🧠Psych Lecture 4- Substance Use Disorders, Sleep Disorders, PTSD, ASD Flashcards

Psychiatry

Fun Q: What’re other medications that can impact sleep?

corticosteroids. albuterol, SSRIs,

What is considered the first-line treatment for insomnia?

Cognitive Behavioral Therapy for Insomnia (CBT-I) is considered the first-line treatment for insomnia, Sleep Hygiene (sleep journal, stop screens, go to bed and wake up at the same time, colder climate, read a book),

Pts can become reliant on medications or tolerant (request higher doses) over time, making CBT-I a preferred option.

What is Sleep Restriction Therapy?

A behavioral treatment that limits the amount of time spent in bed to match actual sleep time, which helps to improve sleep efficiency.

It encourages patients to build a more consistent sleep pattern and reduce time spent awake in bed. Shorten sleep one night—>deeper sleep the next night.

A 22-year-old female comes into the emergency room with a BP 180/100, HR 60, and T 99F. EMS

reports history of opioid abuse. Upon physical exam, you note patient to be fairly unresponsive except to

-elicited pain, decreased respirations, diaphoresis, and pupillary constriction. Which of the following would

be an appropriate option in her initial treatment plan?

a) Secure airway, start IV naloxone 0.8mg per 70kg of body weight

b) Methadone 20-80mg

c) Clonidine 0.1-0.3 mg TID to QID

d) Buprenorphine 8-10mg

e) Suboxone 12mg/3mg SL

Because the patient shows classic signs of opioid overdose — 🧠 CNS depression, 😴 decreased respirations, and 👁 pinpoint pupils — the priority is to protect the airway and reverse the opioid’s effect.

➡ Naloxone is an opioid antagonist that quickly reverses respiratory depression.
So, “secure airway + give naloxone” is the correct and lifesaving first step. ✅

What is codependence?

A family member is affected by or influences the behavior of the substance abuser.

Who is considered an enabler?

Someone who helps or denies the addict’s behavior, allowing it to continue.

What is drug dependence?; What is withdrawal?

Dependence—> Repeated use of a drug; stopping causes withdrawal symptoms.

Withdrawal—> A set of substance-specific symptoms that occur after stopping the drug (e.g., tremor, sweating, agitation)

What is addiction?

Compulsive drug use causing distress and craving when deprived.

What is tolerance?

The need for increasing doses to get the same effect.

What are the three components of dependency?

1) Psychological dependence (craving and behavior around obtaining the substance)
2) Physiologic dependence (withdrawal when discontinued)
3) Tolerance (need to increase dose for desired effect

Is substance use disorder treatable?

Yes — it is a treatable, chronic medical illness.

DSM-V Criteria (Part 1): What are the first five signs of a substance use disorder?

1) Substance taken in larger amounts or longer period than intended.
2) Persistent desire or unsuccessful efforts to cut down.
3) Great deal of time spent obtaining, using, or recovering from it.
4) Craving or strong desire to use the substance.
5) Recurrent use causing failure to meet obligations (work, school, home).

DSM-V Criteria (Part 2): What are the next five criteria?

6) Continued use despite social/interpersonal problems.
7) Important activities given up or reduced.
8) Recurrent use in hazardous situations.
9) Continued use despite knowing it’s causing harm (physical or psychological).
10) Tolerance (need more for same effect).
11) Withdrawal (symptoms appear when stopping).

What are examples of substance use disorders?

➡ Alcohol
➡ Cannabis
➡ Caffeine
➡ Hallucinogens
➡ Inhalants
➡ Opioids
➡ Sedatives/hypnotics/anxiolytics
➡ Stimulants
➡ Tobacco

What defines a Substance Use and Addictive Disorder?

A problematic pattern of use causing significant impairment or distress, shown by ≥2 criteria within 12 months.

What percentage of individuals with Substance Use Disorder (SUD) also have a mental illness?

What percentage of people with both SUD and mental illness receive treatment?

1 in 4 individuals with SUD have a co-occurring mental illness; Only 20%

What are the 2 main active components of cannabis?

1. Δ-THC (delta-9-tetrahydrocannabinol): partial agonist at CB1 & CB2 receptors.

2. CBD (cannabidiol): modulates and counteracts THC effects at CB1.

What are the two main cannabinoid receptors and their locations/functions?

CB1 (CNS):

1. Cognition

2. Memory

3. Motor function

4. Nociception

5. Nausea/vomiting

6. Perception

CB2 (Peripheral / Immune):

1. Immune response

2. Anti-inflammatory action

What are common symptoms of cannabis intoxication? (*8)

1. Euphoria

2. Relaxation

3. Heightened sensory perception

4. Increased appetite (“munchies”)

5. Impaired coordination

6. Time distortion

7. Dry mouth

8. Conjunctival injection (red eyes)

When do cannabis withdrawal symptoms begin and peak?

➡ Start within 1–3 days after last use
➡ Peak within 10 days

Are there any FDA-approved treatments for cannabis use disorder?

❌ No FDA-approved treatments

What are symptoms of cannabis withdrawal? (*7)

1. Irritability

2. Anxiety

3. Sleep disturbance

4. Decreased appetite

5. Depressed mood

6. Restlessness

7. Physical discomfort

How can cannabis affect mental health?

1. Acute psychosis during intoxication

2. Transient psychotic episodes

3. Delayed or persistent psychotic disorders

What percentage of individuals with cannabis-induced psychosis may develop a lifelong psychotic disorder?

➡ Up to 46%.

What forms of cannabis are the most potent?

• Hashish

• Cannabis oils

• Edibles (high THC concentration)

What are off-label treatments used for cannabis use disorder? (*5)

1. N-acetylcysteine 1200 mg (reduces cravings, antioxidant)

2. Gabapentin 1200 mg (anti-seizure, reduces anxiety and withdrawal)

3. CBD 400 mg (helps with anxiety and withdrawal)

4. Naltrexone 50 mg (reduces cravings)

5. Mirtazapine (used as a sleep aid)

How common are alcohol-related disorders?

• Among the most common psychiatric disorders in the Western world.

• Cause ~22,000 deaths/year.

• Rank 3rd largest U.S. health problem (after heart disease and cancer).

Which groups are most affected by alcohol-related disorders?

• Whites

• M > F

• Higher rates in college-educated individuals

• Occur in all socioeconomic classes

What other disorders are linked to alcohol use disorder?

1. Antisocial personality disorder

2. Mood disorders (e.g., depression)

3. Anxiety disorders

What are the genetic and environmental risk factors for Alcohol Use Disorder?

• Genetic component: 60%

• Environmental component: 40%

What behavioral patterns suggest Alcohol Use Disorder or dependence?

1. Daily need for large amounts of alcohol to function

2. Weekend-heavy or binge drinking patterns

3. Long sober periods alternating with binges

4. Classified as Primary or Secondary Alcohol Use Disorder

What is the NIAAA Single Question Screen for Alcohol Use Disorder?

➡ “How many times in the past year have you had X or more drinks in one day?”

• Men: 5 or more drinks

• Women: 4 or more drinks
  💡 Used for initial risk screening for heavy drinking or early AUD signs.

What is the AUDIT Questionnaire and what does it measure in Alcohol Use Disorder?

AUDIT = Alcohol Use Disorders Identification Test
Assesses:

1. Drinking frequency

2. Quantity consumed

3. Binge drinking episodes

4. Signs of dependence

5. Harmful or risky consequences

How is alcohol absorbed and metabolized in the body?

• 10% absorbed in stomach, rest in small intestine

• 90% metabolized by liver

• Remaining excreted by kidneys and lungs

What enzymes metabolize alcohol?

• Alcohol dehydrogenase (ADH)

• Aldehyde dehydrogenase (ALDH)

• Note: Asian populations often have ↓ ALDH activity → ↑ acetaldehyde → flushing 🚨

What is acetaldehyde and why is it important?

➡ A toxic compound formed during alcohol metabolism → causes hangover symptoms & tissue injury.

What type of drug is alcohol classified as?

➡ A CNS depressant 🧠

Slows brain activity by enhancing GABA

What are the physiologic effects of chronic alcohol use on the liver?

• Fat and protein accumulation

• Hepatitis and cirrhosis

• AST > ALT (classic 2:1 ratio in alcoholic hepatitis)

What gastrointestinal complications occur in Alcohol Use Disorder?

• Esophagitis, achlorhydria, gastric ulcers, varices, pancreatitis

• Decreased nutrient absorption →

  • ↓ Folic acid

  • ↓ Vitamin B12

  • ↓ Thiamine (B1) → risk of Wernicke–Korsakoff syndrome

How does alcohol interact with other drugs?

➡ Cross-tolerance develops with other CNS depressants (e.g., benzodiazepines, sedatives). When combined → compete for detoxification pathways → additive CNS depression and overdose risk.

What are the signs of alcohol intoxication?

(Similar to other CNS depressants)

1. Drowsiness 😴

2. Disinhibition

3. Errors of commission (poor judgment)

4. Psychomotor dysfunction

5. Dysarthria (slurred speech)

6. Ataxia (unsteady gait)

7. Nystagmus (involuntary eye movement)

What are signs of severe alcohol intoxication or overdose?

➡ Respiratory depression, stupor, seizures, coma, and death ⚠

When do symptoms of Alcohol Withdrawal begin?

6–12 hours after the last drink.

What are mild symptoms of Alcohol Withdrawal?

1. Anxiety

2. Minor agitation

3. Restlessness

4. Insomnia

5. Tremor

6. Diaphoresis (sweating)

7. Palpitations
   ➡ Usually resolve within 1–3 days.

What type of seizures occur in Alcohol Withdrawal and when?

➡ Tonic-clonic seizures (generalized)

• Occur in 10–30% of withdrawal patients.

• Usually brief.

What is Delirium Tremens (DTs) and when does it occur?

➡ Delirium tremens is the most severe form of alcohol withdrawal.
➡ Occurs 48–96 hours after the last drink, but can appear up to 1 week later if untreated.
➡ Occurs in 5% of alcohol withdrawals.

What are the symptoms of Delirium Tremens? (*7)

1. Mental confusion

2. Whole-body tremor

3. Sensory hyperacuity

4. Diaphoresis (profuse sweating)

5. Fever

6. Visual and auditory hallucinations

7. Autonomic hyperactivity → tachycardia and hypertension (HTN)

Why is Delirium Tremens considered a medical emergency?

➡ It causes a significant increase in morbidity and mortality.
➡ Untreated mortality rate: 35%. ⚠

What can trigger or worsen Delirium Tremens?

1. Pneumonia (PNA)

2. Dehydration / electrolyte imbalances (↓ Mg, ↓ K)

3. Acute renal failure (ARF)

4. Hepatic insufficiency

5. Heart failure

6. Arrhythmias

7. Cardiovascular (CV) collapse

What medication is used for hallucinations during alcohol withdrawal?

• Haloperidol 5 mg BID.

• Used for severe agitation or hallucinations during withdrawal or substance abuse.

What are the First Line medications used in alcohol withdrawal management?

• IV Benzodiazepines: Diazepam 20mg to 5mg taper over several days (long-acting).

What are the other main medications other than Benzodiazepines: short course of tapering long-acting IV benzodiazepines (diazepam 20 mg to 5 mg) for alcohol withdrawal management?

• Thiamine (Vitamin B1) before glucose to prevent Wernicke’s or Korsakoff.

• Folic acid and multivitamins daily.

• Correct electrolytes (Mg, Ca, K) for 3 days, then as needed.

• Adequate hydration.

• Hospitalization if needed.

Why is thiamine given before glucose in alcohol withdrawal?

Always given before glucose to prevent Wernicke’s or Korsakoff syndrome.

What causes Wernicke–Korsakoff Syndrome?

Damage to thalamus and hypothalamus from chronic Vitamin B1 (thiamine) deficiency.

What are the features of Wernicke’s Encephalopathy?

• Confusion

• Ophthalmoplegia

• Ataxia

• Thiamine deficiency

What are the features of Korsakoff Syndrome?

• Retrograde amnesia

• Anterograde amnesia

• Confabulation

• Korsakoff psychosis

What improves prognosis in alcohol use disorder? (*4)

1. No preexisting condition such as antisocial or other personality disorders.

2. Life sustainability through jobs, family, and friends.

3. Successful completion of the full course of initial rehab (2–4 weeks).

4. 60% chance of maintaining sobriety in 1 or more years.

What are the three main steps in treatment and rehabilitation for Alcohol Use Disorder?

• 1. Intervention

• 2. Detoxification

• 3. Rehabilitation

What happens during the intervention stage of Alcohol Use Disorder treatment?

The patient breaks through denial and moves toward acceptance of the disorder.

What does the detoxification stage include?

1. Thorough physical examination

2. Inpatient program: 2–4 weeks

3. Outpatient program: 3–6 months

4. Support groups: AA (Alcoholics Anonymous) and Al-Anon

5. Adequate rest, nutrition, and thiamine supplementation

What is the goal of the rehabilitation stage?

1. Maintain motivation for abstinence

2. Live a lifestyle free of alcohol

3. Focus on relapse prevention

What are the three FDA-approved medications for Alcohol Dependence?

1. Disulfiram

2. Acamprosate (*contraindicated in kidney disease (CrCl <30 mL/min)

3. Naltrexone (oral or extended-release injectable)

What two medications are used off-label for Alcohol Dependence?

1. Topiramate

2. Gabapentin

Which medication for Alcohol Dependence is given as a monthly injection?

Extended-release injectable naltrexone.

What is opioid dependence?

A cluster of physiologic, behavioral, and cognitive symptoms indicating repeated and continuing use of opioid drugsdespite significant related problems.

What is the difference between opiates and opioids?

• Opiates: Natural forms (e.g., heroin, morphine, codeine).

• Opioids: Synthetic or semi-synthetic versions.

What are examples of synthetic opioids?

• Hydromorphone (Dilaudid)

• Oxymorphone (Numorphone)

• Methadone (Dolophine)

• Meperidine (Demerol)

• Fentanyl

• Hydrocodone

• Oxycodone (OxyContin, Percocet, Vicodin)

• Propoxyphene (Darvon)

• Buprenorphine (Buprenex)

• Pentazocine (Talwin)

• Nalbuphine (Nubain)

• Butorphanol (Stadol)

Which opioid is most commonly abused and why?

Heroin — it is more lipid-soluble, allowing it to cross the blood-brain barrier quickly.

How is codeine metabolized in the body?

• Absorbed into the GI tract and transformed into morphine.

What percentage of people with opioid dependence have an additional psychiatric disorder?

About 90%.

What drug class cannot be given with opioids?

MAOIs (Monoamine Oxidase Inhibitors).

What are the key clinical features of opioid intoxication?

1. Respiratory depression

2. Pupillary constriction (miosis)

3. Smooth muscle contraction

4. Constipation

5. Changes in BP, HR, and temperature

6. Severe cases: coma or death

According to DSM-5, what triggers opioid withdrawal?

• Cessation of prolonged or heavy opioid use (weeks or longer)

• OR administration of an opioid antagonist after a period of opioid abuse

How soon can opioid withdrawal symptoms develop?

Within minutes to several days after cessation or antagonist administration

What are the DSM-5 criteria for opioid withdrawal?

At least three or more of the following:

1. Dysphoric mood

2. Nausea or vomiting

3. Muscle aches

4. Lacrimation or rhinorrhea

5. Pupillary dilation (mydriasis), piloerection, or sweating

6. Diarrhea

7. Yawning

8. Fever

9. Insomnia

What must be true for opioid withdrawal to meet DSM-5 criteria?

• Symptoms cause clinically significant distress or impairment in social, occupational, or other areas of functioning.

• Symptoms cannot be explained by another medical or mood disorder.

How quickly does heroin take effect and how long does it last?

Takes effect within seconds to minutes, lasts 4–6 hours.

NOTE: What does heroin look like? White or brown powder, or a black sticky substance.

How long can heroin be detected?

• In urine: up to 24 hours.

• In blood: 48–72 hours.

What is the first step in opioid overdose treatment?

Secure airway and provide mechanical ventilation until naloxone is available.

What medication is used for opioid overdose reversal?

Naloxone

• IV: 0.8 mg per 70 kg of body weight.

• Narcan nasal spray or IM/SQ.

What medication is used for opioid withdrawal management?

Methadone (synthetic opioid) 20–80 mg orally daily.

• Must weigh advantages vs. disadvantages.

What medication is used to address cardiovascular symptoms of withdrawal?

Clonidine 0.1–0.3 mg TID to QID.

What are the main medications for opioid maintenance therapy?

• Buprenorphine (Suboxone) 8–10 mg daily.

• Naltrexone 50 mg daily.

How does Buprenorphine (Suboxone) work?

• Blocks euphoric effects of IV opioids such as heroin or morphine.

• Mainstay of office-based treatment.

• Requires special training for use.

What other treatments support opioid rehabilitation?

• Psychotherapy and Narcotics Anonymous.

• Therapeutic clinics: methadone and naltrexone programs.

• Education and needle exchange initiatives.

What are examples of amphetamines? *low yield

• Dextroamphetamine (Dexedrine)

• Methamphetamine (Desoxyn)

• Mixed dextroamphetamine-amphetamine salts (Adderall)

• Methylphenidate (Ritalin)

What are signs of stimulant intoxication?

• Mydriasis (dilated pupils)

• Psychomotor agitation

• Tachycardia

• Perspiration

• Cardiac arrhythmias

• Chest pain

• Weight loss

• Increased BP

What symptoms develop with stimulant tolerance?

• Paranoid ideation

• Bruxism (teeth grinding)

• Hallucinations or other stimulant-induced psychotic symptoms

How is stimulant-related psychosis treated?

Antipsychotics.

What are signs of cocaine intoxication?

• Cardiovascular collapse

• Arrhythmias

• MI

• TIAs

• Anxiety, mood swings, delirium

What should be suspected if nasal bleeding or septal perforation occurs?

Cocaine use.

What is used for acute cocaine intoxication treatment?

Bromocriptine (dopamine agonist) 1.5 mg oral TID.

What are chronic symptoms after cocaine use stops?

Insomnia, depression, hyperphagia (increased appetite).

What is the single most lethal carcinogen in the U.S.?

Nicotine.

How does nicotine reinforce addiction?

Through dopaminergic pathways.

What are treatments for tobacco-related disorders?

• Quit date and address barriers.

• Psychotherapy + pharmacotherapy combination.

• Hypnotherapy or acupuncture.

• Nicotine replacement therapy (gum, patch, lozenge, nasal spray, inhaler).

• Bupropion (Zyban): 150 mg daily × 2 weeks, then 150 mg BID × 7–12 weeks.

• Varenicline (Chantix)

What are the two physiologic states of sleep?

• Non-rapid eye movement (NREM)

• Rapid-eye movement (REM)

What percentage of sleep does NREM make up and what happens during it?

• 75% of total sleep.

• 4 stages.

• Physiologic function markedly lower than wakefulness.

• Occurs within the first 90 minutes of sleep.

• Exception: narcolepsy and depressive disorders.

What percentage of sleep does REM make up and what are its characteristics?

• 25% of total sleep.

• High levels of brain and physiologic activity, similar to wakefulness.

• Known as the dream state.

• Most REM occurs in the last third of the night.

What are the three types of insomnia?

• Initial: Difficulty falling asleep

• Middle: Waking up during the night

• Terminal: Early morning awakening