Neuropsychiatry and Substance Use Flashcards
Depressant misuse-tx
Medical stabilization if needed
Safe injection practices/needle exchange
If dependent-managed detox, maintenance prescribing
Solvent misuse
Red rash around nose and mouth
Mostly young boys
Initial euphoria then drowsines
Psych dependence > physical dependence
Short acting benzos
More addicting, although sometimes better for old folks
Temazepam, oxazepam
Medium acting benzos
Lorazepam, alprazolam
Long acting benzos
Least addicting. Caution in elderly
Diazepam, nitrazepam, chlordiazepoxide
PCP
Angel dust
Smoked
Euphoria and peripheral analgesia, impaired consciousness or psychosis
Khat
Men from Somali/Yemeni communities
Contains cathionine, an amphetamine-like stimulant
Excitement and euphoria
Not a controlled substance in UK
Nicotine
1/4 British adults smoke
Tx-counselling, nicotine replacement therapy, varenicline, bupripion may help cessation
Cannabis
Most commonly used illegal drug
Can exacerbate chronic psychotic illness
THC is active ingredient-acts on cannabinoid receptor. Also opiate-like effects and barbiturate-like effects
Mild euphoria, sense of well-being, subjective sense enhanced sensation, relaxation, altered time sense, increased appetite
Not associated with physical dependency but heavy users if suddenly stop can get insomnia, anxiety, irritability
Alcohol abuse
Regular or binge consumption alcohol sufficient to cause physical, neuropsychiatric, or social damage
Safe limits: 21u/week for men, 14u/week for women
Alcohol-MOA
Enhancement GABA-A transmission (anxiolytic)
Release Da in mesolimbic pathway (reward)
Inhibition NMDA-mediated glutaminergic transmission (amnesic)
Bio-Psycho-Social causes EtOH dependence
Genetics: high acetaldehyde producers less likely to abuse (worse hangover). E.g. Japanses people and “flush reaction”
Psycho: FHx depression, other psych or physical illness, esp chronic pain. Imitation, classical conditioning, social reinforcement
Social: Occupation (armed forces, doctors, publicans, journalists), culture (Scots, Irish high whereas Jewish, Muslim low)
Wernicke’s encephalopathy
EtOH.
Thiamine deficiency causes mamillary body damage
Ataxia, ophthalmoplegia, acute confusion
Depressants (misuse)
Benzos.
Pleasurable anxiolytic and relaxant properties
Used to come down after stimulant use
Can cause forgetfulness, drowsiness, impaired coordination
Chronically- impaired concentration and memory, depressed mood
Dependency after 3-6w regular use
Withdrawal can be complicated by seizures and delirium
Korsakoff’s psychosis
Profound short-term memory loss characterized by confabulation
Viral encephalitis
Herpes simplex
50% survivors experience disturbaces of behavior, concentration, or social adjustment
May have chronic cognitive impairment
Tertiary syphilis
Rare
Neurosyph “general paralysis of the insane”:
Personality change (disinhibition, irritability, lability)
Cognitive impairment and poor concentration
Dementia
Depression
Grandiosity
Rarely, mania and schizophrenia-lie psychoses
Prion disease
Human forms of spongiform encephalopathy are rare.
vCJD, kuru,
Rapidly fatal dementia
Classic CJD presents with physical sxs
vCJD starts with psych sxs–mood swings, fatigue, social withdrawal
HIV and AIDS
Worried well: preoccupation with possibility of becoming infected
Psychological reactions to HIV infection: periods of crisis after learning of infection, starting HAART, tests indicating problem with tx, development HIV-related illness. Adjustment disorder, acute stress reaction, risk deliberate self-harm
Psychiartirc illness: depression (NB AIDS-like dementia can present similarly), acute mania, schizophrenia-like psychoses
Epilepsy-psychological aspects
Psychosocial consequences of dx, psych syndromes directly attributed to epilepsy, neuropsych effects of medications
Prodromal sxs: tension, dysphoria, insomnia days-hrs before
Ictal:
-automatisms. Usu
Anti-epileptics that also improve mood
Carbamazepine and lamotrigine
Post-concussional syndrome
Anxiety, depression, irritability, emotional lability, insomnia, hypersensitivity to noise and light, reduced concentration, chronic tiredness
Punch-drunk syndrome
Repeated minor head injuries.
Clinical picture of dementia with movement disorder
Retired boxers
Psych complications to cerebrovascular disease
1/3 develop depression within 1 year
May also have anxiety disorder, apathy, emotional incontinence
Progressive CVSs can lead to picture of dementia
Brain tumors–psych effects
Behavioral, affective, psychotic, personality, and cognitive disturbances via mass effect, hydrocephalus etc
Parkinson’s-psych complications
Dementia: 20-30% develop some cognitive deterioration.
usually subcortical dementia with slowing, impaired executive function, personality change, memory impairment
Depression: 40-70%. Partly disease, partly experience thereof
Can have psychosis (psychotic depression) and delirium
Huntington’s-psych complications
Subcortical dementia: mental slowing, impaired executive function. Speech deteriorates faster than comprehension
Psych disturbances v common-changes in personality and behavior. Affective disorders, schizophreniform psychoses. Not related to severity of disease.
Acute alcohol intoxication
Slurred speech, impaired coordination and judgment, labile affect
Severe: hypoglycemia, stupor, coma
Acute alcohol withdrawal
Within 1-2 days abstinence
Malaise, nausea, autonomic hyperactivity, tremulousness, labile mood, imsomnia, transient hallucinations
DTs in 5% with mortality up to 15%
5-15%-tonic clonic seizures 6-48hrs after last drink
DTs
Peak incidence 48 hrs
Features wthdrawal plus clouding consciousness, disorientation, amnesia for recent events, psychomotor agitation, visual/auditory/tactile halluc (Lilliputian common)
Hourly fluctuations (worse at night)
If severe, heavy sweating, fear, paranoid delusions, agitation, suggestibility, temp, sudden CV collapse
Alcohol dependence
Compulsion to drink Loss ability to regulate drinking Altered tolerance Withdrawal phenomena Persistence after attempted abstinence
Biological Tx-alcohol withdrawal
Benzos: Chlordiazepoxide if outpt, diazepam for inpatient
Antipsychotics: prn haloperidol if increasing dose benzos does not manage hallucinations
Vitamins: B1 parenterally. BEFORE glucose
Most pts outpatient. Can follow up daily if worried about compliance, drinking on top of drugs
Inpts if hx complicated withdrawal, comorbidities, suicide risk, Wernicke-Korsakoffs, severe N&V, lack stable home environment
Provide written advice, inform GP, emergency contact #, followup
Disulfiram
Inhibits acetaldehyde dehydrogenase, therefore acetaldehyde builds up (causing hangover sxs). Prescribe once abstinence achieved
Acamprosate
Enhances GABA transmission and diminishes alcohol cravings
Naltrexone in alcohol misuse
Diminishes high from alcohol
Pysch tx for alcohol misuse
Motivational interviewing: aid pt in explaining why they need to change their behavior
Plan interventions with pt
Weekly limits-no saving up
None if pregnant, driving
Do not drink alone, avoid heavy drinkers, don’t buy rounds, alternate soft drinks and alcohol, drink with meal, rehearse declining drink, plan non-drinking activities (social skills training)
Problem-solving skills, relaxation training, anger management, cognitive restructuring
ALCOHOLICS ANONYMOUS
Definition-dependence
Includes withdrawal state and tolerance
usually reduction or neglect of social, occupational, or recreational activities
Dependence syndrome
Drug-seeking behavior
Narrowing of drug repertoire (e.g. instead of different drinks, now only Stella)
Increased tolerance
Loss control of consumption
Withdrawal
Drug taken to avoid withdrawal sxs
Continued drug use despite negative consequences
Rapid reinstatement previous pattern of drug use after abstinence
Opiates
E.g. heroin
Virtually immediate euphoria. Diminished pain, feelings detachment
10% become dependent, 2-3% die annually
Medical problems: N&V, constipation, resp depression, LOC with aspiration. Injected–local abscesses, cellulitis, osteomyelitis, bacterial endocarditis, septicemia, infection
Withdrawal sxs: craving, flu-like, sweating, piloerection, yawning
Tx-opiate misuse
Bio: methadone, buprenorphine for detox. Naltrexone can be used acutely and to prevent relapse
Psychosocial: safer injecting advice
Hallucinogens
Heightened perception, dilated pupils, periph vasoconstricton, increased temp.
No dependence
LSD, PCP, magic muschrooms (“liberty cap”), ketamine
Autobiographical memory
Aka episodic memory
Relates to specific events and issues in one’s life
Procedural memory
Aka implicit memory.
“How to do things”
E.g. drive a car
Semantic memory
Knowledge base
E.g. nine times table
Topographical memory
Orientation
E.g. me forgetting how to get to St Mary’s
Confabulation
False memories
Deja vu
Sense of familiarity
Seen in temporal lobe epilepsy and non-pathological states
Ganser’s syndrome
Give approximate answers.
E.g. when asked how many legs a cow has, answers “5”
Jamais vu
Sense that a familiar place has never before been encountered
Perseveration
“Capital of UK?”
“London”
“Dates of WWII?”
“London”
Seen in organic brain disease
Logoclonia
Repeating last syllable-ble-ble-ble
Seen in parkinsons-sons-sons
Harmful use
Misuse of drug >1/12 despite damage to user’s physical or mental health
Complicated withdrawal
Associated with delirium, seizures, or psychotic features
Wernickes triad
Ataxia, ophthalmoplegia, confusion
Korsakoff’s
Amnesia, normal level consciousness
Marchiafava-Bignami syndrome
Corpus callosum demyelinization
Associated with chronic alcoholism
Sudden stupor, coma, seizures, dementia, incontinence, aphasia, apraxia
Charles-Bonnet syndrome
Complex visual hallucinations in people with severe vision impairment.
Insight retained
Gerstman’s syndrome
L-R disorientation, dyscalculia, agraphia, finger agnosia
Parietal lobe injury
