Psychiatry Flashcards
Schizophrenia
the most common form of psychosis, generally a lifelong condition that can take a chronic or relapsing & remitting form with episodes of acute illness
Schizophrenia epidemiology
usually presents in adolescences & early 20s
generally females have a later age of occurrence
responsible for 25% of all psychiatric hospitalisations of 10-18 year olds
Risk factors for schizophrenia
family history* cannabis use obstetric/perinatal complications ACEs psychological stress migrant status
Presentation of schizophrenia
deterioration in functioning over the preceding months
4 symptomatic domains
Positive symptoms:
hallucinations (usually auditory), delusions, thought disorders (e.g. broadcasting, withdrawal, insertion), speech disorder, derealisation
Negative symptoms:
asocial behaviour, affective blunting, anhedonia, alogia (↓ speech), abolition (↓ motivation), social withdrawal, self neglect
Catatonia:
extreme loss or malignant excess of motor activity
catatonic stupor/rigidity/negativism/excitement
cognitive deficits/affctive symptoms/physical symptoms:
problems with language/memory/attention/excutive function, depression, elation, motor coordination deficits, left-right disorientation, sensory integration deficit
Positive symptoms of schizophrenia
hallucinations (usually auditory) delusions thought disorders (e.g. broadcasting, withdrawal, insertion) speech disorder derealisation
Negative symptoms of schizophrenia
asocial behaviour affective blunting anhedonia alogia (↓ speech) abolition (↓ motivation) social withdrawal self neglect
Catatonic symptoms fo schizophrenia
extreme loss or malignant excess of motor activity
catatonic stupor/rigidity/negativism/excitement
cognitive deficits/affective symptoms/physical symptoms of schizophrenia
problems with language/memory/attention/excutive function depression elation motor coordination deficits left-right disorientation sensory integration deficit
DSM-5 criteria for schizophrenia
Schizophrenia can be diagnosed if the following conditions are met.
Two or more of the following symptoms are present: delusions, hallucinations, disorganised speech, disorganised/catatonic behaviour, or negative symptoms. At least one of the symptoms must be a positive symptom.
Symptoms occur for a period of at least 1 month (less, if treated) and are associated with at least a 6-month period of functional decline
Symptoms do not occur concomitantly with substance use or with a mood disorder episode.
ICD-11 criteria for schizophrenia
Criteria for schizophrenia require a combination of at least one first-rank psychotic symptom or at least two other symptoms, including other positive psychotic symptoms, disorganised thinking or speech, negative symptoms, or catatonia.
First-rank psychotic symptoms include thought echo, thought insertion or withdrawal and thought broadcasting, delusions of control, influence or passivity, delusional perception, other strange delusions, and auditory hallucination commenting on the patient’s behaviour or talking about the patient in the third person.
Investigating schizophrenia
clinical diagnosis
consider FBC & LFTs, urine drug screen
Management of schizophrenia
1st line: PO atypical antipsychotic e.g. risperidone/olanzapine
NB clozapine = antipsychotic of choice for treatment resistant schizophrenia
Cognitive behavioural therapy (CBT) electroconvulsive therapy (ECT) - if resistant to pharmacological treatment
Monitoring of treatment for schizophrenia
- extrapyramidal effects/metabolic syndrome/excessive prolactin
- cardiac abnormalities (baseline ECG, motor for QT prolongation)
- postural hypotension
poor prognostic factors for schizophrenia
↑ duration of untreated psychosis early/insidious/gradual onset of schizophrenia male sex negative symptoms FHx continued substance misuse
Bipolar disorder
Also known as bipolar affective disorder
chronic episodic mental illness associated with behavioural disturbances which is characterised by episodes of mania (or hypomania) and depression
Types of bipolar disorder
Type I: presents with manic episodes interspersed by major depressive episodes (most common type)
Type II: pt do not meet criteria for full mania & are described as hypomanic, has ↓ associated dysfunction
NB: rapid cycling - defined as four or more cycles of depression and mania a year, with no intervening asymptomatic episodes
Bipolar disorder epidemiology
usually develops in late teen years
usually seen <25 y/o
Risk factors for bipolar disorder
family history (50-10x ↑ risk) onset of mood disorder <20y/o stressful life events ACEs history of depression history of substance misuse presence of anxiety disorder
Presentation of bipolar disorder
Manic phase:
elevated mood, ↑quantity&speed of physical/mental activity, grandiose ideas, pressure of speech, ↑energy, racing thoughts/flight of ideas, overactivity, ↑appetite, sexual disinhibition, ↓need for sleep, hallucinations, delusions, lack of isnight
Hypomanic phase:
persistent mild elevation in modd
↑ activity/energy levels
NO psychotic symptoms
Depressive phase: low mood (worse in mornings), ↓energy levels, unkempt, anhedonia, ↓self-esteem, despair, guilt, ↓appetite, weight loss, loss of libido, altered sleep pattern, self neglect
Psychological functioning:
difficulties in relationships & at work
Manic symptoms of bipolar disorder
elevated mood ↑quantity&speed of physical/mental activity grandiose ideas pressure of speech ↑energy racing thoughts/flight of ideas overactivity ↑appetite sexual disinhibition ↓need for sleep hallucinations delusions lack of insight
Depressive symptoms of bipolar disorder
low mood (worse in mornings) ↓energy levels unkempt, anhedonia ↓self-esteem despair, guilt ↓appetite weight loss loss of libido altered sleep pattern self neglect
Differentiating hypomania and mania
NO psychotic symptoms in hypomania
Hypomania does not impair functional ability significantly
hypomania is shorter lasting than mania
ICD-10 criteria for bipolar disorder
≥2 episodes of a persons mood & activity levels being significantly disturbed (at least one of which is mania/hypomania)
3 of the following confirm mania
-grandiosity/inflated self esteem, pressured speech, ↓need for sleep, flight of ideas, distractibility, psychomotor agitation, excessive involvement in pleasurable activity without thought for consequence
±psychotic symptoms e.g. hallucinations/delusions
frequency & duration of episodes are variable and may even vary day to day/within a day between mania/depression/hypomania
Management for bipolar disorder
self help/support groups
CBT/interpersonal therapy
Mood stabilisers
1st line: lithium (valproate/olanzapine if lithium not tolerated)
2nd line: add valproate if lithium alone ineffective
For acute mania:
give antipsychotic e.g. haloperidol/olanzapine/risperidone
consider IM sedation e.g. bentos
For acute depression:
offer fluoxetine ± olanzapine/quetiapine
Depression
refers to both negative affect (low mood) and/or absence of positive affect (loss of interest/pleasure in most activities) which is usually accompanied by a variety of emotional/cognitive/physical/behavioural symptoms
Risk factors for developing depression
female gender history of depression/suicide family history of depression/suicide significant/chronic physical illness history of other mental health problems psychosocial factors (ACEs, unemployment, poverty)
Presentation of depression
depressed/low mood anhedonia functional impairment weight change loss of libido sleep disturbance low energy/fatigue poor concentration suicidal ideation excessive guilt ↓ self-esteem feeling of worthlessness
Screening for depression
PHQ-2 questionnaire
over past month have you:
-felt low/depressed/hopeless
-had little interest/pleasure in doing things
Assessment of depression (assessing degree)
PHQ-9 questionnaire
9 items from DSM-5 criteria scored 0-3 (0 not at all, 3 nearly everyday)
HAD scale
14 questions, 7 for anxiety, 7 for depression scored 0-3
DSM-5 criteria for depression
Five or more of the following symptoms have been present during the same 2-week period and represent a change from previous functioning. At least one of the symptoms is either depressed mood or loss of interest or pleasure:
Depressed mood most of the day, nearly every day, as self-reported or observed by others
Diminished interest or pleasure in all or almost all activities most of the day, nearly every day
Significant weight loss when not dieting, weight gain or decrease, or increase in appetite nearly every day
Insomnia or hypersomnia nearly every day
Psychomotor agitation or retardation nearly every day
Fatigue or loss of energy nearly every day
Feelings of worthlessness or excessive or inappropriate guilt nearly every day
Diminished ability to think or concentrate nearly every day
Recurrent thoughts of death, recurrent suicidal ideation without a specific plan.
In addition, these symptoms:
Cause functional impairment (e.g., social, occupational)
Are not better explained by substance abuse, medication side effects, or other psychiatric or somatic medical conditions.
Management of sub-threshold or mild-to-moderate depression
1st line: Cognitive behavioural therapy (CBT), exercise programmes, counselling
antidepressants not routinely used
Management of unresponsive or severe depression
antidepressants + CBT/interpersonal therapy
antidepressants:
SSRIs = 1st line e.g. citalopram, fluoxetine, sertraline
SNRIs = 2nd line e.g. venlafaxine, duloxetine
Schizoaffective disorder
psychiatric condition with features of both schizophrenia & mood disorders which commonly presents in early adulthood
generally more responsive to mood stabilisers than schizophrenia
generally a non-deteriorating course
DSM-5 criteria for schizoaffective disorder
uninterrupted period of illness during which there is an episode of mood disorder (major depression/mania) concurrent with a schizophrenic episode
characterised by 2 of the following symptoms present for a considerable part of 1 month:
delusions, hallucinations, disorganised speech, grossly disorganised or catatonic behaviour, negative symptoms (affective flattening, apologia, avoliiton)
should have period of at least 2 weeks of hallucinations/delusions in absence of prominent mood disorder
Management of schizoaffective disorder
atypical antipsychotics e.g. clozapine
antidepressants e.g. fluoxetine, sertraline
mood stabilsiers e.g. lithium or valproic acid
Generalised anxiety disorder (GAD)
syndrome of ongoing anxiety & worry about many events or thoughts that the pt generally recognises as excessive & inappropriate
maybe chronic & debilitating
Risk factors for generalised anxiety disorder (GAD)
family history of anxiety physical/emotional stress history of physical/emotional/sexual trauma chronic health conditions social isolation
Screening for generalised anxiety disorder (GAD)
GAD-7 score screening tool & severity measure 7 items scored 0-3 score of 5 = mild score of 10 = moderate score of 15 = severe
DSM-5 criteria for generalised anxiety disorder (GAD)
excessive anxiety&worry regarding several issues are present most of the time for >6months
difficulty controlling worry
≥3 symptoms associated with anxiety for >6 months
restlessness/feeling on edge, easily fatigued, difficulty concentrating, muscle tension, sleep disturbance (restless sleep/difficulty falling asleep)
anxiety causes significant distress or impairment in social/occupational/other areas of functioning
Symptoms of generalised anxiety disorder (GAD)
persistent nervousness trembling muscular tension light headedness palpitations dizziness epigastric discomfort sleep disturbance (restless sleep/difficulty falling asleep)
Management of generalised anxiety disorder (GAD)
Step 1: education & active monitoring
Step 2: low intensity psychological intervention e.g. CBT
Step 3: high intensity psychological intervention or drug therapy e.g. CBT or Sertraline (1st line)
NB alternative to sertraline is venlafaxine
Drug therapy of generalised anxiety disorder (GAD)
Sertraline = 1st line
Venlafaxine = alternative
consider pregabalin if SSRI/SNRI not tolerated
Panic disorder
severe & disabling illness common in primary care which often coexists with agoraphobia
NB agoraphobia rarely occurs without panic disorder
common condition, more frequent in women
DSM-5 criteria of panic disorder
recurring & unexpected panic attacks least one of which is followed by a 1-month period in which the individual worries about having additional attacks or their implications + the individual has changed they behaviour in a maladaptive way
Panic attacks are characterised by sudden surge in intense fear/physical discomfort reaching peak within a few minutes
≥4 of the following symptoms are present during panic attacks
palpitations/heart pounding/tachycardia, sweating, muscle trembling/shaking, SOB, choking sensation, dizziness/lightheadedness/instability/feeling faint, fears of losing control, numbness/tingling
Management of panic disorder
- avoid anxiety inducing substances e.g. caffeine
- trigger avoidance
- CBT
- SSRIs e.g. fluoxetine/sertrlaine (1st line)
- TCAs e.g. imipramine/clomipramine (2nd line)
Agoraphobia
fear of open spaces, especially those in which getaway/escape may be difficult which leads to avoidance of these situations
being in a provoking situation usually leads to panic attacks
the 3 basic elements of agoraphobia
Phobia
severe anxiety
avoidance of situations that might provoke anxiety
DSM-5 criteria for agoraphobia
marked fear/anxiety in ≥2 of the following group situations:
public transport, open spaces, being in shops/cinemas/theatres, standing in line/being in crowd, being outside of home alone
person fears/avoids these situations due to thought that escape may be difficult or help not available
situations are actively avoided, require a companion or are endured with marked fear/anxiety
Management of agoraphobia
CBT + medication
1st line SSRIs eg. fluoxetine/sertrlaine
2nd line imipramine/clomipramine (if no improvement after 12 weeks of SSRI)
Social anxiety disorder (SAD)
the fear of being around people & having to interact with them
one of the most common anxiety disorder especially in young people
Symptoms of social anxiety disorder (SAD)
trembling, blushing, sweating palpitations
chronic insecurity about their relationships with others
excessive sensitivity to criticism
profound fear of being judged negatively
fear of being rejected by other
fear of being mocked
Management of social anxiety disorder (SAD)
CBT based supported self help
SSRIs e.g. escitalopram/sertraline
if no response consider paroxetine or vanlafaxine
Post traumatic stress disorder (PTSD)
may develop at nay age following exposure to 1 or more traumatic events such as deliberate acts of interpersonal violence/sevre accidents/disasters/military action or any situation of exceptionally threatening/catastrophic nature
PTSD risk factors
precipitating events is life threatening refugees/asylum seekers first responders (police/ambulance/fire department) combat exposure low morale poor social support history of drug/alcohol abuse history of psychiatric illness
Presentation of PTSD
re-experiencing:
flashbacks, nightmares, repetitive & distressing intrusive images
avoidance:
avoiding people/situations/circumstances resembling or associated with event
hyperarousal:
hyper vigilance for threat, exaggerated startle response, sleep disturbance, irritability, difficulty concentrating, reckless/self-destrcutive behaviour
Emotional numbing:
feeling detached, lack of ability to experience feelings, persistent negative/distorted beliefs, distorted ideas of blame, anhedonia
Other:
depression, alcohol/substance misuse, anxiety, angerq
Length of symptoms for diagnosis of PTSD
> 1 month
Management of PTSD
watchful waiting if symptoms mild & ,4 weeks
trauma focused CBT or eye movement desensitisation & reprocessing (EMDR)
drug therapy (not 1st line): SNRIs e.g. venlafaxine or SSRIs e.g. sertraline/paroxetine
Phobias
involves intense fears of specific objects or situations that are triggered upon actual/anticipated exposure to the phobic stimuli
more common in women
One of the most common & most treatable psychiatric conditions
Presentation of phobia
usually set in childhood/early adulthood nausea dizziness disgust fainting tachycardia hyperventilation exaggerated startle
Types of phobias
animals (e.g. spiders, snakes, rats) situations (e.g. flying) environmental (e.g. heights) blood/needles/injuries others (e.g. clowns)
Management of phobias
CBT including exposure therapy
SSRIs
Obsessive compulsive disorder (OCD)
characterised by obsessions or compulsions but most frequently both
onset usually in late adolescence & early 20s
Risk factors for OCD
Family history*
DSM-5 criteria for OCD
Must exhibit obsessions, compulsions, or both.
The obsessions and/or compulsions cause marked distress, are time consuming (take more than 1 hour per day), or interfere substantially with the person’s normal routine, occupational or academic functioning, or usual social activities or relationships.
The obsessions and/or compulsions are not attributable to the physiological effects of a substance or other medical condition.
The disorder is not better explained by the symptoms of another mental disorder, such as obsession with food in the context of an eating disorder.
Obsessions are:
Recurrent and persistent thoughts, urges, or images experienced, at some time during the disturbance, as intrusive and unwanted and in most individuals cause marked anxiety or distress.
There is some effort by the affected person to ignore or suppress such thoughts, impulses, or images, or to neutralise them with some other thought or action (i.e., by performing a compulsion).
Compulsions are: Repetitive activities (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession or according to rules that must be applied rigidly. These behaviours or mental acts are performed in order to prevent or reduce distress, or prevent some dreaded event or situation. However, they are either clearly excessive or not connected in a realistic way with what they are designed to neutralise or prevent.
specify the degree of insight
specify if the disorder is tick related
Presentation of OCD
obsession is defined as an unwanted intrusive thought, image or urge that repeatedly enters the person’s mind.
Compulsions are repetitive behaviours or mental acts that the person feels driven to perform.
A compulsion can either be overt and observable by others, such as checking that a door is locked, or a covert mental act that cannot be observed, such as repeating a certain phrase in one’s mind.
OCD associated diseases
depression schizophrenia Tourettes anorexia nervosa body dysmorphic disorder easting disorders ASD
Management of OCD
Mild functional impairement:
low intensity psychological interventions e.g. CBT +exposure and response prevention (ERP)
Moderate functional impairment:
SSRI e.g. fluoxetine or high intensity psychological interventions e.g. CBT + ERP
severe functional impairment:
high intensity CBT + ERP & SSRI
Seasonal affective disorder
a variant of depression characterised by depressive episodes that recur annually at the same time each year usually during winter months
Presentation of seasonal affective disorder
onset of depressive symptoms in autumn/winter
full resolution of symptoms during spring/summer
atypical vegetative symptoms of depression are common e.g. hypersomnia, weight gain, hyperphagia, lethargy
Diagnosis of seasonal affective disorder
over last 2 years ≥2 major depressive episodes have occurred that demonstrated the temporal seasonal pattern
Management of seasonal affective disorder
Education
CBT
SSRIs
Postnatal depression (PND)
refers to the development of a depressive illness following childbirth & may form part of a bipolar or more usually unipolar illness
onset of depression within 6 weeks of childbirth
affects ~9% of new mothers
Presentation of postnatal depression
depressive symptoms e.g. low mood, anhedonia, ↓appetite, poor concentration, low self-esteem, fatigue, ↓energy, ↓ libido, suicidal ideation
fears about babies health/maternal deficiencies
marital tension
Assessment of postnatal depression
via Edinburgh postnatal depression scale
Management of postnatal depression
self-help strategies
antidepressants (SSRIs/SNRIs) at lowest effective dose
CBT/interpersonal therapy
Postnatal blues
occurs in ~50% of women after childbirth
usually 48-72h post partum, symptoms peak at 5-7 days and subside by 10-14 days
Symptoms include tearfulness, irritability, poor concentration, anxiety about the baby, emotional lability, mood swings
if persistent >14 days = postnatal depression
Postpartum psychosis/puerperal psychosis
severe mental illness which develops acutely in the early postnatal period which is a psychiatric emergency
usually develops within 1 month of birth, most commonly within 3-14 days
rapidly develops over 48h generally
Risk factors for postpartum psychosis
personal history of postpartum psychosis
history of bipolar disorder
family history of postpartum psychosis.bipolar disorder
Presentation of postpartum psychosis
rapid transition form normal state/sudden onset
early symptoms:
perplexity, fear, restless agitation, insomnia, purposeless activity, uncharacteristic behaviour, irritation, fleeting anger, resistive behaviours, elation & grandiosity
fear for her own/babys health
late symptoms:
psychosis (hallucinations, delusions, mania, depressive symptoms)
Management of postpartum psychosis
psychiatric emergency
admission to mother-baby-unit
antipsychotics ± mood stabilisers (give rapidly to reduce impact on mother-baby relationship)
Risks of postpartum psychosis
major ↑ in risk of maternal suicide
Delirium (acute confusional state)
hard to define clinical syndrome involving abnormalities of thought, perception level of awareness typically with acute onset and fluctuating change in mental states
Risk factors for delirium
age ≥65 history of dementia polypharmacy severe comorbidity previous episodes of delirium substance misuse frailty multimorbidity drug/substance use/misuse/dependance ITU admission dehydration visual/hearing impairment
Aetiology of delirium
- infection: particularly urinary tract infections
- metabolic: e.g. hypercalcaemia, hypoglycaemia, hyperglycaemia, dehydration
- change of environment
- any significant cardiovascular, respiratory, neurological or endocrine condition
- severe pain
- alcohol withdrawal
- constipation
Presentation of delirium
acute/subacute presentation with fluctuating course
disorientation, impaired cognition, change of consciousness, poor concentration, memory problems, mood changes, agitation, withdrawal, poor attention, disturbed sleep cycle, emotional lability, abnormalities of perception (hallucinations, illusions), psychotic signs (delusions, hallucinations)
Sub types of delirium
hypoactive:
apathy/quiet confusion/withdrawal, easily missed
hyperactive:
agitation/delusions/disorientation are prominent
mixed
Management of delirium
- treat underlying cause
- supportive management (clear communications, reminders of time/location, staff consistency, familiar objects from home)
- environmental measures (avoid sensory extremes, side room, adequate nutrition)
NB if medical management needed
1st line = PO Lorazepam
2nd line = PO haloperidol
Dementia
a syndrome characterised by an appreciable deterioration in cognition resulting in behavioural problems/impairment in the activities of daily living
decline of cognitive function often affects multiple domains of intellectual functioning
Symptoms of dementia
Cognitive impairment:
causing difficulties with memory, language, attention, thinking, language, orientation, calculation, problem solving
Psychiatric/behavioural problems:
changes in personality/emotional control/social behaviour, depression, agitation, hallucinations, delusions
difficulties in activities of daily living
Alzheimers disease
involved progressive degeneration of cerebral cortex with widespread cortical atrophy
most common cause of dementia
Risk factors for Alzheimers
ageing caucasian Down's syndrome hyperlipidaemia smoking obesity alcohol abuse high fat diet diabetes HTN
Genetic factors of Alzheimers
Presenilin-1 (PSEN1) - most common form of familial AD
Presenilin-2 (PSEN2) - rare
amyloid precursor protein (APP) - linked to early onset AD
ApoE4 (apolipoprotein E4) - risk of late onset AD, NB ApoE2 is protective
Presentation of Alzheimers
insidious onset of 7-10 years
memory lapses/short term memory impairment (especially episodic memory)
forgetting appointments/names/places/people
trouble finding words
language impairment
temporal/spatial disorientation
impaired executive function & judgement
behavioural change (apathy/agitation/aggression/irritability)
pathophysiology of Alzheimers
wide spread cerebral atrophy
cortical/senile plaques (extracellular deposition of beat-amyloid)
neurofibrillary tangles (intracellular aggregation hyperphosphorylated tau protein)
Investigating Alzheimers
neurophysiological Testung (MMSE, MoCa) FBC, U&Es, TFTs, Vti B12, urine drug screen, CT?MRI head
Management of Alzheimers
MDT approach with multiple therapies & support e.g. memory enhancement strategies
Pharmacological:
1st line: accetylcholinesterase inhibitors e.g. donepezil, galantamine, rivastigmine
2nd line: memantine (NMDA receptor antagonist)
Vascular dementia (VD)
a group of syndromes of cognitive impairment caused by different mechanisms that cause ischaemia or haemorrhage secondary to cerebrovascular disease (multiple infarcts, single strategic infarct, small vessel disease)
2nd most common form of dementia
Risk factors for vascular dementia
obesity HTN smoking AF history of TIA CHD diabetes family history of CVS disease/stroke genetics e.g. CADASIL
Presentation of vascular dementia
progressive disease with sudden deteriorations in a stepwise manner*
focal neurological abnormalities e.g. visual disturbances, sensory/motor symptoms etc
seizures
difficulty with attention & concentration
memory disturbance
mood disturbance
emotional lability
bladder symptoms
gait disturbance
speech distrubance
Management of vascular dementia
MDT approach with therapies, cognitive stimulation programmes and structured exercise programmes
Pharmacological:
no specific approved pharmacological treatment
Lewy body dementia
neurodegenerative disorder with parkinsonism, progressive cognitive decline, prominent executive dysfunction & visuospatial impairment
dementia characterised by eosinophilic intracytoplasmic neuronal inclusion bodies formed of alphasynuclein
Lewy body dementia presentation
dementia is usually the presenting feature with memory loss, ↓ problem solving ability, spatial awareness difficulties
earlier impairments of attention & executive function compared to AD
fluctuating cognition
Parkinsonism (bradykinesia, resting tremor, rigidity, poverty of facial expression)
frequent falls
sleep disorders (REM sleep disorders)
Management of lewy body dementia
MDT approach with therapies, cognitive stimulation programmes and structured exercise programmes
Pharmacological:
AChE inhibitors e.g. donepezil or memantine may be used
NB avoid neuroleptic drugs (may cause permanent parkinsonism)
Alcohol use disorder
common psychiatric condition that is multifactorial in aetiology, chronic in nature & associated with a wide variety of medical & psychiatric sequelae
major problem in the UK
Risk factors for alcohol use disorders
family history of alcoholism male sex ACEs stressful life events low socio-economic status other substance related disorders mood disorders
Presentation of alcohol dependence
withdrawal symptoms tolerance (↓ response to alcohol) signs of liver disease peripheral neuropathy (due to thiamine deficiency) impaire nutritional status
DSM-5 criteria for alcohol use disorder
Alcohol-use disorder is defined as a problematic pattern of alcohol use leading to clinically significant impairment or distress as manifested by at least 2 of the following criteria over the same 12-month period:
- Alcohol used in larger amounts or over a longer period of time than intended
- Persistent desire or unsuccessful attempts to cut down or control alcohol use
- Significant time spent obtaining, using, and recovering from the effects of alcohol
- Craving to use alcohol
- Recurrent alcohol use leading to failure to fulfil major role obligations at work, school, or home
- Recurrent use of alcohol, despite having persistent or recurring social or interpersonal problems caused or worsened by alcohol
- Recurrent alcohol use, despite having persistent or recurring physical or psychological problems caused or worsened by alcohol
- Giving up or missing important social, occupational, or recreational activities due to alcohol use
- Recurrent alcohol use in hazardous situations
- Tolerance: markedly increased amounts of alcohol are needed to achieve intoxication or the desired effect, or continued use of the same amount of alcohol achieves a markedly diminished effect
- Withdrawal: there is the characteristic alcohol withdrawal syndrome, or alcohol is taken to relieve or avoid withdrawal symptoms.
Assessment of alcohol use disorder
CAGE (cut down, annoyed guilt eye opener)
alcohol use disorder identification test (AUDIT)
Investigating alcohol use disorder
Alcohol level
FBC, LFTs, clotting, U&Es
Management of alcohol use disorder
advise & education
avoidance of drinking triggers
CBT
assisted withdrawal (usually community based)
if drinking >15 units/day or AUDIT score ≥20
with chlordiazepoxide + pabrinex
acamprosate (to ↓ cravings for alcohol)
naltrexone & nalmefene (↓ pleasurable effects from alcohol)
disulfiram (amplifies negative effects of alcohol by blocking acetaldehyde dehydrogenase)
Alcohol withdrawal
occurs in pts who are alcohol dependent & who have stopped/↓ their alcohol intake within hours/days of presenting
symptoms typically begin 6-12h after last alcoholic drink
Presentation of alcohol withdrawal
typically after 6-12h without drink
tremor, sweating, tachycardia, anxiety, nausea&vomiting, headache, restlessness, agitation, insomnia
cravings fro alcohol
alcoholic hallucinosis (12-24h after last drink) auditory/visual/tactile hallucinations
withdrawal seizures (24-48h after last drink) generalised tonic clonic seizures
delirium tremens (48-72h after last drink)
Management of alcohol withdrawal
admit if previous difficult withdrawal or <18y/o
chlordiazepoxide (reducing dose over 5-7 days)
Pabrinex (Vit B complex to replace thiamine)
Delirium tremens
medical emergency die to hyperadrenergic state usually occurring 48-72h after alcohol withdrawal
features include a coarse tremor, altered mental state (severe agitation/hallucinations/confusion), disorientation, tachycardia, HTN, nausea, sweating, insomnia, hyperreflexia
managed with IV benzodiazepines + parbinex
Substance use & addictive disorders
substance related disorders are a class of psychiatric disorder characterised by craving for, the development of tolerance to, difficulties controlling the use of a particular substance/set of substances and withdrawal symptoms upon cessation of substance use
generally more common in males
Features of a substance disorder
≥2 within 1 year
- impaired control (e.g. repeated failed attempts to cut down use, intense desire to obtain/use substance, spending a great deal of time on substance related activities such as buying/using/recovering)
- social impairment (problems fulfilling educational/family/social/occupational obligations, problems with interpersonal relationships, social isolation)
- risky use (use in physically hazardous situations e.g. while driving, continued use despite awareness of problems related to substance use)
- pharmacological indicators (tolerance & withdrawal)
Opioid use disorder
e.g. with fentanyl, heroin, oxycodone, morphine
biggest cause of drug related death
overdose = mitosis, respiratory depression, CNS depression, ↓ GCS, apnoea
Overdose management with naloxone (400 micrograms IM/IV)
detoxification using substitutes such as methadone or buprenorphine
needle exchanges
