PSYCHIATRY 2 Flashcards
What is anxiety?
An unpleasant emotional state involving subjective fear, bodily discomfort and physical symptoms, often a feeling of impending threat or doom
What is the Yerkes-Dodson curve?
Anxiety can be beneficial to a certain point of optimal function, then performance declines with further anxiety
What groups of people is anxiety more common in?
Young adults
Middle age
Women
Causes of anxiety? (5)
Low levels of GABA neurotransmitter Stress in early life - separation, conformity Alcohol/benzodiazepines Genetics - 1st degree relatives Life stress/physical illness
How does stress in early life cause anxiety?
Stress/separation leads to remodelling of the frontal cortex and amygdala, altering behavioural response as adults
What is generalised anxiety disorder?
Generalised, persistent, excessive anxiety or worry about a number of events that the person finds difficult to control lasting over 3 weeks
Symptoms of generalised anxiety disorder? (5)
Apprehension and fear Increased vigilance and restlessness Sleeping difficulty, fatigue on waking Motor tension, tremor Autonomic hyperactivity - tachycardia
Treatment of generalised anxiety disorder? (5)
CBT, group therapy, applied relaxation SSRIs or SNRIs 2nd line pregabalin Short term benzodiazepines Beta blockers propanolol for tachycardia
What is a phobia?
Extreme irrational fear or aversion to something
What is agoraphobia?
Fear and avoidance of places or situations from which escape may be difficult, or help may not be available, often with panic disorder
Give 3 examples of places agorophobes would avoid
Crowds
Public places
Travelling alone or away from home
Treatment of agorophobia? (2)
CBT with graded exposure to situations
SSRIs
What is social phobia? (2)
Persistent fear of social situations in which the individual is exposed to unfamiliar people or to possible scrutiny by others
Fear they will be humiliated or embarrassed
Treatment of social phobia? (3)
CBT
Self help, graded self exposure, social skills training
SSRIs 2nd line
What are specific phobias?
Fear of specific people, objects or situations
Treatment of specific phobias? (2)
Graded exposure and response prevention
Short term benzodiazepines i.e. for flying
What is panic disorder?
Recurrent episodic severe panic attacks which occur unpredictably and are not restricted to any particular situation
What is a panic attack?
Discrete periods of intense feat, impending doom or discomfort accompanied by symptoms
Symptoms of a panic attack? (9)
Palpitations/tachycardia Sweating, trembling, breathlessness Feeling of choking Chest pain or discomfort Nausea/abdominal discomfort Dizziness, paraesthesia Chills and hot flushed Derealisation or depersonalisation Fear of losing control, dying
How long do panic attacks last?
A few minutes but anticipatory fear may develop and maladaptive behavioural changes - i.e. refusal to leave the house or be alone
What is the cognitive model of panic attacks?
Panic attacks occur when catastrophic misinterpretations of ambiguous physical sensations creates a positive feedback loop leading to panic
Treatment of panic disorder? (3)
CBT and SSRIs
2nd line tricyclic antidepressants
What is PTSD?
Post traumatic stress disorder - prolonged abnormal response to a severely stressful experience of an exceptionally threatening or catastrophic nature, usually within 6 month of event
Types of severe psychological stress? (5)
Threat - war, terrorism Disasters Assault Accidents Loss
Normal reaction to psychological stress?
Fear, sadness, fatigue, denial, avoidance
What is abnormal stress reaction?
Exaggerated or maladaptive responses
Symptoms of PTSD? (9)
Persistent intrusive thinking or re-experiencing of trauma - memories, nightmares, flashbacks Avoidance of reminders of the event Numbing and detachment from others Loss of interest in activities Sense of shortened future Increased arousal Hypervigilance, easy to startle Poor concentration Sleep disturbance
Common comorbid conditions with PTSD? (2)
Depression, substance misuse
What increases risk of PTSD? (3)
Magnitude of stress
Lack of support
Other life events occurring
Treatment of PTSD? (3)
Trauma focussed CBT
Eye movement desensitisation and reprocessing therapy (EMDR)
2nd line antidepressants
What are obsessions?
Unwelcome, persistent, intrusive senseless thought that the patient recognises are from their own mind and tried to suppress them
Types of obsessions? (5)
Thoughts - numbers, contamination Images Impulses Ruminations - constant pondering Doubts
What are compulsions?
Repetitive, purposeful physical or mental behaviours performed with reluctance in response to an obsession, carried out by certain rules to try and neutralise discomfort - but often excessive and not realistically related to obsession
Examples of compulsions? (5)
Hand washing Counting, checking Rearranging objects Hoarding Folie du pourquoi - seeking explanations for everything
What is OCD?
Obsessive compulsive disorder - characterised by time consuming (>1 hr a day) obsessions and/or compulsions most days for 2 weeks interfering with activities e.g. avoidance of triggers
Subtypes of OCD? (4)
Obsessions and compulsions related to contamination
Checking compulsions
Obsessions without overt compulsions
Hoarding
Causes of OCD? (4)
Genetics - OCD, tics, Tourette’s
Parental overprotection
Serotonin abnormalities
Abnormalities of cortico-striatothalamic circuit mediating social behaviour
What does brain MRI show in OCD?
Functional abnormalities of the frontal cortex and basal ganglia
How is compulsive behaviour maintained?
Anxiety reduction after performing the compulsion
Treatment of OCD? (4)
Psychoeducation, CBT involving exposure and response prevention
SSRIs
Tricyclic antidepressants
Possible psychosurgery - deep brain stimulation
What is adjustment disorder?
Abnormal psychological responses to life adversity e.g. job loss, moving, divorce which usually occurs within weeks of the event but does not last more than 6 months if the stressor does not persist
Presentation of adjustment disorder? (2)
Anxiety - autonomic symptoms, insomnia, irritable
Depression - sad, teary, worried
How is adjustment disorder diagnosed?
Insufficient symptoms of specific anxiety or depressive disorder
Identified stressor
Treatment of adjustment disorder?
Usually resolves after cause passes
CBT and problem solving strategies, therapy
What are the 5 stages of grief?
Denial, anger, bargaining, sadness, acceptance
What is somatisation disorder?
At least 2 years of multiple physical symptoms with no physical explanation, and patient refusal to accept conclusion that there is nothing wrong
Affects social and relationship functioning
Most common complaints in somatisation disorder?
Skin, GI
Most common group of people in somatisation disorder?
Women under 30
Cause of somatisation disorder?
Healthy anxiety causing misinterpretation of normal body sensations or mild discomfort as illness
Treatment of somatisation disorder?
Patient wants a diagnosis - rule out any illness
CBT
What is hypochondriacal disorder?
Non-delusional preoccupation with possibility of a serious illness (cancer, HIV) despite medical reassurance
Most common 2 groups of people in hypochondriacal disorder?
Men
Health workers
Treatment of hypochondriacal disorder?
Patient wants the all clear or fears confirmed to access treatment - rule out illness
CBT
What is conversion (dissociative) disorder?
Physical (mostly neurological) symptoms/signs occurring in the absence of pathology and with a clear relationship with a stressor
Types of dissociative disorder? (4)
Dissociative motor/sensory deficits - limb weakness, blind
Dissociative convulsions - nonepileptic seizures
Dissociative amnesia
Dissociative fugue - amnesia, planned journey away
Theory of dissociative disorder?
Painful thoughts or feelings are cut off from the conscious self and converted into more bearable physical symptoms
Treatment of dissociative disorder?
Rule out organic cause, treat any mood disorder
Therapy - identify secondary gain i.e. wanting sympathy
Difference between somatisation and dissociative disorders?
Dissociative disorders often present with actual physical signs rather than vague symptoms
What is persistent somatoform pain disorder?
Somatoform disorder where pain is the predominant symptom, cannot be attributed to a physical cause and created significant distress or impairment
Cause of somatoform pain disorder? (3)
Stress i.e. abuse
Learned theory - children ay imitate family for gain
Unconscious conflicts converted to pain to help cope
Treatment of somatoform pain disorder? (4)
Rule out organic cause
CBT
Possible pain medication
Treat concurrent anxiety or depression
What are personality disorders?
Deeply ingrained and enduring patterns of behaviour that are abnormal in a particular culture, leading to subjective stress and potentially distress of others
When do personality disorders usually start?
Childhood or adolescence
What causes personality disorders?
Genetics
Adverse intrauterine/perinatal factors causing abnormal cerebral maturation
Childhood sexual abuse
Poor parenting/adverse childhood environment
What is the cognitive theory of PDs?
People with PDs developed ways of coping with early life adversity that manifest as maladaptive traits later in life
What is the psychodynamic theory of PDs?
PDs result from insecure attachment in childhood and thus in adult relationships
General treatment of PDs? (5)
Need boundaries and consistency Housing and social help Treat other psych illness and substance misuse Short term sedatives in crisis Mood stabilisers if impulsive
What are cluster A personality disorders?
Odd/eccentric
Paranoid, schizoid, schizotypal
What are cluster B personality disorders?
Flamboyant/dramatic
Emotionally unstable, histrionic, antisocial
What are cluster C personality disorders?
Fearful/anxious
Anxious/avoidant, dependent, anankastic
Symptoms of paranoid personality disorder? (5)
Cold affect
Distrust and suspicion
Preoccupied by mistrust of friends/family
Hypersensitive to negativity and rejection
Grandiose sense of personal rights
May progress to psychosis
Symptoms of schizoid personality disorder? (6)
Social withdrawal Restricted range of emotional expression Restricted pleasure Lacking trusted friends, isolated Indifferent to praise or criticism Aloof and insensitive to cultural norms No increased risk of schizophrenia
Symptoms of schizotypal personality disorder? (6)
Pervasive social and interpersonal deficits
Ideas of reference
Magical thinking
Unusual perception - bodily illusions
Vague, circumstantial, tangential thinking
Inappropriate affect
May progress to psychosis
Symptoms of antisocial personality disorder? (6)
Disregard of rights or safety for others Gross irresponsibility Low threshold for frustration and aggression Incapacity for feeling guilt Deceitful and scapegoating Impulsive
How is antisocial personality disorder prevented and treated?
Prevention - target children with conduct disorder and educate parents
Group CBT
Symptoms of emotionally unstable personality disorder? (6)
Unstable and intense interpersonal relationships
Self damaging impulsivity - spending, sex, driving
Identity confusion, low self esteem
Chronic anhedonia
Recurrent self harm, suicidal behaviour
Effort to avoid real or imagined abandonment
Types of emotionally unstable personality disorder?
Impulsive
Borderline
Symptoms of impulsive emotionally unstable personality disorder? (5)
Act unexpectedly without consequence Conflict seeking Angry outbursts Unstable mood Difficulty maintaining actions without immediate reward
Symptoms of borderline emotionally unstable personality disorder? (5)
Uncertainty of self image or aims Unstable relationships leading to crises Effort to avoid abandonment Self harm Feeling empty Strongly linked to childhood sexual abuse
Treatment of emotionally unstable personality disorder? (3)
Dialectical behaviour therapy, CBT
Continuity of care
Treat depression or anxiety
Can predispose to bipolar
Symptoms of histrionic personality disorder? (5)
Excessive shallow emotions, shallow/labile affect
Attention seeking and suggestibility
Inappropriate sexual seductiveness with immaturity
Narcissistic, grandiose
Exploitative actions
Symptoms of anxious/avoidant personality disorder? (4)
Feelings of tension and inadequacy
Social inhibitions
Unwilling to be involved with people unless certain of being liked
Restricted lifestyle to maintain physical security
Symptoms of dependent personality disorder? (6)
Need to be taken care of, submissive
Fear of separation, needs close relationships
Low self esteem, compliant with others
Needs excessive guidance to make decisions
Needs others to assume responsibility
Unwilling to make demands or express disagreement
Symptoms of anankastic personality disorder? (6)
Excessive doubt, caution, rigidity
Preoccupied with details, lists, order
Perfectionism interfering with task completion
Excessive conscientiousness
Productivity excludes pleasure and relationships
Pedantic, adheres to social norms
Difference between anankastic personality disorder and OCD?
Can progress to OCD (or depression)
In anankastic personality disorder, obsessional thoughts or impulses are not resisted - they don’t realise it’s a problem as with OCD who know the thoughts are a product of their own mind
What is anorexia nervosa?
Morbid fear of fatness with a distorted body image, and deliberate weight loss (BMI <17.5)
Restricted eating, compulsive over exercising
When does anorexia nervosa commonly start?
Between 13-20, women
Cause of anorexia nervosa? (7)
Genetics - first degree relatives Anxious, obsessive personality Altered serotonin function Childhood abuse Overcontrolling environment Media overvaluing body image Troubled relationships
How does altered serotonin function predispose to anorexia?
Dysregulation of appetite and mood
Psychological symptoms of anorexia nervosa? (5)
Constricted affect Reduced emotional responsiveness Preoccupied by food Self conscious about eating in public Isolated
Physical symptoms of anorexia nervosa? (4)
Amenorrhoea
Loss of sexual potency in men
Constipation
Cold intolerance
Physical signs of anorexia nervosa? (8)
Emaciation Dry/yellow skin Lanugo hair Bradycardia Hypotension Russell's sign - scarring back of hand from vomiting Pitted teeth Parotid swelling
Signs from blood tests in anorexia nervosa? (4)
Anaemia
Leucopaenia
Hypokalaemia
Alkalosis
Treatment of anorexia nervosa? (3)
Family intervention 1st if teenager
If adult CBT, IPT, family therapy
NG feeding under MHA
When do you have to admit anorexics to hospital? (4)
BMI <12.5
Arrhythmia
Hypoglycaemia
Suicide risk
Complications of anorexia nervosa? (3)
Refuse treatment as they value being thin
Osteoporosis
Suicide
Prognosis of anorexia nervosa?
75% recover or improve, 20% chronic disorder, 5% die
What is bulimia nervosa?
Morbid fear of fatness, craving for food and binge eating, recurrent behaviour to prevent weight gain i.e. vomiting or laxatives
Symptoms of bulimia nervosa? (4)
Normal or excessive weight often fluctuating
Loss of control during binging
Self loathing, depression
Other impulses - self harm
Signs of bulimia nervosa? (3)
Amenorrhoea despite normal weight
Hypokalaemia
Signs of vomiting - Russell’s, pitted teeth
Management of bulimia nervosa? (3)
CBT or IPT
Fluoxetine if depression
Medically stabilise if hypokalaemia is severe
What are psychosexual disorders?
Sexual difficulties with psychological origins rather than physical origins
Types of psychosexual dysfunction in males? (2)
Erectile failure
Ejaculatory failure
Types of psychosexual dysfunction in females? (4)
Low sexual interest or pleasure
Vaginismus
Dyspareunia
Orgasmic dysfunction
Causes of psychosexual dysfunction? (8)
Stress Past sexual abuse Poor relationship with partner Physical conditions - MS, diabetes, hypothyroid Poor adjustment i.e. after mastectomy Depression or anxiety Substance misuse Medications - beta blockers, diuretics, antipsychotics, antidepressants, benzodiazepines
Management of psychosexual dysfunction? (7)
Treat underlying cause Sildenafil for erectile dysfunction Low dose antidepressants for premature ejactulation Mechanical penile pumps CBT Sex education Couples therapy
How are disorders of sexual preference classified?
Variations in the sexual object or of the sexual act
Examples of variations of the sexual object? (3)
Paedophilia
Fetishism - inanimate object
Transvetism
Examples of variations of the sexual act? (2)
Exhibitionism
Voyeurism
Management of variations of the sexual object?
Behaviour therapy
Antiandrogens for men
What is exhibitionism? What are the types?
Indecent exposure
Genital exposure accompanied by excitement and arousal
Either those of aggressive temperament where act involves masturbation or inhibited temperament where penis is flaccid
Treatment of variations of the sexual act? (3)
Psychodynamic therapy
Behavioural therapy
Hormonal treatment i.e. antiandrogens
What is disorder of sexual identity?
Belief that sex assigned inappropriately, strong wish to be of other sex - more common in men
Features of disorders of sexual identity?
Commonly disappears as get older
Do not regard themselves as homosexual
Treatment of disorders of sexual identity? (2)
Gender reassignment surgery and hormones - after 2 years living as other gender
Psychotherapy
What is Munchausen’s syndrome?
Factitious disorder - deliberately feigned symptoms, usually physical but sometimes psychiatric, results in multiple presentations and sometimes surgery
Features of Munchausen’s syndrome? (2)
Patients often use different aliases and have no fixed home
Characteristically occurs in severe PDs
Treatment of Munchausen’s syndrome? (2)
Confrontation without rejection
CBT
What is Munchausen’s by proxy?
When the parent or guardian fakes illnesses in the child or dependent - form of abuse
Possible reasons for Munchausen’s and Munchausen’s by proxy? (2)
Gain attention, sympathy, reassurance
Financial benefits
Name 5 sleep-wake disorders
Insomnia Hypersomnolence Narcolepsy Restless legs Substance use
How common is night time wakefulness in children?
20%
What causes sleep disorders?
Misalignment of the circadian rhythm system and external environment
Social/behavioural factors can perpetuate
What is primary insomnia?
Sleeplessness not attributable to medical, psychiatric or environmental cause
How is primary insomnia diagnosed? (4)
Difficulty initiating or maintaining sleep or suffering from non restorative sleep
Clinically significant distress or impairment in daily functioning
Does not occur exclusively during other illness
Not due to other conditions, or drugs
Treatment of insomnia? (6)
Possibly antihistamines Melatonin Benzodiazepines Sedating low dose antidepressant - trazodone, mirtazepine, amitriptyline CBT Relaxation therapy
What is the difference between learning disability and learning difficulty?
Learning disability - globally reduced intellect (IQ below 70) and difficulty performing everyday tasks
Learning difficulty - specific problems processing certain forms of information e.g. dyslexia, no global reduction in intellect
Types of learning disability and their IQ?
Mild 50-70
Moderate 35-49
Severe 20-34
Profound <20
What causes learning disability?
Mild - limited social/learning opportunities, genetically low IQ
Moderate/severe/profound - specific biological cause e.g. Down’s syndrome
Differences in symptoms between severity of learning disability?
Mild may live independently and have a job but not be able to cope with stress and complex social functioning
ranging to
Profound has very limited skills and language, deficits in movement and continence
Epilepsy more common the more severe the disability
Define learning disability?
Low intellectual performance, from birth or early childhood, leading to reduced life skills
Give a chromosomal, X linked, autosomal dominant and autosomal recessive cause of learning disability
Chromosomal - Down’s, Turner’s
X linked- Fragile X
AD - Neurofibromatosis
AR - metabolic disorders
Give 2 antenatal causes of learning disability?
Infection - rubella, CMV
Hypoxia
Perinatal causes of learning disability? (3)
Prematurity
Hypoxia
Intracerebral bleed
Postnatal causes of learning disability? (5)
Infection Injury Malnutrition Hormonal Epileptic
Name 5 psychiatric conditions increased in people with learning disability?
Depression Anxiety Behavioural disturbance Mania Schizophrenia
What is Down’s syndrome?
Most specific cause of learning disability, trisomy of chromosome 21
Most have moderate-severe LD
Complications of Down’s syndrome? (5)
Alzheimer's Hypothyroidism Cardiac septal defects (AVSD) Duodenal atresia Leukaemia
Physical features of Down syndrome child? (6)
Broad hands with single palmar crease Flat occiput Epicanthal folds Flat nasal bridge Small mouth High arched palate
Treatment of Down’s?
Social and family support
Capacity legislation for best interests
What is fragile x syndrome?
Most common cause of inherited learning disability, mutation of FMR1 gene on X chromosome, affects boys more severely
How is fragile x inherited?
X linked dominant
How is fragile x related to autism?
Fragile X is the most common identified cause of autism - 1/3 of fragile x have autism
Features of fragile x syndrome? (5)
Large head and ears Poor eye contact Abnormal speech Hyperesensitivity to touch, auditory, visual stimuli Head flapping, hand biting
What is autism spectrum disorder?
Developmental disorders characterised by difficulties in social interaction and communication and by restricted/repetitive thought patterns
Symptoms of autism spectrum disorder? (7)
Failure to make relationships - aloof, poor empathy Language and communication difficulties Resistance to change, ritualistic Restricted range of interests Stereotyped behaviour Hypo/hyperrreactivity Some have isolated higher skills
Treatment of autism spectrum disorder? (3)
Intensive behavioural treatments
Reward positive behaviour
Family support
What are Aspergers and autism classified as?
Pervasive developmental disorders
Features of Asperger’s? (4)
Less severe than autism
Later onset
Normal intelligence and language
Schizoid personality - pedantic, preoccupation with obscure facts
What is enuresis?
Non organic, involuntary bladder emptying after 5 years of age, during day or night
Primary or secondary (period of previous continence)
Causes of enuresis? (4)
Family history
Developmental delay
Unsettling events
Behavioural problems
Management of enuresis? (5)
Exclude physical cause e.g. UTI Address fluid intake and toilet patterns Reward systems Enuresis alarms activated by moisture Desmopressin
What is Tourette’s syndrome?
Involuntary facial or vocal tics, mostly males, can be transient or chronic
Causes of Tourette’s?
Family history of tics/OCD
Learning disability, autism, ADHD
Smoking/alcohol/cannabis during pregnancy
Possible imbalance of neurotransmitters
Name 6 types of tic
Coprolalia - swearing Copropraxia - rude signs Echolalia/echopraxia Palilalia - repeating self Self injury Non obscene socially inappropriate behaviours
Treatment of Tourette’s? (3)
Psychoeducation
Behavioural therapy - habit reversal, comprehensive behavioural intervention for tics (CBIT)
Possible antipsychotics
How is attention-deficit hyperactivity disorder diagnosed? (4)
> 6 months of short attention span
Distractibility
Overactivity
Impulsivity
What causes ADHD? (5)
Genetics Social adversity Parental alcohol abuse Diet - lead Tranquilliser exposure
What does ADHD commonly exist with? (5)
Conduct disorder Anxiety/depression Learning difficulty Antisocial behaviour Substance misuse
Treatment of ADHD? (3)
Parent education
Classroom behavioural interventions
Methylphenidate - ritalin
What is conduct disorder?
Persistent disruptive, deceptive, aggressive behaviours
5 examples of behavioural problems in conduct disorder
Disobedience Truancy Lying Arson Stealing
Causes of conduct disorder? (6)
Low socioeconomic class Learning difficulty/ADHD Familial problems such as harsh parenting Parents with alcohol dependence Depression Antisocial PD
What is socialised and unsocialised conduct disorder?
Socialised - behaviour viewed as normal among peers
Unsocialised - solitary behaviour, peer rejection
Management of conduct disorder? (3)
Parental education
Behavioural management
CBT, social skills therapy
What is separation anxiety disorder?
Anxiety disorder in which an individual expresses excessive anxiety regarding separation from home or from people to whom the individual has strong emotional attachment
When is separation anxiety most common?
6 months - 3 years
Causes of separation anxiety disorder? (4)
Parental psychiatric illness
Early/traumatic separation
Life events - parental divorce/new school/bereavement
Predisposing temperament
Management of separation anxiety disorder? (5)
Counselling CBT Family therapy Behavioural therapy SSRIs for anxiety
What are the top 4 most common illicit drugs used?
Cannabis
Cocaine
Ecstasy
Amphetamines
The 7 types of substance use disorders?
Acute intoxication Harmful use Dependence Withdrawal state Psychosis Amnesia Residual/late onset
Signs of dependence? (8)
Compulsion to take substance Aware of harm but persists Neglect of other activities Tolerance Withdrawal on stopping Increasing time taken up by substance Out of control use Persistent futile wish to stop
Causes of substance misuse? (5)
Availability Peer pressure - young men Desire for pleasurable effects Prescription drug use Psychiatric illness - impulsivity, anxiety, PD
Why do drugs give a pleasurable effect?
Activate the dopamine system in the mesolimbic reward pathway
General management of substance misuse? (6)
In community - hospital or rehab if severe Rewards e.g. for sticking to methadone CBT Motivational interviewing Self help groups Harm reduction e.g. needle exchange
Name 3 opioids
Heroin, methadone, morphine
How are opioids taken? (5)
Snorted, smoked, oral, IV, SC
Effects of opioids? (3)
Intensely pleasurable rush
Peace and detachment
CNS depression
Signs of opioid dependence? (8)
Mioisis (constricted pupils) Tremor Malaise Apathy Constipation Weakness Impotence Neglect/malnutrition
Risks of opioid use? (4)
HIV
Hepatitis B/C
Respiratory depression
Death (2-3% annually)
Why are opioids so addictive?
Tolerance and withdrawal develop quickly
Short half life of heroin so need more quickly
Management of opioid misuse? (4)
Methodone or buprenorphine for detox or maintenance
Harm reduction - needle exchange
Psychosocial support
Overdose - give naloxone
Withdrawal symptoms from opioids? (4)
Cravings
Flu like symptoms
Sweating, tachycardia
Abdo cramps, diarrhoea
Why is methadone used for opioid addiction?
Less euphoriant
Longer half life
Prevents withdrawal as prescribed at high dose
What is the active compound in cannabis?
Tetrahydrocannabinol
How is cannabis taken?
Orally, smoked
Effects of cannabis? (4)
Euphoria
Relaxation
Increased appetite
Decreased body temperature
Adverse effects of cannabis? (5)
Conjunctival irritation Decreased spermatogenesis Schizophrenia/transient psychosis Lung disease Depression, apathy
Treatment of cannabis?
Community therapy
Name 2 stimulants
Cocaine
Amphetamines
How are stimulants taken?
IV, snorted, smoked (crack cocaine)
Effects of stimulants? (5)
Brief high and euphoria Increased energy and concentration Depression and tiredness after use Possible psychosis Cocaine - hallucinations of insects, paranoia
Treatment of stimulants?
Community therapy
Name 3 hallucinogens
Ecstasy, LSD, magic mushrooms
How are hallucinogens taken?
Orally
Effects of hallucinogens?
Stimulant
Hallucogenic
Adverse effects of hallucinogens?
Ecstasy - severe dehydration or hyponatraemia from excessive water
LSD - psychosis, seizures
Effects of benzodiazepines? (3)
Dependence common
Seizures when withdrawing
Euphoria, less anxiety, relaxation
How do benzodiazepines work?
Increase GABA-inhibitory neurotransmitter
How are solvents taken and what effect does this cause?
Sniffed, red rash around mouth and nose
Effects of solvents? (4)
Initial euphoria then drowsiness
Weight loss, nausea, vomiting
Cognitive impairment and polyneuropathy
Toxic fatal effects - bronchospasm, arrhythmias
What is alcohol misuse?
Regular or binge consumption of alcohol sufficient to cause physical, neuropsychiatric or social damage
How to work out alcohol units?
Volume of drink (ml) x ABV%
/1000
Recommendations for alcohol per week?
14 units men and woman, 2 drink free days and no binges (4/5 drinks in 2 hours)
Signs of alcohol intoxication? (5)
Slurred speech Impaired coordination and judgment Labile affect Hypoglycaemia Coma
Signs of alcohol withdrawal? (6)
Malaise Nausea Autonomic hyperactivity Tremor Insomnia Hallucinations/seizures
What is delirium tremens? 4 signs
Severe life threatening alcohol withdrawal - rapid confusion, tremor, seizures, arrhythmia
Treatment of delirium tremens/acute alcohol withdrawal? (3)
Give benzodiazepines! 1st
Antipsychotics
Rehydrate, correct electrolytes, give thiamine
2 screening tests for alcohol
CAGE - tried to cut down, annoyed when asked about alcohol, guilty, eye opener
FAST - frequency of: can’t remember night before, failed to function normally, someone else being concerned
Physical signs of alcohol misuse? (3)
Jaundice
Spider naevi
Peripheral neuropathy
Causes of alcohol misuse? (7)
Genetics e.g. different metabolism Depression or other chronic illness Occupation - soldiers, doctors Culture Availability and cost Social reinforcement Environment - learning by copying
What is classical and operant conditioning?
Classical - drinking associated with pleasure, activates mesolimbic dopaminergic reward pathway
Operant - avoiding withdrawal effects
Complications of alcohol misuse? (8)
Peripheral neuropathy Erectile/ejaculatory impotence Cerebellar degeneration Dementia Liver failure Social complications - jobs, relationships Wernicke's/Korsakoff's Depression and suicide
Symptoms of alcohol related dementia?
Caused by long term use
Characterised by impaired executive function - planning, thinking, judgment
Treatment of alcohol related dementia?
Stop drinking
Replace vitamins (thiamine)
May be permanent
How to do acute detoxification of alcohol? (3)
In hospital if risk of seizures/delirium tremens
High dose of benzodiazepines then tapered
Rehydrate, give electrolytes, thiamine
Psychological treatment of alcohol dependence? (3)
Motivational interviewing
Self help groups
Individual psychotherapy
3 medications to maintain alcohol abstinence and how they work
Disulfiram - blocks alcohol metabolism causing headache, nausea if drink
Acamprosate - acts on GABA to reduce relapse and desire for alcohol
Naltrexone - opioid receptor antagonist and reduces desire for alcohol
Prevention of alcohol misuse? (3)
Increase alcohol tax
Restrict advertisement and sale
Educate in schools
Symptoms of Wernicke’s encephalopathy? (4)
Ataxia
Nystagmus
Opthalmoplegia
Acute confusion
What causes Wernicke’s encephalopathy?
Thiamine deficiency - inadequate intake, decreased absorption from GI tract, poor utilisation all due to alcohol
Thiamine deficiency causes mamillary body damage
Treatment of Wernicke’s encephalopathy?
Thiamine
What is Korsakoff’s psychosis?
Confabulation and profound short term memory loss due to long term drinking - thiamine deficiency
Treatment of Korsakoff’s psychosis?
Thiamine but unlikely to recover as damage done
3 conditions lithium is used in
Bipolar
Mania
Schizoaffective disorder
Why is lithium toxicity dangerous?
Lithium interacts with all body systems where sodium, potassium, calcium or magnesium are involved
Probably affects neurotransmitters
What is the therapeutic range of lithium?
Narrow - 0.4-1mmol/L
What monitoring needs to be done with lithium? (2)
Thyroid and renal (excreted by kidneys)
Serum lithium levels
Side effects of lithium? (6)
Nausea Fine tremor Weight gain Oedema Polydipsia and polyuria Hypothyroid
Signs of lithium toxicity? (7)
Vomiting and diarrhoea Coarse tremor Slurred speech Ataxia Drowsy/confused Seizure Coma
Treatment of lithium toxicity? (2)
Stop lithium
Iv fluids
Causes of lithium toxicity? (2)
Dehydration, diuretics
What causes serotonin syndrome?
Drugs that increase serotonin availability e.g. SSRIs, more likely 2 in combination
Symptoms of serotonin syndrome? (7)
Confusion Delirium Shivering Sweating Hypertension Seizures High temperature
Treatment of serotonin syndrome?
Discontinue medications
Benzodiazepines
Body cooling
Serotonin antagonist - cyproheptadine
What is neuroleptic malignant syndrome?
Potentially fatal complication of antipsychotics (usually typical) due to blockage of dopamine receptors
Symptoms of neuroleptic malignant syndrome? (5)
Hyperpyrexia Autonomic instability Confusion Hypertonia Raised creatinine phosphatse
Treatment of NMS? (5)
Stop antipsychotic Body cooling - dontrolene Hydrate Benzodiazepines Bromocriptine - dopamine agonist
What is acute dystonic reaction?
Side effects of antipsychotics (usually typical) - is a movement disorder syndrome in which sustained or repetitive muscle contractions result in twisting movements, fixed postures
Name 4 acute dystonic reactions
Torticollis
Oculogyric crisis
Increased muscle tone
Tardive dyskinesia
What is torticollis?
Head rotates to one side, back, to chest
What is an oculogyric crisis?
Extreme sustained upward deviation of eyes, often with backward neck flexion and jaw clenching
What is tardive dyskinesia?
Grimacing, sticking out tongue, smacking lips
Treatment of acute dystonic reactions? (4)
Rehabilitation
Anticholinergics
Anti Parkinsons meds - ropinirole, bromocriptine
Diazepam
What is paraphilia?
Paraphilic disorders are recurrent, intense, sexually arousing fantasies, urges, or behaviors that are distressing or disabling and that involve inanimate objects, children or nonconsenting adults, or suffering or humiliation of oneself or the partner with the potential to cause harm
