Download Psychoactive substance = any substance that has an effect on the

Addictive Behaviour
Psychoactive substance = any substance that has an effect on the central nervous system.
It includes recreational drugs (including alcohol and nicotine), prescribed/OTC drugs and
poisons/toxins.
Substance abuse = maladaptive pattern of substance use that results in a failure to fulfil
work, home or school obligations; physically hazardous behaviours (e.g.driving); legal
problems (e.g. arrest for disorderly conduct) and recurrent interpersonal problems (e.g.
arguments/fights with spouse).
Substance dependence (dependence syndrome) = syndrome incorporating physiological,
psychological and behavioural elements. ICD-10 criteria:
1. A strong desire or compulsion to take the substance
2. Difficulties in controlling substance-taking behaviour (onset/termination/levels of use)
3. Physiological withdrawal state when substance use is reduced or ceased; or
continued use of substance to relieve or avoid withdrawal symptoms
4. Signs of tolerance: increased qualities of substance required to produce the same
effect originally produced by lower doses
5. Neglect of other interests and activities due to time spent acquiring and taking
substance, or recovering from its effects
6. Persistance with substance misuse despite clear awareness of harmful
consequences (physical or mental)
Substance intoxication = transient substance-specific condition that occurs after use of
substance and features disturbances of consciousness, perception, mood, behaviour, and
physiological functions
Substance withdrawal = substance-specific syndrome that occurs on reduction or cessation
of substance that has usually been used repeatedly in high doses, for a prolonged period
(one of criteria for dependence syndrome)
Differential diagnosis of patients with alcohol/substance misuse
 Primary psychiatric disorder e.g. depression/schizophrenia and pt is coincidentally
using alcohol (usually for relief from symptoms)
 Symptoms are entirely due to direct effect of drug
 Combination of above
Smoking Cessation
Nicotine addiction
The addiction begins when nicotine acts on nicotinic acetylcholine receptors to release
neurotransmitters such as dopamine, glutamate, and gamma-aminobutyric acid. Cessation of
smoking leads to symptoms of nicotine withdrawal such as anxiety and irritability. Methods of
smoking cessation must address nicotine addiction and nicotine withdrawal symptoms.
Methods of smoking cessation
1.
2.
3.
4.
Cold Turkey
Nicotine replacement therapy – patch, gum, lozenge etc
Antidepressants – bupropion
Nicotine receptor partial agonist – verenicline (Champix), cytisine (Tabex)
Health care professionals should :
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Ask — Systematically identify all tobacco users at every visit
Advise — Strongly urge all tobacco users to quit
Assess — Determine willingness to make a quit attempt
Assist — Aid the patient in quitting (provide counselling and medication)
Arrange — Ensure follow-up contact
Alcohol
1 unit of alcohol =10mL pure alcohol
Safe values:
Men = 3-4 units/day (<21units/week)
Women = 2-3 units/day (<14 units/week)
Can of beer = ~1.5 units
Pint of cider = ~3 units
Pint of beer = ~2 units
Bottle of wine = ~7 units
Pint of strong beer = ~4 units
Bottle of spirits = ~30 units
Alcohol abuse and dependence covers 3 main ICD-10 diagnoses (DSM-IV differs slightly in
some regards)
1. Excessive alcohol consumption – more than weekly limits
2. Harmful use - A pattern of use that is causing damage to the health. Actual physical (e.g.
cirrhosis / hepatitis) or psychological (e.g. depression) damage must have occurred.
Acute intoxification / hangover is not sufficient.
3. Alcohol dependence:
5% prevalence in the UK
There are six ICD-10 elements to dependence – a useful mnemonic is:
At least three of these must have been present at the same time within the last year.
D
S
W
T
N
P
Drink
Starts
With
Totally
Normal
People
Difficulty controlling: starting, stopping, quantity
Strong desire to drink (or a sense of compulsion), narrowing of repertoire
Withdrawal – physiological symptoms
Tolerance – needing more alcohol for the same effect
Neglect of other interests
Persistant use despite evidence of harm
Complications
Acute intoxication
 Slurred speech
 Impaired
coordination and
judgement
 Labile affect
Acute withdrawal
Medical
Within 1-2 days
 Hepatitis
of abstinence
 Cirrhosis
 Malaise
 Oesophageal
 Nausea
varices
 Hyperactivity
 Pancreatitis
 Tremulousness
 Peptic ulcer
If severe
 Labile affect
 Gastritis
 Hypoglycaemia  Insomnia
 Cardiomyopathy
 Stupor
 Transient
 Hypertension
 Coma
illusions or
 Anaemia
hallucinations
 Throbocytopaenia
 Seizures
There are also social side effects – may be remembered as the ‘3 Ls’
 Livelihood: job loss
 Love: problems with relationsips and family
 Legal: prostitution, criminal activity, road accidents

Neuropsychiatric
Wernicke’s
2° to thamine
deficiency
- Ataxia
- Nystagmus
- Ophthalmoplegia
 Korsakov’s
- Profound loss of
short term
memory
 Acute confusion
 Cerebellar
degen.
 Depression
 Anxiety
 Hallucinations

-
Treatment for alcohol withdrawal (detox)
Pharmacological:
 Disulfaram (Antabuse): blocks alcohol oxidation, leading to accumulation of
acetaldehyde. This causes unpleasant SEs: anxiety, flushing, palpitations, headache
and choking sensation within 20mins of alcohol consumption. CI: compromised
cardiorespiratory function
 Acamprosate (Campral): enhances GABA transmission and appears to reduce the
likelihood of relapse after detoxification by reducing craving
Psychosocial:
 Motivational interviewing (Miller & Rollnick) and application of Prochaska &
DiClementes stages of change model; moving the patient through a cycle of change
from ‘precontemplation’ to ‘contemplation’ to’determination’ to ‘action’ to
‘maintanance’
 CBT
 Group therapy
 Alcoholics anonymous: 12-step programme
 Social support
 Primary prevention (public health measures!): increase cost of alcohol through tax
Prognosis:
15%
30%
10%
25%
20%
Suicide
Lifetime complications
Improve
Recover
Lost to follow-up
Alcohol withdrawal Syndrome (including delirium)
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Clinical features:
 Tremulosness (hands shaking)
 Sweating
 Nausea and vomiting
 Mood disturbance – anxiety,
depression, “feeling edgy”
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Sensitivity to sound (hyperacusis)
Autonomic hyperactivity
(tachycardia, hypertension,
mydriasis)
Sleep disturbance
Psychomotor agitation
AND/OR
PERCEPTUAL DISTURBANCES
 Develop 8-12 hours after drinking
cessation
 Illusions or hallucination
(visual/auditory)
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WITH WITHDRAWAL SEIZURES
 Develop 7-48 hours after drinking
cessation
 Occurs in 5-15% of all alcoholic
dependants
 Generalised and tonic-clonic
 RFs: PMH withdrawal fits,
epilepsy, low potassium or
magnesium
WITHDRAWAL DELIRIUM (delirium tremens)
Develops 24 hours – one week after drinking cessation, peaking at 72-96 hours
Clouding of consciousness and marked cognitive impairment (i.e. delirium)
Vivid hallucinations and illusions in any sensory modality (patients often interact/are
horrified by them – Lilliputian visual hallucinations = miniature people/animals)
Marked tremor
Autonomic arousal (heavy sweating, raised pulse and BP, fever)
Paranoid delusions (often with intense fear)
Mortality = 5-15% from CVS collapse, hypo/hyperthermia, infection
RFs: physical illness (hepatitis, pancreatitis, pneumonia)
Management of Delirium tremens
Emergency hospitalisation – vigorous search for medical complication e.g. infection (esp
pneumonia), head injury, liver failure, GI haemorrhage, Wernickes Encephalopathy
Meds:
 Benzodiazepines (PO chlordiazepoxide 200mg OD) – cross tolerance of alcohol and
treats seizures
 Parenteral (IM or slow IV) thiamine – 2 Pabinex ampoules 2xdaily for 5 days
 Only use antipsychotics for severe symptoms as SE: lowers seizure threshold
Moniter temp, fluids, electrolytes, glucose – risk of dehydration, hypoglycaemia,
hypokalaemia, hypomagnaesaemia
Alcohol related History
Useful questions to ask in history taking:
The Basics
 Do you ever drink?
 How often do you drink?
 How many drinks do you have on a typical day?
 What do you drink?
CAGE
 Have you ever though you should Cut down on your drinking?
 Have people Annoyed you by critisising your drinking?
 Have you ever felt bad or Guilty about your drinking?
 Have you ever needed a drink Early in the morning to steady your nerves or get rid of a
hangover.
Establishing the problems
 Do you ever have problems with drinking more than you intended?
 Do you feel you really need a drink if you go too long without one?
 How long is this?
 Do you get any physical symptoms if you don’t drink for a few days?
 Does it take a lot to get you drunk?
 How important compared to other things is drinking?
 Has your drinking ever led to problems with work, family, friends or the police?
 Have you ever had any money problems due to drink?
 Have you ever had any illness due to drink?
 Did you continue drinking?
Investigations
 All normal tests to exclude complication etc
 MCV (mean corpuscular volume) – size of RBCs. Increased in heavy drinkers
 Raised liver enzymes – Gamma GT (most useful), AST, ALT
 Raised CDT – carbohydrate deficient transferring is related to the protein that
transports iron
 Blood alcohol concentration (BAC), or breath alcohol via breathalyser
 Raised triglycerides, cholesterol and uric acid are increased secondary to alcohol use
Substance misuse
CLASS A – heroin, morphine, pethidine, methadone, dipipanone, cocaine, LSD, MDMA,
phenycyclidine
CLASS B – oral amphetamines, cannabis, codeine, barbiturates
CLASS C – benzos, buprenorphine, meprobamate, pemoline and dextropropoxyphone
Only listed Rx for top 3 as have read that more than that is beyond our level:
Opiates
– e.g. morphine, heroin/diamorphine (smack), codeine, methadone, dipapone,
opium
Psychological effects – euphoria, drowsiness, apathy, personality change
Physical effect – miosis, conjunctival injection, nausea, pruritis, constipation, bradycardia,
resp depression, coma
Management:
 education (+ HIV/Hep B+C/unsafe sex), clean needles, Hep B vaccine
 withdrawal symptoms can be ameliorated by lofexidine (centrally acting alphaadrenoceptor agonist that reduces sympathetic flow)
 Methadone can be prescribed indefinitely – should aim for gradual reduction
 Sublingual buprenorphine (Subutex) – partial opoid agonist
 Naltrexone (opiate antagonist) once detoxified to block euphoric effects of continued
opiate use
 Psychological interventions – motivational interviewing, CBT, social support
Stimulants
– e.g. Amfetamine (speed), cocaine, crack cocaine, MDMA (Ecstasy),
nicotine, methyphenidate
Psychological effects – Alertness, hyperactivity, euphoria, irritability, aggression, paranoid
ideas, hallucinations (esp. cocaine – formication), psychosis
Physical effect – Mydriasis, tremor, hypertension, tachycardia, arrhythmias, perspiration, fever
(esp. Ecstasy), convulsions, perforated nasal septum (cocaine)
Management:
 Can be stoped abruptly
 Antidepressants may help mood
 Psychotic disorders induced by drugs benefit from short course of benzos or
antpsychotics
Central nervous system depressants – e.g. benzodiazepines, barbiturates
Psychological effects –drowsiness, apathy, disinhibition, confusion, poor concentration,
reduced anxiety, feeling of well being
Physical effect – miosis, hypotension, seizures, impaired co-ordination, resp depression
Management:
 Like alcohol, sudden withdrawal can be potentially fatal and may include
hallucinations, convulsions and delirium
 Initial conversion from short acting (e.g. lorazepam, temazepam) to long acting
(diazepam). Doses then reduced slowly by small amount every few weeks
Hallucinogens – e.g. LSD (acid), mescaline, psilocybin (magic mushrooms)
Psychological effects – marked perceptual disturbances including chronic flashbacks, aranoid
ideas, suicidal and homicidal ideas, psychosis
Physical effect – Mydriasis, conjunctival injection, hypertension tachycardia, perspiration,
fever, loss of appetite, weakness, tremors
Cannabinoids – e.g. cannabis (dope, weed, grass), hashish, hash oil
Psychological effects – euphoria, relaxation, altered time perception, psychosis
Physical effect – Impaired coordination and reaction time, conjunctival injection, nystagmus,
dry mouth
Dissociative anaesthetics – e.g. ketamine, phencyclidine (PCP, angel dust)
Psychological effects – hallucinations, paranoid ideas, thought disorganization, aggression
Physical effect – mydriasis, tachycardia, hypertension
Inhalants – e.g. aerosols, paint, glue, lighter fluid, petrol, benzene, gases
Psychological effects – disinhibition, stimulation, euphoria, clouded consciousness
hallucinations, psychosis
Physical effect – headache, nausea, slurred speech, loss of motor coordination, muscle
weakness, damage to brain/bone marrow/liver/kidneys/myocardium, sudden death
Substance abuse History
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Current use
History of drug use
Consequences of drug use
Current use:
 Which drugs are being used?
 How often?
 By what route?
 What effect are you seeking? e.g. excitement, calmness, relief of cravings
 What happens if you don’t take the drug for a while? (withdrawal, cravings)
 Do you take risks? (needle sharing, unsafe sex, sex for money/drugs)
 How do you afford your drugs?
History of drug use:
 How old were you when you first started to take drugs?
 When did you start using them regularly?
 How often were you using drugs?
 What drugs did you move on to?
 Why did you continue / change?
 What is your favourite drug?
 Where do you get your drugs from?
 Have you ever gone without drugs for a long while?
 Why did you start again?
Consequences:
 Have you ever worried about HIV or hepatitis?
 Why? / Why not?
 Have you ever had any tests for these?
 Have you ever had any injecting problems (DVT, septicaemia, abcess)
 Have you ever OD’d by accident?
 Have you ever seen or heard things that were not there?
 Have you believed strange things?
 Have you been drowsy or confused?
 Any other problems?
Obsessive compulsive disorder
Obsession = involuntary thoughts, images or impulses that have the following
characteristics:
 They are recurrent and intrusive and are experienced as unpleasant or distressing
 They enter the mind against conscious resistance
 They are a product of the patients mind
Compulsion = repetitive mental operations (counting, praying or repeating a mantra silently)
or physical acts (checking, seeking reassurance, hand-washing, strict rituals) that have the
following characteristics:
 Patients feel compelled to perform them in response to their obsessions or irrationally
defined ‘rules’ (e.g. I must count to 10000 4 times before falling asleep)
 They are performed to reduce anxiety through the belief that they will prevent a
‘dreaded event’ from occurring, even though they are not realistically connected to
the event (e.g. compulsive counting each night to prevent a family catastrophe) or are
ridiculously excessive (e.g. spending hours cleaning due to obsession of
contamination)

Intrusive

Senseless
Obsession
A thought or mental image e.g.
 Contamination
 Sex, violence
 Numbers

Repetitive
Compulsion
An action that must be performed e.g.
 Hand-washing
 checking
 touching
Differential diagnosis
Anankastic personality disorder is one differential and is characterized by:
 Perfectionism
 Excessive cleanliness
 Rigidity of thinking
 Orderliness
 Moralistic preoccupation with rules
 Tendency to hoard
Other differentials include:
Depression
Puerperal illness (harming baby)
Tourettes syndrome
Schizophrenia
Temporal lobe epilepsy
Generalised anxiety disorder
Dementia
Parkinson’s disease
Head injury
OCD
ICD-10 diagnosis:
1. Obsessions or compulsions for 2 successive weeks and are a source of distress or
interfere with the patients functioning
2. They are acknowledged as coming from the patients own mind
3. The obsessions are unpleasantly repetitive
4. At least one thought or act is resisted unsuccessfully
5. A compulsive act is not in itself pleasurable
Treatment:
CBT – inc. exposure therapy, response prevention
Family therapy
1st line: SSRIs – sertraline, fluoxetine, fluvoxamine, paroxetine, citalopram
2nd line: (as effective but less well tolerated) Clomipramine
Treatment resistant cases: consider antipsychotics, pindolol, clonazepam
OCD History
Always ask how often a symptom occurs and how long it lasts
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Do you find that some thoughts come into your mind even if you try not to have them?
Do you have any thoughts, ideas, words or pictures that come into your head and you
cannot stop?
What is it like?
How do you explain it?
Are there things you have to do even though you know they seem silly and unnesesary?
Do you have to keep checking things?
Do you get worried about germs or have to wash your hands a lot?
Do you ever have to repeat actions?
What happens if you do not do these things?
Eating Disorders
Anorexia Nervosa
All of the following are required
a) Weight loss (or in children a failure to
gain weight) resulting in a body weight
at least 15% below the normal or
expected weight for age and height
b) Weight loss is induced by avoidance of
‘fattening foods’
c) A self-perception of being too fat, with an
intrusive dread of fatness, which leads
to a self-imposed low weight threshold.
d) A widespread endocrine disorder
involving the hypothalamic-pituitarygonadal axis. Manifest in women as
amenorrhoea and men as loss of sexual
interest and potency.
e) If onset prepubertal then there is a delay
or arrest in the normal sequence of
puberty.
If a person meets criteria for both AN and BN
then AN is the dominant diagnosis.
Bulimia Nervosa
All of the following are required
a) A persistent preoccupation with eating
and a strong desire or sense of
compulsion to eat (craving) There are
recurrent episodes of overeating (at
least twice a week over a period of 3
months) in which large amounts of food
are eaten in short periods of time
b) Patient attempts to counteract the
‘fattening’ effects of food by one or
more of the following
 self-induced vomiting
 self induced purging
 alternating periods of starvation
 use of drugs such as appetite
suppressants, thyroid preps, or
diuretics. In diabetics, insulin may be
self-withheld
c) A self-perception of being too fat, with an
intrusive dread of fatness
Eating disorder history:
Useful questions include
The SCOFF screening tool:
 Do you make yourself Sick because you feel uncomfortably
full?
 Do you worry you have lost Control over how much you eat?
 Have you recently lost more than One stone in a 3 month
period?
 Do you believe yourself to be Fat when others say you are
too thin?
 Would you say that Food dominates your life?
One point for every "yes";
a score of 2 indicates a
likely case of anorexia
nervosa or bulimia
Narrowing the diagnosis
 What do you eat on a normal day?
 Do you ever eat lots more or less than this? How often?
 What exercise do you do on a normal day?
 Do you ever take anything to make yourself sick or go to the toilet more often?
 When was your last period? How often do you have periods? (as appropriate)
 Is your sex drive less than it used to be?