Psychiatry Flashcards
What is meant by the Bio-Psycho-Social model?
Biological - what is the underlying medical issue?
Psychological - is any extra support needed?
Social - Living situation? Financial issues?
What is the Crisis Resolution and Home Treatment Team (CRHTT)?
A team consisting of a psychiatrist, junior doctor, registered mental health nurse, HCA and OT who can see a patient 2-3 times per day and assess mental state and need for admission, give medication etc.
You can discharge people from hospitals with the follow up of the CRHTT
What are section 135 and 136 orders?
The police have the right to take you to a place of safety for assessment by a mental health team - a section 136 allows the police to do this if you are outside your home, while a section 135 is more complicated, but basically allows them to do it when you’re inside your home
What is the Early Intervention Service (EIS)?
A community service with an MDT (similar to CRHTT) who help young people (<35y/o) with their first episode of psychosis
How is the Community Mental Health Team (CMHT) different to the CRHTT?
They look after patients in the long term
What is IAPT?
Improving Access to Psychological Therapies - GP surgeries can refer you for therapies such as CBT or counselling under IAPT. You can also self-refer but the waiting list is often very long
What is the MMSE from start to finish?
30-point test - 1 point for each correct answer: ORIENTATION - Year - Season - Month - Date - Time - Country - Town - District - Hospital - Ward/Floor
REGISTRATION:
Name 3 objects and ask the patient to repeat them (out of 3 marks).
ATTENTION and CALCULATION:
Ask the patient to subtract 7 from 100, then repeat from result (100, 93, 86, 79, 72) - do this 5 times.
Alternative - Spell ‘WORLD’ backwards.
RECALL:
Ask for the names of the 3 objects mentioned earlier (out of 3 marks).
LANGUAGE:
Name two objects (out of 2 marks)
Repeat the sentence ‘no ifs, ands, or buts’ (/1)
Give a 3 stage command (place right index finger on nose and then left ear) (/3)
Ask patient to read and obey a written command (‘close your eyes’) (/1)
Ask patient to write a sentence - score 1 mark if it is sensible and has a subject and a verb (/1)
COPYING:
Ask the patient to copy and image of a pair of intersecting pentagons (/1)
MMSE Scoring:
24-30 No cognitive impairment
18-23 Mild cognitive impairment
0-17 Severe cognitive impairment
What is the AMTS from start to finish?
10 point test:
- Age?
- Time (nearest hour)?
3a. Give an address to recall at the end. - Year?
- Name of location?
- Identification of 2 persons (e.g. doctor, nurse).
- DOB?
- Year of the First World War?
- Name of the present monarch?
- Count back from 20 to 1.
3b. Recall address.
A score of 6 or less suggests delirium or dementia - further tests are necessary to confirm.
What are the ICD-10 and DSM-IV?
Useful literature for mental health diseases - ICD-10 chapter 5 gives all mental health diseases and DSM-IV is all about mental health diseases.
What is the order of the diagnostic hierarchy of mental health?
Organic (head injury, drugs etc.) Psychosis Affective (mood) Neurosis (anxiety) Personality No mental illness
Psychosis:
Definition
Key symptoms (3)
Causes
Definition: Loss of connection with reality
Key Symptoms:
Hallucinations - no external stimulus but you have a perception of any modality
Illusions - external stimulus misinterpreted (e.g. thinking a shadow is a person)
Delusions - false unshakeable beliefs (can be negative/nihilistic in context of depression, or grandiose in context of mania)
Causes:
Organic (drug-induced, delirium, dementia)
Schizophrenia
Delusional disorders
Affective disorders (depressive psychosis or manic psychosis)
In what circumstances do we need to follow the Deprivation of Liberty Safeguards?
DoLS are used when patients who need admission but have no capacity are accepting of that admission - they are series of safeguards which tell hospitals and care homes the process they must follow to ensure that their actions are in the patient’s best interests and they’re kept safe
For how long can someone be admitted under a section 135?
Up to 72 hours for MHA assessment
For how long can someone be admitted under a section 136?
Up to 24 hours for MHA assessment
Which 5 parties should be present in order for an MHA assessment to be performed?
Patient
AMHP
Medical recommendation 1 (S12 approved doctor)
Medical recommendation 2 (any fully registered practitioner - preferably patient’s GP)
Nearest relative (should be consulted, and for a section 3 they must agree)
Who has the final decision on sectioning a patient?
The AMHP
What are the 3 criteria for detention under the MHA?
Person is suffering from a mental disorder
AND
It is of a nature or degree to warrant detention in hospital for assessment or assessment followed by treatment
AND
Person ought to be detained in the interests of their own health or safety or with a view to the protection of others
What are the types of section?
Civil (all unrestricted) - Section 2 or 3
Section 5(2) or 5(4)
Section 117 or 17
CTO
Criminal, unrestricted - Section 37
Criminal, restricted - Section 37/41 or Section 47/49
Section 2:
What power does it provide?
What can it be used for? (3)
What are the legal rights related to it? (2)
Which section can be used to provide leave from the ward?
Power: To detain and treat a person in hospital for up to 28 days.
Uses:
Admit a patient from the community
Prevent a voluntary patient from leaving hospital
Following short-term section (135(1), 136, 5(2), 4)
Legal rights:
Patient can appeal to MH review tribunal
Right to independent mental health advocate
Section 17 can provide leave from the ward.
Section 3:
How long does it last?
What conditions are required to detain someone under section 3? (2)
Lasts 6 months
Must show that treatment cannot be provided unless the patient is detained
Must be able to provide the appropriate medical treatment
Section 5(2):
Who can detain people under section 5(2)? (2)
How long does it last?
What is its purpose?
Who? Consultant psychiatrist or nominated deputy.
How long? 72 hours
Purpose: Detain a patient receiving care for a physical condition on a general ward to be assessed for a mental disorder.
NOTE 1: It cannot be used to authorise treatment (only authorises assessment).
NOTE 2: Cannot be used in A&E or outpatients.
What are the sections in a Mental State Examination (MSE)?
Appearance/Behaviour Speech Mood Thought Perception Cognition Insight
What is meant by each of the following: Pressure of speech Poverty of speech Thought block Circumstantial speech Flight of ideas Derailment Perseveration
Pressure of speech - speaking quickly
Poverty of speech - speaking slowly with little content
Thought block - sudden halt in speech with loss of content
Circumstantial speech - going on a massive tangent
Flight of ideas - sudden changes in thoughts
Derailment (aka loosening of associations or knight’s more thinking) - no obvious link between thoughts
Perseveration - answers to questions are repeated inappropriately
List the types of delusions (10)
Grandiose - exaggerated beliefs of being special or important
Persecutory (paranoid) - beliefs that others are trying to persecute or cause harm
Nihilistic - beliefs regarding the absence of something vitally important (e.g. patient is dead or their organs are rotting)
Delusions of reference - beliefs that ordinary objects, events or other peoples’ actions have a special meaning or significance to the patient
Delusions of control - beliefs that outside forces may control the patient in some way
Passivity - belief that the movement, sensation, emotion or impulse are controlled by an outside force (e.g. someone has a remote control for the patient’s actions)
Delusions of thought interference - occur against the patient’s will and feel like an invasion of privacy (these include thought withdrawal, thought insertion and thought broadcasting)
Amorous (erotomatic) - belief that someone is in love with the patient (more common in women)
Delusions of guilt - belief of having committed an awful sin or crime
Hypochondriacal - belief that the patient has an illness
What are overvalued ideas?
Reasonable ideas pursued beyond the bounds of reason e.g. thinking that the neighbours’ front garden is unsightly due to the gnomes, and then quitting work and taking the neighbour to court to destroy the gnomes with a hammer
What condition are thought echo and running commentary associated with?
Schizophrenia
Thought echo is a hallucination where the patient’s thoughts are heard aloud
Running commentary is a hallucination where there is a running commentary of the patient’s actions
What is the difference between depersonalisation and derealisation?
Depersonalisation = person feeling detached/numb Derealisation = world feeling false (like a film set)
What is the Holmes-Rate Social Readjustment Scale?
A scale that ranks difficult life events (death of a spouse is hardest etc.). Says that the more stressful life events someone has been though, the more likely they are to develop depression.
What are the 3 corners of Beck’s Cognitive Triad?
- Negative views about the world
- Negative views about the future
- Negative views about oneself
This model is the basis of CBT.
What do psychoanalytical theories of depression say?
Early experience, particularly the quality of early relationships, determines the risk of later depression
Explain the monoamine hypothesis of depression.
Suggests that depression results from a deficiency in brain monoamine neurotransmitters:
Noradrenaline (affects mood and energy)
Serotonin (affects sleep, appetite, memory and mood)
Dopamine (affects psychomotor activity)
How might endocrine abnormalities (in theory) cause depression?
Cortisol elevation during stressful life events can damage the hippocampus
What are the 4 subtypes of depression?
Seasonal affective disorder - low mood in winter, overeating, oversleeping
Atypical depression - no seasonal variation but shows reversed biological symptoms (overeating/oversleeping) and may retain mood reactivity
Agitated depression - depression with psychomotor agitation (instead of retardation) such as restlessness and pacing
Depressive stupor - when psychomotor retardation is so profound that the person grinds to a halt, they become mute and stop eating, drinking or moving
In CBT, patients are taught to challenge their negative automatic thoughts (NATs) - which 2 common thinking errors are they taught about?
Generalisation - ‘I always mess everything up’
Minimisation - ‘I only passed the exam by chance. I’m not good enough’
What is transference?
Seen in psychodynamic psychotherapy, it is where the feelings a person has about their past relationships are unconsciously redirected or transferred onto the therapist - e.g. ‘They will reject me’
What are the 4 key themes explored in interpersonal therapy?
Unresolved loss
Psychosocial transitions
Relationship conflict
Social skills deficit
How long should pharmacological treatment continue in a patient with depression?
Until 6 months after the patient is no longer depressed, in order to prevent relapse
Name 6 SSRIs, and list the side-effects of SSRIs.
Fluoxetine, sertraline, paroxetine, fluvoxamine, citalopram, escitalopram
Nausea/Vomiting, appetite/weight change, blurred vision, anxiety/agitation, insomnia/tremor/dizziness, headache, sweating
Name 2 SNRIs, and list the side-effects of SNRIs.
Venlafaxine, duloxetine
Constipation, hypertension and hypercholesterolaemia
+
The side-effects of SSRIs (Nausea/Vomiting, appetite/weight change, blurred vision, anxiety/agitation, insomnia/tremor/dizziness, headache, sweating)
Name 5 TCAs, and list the side-effects of TCAs.
Amitriptyline, clomipramine, imipramine, lofepramine, dosulepin
Tachycardia, arrhythmias, dry mouth, blurred vision, constipation, urinary retention, postural hypotension, sedation, nausea, weight gain
Antidepressants of different classes can have dangerous interactions, so always check carefully before changing. Some can be cross-tapered but others need a drug-free wash out period. Giving multiple antidepressants can lead to serotonin syndrome - what is serotonin syndrome?
Accumulation of excess serotonin leading to agitation, sweating, myoclonus, confusion and seizures. It can be life-threatening.
How do we define treatment resistance in the use of antidepressant drugs?
Failure to respond to 2 adequate trials of different classes of antidepressants at adequate doses and for a period of 6-8 weeks.
What drugs can be given as ‘augmentation strategies’ alongside antidepressants?
Lithium
Thyroxine
Buspirone (anxiolytic that has no antidepressant effect alone but has a synergistic effect with SSRIs)
Name 2 non-drug options for the treatment of depression (therapies such as CBT not included).
Electroconvulsive therapy (ECT) - electrodes used to produce generalised tonic-clonic seizures whilst the patient is anaesthetised. Some patients have a degree of memory loss afterwards.
Light therapy - can be used in seasonal affective disorder (compensates for fewer hours of daylight in winter).
What is the prognosis for depression?
50% will have at least one more episode
Episodes last on average 8-9 months (reduced to 2-3 months with treatment)
Psychotic depression has a poorer prognosis but a better response to ECT
What is the difference between mania and hypomania?
To diagnose a manic episode, symptoms should last at least 1 week and prevent work and ordinary social activities - less severe symptoms which don’t entirely disrupt a patient’s ability to function are termed hypomania (hypomanic periods can lead to high productivity).
What are the core symptoms of mania?
Mood, energy and enjoyment are elevated (raised mood can range from uncontrollable excitement to irritability/aggression)
NOTE: Mood can be labile.
What are the cognitive symptoms of mania? (5)
Inflated self-esteem
Hopefulness (world seems full of opportunity)
Racing thoughts
Poor concentration (although patient may feel they are thinking more clearly than ever)
Flight of ideas (topics changing rapidly)
What are the biological symptoms of mania? (3)
Reduced sleep
Voracious appetites for food and sex
Reckless/Disinhibited behaviour (risky sexual behaviour, drugs/alcohol, driving recklessly, gambling/spending excessively)
What are the psychotic symptoms of mania? (3)
Grandiose delusions
Persecutory delusions
Auditory hallucinations
Complete the following:
A diagnosis of bipolar affective disorder (BPAD) can be made when…
…a patient has suffered a manic episode and any other affective episode (depressed, hypomanic, mixed).
What are the 3 subtypes of bipolar affective disorder (BPAD)?
Type 1 - manic episodes interspersed with depressive episodes
Type 2 - mainly recurrent depressive episodes, with less prominent hypomanic episodes
Rapid Cycling BPAD - four or more affective episodes in a year, more common in women, may respond better to sodium valproate
What is cyclothymia?
Persistent mood instability with many episodes of mild low mood and mild elation - none of them are severe or prolonged enough to meet criteria for mild depression or hypomania.
What are the 3 main mood stabilisers used in mania/BPAD? What other drugs can be used?
Lithium
Sodium valproate
Carbamazepine
Other drugs:
Antipsychotics (usually atypical e.g. olanzapine, risperidone, quetiapine due to fewer side-effects)
Anticonvulsants e.g. lamotrigine (good for prophylaxis in BPAD Type 2
What is the therapeutic range for lithium? At what point does it become toxic?
Therapeutic range = 0.6-1.0mmol/L
Becomes toxic from 1.2mmol/L
Because of this, lithium levels should be checked 1 week after starting or changing dose and monitored weekly until a steady therapeutic level is achieved. They should be monitored every 3 months from then on.
Other than lithium levels, what should be monitored in patients taking lithium?
U&Es and TFTs (every 3-6 months) as lithium can cause renal impairment and hypothyroidism.
Give the symptoms (7), triggers (3) and management (2) of lithium toxicity.
Symptoms: GI disturbance, sluggishness, giddiness, ataxia, gross tremor, fits, renal failure
Triggers: Salt balance changes (e.g. dehydration, D&V), drugs interfering with lithium (e.g. diuretics), accidental or deliberate overdose
Management: Stop lithium, transfer for medical care (rehydration, osmotic diuresis)
Which drug is used to treat acute mania?
Valproate (given as sodium valproate due to reduced side-effects)
Also used for prophylaxis in BPAD
Which drug is 2nd line for BPAD prophylaxis?
Carbamazepine - anticonvulsant, induces liver enzymes, close monitoring required due to toxicity, check drug interactions before prescribing
What are the risks of using mood stabilisers in pregnancy?
They are teratogenic so risk of harm should be weighed against risk of manic relapse.
Lithium - Ebstein’s anomaly
Volproate and carbamazepine - Spina bifida
NOTE: Women of childbearing age should be given contraceptive advice and prescribed folate supplements if using valproate.
What is the management of acute mania?
Stop all medications that may be responsible (e.g. antidepressants)
Monitor food and fluid intake to prevent dehydration
If treatment free:
Give an antipsychotic or mood stabiliser (a short course of benzodiazepines is often added for sedation because sleep deprivation can exacerbate mania)
If already on treatment:
Optimise medication
Check compliance
Adjust doses
Consider addition of antipsychotic or mood stabiliser, and benzodaizepines
ECT can be used if patients are unresponsive to medication
What is the prognosis for bipolar affective disorder?
15% of people with BPAD will commit suicide, but lithium reduces this to same as the general population
Give 4 social causes of suicide.
Life events and stress Social class (I and V are more likely to commit suicide) Social isolation (more common if isolated, divorced, widowed, single, unemployed or living alone) Occupation (higher rates in v its, pharmacists, dentists, farmers and doctors)
What percentage of people who commit suicide have previously self-harmed?
Up to 60%
What percentage of people who commit suicide are depressed?
Up to 80%
What percentage of people who commit suicide have a personality disorder?
Up to 50%
Name a charity for the family of suicide victims.
Survivors of bereavement by suicide (SOBS)
List 4 suicide prevention strategies.
Limiting pack sizes of paracetamol
Installing barriers at suicide hotspots
Providing free telephone services (e.g. Samaritans)
Catalytic converters on cars
Which age group is self-harm most common in?
Children and adolescents
What is the management of self-harm?
Physical treatment (of overdoses, lacerations or burns) Risk assessment (thoughts of repeating, thoughts of hurting others, thoughts of being hurt by others etc.)
NOTE: If the patient is insistent on leaving you must assess their capacity
Immediate interventions:
Admission to psychiatric ward (if high risk and lacking capacity)
Possible to manage at home (depending on circumstance)
Make a plan to deal with future suicidal ideation or thoughts of self-harm (e.g. who can they tell/how can they get help?)
Follow-up interventions:
Follow-up within 1 week of self-harm or discharge
Could be done by community mental health team, outpatient clinic, GP or counsellor
Treat underlying conditions e.g. depression
Offer psychological therapies (CBT, mentalisation-based treatment, transference-focussed therapy)
What percentage of suicides occur within 3 months of discharge from psychiatric wards?
30%
What is the lifetime risk of developing schizophrenia?
1% (which increases to 10% in people with a first degree relative with schizophrenia)
Which obstetric complications increase the likelihood of the child going on to develop schizophrenia? (5)
Maternal prenatal malnutrition Viral infections Pre-eclampsia Low birth weight Emergency C-section
NOTE: May reflect underlying genetic abnormalities or may be linked to hypoxic brain damage.
Which drugs can lead to psychotic symptoms, predisposing to schizophrenia? (4)
Cannabis (especially skunk)
Amphetamines
Cocaine
LSD
Which genetic mutation causes highest risk of developing schizophrenia in cannabis users?
Val-Val mutation in the COMT gene.
Which ethnicity is schizophrenia most common in?
Afro-Caribbean
Premorbid schizoid personality precedes schizophrenia in what percentage of cases?
25%
What theories exist to explain schizophrenia?
Neurodevelopmental - initial brain abnormalities (genetic or due to early brain damage), or maturation of the brain may lead to functional/connectivity abnormalities
Neurotransmitter - Dopamine hypothesis (schizophrenia is a result of dopamine overactivity in certain brain area) - positive symptoms (hallucinations/delusions) are caused by excess dopamine in mesolimbic tracts while negative symptoms (apathy/social withdrawal) are caused by dopamine deficiency in the mesocortiyal tracts
- -> Evidence for this theory is 2 fold:
1. Antipsychotics are dopamine antagonists, and work better against positive symptoms
2. Dopaminergic agents (amphetamine, cocaine, L-dopa) can induce psychosis
Psychological - subtle defects in thinking (e.g. jumping to conclusions) predisposes to delusions
What are the 3 clinical stages of schizophrenia? (No need for details)
Prodrome (At-Risk Mental State (ARM))
Acute phase
Chronic phase
Give details of the prodrome phase of schizophrenia.
Patients are usually late teens to early 20s
Low-grade symptoms such as social withdrawal, loss of interest in work/relationships, but NO frank psychotic symptoms
Give symptoms of the acute phase of schizophrenia, giving details on the various types of each symptom. (3)
Delusions - Types are delusional perception (a real perception is interrupted in a delusional way) and passivity (belief that the movement, sensation, emotion or impulse is controlled by an outside form)
Hallucinations - Types of auditory hallucination include voices arguing about the patient, voices giving a commentary on the patient’s actions and thought echo (voice says the patient’s thought aloud)
Thought interference - Types are thought withdrawal (thoughts removed from patient’s mind), insertion (placed into patient’s mind) and broadcasting (being broadcast to others so everyone knows what they’re thinking
Formal thought disorder - when thoughts are disconnected (loosening of associations) which produces disjointed speech (word salad is when words are so disconnected that sentences make no sense)
Give the symptoms of the chronic phase of schizophrenia. (5)
Apathy Blunted affect Anhedonia Social withdrawal Poverty of thought/speech
List the subtypes of schizophrenia. (5)
Paranoid (most common, mainly positive symptoms)
Catatonic (psychomotor disturbance)
Hebephrenic (15-25y/o, disorganised and chaotic mood/behaviour/speech, shallow affect, child-like behaviour)
Simple (negative features only)
Residual (prominent negative symptoms remain after positive symptoms subside)
What are the symptoms of catatonic schizophrenia (catatonia)? (7)
Stupor (immobile, mute and unresponsive (but appearing conscious))
Excitement - periods of extreme and apparently purposeless motor hyperactivity
Posturing - assuming and maintaining inappropriate and bizarre positions
Rigidity - holding a rigid posture against efforts to be moved
Waxy flexibility - patient’s limbs offer minimal resistance to being placed in odd positions which are maintained for long periods (cataplexy)
Automatic obedience - to any instructions
Perseveration - inappropriate repetition of words or movements
What are Schneider’s first-rank symptoms of schizophrenia? (4)
Delusional perception
Passivity
Delusions of thought interference
Auditory hallucinations
What is meant by mood disorder?
Severe depression or mania leading to psychotic symptoms.
What is meant by schizoaffective disorder?
Schizophrenic and affective symptoms develop together and are roughly evenly balanced.
What is meant by persistent delusional disorder?
Delusions with few or no hallucinations.
What is meant by schizotypal disorder?
Lifelong state of eccentricity with abnormal thoughts and affect which is regarded as a personality disorder - patients may be suspicious, cold or aloof with odd ideas without showing definite symptoms of schizophrenia.
What is the early intervention service (in the context of schizophrenia/psychosis)?
A service which aims to engage patients with very early symptoms - it offers antipsychotics and psychosocial interventions with the aim of keeping duration of untreated psychosis under 3 months.
Typical antipsychotics - examples (3), mechanism of action and side-effects.
Chlorpromazine
Haloperidol
Flupentixol decanoate
They are dopamine antagonists (mostly blocking the D2 receptor).
They can all cause extrapyramidal side-effects (dystonia, akathisia, Parkinsonism, tardive dyskinesia) at normal doses.
NOTE: See Laz’s schizophrenia notes for more side-effects (there are loads).
Atypical antipsychotics - examples (6), mechanism of action and side-effects.
Olanzapine Risperidone Quetiapine Aripiprazole Clozapine Amisulpride
They are dopamine antagonists and serotonin 5-HT2 receptor blockers.
Can cause extra-pyramidal side-effects (dystonia, akathisia, Parkinsonism, tardive dyskinesia) at high doses.
NOTE: See Laz’s schizophrenia notes for more side-effects (there are loads).
What is neuroleptic malignant syndrome (NMS)? What are its symptoms/signs? How is it treated?
A rare but life-threatening side-effect of antipsychotics, usually triggered by a new treatment or increase of dose.
Muscle stiffness
Altered consciousness
Disturbance of autonomic function (fever, tachycardia and labile BP)
Raised CK and WCC
Stop antipsychotics immediately
Urgent medical treatment (ITU)
NOTE: Death may occur due to several causes e.g. rhabdomyolysis leading to renal failure.
What drug is first-line for treatment-resistant (refractory) schizophrenia?
NOTE: Treatment resistance = failure to respond to 2 or more antipsychotics, at least one of which is atypical, each given at a therapeutic dose for at least 6 weeks.
Clozapine
Warning - small risk of agranulocytosis (0.7%) - requires weekly blood tests to detect early signs of neutropenia.
Which psychological therapies should be considered in schizophrenics? (3)
CBT (all patients)
Family therapy
Concordance therapy (collaborative approach where patient is encouraged to consider pros and cons of the management)
The dopaminergic pathway of the brain starts in the ____ ____ area and projects to the ____ ____ (role in motivation/planning) and the ____ ____.
- Ventral tegmental
- Prefrontal cortex
- Limbic system
What are the features of dependency (in the context of substance abuse)? (8)
Tolerance Compulsion Withdrawal Problems controlling use Continued use despite harm Salience (primacy) - obtaining the substance becomes so important that other interests are neglected Reinstatement after abstinence Narrowing of the repertoire - loss of variation in the use of the substance
List some symptoms of alcohol withdrawal.
Headache Nausea and vomiting Tremor Sweating Insomnia Anxiety/Agitation Tachycardia Delirium tremens
What is delirium tremens? What are its symptoms? How is it managed? What is the prognosis?
Severe alcohol withdrawal occurring around 48 hours into abstinence and usually lasting 3-4 days.
Symptoms:
Confusion
Hallucinations (especially visual e.g. formication)
Affective changes (fear or hilarity)
Gross motor symptoms (e.g. hand tremor)
Autonomic disturbance (sweating, tachycardia, hypertension, fever)
Delusions
Management:
Reducing benzodiazepine (chlordiazepoxide) regime and parenteral thiamine (pabrinex)
Manage potentially fatal dehydration and electrolyte abnormalities
Prognosis = 5% mortality.
What is Wernicke-Korsakoff Syndrome?
Combination of Wernicke’s Encephalopathy and Korsakoff Psychosis seen in alcohol abuse.
Wernicke’s:
Caused by acute thiamine deficiency
Triad of confusion, ataxia and ophthalmoplegia
Medical emergency
Korsakoff:
Irreversible anterograde amnesia
Patient can register new events but cannot recall them within a few minutes
Patients may confabulate to fill gaps in their memory
What investigations should you order in cases of alcohol misuse? (2) What might they show?
FBC - microcytic anaemia due to B12 deficiency
LFTs - GGT rises with recent heavy alcohol use, transaminitis indicates hepatocellular damage
What are the stages of the Change Model for alcohol misuse? (6)
Pre-contemplation Contemplation Preparation Action Maintenance Relapse
What is the purpose of giving benzodiazepines (e.g. chlordiazepoxide) in alcohol detox?
They replace alcohol and prevent any withdrawal symptoms, and can be gradually withdrawn and stopped.
What do we give as prophylaxis against Wernicke’s Encephalopathy?
Thaimine (vitamin B1) IV or IM.
Acamprosate and disulfiram can be used to treat alcoholism - what do they do?
Acamprosate = anti-craving
Disulfiram (antabuse) = mimics flush reaction to alcohol thereby making alcohol consumption unpleasant
Which drugs can be detected in a urine drug screen (UDS)? (5) For what duration of time after consumption is each of the drugs detectable in the urine?
Amphetamine - 2 days Heroin - 2 days Cocaine - 5-7 days Methadone - 7 days Cannabis - up to 1 month
What are the colloquial terms for smoking heroin (which people do before their tolerance has built-up) and for SC injections of heroin (which is often done once venous access becomes difficult)?
Smoking = Chasing
SC injection = Skin popping
What are the local (4) and systemic (4) complications of IV drug use?
Local: Abscess, cellulitis, DVT, emboli
Systemic: Septicaemia, infective endocarditis, blood-borne infections, increased risk of overdose
What is the antidote for heroin?
Naloxone
NOTE: After giving naloxone, patients may enter withdrawal.
How long after injection does heroin withdrawal typically start?
Starts 6 hours after injection and peaks at 36-48 hours.
What are ‘the runs’? They are associated with overdose of which drug?
Diarrhoea, vomiting, lacrimation and rhinorrhoea
Heroin
Substitute prescribing of which drugs can be used to help patients with heroin addiction?
Methadone (liquid) - this is a full agonist of opiate receptors.
Buprenorphine (sublingual tablet) - this is a partial agonist of opiate receptors.
Which drug can be used to prevent relapse of heroin use after detox? How does it work?
Naltrexone - it’s an opiate antagonist which blocks the euphoric effects of opiates.
What is the psychoactive compound in cannabis?
delta-9-tetrahydrocannabinol (THC) - acts on cannabinoid receptors in the brain.
Stimulants potentiate the effects of neurotransmitters, increasing energy, alertness and euphoria, and decreases need for sleep. They increase confidence and impulsivity.
What are their side-effects? (6)
Which drugs can be used in the short-term to help with withdrawal anxiety?
Arrhythmias, hypertension, stroke, anxiety, panic and drug-induced psychosis.
Benzodiazepines.
What is the colloquial term for the use of crack cocaine and heroin together?
Speedballing.
What is Khat?
A mild stimulate that comes in chewable leaves that can cause florid psychosis.
What is the mechanism of action of ecstasy?
Causes serotonin re-uptake inhibition and release.
