Psych IV Flashcards
(37 cards)
Describe the acute and chronic pharmacodynamic effects of alcohol exposure [+]
Acute exposure
* Dopamine release
* Mesolimbic pathway = reward pathway
* Acetaldehyde activates also
Chronic exposure
* Downregulation of dopaminergic neurons
* Promotes increased alcohol consumption to achieve reward
Wernicke-Korsakoffs can present with lesions in which part of the brain ? [1]
Symmetrical lesions around 3rd ventricle (mammillary bodies)
Key features of Korsakoffs? [2]
Anterograde amnesia, Confabulation
Describe the pathophysiologial changes to brain seen in Korskoffs [2]
Wernicke’s plus
Marked widening in frontal intratemporal fissure
Reduced blood flow to frontal lobes (fMRI)
State and describe the MoAs of the preventative medications for alcohol dependency [3]
Acamprosate
* stimulates GABAergic inhibitory neurotransmission and antagonisis excitatory amino-acids, particularly glutamate.
Disulfiram (Antabuse)
* Blocking liver enzyme aldehyde dehydrogenase, which leads to an accumulation of acetaldehyde
Naltrexone
* Blocking opioid receptor leads to lower levels of dopamine
Describe the treatment for alcohol withdrawal [+]
Patient either needs to continue drinking or be offered a detox.
Management is generally done as an inpatient, particularly if severe or history of seizures.
Monitor withdrawal with CIWA score.
Management is primarily with Benzodiazepines (usually chlordiazepoxide)
- This can be a fixed reducing withdrawal regimen (5 7 days)
IM/IV pabrinex or oral thiamine is given alongside this
Describe how you manage opioid dependence [+]
Stabilisation on Methadone
* Long half life opioid
* Risk of diversion
* Titration of dose
* Gradual reduction
Treatment with Buprenorphine
* Partial agonist with strong affinity
* Lower risk of diversion
* Must be in withdrawal before using
Treatment with Naltrexone
* Opioid receptor antagonist
* Long term prevention
Generally Opiate withdrawal would be managed with harm reduction methods
* This might include opiate substitution e.g. with methadone and buprenorphine
* Controlled detox over a period of time.
* Withdrawal can be monitored with a COWS score (Clinical Opiate Withdrawal Scale)
Overdose
* Overdose is a significant risk with opiates particularly those new or changing dose of opiates and IV drug users.
* Naloxone would generally be issued to those at risk
Describe how methadone can be used to treat opioid dependence [+]
What are possible side effects? [3]
Methadone:
- SLIGHT Increased risk of mortality in the first 4 weeks of treatment.
- Gradual titration
- Normally tapered down over months.
- Can be used in long term treatment.
- Longer withdrawal syndrome.
Interactions:
* QTc prolongation at high dose > 100mg, and in combination with other medications.
* Medication interactions (CYP3A4).
NB: Methadone = full agonist
Describe how buprenorphine can be used to treat opioid dependence [+]
What are possible side effects? [3]
- Not associated with increased mortality during titration.
- Client needs to be in mild to moderate withdrawals to prevent precipitated withdrawals from opiates.
- Rapid titration.
- Less sedative.
- Client needs to be in mild to moderate withdrawals to prevent precipitated withdrawals from opiates.
- Rapid titration.
How do you manage cocaine toxicity? [2]
chest pain:
* benzodiazepines + glyceryl trinitrate
* if myocardial infarction develops then primary percutaneous coronary intervention
hypertension:
- benzodiazepines + sodium nitroprusside
How do you mx MDMA toxicity? [2]
Management
* supportive
* dantrolene may be used for hyperthermia if simple measures fail
State which drugs you would use to reverse the following causes of an overdose:
* Paracetamol
* Opioids
* Benzos
* Betablockers [2]
Paracetamol:
- Acetylcysteine
Opioids:
- Naloxone
Benzos
- Flumazenil
Betablockers:
* Glucagon for heart failure or cardiogenic shock
* Atropine for symptomatic bradycardia
State which drugs you would use to reverse the following causes of an overdose:
* CCBs
* Cocaine
* Cyanide [2]
* Methanol
* CO
CCBs: Calcium Chloride
Cocaine: Diazepam
Methanol: Fomepizol or ethanol
Cyanide: Dicobalt edetate
CO: 100% oxygen
Describe the presentation of opiate withdrawal [+]
Opiate withdrawal presents with diarrhoea, mydriasis, muscular aches, yawning, a runny nose and insomnia.
Patients show features of sympathetic stimulation with tachycardia, hypertension and piloerection (goosebumps).
Likely that there is difficult venous access; therefore, it is likely that this man injects IV heroin and thus has damaged his veins.
Opiate relapse can be prevented using [] once detox is complete.
Overdose can be managed with []
Relapse can be prevented using neltrexone once detox is complete.
Overdose can be managed with naloxone
NICE suggest a step-wise approach for treating GAD. What are the steps? [4]
step 1:
- education about GAD + active monitoring
step 2:
- low-intensity psychological interventions (individual non-facilitated self-help or individual guided self-help or psychoeducational groups)
step 3:
- high-intensity psychological interventions (cognitive behavioural therapy or applied relaxation) or drug treatment. See drug treatment below for more information
step 4:
- highly specialist input e.g. Multi agency teams
Lecture:
* 50% of people with GAD start their treatment with antidepressants such as SSRIs or SNRIs (comorbidity with depression)
* 35% are treated with benzodiazepines (anxiolytics)
* Stimulus control treatment: behavioural intervention to limit the contexts in which worrying occurs: limited amount of time; specific location
CBT: self-monitoring, relaxation training, cognitive restructuring, behavioural rehearsal
What is the drug tx for GAD? [+]
NICE suggest sertraline should be considered the first-line SSRI
- if sertraline is ineffective, offer an alternative SSRI or a serotonin-noradrenaline reuptake inhibitor (SNRI)
- examples of SNRIs include duloxetine and venlafaxine
If the person cannot tolerate SSRIs or SNRIs
- consider offering pregabalin
- interestingly for patients under the age of 30 years NICE recommend you warn patients of the increased risk of suicidal thinking and self-harm.
- Weekly follow-up is recommended for the first month
Describe the DSM-5 diagnostic criteria for GAD [5+]
A Excessive anxiety and worry, occurring more days than not for at least 6 months, about a number of events or activities
B The individual finds it difficult to control the worry
C The anxiety and worry are associated with at least three of the following symptoms:
* Restlessness
* Being easily fatigued
* Difficulty concentrating or mind going blank
* Irritability
* Muscle tension
* Sleep disturbance
D The anxiety/worry or physical symptoms cause clinically significant distress or impairment in important areas of functioning
E The disturbance is not better explained by physiological effects of a substance, or by another medical condition
The Generalised Anxiety Disorder Questionnaire (GAD-7) can help assess the severity. It involves seven questions, each scored depending on how often the symptoms are experienced. The total score indicates the severity:
[] indicates mild anxiety
[] indicates moderate anxiety
[] indicates severe anxiety
5-9 indicates mild anxiety
10-14 indicates moderate anxiety
15-21 indicates severe anxiety
Describe the management of mild, moderate and severe OCD [+]
PM:
If functional impairment is mild
low-intensity psychological treatments:
* cognitive behavioural therapy (CBT) including exposure and response prevention (ERP)
* If this is insufficient or can’t engage in psychological therapy, then offer choice of either a course of an SSRI or more intensive CBT (including ERP)
If moderate functional impairment
* offer a choice of either a course of an SSRI (any SSRI for OCD but fluoxetine specifically for body dysmorphic disorder) or more intensive CBT (including ERP)
If severe functional impairment
* offer combined treatment with an SSRI and CBT (including ERP)
ZtF:
- Mild OCD may be managed with education and self-help resources.
More significant OCD may require:
* Cognitive behavioural therapy (CBT) with exposure and response prevention (ERP)
* SSRIs
* Clomipramine (a tricyclic antidepressant)
How long is the tx for OCD for if effective? [1]
if treatment with SSRI is effective then continue for at least 12 months to prevent relapse and allow time for improvement
- If SSRI ineffective or not tolerated try either another SSRI
NICE recommend classifying impairment into mild, moderate or severe
they recommend the use of the [] scale
Describe what an example of severe OCD would look like
they recommend the use of the Y-BOCS scale
an example of ‘severe’ OCD would be someone who spends > 3 hours a day on their obsessions/compulsions, has severe interference/distress and has very little control/resistance
Describe what is meant by social anxiety disorder [1]
Marked and XS fear or anxiety that occurs in more or more social situations - can be interactions, perfomance or feeling observed.
- Fear that will act in a way or show anxiety symptomns that be will negatively evaluated by others
- Significant distress or impairment
- Prolonged
