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Lesch Alcoholism Typology Medical Treatment and Research Archives of Psychiatry and Psychotherapy, 2010; 4 : 37–48 Lesch Alcoholism Typology Medical Treatment and Research Dagmar Kogoj, Otto Michael Lesch, Victor Blüml, Anita Riegler, Benjamin Vyssoki, Golda Schlaff, Henriette Walter Summary Aim. Alcohol abuse and alcohol dependence produce very high health costs. Nowadays, early detection and intervention are very well accepted. Due to the well proven theory regarding the heterogeneity of al- cohol dependence and for the purpose of research and therapy, four subgroups of alcohol dependence have been established. Methods. The Lesch Typology was developed as a result of a prospective long - term study and led to a decision tree identifying alcohol dependent patients’ subgroups. The results show that each subgroup re- quires different and specific treatments. Within the framework of a computer programme (www.LAT-on- line.at) the decision tree can be used very easily. Meanwhile, this method has been field – tested in nu- merous basic and clinical trials. After the diagnostic procedure, a protocol of the questionnaire displays reachable and realistic treatment goals. Furthermore, it provides information about the guidance and treat- ment of each patient subgroup. Conclusion. Nowadays, the heterogeneity of the disease alcohol dependence is without any doubt an ac- cepted certainty. By utilizing the Lesch Typology, specific treatment approaches of the diverse subgroups may be applied accordingly. Discussion. Using the subgroups defined in the Lesch Typology for basic and clinical research subgroup customized treatments can be prescribed, and consequently even better treatment outcomes in alcohol dependent patients can be awaited. alcohol dependence/ Lesch typology/ subtypes/ withdrawal and relapse prevention treatment INTRODUCTION treatment is mainly used for alcohol withdraw- al and for relapse prevention. For withdrawal Alcohol dependence represents a chronic brain most authors recommend treatment with benzo- disease with a relapsing course and a high bur- diazepines (Johnson B. [2, 3], Lesch OM et al.). In den of alcohol related disabilities. Smoking com- clinical routine however, many centres also use bined with alcohol dependence is a common Tiapride, Carbamazepine, Clomethiazole, Tra- phenomenon, leading to significantly increased zodone and Sodium Oxybate. mortality rates (NIAAA-website [1]). Medical Relapse prevention includes pharmaceutical and psychotherapeutic approaches. Currently Dagmar Kogoj, Otto Michael Lesch, Victor Blüml, Anita Riegler, almost every psychotherapeutic method is used. Benjamin Vyssoki, Golda Schlaff, Henriette Walter: Medical Uni- For pharmaceutical relapse prevention medica- versity of Vienna, Department for Psychiatry and Psychotherapy, tions with significantly different biological ac- Waehringergurtel 18-20, 1090 Vienna, Austria. Correspondence ad- dress: Univ. Prof. Dr. Otto Lesch, Medical University of Vienna, De- tions are recommended. partment for Psychiatry and Psychotherapy, Waehringerguertel 18-20, In a literature review Hester and Miller [4] 1090 Vienna, Austria. E-mail: [email protected] showed that all these drugs are only effective in 38 Dagmar Kogoj et al. Figure 1. Pharmacological substances presently used for relapse prevention in chronic alcoholism Pharmacotherapeutic relapse prevention Serotonergic System Zimelidine ( Balldin et al. [5]) Buspirone ( Kranzler et al. [6]) Ondansetron (Kranzler HR et al. [7]) Mirtazapine (Lesch et al. unpublished ) Sertraline plus Naltrexone (Pettinati et al. [8]) NoradrenergicSystem Imipramine (McGrath PJ et al. [9]) Dopaminergic System Tiapride (Shaw GK et al. [10,11]) Lisuride (Schmidt LG et al. [12]) GABA- ergic System Gamma - Hydroxybutyric - acid ( Gallimberti et al. [13]) Endorphinergic System Naltrexone (O ’ Malley et al. [14]) Nalmefene (ongoing European Study) Glutamatergic System Homotaurin - Calcium ( Lhuintre JP. [15] Paille FM et al. [16]; Lesch OM. [17]) Aversive Medication Disulfiram (Fuller RK and Gordis E, [18]) Mood Stabiliser: Lithium (Merry et al. [19]; Fawcett et al.[20]) a small subgroup of alcohol dependent patients. typology is only a subset of the mechanisms that Every drug trial in alcohol dependence has pos- lead to a relapse. In a pathway analysis on 83 al- itive but also negative data. Some drugs could cohol dependent patients diagnosed according also increase relapse rates [21, 22]. Acamprosate to ICD-10 and DSM-IV we were able to show the and Naltrexone are two examples with positive multifarious interactions which should be con- as well as negative data [3, 4]. sidered in clinical relapse prevention trials. Fig. All these data clearly show that Alcohol De- 4 (page 40). pendence is a heterogeneous disease and that we Comment: Pathway analysis showing how need the definition of treatment-relevant sub- many factors contribute to relapse groups (with specific treatment for each type). Drinking pattern, craving and subgroups of al- Internationally, a consensus in favour of the “4- cohol dependence have the main impact on re- type solution” exists, meaning that a distinction lapse rates but there are also other psychosocial into 4 subtypes is best concerned the fulfilling of dimensions directly or indirectly influencing re- lapse rates. the following criteria: Homogeneity in the type, Following these international developments we Heterogeneity between the types, multidimen- would like to present the four subtypes accord- sionality and easy to be used. [23]. ing to the Lesch Typology, because these types Fig. 2 (next page) shows an empirically sup- fit very well with the above mentioned develop- ported and clinically feasible classification into ments, they are neurophysiologically and biolog- four subgroups [23]. ically validated, are being used in treatment trials Following this approach of four subgroups the and also used in daily work in our country and in pharmaceutical effect of alcohol in this subgroups some others (Lesch OM et. al. [3]). can be defined as follows: Fig. 3 (next page). These heterogeneous mechanisms reflect a dif- ferent underlying biological vulnerability, so, as a consequence, that fact should result in an in- dividual anticraving medication. However any Archives of Psychiatry and Psychotherapy, 2010; 4 : 37–48 Lesch Alcoholism Typology 39 Figure 2. Types of V. and M. Hesselbrock Are there empirically supported and clinically useful subtypes of alcohol dependence? • Chronic/severe drinking and withdrawal type • Mildly affected type • Depressed/anxious type • Antisocial type Hesselbrock VM and Hesselbrock MN, 2006 Figure 3. Craving is different according to types Heterogeneous Craving Type I - to cope withdrawal (Neuroadaptation) Type II - to cope anxiety (Social learning and Cognitive model) Type III - to cope depression (Self-treatment model) Type IV - pre-alcoholic damage, to cope with surroundings (Socio-cultural, organic model) Lesch et al. 2010 LESCH TYPOLOGY: stability of the previously approved sub-groups. Fig 5 (next page). The Lesch Typology is based on data derived Following the long term course of alcohol de- from a longitudinal prospective study on alco- pendent patients we could show that alcohol de- hol dependent patients (according to ICD-9) in pendence is a severe medical condition. During a catchment area of 210,000 inhabitants. All al- the first period 101 out of 436 patients died. In cohol dependent patients admitted to any psy- the following 12 years, an additional 143 patients chiatric department were assessed during their died. While describing the long term course of hospital stay, while at the same time assessment the patients, we could define four different long procedures in the patients’ families were under- term courses. Fig. 6 (page 41). taken. After the long term observation period we at- In the next step we explored the patients six tempted to correlate psychosocial and medi- times a year over a period of 4 to 7 years. Af- cal items with these four different courses. One ter 12 years, patients were yet again examined hundred thirty-six items we assessed with this by two independent psychiatrists in their fami- questionnaire, but out of these 136 items only a ly environment, with particular emphasis on the few showed statistical power. Finally, 11 items Archives of Psychiatry and Psychotherapy, 2010; 4 : 37–48 40 Dagmar Kogoj et al. Figure. 4. Pathway analyses of relapse in alcohol dependence (n=83) (Unpublished data) Typology Age Gender no Father social situation in (Lesch) the family of origin Structure in the family of origin Abuse in family of origin Psychiatric disturbances Somatic disturbances Social background since the age of 14 since the age of 14 Anxiety Psychiatric diseases Acute somatic Acute social situation Acute psychopathological disturbances symptomatology Drinking pattern Craving Relapse (46%) Figure 5. Study design as developed by OM Lesch to develop the 4 types Prospective long term study of alcohol dependent patients in a catchment area Time unrelated evaluation Hypothesis 444 Pat. 436 Pat. 335 Pat. 326 Pat. 8 Drop out (101† since 1976) 9 Drop out (143 † since 1982) Jan.76- 1982 94-95 Dec.78 15 m ≥ 48 m ≥ 12 years Visits at home Evaluation done Evalutation by home visits (in case of and at hospital by visits at the a patient‘s death indirect anamnesis patients’ home with family or treating physician) + questionnaire for course examination (DGS) Lesch O. M. und Walter H. Alkohol und Tabak Springer Verlag 2009 [29]. were used as predictors for these different cours- out any items of the Types
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