Psych Ix/Mx Flashcards
Questions to as in depression hx?
Core symptoms: low mood (worse in morning), anergia, anhedonia
• Ask patient to rate mood out of 10
Biological: appetite loss, libido loss, early morning waking, insomnia
Cognitive: concentration, memory, thoughts of hopeless/helplessness
Risk: thoughts / acts of harm to self, others
Psychotic: hearing voices, seeing people who may not really be there
Support including family
Drugs/smoking/alcohol
FH or personal history of mental health
What are the differentials for someone presenting w depression
- Atypical Depression – May not have anhedonia, there is hypersomnia + hyperphagia, heavy limbs, looks for proof of rejection despite reassurance
- Seasonal affective disorder – Seasonal pattern, due to melatonin synthesis (is reduced in summer due to sunlight – improvement of symptoms)
- Dysthymia – Longer than 2 years, chronic low grade depressive symptoms
- Organic – Hypothyroidism, Anaemia, Diabetes, Infection
- Pharmacological – Steroids (long term asthma?), Retinoids (isotretinoin / Roaccutane)
- Neurological – Important in elderly (dementia, Pd, stroke, tumours)
Ix in someone presenting w depression
- Bedside – Full physical examination and basic obs
- Bloods – FBC, U+Es, TFTs (Hypothyroidism)
• Rating scales:
PHQ-9 Patient health questionnaire, score out of 27
HADS-D: Hospital Anxiety and Depression scale
BDI-2: Beck Depression Inventory
• May require a collateral history if severe depression
Mx of someone w depression?
Bio-psycho-social
DT – Community mental health team, GP, Self-harm support groups, liaison psych team
Lifestyle modification:
• Sleep hygiene, exercise, self-help books
• Support groups
• Manage stressors
Psychological: CBT, psychodynamic or interpersonal therapy (IPT > CBT if due to death)
• CBT: thoughts, beliefs, behaviours and actions
• Challenging negative beliefs, behavioural experiments
Biological: for moderate-severe depression with psychotherapy (SSRIs, SNRIs, TCAs, Mirtazapine - useful in insomnia / poor appetite)
Advice for pharm management
• Can take up to 4 weeks to have an effect
• Should not suddenly stop: slow taper down dose over few weeks
Follow up
• If start SSRI/SNRI: within 1 week if age <30
• Usually within 2 weeks of starting meds
Safety net? – Crisis resolution and home treatment teams, Samaritans, A+E – if severe thoughts, seek help from community mental health or GP if symptoms persist
Resources – mind.org.uk and Samaritans helplines which are available 24/7
What questions to ask ab in PND hx?
- Biological: sleep, weight, appetite
- Cognitive: memory, concentration
- Thoughts of worthlessness (bad mother, blame, failure)
- Thoughts of harm: to baby, to self
- Psychosis: people speaking to you, people who may not be there, thoughts about baby
- Risk factors: mental health during pregnancy, pre-pregnancy, traumatic birth
- Is she breastfeeding (will affect prescribing)
- FH
- Support, coping
- Social history: alcohol, smoking, drugs
Ix in PND pt?
- Full examination to assess health of mother and baby, Obs
- Edinburgh Postnatal Depression score (10 item questionnaire (max 30), score of >13 = likely depression)
- Bloods: FBC (anaemia), TFT, U+E (electrolyte disturbances)
- Examine baby for signs of neglect
- Collateral history from partner + assessment from OT about activities of daily living + health visitor assessment of M+B’s needs
DDx to consider in PND pts?
Baby blues: occur in first 2 weeks of delivery, lasts a few days, resolves by 2 weeks
Emotional lability, tearfulness, difficulty sleeping
Postnatal depression: usually at 4-6 weeks, gradual onset
Symptoms must be present for at least 2 weeks for diagnosis
Organic causes e.g. hypothyroidism
Puerperal psychosis
Mx of baby blues?
- Generally, explanation and reassurance (very common affects 60-70% of mothers and 1st time mothers are more likely to be effected) = address concerns (eg. bad mother – by coming in it shows that you care about you and your babys health and it shows that you’re being a good mother etc)
- We will ensure that there are regular visits from the health visitor to check how the mother and baby are doing and they can provide more advice on specific coping strategies and identify any areas where you may need extra help if needed can be organised with help of children and families social services
- If mother complains about breastfeeding issues Can arrange an ‘expert’ review of feeding at a mid-wife led breastfeeding clinic and regular monitoring of baby’s health and weight until its satisfactory
- This should last upto 10 days and should get better however can rarely progress to PND hence GP review in 1 weeks time
Mx of PND?
- Bio-psycho-social w/ expedited referral to Improving Access to Psychological Therapies (IAPT)
- MDT approach – Ots, GP, psychiatrists, health visitors
- Supportive: support groups, community nurse visits
- If very severe: admit to mother and baby home - Indications: suicidality, psychotic features, risk to baby
- Psychological: Referral to facilitated self-help (subthreshold / mild-moderate) CBT – can be computerised or telephone if low risk / mum doesn’t have too much freetime, interpersonal therapy
- Pharmacological: - important to monitor baby as this can be secreted in breastmilk - SSRIs, Sertraline first line – paroxetine also good if breastfeeding as it has low milk/plasma ratio- SNRIs second line, Consider low-dose Amitriptyline
- If mother complains about breastfeeding issues Can arrange an ‘expert’ review of feeding at a mid-wife led breastfeeding clinic and regular monitoring of baby’s health and weight until its satisfactory
- We will ensure that there are regular visits from the health visitor to check how the mother and baby are doing and they can provide more advice on specific coping strategies and identify any areas where you may need extra help - if needed can be organised with help of children and families social services
- Severe depression w/ suicidal or infanticidal ideation - admission to MBU and separation should be avoided
- Should be offered crisis management plan with a crisis number to contact in acute instances
What are the key features to ask in a history of puerperal psychosis?
- Psychotic features: hallucinations, delusions, any thought insertion / broadcasting
- Mood
- How is baby doing?
- Risks including to baby
- Anything you are worried about?
- Drugs, alcohol, smoking
- Birth history, if breastfeeding
RFs for puerperal psychosis?
- Personal or FH: puerperal psychosis, depression, BPAD
- Obstetric complications e.g. C section
- Postnatal infection
- Perinatal death
- Lack of support
DDx to consider in puerperal psychosis
- Postnatal depression
- BPAD with psychosis
- First episode psychosis, schizophrenia
- Psychotic depression
What ix to perform in puerperal psychosis?
- Collateral history
- Assessment: Young Mania Rating Scale
- Full Physical examination to assess health of mother and baby
- Examine baby for signs of neglect
- Screen for organic causes: infection – FBC, U+E, CRP, LFTs, TFT, substance misuse
What are the possible complications of puerperal psychosis?
- Risk to baby including neglect and violence
- Recurrence in future pregnancy
- Risk of developing mental illness later in life
What some key questions to ask in a pt w EUPD?
- Explore past relationships, holding down job
- Previous self-harm and suicide attempts
- Risks
- Psychosis
- Forensic history: any criminal offences
What are the main subtypes of EUPD?
Impulsive: impulsive behaviour and emotional instability
Borderline: poor self-image, feel empty, self-destructive behaviours
What are the ddx for someone with EUPD?
- EUPD: most common personality disorder, young adult females
- Adult ADHD
- Adjustment disorder, affective disorder
- Psychosis
What ix are useful in someone with EUPD?
Collateral history
Second interview
Psychological assessment: PDQ-4 (personality diagnostic questionnaire)
Patient must be >18 for diagnosis
What are the main clusters of personality disorder?
Cluster A: weird: schizoid, schizotypal, paranoid
Cluster B: wild: EUPD, histrionic, dissocial
Cluster C: worried: dependent, avoidant, anankastic
Mx of EUPD?
They are treatable and individuals should have clear boundaries and be encouraged to take responsibility for their actions
Bio-psycho-social
1st presentation and suspcion of BPD referral to community mental health service (<18 = CAMHS)
MDT: psychiatrist, community mental health team (nurses, therapists), key worker (point of contact, coordinates care)
Psychological: DBT (can also offer CBT, Mentalization and therapeutic communities)
• Focus on changing unhelpful behaviors and accepting yourself at same time
• Validation: accepting your emotions
• Understand things are not black and white
Meds
• Antidepressants: reduce impulsivity and lability
• Mood stabilisers
• Antipsychotics
• Short term sedative antihistamines may be considered cautiously as part of overall treatment in a crisis
Social: art therapy, support groups, therapeutic communities: group-based approach
Crisis w/ significant risk may require detention under MHA
Important to treat co-morbid problems such as substance abuse, affective and anxiety disorders require management
Mx of anti-social PD?
Assessment tools – Severity can be measured using PCL-SV and another tool called HCR-20 can be used to develop a risk management strategy
Treatment of co-morbid disorder eg substance misuse
Secondary care assessment – Identify antisocial behaviours, coping strategies and needs for treatment
You can consider inpatient mx for crisis management or treatment of co-morbid disorders
What safety netting should be provided for PTs in crisis with a PD?
- Numbers of community mental health nurse, out-of-hours social worker
- Samaritans
- Mind website
What are the key questions to ask about in suicide / self-harm hx?
Before:
• What were they doing before the event?
• Was it pre-planned? Suicide notes? Attempts to conceal.
During:
• How did it happen? When + Where did it happen?
• Which substances did they take? How much? Over how long / when?
• What was their intentions? Suicide or self-harm?
After:
• Current mood? Feelings for regret?
• If we let you go today, would you do this again?
Also ask about protective factors + the opposite
Important to ask about if they have children! – May need SS involvement?
- Triggers / recent life events
- Previous attempts, previous self-harm?
- Risk assessment: to self, to others, by others
- General psych screen: Mood, psychosis, self-harm
- Support
What ix to perform in someone with self-harm / suicide?
- Physical exam, collateral history
- Assessment: GAD-7 and PHQ-9
- Consider FBC, TFT = organic causes
- All need risk assessment by psychiatrist
What does the management of
Immediate
• If high risk / lacking capacity admit to psych ward for own safety admit, discuss with senior
• If lower risk: manage at home with close follow-up
• Set up crisis plan for future suicidal ideation / thoughts of self-harm Who will they tell and how will they get help? how to get help - Samaritans number
• Educate on coping mechanisms when these thoughts appear: - Distraction, mood-raising activities (exercise etc), prevention (put away knives, tablets etc) if unavoidable talk about alternatives like using a cold ice cube
• Arrange for psych liaison review before discharge
Follow-up + Ongoing Mx:
• 1w follow up at GP / Community mental health team, counseller
• Treat underlying diagnosis eg depression – SSRIs, CBT, Support groups
• If obvious social issues contributing – provide help advice about this as well eg. housing issues?
Manage underlying causes: bio-psycho-social approach
• Bio: SSRI - Consider ECT if life-threatening
• Psychological: CBT or psychodynamic therapy
• Social: support groups, encourage healthy diet and exercise, sleep hygiene
• If lacerations – superficial cuts = sutures / steristrips, plastic surgery for deep cuts
• Always provide adequate analgesia
• If patient is insistent on leaving – assess their capacity
Resources – mind.org.uk and Samaritans helplines which are available 24/7
MDT – Community mental health team, GP, Self-harm support groups, liaison psych team
Safety net? – Crisis teams, Samaritans, A+E – if severe thoughts, seek help from community mental health or GP if symptoms persist
Key questions to ask in a hx of pt w bipolar / mania?
- How are you feeling?
- Core symptoms: mood (rate it out of 10), energy
- Biological: sleep, appetite
- Cognition: memory, concentration
- Disturbance of ADL, work
- Shopping, gambling, driving, drugs and alcohol
- Risk: to self, to others, from others
- Episodes of low mood in past
- Psychotic screen:
What thoughts have you been having?
Hallucinations
DDx for pts w mania / bipolar?
- Hypomania: at least 4 days, no psychotic features
- Bipolar
- Schizoaffective disorder
- Organic causes: hypothyroidism (myxoedema madness), frontal lobe disease, drug induced (cocaine, amphetamine), delirium
Ix in pts w BPD / mania?
- Collateral history, physical exam
- Urinary toxicology screen
- Bloods: FBC, CRP, TFT
- Consider CT head
What is the mx of pts w BPD / mania?
Acute
• Consider admission or CMHT (mania v hypomania) (persuade them for an informal admission however may require sectioning)
• Stop any precipitating meds e.g. SSRIs
• Start atypical antipsychotic e.g. Olanzapine ± benzo (if agitated / insomniac)
Long term
• Mood stabilisers: lithium (will be give a lithium information book and alrt card – monitoring, measure lithium 1w after and 3m after, every 6m = U+E & TFTs), carbamazepine, sodium valproate
• Psychological: CBT, psychodynamic therapy
• Social: financial and occupational support, support groups, family therapy, charities such as MIND and Bipolar UK can provide lots of useful support
• If carer present may find carers assessment useful and referral to support groups
• Psychoeducation + identification of relapse signature
• Cannot drive for 3m following acute episode
• Lithium will require regular monitoring
What monitoring is needed in patients with lithium therapy?
Pre-lithium measurement of FBC, U+E, Ca (can increase risk of hyperparathyroid), ECG if known risk factors / cardiac disease
Measure serum lithium 1 week after starting/changing dose
• 12 hours post-dose
• Aim for 0.4 - 1 mmol/L
• Monitored weekly, then every 3 months
TFT and U+E: every 6 months
CK every year
Warn patients about medications that can trigger toxicity and to consult doctors advice if ever concerned about starting new medication
What can cause lithium toxicity? how can it present? how is it managed?
Precipitants:
• Dehydration, D+V, renal failure
• Reduced excretion due to drugs: thiazide diuretics, ACEi, NSAIDs
• Overdose
Presentation:
• GI disturbance: nausea, vomiting, diarrhoea
• Coarse tremor
• Severe: arrhythmias (palpitations), confusion, seizures, coma, renal failure
Management
• Stop lithium and precipitating drugs
• Supportive: osmotic diuresis (fluid resus and rehydrate)
• Consider haemodialysis esp if severe features
Qs to ask in a pt w OCD?
- Recent stress (precipitant)
- Depression / anxiety screen (comorbid)
- Obsessions: are these your thoughts or do you believe someone has put them in your mind?
- Screen for psychosis: irrational delusions
- Impact on QOL
- Family history of OCD
What dx should be considered in a pt w OCD?
- Anankastic personality disorder: lifelong personality of rigidity, orderliness and hygiene
- Anxiety disorder
- Depression, can occur in 50% of patients with OCD
- Schizophrenia: beliefs are delusional not obsessional
- Organic causes e.g. Sydenham chorea
What is the ix for pts w OCD?
- Collateral history – get better insight into how the condition is affecting the pt
- Physical examination to rule out organic causes of sx – can also do urine dip, FBC (anaemia), TFTs (hyperthyroidism), glucose (hypoglycaemia)
- Yale-Brown Obsessive-Compulsive Scale (Y-BOCS)
What is the mx of OCD?
Education, self help
Mild: CBT w/ ERP -> self referral / GP referral to IAPT
• Use hierarchy of feared situations
• Encouraged to resist compulsive behaviours and experience anxiety
Moderate: SSRIs or more intense CBT w/ ERP
Severe: both SSRIs and CBT w/ ERP
About the meds:
• SSRIs e.g. Fluoxetine, citalopram
• Usually higher doses needed than for depression so titrate up quickly
• Continue for at least 12 months after remission
• If not responding after 12 weeks: switch to alternative SSRI or consider Clomipramine TCA
Mx of young people and children with OCD?
- Mild = guided self help + psychoeducation for family
* Mod / severe = CAMHS
Questions to ask about in anxiety hx?
- Do you ever feel particularly worried about certain scenarios? – If any specific triggers may point towards a specific phobia
- Do you ever feel your heart racing more than usual?
- Have you ever had a panic attack? – difficulty breathing, sweating, heart beating out of your chest, GI discomfort
- How long for? – GAD = 6 months
- Do not have to ask all 3, just do a quick screen
- Ask about drug, alcohol and caffeine use
- Medications which can cause anxiety – salbutamol, theophylline, B-blockers, steroids, st johns wart
- Triggers for anxiety
- Recent life events
- Disturbance on ADL
- Sleep, appetite, weight
- Thoughts: what are you thinking about when you get nervous?
- Panic attacks
- OCD symptoms
- Hyperthyroidism features: irregular periods, weight changes, tremor
- Mood
- Risks
- Caffeine intake, drugs and alcohol
What ix for anxiety
- Collateral history
- Bedside – Full physical examination, 12 lead ECG and basic obs
- Bloods – FBC, U+Es, TFTs (Hyperthyroidism), Pulmonary function tests?
- Urine -Tox screen if indicated?
- Special tests – GAD7, HAD (if in hospital), Beck Anxiety Inventory (BAI), Consider doing PHQ9 as well?
- Social and occupational assessments for affect on QOL
What is the mx of anxiety?
MDT: Community mental health team, GP, support groups, liaison psych team
Stepped care model – Start w/ low intensity self help CBT if no functional impairment
Biological:
• SSRIs first line: sertraline, paroxetine, escitalopram = Higher doses than for depression and responses take longer 6-8 weeks, Continue for 12 months after remission
• Second line: change to SNRIs Venlafaxine if no effect after 2-3 months
• 3rd line: Pregabalin
Psychological: CBT, applied relaxation also available
• Reduce expectation of threat, and behaviours that maintain threat-related beliefs
• Explore likelihood and impact of feared situation
• Test feared situation and belief in outcome using behavioural experiments
• Increase confidence in ability to cope
For agoraphobia: exposure therapy, testing feared situations
Social: • Self-help books • Relaxation and breathing techniques • Sleep hygiene, exercise • Support groups, mind website
Charities – Anxiety UK, mind.org.uk
Note if pregnant: High intensity CBT should be offered first
——————————-Other drugs———————————
Benzodiazepines
• Short-term treatments e.g. whilst waiting for SSRIs to work or during acute crisis
• Otherwise, should not be offered in primary care
• Tolerance builds rapidly and dependence is issue
• Must not be used for >4 weeks
• Side-effects: amnesia, ataxia, respiratory depression
• NOTE: Never give a benzodiazepine to anyone with anxiety because of high risk of dependence (it may be given for specific phobia in the short term (e.g. dental phobia))
Beta Blockers
• E.g. propranolol
• Sometimes used to treat adrenergic symptoms e.g. tremor, palpitations
• Consider contraindications e.g. asthmatic
What questions should be asking in a ED hx?
• S – Do you make yourself sick because you feel uncomfortably full?
• C – Do you worry you have lost control over how much you eat?
• O – Have you lost one stone (6kg) in a 3 month period
• F – Do you believe yourself to be fat when others say you are too thin?
• F – Would you say that food dominates your life
—————————————–
- Behaviours to control weight
Diet restriction, fasting
Excessive exercise
Self-induced vomiting
Diuretics, laxatives, appetite-suppressants e.g. caffeine
- Distorted body image: how do you view yourself and your body?
- Binging episodes (suggests BN)
- Physical problems:
Sleep, constipation, weak muscles, recurrent infections
Periods
- Psychological problems:
Mood, concentration, memory, irritability
- Effect on daily life and relationships
- Support
- ICE, risk
- Past history: major life events, mental health
Ddx in pts w ED?
- Anorexia, bulimia, atypical anorexia (BMI >17.5)
- Medical causes of weight loss: hyperthyroidism, malignancy, IBD
- Depression
- Body dysmorphic disorder
Ix in a pt w ED?
- Collateral history
- Physical exam:
Lanugo hair, parotid enlargement, dry skin, brittle nails
Russel’s sign: callous/cuts on knuckles due to vomiting
Basic Obs
BMI
Squat test for proximal myopathy - Bloods:
FBC, U+E, LFT, TFT, B12 and Folate levels
Glucose, CK, other electrolytes
Identify nutritional risk - ECG: bradycardia, arrhythmias, long QT
Mx in a pt w ED?
- Bio-psycho-social approach:
Social – Dieticans? CEDS? (aim for 0.5/1kg pw)
Psychological therapy: CBT-ED, SSCM and MANTRA – in children that present family therapy or CBT should be offered)
- Discussing thoughts that drive our behaviours
- Setting eating plan and feasible weight gain target
- Refer to CEDS community eating disorder service = specialist service which can help with Nutritional advice and support
Bio:
- Treat medical complications
- Admit into hospital if high suicide risk, serious physical compromise (long QT, HR <40, electrolyte abnormality), very rapid weight loss / BMI <13
- Manage comorbidities, may use SSRIs if also depressed
- Support: BEAT, support groups
What questions to ask in a dementia hx?
DOPT (Duration, Onset, Progression, Triggers)
o Short v long term
o Fluctuating levels, gradual or step-wise decline?
Establish Functional Level
o Do they live alone? A
o Are they able to cook, wash and dress themselves?
Risk Assessment
o Self – wandering, leaving iron / cooking on, self-neglect, driving
o Others – aggression, risk behaviours, driving?
ICE
o Do they have insight into their condition?
o What are the concerns of the pt’s relative?
Specific Symptoms
o Tremor, hallucinations, parkinsonian symptoms – Lewy body? Ask about temporal relationship to distinguish LBD vs Parkinsons Disease Dementia?
o Ask about cardiovascular RFs – Vascular dementia?
o Changes to personality / executive function – FTD?
o Rapid progression of symptoms? – Consider creutsfeldt-Jakob
o Altered consciousness – May suggest delirium instead
o Low mood? – May suggest depressive pseudodementia
o Falls / FLAWS ? – Hydrocephalus or SOL
What ix to do in a pt w/ Dementia?
- Bedside – Full physical examination (check for neurological signs) and basic obs, collateral hx
- Bloods – FBC (Anaemia, U+Es (renal failure?), TFTs (Hypothyroidism), CRP, glucose, B12 and folate levels, syphilis VDRL if concerned about tertiary syphilis infection
- Urine – Urinalysis and Tox screen?
- Imaging – MRI Head (Can do CT instead)
- Special tests – MMSE, AMTS, can also do PHQ9
- Consider CT /MRI, refer to neurologist / memory clinic
What is the mx of pts w/ dementia?
General
- Bio-psycho-social approach
- Optimise physical health (review meds), treat sensory impairment e.g. glasses
- Psychological therapy: e.g. reminiscence therapy, art therapy
- Support / Social:
Personal care, meal prep, med prompting
Suggest adaptations (carrying ID, dosset boxes, visible clocks etc
Day centres for activities
Patterned carpets can increase likelihood of hallucinations
Consider OT
Alzheimer’s:
- Reversible anticholinesterases: increase choline (E.g. Donepezil, Rivastigmine), For mild-moderate, Cholinergic side effects e.g. vomiting, diarrhoea, usually settles within days
- Memantine: severe
Non-competitive NMDA antagonist
- Consider antipsychotics for behavioural changes
Vascular: control vascular risk factors e.g. Aspirin
LBD:
- Acetylcholinesterase inhibitors
- Avoid antipsychotics
MDT – Community mental health team, GP, Dementia support groups, old age psychiatrists, occupational therapists, carers?
What qs to ask in schizophrenia hx?
- Psychotic features
Auditory and visual hallucinations
Delusions, thought disorder: someone stealing your thoughts etc - Insight: do you believe these people/voices/things are real
- Mood
- Biological: sleep, appetite, weight
- Risks
- Social history: committed crime, smoked cannabis
What ix to do in schizophrenia hx?
- Collateral history
- Bedside – Full physical examination and basic obs
- Bloods – FBC, U+Es, LFTs (alcohol intox), CRP (infection)
- Urine -Tox screen
- Imaging – CT / MRI Brain – if concerned about SOL
- Lipids before starting treatment
- Social work assessment: housing, activities of daily living, finances
Mx of pts w/ schizophrenia?
- Refer to early intervention service (EIS)
- Biological: first- or second-generation antipsychotics
- Psychological: CBT, family therapy, concordance therapy
- Social: consider admission, social skills training, education/occupation, financial, housing
Key questions to ask in alcohol / opiate abuse hx?
- Quantification of drinking
- CAGE
Have you tried to cut down? How did you feel?
Do you get annoyed when others criticise your drinking habits?
Do you feel guilty about how much you drink?
Do you need to have alcohol every morning to get you up? - Job
- Relationship
- Dependence symptoms
Crave it
Difficult to control how much you drink
Do you know it’s harmful
Are you still eating well and keeping healthy diet / neglect of hobbies (salience)
Increasing in frequency / volume of drinking than in the past
E.g. 6 weeks ago were you drinking this much
Have you tried to go without alcohol and how did you feel - Mood
Including thoughts of self-harm or suicide - Psychotic symptoms / features of delirium tremens
- Risks
Have you been under the influence of alcohol around children?
Have you driven whilst under the influence of alcohol?
What ix to perform in pt w alcohol / opiate abuse?
Rating scales
AUDIT to identify use disorder, 10 item scoring system
SADQ: determines severity of dependence
APQ: alcohol problems questionnaire: assess problems arising from alcohol
CIWA: withdrawal assessment
Physical exam: establish baseline physical state
Bloods: FBC: macrocytic anaemia, low platelets LFTs: high GGT B12, folate, glucose U+E - dehydration Clotting
Urine drug screen, breathalyser or blood alcohol conc BAC
Mx for alcohol abuse?
General:
- Biopsychosocial approach
- Motivational interviewing, establish goal, encourage abstinence
- Warn about risks and complications
- Advise about healthy diet and lifestyle
Biological
- Assisted withdrawal
- Either community or inpatient
- Inpatient indications:
Complex withdrawal history e.g. delirium tremens, seizures
Very severe dependency: 30+ units/day, 30+ score on SADQ
Concurrent withdrawal of alcohol + benzo
- Community based: refer to Drugs and Alcohol service, 2-4 meetings in first week
- Fixed-dose drug regimen with long-acting benzo e.g. chlordiazepoxide or diazepam
Titrate based on severity of dependence
Gradually reduce dose over 7-10 days
Use lorazepam if liver impairment or seizures
- Thiamine supplement
- Warn about withdrawal symptoms
Worse within first 48 hours
Takes up to 7 days since last drink to completely disappear
- After successful treatment: relapse prevention
Acamprosate: weak NMDA antagonist, anti-craving
Naltrexone: opioid antagonist, blocks euphoric feeling
Use for 6 months
If unsuccessful / unsuitable: Disulfiram = flush-reaction
Psychological
- CBT, couples therapy
- Focus on alcohol-related cognitions
- 12 weeks
- Refer to self-help resources and support groups
Alcoholics Anonymous, SMART recovery
Social
- Rehabilitation centre including day centre or residential programmes
Skills-based programmes for jobs
- Direct to services for legal and financial support
- Job centre
- Driving: inform DVLA because cannot drive during treatment
Follow-up and safety net:
- Arrange appointment for after withdrawal complete
- Safety net, if symptoms become severe → A+E
Ix for opiate withdrawal?
- Physical examination (cardio + neuro)
- Urine tox screen
- Bloods – FBC, U+Es, LFTs + screening for blood borne infections eg RPR – syphilis antibodies, hep serology and HIV test
Mx of opiate withdrawal?
Acute rapid + accelerated detox:
- Actively precipitated by opioid antagonist (eg naltrexone or naloxone) – rapid = 1-5d w/ moderate sedation, accelerated = no sedation
Longer process:
- Psycho – motivational interviewing, can offer residential rehab if homeless for upto 3m
- Bio – Long term detox (methadone, liquid – opioid agonist w/ longer ½ life – long withdrawal but mild OR buprenorphine – sublingual tablet, partial agonist – blocks eurphoric effects), important to appoint key worker that can support them through the detox process Can be inpatient (4w) or in the community (12w), after detox can offer naltrexone to prevent relapse as it stops the euphoric effects
- Social – pragmatic harm reduction approach – improving safety of drug use via needle exchanges and vaccination for blood borne viruses and also offering practical solutions to environmental stressors such as employment and housing
- Can also get support from narcotics anonymous
