1 Information on the origination of the book
1.1 Aims of this book
1.2 Personal reasons for the first author writing this book
2 Addiction- a short overview over a widespread disease
2.1 Introduction
2.2 Prevention
2.3 Diagnosis of addiction
2.4 Aetiology of addiction
2.5 Secondary disorders and addiction
2.6 Secondary diseases and brain functions
2.7 Subgroups of addicts
2.8 Motivation of addicts
2.9 The path from motivation to therapy
2.10 Addiction and relapse
2.11 Specific groups of addicts
2.11.1 Co-morbidity of tobacco and alcohol addiction
2.11.2 Overweight, eating disorders
2.11.3 Gender
2.12 Addiction and the homeless
2.13 Polytoxicomania
2.14 Non-substance dependence
3 Aetiology of Addiction
3.1 The psycho-socio-biological model
3.2 Psychological theories
3.2.1 Behavioural approaches
3.2.2. Models of depth psychology
3.2.3 Depth psychological approach
3.2.4 Ego-psychological approaches
3.2.5 The psychological model of object relations
3.2.6 Approach according to theories of Narcissism
3.2.7 Explanation models according to family psychotherapy
3.3 Social explanation approaches
3.4 Biological theories about the aetiology of tobacco and alcohol addiction
3.4.1 Important findings about tobacco and alcohol use from basic research
3.4.2 Aspects of alcohol and tobacco metabolism
3.4.3 Maternal tobacco and alcohol use during pregnancy - a risk factor for the offspring?
3.4.3.1 Smoking during pregnancy
3.4.3.2 Alcohol use during pregnancy
3.5 Aetiological aspects of tobacco and alcohol addiction from an epidemiological perspective
3.6 Aetiology of addiction from a psychiatric perspective
4 Prevention strategies
4.1 Attitude towards addictive drugs
4.1.1 Attitudes towards alcohol consumption
4.1.2 Attitudes towards tobacco consumption
4.2 Primary prevention of tobacco and alcohol addiction
4.3 Secondary prevention: early diagnosis and early intervention
4.3.1 Conclusions for secondary prevention
4.3.1.1 Measures concerning the addictive drug
4.3.1.2 Measures for enabling adolescents to live drug-free
4.4 Tertiary prevention
5 Diagnosis of abuse and addiction
5.1 Problems concerning psychiatric diagnoses
5.2 Development of the term “addiction”
5.3 Substance related diagnoses in the ICD-10
5.3.1 Harmful use (ICD-10 F10.1, F17.1)
5.3.2 Dependence syndrome (ICD-10 F10.2, F17.2)
5.3.3 Withdrawal state (ICD-10: F10.3)
5.4 Substance related diagnosis in DSM-IV (American Psychiatric Association. 1994)
5.4.1 DSM-IV and the multidimensional diagnostic in five axes
5.4.2 Diagnosis according to DSM-IV axis I
5.4.2.1 Tobacco or alcohol abuse
5.4.2.2 Tobacco and alcohol addiction
5.4.3 Specifiers defining subgroups of dependence
5.4.3.1 Tolerance and withdrawl
5.4.3.2 Course specifiers
5.4.4 Therapeutic appraoch
5.4.5 Withdrawal symptoms of tobacco and alcohol
5.5 Commonalities and differences of ICD-10 and DSM-IV
5.6 Implication of these classification systems for therapy and research
5.6.1 Alcohol
5.6.1.1. Studies on medicamentous relapse prophylaxis (according to Hester RK and
Miller WR 2003)
5. 6.1.2 Studies on relapse prophylaxis using psychotherapy
5. 6.1.3 Family psychotherapy
5.6.2 Tobacco
6 Types, dimensions and aetiology
6.1 Alcohol addiction
6.1.1 Development of typology research
6.1.2 Important types for research and practice
6.1.2.1 Two-cluster solutions
6.1.2.2 The four-cluster solutions
6.1.3 Assessment of severity in different dimensions
6.1.3.1 Addiction Severity Index (ASI)
6.1.3.2 Syndrome diagnosis according to Scholz
6.2 Tobacco addiction
6.2.1 Smoking typology according to Schoberberger and Kunze
6.2.2 Smoking typology according to Fagerstroem
6.2.2 European Smoking Classification System
6.3 Alcohol addiction: Lesch’s typology
6.3.1 Framework for the definition of Lesch’s typology
6.3.2 Alcohol addiction from a longitudinal perspective 1976-1982-1995
6.3.3 The “Burgenland Model”
6.3.4 Methodology of the longitudinal study on alcohol dependence (according to DSM-III
and ICD-9), used in the development of Lesch’s typology
6.3.5 Stability in the longitudinal course
6.3.6 The four long-term illness courses used in Lesch’s typology
6.3.7 Results from studies using the Lesch typology
6.3.7.1 Studies on prognosis
6.3.7.2 Studies on biology and genetics
6.3.7.3 Relapse prophylaxis studies, anti-craving substances
6.3.7.4 Other results relating to Lesch’s typology
6.3.8 Lesch’s typology from an international comparative perspective
6.4 The relationship between alcohol dependent patients according to Lesch`s typology and the
severity of tobacco addiction
7 Motives for alcohol and/or tobacco addicted patients to seek medical help
7.1 Tobacco addiction
7.2 Alcohol addiction
7.3 Sequelae that bring patients into therapy
7.3.1 Tobacco and sequelae
7.3.1.1 Introduction
7.3.1.2 Tobacco and neurology
7.3.1.3 Tobacco and internal medicine
7.3.1.3 1Heart disease and circulatory disorders
7.3.1.3 2 Pulmonary diseases
7.3.1.4 Oncological diseases
7.3.1.5 Dentistry
7.3.1.6 Psychiatry
7.3.2 Alcohol and sequelae
7.3.2.1 Introduction
7.3.2.2. Alcohol´s significance for neurology and psychiatry
7.3.2.3 Alcohol and psychiatric disorders
7.3.2.3.1 Alcohol and affective disorders
7.3.2.3.2 Alcohol and anxiety
7.3.2.4 Alcohol and neurological disorders
7.3.2.5 Alcohol and internal medicine
7.3.2.5.1 Gastroenterology
7.3.2.5.2 Cardiovascular system
7.3.2.5.2.1 Alcoholic cardiomyopathy
7.3.2.5.2.2 Cardiac arrhythmia, “Holiday-Heart-Syndrome” and sudden cardiac
arrest
7.3.2.5.2.3 Coronary heart disease and myocardial infarct
7.3.2.5.2.4 Hypertonia
7.3.2.5.2.5. Hypotheses on the aetiology of alcohol addiction and heart diseases
7.3.2.5.2.6 Alcohol typology according to Lesch: homocysteine levels and heart disease
7.3.2.5.3. Oncological diseases
7.3.2.6. Alcohol and medication for sequelae
8 Detection of alcohol and tobacco addiction
8.1 Recommendations for the first contact
8.2 Assessment of drinking behaviour using biological markers
8.2.1 Trait markers
8.2.2 State markers
8.2.3 Associated markers
8.2.4 Practical suggestions for the use of biological markers for forensic purposes
8.2.4.1 Blood alcohol measurement
8.2.4.2 Blood alcohol concentration (BAC)
8.2.4.3 Widmark Formula
8.2.4.4 Breath alcohol
8.2.4.5 Products of alcohol metabolism
8.2.4.5.1 Ethylglucuronide
8.2.4.5.2 %CDT (Carbohydrate-deficient-transferrin)
8.3 The clinical dialogue in tobacco addiction
9 Therapeutic strategies for alcohol and tobacco dependence
9.1 Motivation for therapy in different settings
9.1.2 Motivational interviewing at the general practitioner’s
9.1.3 Motivational interviewing in internal medicine
9.1.4. Motivational interviewing during pregnancy
9.1.5. Motivational interviewing in psychiatric settings
9.2 Pharmacotherapy of alcohol and tobacco dependence
9.2.1 Alcohol dependence
9.2.2 Tobacco dependence
9.3 Pharmacotherapy of alcohol withdrawal
9.3.1 Withdrawal syndrome
9.3.2 Therapy of withdrawal states
9.3.3 Therapy of withdrawal syndromes according to Lesch’s typology
9.3.3.1 Management of detoxification in type I alcohol dependents
9.3.3.2 Management of detoxification in type II alcohol dependents
9.3.3.3 Management of detoxification in type III alcohol dependents
9.3.3.4 Management of withdrawal in type IV dependents
9.3.4 Complications during alcohol withdrawal
9.3.4.1 Withdrawal seizures (Grand Mal)
9.3.4. 2 Delirant and associated states (Meta-alcoholic psychosis)
9.4 Alternatives to withdrawal
9.4.1 Gradual reduction of drinking: “Cut down drinking” method,
according to David Sinclair
9.4.2 Case study: “Cut down drinking”
9.5 Pharmacotherapy of the tobacco withdrawal syndrome
9.5.1 Symptoms of the tobacco withdrawal syndrome
9.5.2 Therapy of the tobacco withdrawal syndrome
9.5.2.1. Withdrawal therapy of tobacco dependency with Fagerstroem ≥ 5
9.5.2.2. Withdrawal therapy of tobacco dependency with Fagerstroem ≤ 4
9.6 Medical strategies for relapse prophylaxis
9.6.1 General guidelines for relapse prophylaxis
9.6.2 Goals for relapse prophylaxis
9.6.3 Medication against so-called “positive” craving (= desire for pleasurable,
rewarding effects of the addictive substance)
9.6.3.1 Alcohol
9.6.3.2 Tobacco
9.6.4 Pharmacotherapy against so called “negative” craving (= desire for addictive
substances to relieve negative mood and anxiety)
9.6.4.1 Alcohol
9.6.4.2 Tobacco
9.6.5 Pharmacotherapy of relapse prevention in alcohol dependence
9.6.5.1 Alcohol
9.6.5.2 Tobacco
9.6.6 Relapse prevention according to Lesch’s typology
9.6.6.1 Relaps prevention in Lesch’s type I
9.6.6.2 Relaps prevention in Lesch’s type II
9.6.6.3 Relaps prevention in Lesch’s type III
9.6.6.4 Relaps prevention in Lesch’s type IV
9.6.7 Treatment of relapse according to Lesch’s typology
9.6.8 Pharmacotherapy of relapse prophylaxis in tobacco dependents
9.6.8.1 Medication for relapse prevention of tobacco dependents
9.6.8.1.1 Nicotine replacement therapy
9.6.8.1.2 Varenicline
9.6.8.1.3 Anti-depressants
9.6 8.1.4 Bupropion
9.6.8.1.5 Nortriptyline
9.6.8.1.6 Doxepin
9.6.8.1.7 Clonidine
9.6.8.1.8 Rimonabant
9.6.8.1.9 Topiramate
9.6.8.2 Therapeutic procedures according to subgroups of nicotine dependent patients
9.6.8.2.1 Subgroups according to Kunze and Schoberberger
9.6.8.2.2 Craving in subgroups of tobacco dependent patients
9.6.8.3 Pharmacotherapy in the relapse prophylaxis of tobacco dependent patients according to
subgroups
9.6.8.3.1 Relapse prophylaxis of cluster I
9.6.8.3.2 Relapse prophylaxis of cluster II
9.6.8.3. 3 Relapse prophylaxis of cluster III
9.6.8.3.4 Relapse prophylaxis of cluster IV
9.6.8.4 Medication of tobacco dependent patients in special situations
9.6.8.4.1 Nicotine consumption in combination with other dependencies and/or
other psychiatric disorders
9.6.8.4.2 Tobacco dependence and pregnancy
10 Sociotherapy of alcohol and tobacco dependents with regards to Lesch’s typology
10.1 Alcohol and tobacco
10.2 The sociotherapeutic mission
10.3 Classification Psychotherapy-Sociotherapy
10.4 Sociogenesis and sociotherapeutic chances
10.4.1 Primary, secondary and tertiary sociogenesis
10.4.2 Sociological factor on a macro level
10.4.3 Co-morbidity and marginal group identity
10.4.4 The link between social relationships (factors on a social macro level): group
coherence and resilience
10.4.5 Analogy to Gerontology: the atrophy of the “social atom”
10.5 Sociotherapy in the context of therapeutic phases
10.5.1 Sociotherapy location(s)
10.5.2 Therapeutic phases and settings
10.6 State of the art: overlapping perspectives for sociotherapeutic housing and support
projects for alcohol dependents
10.6.1 Standard categories
10.6.2 Excursus: supported housing projects - worlds of their own
10.7 Motivation- a challenge for whom?
10.7.1 Ambivalent functions of motivation
10.7.2 Relationship between dependency and motivation systems
10.8 Sociotherapy as a means of promoting networking
10.8.1 Micro and meso levels of networking
10.8.2 Macro levels of networking
10.9 Sociotherapy with alcohol dependents in the context of Lesch’s typology
10.9.1 Critical relationship between psychiatry and sociotherapy
10.9.2 Application of the typology in sociotherapeutic contexts
10.9.2 Relationship between type and self-regulation
10.9.4 Therapeutic goals and strategies
10.9.5 Sociotherapeutic aspects of therapy with alcohol dependents, who are
fundamentally impaired in their performance
10.9.5.1 Type IV characteristics
10.9.5.2 Cerebral damages as a result of chronic alcohol abuse, frontal lobe syndrome
10.9.5.3 Executive Cognitive Functioning
10.9.5.4 Coping with violence
10.9.5.5. Sociotherapeutic structures instead of psychotherapy
10.9.5.6 Stabilisation through social stimulation (SSS)
10.9.5.7 Compliance
10.9.5.8 Overview of pedagogic context variables
10.9.5.9 Over-challenge, “motivation”
10.9.5.10 Case studies of long-term abstinent type IV patients
10.9.5.10.1 Norbert T., Type IV
10.9.5.10.2 Peter N., Type IV
10.9.5.10.3 Karl H., Type IV
Appendix 1 Lesch Alcoholism Typology – Questionnaire
Appendix 2 Lesch European Smoker Classification
Index
About the Authors
