Substance related disorders

Question 1

Most common psychoactive substances

Answer 1

Alcohol and nicotine

Question 2

Substance use disorders

Answer 2

1) Abuse

2) Dependence (physical, psychological)

Question 3

Substance-induced disorders

Answer 3

1) Intoxication
2) Withdrawal
3) Dementia/amnestic disorder (Korsakoff’s SY)
4) Psychotic disorder
5) Mood disorder, anxiety disorder, sleep disorder, sexual dysfunction

Question 4

Promille that can lead to respiratory failure and coma

Answer 4

over 3,5 promille

Question 5

Differential diagnosis alcohol intoxication

Answer 5

• Recent use of another substance
• General medical condition (intracranial hemorrhage!)
• Idiosyncratic intoxication

Question 6

Numbers of units in one go likely to indicate dependence

Answer 6

Men: 6 units

Women 4 units

Question 7

Lab findings supporting alcohol dependence

Answer 7

• Elevated GGT

- Macrocytic anemia

Question 8

Alcohol dependence screening

Answer 8

• CAGE

- AUDIT

Question 9

Alcohol dependence differential diagnosis

Answer 9

• Use of another substance
• Primary mental disorder
• Physical complications and comorbidities must be considered

Question 10

Amnestic disorder (Korsakoff’s SY)

Answer 10

• Often combinde dwith Wernicke’s encephalopathy
• Thiamine deficiency and transketolase defect
• Anterograde amnesia, disorientation, confabulation
• Treat: 500 mg thiamine iv or im

Question 11

Alcohol-induced psychotic disorder with hallucinations vs -//- with delusions

Answer 11

Hallucinations

• Sudden onset, pt alert and oriented
• Anxiety, depressed mood

Delusions

• Chronic course, often combined with other diseases
• Jealousy, violent acts, frequent suicidality

Question 12

Alcohol-related mood disorder

Answer 12

• Chicken vs egg causality dilemma

- High suicidal risk

Question 13

Neurological complications of alcohol abuse

Answer 13

1) Wernicke’s encephalopathy
2) Central pontine myelinosis
3) Marchiafava-Bignami disease
4) Cerebellar degeneration
5) Alcoholic neuropathy

Question 14

Internal medicine complications of alcohol abuse

Answer 14

1) Liver diseases
2) Cardiovascular diseases
3) GI diseases
4) Infections (pneumonia, meningitis, sepsis - common causes of death!)
5) Traumas (intracranial hemorrhage!)

Question 15

Mild or moderate withdrawal symptoms (alcohol)

Answer 15

• Autonomic: tremor, hyperhydrosis, tachycardia, subfebrility, vomiting ++
• Neurological: hyperreflexia, grand mal seizures
• Mental: anxiety, agitation, insomnia, craving ++

Question 16

Severe withdrawal (delirium tremens) symptoms (alcohol)

Answer 16

Mild/moderate symptoms
\+
Mental symptoms
- Confused state of mind
- Attention deficit
- Disorientation
- Complex hallucinations
- Disorganized thinking, speech, behaviour (including psychomotor agitation)

Question 17

Severe withdrawal - level of integrity and vigilance

Answer 17

• Low integrity

- Hypo- or hypervigilance

Question 18

Most common physical complications and comorbidities in withdrawal (?)

Answer 18

• Fluid, electrolytes (hypokalemia!)
• Hypoglycemia
• Cardiac
• Infections
• Traumas (subdural hemorrhage)
• GI hemorrhage
• Liver failure, alcohol induced enceophalopathy (DDx)

Question 19

Medicine that can be administered in case of withdrawal

Answer 19

1) BZD (high-pot, diazepam)
2) Thiamine
3) Beta blockers
4) PPIs
5) Subst. fluid, electrolytes, glucose
6) Antipsychotics
7) Anticonvulsants

Question 20

Psychoactive drugs

Answer 20

1) Cannabis
2) Psychostimulants (cocaine, amphetamine)
3) Opioids (heroin, medical opioids)
4) Designer drugs (MDMA, mephedrone, “crystal” (not same as amphetamine!), “music”, “biograss”)

Question 21

Cannabis

Answer 21

Intox: tachyc, dry mouth, increased appatite, depersonalization

Withdrawal: anxiety, dysphoria, craving

Induced disorders: psychosis, anxiety, amotivational syndrome

Question 22

Psychostimulants

Answer 22

Intox: tachy or bradyc, pupil dilation, elevated or lower BP, psychomotor agitation or retardation, resp dep ++

Withdrawal: fatigue, dreams, altered sleep, anhedonia ++

Induced disorders: psychotic, mood, anxiety, sleeping, sexual

Question 23

Opioids

Answer 23

Intox: euphoria, sedation, apathy, psychomotor, pupil constriction, memory problem++

Withdrawal: dysphoric, vomit, lacrimation, pupil dilation, piloerection ++

Induced disorders: psychotic, mood, sleeping, physical complications (HIV, HCV, endocarditis, sepsis)

Question 24

Designer drugs

Answer 24

Intox: substance-specific (cannabis-like, hallucinogen-like), hyperthermia, DIC ++

Withdrawal: agitation, craving, dysphoria, altered sleep

Induced disorder: psychotic disorder

Question 25

Test for drugs

Answer 25

Urine test (usually negative for designer drugs)

Question 26

Treatment intoxications

Answer 26

• Usually nonspecific therapeutic interventions
• Monitoring and treatment of vital signs, prevention and recognition of complications
• Provision of safety for patients
• Administration of antidotes: naltrexon (opioids), flumazenile (benzodiazepines)
• Cautiousness about possible pharmaceutical interacions when administering medication!

Question 27

Treatment withdrawal

Answer 27

• Substance-specific symptoms
• Rarely life-threatening conditions
• Primary goal is to relieve craving and behavioral symptoms (restlessness, hostility)
• Administraton of benzodiazepines, sometime antipsychotic (e.g, tiapride)
• Substitution in certain cases (e.g. methadon instead of heroin)

Question 28

Treatment induced disorders

Answer 28

• Psychotic disorders are the most common in psychiatric emergency
• Quick and safe behavioral control is essential
• Administration of antipsychotics primarily, but benzodiazepines are also given
• Appropriate human resources and equipment are necessary as violent cases are common