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PSYCH AND EXTRA CONDITIONS Flashcards

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1
Q

MENTAL HEALTH ACT 1983
What are the main principles of the MHA?

A
  • Respect for pts wishes + feelings (past + present)
  • Minimise restrictions on liberty
  • Public safety
  • Pts well-being + safety
  • Effectiveness of treatment
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2
Q

MENTAL HEALTH ACT 1983
What is the purpose, duration, location + professionals involved, evidence needed for a Section 4?

A

P – emergency order
D – 72h
L – anywhere in community
P – 1 S12 Dr, 1 AMHP, nearest relative
E – same as S2 but only in an urgent necessity when waiting for a second dr (for a S2) would lead to undesirable delay/outcome

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3
Q

DEPRESSION
What are 2 theories speculating the causes of depression?

A
  • Stress vulnerability = someone with high vulnerability will withstand less stress before becoming mentally unwell
  • Monoamine hypothesis = depression caused by deficiency in monoamines (serotonin, noradrenaline) hence why Tx works
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4
Q

BIPOLAR DISORDER
What are the 4 types of bipolar?

A
  • Bipolar 1 = mania + depression in equal proportions, M>F
  • Bipolar 2 = more episodes of depression, mild hypomania (easy to miss), F>M
  • Cyclothymia = chronic mood fluctuations over ≥2y (episodes of depression + hypomania, can be subclinical)
  • Rapid cycling = ≥4 episodes of (hypo)mania or depression in 1 year
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5
Q

BIPOLAR DISORDER
In order to differentiate a manic and hypomanic episode, psychotic symptoms must be present.
What are some of these?

A
  • Grandiose idea may be delusional
  • Persecutory delusions sometimes
  • Pressure speech may become so great that it’s incomprehensible
  • Irritability > violence
  • Preoccupation with thoughts > self-neglect
  • Catatonia ‘manic stupor’
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6
Q

SCHIZOPHRENIA
What is schizophrenia?

A
  • Splitting or dissociation of thoughts, loss of contact with reality
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7
Q

SCHIZOPHRENIA
What is the neurotransmitter hypothesis in schizophrenia?

A
  • Excess dopamine + overactivity in mesolimbic tract = +ve Sx
  • Lack of dopamine + underactivity in mesocortical tracts = -ve Sx
  • Overactivity of dopamine, serotonin, noradrenaline + underactivity of glutamate + GABA
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8
Q

SCHIZOPHRENIA
What are some risk factors?

A

Strongest RF = FHx,
others = Black Caribbean, migrants, urban areas, cannabis use + traumatic pregnancy (emergency c-section)

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9
Q

SCHIZOAFFECTIVE
What is schizoaffective disorder?

A
  • Features of both affective disorder + schizophrenia present in equal proportion
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10
Q

GAD
What model can be used to explain the causes of GAD?

A

Triple vulnerability –
- Generalised biological
- Generalised psychological (diminished sense of control)
- Specific psychological (stressful events)

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11
Q

GAD
What are some organic differentials for GAD?

A
  • Endo = hyperthyroidism, pheochromocytoma, hypoglycaemia
  • CVS = arrhythmias, cardiac failure, anti-hypertensives, MI
  • Resp = asthma (excessive salbutamol), COPD, PE
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12
Q

PANIC DISORDER
What is the stepwise management of panic disorder?

A
  • Recognition + diagnosis with treatment in primary care
  • CBT or drug therapy (SSRIs 1st line, if C/I or no response after 12w then imipramine or clomipramine)
  • Psychodynamic psychotherapy + specialist MH services if severe
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13
Q

OCD
What are some risk factors for OCD?

A
  • Genetics = FHx of OCD or tic disorder
  • Abuse, neglect, teasing + bullying
  • Parental overprotection
  • Paediatric neuropsychiatric disorders associated with streptococci (PANDAS)
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14
Q

OCD
What is the biological management of OCD?

A
  • 1st line SSRIs = sertraline
  • 2nd line = clomipramine (TCA) with specific anti-obsessional action
  • ?Psychosurgery (stereotactic cingulotomy if intractable > 2 antidepressants, 3 combination Tx, ECT + behavioural therapy
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15
Q

PTSD
What are the 4 core symptoms of PTSD?
How long do they need to be present for to diagnose?

A

HEAR (≥1m) –
- Hyperarousal
- Emotional numbing
- Avoidance + rumination
- Re-experiencing (involuntary)

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16
Q

ANOREXIA NERVOSA
What is the diagnostic criteria for anorexia?

A

FEED ≥3m with absence of binge eating –
- Fear of fatness
- Endocrine disturbance
- Extreme weight loss
- Deliberate weight loss

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17
Q

ANOREXIA NERVOSA
How may endocrine disturbance present?

A
  • Amenorrhoea
  • Reduced libido/fertility
  • Abnormal insulin secretion
  • Delayed/arrested puberty if onset pre-pubertal
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18
Q

ANOREXIA NERVOSA
What screening tool can be used in anorexia?

A

SCOFF –
- Do you ever make yourself SICK as too full?
- Do you ever feel you’ve lost CONTROL over eating?
- Have you recently lost more than ONE stone in 3m?
- Do you believe you’re FAT when others say you’re thin?
- Does FOOD dominate your life?

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19
Q

ANOREXIA NERVOSA
What are the biological treatments for anorexia nervosa?

A
  • Fluoxetine, chlorpromazine + TCAs may be used for weight gain
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20
Q

ANOREXIA NERVOSA
What is the pathophysiology of refeeding syndrome?

A
  • Reduced carb consumption leads to reduced insulin secretion so the body switches from carb > fat + protein metabolism
  • Electrolyte stores depleted as needed to convert glucose>energy
  • Reintroducing food causes abrupt shift from fat>carb metabolism + insulin secretion surges, driving electrolytes from serum>cells to help convert glucose>energy causing further serum concentration decrease
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21
Q

ANOREXIA NERVOSA
What is the clinical presentation of refeeding syndrome?

A
  • Fatigue, weakness, confusion, dyspnoea (risk of fluid overload)
  • Abdo pain, vomiting, constipation, infections
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22
Q

ANOREXIA NERVOSA
What are the biochemical features of refeeding syndrome?

A
  • Hypophosphataemia main disturbance due to role of converting glucose>energy
  • Hypokalaemia, hypomagnesaemia + thiamine deficiency too
  • Abnormal fluid balance
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23
Q

ANOREXIA NERVOSA
What should be monitored before + during refeeding?

A
  • U+Es (Na+, K+), phosphate, magnesium, glucose, ECG, fluid balance
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24
Q

BULIMIA NERVOSA
What is the diagnostic criteria for bulimia?

A

BPFO ≥2 a week for ≥3m –
- Behaviours to prevent weight gain
- Preoccupation with eating (compulsion to eat but regret after)
- Fear of fatness
- Overeating ≥2/week

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25
BULIMIA NERVOSA What metabolic abnormalities may be present?
- Hypochloraemic hypokalaemic metabolic alkalosis due to vomiting - Hypokalaemia > muscle weakness + arrhythmias
26
PERSONALITY DISORDERS What are some differentials of schizotypal personality disorder?
- Autism - Asperger's - Schizophrenia (50% may develop it)
27
PERSONALITY DISORDERS What are some investigations for personality disorders?
- Assessed (Hx + MSE) more than once - Minnesota Multiphasic Personality Inventory (MMPI) - Eysenck Personality Inventory + Personality Diagnostic Questionnaire
28
PERSONALITY DISORDERS What is the biological management of personality disorders?
- Only use to treat comorbid conditions or if Sx distressing (e.g. antipsychotics in group A to reduce suspiciousness)
29
KORSAKOFF'S What are some causes of Korsakoff's?
- Heavy alcohol drinkers - Head injury, post-anaesthesia - Basal or temporal lobe encephalitis - CO poisoning - Other causes of thiamine deficiency (anorexia, starvation, hyperemesis)
30
LITHIUM TOXICITY What is the clinical presentation of lithium toxicity?
- Ataxia, dysarthria, confusion (drunk) - COARSE tremor, blurred vision, hyperreflexia - N+V, diarrhoea - Myoclonus, seizures + coma if severe
31
LITHIUM TOXICITY What are some complications of lithium toxicity?
- Arrhythmias (VT) - Acute renal failure - Syndrome of irreversible lithium-effectuated neurotoxicity (SILENT) after cessation of lithium >2m = truncal ataxia, ataxic gait, scanning speech, incoordination
32
LITHIUM TOXICITY What is the management of lithium toxicity?
- ABCDE approach as emergency - Stop + check lithium levels, serum creatinine, U+Es - IV fluids (bolus + 1.5–2x maintenance - ?Whole bowel irrigation with polyethene glycol for severe, acute ingestion - Haemodialysis
33
NMS What is the pathophysiology of neuroleptic malignant syndrome (NMS)?
- Dopamine antagonism often due to typical antipsychotic OD or acute withdrawal of Parkinson's meds
34
NMS What is the clinical presentation?
Bodybuilder– - Pyrexia >38 + diaphoresis - Muscle rigidity (diffuse "lead-pipe" rigidity) - Confusion, agitation, altered consciousness - Tachycardia, high/low BP - Hyporeflexia
35
NMS What are some investigations for NMS?
- FBC (leukocytosis) - Low serum iron - U+Es, Ca2+, phosphate - Urinary myoglobin (raised) - Serum creatinine phosphokinase (CPK) may be raised - CK raised
36
NMS What is the management of NMS?
- ABCDE approach - Stop antipsychotic (wait >2w before restarting, consider atypical) - Give L-dopa if dopamine withdrawal in Parkinson's - IV dantrolene or lorazepam to reduce rigidity 1st line (amantadine second) - Bromocriptine prophylaxis
37
SEROTONIN SYNDROME What is the clinical presentation of serotonin syndrome?
Sx onset + recovery fast – - Neuro = confusion, agitation - Neuromuscular = myoclonus, tremors (incl. shivering), hyperreflexia, ataxia - Autonomic = hyperthermia, diarrhoea, tachycardia, mydriasis
38
SEROTONIN SYNDROME What are some investigations for serotonin syndrome?
- FBC, U+Es, biochemistry (Ca2+, Mg2+, phosphate), CK, drug toxicology scren - ECG monitoring for prolonged QRS or QTc interval
39
SEROTONIN SYNDROME What is the management of serotonin syndrome?
- ABCDE - Stop offending agent - IV access to correct volume + reduce risk of rhabdomyolysis as in NMS - BDZs like slow IV lorazepam for agitation, seizures + myoclonus - Serotonin receptor antagonists like PO cyproheptadine or chlorpromazine if severe
40
SEROTONIN SYNDROME What is the management of serotonergic drug OD?
- ?Gastric lavage ± activated charcoal
41
LEARNING DISABILITIES What is the triad in learning disabilities?
- Low intellectual performance (IQ < 70) - Onset during birth or early childhood - Wide range of functional impairment
42
LEARNING DISABILITIES What physical disorders may be present in those with learning disabilities?
- Motor disabilities (ataxia, spasticity) - Epilepsy - Impaired hearing/vision - Incontinence
43
AUTISM SPECTRUM What are some risk factors for autism?
- M>F - Obstetric complications - Perinatal infection (rubella) - Genetic disorders (Fragile X, Down's)
44
AUTISM SPECTRUM What are the 3 areas of impaired functioning that need to be present in autism?
- Social interaction - Communication (speech + language) - Behaviour (imposition of routine with ritualistic or repetitive behaviour)
45
TIC DISORDERS What is Tourette's syndrome?
- Development of tics that are persistent for >1y - More severe expression of the spectrum of tic disorder
46
ADHD What are some risk factors for ADHD?
- Epilepsy, low socioeconomic status, learning difficulties - Premature or LBW - Brain damage (in vitro or after severe head injury later)
47
ADHD What is the triad of symptoms in ADHD?
- Inattention - Impulsivity - Hyperactivity
48
ADHD What is the management for severe ADHD?
- CNS stimulants like methylphenidate (increase monoamine pathway activity, not addictive) - S/E = appetite suppression, insomnia, psychosis, important to monitor growth, baseline ECG (cardiotoxic) - Atomoxetine (SE = liver dysfunction, suicidality) - (Lis)dexamfetamine
49
GENDER DYSPHORIA What are some risks of the hormone therapy?
- Oestrogen = clots, gallstones, high triglycerides - Testosterone = polycythaemia, acne, dyslipidaemia - Both = elevated LFTs, infertility, weight gain
50
SCHIZOAFFECTIVE What are the two types of schizoaffective disorder?
Manic type or depressive type
51
SELF-HARM What are some risk factors for self-harm?
Female Social deprivation, Single or divorced, LGBTQ+, mental illness
52
SCHIZOPHRENIA What are the features of simple schizophrenia?
Pts never really experienced +ve Sx, mostly -ve
53
TIC DISORDERS What might cause them?
- Stress, gestational + perinatal insults, PANDAS
54
TIC DISORDERS How does Tourette's syndrome present?
- Multiple motor tics + at least 1 phonic tic (coprolalia)
55
OCD What is a potential cause of OCD?
Neurochemical dysregulation of 5-HT system
56
PHENOMENOLOGY Define psychosis
Severe mental disturbance characterised by a loss of contact with external reality (schizophrenia)
57
PHENOMENOLOGY Define illusion
The false perception of a real external stimulus
58
PHENOMENOLOGY Define hallucination
An internal perception occurring without a corresponding external stimulus. The person experiences it as they would a real perception.
59
PHENOMENOLOGY Define delusion
A fixed, false, unshakable belief which is out of keeping with the patient's educational, cultural + social norms. It's held with extraordinary conviction + certainty (even despite contradictory evidence)
60
PHENOMENOLOGY What is capgras syndrome?
Capgras = idea someone has been replaced by an imposter.
61
PHENOMENOLOGY what is Fregoli syndrome?
Fregoli = idea various people are the same person
62
PHENOMENOLOGY What is intermetamorphosis?
Intermetamorphosis = one significant relative is replaced by another (father is son).
63
PHENOMENOLOGY Define delusional perception and give an example
A primary delusion of two components – where a normal perception is subject to delusional interpretation E.g. – traffic light changed red so that means I am the son of God
64
TIC DISORDERS What is the epidemiology of tics?
- Transient simple tics affect 10% of children - May be associated with OCD, ADHD + ASD - M>F, usually present around or after 5y
65
TIC DISORDERS What are the two types of tics? How may they manifest?
- Simple - Complex - May be invisible to observer (abdo tensing, toe crunching)
66
TIC DISORDERS Give some examples of simple tics
- Throat-clearing - Blinking - Sniffing - Head jerking - Eye rolling
67
TIC DISORDERS Give some examples of complex tics
- Physical movements (twirling on spot, touching objects) - Copropraxia (obscene gestures) - Coprolalia (obscene words) - Echolalia
68
TIC DISORDERS What improves or worsens tics? What sensations are felt before tics?
- Stress + stimulant meds worsen, distraction improves - Premonitory = pts feel urge to perform tic, often several times to get relief from that urge (can be suppressed but internal tension builds)
69
TIC DISORDERS What is the management of mild tics?
- Watch + wait (usually improve over time - Education + reassurance - Avoid caffeine + stress
70
TIC DISORDERS What is the management of severe tics?
- Habit reversal training - ERP - Antipsychotics considered in VERY severe cases
71
CONDUCT DISORDER What can be used as a last resort in conduct disorder?
- Antipsychotic like risperidone to reduce aggressive tendencies
72
CONVERSION DISORDERS What are the features of conversion disorders?
- Paralysis (any pattern) - Aphonia (complete loss or whispered speech) - Sensory loss (area may cover patient's beliefs about anatomy) - Seizure (NEAD) - Amnesia (short-term memory loss usually too severe for forgetfulness)
73
ANTI-PSYCHOTICS What are the 5 broad categories of SEs caused by anti-psychotics?
- Extra-pyramidal side effects (EPSEs) - Hyperprolactinaemia - Metabolic - Anticholinergic - Neurological
74
ANTI-PSYCHOTICS What are the extra-pyramidal side effects (EPSEs) of anti-psychotics?
- Acute dystonic reaction - Parkinsonism - Akathisia - Tardive dyskinesia
75
ANTI-PSYCHOTICS What are the SEs from hyperprolactinaemia?
- Sexual dysfunction (+ anti-adrenergic) - Osteoporosis risk - Amenorrhoea - Galactorrhoea, gynaecomastia + hypogonadism in men
76
ANTI-PSYCHOTICS What are the metabolic SEs?
- Weight gain (esp. olanzapine) - Hyperlipidaemia, risk of stroke + VTE in elderly - T2DM risk + metabolic syndrome
77
ANTI-PSYCHOTICS What are the anticholinergic SEs?
Can't see, pee, spit, shit – - Blurred vision - Urinary retention - Dry mouth - Constipation + tachycardia
78
ANTI-PSYCHOTICS What are the neurological SEs?
- Seizures - Postural hypotension (anti-adrenergic) - Sedation - Headaches
79
ANTI-PSYCHOTICS What baseline investigations are done for people starting on anti-psychotics?
- FBC, U+Es, LFTs, lipids, BMI, fasting glucose, prolactin, BP, ECG (QTc prolongation) + smoking status (can reduce effects by enhancing metabolism so issues if suddenly stop)
80
ANTI-PSYCHOTICS What regular investigations are done for people on anti-psychotics?
- Lipids + BMI at 3m - Fasting glucose + prolactin at 6m - Frequent BP during dose titration - FBC, U+Es, LFTs, lipids, BMI, fasting glucose, prolactin + CV risk yearly
81
ANTI-PSYCHOTICS What specific monitoring is required for clozapine?
- FBC at baseline + weekly for 18w, fortnightly until 1y + monthly after
82
ANTI-DEPRESSANTS What is the mechanism of action of SSRIs? Give some examples
- Prevents reuptake + subsequent degradation of serotonin from synaptic cleft by inhibiting its reuptake transporter on the post-synaptic membrane - Prolonged serotonin in synaptic cleft = prolonged neuronal activity - Citalopram, sertraline, fluoxetine
83
ANTI-DEPRESSANTS What are the side effects of SSRIs?
- GI Sx most common (N+V, hyponatraemia, abdo pain, bowel issues, increased bleed risk) - Sedation + sexual impotence - Citalopram + QTc prolongation (dose-dependent)
84
ANTI-DEPRESSANTS What is the mechanism of action of monoamine oxidase inhibitors (MAOI)?
- Inhibits monoamine oxidase enzyme which reduces breakdown of adrenaline, noradrenaline + serotonin so increases level
85
ANTI-DEPRESSANTS What are some side effects from MAOIs?
- Sexual dysfunction, weight gain + postural hypotension
86
ANTI-DEPRESSANTS What are some cautions with MAOIs?
- Increased risk of serotonin syndrome if used with other serotonergic drugs - Hypertensive crisis with ingestion of foods containing tyramine (aged cheeses, smoked/cured meats, pickled herring, Bovril, Marmite)
87
ANTI-DEPRESSANTS What is the mechanism of action of tricyclic antidepressants (TCAs)?
- Prevents reuptake + subsequent degradation of serotonin + noradrenaline from synaptic cleft by inhibiting reuptake transporters on post-synaptic neuronal membrane
88
ANTI-DEPRESSANTS What are the side effects of TCAs?
- Anticholinergic (can't see, pee, spit, shit)
89
ANTI-DEPRESSANTS What cautions are there for TCAs?
- Caution in CVD, avoid following MI - Cardiotoxic in overdose so caution in suicidal patients (QTc prolongation)
90
ANTI-DEPRESSANTS In terms of TCA overdose... i) mild-moderate Sx? ii) severe Sx?
i) Dilated pupils, dry mouth, urinary retention, increased tendon reflexes + extensor plantars ii) Fits, coma, cardiac arrhythmias > arrest
91
ANTI-DEPRESSANTS What is the mechanism of action of mirtazapine?
- Blocks alpha-2 adrenergic receptors > increased release of neurotransmitters
92
MOOD STABILISERS What are the side effects of lithium?
LITHIUM – - Leukocytosis - Insipidus (diabetes, nephrogenic) - Tremors (fine if SE, coarse if toxicity) - Hydration (easily dehydrates, renally cleared) - Increased GI motility (N+V, diarrhoea) - Underactive thyroid - Mums beware (Ebstein's anomaly) Can cause weight gain + derm (acne, psoriasis) long-term too
93
MOOD STABILISERS What drugs does lithium interact with?
- NSAIDs, ACEi, ARBs + diuretics may increase lithium levels - Diuretics = dehydration, NSAIDs = renal damage
94
MOOD STABILISERS What baseline measurements are taken for lithium?
- FBC, U+Es, eGFR, TFTs, BMI + ECG
95
MOOD STABILISERS What regular monitoring is done for lithium?
- Weekly serum lithium after initiation + dose changes until stable then every 3m for a year, then every 6m (sample taken 12h after dose) - 6m = TFTs, U+Es, eGFR - Annual = BMI
96
HYPNOTICS What is the mechanism of action of hypnotics?
- GABA agonists on alpha2-subunit of GABA(A)-BDZ receptor/Cl- channel complex
97
ANTI-PSYCHOTICS What are the issues for typical anti-psychotics?
Not selective so can bind to other dopaminergic pathways causing generalised dopamine receptor blockade
98
ANTI-PSYCHOTICS What pathway do typical anti-psychotics work on to cause side effects?
Nigrostriatal (Parkinsonism), tuberoinfundibular (prolactin)
99
ANTI-PSYCHOTICS What is the most common adverse effect of clozapine? What other adverse effects may it have?
- Constipation (big issue in elderly) - Reduced seizure threshold, hypersalivation (Rx hyoscine hydrobromide)
100
ANTI-PSYCHOTICS Why is akathisia dangerous?
It is a massive risk factor for suicide in young men with schizophrenia
101
ANTI-PSYCHOTICS How is akathisia managed?
Reduce dose, introduce beta-blocker (propranolol)
102
ANTI-PSYCHOTICS How is tardive dyskinesia managed?
Prevention crucial, switch to atypical anti-psychotic, tetrabenazine used if mod–severe but unlikely to completely resolve
103
ANTI-DEPRESSANTS What are some interactions of SNRIs?
- NSAIDs warfarin (increased risk of bleeding), lower seizure threshold
104
ANTI-DEPRESSANTS Give some examples of tricyclic antidepressants (TCAs)?
Amitriptyline, dosulepin, imipramine
105
ANTI-DEPRESSANTS In terms of TCA overdose what are the ECG signs?
Sinus tachy, wide QRS, prolonged QT interval
106
ANTI-DEPRESSANTS What is the management of a TCA overdose?
Sodium bicarbonate
107
ANTI-DEPRESSANTS What are some side effects of mirtazapine?
Increased appetite + weight gain + sedation are big ones, also increased triglyceride levels
108
MOOD STABILISERS What is the mechanism of action of mood stabilisers?
Lithium inhibits cAMP production which inhibits monoamines
109
HYPNOTICS What are the adverse effects?
Same as BDZs - Amnesia, ataxia (esp elderly = falls risk), confusion, drowsiness, dizziness next day (hangover effect), tolerance - Monitor for resp depression (caution in resp disease)
110
BDZs What is the mechanism of action of anxiolytics/benzodiazepines (BDZs)?
- Enhance effect of inhibitory GABA by increasing frequency of Cl- channels + flow of Cl- ions causing hyperpolarisation of membrane + so prevention of further excitation
111
BDZs How would you manage an overdose? What is the risk of using this?
IV flumazenil (danger of inducing status epilepticus or death though)
112
SUBSTANCE ABUSE Why is something addictive?
Related to dopamine + mesolimbic reward system a motivational circuit
113
SUBSTANCE ABUSE What are the physical effects of dependent drug use?
- Acute = injecting complications, SEs, OD, poor pregnancy outcomes - Chronic = BBV transmission, chronic illnesses
114
SUBSTANCE ABUSE What are the... i) psychological ii) social effects of dependent drug use?
i) MH issues, fearing withdrawal, craving, guilt, pre-occupation with finding next fix ii) Effects on relationships, criminality + imprisonment, social exclusion, poverty (no money for food)
115
SUBSTANCE ABUSE List 8 features of dependence
- Withdrawal - Cravings - Continued use despite harm - Tolerance - Primacy/salience - Loss of control - Narrowed repertoire - Rapid reinstatement
116
ALCOHOL DEPENDENCE What are the components to alcohol abuse?
- Psychological dependence = feelings of loss of control, cravings, pre-occupation - Physiological dependence = physical withdrawal Sx - +ve reinforcement = drinking to feel euphoric - -ve reinforcement = drinking to avoid withdrawal Sx
117
ALCOHOL DEPENDENCE How does alcohol affect the activity of neurotransmitters in the brain?
- Ethanol > ADH > acetaldehyde > ALDH > acetate > CO2 + H2O - Ethanol binds to GABA + makes inhibitor/depressant effect stronger - Glutamate antagonism which decreases excitatory neurotransmission - Activates opioid receptors to release endorphins - Release dopamine + serotonin
118
ALCOHOL DEPENDENCE What are some causes/risk factors for alcohol dependence?
- Genetics – more likely if FHx, M>F, less likely if acetaldehyde dehydrogenase deficiency - Occupation – army, Drs - Culture/beliefs/background – high in Scottish, Irish, lower in Muslims + Jews - Cost of alcohol - Early use of substances - Social reinforcement - Chronic illnesses - Traumatic life events
119
ALCOHOL DEPENDENCE What are the acute effects of alcohol intoxication? When is it classed as alcohol dependence?
- Euphoria, impaired judgement, reduced anxiety, ataxia, vomiting - ≥3 features of dependence
120
ALCOHOL DEPENDENCE What are the 3 stages of alcohol withdrawal?
- 6–12h = tremors, diaphoresis, tachycardia, anxiety, irritability + aggression - 36h = seizures - 48–72h = delirium tremens
121
ALCOHOL DEPENDENCE What are the CAGE questions?
- Have you ever felt you need to CUT down on your drinking? - Have people ANNOYED you by criticising your drink? - Have you ever felt GUILTY about your drinking? - EYE-opener – ever felt you need drink first thing in morning to steady your nerves?
122
ALCOHOL DEPENDENCE What are the AUDIT questions?
- How often do you have a drink containing alcohol? - How many units of alcohol do you drink on a typical day? - How often did you have >6 units on a single occasion in the past year?
123
ALCOHOL DEPENDENCE What are public health measurements to help prevent alcohol abuse?
- Increasing tax on alcohol + restricting advertisement on alcohol - Drinkaware + know your limits campaign - Keeping alcohol out of site (behind counter + having to ask for it) - School alcohol education to reduce long-term alcohol use + binge drinking
124
ALCOHOL DEPENDENCE What are the indications for an inpatient detoxification?
- Withdrawal seizures or delirium tremens in past - Significant mental/physical illness, including suicidality - Lack of stable home environment
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ALCOHOL DEPENDENCE What are the 3 biological treatments used in alcohol dependence?
- Naltrexone - Acamprosate - Disulfiram
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ALCOHOL DEPENDENCE What is the mechanism of action of naltrexone?
- Opioid receptor antagonist - Blocks euphoric effects of alcohol - Helps people stick to detox programme + avoid relapse
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ALCOHOL DEPENDENCE What is the mechanism of action of acamprosate?
- NMDA antagonist acts on GABA to reduce cravings + risk of relapse
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ALCOHOL DEPENDENCE What is the mechanism of action of disulfiram? What affects does it have?
- Inhibits acetaldehyde dehydrogenase > build-up of acetaldehyde - Produces hangover-like Sx when alcohol is drunk = deterrent (flushing, headaches, anxiety, nausea, reduced BP)
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OPIATES/OPIOIDS How do opioids work?
- Bind to m-receptor > endogenous endorphins causing cortical inhibitor effects (analgesia) almost immediately - Addictive as high reward for minimal effort
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OPIATES/OPIOIDS What routes can opioids be taken via? How long does it take for withdrawal symptoms to develop? What are some examples?
- Smoking, PO, snorted, parenterally (IM/IV) - 6h post-dose - Morphine, diamorphine (heroin), codeine, methadone
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OPIATES/OPIOIDS With opioids, what is the... i) psych effect? ii) physical effect?
i) Euphoria, relaxation, drowsiness, analgesia ii) Resp depression (esp. OD), pinpoint pupils, bradycardia, constipation
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OPIATES/OPIOIDS What are some complications with injecting heroin?
- Abscesses, cellulitis, infective endocarditis, BBV (hep B/C, HIV), VTE
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OPIATES/OPIOIDS What drug can be used to prevent relapses?
- Naltrexone - Opiate antagonist which prevents lapse > relapse
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STIMULANTS What are some examples?
Cocaine, ecstasy (MDMA), amphetamines (speed)
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STIMULANTS What different routes of taking these drugs?
- Cocaine inhaled or IV - MDMA + amphetamines PO - Crack cocaine releases all dopamine straight away when smoked
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STIMULANTS What are the withdrawal effects of stimulants?
Psychomotor agitation, dysphoric mood, insomnia bizarre/unpleasant dreams
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STIMULANTS What are some other adverse effects of cocaine?
- Arrhythmias, MI + damage to nasal septum if used chronically
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CANNABINOIDS Why is cannabis addictive? What can heavy use lead to?
- Addictive as causes release of dopamine, anxiolytic - Anxiety + depression, use in youth > schizophrenia
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CANNABINOIDS What are the... i) psych ii) physical effects of cannabinoids?
i) Euphoria + disinhibition, hallucinations, paranoid, agitation, time passes slowly ii) Increased appetite, dry mouth, tachycardia
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HALLUCINOGENS What are some psych + physical effects of hallucinogens?
- Hallucinations, illusions, depersonalisation + derealisation, paranoia, impulsivity, anxiety, magic mushrooms > euphoria as serotonin release - Tachycardia, palpitations, sweating, blurred vision
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BDZs What drugs can BDZs interact with?
- Anti-hypertensives as enhanced hypotensive effect
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SUBSTANCE ABUSE What is an addiction?
- Compulsive substance taking behaviour with physiological withdrawal state
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SUBSTANCE ABUSE What is an addictive behaviour?
Behaviour which is both rewarding + reinforcing
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OPIATES/OPIOIDS What are some complications from opioids?
- Resp depression, constipation, N+V, coma, OD + death
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OPIATES/OPIOIDS With opioids, what are the symptoms of withdrawal
"Goose flesh" (piloerection), raised HR/BP, fever, pupil dilatation, abdo cramps, insomnia, agitation (everything runs > D+V, lacrimation, rhinorrhoea, diaphoresis)
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SEDATIVES What are the... i) psych ii) physical effects of sedatives?
i) Euphoria + disinhibition, hallucinations, paranoid, agitation, time passes slowly ii) Unsteady gait, dysarthria, hypotension, nystagmus iii) Sweating, myalgia, tremors, risk of seizures
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STIMULANTS What is the action of stimulants?
- Potentiate mood enhancing neurotransmission (dopamine, serotonin, noradrenaline) by blocking their uptake + increase cortical excitability
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STIMULANTS What are the... i) psych ii) physical effects of stimulants?
i) Euphoria, increased alertness + endurance, grandiosity, hallucinations, aggression, impulsivity ii) Tachycardia, HTN, N+V, pupil dilation, CP + convulsions
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CANNABINOIDS What are the withdrawal effects of cannabinoids?
Anxiety, irritable, tremor, conjunctival injection
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HALLUCINOGENS Give some examples of hallucinogens
- LSD, magic mushrooms (PO)
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VOLATILE SOLVENTS What are some psych + physical effects of solvents?
- Apathy, lethargy, impaired judgement, psychomotor retardation - Decreased consciousness, unsteady gait, diplopia
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VOLATILE SOLVENTS Are the effects of solvents dangerous?
Very – laryngospasm due to cold temp, brain damage, hypoxia

C TO REVISE - PHASE 3A (11 decks)

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