Psychiatry - Psychosis & Addiction Flashcards
1
Q
Define psychosis.
A
- a set of symptoms rather than a diagnosis in its own right
- thoughts, affective responses, ability to recognise reality, and the ability to communicate/relate to others is significantly impaired;
- loss of ability to distinguish between subjective experience and objective reality
2
Q
Name and describe the key features of psychosis.
A
- hallucination (described in Mood Disorders)
- ideas of reference: innocuous / coincidental events ascribed significant meaning (‘message about me’)
- paranoia, persecutory delusion: external events related to oneself in some way
- delusion (see Mood Disorder)
- passivity phenomena (made actions/ feelings/ thought; ‘they made me feel this way;)
3
Q
Describe the risk factors for schizophrenia and psychosis, and the structural changes that occur in the brain.
A
- risks for schizophrenia: 2nd trimester viral illness, PET, foetal hypoxia, emergency C/S, childhood viral illness
- risks for psychosis: amphetamines, cocaine, cannabis, ‘legal highs’
- decreased function of frontal lobe, frontotemporal volume, increased lateral ventricles
4
Q
Describe the dopamine hypothesis.
A
- drugs which release dopamine (and D2 agonists) in the brain produce psychosis, and their antagonists are used to treat it
- D1 (and 5) activate cAMP
- D2 (3, 4) inhibits AC and VGCC
5
Q
Describe the differential diagnosis of schizophrenia.
A
- dementia and delirium: formal thought disorder, poverty of thought, delusion, passivity phenomena, hallucination, fluctuant, and impaired LOC
- substance misuse: delusions, passivity phenomena, hallucination, fluctuant, LOC can be impaired
- schizophrenia: formal thought disorder, poverty of thought, delusions, passivity phenomena, hallucination
- mania: formal thought disorder, delusion, auditory hallucination
- depression: poverty of thought, persecutory delusion, auditory hallucinations can occur
6
Q
Give the diagnostic classification of schizophrenia.
A
1 of:
- thought echo, insertion, withdrawalm broadcasting
- delusions of control, influence, passivity
- hallucinatory voices
- persistent delusions of other kinds that are culturally inappropriate or impossible
or 2 of:
- persistent hallucination in any modality every day for 1 month
- neologisms, breaks in train of thought, incoherent speech
- catatonic behaviour / excitement
- negative symptoms: marked apathy, paucity, blunting of responses
7
Q
Name the psychiatric conditions more likely to affect young people.
A
- bipolar disorder
- disruptive behaviour disorders
- ASD
- ADHD
- separation anxiety
- trauma and attachment
8
Q
Name the risk factors for developing delirium (and dementia).
A
I WATCH DEATH
- infection
- withdrawal
- acute
- toxins
- CNS pathology
- hypoxia
- deficiencies
- endocrine
- acute vascular shock
- trauma
- heavy metals
9
Q
Name and describe the four core models concerning addiction and its treatment.
A
- moral: those who take substances do so purely by choice, with no regards for the consequences of their behaviour on themselves or others
- medical: those who take substances are ill, with physiological and psychological changes that override the degree of choice they were once able to use
- dispositional disease: ‘disease’ of addiction is irreversible - no cure, but can be arrested by total abstinence (benevolent models, such as AA and NA use this model)
- personality: personality traits, such as inability to cope with stress, contribute to addiction, and resolution requires restructuring of personality.
10
Q
Define ‘conditioning’ in relation to addiction.
A
an individual comes to associate a desired behaviour with a previously unrelated stimulus; thus, substance misuse is ‘learned behaviour’, requiring relearning.
11
Q
Describe Pavlov conditioning and the conditioned compensatory response theory.
A
- classical conditioning / associative learning
- ringing of a bell with dog food causes the dog to salivate, conditioning the dog to salivate at sound of the bell
- conditioned compensatory response: one is more likely to survive an overdose if taken in the same environment where previously received.
12
Q
Describe Skinner conditioning.
A
- operant / instrumental
- positive: adds a stimulus
- negative: removes a stimulus
- positive reinforcement: relaxed after using drug
- positive punishment: being yelled at after using
- negative reinforcement: removes withdrawal symptoms
- negative punishment: loss of home, family, work etc.
13
Q
Describe and exemplify the five main types of thinking error that may lead to addiction.
A
- permission giving: ‘just a treat’
- minimisation: ‘it’s only one’
- denial: ‘i can stay in control’
- blaming: ‘she made me angry, so i had to use’
- rationalisation: i haven’t used in a week, so why not?
14
Q
Define and describe formulation.
A
- a provisional exploration / hypothesis for how an individual comes to present with a certain disorder at a particular time / circumstance [1996]
- summarises the core problems, how difficulties may relate to one another, and aims to explore the development / maintenance of difficulties, while indicating a plan of intervention rooted in psychological principles; open to constant revision [2014]
15
Q
Describe the social, psychological, and biological factors contributing to a psychological formulation.
A
- social: self-concept, self-esteem, values, relationships, social, cultural, network, environment
- psychological: perception, executive, social function, action, memory function
- biological: metabolism, endocrine, immune, nervous, cardiovascular factors.
16
Q
Describe the addiction cycle.
A
- high risk situation (e.g., an arguement)
- emotion, leading to
- craving / withdrawal (anxiety, tension, irritability); thoughts and beliefs (‘a hit will make me feel better’)
- behaviour (storms out, arranges pick up)
- drug use
- negative reinforcement and outcomes: anger reduced, beliefs fortified etc.
17
Q
Describe the diagnostic criteria for addiction.
A
3+ in the last year of:
- strong desire to take the substance
- difficulty controlling substance use
- a physiological withdrawal state
- tolerance
- neglect of alternative pleasures
- persistence, despite evidence of harm
18
Q
Describe the neurobiological changes associated with addiction.
A
- prefrontal cortex: suppresses mesolimbic pathway and weighs up decisions; underfunctions in addicts
- OFC: internal representation of the importance of events, key creator of motivation to act; increased activation with cues in addicts
- nucleus accumbens and VP: reward/salience, prioritization
- the mesolimbic pathway (VTA -> NAc -> PFC): motivates, incentivises normal pleasurable experiences. repeated stimulation leads to downregulation and reduction, and an increased threshold for pleasure
- hippocampus and amygdala: acquisition, consolidation, expression of drug stimulus, learning on cue, internal states of craving.
19
Q
Describe the classification of alcohol addiction.
A
- acute intoxication with alcohol
- harmful use of alcohol
- dependence syndrome
- withdrawal state
- alcohol induced delirium tremens
- psychotic disorder (hallucination, alcohol jealousy)
- amnesic syndrome, including Korsakoff’s
20
Q
Describe the questioning/screening process for someone with alcohol addiction.
A
- AUDIT-C tool: ask 3 questions, and if <5 no further action
- if 5+, ask remaining questions; 0-19 mandates brief intervention, and 20+ referral to a specialist.
- CAGE tool can be used to assess harmful drinking or dependence
- FAST tool (A&E): how often have you had >6U (female) or >3U (male) on a single occasion in the last year? [anything greater than weekly requires further questioning]
21
Q
Describe the effects of alcohol addiction on the body systems.
A
- mental health: anxiety, depression, dependence
- nervous: brain damage, memory loss,, sleep disturbance, stroke, nerve damage
- hepatic: swelling, pain, cirrhosis, cancer
- cardiovascular: hypertension
- stomach: inflamed lining, bleeding, cancer
- pancreas: pancreatitis
- oncology: mouth and throat, larynx, oesophagus, breast, bowel
22
Q
Describe the cause and symptoms of Wernicke’s encephalopathy.
A
- caused by vitamin B1 (thiamine) deficiency
- triad: ophthalmoplegia, confusion, ataxia
23
Q
Describe the symptoms associated with alcohol withdrawal.
A
- restlessness, tremor, sweating, anxiety, N&V, loss of appetite, insomnia, tachycardia, hypertension
- occurs within hours and peaks at 24-48h
- generalised seizures may occur <24h
24
Q
Describe delirium tremens.
A
- may present insidiously with night confusion, progressing to agitation, HTN, fever, visual and auditory hallucination and paranoia
- symptoms resolve within 5-7days, so management is supportive (hydration, analgesia, antiemetics)
- BZDs may be used and tapered down over 7 days; thiamine must be given parenterally to prevent Wernicke’s encephalopathy.
25
Describe when alcohol detoxification should not occur in the community.
with an AUDIT-C score of 30+ AND
- a history of delirium tremens (DT) or seizure
- history of failed community detox
- poor social support or physical health
- cognitive impairment
- [NB current DT requires immediate transfer to a medical ward]
26
Name the (non-emergency) pharmacological options for alcohol detoxification.
- disulfarim ('antabuse'): inhibits acetaldehyde dehydrogenase, leading to accumulation of acetaldehyde with alcohol ingestion (causing flush, tachycardia, N&V, arrhythmia, and possible hypotension)
- acamprosate: acts centrally on glutamate and GABA, moderately decreasing cravings
- naltrexone.
27
Name and describe the different categories of opiate.
- natural: morphine, codeine, heroin (comes as a brown powder from the opium poppy)
- semisynthetic: hydrocodone, hydromorphine
- fully synthetic: methadone, tramadol
28
Describe the features of opiate withdrawal.
anxiety, feels like yawning, sweating, teary eyes, running nose, goosebumps, shaking, hot flushes, cold flushes, vomiting, muscle twitching, muscle aches, restlessness, stomach cramps, nauseated, desire to use now
- 8+ of these features indicates opiate withdrawal
29
Describe the risks of IV use, snorting, and the psychological risks associated with opiate use.
- IV: skin infection, abscess, DVT, blood-borne viruses (BBVs)
- snorting: nasal mucosa damage, blockade, compromised respiratory tract
- psychological: seizures, delirium, paranoid, anxiety, depression, psychosis
30
Describe the two main options for opiate withdrawal, their mechanism of action, and potential side effects.
- methadone: a mu-agonist, metabolised by CY3P4, reaching a steady state within 5 days
- - methadone is a liquid preperation
- - it may lengthen the QT interval and cause sedation
- buprenorphine: partial mu-agonist, sublingual
