Addictions, Forensics, Sex & Paraphilia Flashcards
Tobacco smoking induces what liver enzyme activity?
P450 1A2. This leads to increase in the metabolism of certain psychotropic medications using this enzyme including clozapine, olanzapine, tri-cyclic antidepressants; which may lead to drug toxicity in patients who quit smoking.
currentpsychiatry.com
The dopaminergic neurons in the ventral tegmental area are particularly important in addiction. These neurons project to be cortical and limbic regions, especially the _____?
Nucleus accumbens
K&S page 387
In various studies, a range of 35 to 60% of patients with substance abuse or substance dependence also meet the diagnostic criteria for what personality disorder?
Antisocial PD
K&S page 387
How is alcohol metabolized?
Alcohol dehydrogenase (ADH) catalyzes the conversion of alcohol into acetaldehyde, which is a toxic compound; aldehyde dehydrogenase catalyzes the conversion of acetaldehyde into acetic acid. (K&S page 394)
How does alcohol effect sleep?
Decreases REM and deep sleep stage 4 and more sleep fragmentation, with more and longer episodes of awakening.
(K&S page 394)
Explain the classic timeline for the appearance of withdrawal symptoms from alcohol.
6-8 hrs - tremulousness
8-12 hrs - psychotic and perceptual symptoms
12-24 hrs- seizures
72 hours - delirium tremens
(K&S page 397)
The essential feature of Delirium tremens is delirium occurring within _________ after a person stops drinking or reduces the intake of alcohol?
One week.
Note: the syndrome usually develops on the third hospital day.
(K&S page 399)
Name 5 lab tests that are elevated in patients with alcohol-related disorders.
GGT MCV Uric acid Triglycerides AST ALT
(K&S page 395)
What are the symptoms and tx of Wernicke’s encephalopathy?
Acute, bilateral, reversible: ataxia, vestibular dysfunction, confusion, a variety of ocular motility abnormalities (horizontal nystagmus, lateral orbital palsy etc.)
Tx: thiamine 100 mg po bid or tid. Or 100 mg of thiamine per litre of IV glucose solution.
(K&S page 400)
What are the symptoms and tx of Korsakoff’s encephalopathy?
Chronic impaired mental syndrome (especially recent memory) and anterograde amnesia in an alert and responsive patient. +/- confabulation.
Tx: thiamine 100 mg po bid or tid for 3 to 12 months. Only about 20% recover.
(K&S page 400)
What is alcoholic pellagra encephalopathy?
Patients suffer from a niacin deficiency and tx is 50 mg po niacin qid.
These patients look afflicted with wernicke-korsakoff syndrome but do not respond to thiamine.
(K&S page 402)
What is the leading cause of mental retardation in the United States?
Fetal alcohol syndrome
K&S page 402
Which 3 prognostic signs combined, predict at least a 60% chance for 1 or more years of abstinence from alcohol?
- absence of preexisting antisocial PD or a dx of other substance abuse.
- life stability
- pt stays for the full course of initial rehab (perhaps 2-4 weeks).
What rare, but potentially fatal, adverse reaction to Disulfiram (Antabuse) should you be aware of?
Hepatitis; “monitor liver function tests periodically”.
K&S page 406
Acamprosate (Campral) is contraindicated in ______?
Severe renal impairment (CrCl less then or equal to 30 mL/min).
(K&S page 406)
The classic amphetamines produce their primary effects by causing the release of _____________, from the __________ terminals?
- Catecholamines (particularly dopamine)
- presynaptic
Note: designer amphetamines release catecholamines and serotonin).
(K&S page 408)
Opioid drugs, associated with abuse/dependence, are all prototypical u-opioid receptor ____________.
Agonists
K&S, p. 443
Name the primary effects of the following opioid receptors:
- mu
- kappa
- delta
Mu = analgesia, respiratory depression, constipation, dependence
Kappa = analgesia, diuresis, sedation
Delta = possibly analgesia
What is the difference between Cloninger et al (1981) Type 1 and Type II alcohol typologies?
Type I: both men & women; late onset; less family hx; anxious/shy; minimal criminality; environmental reactivity.
Type II: Men only; early onset; family hx; risk-taker; aggressive; ASPD
uOttawa 2014
List withdrawal symptoms from opioids
Severe muscle cramps, bone aches, diarrhea, abdo cramps, rhinorrhea, lacrimation, piloerection, yawning, fever, pupillary dilation, HTN, tachycardia, temperature dysregulation
What is the difference between Babor et al (1992) Type A and Type B alcohol typologies?
Type A: late onset; mild dependence; little drug use; promising prognosis, few risk factors.
Type B: early onset; many childhood risk factors; severe dependence; polydrug use; high psychopathology; poor prognosis.
uOttawa 2014
What is the clinical triad associated with opioid overdose?
Coma, pinpoint pupils, respiratory depression
K&S, p. 448
What drug is used to treat opioid overdose?
Naloxone (specific opioid antagonist)
- can administer IV at a slow rate, initially about 0.8 mg/kg.
K&S, p. 448
What is Cocaethylene?
The liver combines ETOH and cocaine and manufactures cocaethylene which intensifies cocaine’s euphoric effects, and is more toxic than either drug alone and increases the risk of sudden death. The mixture of ETOH and cocaine is the most common two-drug combo that results in drug-related death.
uOttawa 2014
What is the mechanism of action of Buprenorphine?
It is a partial mu-opioid agonist; does not fully activate opioid receptors, ceiling effect decreases the likelihood of respiratory depression.
uOttawa 2014
What is the mechanism of action of Disulfiram?
Blocks ETOH metabolism: inhibits enzyme aldehyde dehydrogenase and produces an accumulation of acetaldehyde.
Toxic reaction = flushing, weakness, nausea, tachycardia, hypotension.
uOttawa 2014
How does Naltrexone work?
Decreases dopamine release in the nucleus accumbens, thereby supressing pleasurable feelings associated with alcohol.
Decreases positive reinforcement (the reliable pleasurable effects of the substance used).
uOttawa 2014
What is the half-life of Methadone?
Average = 25 hours (13-55 hr range)
CHPD ed.18, p. 287
How does Acamprosate work?
Binds to NMDA receptors, and normalizes hyperexcitability during alcohol withdrawal. Decreases Negative reinforcement (the effective relief of prevention of withdrawal distress by further use)
uOttawa 2014
Explain the “ceiling effect” seen with Buprenorphine.
It is a partial mu-opiate receptor agonist & kappa-opiate receptor antagonist. The agonist effect increases linearly with increasing doses to a plateau: at high doses will act as an antagonist and can precipitate withdrawal symptoms. This less risk of a fatal overdose
CHPD ed.18, p. 292
When can a physician obtain a blood alcohol level from a patient at the request of the police following a driving accident?
Court order (subpoena, search warrant)
What does ‘Unfit to stand trial’ mean?
- ‘unfit to stand trial’ means unable on account of a mental disorder to conduct a defence at any stage of the proceedings before a verdict is rendered or to instruct counsel to do so, and, in particular, unable on account of mental disorder to:
a. understand the nature or object of the proceedings
b. understand the possible consequences of the proceedings, or
c. communicate with counsel
uOttawa 2014
What happens next if a person is found unfit to stand trial?
- the crown may request the person be tx’d for up to 60 days to restore fitness - then back to court.
- cannot give ECT or psychosurgery
- can treat even if the person is competent to refuse treatment (i.e., right to trial>right to own body)
- if not restored, the accused comes under the Review Board’s jurisdiction.
uOttawa 2014
What 2 components of a crime muct be proven by the Crown beyond a reasonable doubt?
- Actus Reus: illegal act committed consciously & voluntarily
- Mens Rea: the guilty mind; guilty act done purposely, knowingly or recklessly.
uOttawa 2014
True or False: a person must be found NCR prior to going to trial to determine guilt vs. innocence.
False.
- the person must be proven guilty of each offence first. The NCR issue is the second part of the trial.
uOttawa 2014
Correctional Psychiatry:
___ % of inmates have a current DSM-IV dx with substance being the highest at ___ %.
Excluding substances, 43% have a psychiatric disorder.
84% DSM-IV dx (16% have a serious mental illness)
75% substance disorder
Note: the suicide rate is 3.7x higher than the gen. pop.
uOttawa 2014
What are criteria B, C, and D for antisocial personality disorder
B. The individual is at least age 18 years.
C. There is evidence of conduct disorder with onset before age 15 years.
D. The occurrence of antisocial behaviour is not exclusively during the course of schizophrenia or bipolar disorder.
DSM-5
What 4 clusters of sx’s are present in Conduct Disorder?
‘Rule violating LAD’
- Rule violations
- Lie/Theft
- Agression to animals/people
- Destruction of property
uOttawa, DSM-5
True or False: The likelihood of developing antisocial PD in adult life is increased if the individual experienced childhood onset of CD (before age 10 years) and accompanying ADHD.
True
DSM-5
List some static risk factors for violent behaviour.
- previous violence
- substance use
- age: peaks in late teens & early 20s
- male gender
- IQ
- childhood factors
- young age of violence
- socioeconomic status
- psychopathy
uOttawa 2014
List some dynamic risk factors for violent behaviour.
- current substance use
- agitation
- supports
- access to weapons
- stress
- positive attitude towards tx
- insight
- impulsivity
- access to victims
- mental illness
uOttawa 2014
Is mental illness a risk factor for violence?
Yes.
- after years of debate & numerous studies, it appears that mental illness is associated with a small but significant increase in risk.
- schizophrenia ass’d with violence and violent offending, though mostly due to substance abuse (Fazel et al, 2009).
uOttawa 2014
According to the Epidemiological Catchment Study (ECA), what were 5 risk factors for violence?
- young
- male
- low SES
- mental disorders
- substance use
(substance + illness > substance > illness > controls)
uOttawa 2014
What type of delusion is most associated with violent behaviour?
Threat/control-override (TCO) delusions appear most risky.
TCO symptoms are beliefs that one is being threatened (eg, being followed or poisoned) or is losing control to an external source (eg, one’s mind is dominated by forces beyond his or her control).
uOttawa 2014
http://www.currentpsychiatry.com/fileadmin/
cp_archive/pdf/1205/1205CP_Scott.pdf
Capacity for informed consent requires:
- a person must be able to UNDERSTAND the information that is relevant to making a tx decision
- a person must be able to APPRECIATE the reasonably foreseeable consequences of the decision or lack of one.
uOttawa 2014
What does testamentary capacity refer to?
- ability to make a will (according to uOttawa lecturer this was an old exam question)
uOttawa 2014
What are the 4 D’s related to negligence?
- Duty (fiduciary)
- Dereliction of Duty (reasonable degree of knowledge/skills compared to other members of the profession in similar circumstances)
- Damages ($, physical or psychological harm)
- Direct cause (the mistake must cause the negative outcome with 3 components; cause in fact/proximate cause/foreseeable cause)
uOttawa 2014
Rank the following in order of frequency of reasons for Malpractice suits in Canada for psychiatry:
a. Wrongful confinement
b. Problems arising from prescription of medication
c. Sexual impropriety
d. Failure to meet the expected standard of care
e. Failure to undertake an appropriate and thorough suicide and/or homicide risk assessment.
Correct order is:
e. Failure to undertake an appropriate and thorough suicide and/or homicide risk assessment (MOST common malpractice issue)
a. wrongful confinement
b. problems arising from prescription of medication
d. sexual impropriety
c. failure to meet the expected standard of care (LEAST common)
uOttawa 2014
Pharmacology of Sex: are the following neurochemicals increased or decreased in ‘Desire’ ?
a. Dopamine
b. NE
a. Increased dopamine
b. Increased NE in low/mod desire;
Decreased in high desire state
Note: serotonin is DECREASED in orgasm/desire/arousal
uOttawa 2014 (lecturer stated that we should memorize this)
Pharmacology of Sex: are the following neurochemicals increased or decreased in ‘Arousal’?
a. NE
b. ACh
c. Nitrous Oxide
a. decreased NE
b. increased ACh (in arousal and orgasm)
c. increased NO
Note: serotonin is DECREASED in orgasm/desire/arousal
uOttawa 2014 (lecturer stated that we should memorize this)
Pharmacology of Sex: are the following neurochemicals increased or decreased in ‘Orgasm’?
a. NE
b. ACh
a. increased NE
b. increased ACh (in arousal and orgasm)
Note: serotonin is DECREASED in orgasm/desire/arousal
uOttawa 2014 (lecturer stated that we should memorize this)
The most common male sexual complaint is ?
Male Erectile Disorder
- 7% of under 30 yo, 50% of men above 60 yo
uOttawa 2014
PDE-5 inhibitors include ?
- sildenafil (Viagra)
- tadalafil (Cialis)
- vardenafil (Levitra)
uOttawa 2014
Explain the pathophysiology of male erectile dysfunction?
The pathophysiology of ED is an inability of the smooth muscle in the corpus cavernosum to relax enough for blood to fill it to a pressure that is almost equal to the systolic blood pressure. Normally, sexual stimulation will lead to stimulation of the cavernosal nerves, resulting in the release of nitric oxide from the endothelial cells. This in turn will increase the production of cyclic guanosine monophosphate, which will relax the smooth muscle by acting on the calcium channels.
http://www.cfp.ca/content/56/9/898.full
How do PDE-5 inhibitors work?
Normally; an erection leads PDE-5 to break down cGMP which leads to normalized cellular calcium and subsequently to loss of erection.
PDE-5 inhibitors stop the breakdown of cGMP and thus maintains an erection.
uOttawa 2014
Which is incorrect re: Pedophiles
a. Overall 90% are men
e. many have also committed exhibitionism, voyeurism & rape
f. often feel more accepted by kids, have low self-esteem or body image problems
c. 50% have consumed alcohol at time of offence
uOttawa; DSM-5
What is the DSM-5 criteria for Pedophilic Disorder?
A. Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviours involving sexual activity with a prepubescent child or children (generally age 13 years or younger).
B. The individual has acted on these sexual urges, or the sexual urges or fantasies marked distress or interpersonal difficulty.
C. The individual is at least age 16 years and at least 5 years older than the child or children in criterion A.
Note: do not include an individual in late adolescence involved in an ongoing sexual relationship with a 12- or 13-year-old.
Specify whether:
- Exclusive type (attracted only to children)
- Nonexclusive type
- Sexually attracted to males/females/both
- Limited to incest
DSM-5
What drugs can be used to reduce sex drive?
- Partial Sex drive reduction: SSRI’s, Cyproterone (Androcur), Medroxyprogesterone (Provera)
- Ablation of Testosterone: Leuprolide (Lupron), Goserelin (Zoladex)
- Inhibit peripheral testosterone (adjunct): Finasteride
uOttawa 2014
What is untrue of Cyproterone (Androcur)
a. It is a testosterone agonist
b. Contraindicated in liver disease & thromboembolic disease
c. 15-20% get gynecomastia (excess of estradiol/estrogen vs. testosterone)
d. weight gain & decreased body hair often occur
e. risk of fatigue or depression
a. It is a testosterone antagonist
uOttawa 2014
True or False: nicotine replacement products do not induce hepatic enzyme CYP1A2.
True
http://www.currentpsychiatry.com/index.php?id=22661&tx_ttnews[tt_news]=177424
True or False: women metabolize less alcohol in their esophagus and stomach.
True
“Males have higher rates of drinking and related disorders than females. However, b/c females generally weigh less, have more fat, and less water in their bodies, and metabolize less alcohol in their esophagus and stomach, they are more likely to develop higher BAC per drink than males. Females who drink heavily may be more vulnerable than males to some of the physical consequences ass’d with ETOH, including liver disease”
- women have lower alcohol dehydrogenase blood content than men (K&S)
DSM-5 (p.495)
Hypertension secondary to cocaine is commonly responsive to intravenous _______ because _____ minimize the stimulant effects of cocaine on the CNS.
IV benzo’s / benzodiazepines
Cocaine may precipitate hypertensive emergency due to CNS stimulation and peripheral alpha-agonist effects. Toxicity may be superimposed on preexisting hypertension in patients who have become dependent on elevated BP to maintain cerebral perfusion. Carefully consider the patient’s clinical status and history when deciding to treat hypertension.
Medscape article on cocaine toxicity.
