New insights into the neurobiological basis of alcohol problems have been gained mainly in the field of neuropsychology and the acute and chronic effects of alcohol on the relevant neurotransmitter systems. They establish a deeper understanding of the origin and course of the disease. The treatment approach consists of an individually designed combination of outpatient, day patient and inpatient measures, including medical consultations, “qualified withdrawal treatment”, pharmacological and psychotherapeutic relapse prevention and long-term inpatient rehabilitation treatment. Extensive S3 guidelines are now available for this treatment approach. With current treatments, abstinence rates of 50% to 60% can be achieved in one year. However, new findings raise the question whether abstinence always has to be the only therapeutic goal. A reduction in alcohol use was previously described with behavioural therapy and can also be supported pharmacologically.
The Diagnostic and Statistical Manual (DSM-5) of the American Psychiatric Association has significantly changed the diagnoses of dependence disorders: it no longer uses the terms “addiction and abuse” or “harmful use” but encompasses both these terms in a dimensional approach under the new diagnosis “alcohol-related disorders”. The severity can be specified on the basis of the number of symptom criteria fulfilled.
In sum, the above-mentioned advances form the basis for closer involvement of therapists participating in treatment for substance use disorders. The symposium will present the neurobiological principles and new practical aspects for implementing the latest findings.
Development and maintenance of alcohol use disorders
Andreas Heinz, Berlin (Germany)
Essential neurobiological correlates of the most important symptoms of alcohol dependence could be identified that affect our treatment concepts. Genetic studies in animal models and humans indicate that a reduced serotonin and increased glutamate turnover can contribute to sensitivity to the acute effects of alcohol, aggressiveness under alcohol and increased consumption. Chronic alcohol use is accompanied by a change in the composition of the excitatory glutamatergic NMDA receptors and inhibitory GABA-A receptors, which leads to the development of tolerance and triggers withdrawal symptoms when the drug alcohol is suddenly discontinued. Animal models and studies in humans confirm the important role of the dopamine-innervated, so-called “reward system” in alcohol use disorders, as well as in other substance use disorders and obesity. These studies found an increased response to the immediate, alcohol-associated reward and a reduced activation in others, e.g. social reinforcers. A reduced interaction between core regions of the reward system, such as the ventral striatum and the dorsolateral prefrontal cortex, which is responsible for action control, correlates with a reduced learning speed by positive and negative feedback and makes it more difficult for detoxified patients to learn alternative, non–addiction-related behaviours. The alcohol-related changes contribute to a largely “habitual” alcohol consumption and can be specifically influenced by new behavioural therapy training programmes and individual drugs.
Evidence-based treatment of alcohol dependence
Falk Kiefer, Mannheim (Germany)
The psychiatric and psychotherapeutic care of patients with alcohol problems offers new opportunities for practising colleagues. The prevalence figures of around 4 million affected people show that the need for consultation and treatment is extremely high and hardly met. The fact that at the same time the treatment options have expanded considerably in recent years means that the treatment of alcohol dependence is associated with great challenges and opportunities.
Therapeutic strategies for pharmacotherapy and psychotherapy can be derived from the neurobiological findings, together with relapse events and evidence-based treatment guidelines. Abstinence is still the therapeutic goal, but is being increasingly supplemented by the therapeutic goal of reducing the amount of drinking in different patient groups. This will be discussed in the light of the current care situation.
Psychotherapy is based in particular on “motivational interviewing”. This approach addresses the conflict of ambivalence that patients often have with the aim of changing behaviour. Psychotherapy methods such as stimulus exposure training or cognitive behavioural therapy have positive effects, at least in subgroups of patients.