Psychiatry Flashcards
Substance abuse psychiatry: Diclemente’s stages of change
Pre-contemplation (not ready) Contemplation (greeting ready) Preparation (ready) Action Maintenance Termination (no temptation and won't return to previous habit)
Define intoxication
Transient state of emotional and behavioural change following drug use
Define harmful use
Pattern likely to cause physical or psychological damage
Define dependency
Bio-psycho-social symptoms in which the use of substance takes on a much higher priority than other behaviours that once had greater value
Define withdrawal
Transient state occurring while readjusting to lower levels of drug in the body
Epidemiology of addictive behaviour
Young males are the heaviest drinkers
M:F 2:1 for alcohol
M:F 4:1 for drugs
Aetiology of dependence
Condition:
Classical (pavlovian) conditioning
Operant conditioning
Social learning theory
Features of dependence
Tolerance:
Larger dose required to gain the same effect as previously
Compulsion:
Strong desire to use the substance e.g. crabbing
Problems controlling use:
Difficulties controlling starting, stopping or amounts used
Continued despite harm:
Physical, financial, relationships, mental health
Salience (primacy):
Obtaining and using substance becomes so important that other interests are neglected
Reinstatement after abstinence:
Tendency to return to the previous pattern and level of use after a period of abstinence
Narrowing of repertoire:
Loss of variation in use of substance
Features of withdrawal
Physical symptoms:
Shivering, joint aches, stomach cramps, sweating - last ~2 weeks
Emotional symptoms:
Anxiety, low mood, craving, irritability - persist >1yr - trigger for relapse
Early stages:
Reward, +ve reinforcement, “impulse control disorder”
Late stages:
Anti-reward, -ve reinforcement, “compulsion disorder”
Alcohol abuse
Alcohol is a CNS depressant stimulating GABA inhibitor system to reduced brain excitability
Aetiology of alcohol abuse
Genetics:
25-50% predisposition inherited East Asian defective aldehyde dehydrogenase gene (lower rates of dependency in this population)
Occupation:
Publicans, journalists, doctors, armed forces, entertainment industry
Social background:
Difficult childhood with parental separation, educational achievement poor & evidence of juvenile delinquency
Presentation of intoxication
Irritable Aggressive Weepy Morose Disinhibited Impulsivity Poor judgement Slurred speech Ataxic gait Sedation-->confusion-->coma
Presentation of alcohol withdrawal
Headache Nausea + vomiting Retching Tremor Sweating Insomnia Anxiety Agitation Tachycardia Hypotension Pins + needles Seizures Delirium tremens
Timeline of alcohol withdrawal
6-12hrs: CNS hyperactivity (tremor, sweating, tachycardia, anxiety, GI upset, palpitations)
12-48hrs: Seizures and alcohol hallucinations Classically visual 12-24hrs 36hrs: Peak incidence of seizures
48-96hrs:
Delirium tremens
Peak incidence 72 hours
Management of alcohol withdrawal
Reducing regimen of benzodiazepines (chlordiazepoxide)
Parenteral thiamine
Manage dehydration & electrolyte abnormalities
Physical complications of alcohol abuse
Liver:
Alcoholic hepatitis - malaise, hepatomegaly, ascites, hepatic encephalopathy
GI:
Pancreatitis, oesophageal varices, gastritis, peptic ulceration
Neuro:
Peripheral neuropathy, seizures & dementia
Cancers:
Bowel, breast, oesophageal, liver
CVS:
HTN & cardiomyopathy
Head injuries/accidents:
Increased risk SDH
Foetal alcohol syndrome
Social complications of alcohol abuse
Unemployment, poor attendance & performance at work
Domestic violence
Separation & divorce
Vicious cycle
Law breaking while intoxicated (drink-driving, assault, theft)
Wernicke’s encephalopathy
definition + symptoms
Thiamine deficiency due to alcohol overuse (or persistent vomiting, stomach cancer, dietary deficiency)
Symptoms (triad): Ophthalmoplegia/nystagmus Ataxia Confusion (+/- peripheral sensory neuropathy)
Korsakoff syndrome
Chronic memory disorder caused by untreated Wernicke’s encephalopathy
Management of Wernicke’s encephalopathy
Urgent replacement of thiamine
Investigations for Wernicke’s encephalopathy
Decreased red cell transketolase
MRI
Investigations for alcohol abuse
FBC (macrocytic anaemia due to B12 deficiency)
LFTs (raised GGT, ALT due to hepatocellular damage)
Hepatitis serology if IV drug use
ECG
Urine drug screen
Clinical screening tools e.g. AUDIT, Paddington Alcohol Test
Management of alcohol abuse
Motivational interviewing
Detoxification
Reducing regimen of chlordiazepoxide to replace alcohol & prevent withdrawal seizures
Thiamine (prophylaxis against Wernicke’s encephalopathy - IM or IV)
Alcohol abuse relapse prevention
Psychological:
CBT, group therapies
Medical: Acamprosate (anti-craving) - 1st line Naltrexone (relapse prevention) - 2nd line Baclofen Clonidine Propranolol Disulfiram (relapse prevention) Carbamazepine
Rehabilitation:
Residential or day programmes
Harm minimalisation
Which recreational drugs have pharmacotherapy available?
Pharmacotherapy available for: Opioids Alcohol Benzodiazepines Nicotine dependence
Pharmacotherapy NOT available for:
Psychostimulants (cocaine, methamphetamine, cannabis)
Hallucinogens
Signs and symptoms of neonatal heroin withdrawal
Symptoms within hours of birth -> last several weeks High-pitched cry Restlessness Tremor Hypertonia, convulsions Loose stools, vomiting Sweats, fever Tachypnoea
Opiate pharmacotherapy and management
Naloxone
Harm reduction (needle hygiene, vaccinations, free condoms)
Substitute prescribing - weeks or months
Methadone
Buprenorphine (in supervised environment to detox)
Lofexidine (suppresses some components of withdrawal)
