Yr4 Psychiatry - Lectures Flashcards

Question

- What are 2 behaviours that trauma may result in? - What are the 2 aims of a consult when seeing a patient with PTSD? - What are 9 reactions a patient may have once trauma is triggered? - What are the 7 aims in good clinical interaction with patients with PTSD? - What are 6 ways drs can respond to trauma reactions? - How should trauma-informed care be delivered?

Answer 1

**1 - Dissociation** - Dissociation is a protective defense at the time of trauma. - It always indicates past trauma. - It can continue to occur with even minor triggers. - It can be very subtle. **2 - Episodes of High Arousal** - Trauma may also result in the loss of the ability to soothe and lead to episodes of high arousal. - Lack of a secure attachment through trauma impedes the ability of the child to learn to self soothe, to settle their own distress, to be able to be alone and not panic.

Answer 2

- Hypothalamic-pituitary-adrenal (HPA) axis in the physiological state, in major depression, and in post-traumatic stress disorder (PTSD). - **Left**: Physiologically, further cortisol release is reduced via a negative feedback mechanism. - **Center**: In patients with major depression, the HPA axis is typically hyperactive, with increased cortisol levels at reduced feedback sensitivity. A potential underlying mechanism is a decreased function or number of glucocorticoid receptors. - **Right**: In patients with PTSD, cortisol levels are reduced, despite constantly elevated CRH levels. Persistently increased CRH stimulation in the pituitary gland leads to a downregulation of CRH receptors and thus to reduced ACTH production and cortisol release. Also, increased feedback sensitivity further leads to decreased ACTH production. In contrast to depression, the function or number of glucocorticoid receptors is increased.

Answer 3

**Personality trait**: a stable, repetitive pattern of thoughts, feelings, and behaviors characteristics of a particular individual as expressed in a wide range of social and personal contexts. **The Big Five dimensions of personality** - The most widely recognized personality model that maps personality according to five distinct dimensions, namely the degree of conscientiousness, agreeableness, neuroticism, openness to experience, and extraversion expressed by an individual. - The dimensions are equally determined by genetic and environmental factors and remain stable throughout adulthood. - Each dimension is the sum of several factors or characteristics and should not be assessed in binary categories of presence and absence but rather as traits on a spectrum.

Answer 4

**Personality disorders** - **Definition**: pervasive, inflexible, and maladaptive personality patterns that lead to significant distress and/or functional impairment **Epidemiology** - Age of onset: late childhood or adolescence - Antisocial and narcissistic personality disorders are more commonly diagnosed in male individuals. - Histrionic and borderline personality disorders are more commonly diagnosed in female individuals. **Aetiology** - Multifactorial - Caused by a combination of hereditary (e.g., personality disorders in parents) and psychosocial factors (e.g., child neglect, abuse) **Classification**: - The DSM-5 divides personality disorders into three clusters (A, B, and C). - For the general character of each cluster, remember WWW: Weird (A), Wild (B), Worried (C)

Answer 5

**Key Features of all Personality Disorders** 1. Deviates markedly from the expectations of the individual’s culture 2. Is inflexible and pervasive across a broad range of personal and social situations 3. Leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning 4. Is stable and of long duration, with onset able to be traced back at least to adolescence or early adulthood 5. Is not the result of another mental disorder, drug or physical condition 6. Affected individuals consider their symptoms normal and nonproblematic.

Answer 6

**Cluster A personality** - THESE are individuals with longstanding difficulties in relating to others, ranging from distrust to detachment to social deficits

Answer 7

**Paranoid personality disorder** - Paranoid personality disorder is characterised by pervasive distrust and suspiciousness and a tendency to interpret others as malevolent in some way. - These individuals may be preoccupied with unspecified doubts about the motives of others and are reluctant to confide, as they fear information will be used maliciously against them. - Some paranoid individuals have recurrent suspicions about a spouse or partner

Answer 8

**Schizoid Personality Disorder** - The essential feature of schizoid personality disorder is detachment from social relations and a restricted range of expression of emotions in interpersonal settings. - Schizoid individuals appear to lack a desire for intimacy and do not seem to enjoy close relationships. - This clinical picture clearly develops with some features of pervasive developmental disorders and may sometimes be a precursor of schizophrenia

Answer 9

**Schizotypal Personality disorder** - Schizotypal personality disorder refers to a pattern of reduced capacity for interpersonal relatedness with cognitive distortions and eccentricities of behaviour. - Individuals with schizotypal personality disorder often have ideas of reference, that is, they incorrectly interpret external events as having unusual and specific meaning for them. - Schizotypal individuals may be interested in the paranormal and have a range of beliefs about their own mental powers

Answer 10

**Cluster B - Antisocial Personality Disorder** - ANTISOCIAL personality disorder refers to a pervasive pattern of disregard for the rights of others and has been previously known as psyochopathy or sociopathy. - Antisocial individuals frequently have a history of childhood maltreatment and behavioural disturbances, including aggression from an early age. - Some antisocial individuals are superficially charming and confident and can be successful in exploiting others

Answer 11

**Borderline personality disorder** - Identity and self-image - Control of feelings and impulses - Interpersonal functioning - They have difficulty tolerating negative- feeling states and can turn to substance use and risk-taking behaviours to avoid intense emotional experiences

Answer 12

**Cluster B - Histrionic Personality Disorder** - Histrionic personality disorder involves a pattern of excessive emotionality and attention-seeking behaviour. - These individuals are often dramatic in style and demand to be the centre of attention. - Histrionic individuals are prone to exaggeration and are highly suggestible.

Answer 13

**Factors Influencing Stress Responses** 1. **Genetics**: Some individuals may be more predisposed to developing abnormal stress responses due to genetic factors. 2. **Environment**: Exposure to chronic stressors, such as a high-stress job or a traumatic event, can influence how a person responds to stress. 3. **Personality**: Certain personality traits, such as resilience and optimism, can affect an individual's ability to cope with stress. 4. **Support System**: Having a strong support system can buffer against the negative effects of stress.

Answer 14

**Narcissistic personality disorder** - Individuals with narcissistic personality disorder are grandiose, with a need for admiration - They often have a sense of self-importance and overestimate their abilities and accomplishments - They have a limited capacity to understand the feelings or experiences of other people and can be hurtful and inconsiderate

Answer 15

**Avoidant personality disorder** - Socially inhibited and hypersensitive to the negative evaluation of others

Answer 16

**Definition**: A maladaptive emotional (e.g., anxiety) or behavioral (e.g., outburst) response to a stressor, lasting ≤ 6 months following resolution of the stressor. **Epidemiology** - Occurs in ∼ 5–20% of individuals undergoing outpatient mental health treatment. - Up to one-third of patients with a cancer diagnosis develop this disorder. **Aetiology**: A combination of intrinsic and extrinsic stressors (e.g., divorce, losing a job, academic failure, difficulties with a peer group, illness)

Answer 17

**Dependent Personality Disorder** - Dependent personality disorderrefers to a pervasive and excessive need to be taken care of that leads to clinging behaviour with others and a fear of separation - These individuals experience ongoing difficulty in making decisions and taking initiative and responsibility in their lives - They are at risk of being dominated and exploited by others and may acquiesce to unreasonable demands rather than risk disagreement or potential abandonment

Answer 18

**Obsessive–compulsive personality disorder** - Obsessive–compulsive personality disorder describes individuals who are preoccupied with order and control and are seen as perfectionists and rigid in thinking and behaviour - They tend to be focused on minutiae and rules,pay excessive attention to detail and have difficulties in task completion - The perfectionism and self-imposed high standards of performance cause significant dysfunction and distress and impact negatively in interpersonal relationships and activities

Answer 19

**Causes of Personality Disorders** 1. Neurotoxic effects of cortisol - Dysregulation of the developing HPA axis and ongoing vulnerability to stress 2. Disruption of limbic system regulation 3. Effects on neurotransmitter systems 4. Attachment challenges 5. Trauma 6. Genetic **Consequences of Personality Disorders** 1. Social exclusion 2. Poverty 3. Drug and alcohol use 4. Criminal conviction 5. Self-harm 6. Completed suicide

Answer 20

**Principles of Management** 1. Negative attitudes by the clinician towards treatment and a false belief that personality disorder is not treatable. 2. Being overly controlling and giving direct advice can result in either dependency or chronic rejection of all suggestions **Stages of treatment of a personality disorder** - Four major stages in the treatment of personality disorders, beginning with the common entry point of crisis management and stabilisation - Cloninger’s model does not assume that all individuals will be able to undergo major personality change. - It does suggest that the initial clinical response should be on stabilisation and establishing a working alliance with the patient if they can accept ongoing support.

Answer 21

**Risk assessment** 1. Identifies potential triggers that could lead to a crisis 2. Specifies self-management strategies likely to be effective 3. Establishes how to assess crisis services if needed

Answer 22

**The role of medications** - It is not uncommon for a variety of psychotropic medications to be trialled in patients with severe personality disorder, usually aimed at specific symptoms or with the goal of relieving subjective distress - There is little evidence to support the use of antipsychotic drugs in the medium- and long-term treatment of personality disorder and little support for the use of novel antipsychotics for emotional instability, transient psychotic symptoms and aggression - The NICE guidelines suggest that short-term use of sedative medication may be considered cautiously as part of crisis management, but should not be maintained for more than one week

Answer 23

**Dialectics** - **Definition**: The concept of 'dialectics' means that two opposites can coexist and be reconciled. In DBT, the dialectic usually addressed is the tension between acceptance and change. - **Role in therapy**: In DBT, therapists and clients work together to balance the need for acceptance with the need for change in their therapeutic relationship and in their daily lives. - **Core dialectic**: balancing Acceptance and Change - **Main goal** = Building a life worth living

Answer 24

**Overview of DBT Components** - **Individual Therapy**: One-on-one sessions between client and therapist focused on improving problem behaviors. - **Group Skills Training**: Usually taught in a group setting, this is where clients learn and practice behavioral skills. - **Phone Coaching**: Provides in-the-moment support to help clients apply the skills in their everyday lives. - **Therapist Consultation Team**: Aids therapists in managing their own responses to challenging client issues and staying motivated.

Answer 25

**Prolonged Grief Disorder (PGD):** 1. **Persistent Intense Grief**: Severe, debilitating grief lasting more than six months. 2. **Impairment**: Significant impairment in personal, social, and occupational functioning. 3. **Preoccupation with the Deceased**: Constant longing and yearning for the deceased. 4. **Emotional Numbness**: Inability to experience joy or engage in life activities. **Complicated Grief:** 1. **Chronic Symptoms**: Symptoms of acute grief that persist without improvement over time. 2. **Maladaptive Behaviours**: Behaviours such as avoidance of reminders of the deceased or an inability to accept the death. 3. **Severe Depression**: Major depressive episodes that are pervasive and persistent.

Answer 26

**Factors Influencing Bereavement Responses** 1. Relationship with the Deceased: The closeness of the relationship can impact the intensity and duration of grief. 2. Circumstances of Death: Sudden or traumatic deaths often lead to more complicated grief reactions. 3. Previous Mental Health: Individuals with a history of mental health issues may experience more severe grief responses. 4. Social Support: Access to a strong support network can help mitigate the severity of grief reactions.

Answer 27

**3. Social Interventions** **Support Systems:** * **Family Involvement**: Educate family members about BPD and involve them in the treatment process when appropriate. * **Peer Support Groups**: Encourage participation in support groups for individuals with BPD. **Environmental Modifications:** * **Stable Living Situation**: Assist in finding a stable and supportive living environment. * **Work/School Support**: Provide support for maintaining employment or continuing education, which may include accommodations or vocational training. **Social Skills Training:** * **Assertiveness Training:** Help the patient learn to express their needs and desires in a healthy and assertive manner. * **Conflict Resolution**: Teach strategies for resolving conflicts in a constructive way.

Answer 28

- Illnesses which sit at the interface of physical and mental health. - Associated with high morbidity, mortality and suffering in both patients and carers / families. - Often develop as strategies to deal with a variety of distressed emotions and personal conflicts, esp. a sense of lack of adequate control and effectiveness for life situations. - Disordered eating can develop out of an overvaluation of the benefits of “slimness” to deal with these issues, but in genetically vulnerable individuals can also be triggered by weight loss of any cause.

Answer 29

**Anorexia Nervosa ** 1. Restriction of food, leading to significantly low body weight defined as: weight less than minimally normal, or expected 2. Intense fear of gaining weight or becoming fat, or persistent behaviour that interferes with weight gain 3. Disturbance in the way in which one’s body, weight or shape is experienced, OR 4. Undue influence of body weight or shape on self-evaluation, OR 5. Persistent lack of recognition of the seriousness of the current low body weight 6. Restrictive type or binge/purge type (note – 60% of AN patients engage in binge/purge behaviours)

Answer 30

**Bulimia Nervosa** 1. Binge eating = Eating an objectively large amount of food + Experiencing a sense of loss of control 2. Recurrent inappropriate compensatory behaviours in order to prevent weight gain, e.g., * purging (vomiting; laxatives, diuretics, enemas); * fasting; * excessive exercise 3. The binge eating and inappropriate compensatory behaviours both occur, on average, at least once a week for 3 months 4. Self-evaluation is unduly influenced by body shape and weight

Answer 31

- ARFID = Avoidant Restrictive Food Intake Disorder = new category - marked sensory difficulties with eating - more common in OCD and Autism

Answer 32

- Dire situation in W.A. with respect to management and outcomes for public patients with severe eating disorders. - Eating Disorders have the highest mortality of any mental illness (approx 20% - from suicide and malnutrition) - There is no comprehensive specialist public eating disorders service in W.A. for pts over the age of 16 – no beds/ multidisciplinary outpatients / day program or outreach service (CCI great psychological Tx but not MDT for high risk ) - With peak onset age 15-24 and average duration 7 years, around 85% of patients with an ED are over age 16 - Evidence emphasizes medical stabilization and treatment of starvation syndrome are essential for addressing cognitive effects and allowing engagement with psychological therapies

Answer 33

**Psychiatric comorbid disorders that commonly occur with EDs** 1. Mood disorders (40-70%) - Major depression, dysthymia (but need to differentiate from mood disorder secondary to malnutrition) 2. Anxiety disorders – GAD +/- panic 3. OCD (common with anorexia nervosa) 4. ETOH / other substance abuse (esp. with BN) 5. Personality Disorders (again – diagnosis best made once nutrition restored!) - “No-one is “odd” until they are well nourished and odd”

Answer 34

**Risk Assessment** - The biggest risk is unintentional death due to the effects of starvation or purging - Person can feel great and have normal bloods just before sudden death due to arrhythmia - Best indicators of cardiac risk are easily assessed: 1. BMI < 14 2. No oral intake for more than several days (always ask in detail about food intake) 3. Purging several times daily 4. BP < 90mm systolic 5. HR < 50 bpm or > 110 bpm 6. Postural tachycardia/hypotension > 20 bpm/mm 7. Serum potassium, phosphate or glucose below normal range 8. Prolonged QT interval on ECG

Answer 35

**Effect of Starvation on Decision-Making, Self-perception and Insight** - The Minnesota Semi-starvation Study conducted by Ancel Keys - Loss of 25% of body weight led to profound cognitive changes, including obsessive preoccupation with food and eating and loss of perspective and insight. Only reversed when weight restored. - Thus cornerstone of initial treatment of severe eating disorders is nutritional rehabilitation. - Many treated on a compulsory basis later agree that treatment was necessary and remain therapeutically engaged (Guarda et al). - In Minnesota semi-starvation study normal men all became mentally disturbed: Obsessed with food, Nitpicky about detail, Lost touch with the big picture, Depressed, Suicidal, Withdrawn, Bingeing, Purging, Body Image Issues

Answer 36

**REFEEDING SYNDROME** - In first 1-2 weeks of refeeding body can rapidly use up phosphate, potassium, magnesium, glucose and thiamine - Can result in heart failure, brain injury and death - Prevent by: 1. Awareness 2. Thiamine 3. Checking serum phosphate, magnesium, potassium daily and replace if low 4. Lowish meal plan to start (1500Kcal) but get up to 3000kcal within 2-3 weeks (don’t want ‘underfeeding syndrome’)

Answer 37

**Inpatient Nursing Management** - 1:1 special ideal (especially during and after meals; record intake) - No leave off ward - Observations qid including lying/standing BP/HR/BSL (inc 2am) + daily ECG - Notify RMO if systolic BP<90, HR<60, postural changes greater 20 mm/bpm - Monitor and contain food avoidance, exercise, vomiting - Supervise toilet/shower - Weigh twice weekly in morning after voiding

Answer 38

**Eating Disorders and Impairment of Brain Functioning** - Malnutrition is associated with a range of difficulties with cognitive flexibility and emotional regulation. - Many patients describe a sense of “razor sharp focus” during starvation, but exhibit memory difficulties, slowed processing and reduced flexibility of thinking. However bedside cognitive tests may still be in the high normal range. - Assessment of decision-making requires a nuanced review as to whether this person can “walk the walk” not just “talk the talk” with respect to managing their nutrition. **Function of the Medial Pre-frontal Cortex (PFC)** 1. Bodily regulation (autonomic NS) 2. Attuning to others – “being present” 3. Regulating emotional balance 4. Being flexible in our responses 5. Soothing fear 6. Empathy 7. Insight 8. Moral Awareness 9. Intuition

Answer 39

Is Meal support really a Nurse- delivered DBT-informed Therapy Research and feedback from patients themselves reinforce the 4 C’s; 1. **Calm** (Being present and containing) 2. **Confident** (knowledgeable and empathic) 3. **Consistent** (non-negotiables, need containment of potential for compensation or anxiety increases) 4. **Compassionate** (empathic, manage negative counter transference / stigma)

Answer 40

1. Consistency is crucial to reduce anxiety in the patient 2. Consistency across and within MDT is crucial – eating disorders are great at exploiting “chinks in the armor” 3. Weekly case conference MDT then together with pt. and carer - Agree as a team upon the “non-negotiables” and don’t change these outside the meeting 4. Externalise dysfunctional behaviour of the “eating disorder” separate to the person 5. Be transparent about use of the MHA and what is likely to trigger this, be clear that one of the goals of discharge is to know whether the pt or eating disorder is “driving the bus”

Answer 41

**Psychological Factors** 1. **Personality Traits**: Traits like perfectionism, impulsivity, and obsessive-compulsiveness can predispose individuals to disordered eating behaviours. Low self-esteem and a tendency toward self-criticism. 2. **Mental Health Issues**: Pre-existing mental health conditions such as anxiety, depression, or obsessive-compulsive disorder (OCD). Trauma history, including physical, emotional, or sexual abuse. 3. **Cognitive Patterns**: Distorted body image and negative beliefs about body shape and weight. Rigid thinking and black-and-white thinking patterns.

Answer 42

**Psychological Consequences** 1) **Cognitive Effects**: - Impaired Concentration and Memory: Poor cognitive functioning and difficulty with attention and memory. - Obsessive Thoughts: Preoccupation with food, body weight, and shape, often leading to compulsive behaviours and thoughts. 2) **Emotional and Mood Disorders**: - Depression and Anxiety: High rates of depression, anxiety disorders, and panic attacks. - Mood Swings: Irritability, mood instability, and feelings of guilt or shame related to eating behaviours. 3) **Behavioural Changes**: - Social Withdrawal: Isolation from friends and family, often due to shame or the need to maintain eating disorder behaviours. - Self-Harm: Increased risk of self-harm or suicidal ideation, particularly in severe cases of anorexia nervosa or bulimia nervosa.

Answer 43

**Types of Family Therapy Approaches** 1. **Maudsley Family-Based Treatment (FBT)**: A structured approach that involves the family in refeeding the individual with anorexia nervosa. Focuses on empowering parents to take control of their child's eating initially, and then gradually transferring control back to the adolescent as they recover. 2. **Systemic Family Therapy**: Looks at the family as a system and focuses on the interactions and relationships within this system. Aims to identify and modify systemic issues that contribute to the eating disorder. 3. **Structural Family Therapy**: Focuses on restructuring family interactions and hierarchies to promote healthier relationships and support the individual's recovery. Involves modifying family roles, boundaries, and communication patterns. 4. **Multidimensional Family Therapy** (MDFT): Integrates individual therapy for the person with the eating disorder with family therapy. Addresses multiple aspects of the individual's life, including family dynamics, peer relationships, and personal development.

Answer 44

**Starvation Syndrome** When starved of energy, the human body responds in a way known as “Starvation Syndrome”. Starvation syndrome (or semistarvation) refers to the physiological and psychological effects of prolonged dietary restriction. The effects of starvation syndrome are commonly observed in individuals with eating disorders, who often severely restrict their energy intake, eat irregularly, and engage in compensatory behaviours (e.g., purging), which reduce energy absorption. Many of the symptoms once thought to be primary symptoms of eating disorders are actually symptoms of starvation.

Answer 45

**Physical Changes** 1. Heart muscle mass reduced by 25% 2. Heart rate and blood pressure decreased 3. Basal metabolic rate slowed down 4. Feeling cold all the time 5. Fluid retention (edema) 6. Dizziness and blackouts 7. Loss of strength, high fatigue 8. Hair loss, dry skin 9. Decreased hormone levels, causing lack of sexual desire and other changes **Emotional Changes** 1. Depression 2. Anxiety 3. Irritability 4. Loss of interest in life **Changes in Thinking** 1. Impaired concentration, judgement and decisionmaking 2. Impaired comprehension 3. Increased rigidity and obsessional thinking 4. Reduced alertness

Answer 46

- A crucial distinction between men in the Minnesota Study and individuals with eating disorders is that, in addition to experiencing symptoms of starvation, individuals with eating disorders have significant fears about their shape, weight, appearance and eating. - When a person who is starving has the opportunity to eat, they will eat. A person with an eating disorder will continue to restrict what they are eating due to their fears. It is therefore crucial that eating disorder recovery focuses on physical renourishment as well as psychological treatment to address anxiety and fear about eating.

Answer 47

**Australia - Daily Tobacco Smoking** - 12.2% daily smokers - Kills 15,000 p.a - Up to 2/3 die from smoking - Leading cause of preventable death in Australia **WHO IS STILL SMOKING?** - Smokers with: 1. High dependence 2. ATSI 3. Mental health concerns 4. Drug and alcohol comorbidities 5. Diseases related to their smoking e.g. COPD 6. Multiple unsuccessful attempts 7. More stressors *Low socio-economic status is common amongst these groups*

Answer 48

**MH Smoking Patterns** - Smoke more heavily - Have higher levels of nicotine dependence Have more difficulty quitting **Reasons for high smoking rates** 1. Shared genetic predisposition - Depression, Schizophrenia, Alcohol dependence 2. Common environmental factors 3. Self-medication 4. To reduce side-effects of medication 5. Culture of smoking in mental health facilities, group homes 6. Less likely to be offered treatment

Answer 49

**Is it worth stopping?** - Stop at 30 = never smoker - 3 months of life per year quit after 35yo - Every smoker’s health improves when they quit. - At the very least - O2 carrying capacity improves - MH Patient more likely to die from smoking than from mental illness - Mental Health Improves - Need less caffeine, alcohol and medications - Respond to evidence based therapies - Financial implications

Answer 50

**Barriers for Doctors to offer Smoking cessation therapy** 1. Is it a chronic illness? 2. Lack of time 3. Fear of alienating smokers 4. Lack of skills 5. Despondency re: efficacy 6. Fear of adverse events

Answer 51

**Basics of Nicotine** - Nicotine is odourless and Colourless - Most nicotine from smoking a cigarette is blown into the air - Nicotine enters and is absorbed by the respiratory tract (nose, mouth) and lungs and then directly to arterial blood and brain very quickly - Nicotine is not eaten and swallowed but can be chewed (buccal absorption) - Accurate titration – topography of smoking

Answer 52

**Nicotine (Nicotinic) Receptors** - nACHr all over the body and brain (Hipp, NA, Cortex) - Receptors are sensitive to nicotine - Configurations of α and β types: 1. α4β2 responsible for dependence 2. β4 for cognition 3. α3β4 for apetite - Types and subtypes are heritable - Up- and Downregulate quickly

Answer 53

**Polycyclic Aromatic Hydrocarbons** - Produced by smoking organic material - Induces CYP 1A2, therefore need more: 1. Insulin 2. Antipsychotics eg olanzapine, clozapine, haloperidol 3. Antidepressants eg fluoxetine, fluvoxamine 4. Diazepam 5. Analgesia, eg methadone 6. Caffeine 7. Alcohol - This is NOT a nicotine effect. - Important to think about during inpatient admissions/discharge

Answer 54

**Acute** 1. Cravings 2. Anxiety 3. Distress 4. Aggression 5. Reduced concentration **Chronic** 1. Insomnia 2. Headaches 3. Constipation 4. Increased appetite 5. Low mood 6. Apthous Stomatitis 7. Cough

Answer 55

**Stressors, distress and cues to smoke** - Nicotine has an acute anxiolytic effect - Nicotine has an acute antidepressant effect - Nicotine has a very short half-life (40 mins → 2 hrs) and wears off - Nicotine wearing off → acute anxiety and depression (withdrawals): the "stress" paradox - Smokers "manage" stressors better when on NRT - After cessation smokers are "calmer", less volatile, less "reactive" to stressor. - This is a learned process and takes time→ 3 months to unlearn

Answer 56

**3As Approach** - Internationally accepted – USA, Canada, UK, NZ - 3As 1. Ask and record smoking status 2. Advise all patients to quit in clear, non confrontational , personalised way 3. Act (Help): Information, Referral to Quitline, Medications **Assessment of a Smoker** 1. TTFC < 30min (number and type irrelevant) 2. Medical History (psychiatric in particular) 3. Quitting History (previous short lived attempts, pharmacological failures) 4. Family History (heritability) 5. Environmental Contexts (others smoke at home and/or at work)

Answer 57

**Treatment Principles** 1. Best practice is pharmacotherapy + professional counselling - “…pharmacotherapy should be offered to all smokers who have evidence of nicotine dependence” 3. Combination therapy is more effective than monotherapy (NRT) 3 4. Compliance is a major issue: correct use, duration and dose 5. Individuals respond differently to different medications

Answer 58

**Individual Responses to Medication** * Genetic variations associated with response to therapies: 1. Varenicline = Nicotine receptors 2. Bupropion = Rate of metabolism (CY2B6) 3. NRT = Rate of metabolism (CYP2A6)

Answer 59

**NRT** - NRT-as blood levels vary MOST smokers are underdosed with single form (1 x 21mg patch =10ng/ml) - Combination NRT better - Longer NRT better - No evidence to cut down (21 --> 14 --> 7mg) - No evidence to start on lower doses - Safe (except patch in pregnancy)

Yr4 Psychiatry - Lectures Flashcards

(97 cards)