Self-harm and substance misuse Flashcards
1
Q
Forms of psychiatric illness from substance misuse
A
- acute intoxication - usually transient
- harmful use - recurrent misuse a/w physical psychological + social consequences, but not dependence
- dependence syndrome - prolonged compulsive substance use causing addiction, tolerance and potential for withdrawal sx when stopped
- withdrawal state - physical/psychological effects from stopping substance after prolonged/high level of use
- psychotic disorder - psychotic sx within 2w of substance use that persists for >48h
- amnesic syndrome - memory impairment in recent memory + clouding of consciousness
- residual disorder - things like PD, affective disorders, dementia, cognitive impairment. as a result of substance misuse
2
Q
Opiate misuse
A
- psych effects: apathy, disinhibition, psychomotor retardation, impaired judgement, slurred speech, drowsy
- physical effects: resp depression, hypoglycaemia, hypotension, pupillary constriction
- withdrawal signs: craving, rhinorrhoea, lacrimation, myalgia, N+V, abdo cramps, diarrhoea, pupil dilation, tachycardia, HTN, piloerection
3
Q
Cannabis misuse
A
- psych: euphoria, disinhibition, agitation, paranoid ideation, impaired judgement/reaction time, hallucinations, illusions
- physical: increased appetite, dry mouth, conjunctival injection, tachycardia
- withdrawal: anxiety, irritability, tremor, sweating, myalgia
4
Q
Sedative misuse
A
BZD, barbiturates
- psych: euphoria, disinhibition, apathy, aggression, amnesia, labile mood
- physical: unsteady gait, slurred speech, nystagmus, erythematous skin lesions, hypotension, hypothermia, coma
- withdrwal: tremor, N+V, tachycardia, postural hypotension, headache, agitation, malaise, paranoid ideation, convulsions, illusion/hallucination
5
Q
Stimulant misuse
A
Cocaine, crack cocaine, ecstasy (MDMA), amphetamines
- psych: euphoria, increased energy, grandiose beliefs, aggression, illusions, hallucinations, paranoid ideation, labile mood
- physical: tachycardia, HTN, arrhythmia, sweating, N+V, pupil dilation, muscular weakness, CP, acute MI, stroke
- withdrawal: dysphoric mood, lethargy, psychomotor agitation, craving, insomnia/hypersomnia, bizarre dreams
6
Q
Hallucinogen misuse
A
LSD, magic mushrooms
- psych: anxiety, hallucinations, depersonalisation, derealisation, paranoia, ideas of reference, hyperactivity, impulsivity
- physical: tachycardia, palpitations, sweating, tremor, blurred vision, pupil dilation, incoordination
7
Q
Solvent misuse
A
Aerosols, paint, glue, petrol
- psych: apathy, lethargy, aggression, impaired judgement, psychomotor retardation
- physical: unsteady gait, diplopia, nystagmus, reduced consciousness, muscle weakness
8
Q
Anabolic steroid misuse
A
Testosterone, danazol, androstenedione (PO/IM)
- psych: euphoria, depression, aggression, hyperactivity, mood swings, hallucinations, delusions
- physical: increased muscle, reduced fat, acne, male pattern baldness, reduced sperm count, stunted growth
9
Q
Novel psychoactive substance misuse
A
Mamba, spice - powerful cannabinoids
- causes psychosis
- can cause fits, incoordination
10
Q
Opiate withdrawal signs + management
A
- early 12h: sweating, clammy, rihnorrhoea, tachycardia, restlessness, dilated pupils, lacrimation, goose bumps
- late 2-3d: N+V, diarrhoea, insomnia, abdo cramps, muscle pain
Management:
- methadone: less addictive than heroin. titrate as can be fatal in non-tolerant pt. first line
- buprenorphine (subutex): sublingual, partial opiate agonist. easiest to withdraw from, for detoxification + maintenance
11
Q
Principles of management of substance misuse
A
- Bio: hepatitis B immunisation for IV, detoxification (eliminate drugs in a safe manner), maintenance therapy to minimise harm e.g. safe places to inject
- psych: motivational interviewing, CBT
- social: key worker, support for housing etc, self help groups
12
Q
Complications of substance misuse
A
- Physical: death, infection (hepatitis, HIV, staph aureus, TB), endocarditis, superficial thrombosis, DVT, PE
- Psych: craving, anxiety, cognitive disturbance, drug-induced psychosis
- Social: crime, imprisonment, homelessness etc
13
Q
Pathophysiology of alcohol abuse
A
- neurotransmiter effects causing anxiolysis + sedation
- dopaminergic pathway sensitised - pleasurable effects of alcohol
- long term exposure causes down regulation of inhibitory receptors + up regulation of excitatory receptors
- social learning theory + operant conditioning
14
Q
Medical effects of alcohol abuse
A
- hepatic - fatty liver, hepatitis, cirrhosis, HCC
- hepatic encephalopathy - m=lactulose
- Wernicke’s encephalopathy - thiamine deficiency - m is parenteral thiamine
- Korsakoff’s psychosis
- GI: PUD, oesophageal varices, pancreatitis, oesophageal carcinoma
- CVS : HTN, cardiomyopathy, arrhythmias
- Haem: anaemia, thrombocytopenia
- Neuro: seizures, peripheral neuropathy, cerebellar degeneration, head injury from falls
- Foetal alcohol syndrome
15
Q
Psychiatric effects of alcohol abuse
A
- SH/suicide
- Mood + anxiety disorders
- Alcoholic dementia
- Delirium tremens
- Social effects like domestic violence, drink driving, loss of employment, financial issues, homelessness, accidents
16
Q
Alcohol intoxication
A
slurred speech, labile affect, impaired judgement, poor coordination, severe may have hypoglycaemia, stupor and coma
17
Q
Alcohol dependence
A
subjective awareness of compulsion, avoidance/relief of withdrawal symptoms by further drinking, withdrawal symptoms, drink-seeking behaviour predominates, reinstatement of drinking after attempted abstinence, increased tolerance, narrowing of drinking repertoire (i.e. fixed times for drinking, reduced influence from environmental cues)
18
Q
What is meant by harmful alcohol use?
A
drinking above safe levels with evidence of alcohol-related problems
19
Q
What is the recommended maximum alcohol intake per week?
A
14 units
and not binge drinking (>2x recommended daily alcohol level [so >4 units] in one sesh)
20
Q
Alcohol withdrawal
A
symptoms like malaise, tremor, nausea, insomnia, hallucinations, autonomic activity (sweating, tachycardia) at 6-12h after abstinence, seizures peak incidence 36h, severe end of spectrum is delirium tremens (peak incidence 72h after abstinence).
ICD 10:
- General criteria for withdrawal state: clear evidence of recent cessation/reduction of substance after prolonged/high level usage, not accounted for by medical/mental disorder
- Any 3 of the following: tremor, sweating, N/V, tachycardia/hypertension, headache, psychomotor agitation, insomnia, malaise, transient hallucinations, grand mal convulsions
21
Q
Delirium tremens
A
withdrawal delirium. Occurs 24h-1w after alcohol cessation (peak 72h), predisposed by physical illness. Dehydration and electrolyte disturbances are a feature.
Characteristics:
- cognitive impairment
- vivid perceptual abnormalities
- paranoid delusions
- marked tremor
- autonomic arousal
large doses of BZDs e.g. lorazepam first line, haloperidol for psychotic features, IV Pabrinex
22
Q
A tool for screening for alcohol abuse?
A
CAGE
- C-have u felt u should cut down on drinking?
- A-have people annoyed you by criticising your drinking?
- G-have you felt guilty about drinking?
- E-do you have a drink early in morning to steady nerves/wake up (eye opener)
23
Q
Management of alcohol dependence
A
- Bio: disulfiram (causes build up of acetaldehyde when consume alcohol – unpleasant sx like flushing anxiety and headache), acamprosate (Reduces craving by enhancing GABA transmission), naltrexone (opioid receptor antagonist – reduces pleasurable effects)
- Psych: motivational interviewing, CBT
- AA has a 12 step approach using psychosocial techniques to change behaviour
24
Q
Management of acute alcohol withdrawal
A
high dose benzodiazepine e.g. chlordiazepoxide or carbamazepine – controlled withdrawal in community or inpatient (inpatient recommended if high risk of suicide, poor social support or hx of severe withdrawal). Dose tapered down over 5-9 days. Thiamine (vitamin B1) given to prevent Wernicke’s encephalopathy – PO 200-300mg daily or IV as Pabrinex
25
Korsakoff's psychosis
profound, irreversible short-term memory loss with confabulation and disorientation to time, immediate recall usually preserved, other function largely normal
26
Types of DSH
* injury: cutting, burning, stabbing, swallowing objects, jumping from heights etc
* self-poisoning: medication, OTC, illicit drugs, household substances, plant material. majority in UK are with paracetamol/BZDs/ADs
motives: wish to die, cry for help, communication with others, unbearable sx
often coping mechanism for temporary relief of anxiety/stress/sense of failure
27
What should you ask about in a patient who has DSH?
Intentions - suicide? sx/problem temporary relief? influencing others? punishment?
28
How is DSH managed?
* Bio: treat overdose with antidote, suturing, anti-tetanus treatment for deep lacerations, reduce access to DSH methods e.g. prescribe limited amount of meds at a time. Alcohol can add to dangers of OD as it increases toxicity + can delay treatment due to unconsciousness
* Psycho: counselling, CBT for depressive illness, psychodynamic psychotherapy may be appropriate in PD
* Social: social service input, voluntary organisations, drug/alcohol services
* General: risk assessment is mandatory, often involve Crisis team to avoid admission, consider inpatient psychiatric assessment
29
Antidotes for common drugs OD on?
```
Activated charcoal – can prevent/reduce absorption of drug for majority of drugs taken in OD within 1 hour of ingestion
Paracetamol N-acetylcysteine
Opiates naloxone
Benzodiazepinesflumazenil
Warfarinvitamin K
Heparin protamine sulfate
Beta blockers glucagon
TCAs sodium bicarbonate
Organophosphates atropine
```
30
Risk factors for suicide
* clinical RF: history of DSH/attempted suicide, psych illness, childhood abuse, FH, medical illness esp chronic, drugs + alcohol
* social RF: male, age (40s highest), unemployment/low SES, occupation (doctors,,vets,,farmers), access to lethal means, low social support/living alone, recent life crisis
* Protective factors: children, pregnancy, religion (..), strong social support, positive therapeutic relationships, life satisfaction, fear of disapproval, fear of the physical act of suicide
31
CF of suicidal people
* preoccupation with death
* sense of isolation
* emotional distance from others
* distraction + anhedonia
* focus on the past
* feelings of hopelessness + helplessness
32
What is involved in a psychiatric risk assessment?
1. Exploring suicidal ideation-how do you feel about your future, do you feel life is worth living, have you ever thought about taking your own life
2. Exploring suicide intent-was it planned, what method, note, will etc, were they intoxicated, were they alone, precautions to avoid discovery, did they think they were certain to die, how long had they been contemplating suicide for, did they seek help or were they found, how do they feel about being found
3. Exploring risk factors: is there anything making you feel this way, have you tried before-explain, are you aware if you are suffering any MH illness, do you have any health problems bothering you at the moment, is there any FU of suicide/self harm
4. MSE-dishevelled, unkempt, wrist lacerations, neck burns, low mood, flat affect, delusions about benefits of suicide, may have 2nd person auditory command hallucinations
5. Explore protective factors: anything that’d stop you carrying this out, what are positive things, do you have someone to confide in, home support
6. Risk to others: do you ever have thoughts of harming others, do you have close contact with any children (document name, dob, place of residence, nature of relationship), do you ever feel threatened or at risk from other. In psychiatry homicide risk is increased by specific persecutory delusions/hallucinations and command auditory hallucinations. Assess premorbid personality, circumstances of prior violent behaviour, potential victims, aftercare.
7. Determine if medium high or low risk
