Pysch Flashcards
Define acute intoxication
Transient disturbance of consciousness, cognition, perception, affect or behaviour following administration of psychoactive substances
Define substance harmful use
Diagnosis requires actual damage to have been done ot the mental or physical health of subject to qualify
Dependence syndrome (def)
Cluster of symptoms revolving around central theme of desire (strong and sometimes overpowering) to take psychoactive substance
Define withdrawal state
Physical and psychological symptoms occurring on absolute or relative withdrawal of substance
Define amnesic disorder in substance abuse
Chronic, prominent impairment of recent memory and other cognitive impairments caused by substance use (most common alcohol)
Define residual and late onset psychotic disorder with substance use
Effects on behaviour, affect, personality or cognition lasting beyond the period during which direct psychoactive substance effect might be expected
How does ICD10 classify substance abuse disorders
(1) substance
(2) type of disorder e.g. acute intoxication, dependence, withdrawal, psychotic, amnesic, harmful use etc
Biological pathway of addiction/substance misuse - specifying the way cocaine, amphetamine, alcohol and opiate affect this pathway
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.
What drug classes causes physical withdrawal syndrome
Classically the ABO
Alcohol
benzodiazepines
Opiates
But also GBL/GHB
Other drugs cause psychological withdrawal and craving but not physical symptoms
ICD10 features of dependence syndrome
- 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
Stages of change - Prochaska and Diclemente
Enter here: Precontemplation Contemplation Determination Action Exit here: maintenance or relapse
Active ingredient in alcohol
Ethyl alcohol
Epidemiology of alcohol dependence
Lifetime prevalence of 5.4%
12 month prevalence of 1.3%
Features of alcohol - acute intoxication
Relaxation and euphoria
Slurred speech, impaired coordination and judgement
Impulsive and poor judgement
labile affect
if severe: hypoglycaemia, stupor and coma
Features of alcohol - harmful use/at risk drinking
Physical or mental damage caused by alcohol drinking
Features of alcohol - psychotic disorders
Alcoholic hallucinations - mostly auditory, usually persecutory or derogatory
morbid jealousy - overvalued idea that partner is unfaithful
Features of Wernicke’s encephalopathy
Ataxia
Opthalomoplegia
Confusion
Features of Korsakoff’s psychosis
Confabulation
Regular black out
Antegrade amnesia
Features of alcohol withdrawal - acute
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
Features of uncomplicated alcohol withdrawal
4-12 hours
Coarse tremor, sweating, insomnia, tachycardia, psychomotor agitation, anxiety +/- hallucinations (transient tactile, auditory, visual)
Features of complicated alcohol withdrawal
withdrawal features of CNS overexcitability + seizures
5-15% of withdrawal
Grand mal seizures 6-48 hours after last drink
Delirium tremens (medical emergency)
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
investigations for suspected alcohol abuse
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
key aspects of an alcohol history
Lifetime pattern Current consumption level Sighs of dependence Physical and mental health compliants Social previous treatment attempts FHx motivation interviewing
management of alcohol withdrawal
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
Considerations for choosing chlodiazepoxide or diazepam for alcohol withdrawal
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
Who needs alcohol detox therapy for alcohol withdrawal
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
Choosing between OPD alcohol detox v inpatient alcohol detox
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
Advice on pts on alcohol detox
Give verbal and written advice
inform GP
Give pt contact for emergencies
Decide on explicit follow up after detox
Drugs that can prevent alcohol misuse/relapse after detox
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
Safe drinking advice
- 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
how to calculate alcohol units
• 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
Prognosis of alcohol abuse - % die prematurely, % will have lifelong alcohol related problems, % favourable outcomes
40% die prematurely (15% by suicide)
30% have lifelong alcohol related problems
30% favourable outcome
SCOFF questionaire
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?
4 main diagnostic points in Anorexia nervosa (ICD10)
• 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
Describe the cardiac abnormalities seen in AN
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
name the main blood test abnormalities in AN (K, Na. glucose,cortisol, thyroid, progesterone, IGF, RBC, WBC)
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
identifying sepsis in pt with AN with low RBC and WBC
albumin drops and CRP rises but normal/low WBC
First line management of eating disorder AN in GP + biological optional extras
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
- Potassium repletion from purging/laxative abuse
- Mg repletion if hypoK refractory to oral K, Ca repletion, Na repletion
- Pt with hypoglycaemia – give milk over glucagon as it increases BM more slowly
- 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
When does AN pts need admission
- Physical complications – cardiac, severe electrolyte imbalance
- Extremely rapid weight loss or BMI<13.5
- High suicide risk
Common medical risks associated with AN
- 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
Def BN
Repeated episodes of binge eating with compensatory behaviors e.g. purging. Body
weight may be normal – BMI>17.5.
Epidemiology of BN
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
3 diagnostic criteria ICD10 for BN
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)
1st and 2nd line tx for BN
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
prognosis of BN v AN
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
Define learning disability
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
Classification of learning disability by ICD10 and DSM
- 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
Epidemiology of learning disability
2.5% of population has mild LD
0.4% moderate LD
<0.1% for both severe and profound combined
Define disability v impairment v handicap
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
What are some causes and risk factors for learning disability
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
