1
Q
ICD-10 classifies substance misuse disorders according to both the type of substance and type of disorder; state 7 types of substance misuse disorders in ICD-10.
Briefly desribe each
*NOTE: this includes alcohol!
A
- Acute intoxication: acute, usually transient, effect of a substance
- Harmful use: reccurrent use resulting in physical, psychological & social consequences but without dependence
- Dependence syndrome: prolonged substance misuse leading to addiction, tolerance and potential for withdrawal
- Withdrawal state: physical and/or psychological effects from complete or partial cessation of a substance after prolonged or high level of use
- Psychotic disorder: onset of psychotic symptoms within 2 weeks of substance use; must persist >48hrs
- Amensic syndrome: memory impairment in recent memory (impaired learning of new material); sometimes remote memory is also impaired. Disturbances of time sense & ordering of events
- Residual disorder: specific features due to substance misuse (e.g. flashbacks, personality disorder, affective disorder, dementia)
2
Q
What is meant by tolerance?
A
Decrease in the response to a drug, requiring a higher dose to obtain the same effect after repeated use.
3
Q
What is meant by dependence?
A
Inidividual is dependent on/needs the drug for normal physiological funtioning; not having the drug can lead to withdrawal.
4
Q
What is meant by withdrawal?
A
Group of symptoms that occur upon the abrupt discontinuation or decrease in intake of medications or recreational drugs.
5
Q
State some factors that contribute to an individual mis-using substances, consider the following factors:
- Biological
- Environmental
- The substance they take
- Positive reinforcement
A
- *NOTE: reinforcement can be negative (e.g. don’t take feel bad) and positive (take and feel good)*
- Attachment
6
Q
State some examples of commonly misused substances (drugs)
A
- Opiods
- Cannabinoids
- Stimulants
- Sedative-hypnotics
- Hallucinogens
- Volatile solvents
- Anabolic steroids
7
Q
What is the most commonly consumed illegal drug in uk?
A
Cannabis
8
Q
For opiates state:
- Example drugs
- Routes taken
- Psychological effects
- Physical effects
- Withdrawal sate effects
A
Take because get “intensely pleasurable buzz or rush- peaceful”. Heroin is an anxiolytic.
9
Q
For cannabinoids, state:
- Example drugs
- Routes taken
- Psychological effects
- Physical effects
- Withdrawal sate effects
A
10
Q
For sedatives/hypnotics, state:
- Example drugs
- Routes taken
- Psychological effects
- Physical effects
- Withdrawal sate effects
A
11
Q
For stimulants, state:
- Example drugs
- Routes taken
- Psychological effects
- Physical effects
- Withdrawal sate effects
A
12
Q
For hallucinogens, state:
- Example drugs
- Routes taken
- Psychological effects
- Physical effects
- Withdrawal sate effects
A
13
Q
For volatie solvents, state:
- Example drugs
- Routes taken
- Psychological effects
- Physical effects
- Withdrawal sate effects
A
14
Q
For anabolic steroids, state:
- Example drugs
- Routes taken
- Psychological effects
- Physical effects
- Withdrawal sate effects
A
15
Q
State some potential physical consequences of drug use
A
- Death
- Infection (HIV, hep A/B/C, TB, Staphylococcus aureus)
- DVT
- PE
- Endocarditis
- Arrhythmias
… and many more!
16
Q
State some potential psychological consequences of drug use
A
- Craving
- Anxiety
- Cognitive disturbance
- Drug-induced psychosis
17
Q
State some potential social consequences of drug use
A
- Crime
- Imprisonment
- Homelessness
- Prostitution
- Relationship problems
- Homelessness
18
Q
When taking a history about sustance misuse it is helpful to have a structure; describe an example structure you could use
A
- Current use
- Type
- Route
- Amount (this can be clarified by money spent)
- Pattern/how often
- Dependence & withdrawal
- Possible triggers
- Past substance misuse
- Details
- Any complications
- Any treatment
- Any overdose
- Impact of drug use (physical, psychological, social)
- BBV’s (hep B, hep C, HIV)
- Complications of injection
- Criminal record
- PMH
- Social history
- e.g. housing who live with, children
- Coping strategies
- Risk assessment (suicide, self-harm, needle sharing, safeguarding)
19
Q
What invesigations would you want to do in a pt who admits to substance misuse?
A
Bedside
- Urine drug screen
- ECG: arrhythmias
- TB testing
Bloods
- HIV screen
- Hep B & C screen
- U&Es: renal func
- LFTs: liver func
- Clotting: liver func
- Drug levels
Imaging & other
- ECHO: if suspect endocarditis
- *Would also do a full examination of all body systems*
20
Q
Discuss the general management of substance misuse (think about biopsychosocial model to help you think of ideas)
A
Management can be residential rehabilitation, hospital or community
- Medication (relevant for specific drugs)
- Hep B immunisation (for those at risk)
- Contingency management (offering incentives/rewards for abstinence e.g. financial)
- Motivational interviewing
- CBT for comorbid depression & anxiety
- Support groups e.g. Narcotics anonymous
- Supportive help with e.g. housing, finance, employment
- Educate about safe use iniatives e.g. needle exchange
21
Q
What’s the difference between maintenace and detoxification?
A
- Detoxification: is essentially weaning someone off the drug. Replacement drug is given in large enough dose at start to satisfy cravings & prevent withdrawal symptoms then dose is gradually tapered down (eventually to zero) in attempt to attain abstinence.
- Maintenance: find optimal dose of replacement drug that elimates a person’s withdrawal symtpoms and keep them on this dose until they no longer struggle with symptoms of residual withdrawal. Priority is to minimise harm, not abstinence. Can be on replacement drug for years. Eventually the aim is progress to detoxifiationa and abstinence.
22
Q
What drugs can be used for opiate detoxification & maintenance?
A
- Methadone (opiod agonist)
- Buprenorphine (partial opiod agonist)
23
Q
What is the antidote to opiod overdose?
A
Naloxone (IV)
24
Q
Discuss two approaches for benzodiazepine detoxification to prevent withdrawal
A
Either do slow reduction of their current benzo or switch to equivalent dose of diazepam (as has long half life) and taper this down gradually.
*NOTE: benzodiazepine withdrawal is similar to alcohol withdrawal except in benzo withdrawal get hallucinations early and autonomic symptoms later
25
What is dependence syndrome?
A cluster of **physiological, behavioural, and cognitive** phenomena in which the **use of a substance or a class of substances** takes on a **much higher priority** for a given individual t**han other behaviours that once had greater value.**
26
State the ICD-10 criteria for dependence syndrome
*\*HINT: mneumonic Drug Problems Will Continue To Harm*
\>/= 3 of the following must have occured for over 1 month:
* Strong **D**esire to consume substance
* **P**reoccupation with substance use *(progressive neglect of alternative pleasures or interests because of psychoactive substance use)*
* **W**ithdrawal state when substance ingestion is reduced or stopped
* Impaired ability to **C**ontrol substance taking behaviour (e.g. onset, termination or level of use)
* **T**olerance to substance *(require more for same desired effect)*
* Persisting use despite **H**armful effects
27
Remind yourself of the effect of alcohol on both the excitatory and inhibitory pathways in brain
* **Alcohol stimulates GABA receptors** (inhibitory) in brain causing anxiolytic and sedaative effects
* Long term exposure results in **GABA receptors being downregulated** and **glutamate receptors** (excitatory) **being upregulated** (this is the body's attempt to balance out the effects of alcohol)
* \*This pathophysiology is important as when alcohol is withdrawn it results in CNS hyper-excitability*
28
Remind yourself of how most of alcohol is metabolised in liver *(MEH revision)*
29
Define hazardous drinking
Level or pattern of drinking that will **eventually cause harm**; individual has no alcohol-related problems at present.
30
Define harmful drinking
**Drinking above safe levels** with **evidence of alcohol-related problems** (phsycial, psychological or social) **already present.**
Dangerous levels for men: \>50 units per week
Dangerous levels for women: \>35 units per week
*\*NOTE: ICD-10 use 'harmful drinking' whereas DSM-V tends to use 'alcohol abuse'; mean same thing*
31
Define binge drinking
Drinking \>**8** units for men and **\>****6** units for women)
32
State some risk factors for alcohhol problems
* Genetics (differences in alcohol metabolism)
* Consistent exposure to alcohol abuse at a young age
* High stress occupations
* Anxiety or depression
* Chronic physical illness (particuarly if chronic pain)
* Peer pressure/pressure from people you socialise with
* Stressful life evetns
33
State some potential phsycial complications of excessive alchol use
34
State some potential psycological complications of excessive alcohol use
35
State some potential social complications of excessive alcohol use
36
State some clinical features of alcohol intoxication
* Slurred speech
* Labile affect
* Impaired judement
* Poor co-ordination
In severe cases may be hypoglycaemia, stupor & coma
37
Explain why alcohol intake can cause hypoglycaemia
**Alcohol impairs livers ability to release glycogen**
So although many drinks contain lots of sugar& carbohydrates, it is later on that you are at risk of hypoglycaemia
38
State 7 signs of alcohol dependence
*\*HINT: mneumonic SAW DRINk*
39
State some signs of alcohol withdrawal (think about what symptoms occur at what time period)
* 6-12hrs: **tremor, headache, craving, nausea, insomia, autonomic hyperarousal (sweating, tachycardia, fever)**
* 12-24hrs: **hallucinations**
* 24-48hrs: **seizures** *(peak incidence 36hrs)*
* 24hrs-72hrs: **delerium tremens** *(peak incidence 72hrs)*
40
What clinical scoring system can be used for alcohol withdrawal?
**CIWA-AR**
(Clinic institute withdrawal assessment for alchol revised)
41
For delerium tremens, discuss:
* What it is
* Pathophysiology
* Risk factors
* Symptoms & signs
* Mortality
* Severe form of alcohol withdrawal
* Chronic alcohol use causes **GABA receptor downregulation** and **glutamate receptor upregulation**. When alcohol is removed from system GABA underfunctions and glutamate overfunctions causing **extreme excitability** of brain with **excess adrenergic energy.**
* Risk factors: age \>30, previous DT, previous withdrawal seizure, concurrent medical illness
* Characterised by
* **Delerium/cognitive impairment** (may also be agitated)
* Vivid perceptual abnormalities (**hallucinations or illusions**)
* May have paranoid delusions
* **Marked tremor**
* Autonomic arousal *(**tachycardia, fever, sweating, pupil dilation**)*
* **Dehydration & electrolyte disturbances** *(leucocytosis, raised ESR, impaired liver func)*
* Morality of up to 5%
42
State the ICD-10 criteria for acute alcohol intoxication
**A. General criteria for acute intoxication met**
* Evidence of psychoactive substance use at high dose
* Disturbance in consciousness, cognition, perception or behaviour
* Not accounted for my medical or mental disorder
**B. Evidence of dysfunctional behaviour**
* Disinhibition, argumentitiveness, aggression, labile mood, impaired concentration, interference with functioning
* One of following signs: unsteady gait, difficulty standing, slurred speech, flushing, nystagmus, decreased consciousness
43
State the ICD-10 criteria for alcohol withdrawal
**A. General criteria for withdrawal state met**
* Evidence of recent cessation or reduction of substance after prolonged or high level usage
* Not accounted for by medical or psychiatric disorder
**B. Any three of the following**
* Tremor, sweating, nausea/vomitting, tachycardia, increased BP, headache, insomnia, transient hallucinations, malaise, psychomotor agitation, grand mal convulsions
44
Remind yourself of the CAGE questions
0 or 1: low risk drinking problem
2 or 3: suspicion of alcoholism
4: virtually diagnostic for alcoholism
* \*Remember: if someone scores \>2 on CAGE questionnaire should prompt further action using other questionnaires; can use AUDIT or SADQ*
45
Suggest a structure for taking an alcohol history
46
Remind yourself how to calcualte units of alcohol using ABV and volume
State approximately how many units in common drinks such as pint of beer, glass of wine, shot of spirits
1 unit= 10ml (8g) of ethanol
Units= ABV x vol (ml)/1000
47
Discuss the possible MSE of a pt who is intoxicated with alcohol
48
Discuss possible MSE of a pt who has alcohol withdrawal
49
State some investigations you may do for pts presenting with chornic alcohol use
_Bedside_
* Glucose: *hypoglycaemia*
* ECG: *arrhythmias*
_Bloods_
* FBC: *may show macrocytic anaemia*
* U&Es: *renal func may be impaired due to dehydration*
* LFTs: *check liver damage*
* Coagulation: *check liver func*
* Amylase: *pancreatitis*
* Lipids: *increased risk of high cholesterol etc..*
* Vit B12, folate: *alternative cause of macrocytosis*
* TFTs: *alternative cause of macrocytosis, rule out hyperthyroidism*
_Imaging_
* CT head: *if head injury suspected*
50
Wernickes encephalopathy is a potential complication of chronic alcohol abuse, discuss:
* What causes it
* Clinical features
* Diagnostic criteria
* Management
* **Thiamine deficiency** *(can occasionally see in non-alcoholics e.g. anorexia nervosa, hyperemesis gravidarum, post-gastric resection...).* Lead to brain damage (haemorrhages).
* Clinical features:
* Triad of **occulomotor disturbances** (nystagmus, lateral rectal palsies), **ataxia & confusion**
* **Caine criteria- must have at least 2 of:**
* Dietary deficiency
* Occulomotor disturbance
* Altered mental status or memory impairment (confusion)
* Cerebellar dysfunction (ataxia)
* Management:
* **High dose parental thiamine** for 3-7 days (until improvement ceases) **IV or IM**
* ... Alongside **IV magnesium sulfate & other multivitamins**
* **Continue oral thiamine** *(how long for depends on risk)*
51
Korsakoff's psychosis/syndrome is a potential complication of chronic alcohol abuse, discuss:
* What causes it
* Clinical features
* Whether pts can recover
* Management
* **Thiamine deficiency**
* **Short term memory loss (both retrograde and anterograde)**. Immediate recall is often good but if you asked them to repeat after a few minutes they would not able to. Pts **confabulate** (unconscious filling of gaps in memory with imaginery events) and become **disorientated in time.**
* 75% stay same, of the remaining 25% some slightly improve and others decline.
* Management:
* High dose pabrinex then long term thiamine replacement CHECK!!
* Support (e.g. may need residential home)
52
Why might chronic alcohol abuse lead to thiamine deficiency?
* Poor nutritional intake (as alcohol is priority)
* Alcohol reduces absorption of thiamine
* Alcohol decreases hepatic storage
* Alcohol impair usage of thiamine
* Increases urinary thiamine excretion
Enzymes in brain involved in glucose metabolism require thiamine; without the energy necessary to function, neurons and supporting brain cells become impaired and damaged, and cell death can occur.
53
Summarise the management for alcohol abuse; think about the biopsychosocial model
*\*NOTE: question not specific to withdrawal just any alcohol abuse*
*Extra notes:*
* *Family involvement may involve family/systematic therpy*
* *Education for pt and family (e.g. safe drinking advice, who to contact if concerned, risks of chronic alcohol abuse)*
* *Inform pt they must tell DVLA*
54
An alcohol detoxification regime offers controlled withdrawal; describe the regime used to prevent alcohol withdrawal
Can be inpatient or outpatient:
* **Benzodiazepines- commonly chlordiazepoxide**
* 10 day course
* PO
* Initially high dose
* Then dose tapered down
* **Thiamine***(to prevent Wernicke's encephalopathy)*
* IV (pabrinex) or IM
* Or PO
* **Consider prescribing PRN lorazepam 10mg PR in case of seizure**
An example regime of chlordiazepoxide is shown below but always use local guidelines *(don't need to remember just have an idea).* Patients with seizures or delerium tremens may need higher doses for longer.
55
How do benzodiazepines help to prevent alcohol withdrawal? (2)
Prevent alcohol withdrawal by:
* Reducing risk of seizures & delerium tremens
* Decreasing cravings, tremor, anxiety, insomnia and nausea that commonly occur during withdrawal
Chlordiazepoxide is drug of choice because it has long half life and less ability to be abused than diazepam.
56
Discuss the mangement of alcohol dependence *(think about biopsychosocial model)*
_Biological_
* **Disulfiram:** irreversibly inhibits acetaldehyde dehydrogenase causing a build up of acetaldehyde on consumption of alcohol which causes unpleasant symptoms such as headache, flushing, anxiety, choking sensations.
* **Acamprosate**: enhances GABA transmission reducing cravings
* **Naltrexone:** opiod receptor antagonist which inhibits action of endogenous endorphins released when alcohol is drunk hence reduces pleasurable effects of alcohol and so reduces urge to drink it
_Psychological_
* **CBT:** *focusing on alcohol-related beliefs & behaviour*
* **Motivational interviewing:** *guides the person into wanting to change- most effective in pre-contemplation & contemplation stage*
* **Family therapy**
_Social_
* **Support groups e.g. alcoholics anonymous 12 step programme**
57
What is the alcoholics anonymous 12 step programme?
* Programme for pts who accept that they have a drinking problem
* 12 step approach that utilises psychosocial techniques in order to change behaviour (e.g. social support networks, rewards)
* Each new member is given a sponsor (supervisor recovering from alcoholism)
58
Who should prophylactic thiamine be given to?
Harmful drinkers if they are malnourished (or at risk of malnourishment) or have decompensated liver disease
59
State some preventitve measures against alcohol abuse
* Increasing taxation
* Restricted advertising or sales
* More education regarding alcohol issues in schools etc...
60
What are some causes of mortality due to alcohol? Highlight most common
* **Fights & falls**
* Liver failure
* Pancreatitis
* Withdrawal
* Wernicke-Korsakoff syndrome
61
Withdrawal from which two drugs can cause death?
* Alcohol
* Benzodiazepines
62
State some potential complications of stimulants e.g. cocaine
* Strokes
* Myocardial infarction
* Psychosis
*\*stimulants, in particular cocaine, are vasopressors and also cause cardiac intropy hence increase BP which can lead to strokes. Vasoconstriction of coronary arteries can lead to MI.*
63
Motivational interviewing is a commonly used technique in substance misuse; discuss what it involves
Collaborative, goal-orientated style of communication. Aims to strengthen an individual's motivation & comitment to change by exploring their own reasons for change.
64
Card is just a summary highlight which drugs cause which psychiatric presentations
* Opiates don't cause psychosis themselves but people may take them to reduce the anxiety that comes with the psychosis
* Stimulants can cause psychosis
* Cannabis increases prevalence of psychosis
* Alcohol is depressogenic *(if get alcohol dependent pts of alcohol and stay sober then in 98-99% of pts depression goes away without other treatment)*
Yr4: Psychiatry
flashcards
Decks in class (17)
# Cards
-
Psychiatry Basics/Introduction17
-
Psychiatric History Taking & MSE44
-
Affective Disorders75
-
Schizophrenia & Psychoses52
-
Anxiety Disorders101
-
Personality Disorders23
-
Substance Misuse64
-
Eating Disorders65
-
Self Harm & Suicide26
-
Psychotherapies36
-
Psychopharmacology: Antidepressants & Antipsychotics80
-
Psychopharmacology: Mood Stabilisers, Anxiolytics & Others46
-
Legal Aspects of Psychiatry34
-
Child & Adolescent Psychiatry63
-
ECT16
-
Liason Psychiatry8
-
Psychological Problems Presenting with Physical Symptoms31
