Natural History of the Illness
Once the patient was stabilized, a psychiatric consultation team was called to evaluate him. He emphasized that he drank every day but that it "wasn't always that way." His drinking behavior started in high school. His father, who was a heavy drinker, would ask the patient to join him on Friday nights for an "all boys" night that included going from bar to bar and drinking heavy liquor. The patient was just 16 years old at that time and recalls cherishing those nights because he bonded with his father, even if "while drunk." The drinking days continued and eventually turned into 4-day binges starting on Thursday nights. His father later developed cirrhosis of the liver and died of a myocardial infarction when he was age 55 years and the patient was 24 years old. He reported feeling upset and depressed after his father's death, which intensified his "drinking nights" to include more drinks per drinking occasion. Nevertheless, he continued to limit his drinking to 4 days a week, starting on Thursdays and ending on Sunday night.
He managed to continue working as a carpenter in a construction business but occasionally would miss Mondays or go in late due to alcohol-related hangovers. He married at age 26 years, had three children, and then at age 33 years was divorced from his wife because of his drinking, which by that time had escalated to daily heavy drinking. He relayed that during his later 20s, his drinking escalated to the point where he didn't really care whether he had a relationship with his family. It was at this point that he felt he lost control over his drinking, and the illness became a "monster" that was constantly present day and night. The patient's drinking pattern continued to evolve during his 30s and 40s to the point that alcohol ingestion wasn't necessarily pleasurable anymore. Instead, he drank to relieve an "inner tension" that would start with mild withdrawal symptoms including tremors, dysphoria, and increased heart rate coupled with anxiety, which would progress throughout the day if he didn't have a drink. This constellation of symptoms would lead to an intense craving that was manifested by constant thoughts of when he could drink and how he could procure alcohol, followed by the initiation of the drinking behavior.
The patient recounts that he eventually started drinking after he woke up to relieve the morning "shakes" so that he could begin his day. As a result, this habit led to recurrent job absenteeism, lack of productivity, and eventually to being fired from his job. He states that everybody knew he was drinking "a little too much" at work, and some of his friends even covered for him. At this point, he was in his 40s.
Recent Course of Illness
Recently the patient has been working odd jobs, going from "here and there" as a carpenter to picking up aluminum cans for recycling. He states that he works to earn money to buy alcohol. In doing so, he may go days without eating anything and consequently has dropped 30 lb in the last 6 months. Upon further questioning, the patient revealed a daily intake of a pint to a pint and half of 80 proof liquor along with a 6-pack of 12-oz beers. He normally begins drinking shortly after he gets up in the morning if there is liquor available. If not, he starts drinking a bit later after he obtains some alcohol, on those days feeling more tremulous and anxious prior to drinking. He generally continues to drink on and off until the evening, when he would drink beer to "help me go to sleep" because it is cheaper than liquor.
Course of Medical Treatment
The patient was admitted to the medical floor, where he was diagnosed with alcoholic hepatitis. He had signs and symptoms of early alcohol withdrawal with marked tremulousness, anxiety, sweating, and a heart rate of 120 beats/min. Collateral information for this patient revealed a longstanding history of alcohol abuse and dependence and occasional marijuana use.