Substance Misuse

Question 1

Externalising disorders

Answer 1

Abuse of alcohol and drugs from a psychological perspective
- also includes conduct disorders and antisocial disorder
The tendency to act out about their problems
As opposed to internalising disorders such as depression and anxiety

Question 2

Classification of alcohol dependence

Answer 2

Withdrawal
Cravings - strong desire to drink
Drinking despite negative consequences
- on physical or mental health
- on social or work life
Tolerance increased
Priority in life - neglecting other activities
Loss of control
Rapid-reinstatement in people who have stopped drinking
Narrowing of repertoire - range of alcohol and drinking habits

Question 3

Alcohol - harmful misuse

Answer 3

Occurs when the consequences of alcohol involve social, physical or psychological harm to a person

Question 4

Alcohol - safe limits

Answer 4

Men and women
<14 units per week
<3 units per day

Question 5

Alcohol - aetiology

Answer 5

Genetics - risk regardless of upbringing
Psychological factors
- impulsive, aggressive and hyperactive
Anxiety - alcohol relaxes
Occupation
- journalist, armed forces, entertainer and doctor are common
Cultural - e.g. less likely in Muslim community
Availability of alcohol

Question 6

Alcohol - effects on CNS

Answer 6

CNS depressant - enhances the effect on GABA (inhibitory neurotransmitters)

• initial depression of inhibitory neurons
• gradual global CNS depression

Question 7

Alcohol - effects on CVS

Answer 7

Increases BP - due to increased catecholamine sensitivity
Arrhythmia
Alcoholic cardiomyopathy
Vasodilation, so patient feels warm but they are losing heat

Question 8

Alcohol - effects on liver

Answer 8

Increased conversion of glucose to lactic acid, causing hypoglycemia and fatty liver disease
Cirrhosis
Oesophageal varices
Hepatitis

Question 9

Alcohol - effects on GI system

Answer 9

Gastritis

Chronic/acute pancreatitis

Question 10

Alcohol - effects on sexual function

Answer 10

Damage to Leydig cells, causing decreased libido, infertility and decreased male body hair

Question 11

Alcohol - neuropsychiatric effects

Answer 11

Peripheral neuropathy due to decrease in B12 and thiamine
Impaired memory
Depression/anxiety (both a cause and effect)

Question 12

Stages of change

Answer 12

Precontemplation 
Contemplation 
Preparation 
Action 
Maintenance - full recovery

Question 13

Withdrawal - early clinical features

Answer 13

Tremor 
Nausea
Sweating 
Tachycardia 
Palpitations 
Agitation - autonomic overactivity 
All are caused by the lack of inhibitory effect provided by alcohol

Question 14

Withdrawal - late clinical features

Answer 14

Delusions 
Confusion
Diarrhoea 
Convulsions 
Auditory hallucinations 
Delirium tremors (>48 hours)

Question 15

Delirium tremors - signs and symptoms

Answer 15

Restlessness
Scared/paranoid
Confused
Ataxia/tremor
Autonomic features 
Visual hallucinations 
- usually scary and accompanied by formication 
Auditory hallucinations - persecutory

Question 16

Delirium tremors - management

Answer 16

Medical emergency
Benzodiazepines - sedative and anticonvulsant
B-vitamins - reduce encephalopathy
Fluid
Dextrose - avoid hypoglycemia
Be aware of infection and head/self injury

Question 17

Delirium tremors - cause

Answer 17

Long-term changes alcohol has on the brain (total GABA receptors decrease, so there is no inhibition once withdrawn)
- CNS overactivity

Question 18

Wernicke’s encephalopathy

Answer 18

Acute syndrome caused by thiamine deficiency
Signs and symptoms
- eye signs (nystagmus, ophthalmoplegia)
- ataxic gait
- confusion and memory problems
- nausea
Can occur due to any cause in reduced thiamine - e.g. pernicious anaemia

Question 19

Korsakov’s

Answer 19

A state of impaired memory function that is present after signs of Wernicke’s encephalopathy subside
Anterograde memory disorder
- new memories can’t be consolidated
Confabulation
- make up events due to their lack of memory of recent events
Peripheral neuropathy
Can access events from before the syndrome

Question 20

Korsakov’s - Differential diagnosis

Answer 20

Acute brain syndrome of miscellaneous causes (has no neuro effects)
Delirium tremors - no neuro signs
Chronic brain syndromes
- long-term memory is also affected
- can also be caused by chronic alcohol intake

Question 21

Wernicke’s - treatment

Answer 21

Thiamine and other B vitamins
Sedation if required
Fluid/electrolytes

Question 22

Korsakov’s - management

Answer 22

Lifelong chronic illness with no cure
Palsies and ataxia are likely to resolve with treatment
Neuropathy and amnesia fairly permanent

Question 23

CAGE questions

Answer 23

Cut down
Annoyed anyone by drinking
Guilty about drinking
Eye opener

Question 24

Opiate overdose - Clinical features

Answer 24

Pinpoint pupils
Low BP
Track marks

Question 25

Benzo overdose - Clinical features

Answer 25

Gives impression of intoxication, but not drunk

Question 26

Psychostimulants overdose - Clinical features

Answer 26

Rapid speech
Large pupils
Agitation 
Restlessness
Hypertension

Question 27

Withdrawal from drugs - clinical features

Answer 27

Opiates
- dilated pupils, hypertension, sweaty, cramps and runny nose
Benzos
- depersonalisation, hyper-reflexia/sensitivity
Psychostimulants
- agitated and restless

Question 28

Management of harmful misuse of alchol

Answer 28

Methods to moderate drinking without total abstinence (controlled drinking)
Self-help materials

Question 29

Alcohol dependence - management

Answer 29

Total abstinence advised
Detox
- home (if no psych issues or medication)
- medical ward
Benzo for sedation and anticonvulsant
Thiamine and vitamin B substitutes
Fluid replacement
Disulfiram
- inhibits acetaldehyde dehydrogenase, so causes nasty side effects when alcohol is consumed
Acamproste
- inhibits glutamate (excitatory amino acid) seen in cravings
Patient needs to motivated or it wont succeed