Block 6 W2

Question 1

What is addiction?

Answer 1

The continued repetition of a behaviour despite adverse consequences. May continue to point of death.
It is ambivalence.
Affects 2mill

Question 2

Outline the cycle of addiction.

Answer 2

Social drinking -> problem/abusive drinking -> dependence and altered brain function -> excessive and uncontrolled drinking -> abstinence -> acute/protracted withdrawal symptoms -> relapse.

Question 3

Describe end-stage addiction.

Answer 3

Overwhelming desire to take the drug, diminished ability to control drug seeking, reduced pleasure from biological rewards -> drug becomes most salient (important) thing in their life.

Question 4

What structural changes occur in the brain in addiction?

Answer 4

Addicts take alcohol/drugs so often it becomes an automatic habit due to changes in the prefrontal cortex -> over learning of drug-related cues and can be triggered by cues years after abstinence.

Question 5

Outline dependence syndrome.

Answer 5

1. Salience - use of substance is high priority.
2. Tolerance
3. Withdrawal symptoms - body’s homeostasis disrupted.
4. Relief from symptoms with further use.
5. Compulsion to use substance
6. Narrowing of repertoire - neglect of other interests
7. Reinstatement after abstinence - 1 drink ruins it all

Question 6

Define pre-contemplation.

Answer 6

Not ready.

People are not intending to take action and can be unaware that their behaviour is problematic.

Question 7

Define contemplation.

Answer 7

Getting ready.
People are beginning to recognise that their behaviour is problematic and start to look at the pros and cons of their continued actions.

Question 8

Do some people have a vulnerability to addiction?

Answer 8

The alcohol gene - 25% of the sons of alcoholics develop alcohol problems themselves -> definite genetic risk of alcoholism but no single gene.
Twin studies - 4 good studies show increased concordance for monozygotic over dizygotic.
Adoption studies - 3 - 4x increase in risk in adoptees raised apart.

Question 9

Describe the asian flush.

Answer 9

Flush reaction in 50% of asians due to variant of acetaldehyde dehydrogenase gene -> slow metabolism of alcohol.
There is a genetic contribution to heavy drinking but affected heavily by social, upbringing and personality factors.

Question 10

What maintains addiction?

Answer 10

1. Personality factors - thrill seeking, impulsive, mood dysregulation.
2. Social factors - substance use amongst family and friends.
3. Altered physiology in continuous presence of drug - homeostasis altered so can’t function properly without the drug.
   Unpleasant effects when drug is absent - withdrawal -> strong negative reinforcement.

Question 11

Discuss the environmental influences on addiction.

Answer 11

Vietnam war - 1/2 soldiers used heroin, when they returned to US, only 7% were addicted -> shows addiction is high dependent on circumstances.
Rat park - caged rats consume more morphine compulsively and rats in park prefer plain water.
Severely distressed animals like people will relieve their distress pharmacologically if they can.

Question 12

How does addiction occur?

Answer 12

Drugs have highly positive reinforcing effect - high.

Negative reinforcement - feeling hungover/withdrawal - helped by more drinking.

Question 13

Describe Skinner’s box.

Answer 13

Answers question - how is behaviour conditioned? As we go down the list, behaviour increases:

1. rat presses lever to get food - positive reinforcement
2. fixed interval schedule - food comes out every 5mins
3. variable interval schedule - food comes every random number of presses (gambling)
4. rat presses level to turn off electric shock - negative reinforcement.

Question 14

What have studies on rats shown?

Answer 14

Rat in a cage will repeatedly self-administer heroin/cocaine even to point of death -> directly activating the dopamine reward system.
Electrodes implanted in the nucleus accumbens have the same effect.

Question 15

What is the role of dopamine in addiction?

Answer 15

Dopamine levels spike with many pleasurable activities i.e. sex, eating.
All addictive drugs lead to increased dopamine levels in nucleus accumbens.
DA system linked to salience of an activity -> things that activate dopamine reward system become more important.
Addicts become less sensitive to natural reinforcers and substances become more salient.

Question 16

What can you get addicted to?

Answer 16

Alcohol, drugs (legal - benzodiazepines, opiates, illegal - heroin, cocaine), gambling.
Activities associated with pleasure and activates dopamine reward system - sex, eating, porn, video games, shopping, exercise.

Question 17

What makes a substance addictive?

Answer 17

1. pleasure producing potency
2. rapid onset of action
3. short duration of action
4. tolerance and withdrawal

Question 18

What are the social and cultural attitudes to addiction?

Answer 18

Factors that influence societal consumption of alcohol:
- price
- availability
Alcohol has become more available and cheaper.
Education about dangers doesn’t make much difference.

Question 19

Define motivational interviewing.

Answer 19

Counselling method that helps people resolve ambivalent feelings and insecurities to find the internal motivation they need to change their behaviour.
Interviewer evokes a conversation about change and commitment and listens and reflects back the patient’s thoughts so that the patient can hear their reasons and motivations.

Question 20

How does life events cause stress?

Answer 20

Imbalance between the demands made on us and our personal resources to deal with these demands. Not the life events themselves that cause stress but the interpretation and the meaning to the individual.
Life events -> appraisal -> stress.

Question 21

Define primary and secondary appraisal.

Answer 21

Primary - appraisal of the event.

Secondary - appraisal of personal coping abilities or personal resources and resources in the immediate social network.

Question 22

What are the stress responses?

Answer 22

Emotional response - feeling on edge, irritability, tearful.
Cognitive response - difficulty concentrating, self-critical, difficulty making decisions.
Behavioural response - comfort eating, drinking/smoking, activity/underactivity.
Physiological response - increased HR, BR, perspiration.

Question 23

Outline the links between a stress response and misinterpretation of physiological symptoms.

Answer 23

Stress -> physiological response -> physical symptoms -> misinterpretation -> anxiety -> physiological response -> cycles.
e.g. HR -> palpitations -> heart attack

Question 24

Define medically unexplained symptoms.

Answer 24

Physical symptoms not explained by organic disease which cause distress and impair functioning and for which there is positive evidence or a strong assumption that the symptoms are linked to psychological factors e.g. stress, mental illness.
Patients have varying degrees of insight that some symptoms are due to psychological factors.

Question 25

Define somatoform disorders.

Answer 25

Severe, chronic psychiatric disorders where patients have chronic and multiple MUS and are excessively disabled.

Question 26

What are medically descriptive terms?

Answer 26

IBS, chronic fatigue syndrome, fibromyalgia, atypical non-cardiac chest pains.

Question 27

How is stress linked to MUS?

Answer 27

Some MUS arise from normal bodily sensations (physiological processes) with misinterpretation. Some MUS arise from minor pathology and are exaggerated at times of stress.

Question 28

What is the biopsychosocial model of MUS?

Answer 28

Bodily sensations i.e. minor pathology, stress, physiological processes -> misinterpretation fed by beliefs/childhood experience and personality/mental state -> MUS and this is maintained by reaction of other iatrogenic secondary gains.

Question 29

What is the impact of stress on physical illness?

Answer 29

Relates to relapse, control of chronic disease and morbidity. Indirect - via behavioural changes e.g. poor compliance with medication, increased alcohol intake -> epilepsy and heart disease, reduced exercise -> heart disease. Direct - stress activates HPA axis causing cortisol secretion and the sympathetic-adrenal-medullary system causing catecholamine secretion.

Question 30

How does stress impact on heart disease?

Answer 30

Increased risk of death after loss of spouse - CVD accounts for 20-53% of excess deaths. 1. acute bereavement associated with heightened SNS activation -> haemodynamic changes -> causing increases vascular resistance -> ischaemia. 2. takotsubo cardiomyopathy - broken heart syndrome -> left ventricular dysfunction and ECG changes due to high levels of circulating catecholamines in post menopausal women.

Question 31

How does stress impact mental illness?

Answer 31

Significant association between stressful life events and mental illness. 3-6 months preceding depressive illness, 50-80% patients will have experienced a significant life event. 6 fold excess of adverse life events in the months preceding the onset of depressive disorder.

Question 32

What are the individual factors that lead to stress?

Answer 32

Premorbid personality - worrier, obsessive. Prior experience of illness. Mental state. Childhood difficulties - early trauma, difficult interactions with health professionals. Appraisals and coping styles.

Question 33

Define illness appraisal.

Answer 33

``` Leventhal illness cognitions - a patient's own implicit common sense beliefs about their illness - provides framework around which a patient understands and copes with their illness. 5 dimensions: 1. identity - label and symptoms 2. timeline - perceived duration 3. consequences - expected outcome 4. cause - personal ideas about cause 5. control/cure - how to recover. Using this framework, patients make an interpretation of their illness, select a coping style and appraises the coping style. ```

Question 34

Define emotion focused model of coping.

Answer 34

Involves managing emotions and maintaining emotional equilibrium - works well transiently so reserved of brief stress or where nothing realistically can modify stress.

Question 35

Define problem focused model of coping.

Answer 35

Controlling the problem and reconstructing it as manageable.

Question 36

Describe ways of emotion focused coping.

Answer 36

Emotional discharge - talking about problems. Making and maintaining supportive friendships. Gaining emotional support from religion. Resigned acceptance - coming to terms with it.

Question 37

Describe ways of problem focused coping.

Answer 37

Seeking info and support, learning new procedures and behaviours i.e. lifestyle changes, identifying alternative activities, developing a realistic action plan.

Question 38

Define pain.

Answer 38

Unpleasant sensory and emotional experience associated with actual or potential tissue damage. Short-term pain - acute pain e.g. sprained ankle Long-term pain - persistent chronic pain e.g. back ache. Pain extends beyond the expected period of healing and frequently has no identifiable cause.

Question 39

What is the epidemiology of chronic pain?

Answer 39

10% in Yorkshire living with chronic pain, 1,200 new patients/year. Majority managed in primary care.

Question 40

Describe the epidemiology of back pain.

Answer 40

12% sick days in UK, 116 mill days lost production, 3.1 mill adults in UK, 9.4% GP consultations.

Question 41

What are the red flags of LBP?

Answer 41

Cauda equina, cancer, infection, fracture, inflammatory arthopathy. Other specific diagnoses - lumbar radicular syndrome, pain arising from facet joints and discs, spinal stenosis.

Question 42

Define non-specific LBP.

Answer 42

Tension, soreness, stiffness in the lower back region for which it is not possible to identify a specific cause of pain.

Question 43

What are the yellow flags of non-specific LBP?

Answer 43

Negative attitude that back pain is harmful or potentially disabling, fear avoidance behaviour, reduced activity level, expectation that it is passive, tendency to depression, low morale and social withdrawal, social and financial problems.

Question 44

What is the pain gate theory?

Answer 44

The spinal cord has a series of gate into which messages about pain arrive from all over the body via nerves. These can sometimes be more open than at other times thus the more you think about pain, the worse it feels.

Question 45

What can open the gates more?

Answer 45

Stress and anxiety Psychological factors - focusing attention on it and boredom. Lack of activity - stiff joints, reduced fitness.

Question 46

Define central sensitisation.

Answer 46

Condition of the NS that is associated with the development and maintenance of chronic pain. When CS occurs, the NS goes through a process "wind up" and gets regulated in a persistent state of high reactivity - this lowers the threshold for what causes pain and subsequently comes to maintain pain even after the initial injury might have healed.

Question 47

What are the 2 characteristics of CS?

Answer 47

1. allodynia - at pain with things that isn't normally painful - nerves in the area are in heightened state of reactivity. 2. hyperalgesia - stimulus is more painful than it should be - heightened reactivity.

Question 48

What are the causes of CS?

Answer 48

Changes in dorsal horn of spinal cord and in the brain - at cellular level, receptors sites. Strokes and spinal injuries can cause damage to CNS -> CS.

Question 49

How is chronic pain managed?

Answer 49

NICE recommendation - paracetamol, NSAIDs, tricyclic antidepressants and opioids only if low and intermittent. Multimodal approach is recommended: - behavioural/social -> pacing, goal setting, relaxation, return to work. - psychological -> acceptance, CBT, mindfulness, psychoeducation. - physical -> graded exercise, medication management, TENS, acupuncture.

Question 50

Describe the chronic pain MDT.

Answer 50

Medic/anaesthetists - medication, injections, spinal cord stimulators. Specialist nurses - TENS, medication knowledge Physiotherapists - TENS, strengthening and fitness exercises, posture. OTs - pacing, goal setting, adaptations for functioning. Psychologists - 1:1, group, risk management.

Question 51

What are the psychological factors in chronic pain?

Answer 51

Psychological threat can increase sensitivity to potential physical threats -> possibility of increased pain. Pain can be a protective response to psychological stimuli and pain can be activated by non-physical elements e.g. memory.

Question 52

What is the holistic model of pain?

Answer 52

Looking at behaviour, thoughts, environment, moods and physical factors that could affect the patients chronic pain.

Question 53

What did Lazarus and Folkman say about chronic pain?

Answer 53

The meaning that people give to an event determines their response to it. So people with negative beliefs about their pain can experience greater suffering. e.g. if you think the LBP is due to a muscular strain from gardening -> paracetamol and hot shower. If you think something is really wrong -> significant worry and visit GP.

Question 54

What are the cognitive behavioural model of pain and depression?

Answer 54

Patient appraisals of the impact of their pain on their lives and their sense of control over their pain determines the pain-depression relationship. Patients who believe they could still function despite pain and believed had some control - didn't become depressed.

Question 55

What are the psychological approaches of managing chronic pain?

Answer 55

CBT Third wave cognitive therapies - mindfulness, acceptance and commitment therapy (ACT) and compassion-focused therapy (CFT).

Question 56

How does CBT work?

Answer 56

Challenge thoughts + develop more helpful thoughts + develop and experiment new behaviours.

Question 57

How does mindfulness work?

Answer 57

Based on Buddhist meditative techniques. Imaging studies have shown that mindfulness can soothe the brain patterns underlying pain. Significantly reduces anxiety, stress, depression, irritability, insomnia that can arise from living with chronic pain.

Question 58

How is childhood trauma a risk factor for chronic pain?

Answer 58

Research shows prolonged anxiety, hyper-vigilance and fearfulness associated with early trauma leads to pain behaviour. 49% chronic pain patients report childhood physical and sexual abuse. Morison found 55% of women being treated for somatic disorders also had history of childhood sexual abuse.

Question 59

Define somatisation.

Answer 59

The physical expression of psychological pain e.g. headaches, GI pain, pelvis and abdominal pain, back and neck pain.

Question 60

Define stress.

Answer 60

Any condition that actually or potentially poses a challenge to the body's abilities to maintain homeostasis.

Question 61

Differentiate between eustress and distress.

Answer 61

Eustress - good, helpful, prepares us to meet challenges and improves performance. Distress - bad, unpleasant, disease producing stress, impairs performance.

Question 62

Define stressors.

Answer 62

Any stimulus that produces a stress response.

Question 63

What are the different types of stressors?

Answer 63

External - physical environment, social interaction, major life events, daily hassles. Internal - lifestyle choices, personality traits, negative self-talk. Psychosocial events - unemployment, marriage, divorce, bereavement, work problems, money concerns. Physiological events - blood loss, low blood glucose, cold or flu, surgery.

Question 64

Describe the stress response.

Answer 64

1. alarm phase - initial fight or flight response (short-term) 2. resistance or adaptation phase - body attempts to cope with prolonged stress (long-term). 3. exhaustion phase - resources depleted and body unable to maintain function.

Question 65

Describe the alarm phase.

Answer 65

Fight or flight, rapid reaction to acute stress, short lived, activates the sympathetic branch of ANS. Controlled by chemicals called catecholamines - adrenaline and NA.

Question 66

What is the sympathetic response to stress?

Answer 66

Increased HR, BP, blood diverted to heart and skeletal muscles, away from non-essential organs i.e. digestive, reproductive tracts. Dilation of airways, conversion of glycogen to glucose in liver, increases alertness and sweating.

Question 67

Describe the HPA axis.

Answer 67

Resistance/adaptive phase: Stress activates HPA axis - hypothalamic-pituitary-adrenal. 1. neurosecretory cells in hypothalamus releases corticotropin releasing hormone (CRH) 2. CRH activates anterior pituitary gland 3. anterior pituitary secretes adrenocorticotropic hormone (ACTH) 4. ACTH travels through blood to adrenal glands 5. ACTH stimulates cells in adrenal cortex to release cortisol (glucocorticoid).

Question 68

What are the effects of cortisol?

Answer 68

Lipids released into blood Amino acids/proteins released from muscles to blood Increase in blood glucose Aldosterone released by adrenal cortex causes retention of Na+, increased water retention and increased BP Immune suppression

Question 69

Differentiate between short-term stress response and long-term stress response.

Answer 69

Short term: - increased HR and BP - increased blood glucose - muscles become energised Long term: Cortisol -> protein and fat metabolism instead of glucose breakdown and inflammation and immune cells suppressed. Aldosterone -> Na+ and water retention and increased blood volume and BP.

Question 70

Define glucocorticoids.

Answer 70

Group of hormones of the adrenal cortex secreted during stress i.e. cortisol.

Question 71

What are the effects of excessive stress?

Answer 71

Anxiety, depression, high BP, ulcers, immune dysfunction, ageing, cancer, increased migraines and suppresses sex steroids.

Question 72

Describe the exhaustion phase.

Answer 72

``` Resources of the body become so depleted, they can't sustain the resistance phase. Prolonged exposure to high cortisol: - muscle breakdown - IR suppression - ulceration - depression/psychosis - failure of pancreatic beta cells - ageing ```

Question 73

How is the amygdala and hippocampus involved in stress?

Answer 73

Involved in fear responses - activation of the central nucleus leads to stress response. - amygdala and hippocampus regulate CRH neurons in hypothalamus - amygdala activation stimulates HPA axis - hippocampal activation suppresses HPA axis

Question 74

Describe the cortisol feedback mechanism.

Answer 74

Circulating cortisol binds to glucocorticoid receptors in hippocampus -> activates hippocampus, which suppresses CRH released by hypothalamus -> reduces HPA activation -> less cortisol released by adrenals.

Question 75

Describe the role of stress in memory.

Answer 75

Emotionally salient events are remembered better than at neutral as amygdala and stress hormones involved. Injecting cortisol enhances memory whereas propranolol and amygdala lesions reduces memory.

Question 76

What is the role of stress on the immune system?

Answer 76

Acute stressors upregulate IS Chronic stress inhibits IS - mediated by glucocorticoid: - cortisol decreases B and T cell numbers e.g. widows have dampened IS Glucocorticoid have a potent anti-inflammatory and immunosuppressive properties i.e. prednisolone used to treat arthritis.

Question 77

Define anxiety.

Answer 77

Inappropriate expression of fear - unrealistic and unfounded. Fear response occurs in an anticipatory manner - interferes with daily life. Psychological disorder.

Question 78

What are the typical symptoms of anxiety?

Answer 78

Tension, overactivity of ANS, upset stomach, expectation of an impending disaster, continuous vigilance, insomnia.

Question 79

List the types of anxiety disorders.

Answer 79

``` Generalised anxiety disorder Panic disorder Phobias OCD PTSD ```

Question 80

Describe GAD.

Answer 80

Ongoing state of anxiety lacking any reason or focus. Duration - at least 6 months Worrying excessive about many issues i.e. money, health, family.

Question 81

Describe panic disorder.

Answer 81

Brief periods of intense terror and apprehension. Symptoms - SOB, hyperventilation, heart palpitations, chest tightness, trembling, dizziness - misinterpreted as heart attack.

Question 82

Describe phobias.

Answer 82

Strong fear of specific things or situations i.e. open spaces, flying, snakes.

Question 83

Describe OCD.

Answer 83

``` Intrusive thoughts (obsessions) cause anxiety i.e. contamination with germs. Compulsions are repetitive behaviours that try to neutralise anxiety i.e. frequent hand washing. ```

Question 84

Describe PTSD.

Answer 84

Anxiety triggered by recall of past stressful experiences i.e. military combat, serious accidents. People relive the experience through nightmares and flashbacks and have difficulty sleeping and feel detached. Increased arousal and avoidance of stimuli associated with trauma. Hippocampus size reduced and abnormal activation of amygdala.

Question 85

What treatment options are there for anxiety?

Answer 85

Psychological - first line i.e. CBT | Pharmacological - second line but in combo with psychotherapy i.e. benzodiazepines, SSRIs, beta-blockers.

Question 86

Describe the MoA of benzodiazepines.

Answer 86

GABA agonists - bind to regulatory sites on GABA receptors to enhance the inhibitory effects of GABA in the brain. Increases the influx of negatively charged Cl- into neurones -> hyper polarisation and inhibits AP. Causes suppression of brain circuits in stress response.

Question 87

What are the effects, examples and side effects of benzodiazepines?

Answer 87

Effect - reduces anxiety, sedative for insomnia, muscle relaxant. Effective in short-term for acute anxiety. e.g. diazepam, temazepam, clonazepam Side effects - drowsiness, confusion, amnesia, impaired concentration, withdrawal symptoms and addictive with long-term use.

Question 88

Describe the use of SSRIs for anxiety.

Answer 88

e.g. fluoxetine (prozac) Used to treat mood disorders - antidepressants but also used for anxiety e.g. GAD and OCD. Prolonged action of serotonin by blocking reuptake.

Question 89

Describe the use of beta-blockers for anxiety.

Answer 89

e.g. pronanolol | Reduces sympathetic symptoms of anxiety i.e. tremor, palpitations and sweating.