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Sera's MBBS > Pysch > Flashcards

Pysch Flashcards

1
Q

Define acute intoxication

A

Transient disturbance of consciousness, cognition, perception, affect or behaviour following administration of psychoactive substances

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2
Q

Define substance harmful use

A

Diagnosis requires actual damage to have been done ot the mental or physical health of subject to qualify

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3
Q

Dependence syndrome (def)

A

Cluster of symptoms revolving around central theme of desire (strong and sometimes overpowering) to take psychoactive substance

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4
Q

Define withdrawal state

A

Physical and psychological symptoms occurring on absolute or relative withdrawal of substance

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5
Q

Define amnesic disorder in substance abuse

A

Chronic, prominent impairment of recent memory and other cognitive impairments caused by substance use (most common alcohol)

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6
Q

Define residual and late onset psychotic disorder with substance use

A

Effects on behaviour, affect, personality or cognition lasting beyond the period during which direct psychoactive substance effect might be expected

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7
Q

How does ICD10 classify substance abuse disorders

A

(1) substance

(2) type of disorder e.g. acute intoxication, dependence, withdrawal, psychotic, amnesic, harmful use etc

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8
Q

Biological pathway of addiction/substance misuse - specifying the way cocaine, amphetamine, alcohol and opiate affect this pathway

A

Dopamine reward pathway
Central tegmental area -> prefrontal cortex -> limbic system
Release of dopamine in nucleus accumbens gives rise to sensation of pleasure
Cocaine and amphetamine block dopamine reuptake. Alcohol and opiates increase dopamine levels.

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9
Q

What drug classes causes physical withdrawal syndrome

A

Classically the ABO
Alcohol
benzodiazepines
Opiates

But also GBL/GHB
Other drugs cause psychological withdrawal and craving but not physical symptoms

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10
Q

ICD10 features of dependence syndrome

A
  • Salience (‘drug most impt in life’)
  • Narrowing of repertoire
  • Tolerance
  • Problem controlling use
  • Withdrawal
  • Continued use despite harm
  • Reinstatement after abstinence

Diagnosis of dependence made if 3 or more present together at the same time in the previous year

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11
Q

Stages of change - Prochaska and Diclemente

A 
Enter here: Precontemplation 
Contemplation 
Determination 
Action 
Exit here: maintenance or relapse
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12
Q

Active ingredient in alcohol

A

Ethyl alcohol

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13
Q

Epidemiology of alcohol dependence

A

Lifetime prevalence of 5.4%

12 month prevalence of 1.3%

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14
Q

Features of alcohol - acute intoxication

A

Relaxation and euphoria
Slurred speech, impaired coordination and judgement
Impulsive and poor judgement
labile affect

if severe: hypoglycaemia, stupor and coma

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15
Q

Features of alcohol - harmful use/at risk drinking

A

Physical or mental damage caused by alcohol drinking

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16
Q

Features of alcohol - psychotic disorders

A

Alcoholic hallucinations - mostly auditory, usually persecutory or derogatory
morbid jealousy - overvalued idea that partner is unfaithful

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17
Q

Features of Wernicke’s encephalopathy

A

Ataxia
Opthalomoplegia
Confusion

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18
Q

Features of Korsakoff’s psychosis

A

Confabulation
Regular black out
Antegrade amnesia

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19
Q

Features of alcohol withdrawal - acute

A

Occurs within 1-2 days
malaise, nausea and vomiting, autonomic hyperactivity, tremor, labil mood, insomnia, transient hallucinations, restless (because alcohol is CNS depressant) hence withdrawal = overexcitability

Delirium tremens occurs in 5% of withdrawal

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20
Q

Features of uncomplicated alcohol withdrawal

A

4-12 hours
Coarse tremor, sweating, insomnia, tachycardia, psychomotor agitation, anxiety +/- hallucinations (transient tactile, auditory, visual)

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21
Q

Features of complicated alcohol withdrawal

A

withdrawal features of CNS overexcitability + seizures
5-15% of withdrawal
Grand mal seizures 6-48 hours after last drink

22
Q

Delirium tremens (medical emergency)

A

5% of withdrawal
peak 48 hours after last drink
Last 3-4 days
Features of withdrawal + confusion, disorientation, amnesia, psychomotor agitation, tactile hallucinations (Lilliputian hallucinations of diminuative people or animals), hour by hour fluctuations, autonomic disturbance: heavy sweating, hypertension, dilated pupils, feer, paranoid
Death by fatal dehydration and electrolyte abnormalities
Managed by reducing BDZ and IV thiamine

23
Q

investigations for suspected alcohol abuse

A

breath testing - recent drinking, correlates with blood alcohol levels

Blood test - MCV (raised for 3-5 months, beware false positive in B12 and folate def), yGT (raised for 2-3 weeks, false positive in liver disease, obesity, diabetes, CLD), CDT (carbohydrate deficient transferrin, raised 2-3 weeks, more expensive to do thatn yGT)

urine tests - urinary ethyl glucoronide, sensitive for1-2 drinks

hair testing - detecting alcohol/drug use over period of month, research tool

CAGE questionaire

CIWA score

24
Q

key aspects of an alcohol history

A 
Lifetime pattern 
Current consumption level 
Sighs of dependence 
Physical and mental health compliants 
Social 
previous treatment attempts 
FHx 
motivation interviewing
25
Q

management of alcohol withdrawal

A

BDZ: most effective for alcohol withdrawal seizures, rapidly reducing regime prevents BDZ dependence. Chlordiazepoxide for OPD use, diazepam for inpatient

Antipsychotics: PRN haloperidol 5-10mg PO if BDZ does not manage hallucinations

Vitamins: IV thiamine, Pabrinex

26
Q

Considerations for choosing chlodiazepoxide or diazepam for alcohol withdrawal

A

Chlordiazepoxide is used in OPD because of long half life, lower abuse potential

Diazepam works faster and used in patient because allows for dose titration

27
Q

Who needs alcohol detox therapy for alcohol withdrawal

A

Pt with clinical symptoms of withdrawal, Hx of alcohol withdrawal symptoms
Or Hx of drink >10 units/day for past 10 days, BAC=0, no withdrawal symptoms

28
Q

Choosing between OPD alcohol detox v inpatient alcohol detox

A

OPD - if uncomplicated, if worried about compliance can see pt daily and breathanalyse before dispensing drug

Inpt - Complicated withdrawal with seizures, confusiong, suicide risk, Wernicke-korsaff, lack of stable home environment

29
Q

Advice on pts on alcohol detox

A

Give verbal and written advice
inform GP
Give pt contact for emergencies
Decide on explicit follow up after detox

30
Q

Drugs that can prevent alcohol misuse/relapse after detox

A

Disulfiram - irreversible acetyladehyde dehydrogenase inhibition, causes ahngover if drinking. prescribed once abstinence is achieved, loading dose of 800mg then reduce over 5 days to 100-200mg/day

Acamprosate - to prevent craving for alcohol. Enhance GABA transmisison. Give 333mg/tds or 666mg/tds depending on weight. Start after abstinence

31
Q

Safe drinking advice

A
  • 14 units/week. Check pt understanding of what is a unit
  • Should be at least two non-drinking days a week
  • Amounts should be spread over several days, not drunk at one sitting
  • Weekly limits. Don’t ‘save up’ units from one week to use in another week
  • Some situations where the safe amount is zero, e.g. pregnancy, driving
  • Do not drink alone, avoid company of heavy drinkers
  • Don’t buy rounds
  • Alternative soft drinks and alcohol. Drink with meal
  • Rehearse what to say when declining offer of drink
  • Plan alternative non-drinking activities
32
Q

how to calculate alcohol units

A

• One unit is 8g of alcohol
• Number of units = volume in L x % alcohol
• Pint of beer is 2 units, can of strong lager 9% is 4 units, pint of cider is 2.5 units, 125ml
glass of unit is 1.5 units, 25ml shot of gin/vodka/rum is 1 unit

33
Q

Prognosis of alcohol abuse - % die prematurely, % will have lifelong alcohol related problems, % favourable outcomes

A

40% die prematurely (15% by suicide)
30% have lifelong alcohol related problems
30% favourable outcome

34
Q

SCOFF questionaire

A

For AN and BN (eating disorder)
• Used in primary care but low sensitivity, score of 2+ yes indicates more detailed history is
needed

Do you make yourself sick because you feel uncomfortably full?
Do you worry you have lost control over how much you eat?
Have you recently lost more than one stone (6kg) in a 3 month period?
Do you believe yourself to be fat when others say you are too thin?
Would you say that food dominates your life?

35
Q

4 main diagnostic points in Anorexia nervosa (ICD10)

A

• BMI <17.5 (or weight 15% less than expected)
• Deliberate weight loss – extraordinary lengths to lose weight, laxative abuse, vomiting or
excessive exercise. Use of appetite suppressants, thyroxine, diuretics and stimulants
o Common history of exercising before onset
• Distorted body image – preoccupation with body shape and dread of weight gain.
Overvalued ideas that they are fat, this thought persists above all
• Endocrine dysfunction – amenorrhoea in women and impotence in man, decreased
libido. AN before puberty can lead to delay of menarche and breast development

36
Q

Describe the cardiac abnormalities seen in AN

A

Hypotension (systolic <70mmHg), cardiomyopathy (heart is a muscle, muscle
breakdown in starvation), significant bradycardia (30-40bpm)

ECG changes
• Sinus bradycardia
• ST segment elevation
• T wave flattening
• Low voltage
• Right axis deviation
• All of which predisposes to arrhythmias

Echo/cardiomyopathy
• Decreased heart size
• Decreased left ventricular mass
• Mitral valve prolapse without significant mitral regurgitation

37
Q

name the main blood test abnormalities in AN (K, Na. glucose,cortisol, thyroid, progesterone, IGF, RBC, WBC)

A

Hypokalaemia (from vomiting), hyponatraemia (water-loading),
hypoglycaemia, hypothermia (very common because they have lost all their
brown fat and they tend to take cold showers which apparently burn
calories), altered thyroid function, hypercortisolaemia, amenorrhoea
(diagnostic criteria), delay in puberty, arrested growth, osteoporosis 
fractures

MOA of osteoporosis
• Due to low levels of progesterone and decrease IGF-1 levels

Anaemia, leukopenia, thrombocytopenia  pancytopenia due to bone
marrow hypoplasia  increased infections and challenging to tell if they are
suffering from sepsis – albumin drops and CRP rises but normal/low WBC

38
Q

identifying sepsis in pt with AN with low RBC and WBC

A

albumin drops and CRP rises but normal/low WBC

39
Q

First line management of eating disorder AN in GP + biological optional extras

A

1st line = structured eating plan with oral nutrition by dietician accompanied by psychological and biological treatments
• Realistic weight gain of 0.5-1kg/week

BIOLOGICAL

  1. Potassium repletion from purging/laxative abuse
  2. Mg repletion if hypoK refractory to oral K, Ca repletion, Na repletion
  3. Pt with hypoglycaemia – give milk over glucagon as it increases BM more slowly
  4. Pharmacological: fluoxetine (especially if obsessional ideas about food or pt with
    depression) but only when AN pts have normalised electrolyte and heart rate. SSRIs can cause long-QT
40
Q

When does AN pts need admission

A
  • Physical complications – cardiac, severe electrolyte imbalance
  • Extremely rapid weight loss or BMI<13.5
  • High suicide risk
41
Q

Common medical risks associated with AN

A
  • Severely underweight <14BMI
  • Rapid weight loss – more dramatic methods used, no compensation
  • Binge purge subtypes – hypoK, hypoNa
  • Exercise – increases strain on the heart
  • Alcohol problems
  • Medical comorbidities/pregnancy
  • Early stages of refeeding
42
Q

Def BN

A

Repeated episodes of binge eating with compensatory behaviors e.g. purging. Body
weight may be normal – BMI>17.5.

43
Q

Epidemiology of BN

A

Incidence 1-1.5% of women with mid-adolescent onset

Presentation later than for anorexia nervosa (late teens or twenties)

Pt with AN can progress to BN

44
Q

3 diagnostic criteria ICD10 for BN

A

Diagnostic criteria – ICD-10:
1. Persistent preoccupation with eating and irresistible craving for food. Binging.
2. Attempts to counteract “fattening” effects of food by one of: self-induced vomiting,
purgative abuse, alternation periods of starvation, drugs to suppress appetite, thyroid
preparations or diuretics. Diabetics may neglect insulin treatment
3. Psychopathology consists of morbid dread of fatness; patient sets sharply defined
weight threshold (well below premorbid weight or healthy weight). Often but not
always Hx of anorexia nervosa (months to years previously)

45
Q

1st and 2nd line tx for BN

A

Most are managed in the community.

1st line = CBT + nutritional and meal support (dietician) +/- SSRI and other psychological therapies.

2nd line = SSRI alone

Admission only if suicidal, DM, physical symptoms e.g. LOC, syncope, seizures, pregnant

46
Q

prognosis of BN v AN

A

BN generally good - almost all recover except those with sig issues of low self-esteem, PD

AN rule of 1/3. 1/3 recover, 1/3 partial 1/3 chronic

47
Q

Define learning disability

A

Learning disability is a developmental condition characterised by global impairment of intelligence (IQ<70) and significant difficulties in socially adaptive functioning.
Both must be present before age <18 years.

It is NOT A DIAGNOSIS – it merely describes a constellation of symptoms for which the aetiology may or may not be known e.g. Down’s syndrome

48
Q

Classification of learning disability by ICD10 and DSM

A
  • Mild: IQ50-69 Mental age 9-12 years old
  • Moderate: IQ34-49 Mental age 6-9 years old
  • Severe: IQ20-34 Mental age <6 years
  • Profound: IQ<20
49
Q

Epidemiology of learning disability

A

2.5% of population has mild LD
0.4% moderate LD
<0.1% for both severe and profound combined

50
Q

Define disability v impairment v handicap

A

Impairment = any loss or abnormality of psychological, physiological, or anatomical structure or function

Disability = restriction or lack (resulting from impairment) of ability to perform an activity in the manner or within the range considered normal for a human being

Handicap= disadvantage for a given individual, resulting from impairment or disability that limits or prevents the fulfilment of a role that is normal to that individual

51
Q

What are some causes and risk factors for learning disability

A

Specific cause of LD can be identified in 80% of severe and 50% of mild LD. Modern classification of aetiological factors are based on timing of the causative event:

Antenatal
* Genetics (see later) 
* During pregnancy 
•	Alcohol: FAS 
•	Drugs
•	Medication 
•	Smoking
•	Infection e.g. rubella

Perinatal

  • Neonatal hypoxia/sepsis
  • Birth trauma
  • Hypoglycaemia
  • Prematurity

Postnatal

  • Social deprivation
  • Malnutrition
  • Lead
  • Infections e.g. meningitis
  • Head injury

Mild disability often no aetiology can be found

Sera's MBBS (12 decks)

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