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Year 4 Psych > Psychoactive Substances and Psychotic Disorders > Flashcards

Psychoactive Substances and Psychotic Disorders Flashcards

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1
Q

What does the term ‘hazardous drinking’ mean?

A

A level or pattern of drinking that will eventually cause harm. It applies to anyone drinking above the recommended limits, but without current alcohol-related problems

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2
Q

What does the term ‘harmful drinking’ mean?

A

A pattern of use that has already caused physical, mental, or social damage to the user. It excludes those with dependence syndrome

Damage may be acute or chronic

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3
Q

What does the term ‘alcohol abuse’ mean?

A

Continued drinking of alcohol despite significant employment, social, legal, or dangerous problems resulting from it

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4
Q

What are the characteristics of dependent drinking?

A

3 must have been present in the previous year to make a diagnosis:

1) Tolerance
- A need for markedly increased amounts of alcohol to achieve desired effect
- A markedly diminished effect with continued use of the same amount of alcohol

2) Withdrawal
3) Alcohol taken in larger amounts or over longer periods than was intended
4) Persistent desire for or unsuccessful efforts to cut down
5) Great deal of time is spent

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5
Q

What is the safe level of alcohol consumption in M and F?

A 
M = up to 21 units / week
F = up to 14 units / week

Been changed to 14 / week for both

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6
Q

List some GI effects of excessive use of alcohol (7)

A

1) Malnutrition and vit def - A, B, C, D E
2) Carcinoma of the lip, tongue, pharynx and larynx
3) Gastritis and peptic ulcer
4) Oesophageal varices
5) Oesophageal carcinoma
6) Acute and chronic pancreatitis
7) Fatty liver, hepatitis, cirrhosis and primary liver carcinoma

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7
Q

List some neurological effects of excessive use of alcohol (7)

A

1) Peripheal neuropathy
2) Dementia
3) Wernicke’s encephalopathy
4) Korsakoff’s syndrome
5) Cerebellar degeneration
6) Epilepsy
7) Fetal alcohol syndrome

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8
Q

What is the pathophysiology of alcohol addiction?

A

Alcohol has a variety of effects from which euphoric effects arise such as GABA, DA, 5HT and glutamate

In addiction = upregulation of glutamate to compensate for depressive effects on CNS of alcohol (thus why suddenly removing alcohol leads to CNS hyperexcitability)

Alcohol interferes with thiamine absorption from GIT

Alcohol causes decreased production of ADH = excessive urination and dehydration

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9
Q

List some features of alcohol dependence

A

CANT STOP

Compulsion to drink
Awareness of consequences but continues to drink
Narrowing of drinking repertoire
Tolerance increases

Stopping leads to withdrawal
Time spent using alcohol - other activities neglected
Out of control
Pattern resumes after abstinence

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10
Q

Describe alcohol withdrawal symptoms / when they happen

A

Occur in chronic heavy drinkers 4-12hrs after last drink

Anxiety
Sweating
Tremor
Vomiting
Tachycardia
Sleep disturbance

Grand mal seizures in 10% (6-48hrs)

Severe cases - delirium tremens

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11
Q

What is delirium tremens?

A

Medical emergency

Presents 1-3 days after alcohol withdrawal (in 4% withdrawing)

Altered mental state
Clouding of consciousness
Visual hallucinations (eg insects / small animals)
Confusion
Delusions
Sever agitation
Fever
Seizures
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12
Q

What is Wenicke-Korsakoff syndrome?

A

Wernicke’s encephalopathy and Korsakoff psychosis are the acute and chronic parts of a single disease, caused by neuronal degradation due to thiamine deficiency

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13
Q

What is Wernicke’s encephalopathy?

A

Triad of:

1) Mental confusion
2) Gait ataxia
3) Ophthalmoplegia

Only 10% have all three

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14
Q

What may be found on examination of someone presenting with Wernicke’s encephalopathy?

A

1) Vision changes:
- Double vision
- Eye movement abnormalities
- Eyelid drooping

2) Loss of muscle co-ordination:
- Unsteady, unco-ordinated walking

3) Loss of memory
4) Inability to form new memories
5) Hallucinations
6) Confabulation

OE:

  • Polyneuopathy
  • Decreased reflexes
  • Abnormal gait
  • Nystagmus
  • Low BP
  • Tachycardia
  • Cachexia
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15
Q

What happens if Wernicke’s encephalopathy is left untreated?

A

Acute phase lasts 2 weeks

84% will develop Korsakoff psychosis

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16
Q

How does Korsakoff’s psychosis present?

A

Anterograde and retrograde amnesia = loss of old memories and failure to make new ones

Working memory unimpaired

Confabulation

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17
Q

How does chronic alcohol consumption lead to thiamine deficiency?

A

1) Inadequate nutritional thiamine intake
2) Decreased absorption of thiamine from GIT
3) Impaired thiamine utilisation in cells

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18
Q

List 3 differentials for delirium tremens

A

1) Hypoglycaemia
2) Drug misuse / OD
3) Physical cause of delirium eg UTI

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19
Q

List 3 differentials for Wernicke’s-Korsakoff’s syndrome

A

1) Hypoglycaemia
2) Hepatic encephalopathy
3) Subdural haemorrhage

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20
Q

What alcohol screening tools are used?

A

CAGE + AUDIT questionnaire

Have you ever thought about CUTTING BACK?
Have you ever become ANGRY when someone comments on your drinking?
Have you ever felt GUILTY about your drinking?
Have you ever had an EYE-OPENER to get up in the morning?

(+2)
What is the most you have drunk in a DAY?
What is the most you have drunk in a WEEK?

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21
Q

Outline an alcohol history

A

1) CAGE
2) Alcohol intake
3) Assess impact of alcohol
4) PMH
5) Psychological assessment
- INC RISK
6) Conclude - leaflet / ?alcohol rehabilitation service referral

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22
Q

What questions should be asked to assess alcohol intake?

A

When did they have their first drink?
- Good / bad experience

When did they notice their alcohol intake increase?

  • Gradual / sudden
  • Any triggers

Current drinking pattern:

  • Every day / weekends
  • Time of day: mornings / evening / all day

Do you drink with other people? Where?

Why do you drink?

How long has this been going on for?
- What did you used to drink / where / when?

How much do you spend on alcohol?

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23
Q

What questions should be asked to assess the impact of alcohol?

A

Dependence:
Biological
- If you stop drinking do you get the shakes / sweat / feel sick?
- Do you have to drink more to get the same effects?

Physiological

  • Do you feel a compulsion / need to drink?
  • How important is drinking to you?
  • If you stop drinking, do you feel down / angry / anxious?

Effects on ADL:

  • Diet
  • Occupation
  • Relationships
  • Alcohol related crime = “have you ever been in contact with the police as a result of alcohol related incidents?”
  • Living situation
  • Previous attempts at abstinence = “have you ever tried to stop drinking before / why? Why do you think it was unsuccessful”

Assess desire to stop drinking

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24
Q

What PMH should be asked in an alcohol history?

A

General medical screen

Alcohol specific - liver disease, peptic ulcers, pancreatitis, IHD

DH
Allergies
FH - alcohol / drugs / mental illness

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25
Q

What questions should be asked in a psychological assessment in an alcohol history?

A

Risk to self:

  • Mood / appetite / sleep
  • Are there things you enjoy in lie? What?
  • How is your concentration?
  • Have you had any thoughts of hurting yourself?
  • Have you ever thought of ending it all? If so, plans?

Risk to others:
- Do you have any thoughts of harming others

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26
Q

What is the management of acute alcohol toxicity?

A

Maintain patent airway and wait for alcohol to metabolise

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27
Q

What is the management alcohol of withdrawal?

A

PO thiamine 100mg TDS for 1 month

Benzodiazepines help with tremor and agitation

  • Diazepam
  • Chlordiazepoxide

IV lorzepam can be given for seizures

Avoid NSAIDs and paracetamol due to compounding effects on liver

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28
Q

What is the management of delirium tremens?

A

Parenteral thiamine = Pabrinex

Benzodiazpeines = lorazepam

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29
Q

What is the management of Wernicke’s encephalopathy?

A

IV thiamine (Pabrinex) - 2 ampoules BD for 3-7days

Parenteral vitamins

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30
Q

What is the management of Korsakoff’s?

A

Continue PO thiamine replacement for up to 2 years

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31
Q

What can be given to deter people from drinking alcohol?

A

Disulfram (antabuse) - makes people sick when they drink alcohol (do not use until blood alcohol level returns to 0)

Acamprosate = neuroprotective
Naltrexone = reduces cravings
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32
Q

What psychological methods can be used in alcohol addiction?

A

Techniques of controlled drinking:

  • Daily / weekly limits
  • Don’t drink alone or with heavy drinkers
  • Alternate with soft drinks
  • Drink with a meal
  • Rehearse a refusal for a drink offer

AA - 12 steps

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33
Q

What is the prognosis of alcoholism?

A

Relapsing common (60%) before achieving long-standing abstinence

4 x inc risk of mortality

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34
Q

What is the prognosis of delirium tremens?

A

10% mortality if untreated

35
Q

What is the prognosis of Wernicke’s encephalopathy?

A

Untreated mortality - 15%

With treatment:

  • Ophthalmoplegia and confusion resolve in days
  • Ataxia, neuropathy and nystagmus may be permanent
36
Q

What is the prognosis of Korsakoff’s?

A

25% may improve some degree over time

25% require long term institutional care

37
Q

List some risk factors for drug addiction

A 
Either lower social class or 'social drift'
Young age
Male
Unemployed
Single
Opiate = under 30yr
BNZ = middle aged
38
Q

Give examples of opioids

A 
Morphine
Diamorphine
Codeine
Dihydrocodeine
Heroin
Oxycodone
Methadone
Opium
Tramadol
Loperamide
Meptazinol
Pentazocine
39
Q

What is the mechanism of action of opioids?

A

Act on opioid mu receptors in CNS, reducing neuronal excitability and pain transmission

  • In medulla = blunt response to hypoxia and hypercapnoea, reducing respiratory drive and breathlessness

By relieving pain, breathlessness and associated anxiety, they reduce the sympathetic nervous system

40
Q

What are the effects of opioids?

A 
Cortical inhibition
Euphoria
Analgesia
Constipation
Respiratory depression
Anorexia
Loss of libido
Pruritus
Miosis

= Effects almost immediate

41
Q

What can happen in opioid overdose?

A

Respiratory depression and death

42
Q

When are withdrawal symptoms experienced in opioid addiction?

A

Symptoms begin 8-12hrs after last dose, peak at 36-72hrs and subside over 7-10 days

Longer for methadone

43
Q

List some symptoms of opioid withdrawal?

A 
Anxiety
Pain
Breathlessness
Intense craving
Restlessness
Insomnia
Tachycardia
Dilated pupils
Running nose and eyes
Sweating
Piloerection = "cold turkey"
Abdo cramps
D&V
44
Q

What is the treatment of an opioid overdose?

A

IV Naloxone

beware has a shorter half-life than heroin so revived pt can relapse unconscious again

45
Q

What can be given to detoxify and prevent relapse of opioids?

A

Naltrexone

= Long acting opioid antagonist

46
Q

What can be given to help treat the withdrawal symptoms from opioids?

A

Lofezidine = alpha-adrenergic agonist
Loperamide
Metoclopramide
Ibuprofen

47
Q

What can be given as a substitute to opioids?

A

Methadone = long acting synthetic opioid

  • 24hr half-life so useful for daily dosing
  • Unsuitable for injection (given PO)

Buprenorphine = partial opioid agonist, less euphoria at higher doses than methadone
- Can be given IV

48
Q

What is loperamide?

A

An opioid

But cannot penetrate CNS so has no analgesic effects

Acts on mu eceptors in GIT slowing bowel transit = anti-diarrhoea

49
Q

List some types of benzodiazepines

A 
Diazepam
Temazepam
Lorazepam
Chlordiazepoxide
Midazolam
50
Q

What is the mechanism of action of benzodiazepines?

A

Facilitate and enhance binding of GABA to GABA receptor

GABA = main inhibitory neurotransmitter in brain

Thus benzos cause widespread depressant effect on synaptic transmission

51
Q

What effects do benzodiazepines have on the body?

A 
Reduced anxiety
Sleepiness
Sedation
Anti-convulsive effects
Forgetfullness

Chronic use associated with depression, impaired memory and concentration

52
Q

Why are benzos used in alcohol withdrawal?

A

Ethanol also acts on GABA, and in chronic excessive use the pt becomes tolerant to its presence

Abrupt cessation = excitatory state of alcohol withdrawal, which can be treated with benzos

53
Q

How long does it take for addiction to develop with benzos?

A

3-6 weeks of regular use

54
Q

What are the risks of benzo overdose?

A

Over-sedation
Coma
Death

55
Q

What are the symptoms of benzo withdrawal?

A 
Anxiety
Insomnia
Tremor
Headache
Nausea
Depersonalisation
Seizures
Delirium
56
Q

When do symptoms of benzo withdrawal present?

A

24hrs (short acting) or up to weeks (long acting) after last dose

57
Q

What is the management of benzodiazepam:

  • Over dose
  • Detox
  • Dose reduction?
A

Overdose - Flumazenil = BDZ receptor antagonist

Detox - switch from short half life (eg temazepam / oxazepam)

Dose-reduction - no more than 30mg diazepam

58
Q

What is the mechanism of action of cocaine?

A

Blocks reuptake of serotonin and catecholamines (esp dopamine)

59
Q

What are the effects of cocaine?

A 
Increased energy
Increased confidence
Euphoria
Reduced need for sleep
Local anaesthesia
Dilated pupils
Tachycardia
HTN
Hyperthermia
Aggression

= A few minutes after consumption

60
Q

What can happen in a cocaine overdose?

A 
Tremor
Confusion
Seizures
Arrhythmia
MI
Perforation of nasal septum
61
Q

What symptoms are experienced in cocaine withdrawal?

A 
Intense craving
Anxiety
Dysphoria
Irritability
Formication (feeling of insects under the skin v common)
62
Q

What is the treatment of acute cocaine toxicity?

A

Symptomatic benzodiazepines and/or antipsychotics

63
Q

Is dependency seen in amphetamines?

A

No but psychological addiction occurs based on social situations

64
Q

What is the mechanism of action of amphetamines?

A

Monoamine agonist stimulants

Block reuptake or noradrenaline and dopamine

(used in treatment of narcolepsy and hyperactivity)

65
Q

What are the effects of amphetamines?

A 
Increased energy
Increased confidence
Disinhibition
Euphoria
Reduced need for sleep
Tachycardia
HTN
Hyperthermia
Post-use depression

Chronic use - associated with anxiety and depression

66
Q

In what way do the effects of amphetamines differ from cocaine?

A

Similar effects but metabolism slower so effects are longer

67
Q

What can happen in an overdose of amphetamines?

A 
Arrhythmia
Severe HTN
Dehydration
Seizures
Coma
68
Q

What are the effects of amphetamine withdrawal?

A 
Dysphoria
Decreased energy
Depression
Anxiety
Fatigue
Nightmares
69
Q

What is the management of acute amphetamine toxicity?

A

Symptomatic benzodiazepines and/or antipsychotics

70
Q

Is dependency seen in ecstasy use?

A

No but tolerance increases

71
Q

What is the mechanism of action of ecstasy?

A

Cause serotonin release and blocks reuptake

72
Q

What are the effects of ecstasy?

A

Euphoria / sweating / tachycardia / hyperthermia etc etc

73
Q

What can happen in ecstasy overdose?

A

Death from dehydration and hyperthermia

74
Q

What is LSD?

A

Lysergic acid diethylamide

75
Q

What is the mechanism of action of LSD?

A

Partial agonist of 5HT2A

Dopaminergic effects

76
Q

What are the effects of LSD?

A 
Distortion or intensification of senses
Synaesthesia = crossing of senses eg hearing colours
Mood changes
Pupil dilation
Tachycardia
HTN

Effects begin 15-30min after ingestion and last 8-14hrs

77
Q

What does cannabis contain?

A

> 60 psychoactive cannabinoids

Most importantly 9-delta-tetrahydrocannavinol (THC)

78
Q

What is the timeframe of cannabis effects?

A

If smoked, effects felt within minutes, reach peak at 30 mins, last 2-5hrs

79
Q

What is chronic cannabis use associated with?

A 
Dysthymia
Anxiety
Amotivation
Paranoia
Schizophrenia / psychotic episodes
80
Q

What can cannabis withdrawal lead to?

A

Heavy users who stop suddenly may experience insomnia, anxiety and irritability

81
Q

What is the “craving centre” in the brain?

A

Nucleus accumbens

82
Q

What areas of the brain are involved in addiction?

A

Nucleus accumbens is stimulated but is down regulated over time with repeated stimulation

This causes up regulation of the ventral tegmental area which is responsible for compulsion = compulsive behaviour continues even though you no longer get pleasure

Pre-frontal cortex also changes so that overtime it feeds into the system to regulate and sustain these behaviours

83
Q

What are the 4 x C’s for addiction

A

1) Control - loss of control and some attempts to control it
2) Compulsion - feeling compelled to use
3) Continued - continued use despite consequences
4) Cravings

Year 4 Psych (10 decks)

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