Diagnostic features of Alcohol dependence

According to the ICD – 10 criteria developed by the WHO, Alcohol dependence is defined as “A cluster of physiological, behavioural, and cognitive phenomena due to alcohol use takes on a much higher priority for a given individual than other behaviours that once had greater value”.


It means that alcohol taking behavior takes over the persons other behaviors like working, socializing and other entertainments.




Diagnostic guidelines


1. Strong desire and sense of compulsion to take alcohol
2. Difficulty in controlling alcohol taking behavior.
3. Symptoms of withdrawal like tremors, sweating, increased heart rate, nausea, vomiting and hallucinations, once alcohol is stopped.
4. Tolerance to alcohol, meaning that increase in the amount of alcohol needed to get the same effect. This will result in progressive increase in the amount of alcohol intake.
5. Progressive neglect of alternate pleasure activities. Previous hobbies are stopped to take on alcohol.
6. Persistent use of alcohol despite clear evidence of mental, physical and social harm.

If three or more of above features are present in an individual then alcohol dependence syndrome can be diagnosed.

Since most people are secretive about their alcohol habits, it is difficult to elicit above features. Sometimes doctors need to take comprehensive history from persons family/friends to diagnose Alcohol dependence syndrome.

Use and side effects of Zaleplon(Sonata, Zalep, Zalpilo, Zanlop, Zaplon, Zaso)

Sonata is a prescription only medication used for short term relief of insomnia. Its generic name is Zaleplon. This drug is quite useful for initiation of sleep. However, it is not helpful in maintaining sleep and it usually does not prevent frequent nighttime awakenings.


 Similar to benzodiazepines, Sonata Modulate GABA Type A receptors in the brain and increase their action. This action increases the inhibitory neuro transmission and it ultimately relieves insomnia.


 What the doctor should know before prescribing Sonata?
 If the patient has kidney disease, liver disease, breathing disorder, clinical depression, ataxia (poor control of body movements), or myasthenia gravis then he/she should discuss that with the doctor before taking Sonata. In addition, the doctor should know what the over the counter medications patient is on.


  The doctor may not prescribe this medication to pregnant and nursing mothers. Problematic effects to the new born are reported in regular use, especially in the last three months of the pregnancy.


In addition, this drug increases adverse effects of alcohol and other recreational drugs. Therefore the doctor should know the patients sober habits, before prescribing Sonata.


What should the patient know before taking Sonata?


This medication is available as tablets. Tablets should be taken with full glass of water without crushing, to minimize side effects. It can be taken with or without meals. This is a very short acting drug. Therefore patients should take this medication immediately before sleep.


What are the common side effects?


 If taken in the night drowsiness is usually not continued to the next day. However, operating machinery and driving motor vehicles are not recommended in the following day. 


 Other common side effects are numbness in extremities and menstrual pain. Reduced muscle strength and co-ordination problems of movements are side effects as well. In addition, people can get poor mental concentration, restlessness, confusion and memory loss with this drug.


In addition, one of the main problems associated with Sonata is dependence and withdrawal symptoms like rebound insomnia and fits. Dependence and withdrawal means getting adverse effects when the drug is stopped. However, unlike other hypnotics, tolerance is not reported with regular use. In addition, tolerance means requiring increased amount of the drug to achieve the same benefit.

What is a severe depressive episode?

According to the WHO ICD – 10 criteria (Alternative to the DSM IV of the American psychiatric association), Depression is diagnosed, when the following features are present for more than 2 weeks.

Three Major symptoms of a Depressive episode

1. Depressed mood persisting throughout the day and varies little from day to day and it is usually unresponsive to the circumstances.

2. Loss of interest, enjoyment of the normally pleasurable activities.

3. Reduced energy which leads to increased tiredness (fatigability) and reduced activity.

Seven other minor symptoms of depressive episode

1. Reduced concentration and attention leading to forgetfulness and other mental functions

2. Reduced self esteem and self confidence

3. Ideas of guilt and worthlessness (e.g. believing that a person is a worthless person not suitable for the society)

4. bleak and pessimistic ideas of the future

5. Ideas of self harm and suicide

6. Sleep problems

7. Loss of appetite for food

How severe depressive episode is diagnosed ?

Depressed man -
Vincent van gough
image via Wikipedia

To diagnose severe depressive episode All three major criteria must be present and at least four of the minor criteria must also be present. In addition, person’s work performance, day to day activities should be completely disrupted.
When the person has delusions and hallucinations then the diagnosis is changed to severe depressive episode with psychotic features.

If the person has one or more depressive episodes in the past then the diagnosis should be changed to Recurrent depression current episode Severe depression.

If the person has one or more hypomanic or manic features then the diagnosis should be chaned to bipolar disorder current episode severe depression.

This diagnosis is comparable to the major depressive episode in DSM IV.
Patients with severe depressive episode should be managed in a psychiatric unit.

Further reading

1. ICD – 10 

Side effects of Namenda or Memantin (generic name)

This is a medication prescribed for dementia caused by Alzheimer’s disease. In addition, Namenda is also prescribed for other memory disorders and chronic pain syndromes. It can help Alzheimer’s disease patients to think more clearly and do activities of daily living. However, it cannot cure Alzheimer’s disease. Side effects of this drug are usually tolerable.


This drug has quite unusual mechanism of action. It causes mild reduction in glutamate neurotransmission inside the brain. It causes reduction in exitotoxicity that is associated with glutamate neuro transmission. This results in prolongation of neuronal survival. But this drug is rather expensive and most patients in developing world could not afford it. In addition, long term cost benefit ratio is rather controversial. 

Most common side effects of Namenda

Most common side effects of Namenda are constipation, Dizziness and headache. In addition, Namenda can rarely cause seizures. Weight gain is minimal. But it is reported in some patients. Some patients may get excessive fatigue. Namenda  usually do not cause any sexual side effects. 

Does Namenda cause sedation?

This is a question frequently asked from me. Namenda can cause drowsiness and sedation but it is little rare. Since it can cause fatigue, some patients may find it comfortable to lie on the bed, which can cause sleepiness.  

How lithium toxicity is cured?

Lithium is a mood stabilizing drug used for bipolar affective disorder. Most people with this disorder need to take this drug for longer duration of time to prevent mood problems from recurring. However, lithium is a toxic metal with very narrow margin between toxicity level and therapeutic level. Therefore, it can easily become toxic and early warning signs of toxicity must known by the patients.




Click Here to read on signs of Lithium toxicity

However, lithium also can cause side effects which are not dangerous.

Click Here to read on side effects of Lithium

How lithium toxicity is treated?

Lithium toxicity is treated according to the blood level of lithium, if the patient has >2 mmol/l and patient is clinically not very upset then it is treated with
1. Stopping the lithium therapy
2. Hydrating the patient via intravenous normal saline and increased oral water to washout lithium inside the blood
3. If the patient is not responding or the lithium level is >3mmol/l or patient is having very significant toxic features, Hemodialysis (artificial cleaning of the blood) is the treatment option.
4. After the treatment, doctor will usually look into the cause for lithium toxicity and he/she may start a mood stabilizer that is different to lithium such as sodium valproate. However, Lithium is the usual gold standard in treating and preventing bipolar affective disorder

Further reading


1.  Contraindications for Lithium treatment


2.  Mood stabilizers for bipolar disorder: Uses and side effects

3. Characteristics of the bipolar disorder