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Flashcards in Psychiatry Deck (230):
1

What is mental health?

State of well-being in which the individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community

2

What are the 6 primary emotions?

Happiness
Disgust
Anger
Sadness
Surprise
Fear

3

What is the definition of anxiety?

State of apprehension, uncertainty or fear, resulting from the anticipation of a realistic or imaginary threatening event or situation
May have emotional, behavioural, cognitive and physical components

4

Describe how the HPA axis leads to the release of glucocorticoids

Stress can directly trigger or ciracdian rhythms controlled by suprachiasmatic nucleus of the hypothalamus cause release of corticotropic releasing hormone
This leads to the release of adrenocorticotropic hormone from the anterior pituitary
This triggers the adrenal cortex to release glucocorticoids

5

What roles do glucocorticoids play a part in, in the body?

Cognition/mood
Metabolism
Growth & reproduction
Clock resetting
Sleep/wake cycle
Cardio
Immune and inflammation

6

What is the fight or flight response in physiological terms?

Physiological response to a stressor
Mediated through hypothalamus and locus coeruleus (pons, releases noradrenaline)
Initial activation of the sympathetic nervous system
Subsequent activation of the pituitary adrenal axis
Terminated by negative feedback and parasympathetic system

7

What is an alert state?

Heightened sense of vigilance to possible threats
Less intense levels of inhibition, physical distress and behavioural impairment

8

What structures and neurotransmitters are involved in an alert state?

GABA mechanism
Limbic structures: hippocampus/amygdala

9

What is the difference between anxiety as a normal response and abnormal anxiety?

Some amount of anxiety is “normal” and is associated with optimal levels of functioning
Only when anxiety begins to interfere with social or occupational functioning is it considered abnormal

10

What is the Yerkes-Dodson law? What relationship does this share with glucocorticoid levels?

Relationship between arousal and performance
Performance increases with physiological or mental arousal but only up to a point
When arousal levels are too high, performance decreases
Normal distribution bell shaped curve
Memory performance vs circulating levels of glucocorticoids manifests as a similar curve: LTP is optimal when glucocorticoid levels are mildly elevated whereas significant decreases in LTP are observed after adrenalectomy or exogenous glucocorticoid administration

11

What are glucocorticoids? Where are they made?

Synthesised in zona fasciculata of adrenal cortex
Cortisol: regulates metabolism of glucose, especially in times of stress

12

Describe the characteristics of pathological anxiety

Intensity: Relatively high and/or out of proportion to the situation or circumstances
Duration: Generally longer lasting or recurrent
Preoccupation with anxiety: Yes
Distressing, overwhelming, incapacitating
Causes long-standing changes in behaviour, impairs functioning

13

What is health?

State of complete physical, mental and social well-being and not merely the absence of disease or infirmity

14

Describe the characteristics of normal anxiety

Relatively low and/or proportionate to the situation or circumstances
Generally shorter lasting
No preoccupation with anxiety
Unpleasant, but not too distressing or not distressing for a long time
Generally does not affect behaviour more than temporarily
Does not impair functioning

15

What is the lifetime risk of having a mental disorder? Which is the most prevalent?

46.4%
Anxiety disorder

16

What percentage overlap is there between depressive and anxiety disorders?

59%

17

When are specific phobias most likely to develop?

Childhood

18

When are social anxiety disorders most likely to develop?

Adolescence

19

When are panic disorders most likely to develop?

Early adulthood through to mid to late adulthood

20

When is agoraphobia most likely to develop?

Adolescence through to early adulthood

21

When is generalised anxiety disorder most likely to develop?

Any time from adolescence through to old age

22

What are the domains of anxiety?

Physical
Affective
Cognitive
Behavioural

23

Name some physical symptoms of anxiety

Anorexia
Butterflies in stomach
Chest pain/tightness
Diaphoresis: sweating
Dry mouth
Faintness
Flushing
Hyperventilation
Light-headedness
Muscle tension
Nausea
Pallor
Palpitations
Paresthesias
Sexual dysfunction
Headache
Shortness of breath
Stomach pain
Tachycardia
Tremulousness
Urinary frequency
Vomiting
Increased Arousal

24

What are affective symptoms of anxiety?

Ranges from edginess and unease to terror and panic

25

What are cognitive symptoms of anxiety?

Worry
Apprehension
Thoughts concerned with emotional or bodily danger

26

What are behavioural symptoms of anxiety?

Anxiety triggers many different responses concerned with diminishing or avoiding the distress

27

What is stress?

Experiencing events that are perceived as endangering one’s physical or psychological well-being. The events are known as stressors and the result is the stress response

28

What factors influence our response to stressors?

Controllability, predictability and challenge to our limits

29

What is the Holmes life stress scale?

Series of events which are given values - life change units
The more of these a patient has experienced, the more likely they are to become ill

30

Name some different psychological responses to stress

Anxiety
Anger and aggression
Apathy and depression
Cognitive impairment

31

Which acute psychological tasks are the most stressful?

Motivated performance with social evaluative threat and uncontrollability

32

What are the different classifications of anxiety disorders according to the ICD-10?

Phobic Anxiety Disorders: Agoraphobia without panic disorders, Agoraphobia with panic disorder, Social phobias, Specific phobias
Other Anxiety Disorders: Panic disorder (episodic paroxysmal anxiety), Generalized anxiety disorder, Mixed anxiety and depressive disorder
Obsessive-Compulsive Disorder
Reaction to Severe Stress and Adjustment Disorders: Acute stress reaction, Post Traumatic stress disorder, Adjustment disorders

33

What is generalised anxiety disorder?

Characterised by at least 6 months of persistent and excessive anxiety, worry, fear, dread, uneasiness which is difficult to control
Symptoms: restlessness, tiredness, irritability, muscle tension, lack of concentration, sleeplessness, SOB, tachycardia, sweating, dizziness

34

What is a specific phobia?

Clinically significant anxiety provoked by exposure to a specific feared object or situation, often leading to avoidant behaviour

35

What is social phobia?

Clinically significant anxiety provoked by exposure to certain types of social or performance situations, often leading to avoidant behaviours

36

What is separation anxiety disorder?

Excessive anxiety concerning separation from the home or from those to whom the person is attached (must begin before 18 years old)

37

What is obsessive compulsive disorder?

Characterised by obsessions (which cause marked anxiety or distress) and/or by compulsions (which serve to neutralise anxiety) severe enough to be time consuming or cause marked
distress or impairment

38

What is panic disorder with or without agoraphobia?

Recurrent unexpected panic attacks about which there is persistent concern

39

What is post traumatic stress disorder?

Re-experiencing of an extremely traumatic event accompanied by symptoms of increased arousal and by avoidance of stimuli associated with the trauma

40

What are the sections that you would include in a psychiatric history?

PC / HPC
Past psychiatric history
Past medical history
Family Hx
Personal Hx: Pregnancy / Birth / Early Development, Schooling / Education, Employment, Relationships
Substance Misuse
Forensic History
Pre morbid personality

41

What headings would you use to take a generic anxiety history?

S ymptoms of Anxiety
E pisodic or Continuous
D epression / Drink / Drugs
A voidance & Escape
T iming + Triggers
E ffect on Life

42

What drug abuse is commonly present in anxiety to help to avoid the feelings of anxiety?

Alcohol: social phobia / PTSD
Benzos / sleeping pills: panic disorder / agoraphobia
Cannabis
NB: caffeine / smoking may be making anxiety worse

43

What are the categories of the mental state examination?

Appearance and behaviour
Speech: Rate, volume, tone
Mood: Subj, Obj
Affect
Thoughts: Content & Form: Abnormal experiences and beliefs, Delusions & ideas of reference, Passivity phenomena (Inc. thought insertion, broadcast & withdrawal), Symptoms of severe anxiety, esp. obsessions & compulsions, suicidal thoughts, intentions and plans Perceptions: Hallucinations (modality, person, content), Illusions, Derealisation, Depersonalisation
Cognitive Functions: Attention and Concentration, Orientation (T, P and P)
Memory: Immediate, Short-term, Long Term
Insight: Recognise nature and severity of condition, Willingness to accept appropriate help

44

What is agoraphobia? What behaviours might a patient present with?

Includes various phobias embracing fears of leaving home: fears of entering shops, crowds, and public places, or of traveling alone in trains, buses, underground or planes
Lack of an immediately available exit is one of the key features of many agoraphobic situations
Avoidance behaviour causes sometimes that the sufferer becomes completely housebound
Most sufferers are women. Onset - early adult life
Lifetime prevalence 5-7%
High co-morbidity with panic disorder; depressive and obsessional symptoms and social phobias may be also present

45

What is panic disorder? What behavioural symptoms might the patient present with?

Recurrent attacks of severe anxiety (panic attacks) which are not restricted to any particular situation or set of circumstances
Typical symptoms are palpitations, chest pain, choking sensations, dizziness, and feelings of unreality (depersonalisation or derealisation)
Individual attacks usually last for minutes only. The frequency of attacks varies substantially
Frequent and predictable panic attacks produce fear of being
alone or going into public places
Course of panic disorder is long-lasting and is complicated with various comorbidities, in half of the cases with agoraphobia
Estimation of lifetime prevalence is between 1-3%

46

What are the criteria for diagnosis of panic disorder?

Panic attacks not in background of another disorder
Several severe autonomic attacks in last month
No objective danger, not only in specific circumstances, relatively free from anxiety between attacks

47

What is social phobia? What symptoms might the patient present with?

Fear of scrutiny by other people in comparatively small groups leading to avoidance of social situations
Fears may be: discrete - restricted to eating in public, to be introduced to other people, to public speaking, encounters with the opposite sex or diffuse - social situations outside the family circle
Direct eye-to-eye confrontation may be stressful
Low self-esteem and fear of criticism
Symptoms may progress to panic attacks
Avoidance - almost complete social isolation
Usually start in childhood or adolescence
Estimation of lifetime prevalence between 10-13 % equally common in both sexes
Secondary alcoholism

48

What are features of specific phobias?

Restricted to highly specific situations
Persistent irrational fear of object
Contact with this causes immediate anxiety response
Avoidance of object
Fear/avoidance/distress can interfere with individual’s life
Fear is recognised as being irrational/excessive
Start in childhood/early adulthood

49

Give examples of some specific phobias

Fear of proximity to particular animals / insects: spiders (arachnophobia), insects (entomophobia), snakes (ophidiophobia)
Fears of specific situations: heights (acrophobia), thunder (keraunophobia), darkness (nyctophobia), closed spaces (claustrophobia)
Fears of diseases, injuries or medical examinations: visiting a dentist, sight of blood (hemophobia) or injury (pain - odynophobia), fear of exposure to venereal diseases (syphilidophobia) or AIDS-phobia

50

What is generalised anxiety disorder? What symptoms will patient present with?

Anxiety lasting more than 6 months, which is generalised and persistent but not restricted to, or even strongly predominating in, any particular environmental circumstances
Symptoms: continuous feelings of nervousness, trembling,
muscular tension, sweating, lightheadedness, palpitations,
dizziness, and epigastric discomfort
Fears that patient or a relative will shortly become ill or have an accident are often expressed, together with a variety of other worries and forebodings
Lifetime prevalence between 4-6 %
More common in women, often related to chronic environmental stress
Fluctuating chronic course connected with symptoms of frustration, sadness and complicated with abuse of alcohol and other illicit drugs

51

What factors are required for a diagnosis of generalised anxiety disorder to be made?

Primary symptom of anxiety (most days, for weeks/months)
To include apprehension, motor tension, autonomic over-activity

52

What are the 3 most common presenting symptoms of patients with generalised anxiety disorder?

Somatic illness
Pain
Sleep disturbance

53

Which disorders are commonly co-morbid with generalised anxiety disorder?

Depression, social anxiety disorder, panic disorder

54

What are obsessional thoughts?

Ideas, images or impulses that enter the individual’s mind again and again in a stereotyped form
Recognised as individual’s own thoughts, even though they are involuntary and often repugnant
Common obsessions include fears of contamination, of harming other persons or sinning against God

55

What are compulsions?

Repetitive, purposeful, and intentional behaviours or mental acts performed in response to obsessions or according to certain rule that must be applied rigidly
Compulsions are meant to neutralise or reduce discomfort or to prevent a dreaded event or situation

56

What is obsessive compulsive disorder commonly co-morbid with?

Depression (about 80%)- suicidal thoughts
Obsessive-compulsory symptoms may appear in early stages of schizophrenia

57

What features are required for a diagnosis of OCD?

Obsessional thoughts +/- Compulsive acts
Most days for 2 weeks
Be distressing/interfere with activities

58

What are the 3 major elements to post traumatic stress disorder?

Re-experiencing trauma through dreams or recurrent and
intrusive thoughts (flashbacks)
Showing emotional numbing such as feeling detached from others
Having symptoms of autonomic hyperarousal such as irritability
and exaggerated startle response, insomnia

59

Which disorders are commonly co-morbid with post traumatic stress disorder?

Commonly there is fear and avoidance of cues that remind the sufferer of the original trauma
Anxiety and depression are commonly associated with the above symptoms. Excessive use of alcohol and drugs may be a complicating factor

60

What is the usual latency of onset for post traumatic stress disorder after this initial traumatic event?

The onset follows the trauma with a latency period, which may range from several weeks to months, but rarely more than half a year

61

What features are required for diagnosis of post traumatic stress disorder?

Within 6 months (usually)
Traumatic, exceptional event-Symbolic
Repetitive intrusive recollections, flashbacks
Re-enactment of events in memory/imagery/dreams

62

What additional symptoms may be present in post traumatic stress disorder?

Emotional numbing
Autonomic symptoms: hyper-arousal, hypervigilance (startle reaction), insomnia
Anxiety & depression: suicidal ideation
Cues lead to increased arousal, so avoidance of such cues

63

What is an acute stress reaction and what might the symptoms be?

Transient disorder of significant severity, which develops in an individual without any previous mental disorder in response to
exceptional physical and/or psychological stress
Not all people exposed to the same stressful event develop the
disorder
Symptoms: initial state of daze, with some constriction of the field of consciousness and narrowing of attention, inability to comprehend stimuli, and disorientation. This state may be followed either by further withdrawal from surrounding situation (extreme variant - dissociative stupor), or by agitation and overactivity
Autonomic signs: tachycardia, sweating or flushing, as well as
other anxiety or depressive symptoms
Symptoms usually appear within minutes of the impact of the stressful event, and disappear within several hours, maximally 2-3 days

64

What is adjustment disorder? What might the symptoms be?

States of subjective distress and emotional disturbance arising in the period of adaptation to a significant life change or to the consequences of a stressful life event, such as serious physical illness, bereavement or separation, migration or refugee status
Symptoms: depressed mood, anxiety, worry, feeling of inability to cope, plan ahead, or continue in the present situation, and some degree of disability in the performance of daily routine
Onset: within 1 month; duration - below 6 months
> 6 months but > 2 years: Prolonged Depressive Reaction
More frequently women, unmarried and young persons

65

What is the first line treatment for adjustment disorder?

Psychotherapy is the first line treatment of this disorder
Symptomatic treatment may comprise short trial of hypnotics or benzodiazepines

66

What is mixed anxiety and depressive disorder?

Symptoms of both anxiety and depression are present, but neither of symptoms, considered separately, is sufficiently severe to justify a diagnosis of depressive episode or specific anxiety disorder
Some autonomic symptoms, tremor, palpitations, dry mouth, stomach churning, must be present
Individuals with this mixture of comparatively mild symptoms are frequently seen in primary care

67

What are dissociative/conversion disorders?

Partial or complete loss of normal integration between memories of the past, awareness of identity and immediate sensations, and control of bodily movements
Normally a considerable degree of conscious control over the memories and sensations that can be selected for immediate attention, and the movements that are to be carried out

68

What is dissociative amnesia?

Main feature is loss of memory, usually of important recent event, which is not due to organic mental disorder and is too extensive to be explained by ordinary forgetfulness or fatigue
Amnesia is usually centered on traumatic events, such as accidents, combat experiences, or unexpected bereavements, and used to be partial and selective
Typically develops suddenly and can last from minutes to days

69

What is dissociative stupor?

Diminution or absence of voluntary movement and normal responsiveness to external stimuli such as light, noise, and touch
Person lies or sits largely motionless for long periods of time
Speech and spontaneous and purposeful movement are completely absent
Muscle tone, posture, breathing, and sometimes eye-opening and coordinated eye movements are such that it is clear that the individual is neither asleep nor unconscious
Positive evidence of psychogenic causation in the form of either recent stressful events or prominent interpersonal or social problems

70

What are trance and possession disorders?

Temporary loss of both the sense of personal identity and full awareness of the surroundings
Individual can act as if taken over by another personality, spirit, deity, or force
Repeated sets of extraordinary movements, postures, and utterances can be observed

71

What are dissociative disorders of movement or sensation?

Loss of or interference with movements or loss of sensations (usually cutaneous). Mild and transient varieties of these disorders are often seen in adolescence, particularly in girls, but the chronic varieties are usually found in young adults

72

What is Ganser’s syndrome?

Mental illness where a person deliberately and consciously acts as if they have a physical or mental illness when they are not really sick

73

What is multiple personality disorder?

Dissociative Identity Disorder
Apparent existence of two or more distinct personalities within an individual, with only one of them being evident at a time (Jekyl and Hyde)
Each personality is complete, with its own memories, behaviours, and preferences, but neither has access to the memories of the other and the two are almost always unaware of each other’s existence. Change from one personality to another is in the first instance usually sudden and closely associated with traumatic events

74

What factors are required for the diagnosis of a somatization disorder?

At least 2 years of multiple and variable physical symptoms for which no adequate physical explanation has been found
Persistent refusal to accept the advice or reassurance of several doctors that there is no physical explanation for the symptoms
Some degree of impairment of social and family functioning attributable to the nature of symptoms and resulting behavior

75

What medical conditions might be confused with somatoform disorder, especially early in their course?

Multiple sclerosis, brain tumour, hyperparathyroidism, hyperthyroidism, lupus erythematosus

76

What is hypochondriacal disorder?

Persistent preoccupation and a fear of developing or having one or more serious and progressive physical disorders
Persistently complain of physical problems or are persistently preoccupied with their physical appearance
Fear is based on the misinterpretation of physical signs and sensations
Physician physical examination does not reveal any physical disorder, but the fear and convictions persist despite the reassurance

77

What are the diagnostic criteria for hypochondriacal disorder?

Persistent belief in the presence of at least one serious physical illness underlying the presenting symptom or symptoms, even thought repeated investigations and examinations have not identified any adequate physical explanation, or a persistent preoccupation with presumed deformity or disfigurement
Persistent refusal to accept the advice and reassurance of several different doctors that there is no physical illness or abnormity underlying the symptoms

78

What is Persistent Somatoform Pain Disorder?

Predominant symptom is a persistent severe and distressing pain that cannot be explained fully by a physiological process of physical illness
Pain occurs in association with emotional conflicts or psychosocial problems
The expression of chronic pain may vary with different personalities and cultures
The patient is not malingering and the complaints about the intensity of the pain are to be believed

79

Which physical illnesses may mimic anxiety disorder?

Phaeochromocytoma
Hyperthyroidism
Hypoglycaemia
Temporal lobe epilepsy
Alcohol
Paroxysmal arrhythmias

80

Name some options for the treatment of anxiety disorders

Psychotherapeutic techniques: CBT, Behavioural Therapy, Psychodynamic approaches, Relaxation Exercises
Pharmacotherapy: benzos, Buspirone, Beta-blockers, Antihistaminics, Calcium Channel Modulators : Pregabalin, TCAs: Clomipramine, SSRIs : Escitalopram, Citalopram, Fluoxetine, Fluvoxamine, Paroxetine, Sertraline, MAOIs: Tranylcypromine, Moclobemide and SNRIs: venlafaxine

81

What non pharmacological approaches are available to treat anxiety disorders?

Provision of information about Anxiety Disorders
Relaxation Exercises to reduce excessive arousal
Cognitive techniques to teach strategies for managing difficult situations & stop anxiety from spiralling out of control
Behavioural techniques such as building up the level of activity & other strategies to improve self-confidence

82

What are the aims of self monitoring in CBT for anxiety?

Objective observation of anxious responses and triggering environmental cues
Determination of characteristic cognitive, somatic,affective and behavioural reactions involved in the anxious response
Discovering what patients think affects how they feel and how they feel affects what they think
Identification of external environment and perceptions of threat

83

How is relaxation training used in CBT for anxiety?

Creation of a relaxed lifestyle
Methods of coping with anxiety at any time it appears: diaphragmatic breathing, progressive muscular relaxation, meditation

84

How is cognitive therapy used in CBT for anxiety?

Identifying how the patient is thinking and the beliefs about self, world and future that underlie those thoughts
Generating alternative, more accurate interpretations , predictions
and ways of believing
Using these new perspectives whenever anxiety and worry are detected

85

How is rehearsal of new skills used in CBT for anxiety?

Frequent practice of new , more adaptive actions
Rehearsal of new coping skills

86

Which neurotransmitters are involved in mood and behaviour? And which specific aspects are they involved in?

Dopamine: motivation, pleasure, reward
Noradrenaline: alertness, energy
Serotonin: obsession, compulsion

87

What are first line treatments for anxiety disorders?

SSRI
Potentially plus a benzo short term

88

How is antidepressant use different for anxiety to depression?

Half the starting dose of depression
Slow titration as anxiety disorder patients are more prone to side effects
Could be initial worsening of anxiety
Watch out for akathisia, agitation and suicidal ideation in the first few days/ weeks (commoner in younger patients

89

What are some side effects of SSRIs?

Headache
Anxiety
Transient nausea
Vomiting
Diarrhea
Weight gain
Sexual dysfunction

90

Name 3 SNRIs and give what they might be specifically used for

Venlafaxine: pain related conditions
Duloxetine: stress incontinence
Mirtazapine: sedative - sleep problems

91

What is a known major side effect of lithium?

Development of diabetes insipidus

92

What harms to others can alcohol cause?

Injury: assault, car crash, accident
Neglect or abuse: person in drinkers care
Default on social role: as family member, friend, worker
Property damage: clothing, car, building
Toxic effects: foetal alcohol syndrome, pre term birth complications
Loss of amenity and peace of mind: children, friends, coworkers, kept awake or frightened

93

What top 3 diseases or injuries have the highest proportion of deaths attributable to alcohol?

Cardiovascular disease
Unintentional injuries
Gastrointestinal diseases

94

What age group have the highest rate of alcohol related hospital admissions?

45-54

95

What are the new guidelines on alcohol use?

Should not drink > 14 units per week and these should be spread evenly
Single drinking episode: limit total amount, drink slowly, avoid risky places
Pregnant women: no alcohol

96

What proportion of U.K. Cancer deaths are attributed to alcohol?

6%

97

What is the new guidance for childhood drinking?

Alcohol free childhood is best
Shouldn't drink until age 15 and never more than once per week, supervised

98

How many units in a bottle of wine?

9

99

How many units in a large glass of wine?

3

100

How many units in a pint of standard lager?

2

101

How many units in a pint of premium lager?

3

102

How many units in an alcopop?

2

103

How do you calculate units?

Strength x volume / 1000

104

What pledges have been made by the alcohol industry to public health?

Restriction on advertising
Responsible sales
Drink aware site
Alcohol labelling

105

What are the legal driving limits for alcohol?

35 micrograms of alcohol per 100 ml breath
80mg in 100ml blood
107 mg in 100ml urine

106

What symptoms might a person taking heroin describe/experience?

Euphoric rush
Sedation
Reduction in pain, fear, tension and anxiety

107

How many bags/grams a day might a moderate/heavy user of heroin have?

3-4 bags a day, at 0.1-0.2 gram per bag

108

What different ways of taking heroin are there?

Smoking - brown heroin, high oil content runs on foil
Injecting - China white

109

What is methadone? How is it taken?

Substitute opiate
Full mew agonist
Taken orally once a day
Start at 30ml
Daily supervised for 3-6 months
Increase to 80-120ml
Regular mouth swab/urine to check compliance

110

What is buprenorphine and how is it taken?

Subutex - taken sublingually
Partial mew agonist
Safer in overdose
More expensive
Doses of 8-12mg per day

111

How much cocaine is in a wrap? And how much does this cost?

1g, £40

112

How can cocaine be taken?

Snorting - absorbed through mucous membrane of the nose
Injecting - mix powder with water and use a syringe to inject IV

113

How long do the effects of cocaine last? What are they?

Onset 1 min
Lasts 30-40 mins
Euphoria, stimulant

114

How is crack cocaine sold?

As rocks - £10, £20

115

Why can't cocaine be smoked?

Cocaine hydrochloride
Heat sensitive
Cannot be smoked as it destabilises when burned

116

How is crack cocaine different to cocaine?

Base form, hydrochloride molecule removed
Can be smoked

117

How long do the effects of crack cocaine last?

Onset 5 secs
Lasts 5-10 mins
Intense craving

118

How long does ecstasy/MDMA take to have an effect?

30-45 mins
Peak at 60-90mins
Last for 2-4 hours followed by gradual comedown

119

What effects does ecstasy have?

Rushes of exhilaration
Nausea and disorientation
Panic
Stomach churning

120

How much does ecstasy cost?

Each pill £3-5

121

What is crystal meth?

Methamphetamine
Made from phosphorus, pseudoephedrine and blue iodine

122

How is crystal meth used?

Smoked in glass pipes

123

How much does crystal meth cost?

Half a gram is £25

124

How long do the effects of crystal meth last?

4-12 hours

125

What is the ICD 10 criteria for a diagnosis of dependence?

3 or more of the following present together at some point during the previous year:
Strong desire or sense of compulsion to take the substance
Difficulties in controlling substance taking behaviour in terms of its onset, termination or levels of use
A physiological withdrawal state
Evidence of tolerance
Progressive neglect of alternative pleasure or interests
Increased amount of time necessary to obtain or take the substance or recover from its effects
Persisting with substance abuse despite clear evidence of overtly harmful consequences

126

Which pathways are involved in controlling reward or positive feelings?

Mesolimbic and mesocortical dopamine pathways

127

What are common side effects of codeine and heroin?

Nausea and vomiting
Constipation
Sedation

128

What are common side effects of MDMA/ecstasy?

Anxiety, psychosis, increased BP and other homeostatic changes (temp, osmotic)

129

Which receptor does MDMA act on?

5-HT, increases release

130

What receptor does ketamine/PCP act on?

Glutamate receptor agonist

131

What are common side effects of ketamine?

Nausea and vomiting, hallucinations, Confusion/psychosis

132

What receptor does alcohol have an effect on?

Potassium channel, increases open time

133

What are common side effects of alcohol?

Drowsiness/dizziness, memory loss, loss of coordination

134

What receptors does cocaine act on?

Inhibitor of monoamine reuptake: dopamine, NA, 5HT
Binds to some of the 5HT receptors altering ion channel activity

135

What are some common side effects of cocaine?

Anxiety, psychosis, increased BP/HR

136

What receptor does Valium act on?

GABA receptor Co-agonist

137

What are some common side effects of Valium?

Sedation, memory loss, decreased coordination

138

What receptor does cannabis act on?

Cannabinoid receptor agonist

139

What are some common side effects of cannabis?

Slowing of thought processes and memory loss, psychosis with long-term use

140

What receptor does Dramamine act on?

Ach receptor antagonist

141

What is Dramamine?

Treat nausea vomiting and dizziness caused by motion sickness

142

What are common side effects of Dramamine?

Hot, Dry mouth/skin, Dilated pupils, Confusion/psychosis

143

What are the 4 dopaminergic pathways of the brain?

Nigrostriatal: projections from substantia nigra pars compacta
(midbrain) release dopamine in striatum (caudate and putamen)
Mesocortical: projections from ventral tegmental area (midbrain) release dopamine in frontal cortex, particularly pre-frontal cortex, to modulate reward, motivation and attention
Mesolimbic: projections from ventral tegmental area (midbrain)
release dopamine in limbic system structures and are involved in cognition, learning and memory
Tuberoinfundibular: connects hypothalamus to median eminence,
dopamine release from these cells control prolactin secretion from pituitary

144

Where does deep brain stimulation affect?

Striatum

145

What is the key nucleus involved in reward pathways?

Nucleus accumbens in basal forebrain (part of ventral striatum)

146

Describe the development of addictive behaviours

Intoxication leads to activation of reward pathways (via nucleus accumbens/ventral striatum) which provide positive reinforcement for behaviour
Activation of reward pathways increases activity in cognitive and emotional circuits of forebrain ‘pleasure centres’, which then
activates binge/intoxication circuitry (striatum and thalamus) leading to repetition of behaviour that causes high feeling, ie drug taking
Once positive effects of drugs have occurred there is a rapid drop in mood and descent into negative effects, even though plasma concentration may be relatively high still
During these negative effects, amygdala and associated areas and ventral striatum are strongest, creating increasingly negative moods and behaviours. This subsides and returns towards control levels as plasma levels of drugs decrease
As this activity decreases, associational areas are activated, those that remember that bad feeling could be reversed by taking of drug. This triggers activation of drug-seeking/craving behaviours, which link memory and anticipation of positive effects of drugs, so mainly hippocampus and prefrontal cortex are activated
This cycle is followed by drug-taking and intoxication and the cycle repeats again

147

What factors slow absorption of alcohol?

Higher concentrations of alcohol slow peristalsis
Food, especially fatty food and carbs

148

How does alcohol cause a CNS depressant effect?

Enhances GABA activity and reduces higher levels of activity via inhibition of glutamatergic NMDA receptors and voltage dependent calcium channels

149

Which areas of the brain are particularly sensitive to alcohol?

Cerebellum: comparatively more cells in this region so effects seem stronger. Control and fine tuning of movement and gait are amongst first to be affected
Frontal lobes are comparatively sensitive to alcohol explaining changes on cognitive function and bladder control (frontal micturition centre)

150

What can happen with chronic alcohol use in pregnancy?

Spontaneous miscarriage and amenorrhoea

151

When is damage from drinking in pregnancy most likely to occur? And what can happen as a result?

First three months resulting in foetal alcohol syndrome

152

What are features of foetal alcohol syndrome?

Growth and cognitive retardation
Children: irritability, slow development and hyperactivity
Teens/adulthood: learning difficulties, poor impulse control and coordination
Heart defects
Characteristic facial features: thin upper lip, flat midface, short nose, short palpebral fissures, epicanthal folds, low nasal bridge, indistinct philltrum, micrognathia (Mandibular hypoplasia)

153

What drugs can be used to treat alcohol withdrawal?

Long lasting benzodiazepines reduce withdrawal symptoms: chlordiazepoxide
Recovery is dependent on use of reducing regimens
Patients with agitation/hallucinations or DTs can be given haloperidol as an adjunct but are not used alone as they may reduce seizure threshold and have no effect on withdrawal

154

What drugs can be used to prevent relapse from alcohol withdrawal?

Acamprosate: GABA and glutamate
Naltrexone: opioid antagonist

155

What receptors does nicotine act on? And what does this lead to?

Cholinergic nicotinic receptors (nAChR)
Not selective on brain nicotinic receptors also autonomic ganglia
Stimulant and relaxant, parasympathomimetic
Release of acetylcholine, noradrenaline and adrenaline (via the ANS) associated with stimulant effects of smoking
Endorphins, dopamine and serotonin accounting for the positive mood effects and addictive quality of substance

156

What do smoking cessation services offer?

Combination counselling and pharmacological interventions to increase adherence to cessation
Pharmacological: nicotine replacement therapy (patches/ inhalation/ spray/ lozenge), bupropion (atypical antidepressant), varenicline (partial agonist at nicotine receptor)

157

What needs careful monitoring in patients taking varenicline for smoking cessation?

Suicidal thoughts

158

What drugs are licensed for use in opioid addiction?

Methadone (agonist at mew opioid receptor)
Buprenorphine (mixed agonist/antagonist: partial agonist at mew receptor, antagonist/partial agonist at the kappa receptor)

159

What drugs can be used as adjuncts in opioid withdrawal to reduce symptoms?

Loperamide – control of diarrhoea
Paracetamol and NSAIDs - pain and headaches (including muscular pain)
Metoclopramide – Nausea and vomiting

160

Where do amphetamines act?

VMAT: vesicular monoamine transporter (which carries monoamines into vesicles for release)
Amphetamine is incorporated into vesicles and displaces monoamine, which then gets dumped into cleft when channels open
Amphetamines also reverse MAT, to a certain extent, further increasing concentration of monoamines within the synaptic cleft

161

What are the 2 groups of tranquillisers?

Major: antipsychotics (non-addictive)
Minor: relaxants (muscle and neuro), which are addictive

162

What are the most common group of minor tranquillisers?

Benzodiazepines

163

What is the mechanism of action of benzodiazepines?

Co-agonist on GABAA receptor and bind to the gamma-subunit
to increase chloride ion movement into cell causing hyperpolarisation of the cell, reducing likelihood of firing

164

What can be effects of withdrawal of long term benzodiazepine treatment?

Rebound seizure, hallucinations, anxiety and panic

165

What is an issue with using flumazenil as part of the coma cocktail to reverse the effects of benzos?

Predisposes susceptible patients to seizure onset

166

Where are Cannabinoid receptors located?

CB1 in brain
CB2 in periphery (associated with immune responses)
CB2 brain (microglia)
Hypothalamus in regions associated with feeding
Mesocortical/limbic via this route to activate the reward pathways
Hippocampus, activation of which result in memory and spatial distortion, which also impairs movement through alteration of body-image, spatial perception
Vas deferens, which may explain some of positive effects of marijuana intake on sexual function

167

Which are the psychotomimetic drugs?

Drugs acting on 5HT: LSD, mescaline and MDMA
Drugs acting on glutamate receptors (NMDA): ketamine and PCP

168

What enzyme breaks down ecstasy?

CYP2D6

169

What is frequent use of ketamine associated with?

Depression and bladder dysfunction (dysuria)

170

What proportion of the population consume hazardous amounts of alcohol?

24%

171

What screening questionnaires can be used to detect hazardous drinkers?

AUDIT: alcohol use disorder identification test
FAST: fast alcohol screening test
AUDIT C: audit alcohol consumption questions
M-SASQ: modified single alcohol screening questionnaire

172

Who are the targets for brief interventions on alcohol advice?

Hazardous drinkers, including regular excessive drinkers and ‘binge drinkers’
Harmful drinkers, including regular excessive drinkers and ‘binge drinkers’
Not ‘severely dependent drinkers’

173

What is a level 1 brief intervention on alcohol advice?

Some assessment of alcohol use (units??)
Feedback on screening assessment explain why the individual is deemed to be drinking hazardously or harmfully, how do they compare to the general population?
Some clear advice on how to cut down or stop drinking

174

What is motivational interviewing with regards alcohol advice?

Client-centred, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence
Express empathy
Develop discrepancy
Avoid argumentation
Roll with resistance
Support self-efficacy

175

What does achieving long term sobriety usually involve?

Less harmful, substitute dependency
New relationships
Sources of inspiration and hope
Alcoholics Anonymous

176

What is there reduction goal in a patient who is harmful drinking or mild dependence, without significant comorbidity, and if there is adequate social support?

Consider a moderate level of drinking as the goal of treatment
unless the service user prefers abstinence or there are other reasons for advising abstinence

177

What is disulfiram?

Antabuse
Prevents the breakdown of alcohol by acetaldehyde
dehydrogenase
Causing headache, flushing, palpitations, nausea and vomiting

178

What is Acamprosate?

An analogue of GABA
Anti-craving medication
Benefits in highly motivated patients also engaged in psychological treatments

179

What role does naltrexone have in alcohol abuse?

Orally active opiate receptor antagonist
Thought to reduce the pleasurable effects of drinking

180

What is nalmefene?

Opioid system modulator
Diminishes reinforcing effects of alcohol, helping the patient to reduce drinking possibly by modulating cortico-mesolimbic functions

181

What is pabrinex?

Vitamin c, b1, b2, b3 and b6 injection

182

What symptoms might a person taking heroin describe/experience?

Euphoric rush
Sedation
Reduction in pain, fear, tension and anxiety

183

How many bags/grams a day might a moderate/heavy user of heroin have?

3-4 bags a day, at 0.1-0.2 gram per bag

184

What different ways of taking heroin are there?

Smoking - brown heroin, high oil content runs on foil
Injecting - China white

185

What is methadone? How is it taken?

Substitute opiate
Full mew agonist
Taken orally once a day
Start at 30ml
Daily supervised for 3-6 months
Increase to 80-120ml
Regular mouth swab/urine to check compliance

186

What is buprenorphine and how is it taken?

Subutex - taken sublingually
Partial mew agonist
Safer in overdose
More expensive
Doses of 8-12mg per day

187

How much cocaine is in a wrap? And how much does this cost?

1g, £40

188

How can cocaine be taken?

Snorting - absorbed through mucous membrane of the nose
Injecting - mix powder with water and use a syringe to inject IV

189

How long do the effects of cocaine last? What are they?

Onset 1 min
Lasts 30-40 mins
Euphoria, stimulant

190

How is crack cocaine sold?

As rocks - £10, £20

191

Why can't cocaine be smoked?

Cocaine hydrochloride
Heat sensitive
Cannot be smoked as it destabilises when burned

192

How is crack cocaine different to cocaine?

Base form, hydrochloride molecule removed
Can be smoked

193

How long do the effects of crack cocaine last?

Onset 5 secs
Lasts 5-10 mins
Intense craving

194

How long does ecstasy/MDMA take to have an effect?

30-45 mins
Peak at 60-90mins
Last for 2-4 hours followed by gradual comedown

195

What effects does ecstasy have?

Rushes of exhilaration
Nausea and disorientation
Panic
Stomach churning

196

How much does ecstasy cost?

Each pill £3-5

197

What is crystal meth?

Methamphetamine
Made from phosphorus, pseudoephedrine and blue iodine

198

How is crystal meth used?

Smoked in glass pipes

199

How much does crystal meth cost?

Half a gram is £25

200

How long do the effects of crystal meth last?

4-12 hours

201

What is the active ingredient of cannabis?

THC

202

How much does cannabis cost?

Weed £20 1/8th ounce
Hash £10 1/8th ounce

203

What symptoms does cannabis cause?

THC: Anxiety, psychotic like symptoms
CDB: sedative, anxiolytic, antipsychotic

204

What legal high active ingredients are there?

Phenethylamines
Tryptamines

205

Janet presents to the ED after taking an impulsive overdose of 15 paracetamol with a bottle of vodka. This is her 6th admission for similar issues. She is review by the psych doctor on call who finds that she had taken them after a row with her boyfriend. She was the victim of childhood abuse. She has multiple intensive relationships but they do not seem to last. She describes herself as empty inside and has felt this way for many months. What is the most likely diagnosis?

Emotionally unstable personality disorder - borderline type

206

What are characteristics of histrionic personality disorder?

Shallow and labile affectivity
Self dramatisation
Theatricality
Egocentricity
Continual seeking of appreciation, excitement and attention

207

What signs and symptoms would a patient have who has taken an overdose of TCAs?

Tachycardia
Tachypnoea
Urinary retention
Dilated pupils
Pyrexia
Hyperreflexia
Hypotension

208

What are some psychological problems associated with alcohol misuse?

Depression
Anxiety
Memory problems
Delirium tremens
Attempted suicide
Pathological jealously

209

What are some social problems associated with alcohol misuse?

Domestic violence
Marital and sexual difficulties
Child abuse
Employment problems
Financial difficulties
Accidents
Delinquency and crime
Homelessness

210

What are some complications of delirium tremens?

Dehydration
Infection
Hepatic disease
Wernicke Korsakoff's syndrome

211

What is the management for delirium tremens?

Correct electrolyte abnormalities and dehydration
Parenteral thiamine
Prophylactic phenytoin or carbamazepine if hx of withdrawal seizures
Diazepam or chlordiazepoxide

212

What drugs can be used to prevent alcohol dependence?

Naltrexone: reduce relapse into heavy drinking
Acamprosate: reduce drinking frequency
Disulfiram: unpleasant acetaldehyde intoxication with alcohol, histamine release

213

What symptoms occur 12-16 hours after last dose of opiate in someone in withdrawal?

Yawning
Rhinorrhoea
Lacrimation
Pupil dilatation
Sweating
Piloerection
Restlessness

214

What symptoms occur 24-72 hours after last dose of opiate in someone in withdrawal?

Muscular twitches
Aches and pains
Abdominal cramps
Vomiting
Diarrhoea
HTN
Insomnia
Anorexia
Agitation
Profuse sweating

215

What are the key diagnostic factors for GAD?

Require 3/6
Restless/nervous
Easily fatigued
Poor concentration
Irritability
Muscle tension
Sleep disturbance

216

What would be on your differential list for anxiety disorders?

Depressive illness
OCD
Presenile dementia
Alcohol dependence
Drug dependence
Benzo withdrawal
Hyperthyroidism
Hypoglycaemia
Phaechromocytoma

217

What are risk factors for the development of GAD?

FHx of anxiety
Physical or emotional stress
Hx physical or emotional trauma
Other anxiety disorder
Female gender

218

What are obsessional thoughts?

Unpleasant or distressing thoughts, ideas or images that are unwanted. Individual recognises the thoughts as their own

219

What are symptoms of depression?

Low mood
Loss of interest and enjoyment
Fatigue
Early morning waking
Loss of appetite and weight loss
Social withdrawal
Loss of libido
Constipation
Diurnal variation
Poor concentration and memory
Worthlessness and hopelessness
Guilt
Self harm and suicide
Psychomotor retardation

220

How is depression classified?

Mild, moderate, severe
Unipolar, bipolar
Postnatal
Seasonal affective disorder
Mixed anxiety depressive disorder
Adjustment disorder

221

Which symptoms of depression are characteristic of bipolar depression?

Early morning waking
Diurnal variation
Cognitive difficulty
Psychomotor retardation

222

Which long term health conditions often cause patients to also have depression?

MI
Coronary artery disease
Parkinson's
MS
Stroke
Cancer
Diabetes

223

What are the models of causes of depression?

Neurotransmitters
Genetics
Stress
Cognitive psychology
Social causation

224

What sleep disturbances can occur in depression?

Increased sleep latency
Reduced sleep time
Increased fragmentation
Deceased REM latency
Increased REM in first half of night
Decreased slow wave sleep

225

What are some side effects of antidepressant medications?

Insomnia
Sedation
Headache
Tremor
Dry mouth
Sweating
Nausea
Diarrhoea
Constipation

226

What are possible psychotherapies for major depressive disorder?

CBT
Interpersonal therapy
Behavioural activation

227

What are the activities performed in CBT?

Recognise negative cognitions
Respond to negative thoughts and behaviours
Problem solve and test assumptions

228

What are the 4 forms of neurostimulation?

Electroconvulsive therapy
Repetitive transcranial magnetic stimulation
Vagus nerve stimulation
Deep brain stimulation

229

What are possible complimentary and alternative medicine treatments for depression?

Physical: light therapy, sleep deprivation, exercise, yoga, acupuncture
Nutraceuticals: omega 3, DHEA, tryptophan, SAM-e
Herbal remedies: St. John's wort

230

According to the ICD10, what features must be present for a diagnosis of dependence?

3 or more of following have been present together at some time during previous year:
Strong desire or sense of compulsion to take substance
Difficulties in controlling substance taking behaviour in terms of its onset, termination or levels of use
Physiological withdrawal state
Evidence of tolerance
Progressive neglect of alternative pleasure or interests
Increased amount of time necessary to obtain or take substance or recover from its effects
Persisting with substance abuse despite clear evidence of overtly harmful consequences