Psychiatry - Addiction and substance misuse

Question 1

What is the aetiology of addictive behaviours and substance misuse?

Answer 1

Multifactoral - biopsychosocial influences
Biological: FHx, twin studies (MZ > DZ), adoption studies, weak genetic loading though (environmental factors important as well)

Psychological:

i) Childhood experiences: - ADHD, parental abandonment, death of parent, sexual/ emotional abuse
ii) Adolescent experiences: - learning or conduct disorder, poor parental/ child relationships, family structure breakdown, loss events

Social/ environmental: - substance abusing peers, economic availability, employment, stress,

Question 2

What is dependence?

Answer 2

Addiction is a spectrum disorder.
Social use of alcohol or illicit substances becomes problematic and eventually habitual.
Dependance occurs when use becomes compulsive and manifests as the dependence syndrome

Question 3

What are the diagnostic features of the dependence syndrome?

Answer 3

Salience (substance/ alcohol abuse becomes the most important thing)
Tolerance
Impaired control
Compulsion (all behaviours are directed towards abuse)
Withdrawal syndrome (hint - features of the withdrawal are generally opposite to the effects of the substance, i.e. alcoholic withdrawal is characterised by agitation and anxiety even though alcohol is a depressant)
Relief use
Reinstatement (after a period of abstinence)

ICD-10 require 3 or more of the above to diagnose dependence

Question 4

Areas of the brain implicated in addiction

Answer 4

Dopamine pathways
VTA –> nucleus accumbens –> prefrontal cortex

Pathways undergo neuroadaptation (addictive pathway established and cannot be broken down)

Question 5

Screening tools to identify problem drinking

Answer 5

1) AUDIT - 10 questions; superior to CAGE or biochemical markers for alcohol; minimum score = 0, maximum score = 40; score of 8 for men and 7 for women indicates strong likelihood of harmful alcohol consumption; score of 15 indicates alcohol dependence
2) FAST - 4 item question; minimum score = 0, maximum score = 16; score for hazardous drinking = 3; if answer to the first question is “never” then the patient is not abusing alcohol

3) CAGE - well known, but may be poor screening tool; two or more positive answers considered a “positive” result:
C - Have you ever felt you should Cut down on your drinking?
A - Have people Annoyed you by criticising you about your drinking?
G - Have you ever felt bad or Guilty about your drinking?
E - Have you ever had a drink in the morning to get rid of a hangover (Eye opener)

Question 6

Pathological intoxication

Answer 6

Rare psychological complication associated with alcohol abuse. Patients who have ingested only a small amount of alcohol are observed to be in a trance or automatism

EEG abnormality strengthens diagnosis

Has been used as a defence to exonerate unlawful behaviour

Question 7

What are alcohol related amnesias?

Answer 7

Transient amnesia due to intoxication, can be total with abrupt onset and recovery with no recall. Can also be patchy amnesia with indistinct boundaries

Journey syndrome - the patient regains awareness in strange place - “fugue”

Question 8

Transient hallucinatory experiences

Answer 8

Difficult to classify as alcohol related psychological experience. May preceed onset of DTs or alcoholic hallucinosis and are best described as fleeting, brief perceptual disturbances

Question 9

What is delirium tremens?

Answer 9

= severe alcohol withdrawal syndrome
Patient may decide to stop drinking suddenly, or may be arrested or incarcerated. Some people may still be drinking a decreased amount leading to a partial withdrawal

Triad - delirium, hallucinations and tremor
Disturbance fluctuates - worse during the night

Question 10

Symptoms of delirium tremens

Answer 10

1) Delirium* - fluctuating, clouding of consciousness, potentially disorientated
2) Hallucinations* - vivid, chaotic, bizzare
3) Visual hallucinations* - classically horrible, frightening
4) paranoid delusions
5) Occupational delusions

• triad of DTs

Question 11

Course of DTs

Answer 11

Usually lasts 3-5 days
Fluctuating course
Complicating factors - liver failure, head injury, benzodiazepine withdrawal (all these may prolong the course)
Recurrent attacks common once one has occurred

Question 12

Alcoholic hallucinosis

Answer 12

Rare psychiatric complication of alcohol abuse
Auditory hallucinations (unformed voices)
Phonemes
Differentiated from DTs as there is no clouding of consciousness
Patients may not tell you about the event
If occur for longer than 6 months think about other psychotic illness (formal thought disorder usually absent)

Question 13

Withdrawal fits

Answer 13

Occur in heavily dependent patients - withdrawal or partial withdrawal cause convulsions
30% proceed to DTs and are more likely to occur in the first 12-24 hours
Future withdrawal associated with higher risk of DTs

Question 14

What is Wernicke-Korsakoff syndrome?

Answer 14

Occurs in 10% of chronic alcoholics
Essentially 2 components:
1) Wernicke’s encephalopathy- neurological component
- acute presentation of a triad (i) ophthalmoplegia (6th nerve), (ii) clouding of consciousness and (iii) ataxia
- caused by thiamine deficiency
- petchial haemorrhages on floor of 3rd ventricle, mammilary bodies, brainstem
- 20% mortality

2) Korsakoff’s psychosis
- progresses from Wernicke’s - 80% of survivors of Wernicke’s develop Korsakoff
- loss of short term memory with preservation of other functions
- confabulation is a key feature
- 20% require long term residential care

Question 15

Alcoholic dementia

Answer 15

Brain shrinkage in alcoholics due to loss of white matter leading to increase in ventricular size.
Corpus callosum decreases in size.
50% of alcoholics aged > 50 attending tertiary care will show evidence of cortical degeneration

Question 16

What is alcoholic organic brain damage?

Answer 16

Varied presentation - impairment of judgment, concentration, minor memory problems
Cerebellar degeneration can also occur, causing an unsteady gait
Alcoholic amblyopia is gradual blurred vision with a central scotoma

Question 17

Phobic anxiety

Answer 17

Very common
Panics relieved by anxiolytic action of alcohol, leading to high risk for developing dependence
Withdrawal symptoms precipitate phobic symptoms

Question 18

What defence mechanisms are used by alcoholics?

Answer 18

Denial - most common
Passive aggression = indirectly asserting self by appearing compliant
Projection = acknowledging ones on feelings or impulses to others
Rationalisation

Question 19

Pathologic jealousy

Answer 19

Can occur in alcoholics
Otherwise known as Othello syndrome - preoccupation with delusions of infidelity
Dangerous

Question 20

How is alcohol dependence treated?

Answer 20

1) Acute interventions
2) psychosocial
3) Maintaining abstinence

Different treatments are used for each of these

Question 21

What are the indications for admission for detox?

Answer 21

Severe withdrawal symptoms 
Medical/ psychiatric symptoms 
Hx of withdrawal fits
Hx of DTs
No social support

Question 22

Indications for medication in alcohol dependence

Answer 22

Severe symptoms
Hx of withdrawal fits
Malnutrition
Physical illness

Question 23

Which benzodiazepines are used to treat alcohol withdrawal?

Answer 23

Long acting diazepam or chlordiazepoxide
Important to titrate dose to symptoms
- start at 20-30mg QDS and up titrate as needed
Once symptoms controlled, decrease over a period of 7-10 days
If vomiting, use sub lingual lorazepam
Severe liver damage lorazepam/ oxazepam not hydroxylated by the liver

Question 24

Treatment of alcohol withdrawal seizures

Answer 24

BDZ
Diazepam more effective cf. phenytoin
In severe withdrawal give loading dose of chlordiazepoxide 80-100mg

Question 25

Management of the DTs

Answer 25

Give BDZ in adequate dose orally
Vitamins - pabrinex and i.v. thiamine
Treat physical problems - e.g. pneumonia
Rehydrate and correct any electrolyte imbalance

Question 26

When an alcoholic presents what investigations should be performed?

Answer 26

Always due a neuro exam on an alcoholic patient 
FBC - MCV incr
LFTs
Vit B12 + folate
TFT
CXR

Question 27

Difference between acute drug intoxication and drug misuse

Answer 27

Intoxication = transient disturbance of behaviour, cognition or perception after taking a substance

Misuse = maladaptive and recurrent use of substance leading to significant impairment or distress. Dependence - opioid dependence has the same features as alcohol dependence

Question 28

Important points to cover in drug history

Answer 28

Establish a drug taking pattern and quantity consumed

• what drugs used?
• how frequently?
• what amount is used?
• how much is spent on drugs?
• how long have they been using at the current level?
• what route is used? Are they injecting?
• what effect are they seeking?

Check for features of opioid dependence syndrome. Withdrawal features include:

• flu like symptoms
• yawning
• sweating
• dilated pupils
• piloerection

Establish the impact:

• Physical - infections, abscesses, hep B, C and HIV
• Mental - psychosis, anxiety
• Social - unemployment, divorce, debt
• Legal - drug offences, theft