21000000 |Idiosyncratic intoxication (disorder)| and 191477001 |Pathological alcohol intoxication (disorder)|

Cathy,

It looks like the APA introduced term "Pathological Intoxication" in DSM-II (APA, 1968) and defined it as an "acute brain syndrome manifested by psychosis after minimal alcohol intake" (p. 26). There was no corresponding code in ICD-8 at the time, and APA recommended coding it as 291.6* (a non-existing ICD code).

The APA changed the name of the disorder to "Alcohol idiosyncratic intoxication" in DSM-III (1980), and provided a more detailed description of the disorder, along with specific diagnostic criteria. The expanded definition describes the essential feature as "a marked change in behavioral change - usually to aggressiveness - that is due to the recent ingestion of an amount of alcohol insufficient to induce intoxication in most people" (p. 128). The corresponding ICD-9 code is listed as 291.4.

When I searched for 291.4 online (https://icd.codes/icd9cm/2914) it looks like both terms are listed (one as the long description, the other as the short description).

I'll leave it to the clinical folks in the group to address your question about whether these terms are used in practice today. From the strict perspective of disease constructs published in ICD and DSM, neither the disorders nor the terms appear in the most recent edition of these manuals.

Piper Allyn Ranallo , Cathy Richardson and I were wondering if you had managed to get any feedback from the clinical folks regarding this issue. You may have covered it in a meeting which I have not been able to attend, but of those that I have attended I can't recall that this topic has been raised.

Apologies for chasing, but we have an SLA on responding to queries which are made via our request system so anything you can do to progress this would be very much appreciated.

Many thanks

Paul

I recall discussing this on one of the calls right after this was posted. Though I don't recall the consensus, perhaps Piper Allyn Ranallo has more recollection or minutes from the call.  There was also some discussion via email and I found the email that I wrote at the time and also one that Alisa Busch had written. Alisa noted that she hadn't heard the terms before but thought they were basically synonymous. She also thought they might be worth keeping from a phenomenological perspective even though they are outdated.

I had heard the term "pathological intoxication" used early in my career (late 1970s and 1980s) but don't recall hearing it used lately. My understanding based on the way that I'd heard it used was that the person behaved in an way with alcohol ingestion that seemed out of proportion to the level of alcohol that was actually ingested.  I wouldn't have used in in someone who was just sensitive to alcohol (e.g., promptly falls asleep with a half-glass of wine).  Rather, when I heard it used it was in the context of a person who says they only had "a little" to drink who then proceeded to do fairly outlandish things that got them into trouble (e.g., legally, socially).  As you can see, however, my recollection of the term corresponds to the DSM III definition of "Alcohol idiosyncratic intoxication".  In contrast, the DSM II term for "pathological intoxication" includes distinct mention of psychosis, which was not part of any conceptualization that I would have incorporated into this concept.

When we had discussed this initially, I did a complete pubmed search on the various terms and came up with the following articles that seemed relevant:

https://www.ncbi.nlm.nih.gov/pubmed/13064375
https://www.ncbi.nlm.nih.gov/pubmed/5491548
https://www.ncbi.nlm.nih.gov/pubmed/979273
https://www.ncbi.nlm.nih.gov/pubmed/489519
https://www.ncbi.nlm.nih.gov/pubmed/390593
https://www.ncbi.nlm.nih.gov/pubmed/3734742
https://www.ncbi.nlm.nih.gov/pubmed/3734743
https://www.ncbi.nlm.nih.gov/pubmed/2210931

But they're predominantly from the older literature and seem to be historical/descriptive in nature.  I don't have access to the original journals but it does seem that the concepts were controversial, even then.

I suspect that few people, at least in the U.S., are using either term currently.  And of the people who might have heard of it, I suspect that few would appreciate the subtle distinction between one having associated psychosis vs. having a disproportionate reaction to the amount of ingested alcohol.  The terms sound similar enough that most people (myself included) would have viewed them as likely synonymous, at least before I read the history that Piper had outlined. (For the concept of alcohol use associated with psychosis, I think there are better terms in use.)

It may be reasonable to keep one or both for historical purposes, but if one or both the terms were eliminated, I doubt that there would be many/any howls of protest. 

If there are additional, specific questions that you'd like me to try to answer, please let me know.

Laura

Alcohol idiocyncratic intoxication was deleted from DSM-IV (one of only a couple of DSM-III-R disorders to be delted) because of a lack of evidence that it actually exists.  There was virtually no resaerch on it..just cases reports that did not adqualtely establish the alcohol blood levels corresponding to the behavioral disorder. 

Hi All

I am the UK Member Forum representative to SNOMED International, a terminology author in the UK and a Mental health nurse in the dim and distance past.  I now have a UK Psychiatrist who is happy to canvas his colleagues for clinical questions like this and may be able to attend calls for specific items.  Dr Ben Wright is a Consultant Psychiatrist and Associate Medical Director for Clinical Information at East London NHS Trust.

Hopefully we will be able to contribute to discussions going forward.

Best wishes

Elaine 

Hi I have consulted with UK psychiatrists and the unanimous consensus is:

1) allow the subdivision of pathological reaction to alcohol 

2) have subdivisions idiosyncratic (disinhibition) and psychotic to cater for the two subtypes described

Hope this helps.

A couple of thoughts:

• Per Elaine Wooler, it sounds like it's clinically  useful to distinguish between two reactions to ingesting amounts of alcohol that would not normally lead to intoxication in most people - either uninhibited (aggressive) behavior or psychotic behavior
• PerMichael First, it sounds like the APA didn't find enough evidence to suggest this constitutes a valid disorder (v. a clinical finding)
• Per this entire thread, it sure seems that the concepts (as currently defined) are a little fuzzy - both concepts violate SNOMED's URU rule and the FSN (fully specified name) doesn't make the meaning of either concept obvious 

What do folks think about retiring both concepts as "ambiguous" and point to new, more clearly defined concepts:

1. Concept 1: Psychosis caused by ingestible alcohol (finding) 
2. Concept 2: Aggression caused by ingestible alcohol (finding) OR Disinhibition caused by ingestible alcohol (finding)

Remaining question would be: is it important to capture the idea that the amount of alcohol ingested is smaller than the amount typically required to cause intoxication?

Piper