Addiction Flashcards
Define alcohol abuse and binge drinking
Alcohol abuse: consumption of alcohol to cause physical, psychiatric and/or social harm
Binge drinking: drinking over twice the amount recommended level of alcohol per day in one session
Guidance: no more than 14 units per week (for males and females
ICD-10 alcohol intoxication?
General criteria for acute intoxication
• Clear evidence of psychoactive substance use at high dose
• Disturbed consciousness, cognition, perception or behaviour
• Not accounted for by mental or medical disorder
Evidence of dysfunctional behaviour
• Disinhibition, argumentativeness, aggression, labile mood, impaired concentration/attention
• One of the following signs: unsteady gait, slurred speech, nystagmus, flushing, reduced consciousness, conjunctival injection
ICD-10 alcohol withdrawal?
General criteria
• Clear evidence of recent cessation or reduction of substance after prolonged/high level usage
• Not accounted for by medical or mental disorder
• Any 3 of the following: tremor, sweating, nausea/vomiting, tachycardia/HTN, headache, psychomotor agitation, insomnia, malaise, transient hallucinations, grand mal convulsions
Symptoms of alcohol intoxication?
Symptoms of alcohol dependence?
- Slurred speech
- Loss of balance; poor coordination
- Impaired judgement
- Severe: hypoglycaemia, coma
Alcohol dependence • Compulsion to drink • Withdrawal symptoms relieved by further drinking • Increased tolerance to alcohol • Drink seeking behaviour predominates
What is Wernicke’s encephalopathy?
- Acute encephalopathy due to thiamine deficiency
- Presentation: delirium, nystagmus, ophthalmoplegia, hypothermia and ataxia
- Can progress to Korsakoff’s psychosis
- Tx: parenteral thiamine
What is Korsakoff’s psychosis?
- Irreversible short term memory loss
- With confabulation (filling in empty gaps in memories with imaginary events)
- Disorientation to time
What is alcohol withdrawal?
Alcohol withdrawal
6-12 hours after abstinence • Malaise • Tremor • Insomnia • Transient hallucinations • Autonomic hyperactivity
Around 36 hours
• Seizures
Around 72 hours
• Delirium tremens (severe)
Withdrawal mediation – GABA, glutamatergic and NA systems
What is delirium tremens?
Develops between 24 hours and 1 week
Predisposing factor: physical illness
Characteristics:
- Cognitive impairment
- Visual abnormalities (hallucinations and/or delusions)
- Paranoid delusions
- Marked tremor
- Autonomic arousal (tachycardia, fever, pupil dilatation, increased sweating)
Medical treatment: high dose of benzodiazepines; psychotic features: haloperidol
Aetiology of alcohol dependence?
Stimulant effects of alcohol are mediated by the dopaminergic pathway
Repeated alcohol ingestion sensitises pathway > dependence
Long term exposure: down-regulation of GABA and up-regulation of glutamate (so when alcohol is withdrawn, it results in CNS hyper-excitability)
Positive reinforcement mediation – dopaminergic, serotonergic and opioid systems
Social learning theory – drinking behaviour is based on imitation of social circle
Operant conditioning – positive or negative reinforcements will either perpetuate or deter drinking habits respectively
Risk factors for alcohol dependence?
Males – increased alcohol metabolism > consume more alcohol
Younger adults
Genetics
Antisocial behaviour
Lack of facial flushing – flushing is caused by a mutation in the aldehyde dehydrogenase gene that metabolises acetaldehyde more slowly
Life stressors - financial problems, marital stress etc.
Investigations for alcohol dependence?
CAGE questionnaire: felt you should cut down? felt annoyed by people commenting? guilty about drinking? eye opener in mornings?
AUDIT questionnaire >8 suggests harmful
Collateral Hx is important
Bloods: FBC U+Es (dehydration) LFTs Blood alcohol concentration MCV (raised; macrocytosis) Vit B12/folate/TFTs (identify alternative causes of macrocytosis) Glucose (hypoglycaemia)
Treatment of alcohol withdrawal?
High dose benzodiazepine (1st line) – e.g. chlordiazepoxide
Thiamine – to prevent Wernicke’s encephalopathy (oral or IV)
Tx of alcohol dependence?
Biological: chlordiazepoxide for wihdrawal
Disulfiram, Acamprosate, Naltrexone
Tx medical and psychiatric complications
Psychological: motivational interviewing and CBT
Social: AA, social support including family involvement
ICD-10 Substance misuse - define:
Alcohol intoxication
Harmful use
Dependence syndrome
Alcohol intoxication: acute, transient effect of the substance
Harmful use: recurrent misuse associated with physical, psychological and social consequences, but without dependence
Dependence syndrome: prolonged, compulsive substance use leading to addiction, tolerance and potential for withdrawal syndromes
ICD-10 Substance misuse - define:
Withdrawal state
Psychotic disorder
Amnesic syndrome
Residual disorder
Withdrawal state: physical and/or psychological effects from complete/partial cessation of a substance after prolonged, repeated or high levels of use
Psychotic disorder: onset of psychotic symptoms within 2 weeks of substance use
Amnesic syndrome: memory impairment in recent memory and ability to recall past experiences. Defect in recall, clouding of consciousness and global intellectual decline
Residual disorder: specific features (flashback, PD, affective disorder, dementia, persisting cognitive impairment) subsequent to substance misuse
Opiates - examples, psychological and physiological effects?
Morphine, codeine, heroine, methadone
Apathy, disinhibition, impaired judgement, drowsiness, slurred speech
Respiratory depression, hypoxia, hypotension, coma, hypothermia, pupillary constriction
Cannabinoids - examples, psychological and physiological effects?
Cannabis
Acts on cannabinoid receptors (most commonly THC)
Euphoria, disinhibition, agitation, paranoid ideation, temporal slowing, illusions and hallucinations
Increased appetite, dry mouth, tachycardia, conjunctival injection
Sedatives (hypnotics)- examples, psychological and physiological effects?
Benzodiazepines, barbituates
Benzodiazepines enhance GABA by increasing the frequency of chloride channels
Euphoria, disinhibition, apathy aggression, labile mood
Unsteady gait, slurred speech nystagmus, hypotension, hypothermia, erythematous skin lesions, depression of gag reflex, coma
Stimulants - examples, psychological and physiological effects?
Cocaine, ecstasy (MDMA), amphetamine
Euphoria, increased energy grandiose beliefs, aggression, argumentative, illusions, hallucinations, paranoid ideation, labile mood
Tachycardia, HTN, arrhythmias, sweating, N+V, pupillary dilatation, muscular weakness, convulsions
Hallucinogens - examples, psychological and physiological effects?
LSD, mushrooms
Anxiety, illusions, hallucinations, depersonalisation, derealisation, paranoia, hyperactivity, impulsivity, inattention
Tachycardia, palpitations, sweating, tremor, blurred vision, pupillary dilatation
What is addiction?
Key theories?
Impaired control over a reward seeking behaviour from which harm ensues
Learning theories of addiction – classical and operant
Social learning theories
o Self regulation – e.g. goal setting behaviours and motivation
o Vicarious learning (modelling) – through implicit (non-conscious) and explicit (conscious) processes
o Self efficacy – the belief in how successful one would be in engaging in a behaviour/achieving a goal
o Outcome expectancies – “If-then” associations/beliefs; e.g. “If I drink alcohol I will be more sociable”; “If I do this I won’t feel pain”
Self-medication hypothesis
o Using self substances to self soothe during times of stress – e.g. cannabis (anxiety), alcohol (stress, social anxiety), benzodiazepines (depression), heroine, amphetamines (schizophrenia)
o Often linked top problematic childhood relationships and/or trauma
o Substance of choice is based on compensatory effect of the psychoactive properties
o E.g.
Severe trauma involving violence/aggression – heroin and opiates
Constricted emotions – alcohol
Low mood and poor self confidence - stimulants
• Impulse and self-control theories
o Energy, Cognitive and Skill models (Baumesiter 2003)
Energy: dual processing of the brain:
• System 1 – older part of brain, faster response
• System 2 – reasoning and processing, slower
• When we are low on energy, we end up processing more things through system
o Inhibitory Dysregulation Theory – damage to the reward pathways resulting in reduced ability to inhibit behaviours that are rewarding
Treatment
Alcohol
• SADQ – severity of alcohol dependence questionnaire (score out of 60, anything above 30 is severe)
o Other uses: anxiety, panic attacks, IBS, insomnia
