liason psych day 5 Flashcards
The commonest psychosexual disorder among men is:
E.Erectile dysfunction
The commonest psychosexual disorder among women is:
Loss of sexual desire
Risk factors for male erectile dysfunction include
A.Smoking
B.Diabetes
C.Radical prostatectomy
D.Depression
What is the treatment of choice for male sexual performance anxiety?
B.CBT
what is sildenafil
viagra
OSCE Scenario - Mr Lyman is a 45 year old man who has been referred because of depression. He has tried three different antidepressants but has reported a number of side effects from these.
•He has had longstanding problems with interpersonal relationships and his current depressive episode has arisen in the context of relationship problems.
•Please take a psychosexual history
Candidates should demonstrate:
•An ability to quickly establish trust and rapport
•Ease in discussing sensitive subjects
•That they are comfortable asking very personal questions and able to decide which questions are relevant to the history.
Marking sheet •Current relationship –Duration of relationship –Quality of relationship –Sexual behaviours – libido, freq, practices, preferences, satisfaction –Sexual orientation –Contraception –History of splits, aggression –Children
Other questions
•Difficulties with initiating an erection
•Difficulties with maintaining an erection
•Frequency of masturbation
•Worries about ejaculation (too fast, too slow)
•Frequency of waking erections
•Previous relationships
–Overall number, longest lasting, sexual orientation, patterns of behaviour
–Patients views on quality of relationships in past
–Fantasies, encounters
•Sexual history –Age of first sexual activity –Age at first intercourse –Age at first girl/boyfriend –Sexual abuse / trauma
•Attitudes –Development of secondary sexual characteristics –Acquisition of sexual information –Sexual attitude, inclinations, practice –History of sexual problems
Masturbation: What is common or usual?
98% men, ? 70% women
Common sexual problems –men (GP population)
Common problems –men (GP population) Erectile dysfunction – 9% Impaired sexual drive – 7% Sexual aversion – 3% Premature ejaculation – 4% Anorgasmia – 3% Non-organic dyspareunia -1% Any disorder – 22%
Erectile dysfunction in smoking
Relative risk of ED - 1.3 for each 10-
pack-years smoked
86% of smokers have an abnormal
penile vascular state
Sildenafil (Viagra) action
Inhibits phosphodiesterase 5 Prolongs cyclic GMP in erectile tissue Therefore amplifies vasodilation effect of NO Enhances ‘stimulated’ erections Rapidly absorbed (30-90 min) Half life 3-5 hours
Useful in psychological difficulties if
CBT or other psychotherapy not effective
Restores confidence
Restrictions on prescribing in UK
what is Vaginismus
“Phobic” avoidance Anxiety + spasm of pelvic musculature Not necessarily lack of arousal Approach depends on sex of therapist Patient centred examination Self examination Education/self focusing (desensitisation)
Management of Sexual Variations (paraphilias) such as Exhibitionism
Voyeurism
Sadomasochism
Paedophilia
Management
Biopsychosocial
Reduce undesirable/inappropriate thoughts,
feelings and behaviour
Increase alternative thoughts, feelings and
behaviour
4 Abnormal Reactions to stress
Acute stress reaction
• Acute Stress disorder
• PTSD
• Adjustment disorder
what is Acute Stress Reaction
Transient reactions to exceptional physical
and or mental stress.
• ICD-10 diagnosis
Clinical Features • Initial daze • Narrowing of attention • Inability to comprehend stimuli • Disorientation
Time course:
Start within 1 hr
Diminish within 8 hrs for transient and 48 hrs
for enduring stressor.
synonymous with DSM’s acute stress disorder
what is Acute stress disorder
DSM-IV diagnosis • Dissociation • Hyperarousal • Anxiety • Re-experiencing
synonymous with ICD’s acute stress reaction
Treatment
Psychoeducation
• Normalisation of symptoms
• Practical support
Psychological therapies • Debriefing • CBT Medication • Tricyclic anti-depressant use, benzodiazepines and anxiolytics- little evidence
what are Adjustment disorders
• ICD-10 • F43 • Identifies disorders not only on the basis of symptoms but also the presence of stressor.
Development within 1 month of an exposure
to a psychosocial stressor not of an unusual
or catastrophic type.
Generally do not last more than 6 months ()
(except in cases of prolonged depressive reactions)
wiki - An adjustment disorder (AD) occurs when an individual is unable to adjust to or cope with a particular stressor, like a major life event. Since people with this disorder normally have symptoms that depressed people do, such as general loss of interest, feelings of hopelessness and crying, this disorder is sometimes known as situational depression. Unlike major depression the disorder is caused by an outside stressor and generally resolves once the individual is able to adapt to the situation. The condition is different from anxiety disorder, which lacks the presence of a stressor, or post-traumatic stress disorder and acute stress disorder, which usually are associated with a more intense stressor.
According to the DSM-IV-TR, there are six types of adjustment disorders, which are characterized by the following predominant symptoms: depressed mood, anxiety, mixed depression and anxiety, disturbance of conduct, mixed disturbance of emotions and conduct
what is PTSD
DSM-IV
‘experienced, witnessed or was confronted
with an event or events that involved actual or
threatened death or serious injury or a threat
to the physical integrity of self or others.
ICD10- a stressful situation or event…of an
exceptionally threatening or catastrophic
nature which is likely to cause pervasive
distress in almost anyone
Clinical features • Flashbacks • Avoidance • Inability to recall • Arousal
Co-morbidity o Mental health • Affective disorders • Anxiety disorders • Substance misuse • Somatization o Social • Family and marital adjustment problems • Violence
o Psychological processes • Fear conditioning • Appraisal of traumatic event and its sequelae • Traumatic memories • Maintaining behaviours
Treatment Psychological • CBT • Psychodynamic therapy • Hypnotherapy • EMDR Pharmacological • SSRIs
Mr A is a 24 year old in A&E with palpitations,
chest pain, nausea and irritability shortly after
being rescued from a car crash. Physical
investigations reveal no abnormalities.
What psychiatric diagnosis would you consider? treatment?
Acute Stress Reaction
If you believe Mr A has an acute stress
reaction, you will offer Mr A - c)Social support and information
True or false
Flashbacks are not essential for diagnosis of
PTSD
False
True or false
Medication plays no role in treatment of PTSD
False
effects both short and long term of amphetamines
Feel powerful, alert, energised
Sweat, tremor, headaches, sleepiness, blurred vision
Increase in HR, RR, BP
Crash- irritable/depressed for 1-2 days
Prolonged use – hallucinations and intense paranoia
Psychologically addictive – aggression, anxiety, intense
cravings
effects of benzodiazepines
Effects relief of anxiety sedation relaxation impaired memory muscle relaxation anticonvulsant confusion stupor
different ways of consuming cannabis
smoked in rolled paper – ‘joint’ hollowed out cigar – ‘blunt’ pipes – ‘bowls’ water pipes – ‘bongs’ mix in food or brewed as an infusion
effects of cannabis
Effects;- euphoria anxiety/panic altered perceptions impaired coordination and memory red eyes sleepy hungry paranoia hallucination
what is ‘coke’
cocaine
what is ‘crack’
cocaine minus the hydrochloride = freebase, rocks.
Cocaine: snort, inject, rub on gums, Crack:
smoked, inject
effects of cocaine/crack
Feel confident, physically and mentally strong
Dry mouth, sweating, ↓ appetite, increased HR,
restlessness, anxiety, paranoia, hallucinations and
rarely death from respiratory or heart failure
After effects include fatigue, depression, difficulty
sleeping, diarrhea, vomiting, the “shakes”, insomnia,
anorexia, weight loss and sweating
Acute effects ischaemia, infarction
Long-term effects include inflammed nasal mucosa,
perforated septum, respiratory problems and partial
aphonia
effects of GHB
Euphoria, increased confidence and libido
Anesthetic- sedative
Easy to overdose – small window between
recreational dose and overdose
Vomiting, convulsions, muscle spasm, coma
and respiratory depression
Physical dependence- withdrawals include
insomnia, anxiety, tremor and psychosis
what is mephedrone
MMCAT/Miaow/meow
Synthetic stimulant drug recently made illegal
Causes euphoria, alertness, talkativeness
and feelings of empathy
Snort or swallow
Increases heart rate/BP/vasoconstriction
Some reports of paranoia, convulsions +
death
Low mood after use
effects of methamphetamine
Effects: euphoria, sexual arousal, increased energy, decreased
appetite, nausea, meth mouth, perceptual disturbances e.g. insects
crawling under skin, sleeplessness, panic attacks, compulsive
repetitive movements, paranoia, hallucinations.
Prolonged use
violent, aggressive behaviour
psychosis resembling paranoid schizophrenia
brain damage
effects of MDMA
Mild hallucinogenic/stimulant effect intensifying emotions
Tingly skin, dry mouth, cramps, pupils dilated, blurred vision, chills,
sweats, nausea, jaw clenching
May experience depression, paranoia, anxiety, confusion
Increase BP, HR, Temp
>200 deaths in last 15yrs – heatstroke/ dilutional hyponatraemia
/heart failure
After use- tired and low for 3-4 days.
names for heroin
Smack, gear, junk, brown £50 for 1g
effects of heroin
Euphoria, relaxation, detachment, reduced
anxiety – followed by drowsiness, nausea,
stomach cramps, vomiting
Overdose – coma and respiratory failure
Long-term- constipation, amenorrhoea,
decreased resistance to infections
what inhalant drugs are there
Glue, paint thinner, dry cleaning fluids, petrol, hair spray,
aerosol deodorants, spray paint
sniffed- breathe directly from container
bagging- from plastic bag
huffing holding inhalant-soaked rag in mouth
effect of inhalants
Immediate high, giddy and confused
Long-term users get headaches, nosebleeds, lose hearing
and smell, neurological damage, liver damage
Abused substance most likely to cause severe toxic reaction
and death
what is ketamine
Quick acting anaesthetic
effects of ketamine
Intoxication and hallucinations like LSD
Lose sense of time/reality <2 hours – trip or K-hole
Also nausea, vomiting, delirium, memory disturbance,
movement difficulties, body numbness and decreased RR –
can cause coma, cardiovascular or respiratory arrest
methods of taking heroin
Heroin – smoked (“chasing”), injecting
(“shooting up”), snorting. If injecting, where?
methods of taking crack
Crack – smoked (“on the pipe”), injected
(often with heroin known as “snowballing”
methods of taking cocaine
Cocaine – snorted through a straw or bank
note – “tooting”.
use pattern of heroin and alcohol
Daily use – Heroin and alcohol – dependent
users tend to use daily, if they don’t, they get
sick.
use patttern of crack/cocaine
Binge pattern – crack/cocaine – binge pattern
common, e.g. 3 days of use, 2 days without
using, etc. Alcoholic binges or benders
crack/cocaine withdrawal
Cocaine/crack withdrawal is more
psychological: irritability, craving,
restlessness.
alcohol withdrawal symptoms
Alcohol: sweats, tremors, tachycardia,
nausea, retching, anxiety, raised blood
pressure – may lead to withdrawal fits (within
a few hours) and even DTs (disorientation,
visual hallucinations and withdrawal
symptoms).
opiate withdrawal
Alcohol: sweats, tremors, tachycardia,
nausea, retching, anxiety, raised blood
pressure – may lead to withdrawal fits (within
a few hours) and even DTs (disorientation,
visual hallucinations and withdrawal
symptoms).
what is ‘dependence’ on a drug
ICD10:A cluster of behavioural, cognitive, and
physiological phenomena that develop after
repeated substance use and that typically include:
1. a strong desire to take the drug.
2. difficulties in controlling its use.
3. persisting in its use despite harmful consequences.
4. a higher priority given to drug use than to other
activities and obligations.
5. increased tolerance.
6. and sometimes a physical withdrawal state.
heroin overdose
• Overdose – pinned pupils, shallow
respiration, cyanosis, low O2 saturation,
loud snoring, unrousable, respiratory
depression and death
treatment of opiate overdose
Overdose Treatment:
• Naloxone – opiate antagonist
• Will reverse opiate effects (some patients may
have it at home, ambulances carry it)
• But has short half-life, so patient may try to
leave after being given naloxone, but risk of
becoming unconscious again when naloxone
wears off.
treatment of benzodiazepine overdose
• Flumazenil will reverse benzodiazepine
effects
rapidity of GHB withdrawal
• GBL has a short half-life and intoxication can rapidly progress to withdrawal symptoms. In some cases this is a medical emergency requiring admission to ITU
cocaine/crack overdose
Cocaine/crack • Stimulant drug with effects on dopamine • Binge pattern of use. • High doses can lead to intoxication, fits, hypertension, ischemia (MI, ischaemic stroke, intestinal infarction, rhabdomyolosis)
problems with repeated IVDU
Physical complications - Infections: – Lack of venous access due to repeated episodes of thrombophlebitis – Mainly related to injecting – e.g. abscesses, cellulitis, septicaemia, acute endocarditis, – Rare complication such as botulism, tetanus and anthrax
Other vascular complications: – Groin injecting – Deep Vein Thrombosis with secondary pulmonary embolus – Acute endocarditis – infection of the heart valves – Ischaemia from injecting into an artery and causing a blockage down-stream with secondary compartment syndrome
opiate withdrawal and treatment
Opiate withdrawal
• Sweaty, mild tremor, muscle aches, muscle jerks, abdominal cramps
and diarrhoea, piloerection, dilated pupils, runny nose, yawning,
nausea.
Treatment
• In A&E substitute drugs such as methadone not usually prescribed
• Symptomatic medications, e.g. diazepam, loperamide, buscopan
• On AMU may need to prescribe methadone to prevent further
withdrawal symptoms, patient using drugs on the ward or patient
discharging self
• Follow local protocols for prescribing methadone
• Seek advice from local drug service
GBL withdrawal and treatment
GBL withdrawal
• From mild anxiety to confusion, agitation, tremor,
muscular cramps, insomnia, combativeness, delirium,
delusions, paranoia with hallucinations (auditory, tactile
and visual), tachycardia, hypotension
Treatment – with benzodiazepines and Baclofen. May
need admission to ITU
Benzodiazepine withdrawal and treatment
Benzodiazepine withdrawal: • Anxiety, depersonalisation and derealisation, sensitivity to light and sound, fits Treatment: • Diazepam detoxification
Managing opiate dependence
on the AMU
History: • Confirm history of opiate use (heroin, Methadone, Buprenorphine, other opioids) • Confirm history of dependence – withdrawal symptoms when stops using, e.g. COWS (clinical opiate withdrawal scale) • Confirm treatment history – is patient on a prescription for Methadone or Buprenorphine – if so confirm with treatment agency and community pharmacy
Examination: • Examine for signs of drug use (e.g. injection sites) and for withdrawal symptoms • Do urine drug screen Treatment: • Follow protocol for prescribing Methadone or Buprenorphine
Drink drive limit in UK:
80mg of alcohol/100mL blood
35microgrammes/100mL breath
Chronic effects
of alcohol
Gastritis • Alcoholic hepatitis • Fatty liver • Fibrosis • Cirrhosis • De-compensated cirrhosis • Encephalopathy • Oesophageal varices • Alcoholic hallucinosis
• Alcohol withdrawal symptoms:
Alcohol withdrawal symptoms: Sweating, tremor, tachycardia, anxious, nausea and vomiting • Withdrawal seizures • Delirium tremens – disorientation, visual hallucinations and signs of alcohol withdrawal
Wernicke’s encephalopathy
Wernicke’s encephalopathy – caused by
thiamine deficiency – ophthalmoplegia,
nystagmus, ataxia, confusion – petechial
haemorrhages in brain stem – medical
emergency – treated with intravenous thiamine (also glucose and saline but thiamine is priority
– Correct magnesium deficiency and hypoglycaemia
Korsakoff’s syndrome
Korsakoff’s syndrome – caused by thiamine
deficiency – sequellae of Wernicke’s - loss of
short term memory (ability to register and recall
new information)
Identification of Alcohol Dependence
≥3 during the past year: (a) Strong desire or compulsion to drink (b) Difficulty controlling drinking in terms of onset, termination or level of drinking (c) Physiological withdrawal symptoms or drinking to relieve or avoid withdrawal symptoms (d) Tolerance (e) Neglect of alternative interests because of drinking or time recovering (f) Persisting drinking despite clear evidence of harmful consequences
a better version is the SADQ questionnaire (severity of alcohol dependence quotient), gives you stages of dependence based on self reported score from phisical symptoms, behaviours and psych.
Managing alcohol
dependence on AMU
- Full history, alcohol history
- Physical Examination
• SADQ Score
30 Severe
• Bloods, inc. – Full Blood Count – Urea & Electrolytes – Liver Function Tests – GammaGT – Amylase – Clotting
• Supportive Measures • Chlordiazepoxide – Reducing regimen, e.g. – As per SADQ (Severity of Alcohol Dependence Questionnaire) score – Physical observations – Monitor withdrawal symptoms • Thiamine po 100mgs tds; or Pabrinex I + II im/iv for 3-5 days • Discharge planning early
what is delerium tremens?
• Delirium tremens – disorientation, visual hallucinations and signs of alcohol withdrawal
– Medical emergency
– Consider Haloperidol
• 5-10mg orally or 5mg IM
• (max 30mg daily orally, 18mg daily IM lower in elderly)
what is the CAGE questionnaire
This easy to use patient questionnaire is a screening test for problem drinking and potential alcohol problems.[1] The CAGE questions should not be preceded by any questions about alcohol intake - ie its sensitivity is dramatically enhanced by an open-ended introduction
Two “yes” responses indicate that the possibility of alcoholism should be investigated further.
The questionnaire asks the following questions:
Have you ever felt you needed to Cut down on your drinking?
Have people Annoyed you by criticizing your drinking?
Have you ever felt Guilty about drinking?
Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover?
By far the most important question in the CAGE questionnaire is the use of a drink as an Eye Opener, so much so that some clinicians use a “yes” to this question alone as a positive to the questionnaire; this is due to the fact that the use of an alcoholic drink as an Eye Opener connotes dependence since the patient is going through possible withdrawal in the morning, hence the need for a drink as an Eye Opener
