Alcoholism: Long-term Effects and Withdrawal

So your character has a habit. A bad habit. And of course, writing fiction is all about making the characters day a little more difficult. What better time to go cold turkey off the booze than the middle of an action-filled, intensely stressful plot?

Alcohol consumption can be good for the body, in small regular doses. A glass of red wine a day has been proven to have protective benefits for the heart and contains many cancer-fighting anti-oxidants. A pattern of binge drinking or heavy consumption of alcohol, however, can have major negative impacts on social situation, health, and well-being. Alcohol withdrawal can cause life-threatening problems called DTs, or delirium tremens.

Long-term complications

Most of the long-term complications of alcoholism fall into two categories - damage from the drug itself and damage caused by the exceedingly poor nutritional status of most chronic alcoholics.

Probably the most well-known complication of alcoholism is cirrhosis of the liver. Basically, the liver fills up with scar tissue. Below, you'll find photos of both a healthy liver and a scarred liver with cirrhosis. Cirrhosis can also be caused by viral infections, including several strains of viral Hepatitis, an infection alcoholics and drug users are particularly prone to get. The healthy liver is on the right.


















Other direct complications of alcoholism include withdrawal (DTs), physical dependence, inability to abstain from drinking, tolerance (needing more and more alcohol to get drunk), or are primarily social complications like inability to hold a job, dysfunction of relationships, homelessness.

Indirect complications are sometimes worse for the body than the direct ones. Every system of the body is impacted by excessive alcohol intake. Just a few of the massive list of possibilities are below:

• Altered brain function, including decreased ability to think and reason
• Impaired judgment both when drinking and when sober
• Ulcers of the stomach and intestines, bleeding from the intestines (coffee-grounds appearance to the poop)
• Extreme malnutrition - alcohol has more calories per gram than sugar and carbohydrate foods (breads, cereals, fruits, vegetables), but none of the protein, vitamins or minerals the body needs to stay strong. Weight is not a predictor of nutritional health.
  
• Brittle teeth and bones - I once took care of a fellow in the ICU who broke his neck by falling off a couch onto carpet after a bender and 20 years of hard drinking. He is now quadroplegic (unable to move arms or legs)
  
• Bleeding - alcohol "thins" the blood, making blood clotting take longer from cut to clot, so chronic alcoholics bleed longer when cut, bruise easier, and are more prone to strokes and brain bleeding with head traumas

Cold Turkey: Delirium Tremens
Cutting the stuff out? If your character has been an addict for a while or has gone on a major binge (even just one if the blood alcohol level was super-high), they can suffer Delirium Tremens. These very uncomfortable physical signs of withdrawal can last for up to a week after the last drink and can get very suddenly worse. People have died from Delirium Tremens and for very chronic alcoholics or long-term very heavy drinkers, the best place to withdrawal is at an in-patient treatment facility. Symptoms of the DTs are below.

• Tremors/shakes
• Agitation, confusion, deep sleep for very long periods (a day or longer), stupor, inability to fully wake up,
  
• Delirium - a loss of the ability to determine person, place, time, or situation - the person might not be able to remember what year it is, not recognize family members, not understand where he/she is or why things are happening
• Hallucinations - seeing, hearing, smelling, feeling physical sensations, or tasting things that aren't really there
  
• Fear, anxiety, restlessness, excitement, nervousness, irritability
  
• Very sensitive to light, sound, touch, jumpy
  
• Rapid changes of mood, depression
  
• Seizures - usually full body large motor jerking (to see a seizure click HERE). Seizures of this type are very rhythmic and often involve eye rolling, teeth grinding, a bluish tinge to the face/lips and severe confusion and tiredness or feeling too heavy to move afterward. Seizures are most common in the first 1-2 days after the last drink
  
• Pulsing headaches
• Loss of appetite, nausea, vomiting, stomach pain
  
• Pallor, heart palpitations (feels like your heart is doing cartwheels), chest pain
  
• Heavy sweating (especially facial and on the palms)
• Fever

After the physical withdrawal period, the patient is no longer physically dependent on alcohol, but they may continue to by psychologically addicted. They feel like they need alcohol to function, to escape, or just because. Psychological addiction can be a powerful enemy. Alcoholics Anonymous is a 12-step program to help people cope with alcohol addiction. It works. It also requires one to profess a belief in God or a higher power, which isn't something everyone can do. Cognitive-behavioral therapy and aversion therapy (where drinking is repeatedly associated with a very noxious stimulation, vomiting for instance) have also show to be very successful.

In severe cases where alcohol addiction has become life-threatening, controversial medications which cause the body to violently react to ANY alcohol consumption have been used. These include Antabuse and Disulfiram. Other medications are available for treatment of alcohol addiction, including anti-depressants and drugs to control cravings.

Recent studies suggest that alcoholics who continue to smoke while attempting to stay sober are more likely to relapse than those who quit smoking and drinking at the same time.

For more information on alcoholism, its symptoms, effects, treatments and complications, see:

• The Mayo Clinic
• The US National Library of Health

As an added disclaimer, if you think you or someone you know has an alcohol addiction, seek professional help. Resources in your community can be found through Alcoholics Anonymous, your physician, the local health department, and at any hospital. Remember, information here is for fiction-writing purposes only.

Infection: Malaria

I vant to suck your blood!

What better time than Halloween to be thinking about blood suckers. The one you see to the right is Anopheles mosquito, and its bite probably doesn't even hurt, though it might itch later. 41% of the world's population lives in the home territory of these little vampires, but the loss of blood isn't that harmful. What your characters have to be wary of is the VTD - Vampire Transmitted Disease. Anopheles mosquitos are often infected with tiny, microscopic parasites that are the cause of one of the most common parasitic diseases in the world - malaria.

Every year around the world, 350-500 million cases of malaria are diagnosed. This disease is anything but rare.

Malaria is caused by several species of parasites - P. falciparum, P. vivax, P. ovale, and P. malariae. These yummy little microscopic bugs have a powerful hunger for red blood cells. The parasites are injected into the body through the bite of infected mosquitoes. Once injected, they race to the liver and begin to multiply. Victims rarely know they are infested during this stage as the 15-100 parasites build an army 30,000 strong before attacking the choice buffet that is the blood stream.

Once inside the blood cells, the parasites multiply and feed, eventually rupturing the blood cell and causing the symptoms of malaria. Symptoms begin anywhere from 7 to 30 days after the mosquito bite, but can be suppressed up to a year by modern anti-malarial drugs. How fast the symptoms start depends on which species of the parasite are infecting the person, and on the person's own body. Classical malaria attacks are rarely observed these days, but attacks occur every 2-3 days and last 6-10 hours each. The reason for this timing is that the parasites incubate inside infected red blood cells for 2-3 days before the blood cells rupture. In classical episodes, the victim goes through three distinct stages of illness.

• The cold stage - shivering, chills


• The hot stage - headaches, fever, possibly seizures (especially in children), vomiting


• The sweating stage - sweats, normal temperature, extreme tiredness

In general, a victim can experience any of the following symptoms, in any order: chills, fever, weakness, vomiting, sweats, headaches, nausea, muscle aches and generally feeling under the weather. In cases of infection with P. falciparum jaundice (yellowing of the skin and whites of the eyes) can occur along with enlargement of the liver and fast breathing.

Right. Sounds like a nasty case of the flu. What's the big deal?

Malaria infection killed nearly a million people in 1995 alone, and accounts for over 10% of all childhood death in developing nations. The strain of parasite, P. falciparum, are much more aggressive than the others and can lead to "severe malaria" in which one or more organ system fails to function. Systems and their symptoms are listed below:

• Brain infection - abnormal behavior, seizures, decreased ability to remain awake, coma or death


• Severe anemia leading to extreme tiredness and breathing trouble


• Respiratory distress (breathing trouble) - flaring of the nose, head bobbing, panting, fast breathing, blue tinge to the fingertips, lips or mouth, the inability to get enough air, passing out, death


• Longer bleeding times before clotting - this can lead to strokes, bruising, actual bleeding, gut-bleeds (bloody or coffee-ground appearance to the poop), bloody urine, etc..


• Cardiovascular collapse (failure of the blood stream to hold enough fluid in to meet the body's needs or failure of the heart to pump blood) - symptoms can include chest pain or difficulty breathing or may mimic shock - low blood pressure, loss of consciousness, rapid heart rate, shaking, cold extremities, sweating, lightheadedness, confusion


• Low blood sugar (starving the brain) - symptoms include dizziness, hunger, headache, shaking, anxiety, and heart palpitations (feels like your heart's doing flip-flops in your chest. On this I speak from experience)

Today, treatment with antimalarial agents reduces the severity and duration of malaria infection. A list of drugs used appears below, taken from the Centers for Disease Control website.

chloroquine
sulfadoxine-pyrimethamine (Fansidar®)
mefloquine (Lariam®)
atovaquone-proguanil (Malarone®)
quinine (Best bet for pre-modern settings)
doxycycline
artemisin derivatives (not licensed for use in the United
States, but often found overseas)

One more nasty little surprise, malaria caused by the P. ovale or P. vivix strains can lay dormant for months to years in the liver, eventually re-emerging to cause symptoms all over again.

A pound of prevention

Currently, the gold standard for prevention of malaria is using mosquito netting around beds and cribs to prevent mosquito bites. A multitude of non-profit organizations exist whose mission it is to send mosquito netting to poor and under-served populations in areas where malaria is endemic. Other methods include draining wet areas and eliminating standing water where mosquitoes breed, using pesticides to reduce mosquito populations, and using anti-malaria drugs prophylactically (to prevent infection) for pregnant women and individuals traveling to areas where the infection is endemic (native).

An evolutionary twist

One of the most fascinating phenomenon I studied in nursing school was Sickle Cell Anemia. This disorder is a genetic change to the shape of red blood cells that can cause severe problems and even death in those who are symptomatic. However, the trait for Sickle Cell disease actually conveys a protective factor against malaria infection! Considering that this trait developed in the part of the world where malaria have been endemic for the whole of human history, it's interesting that a twist of genetic selection could breed a trait to keep people from getting sick.

Despite this protective factor, those who develop full-blown sickling, where many red blood cells actually change shape to resemble a curved sickle (see picture), can have life-long severe pain and complications.

Addendum - you can find a map of the parts of the world where malaria is currently endemic (native) at the World Health Organization's website, this URL http://www.who.int/malaria/malariaendemiccountries.html.

Fellows in Need

The idea for this blog came about because of the literally hundreds of medical questions I have answered over the years at NaNoWriMo.org and Forward Motion for Writers. So despite my personal no-ads policy, I'm going to throw up this link.

Forward Motion is a free site for writers with over 13,000 members and a hefty history of chewing a hole in its owner's personal pocket. Said owner - Lazette Gifford - is in need. Click the button to find out how you can help her and maybe help yourself in the process.



Thanks to Holly Lisle for organizing this grassroots and undercover operation to help out a fellow writer in need.

This post expires 12/31/08.

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Happy Reading!

Character Psychology: PTSD

I write dark fantasy. Very, very dark fantasy. My characters go through hell and back on the page, and they genuinely suffer those events. Despite the most recent trend in fiction of the blase hero who shrugs off torture, maiming and psychological terror with a witty one-liner, my characters get to experience the full range of horror, grief, self-doubt, and pain as well as the relief, joy, and love that accompany their travails.

If yours do, too, this is the post for you.

Self-Defense
The human psyche is set up to defend us against long-term dysfunction associated with traumatic events. Factors that modern psychology label "defense mechanisms" - like denial and overcompensating - are meant to prevent us from being overwhelmed by all sorts of nastiness - warfare, muggings, rape, torture, natural disasters... you name it.


Most of the time, the defense mechanisms do their job - they defend the integrity of the person's mental state until the person has a chance to cope with the problem. But when defense mechanisms fail, or are carried on well beyond the period when acceptance and healing should have begun, mental health problems can set in.

Dysfunction

One of the best tools in the resource bag of an writer whose characters genuinely suffer their tragedies, is PTSD, or post-traumatic stress disorder. Originally used to describe the mental health problems of post-war combat veterans, this term has come to mean an anxiety disorder that comes about following significant traumatic exposure in any age group or population. Examples include folks who experience, have loved ones experience, or observe violent events like mugging, rape, murder, torture, kidnapping, terrorism, natural disaster, child abuse, or any form of significant physical or threatened harm.

So how do you know if your character has PTSD? Symptoms of PTSD include sleeping disturbances (especially nightmares), irritability, loss of pleasure in things once enjoyed, apathy or numbness toward people once close to, jumpiness or being easy to startle, and the potential to become aggressive or even violent.

The hallmark of PTSD are flashbacks - intense, uncontrollable memories of the traumatic event that have the power to remove the person from the here-and-now and take them right back to the moment of greatest trauma. Flashbacks are often triggered by everyday events, sounds, or smells. A backfiring car, the smell of a certain cologne, flashes of light, the sound of a balloon popping, certain phrases of dialogue - anything that triggers a memory can, in PTSD, trigger a flashback. Not every person with PTSD will have flashbacks, but all will suffer from vivid emotional or memory recurrences of the event. Fear, anxiety, and a sense of helplessness are very common.

People with the disorder often describe flashbacks as replaying the event in their minds, of forgetting where they really are and reliving the experience, of being in a bubble of terror. Unlike normal memories, flashbacks trigger not just an emotional response, but a physiological response as well. Release of adrenaline (the fight-or-flight reflex hormone) causes pounding heart, increased blood pressure, sweating palms, stomach upset (up to and including vomiting), a tendency toward aggression, dry mouth, an intense desire to flee...

All writers have some experience with adrenaline to draw from for painting their character's emotions. Just think of a time when you've been utterly terrified, or even nervous. The hormones that control your body's reaction to these emotions are the same. Maybe asking Susie Q to the spring formal got your heart pounding and your palms sweating. Maybe it was a traumatic event of your own that you have overcome or not yet faced. Draw on these experiences to let your characters experience emotions as real as those you felt when you stood there shaking, pupils dilated to take in more light, heart racing, mouth dry.

The purpose of adrenaline is to get your body ready to either flee from immediate danger, or to fight for your life. With PTSD, it's just a matter of that hormone being triggered strongly at inappropriate times, for memory rather than immediate threat.

Not every character needs to experience PTSD, but every character should have some reaction to horrible things that happen in their experience. If you think PTSD might be just what your character needs, read on.

The symptoms of PTSD usually occur within six months of a traumatic event, but can take years to show up. Symptoms must last longer than a month to qualify as a disorder under current psychological diagnosing guidelines.

Most individuals diagnosed with PTSD today get relief from a class of drugs known as selective seritonin-reuptake inhibitors (SSRI), which are also used to treat depression. Drugs in this class include Prozac, Lexapro, Zoloft, and Paxil. Individuals not treated medically can see symptoms resolve over time or by 'working through' their delayed reaction to the trauma. Psychotherapy and even virtual reality have been successfully employed in resolving PTSD. However, for some individuals, PTSD symptoms can become chronic, lasting years or throughout the remainder of life.

Women are more likely to develop PTSD than men, and individuals who experience traumatic events that were intentionally caused by another person, such as rape, kidnapping, or torture, are more likely to develop the disorder than survivors of natural disasters or events that are not directed specifically at the individual, like car accidents. People who suffer from severe PTSD may have difficulty keeping jobs. Some may attempt to avoid situations that trigger flashbacks or engage in "escape" behaviors like heavy drinking and drug use or attempt suicide.

PTSD, in fiction, can be a powerful tool to draw tension and internal conflict (and external if your PTSD sufferer gets violent). As in the real world, it can be devastating to the person's life and overall well-being. Combat soldiers, particularly from the Vietnam era, have been widely known to suffer PTSD to varying degrees. New therapies have been successful at helping many, but chronic PTSD remains a problem for many.