG, electromyogram, nerve conduction studies and electro retinogram was found to be normal. The contrast study of the head sequential sections showed cerebellar atropy and cortical atropy and generalized attenuation of white matter [Table/Fig-1]. The patient was admitted for the treatment of alcohol withdrawal and management of withdrawal due to volatile substance abuse; pharmacological therapy was begun using thiamine, Lorazepam, were given to decrease agitation and maintenance fluids were begun as well. Buspirone was begun at 5 mg/day and increased to 30mg/day. When the condition of the child stabilized; a short term course of supportive psychotherapy which included cognitive behavioural therapy was employed. This involved exploring and addressing problems which co-occurred with the abuse as well as the positive and negative consequences of drug use. A family based approach and person centered general counselling was adopted to help in recognizing and reducing craving and avoiding high risk situations. With the management of the patient; there was a subsequent decrease in the frequency of volatile substance abuse as well as decreased craving for the volatile substances as well as the alcohol. The general debilitation of the adolescent was improved during the process of detoxification and high energy feeds were instituted after correcting the vitamin and metabolic disturbances. Social workers were also involved in the process. They took detailed histories, delivered brief interventions to help the child for a behavioural change, and assessed the progress and provided encouragement and assistance to rebuild the child's life. It also included the development of drug logs (when the child took the drug and when he was abstinent) and progress reviews to avoid the risky situations. Engagement in healthy was promoted and periodic rewards for abstaining were offered to the child. Alcohol dependence in father was also addressed and was included in the treatment. The child was discharged from the hospital uneventfully. The alcohol intake decreased during the subsequent follow-up visits. The child had a regular follow up with the clinic for a span of 1 year during which general condition of the child showed improvement however then subsequently dropped out.

Questions: Please read the following case report titled A 16-Year-old Boy with Combined Volatile and Alcohol Dependence: A Case Report" and answer the following questions:

1) Describe the addiction(s) the patient had- which began first? Which developed later and why? Which was the easier addiction to sustain? Why?

2) Describe the symptoms experienced while the patient was using . Describe the symptoms experienced while the patient was on withdrawal.

3) What were the interventions used to treat his addiction(s)? Were they effective ? Why or why not ?

4) Suggest an action plan to help this patient sustain his recovery from withdrawal symptoms - what do you think he could do to balance and continue attending treatment regularly?

5) Do you think addictions are easier to cure at younger or older ages? Explain why?