Psychiatry Flashcards
What is mental health?
State of well-being in which the individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community
What are the 6 primary emotions?
Happiness Disgust Anger Sadness Surprise Fear
What is the definition of anxiety?
State of apprehension, uncertainty or fear, resulting from the anticipation of a realistic or imaginary threatening event or situation
May have emotional, behavioural, cognitive and physical components
Describe how the HPA axis leads to the release of glucocorticoids
Stress can directly trigger or ciracdian rhythms controlled by suprachiasmatic nucleus of the hypothalamus cause release of corticotropic releasing hormone
This leads to the release of adrenocorticotropic hormone from the anterior pituitary
This triggers the adrenal cortex to release glucocorticoids
What roles do glucocorticoids play a part in, in the body?
Cognition/mood Metabolism Growth & reproduction Clock resetting Sleep/wake cycle Cardio Immune and inflammation
What is the fight or flight response in physiological terms?
Physiological response to a stressor
Mediated through hypothalamus and locus coeruleus (pons, releases noradrenaline)
Initial activation of the sympathetic nervous system
Subsequent activation of the pituitary adrenal axis
Terminated by negative feedback and parasympathetic system
What is an alert state?
Heightened sense of vigilance to possible threats
Less intense levels of inhibition, physical distress and behavioural impairment
What structures and neurotransmitters are involved in an alert state?
GABA mechanism
Limbic structures: hippocampus/amygdala
What is the difference between anxiety as a normal response and abnormal anxiety?
Some amount of anxiety is “normal” and is associated with optimal levels of functioning
Only when anxiety begins to interfere with social or occupational functioning is it considered abnormal
What is the Yerkes-Dodson law? What relationship does this share with glucocorticoid levels?
Relationship between arousal and performance
Performance increases with physiological or mental arousal but only up to a point
When arousal levels are too high, performance decreases
Normal distribution bell shaped curve
Memory performance vs circulating levels of glucocorticoids manifests as a similar curve: LTP is optimal when glucocorticoid levels are mildly elevated whereas significant decreases in LTP are observed after adrenalectomy or exogenous glucocorticoid administration
What are glucocorticoids? Where are they made?
Synthesised in zona fasciculata of adrenal cortex
Cortisol: regulates metabolism of glucose, especially in times of stress
Describe the characteristics of pathological anxiety
Intensity: Relatively high and/or out of proportion to the situation or circumstances
Duration: Generally longer lasting or recurrent
Preoccupation with anxiety: Yes
Distressing, overwhelming, incapacitating
Causes long-standing changes in behaviour, impairs functioning
What is health?
State of complete physical, mental and social well-being and not merely the absence of disease or infirmity
Describe the characteristics of normal anxiety
Relatively low and/or proportionate to the situation or circumstances
Generally shorter lasting
No preoccupation with anxiety
Unpleasant, but not too distressing or not distressing for a long time
Generally does not affect behaviour more than temporarily
Does not impair functioning
What is the lifetime risk of having a mental disorder? Which is the most prevalent?
46.4%
Anxiety disorder
What percentage overlap is there between depressive and anxiety disorders?
59%
When are specific phobias most likely to develop?
Childhood
When are social anxiety disorders most likely to develop?
Adolescence
When are panic disorders most likely to develop?
Early adulthood through to mid to late adulthood
When is agoraphobia most likely to develop?
Adolescence through to early adulthood
When is generalised anxiety disorder most likely to develop?
Any time from adolescence through to old age
What are the domains of anxiety?
Physical
Affective
Cognitive
Behavioural
Name some physical symptoms of anxiety
Anorexia Butterflies in stomach Chest pain/tightness Diaphoresis: sweating Dry mouth Faintness Flushing Hyperventilation Light-headedness Muscle tension Nausea Pallor Palpitations Paresthesias Sexual dysfunction Headache Shortness of breath Stomach pain Tachycardia Tremulousness Urinary frequency Vomiting Increased Arousal
What are affective symptoms of anxiety?
Ranges from edginess and unease to terror and panic
What are cognitive symptoms of anxiety?
Worry
Apprehension
Thoughts concerned with emotional or bodily danger
What are behavioural symptoms of anxiety?
Anxiety triggers many different responses concerned with diminishing or avoiding the distress
What is stress?
Experiencing events that are perceived as endangering one’s physical or psychological well-being. The events are known as stressors and the result is the stress response
What factors influence our response to stressors?
Controllability, predictability and challenge to our limits
What is the Holmes life stress scale?
Series of events which are given values - life change units
The more of these a patient has experienced, the more likely they are to become ill
Name some different psychological responses to stress
Anxiety
Anger and aggression
Apathy and depression
Cognitive impairment
Which acute psychological tasks are the most stressful?
Motivated performance with social evaluative threat and uncontrollability
What are the different classifications of anxiety disorders according to the ICD-10?
Phobic Anxiety Disorders: Agoraphobia without panic disorders, Agoraphobia with panic disorder, Social phobias, Specific phobias
Other Anxiety Disorders: Panic disorder (episodic paroxysmal anxiety), Generalized anxiety disorder, Mixed anxiety and depressive disorder
Obsessive-Compulsive Disorder
Reaction to Severe Stress and Adjustment Disorders: Acute stress reaction, Post Traumatic stress disorder, Adjustment disorders
What is generalised anxiety disorder?
Characterised by at least 6 months of persistent and excessive anxiety, worry, fear, dread, uneasiness which is difficult to control
Symptoms: restlessness, tiredness, irritability, muscle tension, lack of concentration, sleeplessness, SOB, tachycardia, sweating, dizziness
What is a specific phobia?
Clinically significant anxiety provoked by exposure to a specific feared object or situation, often leading to avoidant behaviour
What is social phobia?
Clinically significant anxiety provoked by exposure to certain types of social or performance situations, often leading to avoidant behaviours
What is separation anxiety disorder?
Excessive anxiety concerning separation from the home or from those to whom the person is attached (must begin before 18 years old)
What is obsessive compulsive disorder?
Characterised by obsessions (which cause marked anxiety or distress) and/or by compulsions (which serve to neutralise anxiety) severe enough to be time consuming or cause marked
distress or impairment
What is panic disorder with or without agoraphobia?
Recurrent unexpected panic attacks about which there is persistent concern
What is post traumatic stress disorder?
Re-experiencing of an extremely traumatic event accompanied by symptoms of increased arousal and by avoidance of stimuli associated with the trauma
What are the sections that you would include in a psychiatric history?
PC / HPC Past psychiatric history Past medical history Family Hx Personal Hx: Pregnancy / Birth / Early Development, Schooling / Education, Employment, Relationships Substance Misuse Forensic History Pre morbid personality
What headings would you use to take a generic anxiety history?
S ymptoms of Anxiety E pisodic or Continuous D epression / Drink / Drugs A voidance & Escape T iming + Triggers E ffect on Life
What drug abuse is commonly present in anxiety to help to avoid the feelings of anxiety?
Alcohol: social phobia / PTSD
Benzos / sleeping pills: panic disorder / agoraphobia
Cannabis
NB: caffeine / smoking may be making anxiety worse
What are the categories of the mental state examination?
Appearance and behaviour
Speech: Rate, volume, tone
Mood: Subj, Obj
Affect
Thoughts: Content & Form: Abnormal experiences and beliefs, Delusions & ideas of reference, Passivity phenomena (Inc. thought insertion, broadcast & withdrawal), Symptoms of severe anxiety, esp. obsessions & compulsions, suicidal thoughts, intentions and plans Perceptions: Hallucinations (modality, person, content), Illusions, Derealisation, Depersonalisation
Cognitive Functions: Attention and Concentration, Orientation (T, P and P)
Memory: Immediate, Short-term, Long Term
Insight: Recognise nature and severity of condition, Willingness to accept appropriate help
What is agoraphobia? What behaviours might a patient present with?
Includes various phobias embracing fears of leaving home: fears of entering shops, crowds, and public places, or of traveling alone in trains, buses, underground or planes
Lack of an immediately available exit is one of the key features of many agoraphobic situations
Avoidance behaviour causes sometimes that the sufferer becomes completely housebound
Most sufferers are women. Onset - early adult life
Lifetime prevalence 5-7%
High co-morbidity with panic disorder; depressive and obsessional symptoms and social phobias may be also present
What is panic disorder? What behavioural symptoms might the patient present with?
Recurrent attacks of severe anxiety (panic attacks) which are not restricted to any particular situation or set of circumstances
Typical symptoms are palpitations, chest pain, choking sensations, dizziness, and feelings of unreality (depersonalisation or derealisation)
Individual attacks usually last for minutes only. The frequency of attacks varies substantially
Frequent and predictable panic attacks produce fear of being
alone or going into public places
Course of panic disorder is long-lasting and is complicated with various comorbidities, in half of the cases with agoraphobia
Estimation of lifetime prevalence is between 1-3%
What are the criteria for diagnosis of panic disorder?
Panic attacks not in background of another disorder
Several severe autonomic attacks in last month
No objective danger, not only in specific circumstances, relatively free from anxiety between attacks
What is social phobia? What symptoms might the patient present with?
Fear of scrutiny by other people in comparatively small groups leading to avoidance of social situations
Fears may be: discrete - restricted to eating in public, to be introduced to other people, to public speaking, encounters with the opposite sex or diffuse - social situations outside the family circle
Direct eye-to-eye confrontation may be stressful
Low self-esteem and fear of criticism
Symptoms may progress to panic attacks
Avoidance - almost complete social isolation
Usually start in childhood or adolescence
Estimation of lifetime prevalence between 10-13 % equally common in both sexes
Secondary alcoholism
What are features of specific phobias?
Restricted to highly specific situations
Persistent irrational fear of object
Contact with this causes immediate anxiety response
Avoidance of object
Fear/avoidance/distress can interfere with individual’s life
Fear is recognised as being irrational/excessive
Start in childhood/early adulthood
Give examples of some specific phobias
Fear of proximity to particular animals / insects: spiders (arachnophobia), insects (entomophobia), snakes (ophidiophobia)
Fears of specific situations: heights (acrophobia), thunder (keraunophobia), darkness (nyctophobia), closed spaces (claustrophobia)
Fears of diseases, injuries or medical examinations: visiting a dentist, sight of blood (hemophobia) or injury (pain - odynophobia), fear of exposure to venereal diseases (syphilidophobia) or AIDS-phobia
What is generalised anxiety disorder? What symptoms will patient present with?
Anxiety lasting more than 6 months, which is generalised and persistent but not restricted to, or even strongly predominating in, any particular environmental circumstances
Symptoms: continuous feelings of nervousness, trembling,
muscular tension, sweating, lightheadedness, palpitations,
dizziness, and epigastric discomfort
Fears that patient or a relative will shortly become ill or have an accident are often expressed, together with a variety of other worries and forebodings
Lifetime prevalence between 4-6 %
More common in women, often related to chronic environmental stress
Fluctuating chronic course connected with symptoms of frustration, sadness and complicated with abuse of alcohol and other illicit drugs
What factors are required for a diagnosis of generalised anxiety disorder to be made?
Primary symptom of anxiety (most days, for weeks/months)
To include apprehension, motor tension, autonomic over-activity
What are the 3 most common presenting symptoms of patients with generalised anxiety disorder?
Somatic illness
Pain
Sleep disturbance
Which disorders are commonly co-morbid with generalised anxiety disorder?
Depression, social anxiety disorder, panic disorder
What are obsessional thoughts?
Ideas, images or impulses that enter the individual’s mind again and again in a stereotyped form
Recognised as individual’s own thoughts, even though they are involuntary and often repugnant
Common obsessions include fears of contamination, of harming other persons or sinning against God
What are compulsions?
Repetitive, purposeful, and intentional behaviours or mental acts performed in response to obsessions or according to certain rule that must be applied rigidly
Compulsions are meant to neutralise or reduce discomfort or to prevent a dreaded event or situation
What is obsessive compulsive disorder commonly co-morbid with?
Depression (about 80%)- suicidal thoughts
Obsessive-compulsory symptoms may appear in early stages of schizophrenia
What features are required for a diagnosis of OCD?
Obsessional thoughts +/- Compulsive acts
Most days for 2 weeks
Be distressing/interfere with activities
What are the 3 major elements to post traumatic stress disorder?
Re-experiencing trauma through dreams or recurrent and
intrusive thoughts (flashbacks)
Showing emotional numbing such as feeling detached from others
Having symptoms of autonomic hyperarousal such as irritability
and exaggerated startle response, insomnia
Which disorders are commonly co-morbid with post traumatic stress disorder?
Commonly there is fear and avoidance of cues that remind the sufferer of the original trauma
Anxiety and depression are commonly associated with the above symptoms. Excessive use of alcohol and drugs may be a complicating factor
What is the usual latency of onset for post traumatic stress disorder after this initial traumatic event?
The onset follows the trauma with a latency period, which may range from several weeks to months, but rarely more than half a year
What features are required for diagnosis of post traumatic stress disorder?
Within 6 months (usually)
Traumatic, exceptional event-Symbolic
Repetitive intrusive recollections, flashbacks
Re-enactment of events in memory/imagery/dreams
What additional symptoms may be present in post traumatic stress disorder?
Emotional numbing
Autonomic symptoms: hyper-arousal, hypervigilance (startle reaction), insomnia
Anxiety & depression: suicidal ideation
Cues lead to increased arousal, so avoidance of such cues
What is an acute stress reaction and what might the symptoms be?
Transient disorder of significant severity, which develops in an individual without any previous mental disorder in response to
exceptional physical and/or psychological stress
Not all people exposed to the same stressful event develop the
disorder
Symptoms: initial state of daze, with some constriction of the field of consciousness and narrowing of attention, inability to comprehend stimuli, and disorientation. This state may be followed either by further withdrawal from surrounding situation (extreme variant - dissociative stupor), or by agitation and overactivity
Autonomic signs: tachycardia, sweating or flushing, as well as
other anxiety or depressive symptoms
Symptoms usually appear within minutes of the impact of the stressful event, and disappear within several hours, maximally 2-3 days
What is adjustment disorder? What might the symptoms be?
States of subjective distress and emotional disturbance arising in the period of adaptation to a significant life change or to the consequences of a stressful life event, such as serious physical illness, bereavement or separation, migration or refugee status
Symptoms: depressed mood, anxiety, worry, feeling of inability to cope, plan ahead, or continue in the present situation, and some degree of disability in the performance of daily routine
Onset: within 1 month; duration - below 6 months
> 6 months but > 2 years: Prolonged Depressive Reaction
More frequently women, unmarried and young persons
What is the first line treatment for adjustment disorder?
Psychotherapy is the first line treatment of this disorder
Symptomatic treatment may comprise short trial of hypnotics or benzodiazepines
What is mixed anxiety and depressive disorder?
Symptoms of both anxiety and depression are present, but neither of symptoms, considered separately, is sufficiently severe to justify a diagnosis of depressive episode or specific anxiety disorder
Some autonomic symptoms, tremor, palpitations, dry mouth, stomach churning, must be present
Individuals with this mixture of comparatively mild symptoms are frequently seen in primary care
What are dissociative/conversion disorders?
Partial or complete loss of normal integration between memories of the past, awareness of identity and immediate sensations, and control of bodily movements
Normally a considerable degree of conscious control over the memories and sensations that can be selected for immediate attention, and the movements that are to be carried out
What is dissociative amnesia?
Main feature is loss of memory, usually of important recent event, which is not due to organic mental disorder and is too extensive to be explained by ordinary forgetfulness or fatigue
Amnesia is usually centered on traumatic events, such as accidents, combat experiences, or unexpected bereavements, and used to be partial and selective
Typically develops suddenly and can last from minutes to days
What is dissociative stupor?
Diminution or absence of voluntary movement and normal responsiveness to external stimuli such as light, noise, and touch
Person lies or sits largely motionless for long periods of time
Speech and spontaneous and purposeful movement are completely absent
Muscle tone, posture, breathing, and sometimes eye-opening and coordinated eye movements are such that it is clear that the individual is neither asleep nor unconscious
Positive evidence of psychogenic causation in the form of either recent stressful events or prominent interpersonal or social problems
What are trance and possession disorders?
Temporary loss of both the sense of personal identity and full awareness of the surroundings
Individual can act as if taken over by another personality, spirit, deity, or force
Repeated sets of extraordinary movements, postures, and utterances can be observed
What are dissociative disorders of movement or sensation?
Loss of or interference with movements or loss of sensations (usually cutaneous). Mild and transient varieties of these disorders are often seen in adolescence, particularly in girls, but the chronic varieties are usually found in young adults
What is Ganser’s syndrome?
Mental illness where a person deliberately and consciously acts as if they have a physical or mental illness when they are not really sick
What is multiple personality disorder?
Dissociative Identity Disorder
Apparent existence of two or more distinct personalities within an individual, with only one of them being evident at a time (Jekyl and Hyde)
Each personality is complete, with its own memories, behaviours, and preferences, but neither has access to the memories of the other and the two are almost always unaware of each other’s existence. Change from one personality to another is in the first instance usually sudden and closely associated with traumatic events
What factors are required for the diagnosis of a somatization disorder?
At least 2 years of multiple and variable physical symptoms for which no adequate physical explanation has been found
Persistent refusal to accept the advice or reassurance of several doctors that there is no physical explanation for the symptoms
Some degree of impairment of social and family functioning attributable to the nature of symptoms and resulting behavior
What medical conditions might be confused with somatoform disorder, especially early in their course?
Multiple sclerosis, brain tumour, hyperparathyroidism, hyperthyroidism, lupus erythematosus
What is hypochondriacal disorder?
Persistent preoccupation and a fear of developing or having one or more serious and progressive physical disorders
Persistently complain of physical problems or are persistently preoccupied with their physical appearance
Fear is based on the misinterpretation of physical signs and sensations
Physician physical examination does not reveal any physical disorder, but the fear and convictions persist despite the reassurance
What are the diagnostic criteria for hypochondriacal disorder?
Persistent belief in the presence of at least one serious physical illness underlying the presenting symptom or symptoms, even thought repeated investigations and examinations have not identified any adequate physical explanation, or a persistent preoccupation with presumed deformity or disfigurement
Persistent refusal to accept the advice and reassurance of several different doctors that there is no physical illness or abnormity underlying the symptoms
What is Persistent Somatoform Pain Disorder?
Predominant symptom is a persistent severe and distressing pain that cannot be explained fully by a physiological process of physical illness
Pain occurs in association with emotional conflicts or psychosocial problems
The expression of chronic pain may vary with different personalities and cultures
The patient is not malingering and the complaints about the intensity of the pain are to be believed
Which physical illnesses may mimic anxiety disorder?
Phaeochromocytoma Hyperthyroidism Hypoglycaemia Temporal lobe epilepsy Alcohol Paroxysmal arrhythmias
Name some options for the treatment of anxiety disorders
Psychotherapeutic techniques: CBT, Behavioural Therapy, Psychodynamic approaches, Relaxation Exercises
Pharmacotherapy: benzos, Buspirone, Beta-blockers, Antihistaminics, Calcium Channel Modulators : Pregabalin, TCAs: Clomipramine, SSRIs : Escitalopram, Citalopram, Fluoxetine, Fluvoxamine, Paroxetine, Sertraline, MAOIs: Tranylcypromine, Moclobemide and SNRIs: venlafaxine
What non pharmacological approaches are available to treat anxiety disorders?
Provision of information about Anxiety Disorders
Relaxation Exercises to reduce excessive arousal
Cognitive techniques to teach strategies for managing difficult situations & stop anxiety from spiralling out of control
Behavioural techniques such as building up the level of activity & other strategies to improve self-confidence
What are the aims of self monitoring in CBT for anxiety?
Objective observation of anxious responses and triggering environmental cues
Determination of characteristic cognitive, somatic,affective and behavioural reactions involved in the anxious response
Discovering what patients think affects how they feel and how they feel affects what they think
Identification of external environment and perceptions of threat
How is relaxation training used in CBT for anxiety?
Creation of a relaxed lifestyle
Methods of coping with anxiety at any time it appears: diaphragmatic breathing, progressive muscular relaxation, meditation
How is cognitive therapy used in CBT for anxiety?
Identifying how the patient is thinking and the beliefs about self, world and future that underlie those thoughts
Generating alternative, more accurate interpretations , predictions
and ways of believing
Using these new perspectives whenever anxiety and worry are detected
How is rehearsal of new skills used in CBT for anxiety?
Frequent practice of new , more adaptive actions
Rehearsal of new coping skills
Which neurotransmitters are involved in mood and behaviour? And which specific aspects are they involved in?
Dopamine: motivation, pleasure, reward
Noradrenaline: alertness, energy
Serotonin: obsession, compulsion
What are first line treatments for anxiety disorders?
SSRI
Potentially plus a benzo short term
How is antidepressant use different for anxiety to depression?
Half the starting dose of depression
Slow titration as anxiety disorder patients are more prone to side effects
Could be initial worsening of anxiety
Watch out for akathisia, agitation and suicidal ideation in the first few days/ weeks (commoner in younger patients
What are some side effects of SSRIs?
Headache Anxiety Transient nausea Vomiting Diarrhea Weight gain Sexual dysfunction
Name 3 SNRIs and give what they might be specifically used for
Venlafaxine: pain related conditions
Duloxetine: stress incontinence
Mirtazapine: sedative - sleep problems
What is a known major side effect of lithium?
Development of diabetes insipidus
What harms to others can alcohol cause?
Injury: assault, car crash, accident
Neglect or abuse: person in drinkers care
Default on social role: as family member, friend, worker
Property damage: clothing, car, building
Toxic effects: foetal alcohol syndrome, pre term birth complications
Loss of amenity and peace of mind: children, friends, coworkers, kept awake or frightened
What top 3 diseases or injuries have the highest proportion of deaths attributable to alcohol?
Cardiovascular disease
Unintentional injuries
Gastrointestinal diseases
What age group have the highest rate of alcohol related hospital admissions?
45-54
What are the new guidelines on alcohol use?
Should not drink > 14 units per week and these should be spread evenly
Single drinking episode: limit total amount, drink slowly, avoid risky places
Pregnant women: no alcohol
What proportion of U.K. Cancer deaths are attributed to alcohol?
6%
What is the new guidance for childhood drinking?
Alcohol free childhood is best
Shouldn’t drink until age 15 and never more than once per week, supervised
How many units in a bottle of wine?
9
How many units in a large glass of wine?
3
How many units in a pint of standard lager?
2
How many units in a pint of premium lager?
3
How many units in an alcopop?
2
How do you calculate units?
Strength x volume / 1000
What pledges have been made by the alcohol industry to public health?
Restriction on advertising
Responsible sales
Drink aware site
Alcohol labelling
What are the legal driving limits for alcohol?
35 micrograms of alcohol per 100 ml breath
80mg in 100ml blood
107 mg in 100ml urine
What symptoms might a person taking heroin describe/experience?
Euphoric rush
Sedation
Reduction in pain, fear, tension and anxiety
How many bags/grams a day might a moderate/heavy user of heroin have?
3-4 bags a day, at 0.1-0.2 gram per bag
What different ways of taking heroin are there?
Smoking - brown heroin, high oil content runs on foil
Injecting - China white
What is methadone? How is it taken?
Substitute opiate Full mew agonist Taken orally once a day Start at 30ml Daily supervised for 3-6 months Increase to 80-120ml Regular mouth swab/urine to check compliance
What is buprenorphine and how is it taken?
Subutex - taken sublingually Partial mew agonist Safer in overdose More expensive Doses of 8-12mg per day
How much cocaine is in a wrap? And how much does this cost?
1g, £40
How can cocaine be taken?
Snorting - absorbed through mucous membrane of the nose
Injecting - mix powder with water and use a syringe to inject IV
How long do the effects of cocaine last? What are they?
Onset 1 min
Lasts 30-40 mins
Euphoria, stimulant
How is crack cocaine sold?
As rocks - £10, £20
Why can’t cocaine be smoked?
Cocaine hydrochloride
Heat sensitive
Cannot be smoked as it destabilises when burned
How is crack cocaine different to cocaine?
Base form, hydrochloride molecule removed
Can be smoked
How long do the effects of crack cocaine last?
Onset 5 secs
Lasts 5-10 mins
Intense craving
How long does ecstasy/MDMA take to have an effect?
30-45 mins
Peak at 60-90mins
Last for 2-4 hours followed by gradual comedown
What effects does ecstasy have?
Rushes of exhilaration
Nausea and disorientation
Panic
Stomach churning
How much does ecstasy cost?
Each pill £3-5
What is crystal meth?
Methamphetamine
Made from phosphorus, pseudoephedrine and blue iodine
How is crystal meth used?
Smoked in glass pipes
How much does crystal meth cost?
Half a gram is £25
How long do the effects of crystal meth last?
4-12 hours
What is the ICD 10 criteria for a diagnosis of dependence?
3 or more of the following present together at some point during the previous year:
Strong desire or sense of compulsion to take the substance
Difficulties in controlling substance taking behaviour in terms of its onset, termination or levels of use
A physiological withdrawal state
Evidence of tolerance
Progressive neglect of alternative pleasure or interests
Increased amount of time necessary to obtain or take the substance or recover from its effects
Persisting with substance abuse despite clear evidence of overtly harmful consequences
Which pathways are involved in controlling reward or positive feelings?
Mesolimbic and mesocortical dopamine pathways
What are common side effects of codeine and heroin?
Nausea and vomiting
Constipation
Sedation
What are common side effects of MDMA/ecstasy?
Anxiety, psychosis, increased BP and other homeostatic changes (temp, osmotic)
Which receptor does MDMA act on?
5-HT, increases release
What receptor does ketamine/PCP act on?
Glutamate receptor agonist
What are common side effects of ketamine?
Nausea and vomiting, hallucinations, Confusion/psychosis
What receptor does alcohol have an effect on?
Potassium channel, increases open time
What are common side effects of alcohol?
Drowsiness/dizziness, memory loss, loss of coordination
What receptors does cocaine act on?
Inhibitor of monoamine reuptake: dopamine, NA, 5HT
Binds to some of the 5HT receptors altering ion channel activity
What are some common side effects of cocaine?
Anxiety, psychosis, increased BP/HR
What receptor does Valium act on?
GABA receptor Co-agonist
What are some common side effects of Valium?
Sedation, memory loss, decreased coordination
What receptor does cannabis act on?
Cannabinoid receptor agonist
What are some common side effects of cannabis?
Slowing of thought processes and memory loss, psychosis with long-term use
What receptor does Dramamine act on?
Ach receptor antagonist
What is Dramamine?
Treat nausea vomiting and dizziness caused by motion sickness
What are common side effects of Dramamine?
Hot, Dry mouth/skin, Dilated pupils, Confusion/psychosis
What are the 4 dopaminergic pathways of the brain?
Nigrostriatal: projections from substantia nigra pars compacta
(midbrain) release dopamine in striatum (caudate and putamen)
Mesocortical: projections from ventral tegmental area (midbrain) release dopamine in frontal cortex, particularly pre-frontal cortex, to modulate reward, motivation and attention
Mesolimbic: projections from ventral tegmental area (midbrain)
release dopamine in limbic system structures and are involved in cognition, learning and memory
Tuberoinfundibular: connects hypothalamus to median eminence,
dopamine release from these cells control prolactin secretion from pituitary
Where does deep brain stimulation affect?
Striatum
What is the key nucleus involved in reward pathways?
Nucleus accumbens in basal forebrain (part of ventral striatum)
Describe the development of addictive behaviours
Intoxication leads to activation of reward pathways (via nucleus accumbens/ventral striatum) which provide positive reinforcement for behaviour
Activation of reward pathways increases activity in cognitive and emotional circuits of forebrain ‘pleasure centres’, which then
activates binge/intoxication circuitry (striatum and thalamus) leading to repetition of behaviour that causes high feeling, ie drug taking
Once positive effects of drugs have occurred there is a rapid drop in mood and descent into negative effects, even though plasma concentration may be relatively high still
During these negative effects, amygdala and associated areas and ventral striatum are strongest, creating increasingly negative moods and behaviours. This subsides and returns towards control levels as plasma levels of drugs decrease
As this activity decreases, associational areas are activated, those that remember that bad feeling could be reversed by taking of drug. This triggers activation of drug-seeking/craving behaviours, which link memory and anticipation of positive effects of drugs, so mainly hippocampus and prefrontal cortex are activated
This cycle is followed by drug-taking and intoxication and the cycle repeats again
What factors slow absorption of alcohol?
Higher concentrations of alcohol slow peristalsis
Food, especially fatty food and carbs
How does alcohol cause a CNS depressant effect?
Enhances GABA activity and reduces higher levels of activity via inhibition of glutamatergic NMDA receptors and voltage dependent calcium channels
Which areas of the brain are particularly sensitive to alcohol?
Cerebellum: comparatively more cells in this region so effects seem stronger. Control and fine tuning of movement and gait are amongst first to be affected
Frontal lobes are comparatively sensitive to alcohol explaining changes on cognitive function and bladder control (frontal micturition centre)
What can happen with chronic alcohol use in pregnancy?
Spontaneous miscarriage and amenorrhoea
When is damage from drinking in pregnancy most likely to occur? And what can happen as a result?
First three months resulting in foetal alcohol syndrome
What are features of foetal alcohol syndrome?
Growth and cognitive retardation
Children: irritability, slow development and hyperactivity
Teens/adulthood: learning difficulties, poor impulse control and coordination
Heart defects
Characteristic facial features: thin upper lip, flat midface, short nose, short palpebral fissures, epicanthal folds, low nasal bridge, indistinct philltrum, micrognathia (Mandibular hypoplasia)
What drugs can be used to treat alcohol withdrawal?
Long lasting benzodiazepines reduce withdrawal symptoms: chlordiazepoxide
Recovery is dependent on use of reducing regimens
Patients with agitation/hallucinations or DTs can be given haloperidol as an adjunct but are not used alone as they may reduce seizure threshold and have no effect on withdrawal
What drugs can be used to prevent relapse from alcohol withdrawal?
Acamprosate: GABA and glutamate
Naltrexone: opioid antagonist
What receptors does nicotine act on? And what does this lead to?
Cholinergic nicotinic receptors (nAChR)
Not selective on brain nicotinic receptors also autonomic ganglia
Stimulant and relaxant, parasympathomimetic
Release of acetylcholine, noradrenaline and adrenaline (via the ANS) associated with stimulant effects of smoking
Endorphins, dopamine and serotonin accounting for the positive mood effects and addictive quality of substance
What do smoking cessation services offer?
Combination counselling and pharmacological interventions to increase adherence to cessation
Pharmacological: nicotine replacement therapy (patches/ inhalation/ spray/ lozenge), bupropion (atypical antidepressant), varenicline (partial agonist at nicotine receptor)
What needs careful monitoring in patients taking varenicline for smoking cessation?
Suicidal thoughts
What drugs are licensed for use in opioid addiction?
Methadone (agonist at mew opioid receptor)
Buprenorphine (mixed agonist/antagonist: partial agonist at mew receptor, antagonist/partial agonist at the kappa receptor)
What drugs can be used as adjuncts in opioid withdrawal to reduce symptoms?
Loperamide – control of diarrhoea
Paracetamol and NSAIDs - pain and headaches (including muscular pain)
Metoclopramide – Nausea and vomiting
Where do amphetamines act?
VMAT: vesicular monoamine transporter (which carries monoamines into vesicles for release)
Amphetamine is incorporated into vesicles and displaces monoamine, which then gets dumped into cleft when channels open
Amphetamines also reverse MAT, to a certain extent, further increasing concentration of monoamines within the synaptic cleft
What are the 2 groups of tranquillisers?
Major: antipsychotics (non-addictive)
Minor: relaxants (muscle and neuro), which are addictive
What are the most common group of minor tranquillisers?
Benzodiazepines
What is the mechanism of action of benzodiazepines?
Co-agonist on GABAA receptor and bind to the gamma-subunit
to increase chloride ion movement into cell causing hyperpolarisation of the cell, reducing likelihood of firing
What can be effects of withdrawal of long term benzodiazepine treatment?
Rebound seizure, hallucinations, anxiety and panic
What is an issue with using flumazenil as part of the coma cocktail to reverse the effects of benzos?
Predisposes susceptible patients to seizure onset
Where are Cannabinoid receptors located?
CB1 in brain
CB2 in periphery (associated with immune responses)
CB2 brain (microglia)
Hypothalamus in regions associated with feeding
Mesocortical/limbic via this route to activate the reward pathways
Hippocampus, activation of which result in memory and spatial distortion, which also impairs movement through alteration of body-image, spatial perception
Vas deferens, which may explain some of positive effects of marijuana intake on sexual function
Which are the psychotomimetic drugs?
Drugs acting on 5HT: LSD, mescaline and MDMA
Drugs acting on glutamate receptors (NMDA): ketamine and PCP
What enzyme breaks down ecstasy?
CYP2D6
What is frequent use of ketamine associated with?
Depression and bladder dysfunction (dysuria)
What proportion of the population consume hazardous amounts of alcohol?
24%
What screening questionnaires can be used to detect hazardous drinkers?
AUDIT: alcohol use disorder identification test
FAST: fast alcohol screening test
AUDIT C: audit alcohol consumption questions
M-SASQ: modified single alcohol screening questionnaire
Who are the targets for brief interventions on alcohol advice?
Hazardous drinkers, including regular excessive drinkers and ‘binge drinkers’
Harmful drinkers, including regular excessive drinkers and ‘binge drinkers’
Not ‘severely dependent drinkers’
What is a level 1 brief intervention on alcohol advice?
Some assessment of alcohol use (units??)
Feedback on screening assessment explain why the individual is deemed to be drinking hazardously or harmfully, how do they compare to the general population?
Some clear advice on how to cut down or stop drinking
What is motivational interviewing with regards alcohol advice?
Client-centred, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence Express empathy Develop discrepancy Avoid argumentation Roll with resistance Support self-efficacy
What does achieving long term sobriety usually involve?
Less harmful, substitute dependency
New relationships
Sources of inspiration and hope
Alcoholics Anonymous
What is there reduction goal in a patient who is harmful drinking or mild dependence, without significant comorbidity, and if there is adequate social support?
Consider a moderate level of drinking as the goal of treatment
unless the service user prefers abstinence or there are other reasons for advising abstinence
What is disulfiram?
Antabuse
Prevents the breakdown of alcohol by acetaldehyde
dehydrogenase
Causing headache, flushing, palpitations, nausea and vomiting
What is Acamprosate?
An analogue of GABA
Anti-craving medication
Benefits in highly motivated patients also engaged in psychological treatments
What role does naltrexone have in alcohol abuse?
Orally active opiate receptor antagonist
Thought to reduce the pleasurable effects of drinking
What is nalmefene?
Opioid system modulator
Diminishes reinforcing effects of alcohol, helping the patient to reduce drinking possibly by modulating cortico-mesolimbic functions
What is pabrinex?
Vitamin c, b1, b2, b3 and b6 injection
What symptoms might a person taking heroin describe/experience?
Euphoric rush
Sedation
Reduction in pain, fear, tension and anxiety
How many bags/grams a day might a moderate/heavy user of heroin have?
3-4 bags a day, at 0.1-0.2 gram per bag
What different ways of taking heroin are there?
Smoking - brown heroin, high oil content runs on foil
Injecting - China white
What is methadone? How is it taken?
Substitute opiate Full mew agonist Taken orally once a day Start at 30ml Daily supervised for 3-6 months Increase to 80-120ml Regular mouth swab/urine to check compliance
What is buprenorphine and how is it taken?
Subutex - taken sublingually Partial mew agonist Safer in overdose More expensive Doses of 8-12mg per day
How much cocaine is in a wrap? And how much does this cost?
1g, £40
How can cocaine be taken?
Snorting - absorbed through mucous membrane of the nose
Injecting - mix powder with water and use a syringe to inject IV
How long do the effects of cocaine last? What are they?
Onset 1 min
Lasts 30-40 mins
Euphoria, stimulant
How is crack cocaine sold?
As rocks - £10, £20
Why can’t cocaine be smoked?
Cocaine hydrochloride
Heat sensitive
Cannot be smoked as it destabilises when burned
How is crack cocaine different to cocaine?
Base form, hydrochloride molecule removed
Can be smoked
How long do the effects of crack cocaine last?
Onset 5 secs
Lasts 5-10 mins
Intense craving
How long does ecstasy/MDMA take to have an effect?
30-45 mins
Peak at 60-90mins
Last for 2-4 hours followed by gradual comedown
What effects does ecstasy have?
Rushes of exhilaration
Nausea and disorientation
Panic
Stomach churning
How much does ecstasy cost?
Each pill £3-5
What is crystal meth?
Methamphetamine
Made from phosphorus, pseudoephedrine and blue iodine
How is crystal meth used?
Smoked in glass pipes
How much does crystal meth cost?
Half a gram is £25
How long do the effects of crystal meth last?
4-12 hours
What is the active ingredient of cannabis?
THC
How much does cannabis cost?
Weed £20 1/8th ounce
Hash £10 1/8th ounce
What symptoms does cannabis cause?
THC: Anxiety, psychotic like symptoms
CDB: sedative, anxiolytic, antipsychotic
What legal high active ingredients are there?
Phenethylamines
Tryptamines
Janet presents to the ED after taking an impulsive overdose of 15 paracetamol with a bottle of vodka. This is her 6th admission for similar issues. She is review by the psych doctor on call who finds that she had taken them after a row with her boyfriend. She was the victim of childhood abuse. She has multiple intensive relationships but they do not seem to last. She describes herself as empty inside and has felt this way for many months. What is the most likely diagnosis?
Emotionally unstable personality disorder - borderline type
What are characteristics of histrionic personality disorder?
Shallow and labile affectivity Self dramatisation Theatricality Egocentricity Continual seeking of appreciation, excitement and attention
What signs and symptoms would a patient have who has taken an overdose of TCAs?
Tachycardia Tachypnoea Urinary retention Dilated pupils Pyrexia Hyperreflexia Hypotension
What are some psychological problems associated with alcohol misuse?
Depression Anxiety Memory problems Delirium tremens Attempted suicide Pathological jealously
What are some social problems associated with alcohol misuse?
Domestic violence Marital and sexual difficulties Child abuse Employment problems Financial difficulties Accidents Delinquency and crime Homelessness
What are some complications of delirium tremens?
Dehydration
Infection
Hepatic disease
Wernicke Korsakoff’s syndrome
What is the management for delirium tremens?
Correct electrolyte abnormalities and dehydration
Parenteral thiamine
Prophylactic phenytoin or carbamazepine if hx of withdrawal seizures
Diazepam or chlordiazepoxide
What drugs can be used to prevent alcohol dependence?
Naltrexone: reduce relapse into heavy drinking
Acamprosate: reduce drinking frequency
Disulfiram: unpleasant acetaldehyde intoxication with alcohol, histamine release
What symptoms occur 12-16 hours after last dose of opiate in someone in withdrawal?
Yawning Rhinorrhoea Lacrimation Pupil dilatation Sweating Piloerection Restlessness
What symptoms occur 24-72 hours after last dose of opiate in someone in withdrawal?
Muscular twitches Aches and pains Abdominal cramps Vomiting Diarrhoea HTN Insomnia Anorexia Agitation Profuse sweating
What are the key diagnostic factors for GAD?
Require 3/6 Restless/nervous Easily fatigued Poor concentration Irritability Muscle tension Sleep disturbance
What would be on your differential list for anxiety disorders?
Depressive illness OCD Presenile dementia Alcohol dependence Drug dependence Benzo withdrawal Hyperthyroidism Hypoglycaemia Phaechromocytoma
What are risk factors for the development of GAD?
FHx of anxiety Physical or emotional stress Hx physical or emotional trauma Other anxiety disorder Female gender
What are obsessional thoughts?
Unpleasant or distressing thoughts, ideas or images that are unwanted. Individual recognises the thoughts as their own
What are symptoms of depression?
Low mood Loss of interest and enjoyment Fatigue Early morning waking Loss of appetite and weight loss Social withdrawal Loss of libido Constipation Diurnal variation Poor concentration and memory Worthlessness and hopelessness Guilt Self harm and suicide Psychomotor retardation
How is depression classified?
Mild, moderate, severe Unipolar, bipolar Postnatal Seasonal affective disorder Mixed anxiety depressive disorder Adjustment disorder
Which symptoms of depression are characteristic of bipolar depression?
Early morning waking
Diurnal variation
Cognitive difficulty
Psychomotor retardation
Which long term health conditions often cause patients to also have depression?
MI Coronary artery disease Parkinson's MS Stroke Cancer Diabetes
What are the models of causes of depression?
Neurotransmitters Genetics Stress Cognitive psychology Social causation
What sleep disturbances can occur in depression?
Increased sleep latency Reduced sleep time Increased fragmentation Deceased REM latency Increased REM in first half of night Decreased slow wave sleep
What are some side effects of antidepressant medications?
Insomnia Sedation Headache Tremor Dry mouth Sweating Nausea Diarrhoea Constipation
What are possible psychotherapies for major depressive disorder?
CBT
Interpersonal therapy
Behavioural activation
What are the activities performed in CBT?
Recognise negative cognitions
Respond to negative thoughts and behaviours
Problem solve and test assumptions
What are the 4 forms of neurostimulation?
Electroconvulsive therapy
Repetitive transcranial magnetic stimulation
Vagus nerve stimulation
Deep brain stimulation
What are possible complimentary and alternative medicine treatments for depression?
Physical: light therapy, sleep deprivation, exercise, yoga, acupuncture
Nutraceuticals: omega 3, DHEA, tryptophan, SAM-e
Herbal remedies: St. John’s wort
According to the ICD10, what features must be present for a diagnosis of dependence?
3 or more of following have been present together at some time during previous year:
Strong desire or sense of compulsion to take substance
Difficulties in controlling substance taking behaviour in terms of its onset, termination or levels of use
Physiological withdrawal state
Evidence of tolerance
Progressive neglect of alternative pleasure or interests
Increased amount of time necessary to obtain or take substance or recover from its effects
Persisting with substance abuse despite clear evidence of overtly harmful consequences
