Substance Abuse, Human Sexuality and Sleep Flashcards
Drugs working in nucleus accumbens
- Amphetamines
- Cocaine
- Opiates
- TCH
- PCP
- Nicotine
- Ketamine
Sexual Identity
Based on person’s secondary sexual characteristics
Stage 1 EEG waves
Theta waves (3-7 cps)
Substance Abuse Diagnosis
One or more of the following in 1 year:
- Failure to fulfill responsibilities at work, school or home
- Use in physically hazardous situations (driving while intoxicated)
- Legal problems during the time of use
- Continued used despite recurrent social or interpersonal problems secondary to the effects of such use
Benzodiazepines Withdrawal specific findings and Treatment
- Sleep disturbance
- Depression and rebound anxiety
- Rx: supportive
Circadian rhythm sleep disorders Treatment
- Sleep hygiene
- Dark therapy: blue blocking goggles (blocks blue and bluegreen wavelength) during evening hours so production of melatonin is not reduced or eliminated
- Modafinil
- Melatonin may be useful if given 5 and a half hours before the desired bed time
- Tasimelteon (melatonin agonist) for treatment of just non-24-hour sleep-wake disorder in totally blind people
- Sleep phase chronotherapy
Alcoholism treatment
Important notes
- Most successful way to get person to treatment is to be referred by employer
- The 12-step program (Grassroots movement)
- Spiritual program
- Al-Anon program for family and friends: deals with codependence and enabling behavior
- Disulfiram which interferes with aldehyde dehydrogenase and produces symptoms of nausea, chest pain, hyperventilation, tachycardia and vomiting. It should be used with psychotherapy
- Naltrexone: reduces cravings
- Acamprosate
Consequences of sleep deprivation
- Decreased lymphocyte levels
- Cortisol level rises
- Blood pressure rises
- Glucose tolerance is reduced
- Greater amygdala activation
- Lower prefrontal cortical activity
- Increased negative mood
Melatonin and Sleeping
- It’s not related to sleep but rather to feelings of sleepiness
- Produced by pineal gland and directly in the retinas of the eyes
- Release inhibited by daylight, while at night time levels rise dramatically
- Responsible for “jet lag” and seasonal affective disorder (SAD)
- Adjust it with bright light therapy not pills
Heroine addiction risks and treatment
- Users at increased risk of hepatitis, HIV, abscesses, bacteremia, right-heart endocarditis
- Rx:
- Methadone: for detoxification or long-term maintenance
- Naloxone+buprenorphine: withdrawal symptoms occur only if injected (lower abuse potential)
- Naltrexone: relapse prevention once detoxified
Barbiturates Withdrawal specific findings and Treatment
- Autonomic hyperactivity
- Hallucinations
- Grand mal seizures
- Delirium
- Life-threatening cardiovascular collapse and death
- Rx: supportive
Physiology of substance abuse
Mesolimbic pathway: stimulus (food, drugs, sex, kindness) —-> cerebral cortex —-> ventral tegmental area —-> nucleus accumbens (Dopamine which increases desire for stimulus and Serotonin which gives body the impression of satisfaction so cravings are reduced)
CNS Stimulants drugs
- Amphetamines
- Cocaine
- Caffeine
- Nicotine
Sleep Apnea consequences
- High risk of death during sleep, development of severe nocturnal hypoxemia, pulmonary and systemic hypertension (elevated diastolic pressure)
- Nocturnal cardiac arrhythmias (life-threatening)
- EDS and insomnia
- Short sleep duration, frequent waking, decreased stage 1, delta and REM
Nicotine Intoxication specific findings and Treatment
- None in usual doses
- Restlessness, insomnia and anxiety
- Impotence and depression
- Traffic accidents and more days lost from work
- Rx: none
Wernicke-Korsakoff syndrome
- Caused by vitamin B1 (thiamine) deficiency
- Confusion, ophthalmoplegia and ataxia (Wernicke encephalopathy)
- Which may progress to irreversible memory loss, confabulation, and personality change (Korsakoff syndrome)
- Associated with periventricular hemorrhage/necrosis of mammillary bodies
- Rx: IV vitamin B1
Lysergic acid diethylamide (LCD), mescaline and ketamine Intoxication specific findings and Treatment
- Hallucinations (visual and auditory)
- Illusions
- Ideas of reference and depersonalization
- Anxiety, incoordination and pupillary dilation
- Psychosis and possible flashbacks
- Rx: supportive counseling, talking down, anti-psychotics and/or benzodiazepines
Consequences of teenage pregnancy
- For mother:
- Leading cause of school dropout
- High risk of obstetric complications
- For child:
- Neonatal deaths and prematurity are common
- Possible lower level of intellectual functioning
- Problems of single-parent family (increased risk of delinquency and suicide)
Barbiturates Intoxication specific findings and Treatment
- Very low safe margin
- Slurred speech, uncoordination and unsteady gait
- Impairment judgment
- Severe respiratory depression
- Coma and death
- Rx: supportive (mechanical ventilation and increase BP), and sodium bicarbonate to alkanize urine in overdose
Awake EEG waves
Low voltage random fast beta waves
Sexual Desire Disorders
- Hypoactive: deficiency or absence of fantasies or desires, 20% of population, more common in women. Causes: low testosterone in men, CNS depressants, common post-surgery, depression, marital discord, and oral contraceptives which depress libido
- Sexual aversion: aversion to all sexual contact
Colleague physician with substance abuse (steps of management)
1- Get the colleague to suspend patient contact
2- You must report it to hospital administration and the State Board (according to your position)
3- Ideally, get the colleague into treatment
Stage 2 EEG waves
Sleep spindles (12-14 cps) and K complexes
Sleep Facts
- Circadian rhythm which is regulated by superchiasmatic nucleus (SCN)
- Most NREM stages 3 and 4 occur during the first half of night
- Stage 3 and 4 are known as delta sleep or slow-wave sleep
- Most REM occurs during the last half of night. REM gets progressively longer as night goes on. REM is an example of ultradian rhythm
- Average adult spends most sleep time in stage 2, and least in stage 1. Most commonly wake out of REM or stage 2
- Sleep latency 5-15 minutes
- REM latency 90 minutes
Caffeine Psychopharmacology
Antagonist of adenosine receptors, increased cAMP in neurons that have adenosine receptors
Sudden Infant Death Syndrome (SIDS)
- Maternal smoking and families where someone smokes are high risk
- 5-HT levels 25% below normal
- 50% reduction if baby placed on back rather than on stomach
Phencyclidine (PCP, angel dust) Psychopharmacology
Antagonist of N-methyl D-aspartate glutamate receptors, prevents influx of calcium ions, activates dopaminergic neurons
Delta sleep changes
Increase after exercise and seems to be the result of raised cerebral temperature
Lysergic acid diethylamide (LCD), mescaline and ketamine Withdrawal specific findings and Treatment
None
Female Sexual Arousal Disorder
- Women unable to achieve adequate vaginal lubrication
- May be hormonally related: many women report peak sexual desire just prior to menses
- Anti-histamines and anti-cholinergics cause decrease in vaginal lubrication
Notes on Diagnosis and Treatment of Substance abuse
- Substance use is often denied or under-reported, so seek out collateral info from family and friends
- Check urine and blood toxicology screens, LFTs and serum EtOH level
- Detoxification: usually 5 to 10 days in hospital settings to assure safe detoxification
- Rehabilitation: usually 28 days or more, with focus on relapse prevention techniques
- Other Rx is according to the type of substance abused
Opiates (heroine, codeine, oxycodone) Psychopharmacology
Opiate receptors, locus cereleus pathway (noradrenergic), NAC pathway
Sexual dysfunction differential diagnosis
- Drugs like anti-hypertensives, neuroleptics, SSRIs and ethanol
- Diseases like depression, diabetes and STIs
- Psychological (performance anxiety)
Anabolic steroids Intoxication specific findings and Treatment
- Skin atrophy, spontaneous bruising, acne and low serum potassium. In men: breast development, scrotal pain, and premature baldness. In women: disrupted menstrual cycle, deepening of voice and excessive body hair
- Irritability, aggression, mania and psychosis
- With chronic use: cardiomyopathy, bone mineral loss with later osteoporosis, hypertension, diabetes, atrophy of testes
- Rx: Anti-psychotics
MDMA (ecstasy) Withdrawal specific findings and Treatment
- Depression, fatigue and change in appetite
- Difficulty in concentration and anxiety
- Rx: none
Rapid Eye Movement (REM) Sleep
- Awake brain in a paralyzed body
- Fast EEG waves, sexual arousal, saccadic eye movements and dreaming
- Associated with Pons
Alcoholic hallucinosis
- Visual hallucinations (12-48 hours) after last drink
- Rx: benzodiazepines (chlordiazepoxide, lorazepam and diazepam)
CNS Stimulants Intoxications non-specific findings
- Mood elevations
- Psychomotor agitation
- Insomnia
- Cardiac arrhythmias
- Tachycardia
- Anxiety
Alcohol and Alcoholism
Important facts
- It is the most abused drug for all ages
- Most widely used illicit drug for teenagers while marijuana for adults
- Higher in low SES, but recovery is sooner
- It is implicated in 15% of all auto accidents and 50% of all auto accidents not involving pedestrians, auto accident deaths, homicides (killer or victim), and hospital admissions
Paraphilic Disorders
- Voyeurism: pleasure from watching others who are naked, grooming, or having sex
- Fetishism: focus on objects like shoes or stockings
- Transvestite fetishism: heterosexual males who dress as females for sexual arousal
- Frotteurism: rubbing genitals against clothed nonconsenting people
- Coprophilia: combining sex and defecation
- Most common one is pedophilia and more common in men. Must occur for more than 6 months and cause distress as well as adversely affect level of functioning to diagnose
- Rx: individual psychotherapy, behavioral modification techniques such as aversive conditioning, and antiandrogens or SSRIs to reduce sexual drive
Inhalants (glue, paint thinner) Withdrawal specific findings and Treatment
None
Mallory-Weiss syndrome
- Partial thickness tear at gastroesophageal junction caused by excessive/forceful vomiting
- Often present with hematemesis and misdiagnosed as ruptured esophageal varices
Circadian rhythm sleep disorders Definition and Types
- Misalignment between desired and actual sleep periods
- Extrinsic:
- Shift work sleep disorder
- Jet lag (formerly)
- Intrinsic:
- Advanced phase sleep disorder (APSD): difficulty staying awake in evening and difficulty staying asleep in morning
- Delayed phase sleep disorder (DPSD): much later than normal timing of sleep onset and offset and a period of peak alertness in the middle of night
- Irregular sleep-wake rhythm: sleeping at very irregular times (usually more than twice per day)
- Non-24-hour sleep-wake disorder: timing of sleep onset and offset with peak alertness are continuously moving around the clock from day to day
Opioids Intoxication specific findings and Treatment
- Euphoria that leads to apathy, slurred speech and drowsiness
- Pupillary constriction (pin-point pupils) and decreased gag reflex
- Respiratory depression that could be fatal
- Constipation
- Seizures (overdose)
- Coma and death
- Rx: Naloxone and naltrexone (be aware of antagonist clearing before opioid especially with long acting ones like methadone)
Marijuana (cannabinoid) Psychopharmacology
Inhibitory G protein, GABA, increased serotonin, lower level of NAC activation
Dopamine and Sleep
- Increases wakefulness
- Dopamine blockers like anti-psychotics increases sleep somewhat
Alcohol Intoxication specific findings and Treatment
- Emotional liability and slurred speech
- Ataxia, blackouts and memory impairment
- Judgment impairment and coma
- Serum gamma-glutamyltransferase (GGT) is sensitive indicator of alcohol use. AST value is twice ALT value
- Rx: supportive, and mechanical ventilation if severe
Bruxism (Teeth-grinding)
- Stage 2 sleep
- Prevention is to use oral device
Causes of Secondary Insomnia
- Hypnotic medications abuse (tolerance with sleep architecture disruption and sleep fragmentation)
- Emotional problems like anxiety, depression and mania
- Conditioned poor sleep: sleep cycle is disrupted so that the habit of sleep is lost
- Withdrawal from drugs and alcohol
- CNS stimulants drugs like amphetamines, caffeine and nicotine
- Deviated nasal septum, Restless leg syndrome and periodic limb movement disorder
- Hormonal like menstruation, menopause and hyperthyroidism
- Physical exercise
- Fatal familial insomnia (AD, extremely rare, prion disease, methionine codon at position 129[valine in Creutzfeldt-Jacob disease])
Stages of behavioral changes in substance abuse
1- Precontemplation: unaware of problem
2- Contemplation: aware of problem but ambivalent about action
3- Preparation (Determination): first decision to change (small steps taken)
4- Action (Willpower): change begins (trial and error)
5- Maintenance: new behaviors practiced (focus on relapse prevention)
6- Relapse: efforts to change abandoned
Substance Abuse
Maladaptive pattern of substance use that leads to engaging in hazardous situations, legal problems, inability to fulfill obligations, and continued use despite adverse consequences
Amphetamines and Cocaine Psychopharmacology
- Noradrenaline system, NAC pathway (dopaminergic)
- Amphetamine release DA
- Cocaine prevent DA re-uptake
Narcolepsy Definition and diagnosis
- Inability of brain to control sleep-wake cycle due to decreased hypocretin (orexin) production in lateral hypothalamus leading to REM sleep disorder (REM latency is 10 minutes)
- Narcoleptic tetrad for 3 months
- Sleep attacks and excessive daytime sleepiness
- Cataplexy (pathognomonic)
- Hypnagogic (while falling asleep) and Hypnopompic (while waking up) hallucinations
- Sleep paralysis (while waking up)
Phencyclidine (PCP, angel dust) Withdrawal specific findings and Treatment
None
Inhalants (glue, paint thinner) Psychopharmacology
GABA, cross tolerance, cerebellum (versus basal ganglia for Parkinson’s)
Gender Role
Based on external patterns of behavior that reflect inner sense of gender identity
Sexually transmitted diseases Facts
- Highest incidence is HPV
- Highest prevalence is HSV-2
- Most reported STD in women is chlamydia
- Most reported STD in men is gonorrhea
Alcohol Withdrawal specific findings and Treatment
- Agitation and hallucinations (visual)
- Autonomic hyperactivity (tachycardia and hypertension) and delirium tremens which is expected on second to fourth day (5-15% mortality rate)
- Rx: Benzodiazepines (oxazepam, temazepam, and lorazepam), thiamine, folic acid and multivitamins
Substance Withdrawal
Cessation or reduction of a substance leading to either psychological or physiological changes
Substance Dependence
Maladaptive pattern of substance use that leads to tolerance. There is withdrawal when trying to cut down. Patients spend a great deal of time engaging in drug use. There is continued use despite adverse consequences
MDMA (ecstasy) Intoxication specific findings and Treatment
- Effects begin in 45 minutes and last for 2-4 hours
- Derealization, hallucinations and mania-like mood
- Hyperthermia, hypertension and death (hyponatremia)
- Serotonin syndrome
- Rx: none
Sexual Pain Disorders
- Dyspareunia: recurrent and persistent pain before, during, or after intercourse in either men or women (more common in women). Not diagnosed if due to medical condition. Rx: psychotherapy
- Vaginismus: involuntary muscle constriction of the outer third of vagina. Prevent penile insertion. Rx: relaxation and Hegar dilators
Narcolepsy Treatment
- Modafinil or amphetamines for excessive daytime sleepiness (inhibits DA re-uptake and activates glutamate while inhibits GABA
- Anti-depressants (TCA, SNRI)
- Gamma hydroxybutyrate (GBH) (sodium oxybate) to reduce excessive daytime sleepiness and cataplexy
- Forced daytime naps
Drugs working in ventral tegmental area
- Opiates
- Alcohol
- Barbiturates
- Benzodiazepines
Benzodiazepines Intoxication specific findings and Treatment
- Greater safety margin
- Slurred speech, uncoordination and unsteady gait
- Impairment judgment
- Minor respiratory depression
- Rx: Flumazenil (BZs receptor antagonist, but rarely used as it can precipitate seizures)
Sleep Apnea Treatment
- Weight loss (if applicable)
- Behavioral conditioning to change sleep position
- Continuous positive airway pressure (CPAP). most likely medical intervention
- Mechanical ventilation (BiPAP) in central sleep apnea
- For severe obstructive and mixed: tonsillectomy or tracheostomy
Substance Dependence Diagnosis
Three or more of the following in 1 year:
- Withdrawal
- Interest or Important activities given up or reduced
- Tolerance
- Harm (physical or psychological) with continued use
- Desire to cut down/control
- Intended time/amount exceeded
- Time spent obtaining
Night Terrors vs Nightmares
- Night terrors in stage 4 (delta sleep) while nightmares during REM
- No recall in night terrors while there is in nightmares
- Triggers are emotional stress, fever and lack of sleep
- Night terrors run in families, more common in boys and may be a precursor for temporal lobe epilepsy
- Nightmares common in ages 3-7, and if chronic there is likelihood of serious pathology
- Getting 30 to 40 minutes extra sleep at night greatly reduces both of them
Major Depression and Sleep
- Increases REM and decreases REM latency (45 minutes rather than 90)
- Decreases stage 3 and 4 sleep
- Increased sleep in multiple periods over 24 hours
- Early morning waking
- Diurnal improvement
- Sleep deprivation gives 60% remission from symptoms
- People with a lot of REM are more susceptible to onset of depression
Marijuana (cannabinoid) Withdrawal specific findings and Treatment
- Irritability, anxiety and depression
- Restlessness, insomnia, and decreased appetite
- Rx: none
Male Orgasm Disorder (Premature ejaculation)
- More common if early sexual experiences were in back seat of car or with prostitute, anxiety about sexual act
- Rx: stop and go technique, squeeze technique and SSRIs
Medical complications of alcohol abuse
- Alcoholic hepatitis and cirrhosis
- Pancreatitis
- Gastric or duodenal ulcers
- Esophageal varices
- Middle-age onset diabetes
- GI cancer
- Hypertension
- Peripheral neuropathies and myopaties
- Cardiomyopathy
- CVA
- Erectile dysfunction, vitamin deficiencies, and pernicious anemia
- Brain disorder including Wernicke-Korsakoff syndrome
Amphetamines Intoxication specific findings and Treatment
- Euphoria, grandiosity, paranoia, and hypervigilance
- Hallucinations
- Stereotyped behavior and impaired judgment
- Anorexia, diaphoresis, tachycardia and hypertension
- Pupillary dilation
- Angina,cardiac arrest and seizures (severe intoxication)
- Rx: Anti-psychotics (haloperidol for severe agitation) and/or benzodiazepines and/or anti-hypertensives
Neurotransmitters Associated with Sleep
- Serotonin: helps initiate sleep
- Acetylcholine (ACh): higher during REM (associated with erection in men)
- Norepinephrine (NE): lower during REM
- Dopamine: produces arousal and wakefulness
Nicotine Psychopharmacology
Agonist at Ach receptors, activates dopaminergic pathway (positive reinforcer), speeds and intensifies flow of glutamate
Enuresis (Bed-wetting)
- It can occur at any stage of sleep, but most commonly in stage 3 and 4
- More in boys
- History of same sex parent
- Defense mechanism of regression
- Rx: Bell-pad technique, desmopressin, and imipramine
Homosexuality
- 4-10% of all males and 1-3% of all females
- Ego-syntonic: agrees with sense of self (comfortable)
- Ego-dystonic: disagree with sense of self (non-comfortable) and needs to be treated
Phencyclidine (PCP, angel dust) Intoxication specific findings and Treatment
- Belligerence (assaultiveness), violence, impulsiveness and agitation
- Vertical/horizontal nystagmus
- Hyperacusis, muscle rigidity and decreased response to pain
- Tachycardia and hypertension
- Impaired judgment, seizures, delirium and psychosis
- Trauma is the most common complication
- Rx: Nonstimulating environment, restrains, vitamin C, benzodiazepines and anti-psychotics
Substance Intoxication
Reversible experience with a substance that leads to either psychological or physiological changes
Barbiturates and Benzodiazepines Psychopharmacology
GABA, cross-tolerance, delirium
Gender Identity
Based on person’s sense of maleness or femaleness, established by the age of 3
Nicotine Withdrawal specific findings and Treatment
- Irritability, difficulty concentrating and anxiety
- Insomnia, depressed mood and heart rate
- Headache
- Rx: education, nicotine (patches, gums or lozenges), bupropion, varenicline and bromocriptine
Barbiturates and Sleep
- Moderate:
- Early sleep onset
- Increase wakefulness during the second half of night
- Intoxication:
- Decreases REM
- REM rebound (with nightmares) during withdrawal
Alcohol and Sleep
- Moderate:
- Early sleep onset
- Increase wakefulness during the second half of night
- Intoxication:
- Decreases REM
- REM rebound (with nightmares) during withdrawal
CNS Depressants Intoxications non-specific findings
- Mood elevation
- Decreased anxiety
- Sedation
- Behavioral disinhibition
- Respiratory depression
CNS Hallucinogens
- Phencyclidine
- Lysergic acid diethylamide
- Marijuana (cannabinoid)
- MDMA (ecstasy)
Benzodiazepines and Sleep
- Limited decrease in REM and stage 4, much less than previously thought
- Little rebound effect
- Chronic use increases sleep latency
Drowsy EEG waves
Alpha waves (8-12 cps)
Inhalants (glue, paint thinner) Intoxication specific findings and Treatment
- Belligerence, impaired judgment and nystagmus
- Uncoordination, unsteady gait and lethargy
- Crusting around nose/mouth
- Apathy and coma
- Rx: education and counseling, and anti-psychotics
Somnambulism (Sleep-walking)
- First third of night
- Stage 4 (delta sleep)
- If wakened, the person is confused and disoriented
- Rx: benzodiazepines
CNS Depressants Withdrawal non-specific findings
- Anxiety
- Tremor
- Seizures
- Insomnia
Caffeine Withdrawal specific findings and Treatment
- Headache, fatigue and drowsiness
- Nausea or vomiting (1-4 days)
- Rx: Analgesics
Female Orgasm Disorder
- Inability to achieve orgasm
- Overall prevalence from all cause 30%
- Rx: fantasy, vibrators
Amphetamines Withdrawal specific findings and Treatment
- Fatigue, headache and depression
- Suicide
- Rx: bromocriptine, amantadine, and bupropion
Fetal Alcohol syndrome (FAS)
- The leading known cause of mental retardation (Down syndrome is second and the first genetic cause or may be fragile X)
- Developmental and mental retardation, craniofacial abnormalities (epicanthal folds, small eye openings, short nose, indistinct philtrum, and thin upper lip) and limb dislocation
Opioids Withdrawal specific findings and Treatment
- Dysphoria, insomnia and yawning
- “Flu-like” symptoms including fever, myalgias, rhinorrhea, piloerection and diaphoresis
- Abdominal cramps, anorexia, nausea, vomiting and diarrhea
- Dilated pupils (7-10 days)
- It is not life-threatening, “hurts all over”, and does not cause seizures
- Rx: Long-term support, clonidine, methadone, and buprenorphine
Primary Insomnia Definition and Diagnosis
- Affects up to 30% of general population
- Difficulty in initiating or maintaining sleep that is not attributable to physical or mental conditions
- It should be present for at least 3 times per week for one month
Non-rapid Eye Movement (NREM) Sleep
- Idling brain in a movable body
- 4 stages
- Slow EEG waves, absence of eye movement and thought-like mental activity
- Increased muscle tone
Changes in first 3 hours of sleep (Hormonal)
- Human growth hormone (HGH) increases
- Prolactin increases
- Dopamine decreases
- Serotonin Increases
- Thyroid stimulating hormone (TSH) decreases
Delta Sleep EEG waves
Delta waves (1/2-2 csp)
LCD, mescaline and ketamine Psychopharmacology
Partial agonist at post-synaptic 5-HT receptors
Alcoholism simple screening test
CAGE questions
- Have you ever tried to CUT down on alcohol intake and not succeeded?
- Have you ever been ANNOYED about criticism concerning your drinking?
- Have you ever felt GUILTY about your drinking behavior?
- Have you ever had to drink as an EYE-opener in the morning to relieve anxiety and shakiness?
If 2 are positive Alcoholism is present
Caffeine Intoxication specific findings and Treatment
- Restlessness, agitation and excitement
- GI disturbances and diuresis
- Insomnia and muscle twitching
- Flushed face, tachycardia and arrhythmia
- Rx: none
REM sleep deprivation
- Does not impede performance of simple tasks
- Interferes with performance of more complex tasks and make it more difficult to learn them
- Decreases attention to details but not the capacity to deal with crisis situations
Sexual Orientation
Based on person’s choice of love object; may be heterosexual, homosexual, bisexual, or asexual
REM Sleep EEG waves
Low voltage random fast with sawtooth waves
Sleep Deprivation Facts
- Only one third of lost sleep is made up (80% of lost stage 4 and about 50% of REM are recovered)
- 5 hours or less per night, person functions at level of someone legally drunk
- The longer period of wakefulness, the more stage 4 sleep increases during the first half of night and the more REM declines
CNS Stimulants Withdrawal non-specific findings
- Post-use “crash” including depression
- Lethargy
- Increase appetite
- Sleep disturbance
- Vivid nightmares
CNS Depressants drugs
- Alcohol
- Opioids
- Barbiturates
- Benzodiazepines
Synthetic drugs Intoxication specific findings and Treatment
- K2/spice (synthetic marijuana): psychosis and agitation
- Bath salts (Wow, da bomb): psychosis and autonomic instability
- Krokodil (synthetic opiates): skin and tissue degeneration
REM sleep changes
- Increase in children and adults after learning, especially learning of complex material in the previous waking period
- It is when most long term memories are consolidated by the hippocampus
Male Sexual Arousal Disorder (Impotence)
- Check for smoking, alcohol usage, diabetes and marital conflict
- Determine weather is it organic vs psychological via postage stamp test or snap gauge test
- Rx: sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis)
Marijuana (cannabinoid) Intoxication specific findings and Treatment
- Impaired motor coordination and judgment
- Euphoria, anxiety, and slowed sense of time
- Increased appetite, dry mouth and conjunctival injection
- Psychosis
- Rx: Abstinence and support
- Dronabinol (tetrahydrocannabinol isomer) used as anti-emetic (chemotherapy) and appetite stimulant (in AIDS)
Primary Insomnia Treatment
- Good sleep hygiene measures (regular sleep schedule, limiting caffeine intake, avoidance of daytime naps, warm baths in evening, use of bedroom for sleep and sexual activity only, exercising early in morning, relaxation techniques, and avoidance of large meals near bedtime)
- Drugs are second line and used for short periods of time (<2 weeks): diphenhydramine (Benadryl), zolpidem (Ambien), zaleplon (Sonata), eszopiclone and trazodone (Desyrel), Ramelteon (MT1, MT2 receptors agonist, low chance of dependence, and no hangover or rebound)
Gender Dysphoria
- Strong, persistent cross-gender identification that leads to persistent discomfort with sex assigned at birth, causing significant distress and/or impaired functioning
- Transsexualism: desire to live as the opposite sex, often through surgery or hormone treatment
- Rx: Sex-reassignment surgery or hormonal treatment in addition to supportive psychotherapy
Sleep Apnea Types
- Obstructive (upper airway) sleep apnea: middle-age, overweight and rasping snoring
- Central (diaphragmatic) sleep apnea: elderly, overweight, Cheyne-Stokes (60-seconds hyperventilation followed by apnea)
- Mixed sleep apnea
Anabolic steroids Withdrawal specific findings and Treatment
- Depression, headache and anxiety
- Increased concern over body’s physical state
- Rx: SSRIs
Cocaine Intoxication specific findings and Treatment
- Euphoria, grandiosity, paranoia, and hypervigilance
- Hallucinations (tactile [cocaine bugs])
- Stereotyped behavior and impaired judgment
- Anorexia, diaphoresis, tachycardia and hypertension
- Pupillary dilation
- Angina,cardiac arrest and seizures (severe intoxication)
- Rx: Anti-psychotics (haloperidol for severe agitation) and/or benzodiazepines and/or anti-hypertensives (beta-blockers not recommended)
Cocaine Withdrawal specific findings and Treatment
- Fatigue, headache and depression
- Suicide
- Rx: bromocriptine, amantadine, and bupropion
