CASC Stations 3 Flashcards
Legal questions to ask in alcohol use
- Have you actually had an accident or hurt yourself?
- Have you ever been convicted of drink driving?
- Have you ever been arrested because of your dinking?
What is detox
Detoxification is a treatment designed to control both the medical
and psychological complications that may occur temporarily after
a period of sustained alcohol misuse
What does detox involve
• It usually involves chlordiazepoxide at diminishing doses over 7 to
10 days with thiamine supplementation
• The doses of medication should be titrated against withdrawal
symptoms.
Indications for prescribing a reducing regime of CPZ
– Clinical evidence of alcohol withdrawal features
– History of alcohol dependence syndrome
– Consumption of alcohol is greater than 10 units per day over the
last 10 days
Indications of inpatient detox
– Symptoms of Wernicke-Korsakoff syndrome
– Past history of seizures or delirium during withdrawals
– Acute confusional presentation
– High risk of suicide
– History of poly drug misuse
– Co-morbid mental health illness, e.g., depression, psychosis
– Lack of stable support in the community, e.g., homelessness
– Severe malnutrition/severe physical health conditions.
SEs of disulfiram
Headache
Halitosis
Hepatotoxicity
Psychosis
How does disulfiram work
Irreversible inhibitor of acetaldehyde dehydrogenase
Acts as adjunct to therapy and prescribed once abstinence is achieved
How does acamprosate work
Enhances GABA transmission in the brain
Diminishes alcohol craving
SEs of acamprosate
Pruritis
GI upset
Rash
How does naltrexone work
Antagonizes effect of endorphins released by alcohol consumption
Reduces total alcohol consumed and number of drinking days
SEs of acamprosate
Anxiety Headache Fatigue Flu-likw sx GI sx Sleep disturbance
Describe supportive psychotherapy in alcohol use
Education
Advice and counselling on physical and psychosocial complications of alcohol use and problem solving approach to normal day-to-day difficulties
Describe CBT in alcohol use
Education and improvement of social and interpersonal skills
Relapse prevention including identifying situational or interpersonal triggers than result in excessive drinking, suggestions to change social milieu to get away from drinking and developing new interests and planning and rehearsing new methods of coping
Adopting behavioural approaches - self-monitoring, diary keeping
What does motivational interviewing involve
Feedback of personal risk or impairment
Emphasis on personal responsibility for change
Clear advice to change
Menu of alternative change options
Therapeutic empathy as a counselling style
Enhancement of patient self-efficacy or optimism
Duration of alcohol hallucinosis
Begins 12-24 hours after last drink
Resolves after 24-48 hours
What makes alcohol hallucinosis different from DT
Develops and resolves rapidly
Limited set of hallucinations - auditory and visual, usually accusatory or threatening voices
No other physical sx
What increases risk of alcohol hallucinosis
Long-term heavy alcohol abuse
Use of other illicit drug use
Questions to ask about needle usage in drug use
Where are they obtained?
Are they shared?
What sites are used for injection?
Risks to ask about in drug use
Sharing needles
Unsafe sex
Sex of drugs
Financing of drugs
Features of dependence syndrome in drug use
Compulsion
Tolerance
Withdrawal sx
Treatment and re-instatement
Timeframe of opioid withdrawal
Appear 6-24 hours after last dose
Last 5-7 days
Peak on 2nd or 3rd day
Pharmacological options for opioid use
Methadone
Buprenorphine
Lofexamine
Symptomatic treatment
What is methadone
Long acting, synthetic opioid
Long half-life of 24 hours
Prescribed as a liquid
What happens in rapid reduction regime of methadone
Reduce dose over 14-21 days using symptomatic drugs as adjuncts
Slow reduction technique in methadone use
Reduce over 4-6 months by 5-10mg every 2 weeks
What is oral methadone effective in
– Reducing illicit drug use – Reduced injecting – Reduced criminal activity – Improved physical health – Improved social well-being -Reduced drug-related mortality
What is Buprenorphine
Partial opiate agonist
Reduces effects of additional opioid use because of its high receptor affinity
How does Buprenorphine titration occur
Dose increases made 2-4mg at a time
Maintenance should be achieved within 1-2 weeks
What is Lofexedine
Alpha-adrenergic agonist
Given as 7-10 day course with 2-4 day withdrawal
Risks with Lofexidine
Postural hypotension - BP should be monitored
Symptomatic meds used in opioid withdrawal
Metoclopramide - vomiting
Loperamide - diarrhoea
Ibuprofen - pain
What is Naltrexone used for in opioid use?
Relapse prevention in those who have completed detox
Can be used to facilitate rapid detox over 5-7 days
What is harm reduction
Reduce morbidity and mortality in drug users without necessarily insisting on abstinence
Examples of harm reduction
- Advice regarding safe sex
- Advice directed at the use of safer drugs
- Advice directed at safer routes of administration
- Advice regarding safer injecting practice
- Treatment of co-morbid mental or physical health problems
- Engagement with other sources of help
- Prescription of maintenance opiates or benzodiazepines.
Risks of heroin use in pregnancy
Provoke miscarriage or intrauterine death
Can cross placenta resulting in neonatal abstinence syndrome, baby may need to be treated for withdrawal
Baby more likely to be premature and small for dates
Impact of cocaine use on the baby
Impact development of GU system and bones of skull
Risk of placental abruption
Abstinence syndrome in baby
Sudden infant death syndrome
What to do if woman is on high dose methadone when pregnant
Reduce slowly
Fetal monitoring
Dose may need to be increased in third trimester due to increased metabolism
Can women breast feed while on Methadone
Yes
When does opioid withdrawal syndrome start in babies
24-48 hours after birth depending on time of last dose
Signs may not appear for 3-4 days
Risk of congenital defects on Methadone
No increase
Is Buprenorphine licensed for use in pregnancy?
No
Sx of DT
Clouding of consciousness
Disorientation to time and place
Poor attention
Visual hallucinations - vivid and frightening
Tactile hallucinations - insects crawling over skin
Autonomic disturbance - fever, sweating, tachycardia, hypertension, pupil dilation
Treatment of DT
Treat any underlying cause e.g. infection, dehydration
• Ensure adequate fluid and electrolyte balance, providing
adequate nutrition
• Optimisation of environment- well lit quiet room with
adequate lighting
• Nursing support-Consistent nursing support to offer
reassurance, reorientation and explanation. If possible, discuss
about providing input from the psychiatric nursing team
• Librium sliding scale (detoxification regime with
Chlordiazepoxide (Librium) in a reducing dose).
• Using parenteral benzodiazepines to achieve quick sedation.
• Instituting parenteral, high potency vitamins (thiamine
supplementation or multivitamins).
• Avoiding use of phenothiazine antipsychotics (Haloperidol)
due to risk of inducing seizures.
• Warn about the risk of withdrawal seizures and Wernicke’s
encephalopathy.
What is conversion disorder
A loss or disturbance of normal function, which initially
appears to have a physical cause but is attributed to a psychological
cause
Treatment of conversion disorder
• Obtain medical and psychiatric history from patient and
informants
• Physical causes should be ruled out by full examination and
appropriate investigation
• Supportive psychotherapy; Sympathetic explanation and
reassurance that the patient is suffering from a temporary
condition and does not have a permanent disabling disorder.
• Treatment of psychiatric co morbidity like depression etc. Offer
continuing assessment and treatment of psychiatric and social
problems
• Avoidance of reinforcement of disability.
Prognosis of conversion disorder
• The prognosis is generally good for those patients with a clear
precipitant and if symptoms were of sudden onset and shorter
duration.
• Complete resolution of symptoms is possible and has been
observed in 70-90% of cases at follow-up.
• If the symptoms are longer lasting and well established, then
the outcome is more likely to be poorer.
Risk factors for conversion disorder
Childhood experience of illness Negative life events Relationship conflict Modelling of others illnesses Physical illness such as epilepsy
Perpetuating factors of conversion disorder
Behavioural responses such as avoidance, disuse, reassurance
seeking
Cognitive responses such as fear of worsening, fear of serious disease
Diagnostic criteria of dissociative disorders
v Dissociative disorders are presumed to be “psychogenic” in
origin, being associated closely in time with traumatic events,
insoluble and intolerable problems, or disturbed
relationships.
v The onset and termination of dissociative states are often
reported as being sudden and the symptoms usually develop in
close relationship to psychological stress.
v In these disorders there is a loss of or interference with
movements or loss of sensations (usually cutaneous). The
patient therefore presents as having a physical disorder,
although none can be found that would explain the symptoms.
v The commonest varieties are loss of ability to move the whole
of part of a limb or limbs. Paralysis may be partial, with
movements being weak or slow, or complete. Various forms
and variable degrees of incoordination (ataxia) may be evident,
particularly in the legs, resulting in bizarre gait or inability to
stand unaided (astasia-abasia). There may also be exaggerated
trembling or shaking of one or more extremities or the whole
body.
v The symptoms can often be seen to represent the patient’s
concept of physical disorder, which may be a variance with
physiological or anatomical principles.
v In addition, assessment of the patient’s mental state and
social situation usually suggests that the disability resulting
from the loss of functions is helping the patient to escape
from an unpleasant conflict, or to express dependency or
resentment indirectly
v Individuals with dissociative disorders often show a striking
denial of problems or difficulties that may be obvious to others.
v A variable amount of attention-seeking behaviour may be
present in addition to a central and unvarying core of loss of
movement or sensation which is not under voluntary control.
v Premorbid abnormalities of personal relationships and
personality are usually found, and close relatives and friends
may have suffered from physical illness with symptoms
resembling those of the patient.
Management of dissociative disorders
v Thorough neurological and medical evaluation is absolutely
crucial
v Timely diagnosis
v Treatment of any co-morbid depression and other psychiatric
disorder
v Combined treatment that uses a medical model approach and
psychological modalities to best address any physical needs
and that invites the patient to engage in treatment without
feeling humiliated (Addressing psychological factors and
reactions to the presented deficits is combined, if appropriate,
with progressive physical therapy).
v Some form of physical therapies or rehabilitation such as
physiotherapy for a patient with paralysis and speech therapy
for a patient with aphonia.
v Working through patient’s defences and helping him/her to
develop more mature and adaptive defense mechanisms to
prevent future development of conversion episodes.
v The ultimate goal is development of an appropriate level of
control and mastery, through psychotherapeutic modalities,
that may be used to help to manage their conversion symptoms
v When a specific psychological factor is identified, clinical
experience suggests that addressing the stressors that may
have led to the onset of conversion symptoms, including any
identified trauma is paramount for an effective intervention.
Helping patients make the connection between recent or
current stressors and earlier conflicts may allow them to
understand the significance and reasons for conversion
symptoms. After this is accomplished, the patients themselves
may recognise the need to address the areas of conflict, which
may dramatically ameliorate the severity or frequency of
symptoms
Prognosis of dissociative disorder
v There is no good estimates of average duration of symptoms or
time to symptom resolution
v Sometimes, simply removing the acute stressors or placing the
patient in a protective environment like a medical or inpatient
psychiatric ward may lead to resolution in a matter of hours or
days
v Sometimes reassurance about absence of a medical cause along
with supportive psychotherapy achieves the same quick
resolution of symptoms
v Adjunctive use of relaxation techniques, with or without formal
hypnosis training may be beneficial, often accelerating the
course of progress in therapy
v If symptoms do not improve/resolve with these approaches, a
more intensive intervention may be needed
v A number of techniques used alone/jointly have been found
useful, including pharmacologically facilitated interview
(Narco-analysis), CBT approach and hypnotically facilitated
psychotherapy
v Data have suggested that a quicker resolution of symptoms
have been associated with a better prognosis (Ford & Folks
1985). Thus it makes sense to consider approaches relatively in
the early course of treatment
v In many cases, the symptoms may remit dramatically with a
variety of symptoms such as physiotherapy, psychotherapy,
hypnotism, electrical stimulation, persuasions, explanation,
reassurance or no treatment at all
What is BDD
ü Body dysmorphic disorder also called as Dysmorphophobia, is described
as a ‘subjective description of ugliness and physical defect which the
patient feels is noticeable to others’
ü It is characterized by a preoccupation with an imagined defect in
appearance, or if there is a slight physical anomaly and the concern is out
of proportion to the anomaly
ü It is an excessive concern (overvalued idea) about trivial or non-existent
physical abnormalities, which are perceived to be deformities. Here the
patient is constantly pre-occupied, convinced and tormented by abnormal
belief that some part oh his/her body is too large, too small or misshapen,
which to other people, the appearance is normal or there is a trivial
abnormality
