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CP2 - Psychiatry - Kinsky > Alcohol and substance related disorders > Flashcards

Alcohol and substance related disorders Flashcards

1
Q

In 2007, what proportion of men were found to engage in hazardous drinking?

A

33%

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2
Q

In 2007, what proportion of women were found to engage in hazardous drinking?

A

16%

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3
Q

In 2007, what proportion of men (16-75) were found to have a dependence to alcohol?

A

9%

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4
Q

In 2007, what proportion of women (16-75) were found to have a dependence to alcohol?

A

4%

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5
Q

What is the safe daily alcohol limit for men?

A

3-4 units a day with at least 2 alcohol free days a week

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6
Q

What is the safe daily alcohol limit for women?

A

2-3 units a day with at least 2 alcohol free days a week

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7
Q

What are the causes of and risk factors for alcohol dependence?

A

They are multifactorial:

Genetic element
Positive reinforcement - eg loss of inhibition
Negative reinforcement - eg withdrawal symptoms
Relatives and peers
Presence of other mental health problems
Culture
Social class
Profession - stress
Significant life event - eg. rape, bereavement

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8
Q

What are the 4 L’s which represent the areas affected by harmful use of alcohol?

A

Love
Livelihood
Liver
Law (crime)

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9
Q

What are the different psychoactive substance-related disorders?

A 
Hazardous use of substance
Harmful use of substance
Substance dependence
Substance intoxication
Substance withdrawal
Substance withdrawal delirium
Substance-related cognitive disorders
Substance-related psychotic disorder
Substance-related mood disorder
Substance-related anxiety disorder
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10
Q

What is the difference between harmful use and hazardous use of a substance?

A

Hazardous use - quantity or pattern of substance use that places the user AT RISK of adverse consequences, without dependence. eg drink driving

Harmful use - quantity or pattern of substance use that ACTUALLY CAUSES adverse consequences, without dependence. eg binge drinking

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11
Q

How does the ICD-10 define the diagnosis of dependence syndrome of any substance?

A

3 or more of the following have been present together at some time during the previous year:

  1. A strong desire or compulsion to take the substance
  2. Difficulties in controlling substance-taking behaviour (onset, termination, levels of use)
  3. Physiological withdrawal state when substance use has reduced or ceased; or continued use of substance to avoid withdrawal symptoms
  4. Signs of tolerance: increased quantities of substance are required to produce same effect originally produced by lower doses.
  5. Neglect of other interests activities due to time spent acquiring and taking substance, or recovering from its effects.
  6. Persistence with substance use despite clear awareness of harmful consequences (physical or mental)
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12
Q

Are patients who do not display or report signs of tolerance or withdrawal considered not dependent on a substance?

A

No. They may be dependent despite not exhibiting either tolerance or withdrawal. However, if they do exhibit either tolerance or withdrawal they are likely to be dependent.

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13
Q

What are the ‘uncomplicated’ features of alcohol withdrawal syndrome?

A 
Tremulousness
Sweating
Nausea and vomiting
Mood disturbance
Sensitivity to sound
Tachycardia
Hypertension
Mydriasis
Pyrexia
Sleep disturbance
Psychomotor agitation

These features tend to develop 4-12 hours after drinking cessation

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14
Q

What are the more ‘complicated’ features of alcohol withdrawal syndrome?

A

Perceptual disturbances - illusions, hallucinations
Withdrawal seizures
Delirium tremens

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15
Q

How long after cessation of drinking do withdrawal seizures tend to develop?

A

6-48 hours

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16
Q

In what proportions of alcohol-dependant drinkers do withdrawal seizures occur?

A

5-15%

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17
Q

What type of seizures are associated with alcohol withdrawal syndrome?

A

Generalized and tonic-clonic

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18
Q

What electrolyte disturbances in an alcoholic patient might precipitate withdrawal seizures?

A

Low potassium

Low magnesium

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19
Q

What are the features of delirium tremens?

A 
Altered consciousness
Marked cognitive impairment - delirium
Vivid hallucinations and illusions
Marked tremor
Autonomic arousal - sweating, raised BP and HR, pyrexia
Paranoid delusions
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20
Q

How long after cessation of drinking does delirium tremens tend to develop?

A

1-7 days

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21
Q

What is the deficiency associated with Wernicke’s encephalopathy and Korsakoff psychosis?

A

Vitamin B1 - thiamine

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22
Q

What is the difference between Wernicke’s encephalopathy and Korsakoff psychosis?

A

Wernicke’s encephalopathy occurs in the acute brain damage phase due to thiamine deficiency whereas Korsakoff psychosis is the chronic state that emerges after Wernicke’s encephalopathy. They represent a continuum.

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23
Q

What is the classical triad that characterises Wernicke’s encephalopathy?

A

Delirium
Opthalmoplegia - nystagmus, sixth nerve palsy or conjugate gaze palsy
Ataxia

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24
Q

What features is Korsakoff’s psychosis characterised by?

A

Extensive anterograde amnesia
Frontal lobe dysfunction
Psychotic symptoms occurring in the absence of delirium

25
Q

How do you treat Wernicke’s encephalopathy?

A

Parenteral thiamine (Pabrinex)

26
Q

What types of psychotic symptoms are most commonly associated with alcohol related psychotic disorder?

A

Visual (alcohol hallucinosis) and auditory hallucinations

Grandiose delusions

27
Q

What are the common psychological effects of opiate misuse?

A

Euphoria
Drowsiness
Apathy
Personality change

28
Q

What are the physical effects of opiate misuse?

A 
Miosis (pin point pupils)
Conjunctival injection
Nausea
Pruritus
Constipation
Bradycardia
Respiratory depression
Coma
29
Q

What are the psychological effects of misuse of sedatives such as benzodiazepines and GHB?

A 
Drowsiness
Disinhibition
Confusion
Poor concentration
Reduced anxiety
Feeling of well being
30
Q

What are the physical effects of misuse of sedatives such as benzodiazepines and GHB?

A 
Miosis (pin point pupils)
Hypotension
Withdrawal seizures
Impaired coordination
Respiratory depression
31
Q

What are the psychological effects of misuse of stimulants such as amphetamines, cocaine, MDMA, mephedrone and legal highs?

A 
Alertness
Hyperactivity
Euphoria
Irritability
Aggression
Paranoid ideas
Hallucinations (especially cocaine)
Psychosis
32
Q

What are the physical effects of misuse of sedatives such as amphetamines, cocaine, MDMA, mephedrone and legal high?

A 
Mydriasis (dilated pupils)
Tremor
Hypertension
Tachycardia
Arrythmias
Perspiration
Fever (especially MDMA)
Convulsions
Perforated nasal septum (cocaine)
33
Q

What are the psychological effects of misuse of hallucinogens such as LSD and magic muschrooms?

A 
Marked perceptual disturbances
Flashbacks
Paranoid ideas
Suicidal and homicidal ideas
Psychosis
34
Q

What are the physical effects of misuse of hallucinogens such as LSD and magic muschrooms?

A 
Mydriasis
Conjunctival injection (red eye)
Hypertension
Tachycardia
Perspiration
Fever
Loss of apetite
Weakness
Tremor
35
Q

What are the psychological effects of misuse of cannabinoids such as cannabis, hashish, hash oil?

A

Euphoria
Relaxation
Altered time perception
Psychosis

36
Q

What are the physical effects of misuse of cannabinoids such as cannabis, hashish, hash oil?

A

Impaired coordination and reaction time
Conjunctival injection
Nystagmus
Dry mouth

37
Q

What are the psychological effects of misuse of ketamine?

A

Hallucinations
Paranoid ideas
Thought disorganisation
Aggression

38
Q

What are the physical effects of misuse of ketamine?

A

Mydriasis
Tachycardia
Hypertension

39
Q

What are the psychological effects of misuse of inhalants such as aerosols, glue, lighter fluid and petrol?

A 
Disinhibition
Stimulation
Euphoria
Clouded consciousness
Hallucinations
Psychosis
40
Q

What are the physical effects of misuse of inhalants such as aerosols, glue, lighter fluid and petrol?

A 
Headache
Nausea
Slurred speech
Loss of motor coordination
Muscle weakness
Damage to brain/bone marrow/liver/kidneys/heart
Sudden death
41
Q

What are the main two questionnaires used for screening of alcohol dependence?

A

CAGE

AUDIT

42
Q

What are the four parts of the CAGE screening questionnaire?

A
  1. Have you ever felt you ought to Cut down on your drinking?
  2. Have people ever made you Angry by criticising your drinking?
  3. Have you ever felt Guilty about your drinking?
  4. Have you ever needed an ‘Eye opener’ in the morning?
43
Q

What are the main things you should look out for when examining a patient who you suspect is misusing a substance?

A

Signs of intoxication:
Pupi constriction
Slurred speech
Incoordination

Signs of withdrawal:
Tremulousness
Sweating
Nausea and vomiting
Tachycardia
Pupil dilatation (alcohol)

Signs of complications:
Head injury
Infection through IV drug use (Hep C / HIV)
Liver disease

44
Q

Which patients will need admitting for treatment of alcohol withdrawal?

A

Severe dependence
History of withdrawal seizures or delirium tremens
Unsupportive home environment
Previous failed community detoxification

45
Q

What drugs can be used to treat alcohol withdrawal?

A

Benzodiazepines - chlordiazepoxide, diazepam, lorazepam

Initially started on high dose and gradually decreased over 5-7 days

46
Q

How would you treat someone who presents to A&E with the signs and symptoms of delirium tremens?

A

Admit them
Search for medical complications (infection, head injury, liver failure, haemorrhage, Wernicke’s encephalopathy)

Large dose benzodiazepine. Use haloperidol for severe psychotic symptoms only (risk of seizures with antipsychotics)

Intramuscular thiamine. Oral is not adequate in delirium tremens.

Monitor and treat temperature, fluid, electrolytes and glucose.

47
Q

What medications can be used to help the patient maintain abstinence?

A

(Brand name in brackets)

Disulfiram (Antabuse)
Acamprosate (Campral)
Naltrexone (Nalorex)

Antidepressants and benzodiazepines are not used in the maintenance of abstinence, but they can be useful for treatment of co-morbid psychiatric illness.

48
Q

How does disulfiram work (drug used to help patients abstain from alcohol)?

A

Blocks aldehyde dehydrogenase which causes an accumulation of acetaldehyde when alcohol is consumed. This causes symptoms of anxiety, flushing, palpitations, headache and nausea. It is contraindicated in patients with cardiorespiratory problems.

49
Q

How does acamprosate work (drug used to help patients abstain from alcohol)?

A

Enhances GABA transmission and appears to reduce craving. Safe to use while drinking.

50
Q

How does naltrexone work (drug used to help patients abstain from alcohol)?

A

Blocks opioid receptors and appears to reduce cravings and also reduces pleasant effect of alcohol, thereby decreasing desire to drink.

51
Q

What is the neurotransmitter associated with dependence and the brain’s reward system?

A

Dopamine in the mesolimbic pathway

52
Q

Is opiate withdrawal life threatening?

A

No, but it is very unpleasant and patient may require help.

53
Q

What drug can be used to help people with withdrawal symptoms of opiate dependence?

A

Lofexidine - centrally acting α-adrenoceptor agonist which reduces sympathetic outflow.

54
Q

What is substitution therapy with reference to treatment of opiate dependence?

A

Another substance is prescribed as an alternative to illicit drug use. Oral opiate alternatives act to stabilise patient’s life and prevent complications of needle use. May be prescribed indefinitely but the aim is normally for gradual reduction with long term abstinence.

The two drugs used are methadrone and sublingual buprenorphine (subutex). Subutex is a partial agonist so may precipitate withdrawal in those who are dependent on high doses of opiates.

55
Q

Once a opiate dependent patient has been detoxified, what drug is used to block the euphoriant effects of future opiate use?

A

Naltrexone - opiate antagonist. It can induce withdrawal if the patient is still dependent.

56
Q

Is benzodiazepine withdrawal life threatening?

A

Yes.

57
Q

What are the symptoms of benzodiazepine withdrawal syndrome?

A

Hallucinations
Convulsions
Delirium

Symptoms can emerge within hours to days, depending on half life of benzodiazepine.

58
Q

How is benzodiazepine withdrawal managed?

A

Initially converting drugs with a shorter half life (lorazopam) to drugs with longer half life (diazepam). Dose then reduced very slowly by small amount every few weeks.

59
Q

A 52-year-old man is admitted to hospital with acute pancreatitis. He drinks 90 units of alcohol per week. When is the peak incidence of delirium tremens following alcohol withdrawal?

2 hours

6 hours

24 hours

36 hours

72 hours

A

72 hours

CP2 - Psychiatry - Kinsky (18 decks)

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