CAM III Exam - Psych (substance use disorders and mood disorders)

the emotion that the patient tells you they feel

mood

the level of awareness of the illness and understanding the problem - can be complete denial of illness or blaming

insight

the patient's ability to understand the outcome of their actions and use this awareness in decision making

judgement

reduced ability to experience pleasure or joy in activities that were once enjoyable

anhedonia

lack of interest, enthusiasm or concern

apathy

tactile hallucination that feels like insects crawling on or under the skin even though none are present

formication

T/F: substance intoxication and substance withdrawal have the same s/sx

F: they have opposite s/sx

What is considered binge drinking for women?

4 or more drinks in 2 hours

What is considered binge drinking in men?

5 or more drinks over 2 hours

What makes someone at risk for heavy drinking?

Women - >3 drinks/d OR >7/week

Men - >4 drinks/d or >14/wk

Who has the highest AUD prevalance?

Native American population

Who has the lowest AUD prevalance?

Asian population

What are the complications of alcoholism?

metabolic/malnutrition, GI, endocrine, neurologic

When does BAC typically peak? What is considered legally intoxicated?

30-90 minutes after consumption

BAC 0.08%

What are the federal guidelines for moderate drinking for men and women?

men - no more than 2 standard drinks per day

women - no more than 1 standard drink per day

What is the DSM-5 criteria for acute alcohol intoxication?

clinically significant problematic behavioral or psychological changes that developed during, or shortley after, alcohol ingestion along with ONE OR MORE of:

slurred speech, incoordination, unsteady gait, nystagmus, impairment in attention or memory, stupor or coma

How do you treat acute alcohol intoxication?

"Banana Bag" (Thiamine 100 mg, Folic Acid 1 mg, Magnesium Sulfate 2g, Potassium 40 mEq, one ampule of multivitamin concentrate, saline solution)

additional electrolytes PRN

How do you diagnose alcohol withdrawal?

clinical dx based on H&P, can utilize VS and CIWA-Ar to assess withdrawal symptoms

What is the CP of minor alcohol withdrawal? When does it onset?

mild anxiety, HA, tremulousness, palpitations, diaphoresis, GI upset, anorexia, normal mental status

onset: 6-36 hours after last drink

What is the CP of alcohol hallucinosis? When does it onset?

orientation intact, normal VS, visual, auditory +/or tactile hallucinations

onset: 12-48 hours after last drink

What is the CP of alcohol withdrawal seizures? When does it onset?

single or brief flurry of generalized tonic-clonic seizures, post ictal period-short, rare status epilepticus

onset: 6-48 hours after last drink, usually 12-24 hrs

What is the CP of alcohol withdrawal Delirium/DTs? When does this usually onset?

delirium, hallucinations (visual MC), agitation, gross tremor, autonomic instability (tachy, htn, fever, diaphoresis), psychomotor activity fuctuates

onset: 48-96 hours

*hypomagnesium can predispose

What is the CP of post-acute withdrawal syndrome (PAWS)? When does it onset?

anxiety, hostility, irritability, depression, mood changes, fatigue, insomnia, problems concentrating and thinking, decreased sex drive, and unexplained physical pain

onset: weeks to months; protracted withdrawal symptoms can last for at least a year

How do you treat a patient if they have mild withdrawal syndrome AND no risk factors for progression to severe withdrawal?

consider psychosocial support, supportive environment and person to monitor

follow up daily w/ outpatient provider either in person or via telehealth

How do you treat a patient in moderate/severe withdrawal or mild withdrawal with RF to progress to severe?

Admit - usually ICU

-IV fluid resuscitation

-Banana Bag initial then additional IV fl, folic acid, and thiamine

-Folic acid PO or IV 1 mg QD

-Thiamine IM, IV, or PO min 100 mg daily

-Multivitamin PO

-PRN med for elev BP

-benzo prn per CIWA scale

-comfort measures

Which benzo for alcohol withdrawal is better in an outpatient setting?

chlordiazepoxide

What is the gold standard treatment for alcohol withdrawal? Why?

Benzos

help relieve symptoms and prevent w/d seizures and delirium

Which benzo is preferred for someone in alcohol withdrawal with severe liver disease?

lorazepam

What is the gold standard assessment for alcohol w/d?

CIWA

T/F: you can use the CIWA tool if a patient is unconscious

F: patient must be conscious

What is the DSM-5 criteria for diagnosing mild Alcohol Use Disorder?

presence of 2-3 symptoms

What is the DSM-5 criteria for diagnosing moderate Alcohol Use Disorder?

presence of 4-5 symptoms

What is the DSM-5 criteria for diagnosing severe Alcohol Use Disorder?

presence of 6 or more symptoms

What classifies someone in early remission of AUD?

none of the criteria for AUD have been met for at least 3 months, but less than 12 mo

What classifies someone in sustained remission from AUD?

none of the criteria for AUD have been met for 12 months or longer

What labs are seen in alcoholic liver disease?

AST:ALT ≥ 2:1

What are the screening tools used to screen for AUD?

CAGE, CRAFT, alcohol use disorders identification test, michigan alcoholism screening test

What treatment do you use for benzo refractory alcohol withdrawal syndrome?

phenobarbital

What does alcohol activate in the CNS?

GABA (leads to increased inhibition of neuronal activity, contributing to its sedative and anxiolytic effects)

Dopamine (contributes to pleasurable effects of drinking and can lead to reinforcement and potential addiction

Serotonin receptors (influences mood and behavior)

What does alcohol inhibit in the CNS?

Glutamate receptor activity (reduces excitatory neurotransmission, contributing to cognitive impairment and decreased motor coordination)

What happens with chronic alcohol use?

Neuroadaptive changes (balance GABA-glutamate)

-upregulation of glutamine --> compensates for alcohol-related increase in GABA

-downregulation of endogenous GABA

What is the pathophysiology of alcohol withdrawal?

relative deficit of GABA at the same time excess glutamate, causes excitatory symptoms seen in alcohol withdrawal syndrome

What syndrome is a result of damage to the brain from AUD + Vit B1 defeciency?

Wernick-Korsakoff syndrome

What is the main CP of Wernicke Encephalopathy?

confusion, indifference, inattentiveness, gait ataxia, oculomotor dysfunction (nystagmus, dbl vision, muscle imbalance, eyelid drooping), fatigue, hypothermia, hypotension, coma

What is the diagnostic criteria for Wernicke Encephalopathy/Korsakoff Psychosis?

clinical - can confirm w/ MRI

What lab value do you for sure wanna check on someone with Wernicke Encephalopathy?

ammonia

What do you treat Wernicke Encephalopathy/?

High dose IV Vit B1 followed by glucose

alcohol abstinence

What is the main CP of Korsakoff Psychosis?

irreversible sx, confabulation, remembering events incorrectly, hallucination, repeating speech/actions, lack of motivation/emotional apathy

How do you treat Korsakoff Psychosis?

IV Vit B1 then PO for several weeks

want to tx s/sx, nutrition, proper hydration, supportive care, alcohol abstinence

What medications are FDA for AUD tx?

Disulfiram, Naltrexone, Acamprosate

what are the adverse effects of Disulfiram?

ADE, facial flushing, HA, CP

When do you not want to give a patient Disulfiram?

if they are intoxicated

Why is Disulfiram not commonly used for AUD?

has to be taken everyday

What are the contraindications for Disulfiram use?

severe cardiac disease, psychosis, pregnancy

Which AUD med is an opiate antagonist, can also be used for opioid use disorder, and is typically given at bedtime?

Naltrexone

Which AUD med has to be taken 3x/d, but is well tolerated?

Acamprosate

What AUD med is CI in severe renal disease?

Acamprosate

Which drugs are classified as sedative, hypnotic, or anxiolytic?

Benzos (diazepam, alprazolam, lorazepam, etc)

Barbiturates (phenobarbital)

Z-drugs (zolpidem, zaleplon, eszopiclone)

Gamma-hydroxybutyrate

What is the DSM-5 criteria for diagnosis of Sedative, Hypnotic, or Anxiolytic Intoxication?

clinically significant maladaptive behavior or psychological changes that developed during, or shortly after use AND one or more of the following:

-slurred speech, incoordination, unsteady gait, nystagmus, impairment in cognition, stupor or coma

*same as alc intox

How do you treat a sedative, hypnotic, or anxiolytic overdose?

-ABCs/monitor VS

-if drug ingested in prior 4-6 hours --> activated charcoal and gastric lavage

-if OD benzos only --> flumazenil

-if OD barbiturates only --> sodium bicarb to alkalinize urine and promote renal excretion

When are sedative, hypnotic, or anxiolytic withdrawal symptoms seen for short-acting agents?

within hours

When are sedative, hypnotic, or anxiolytic withdrawal symptoms seen for long-acting agents?

1-2 days

What is the DSM-5 criteria for mild sedative, hypnotic, or anxiolytic use disorder?

presence of 2-3 symptoms

What is the DSM-5 criteria for moderate sedative, hypnotic, or anxiolytic use disorder?

presence of 4-5 symptoms

What is the DSM-5 criteria for severe sedative, hypnotic, or anxiolytic use disorder?

presence of 6 or more symptoms

which drugs are associated with more deaths than any other drug?

opioids

What is included in the DSM-5 criteria for Opioid Intoxication?

-clinically significant problematic behavior or psychological changes that developed during, or shortly after, opioid use

-pupillary constriction and one or more of following: drowsiness or coma, slurred speech, impairment in attention or memory

other s/sx: N/V, constipation

What is seen in the classic triad of opioid OD?

respiratory depression, AMS, miosis (pupil constriction)

except for meperidine (Demerol) which dilates pupils (mydriasis)

What is the treatment for opioid OD?

ABCs, educate pt about calling EMS, opioid overdose reversal medications are opioid ANTAGONISTS (precipitate w/d)

Naloxone --> rapidly reverses OD, IM/SQ/IV/intranasal

Nalmefene --> rapidly reverses OD, longer half-life than naloxone, IV/IM/intranasal

T/F: opioid withdrawal is not life threatening

true

How do you treat opioid withdrawal?

tx symptoms

autonomic - clonidine

Myalgias/arthralgias - NSAIDs, acetaminophen

Muscle cramps - cyclobenzaprine

Diarrhea - loperamide

Abdominal cramps - dicyclomine

N/V - promethazine or ondansetron

Insomnia - trazodone

Anxiety - hydroxyzine

*can use buprenorphine or methadone for w/d management as well and taper dose or continue as OUD tx

What is the clinical opioid w/d scale?

5-12 = mild w/d

13-24 = mod

25-36 = moderately severe

> 36 = severe

What is the DSM-5 criteria for mild opioid use disorder?

presence of 2-3 symptoms

What is the DSM-5 criteria for moderate opioid use disorder?

presence of 4-5 symptoms

What is the DSM-5 criteria for severe opioid use disorder?

presence of 6 or more symptoms

How do you treat opioid use disorder?

-prescribe naloxone for OD tx

-pts at higher risk of OD w/ relapse

-harm reduction education including clean needle use

-educate support system

-FDA approved meds: methadone, buprenorphine, naltrexone, naloxone (for OD)

What are the symptoms of cannabis intoxication?

memory, learning, attention, decision making, increased risk of psychosis/schizophrenia, tachycardia, lung damage, cannabinoid hyperemesis syndrome, pupil dilation

What has a 200-fold higher incidence of acute psychosis relative to natural marijuana?

synthetic cannabinoids

What is the DSM-5 criteria for cannabis related disorders withdrawal?

cessation of cannabis use that has been heavy or prolonged, three of more of the following s/sx develop within approx 1 week after stopping: irritability, anger, nervousness, sleep difficult, decreased appetite, weight loss, restlessness, depressed mood, and at least one physical symptom

What are the hallucinogens?

Mescaline, Psilocybin, Salvia, Ayahuasca, Phencyclidine ("angel dust"), 3,4-methylenedioxymethamphetamine-MDMA, Lysergic acid diethylamide (LSD "acid"), ketamine

What s/sx would you see in opioid dextromethorphan OD?

slurred speech, increased heart rate and BP, dizziness, N/V, dyspnea, seizures

what is the most common CP of phencyclidine (hallucinogen) intoxication?

Disorientation, confusion w/o hallucinations, nystagmus, numbness/diminished response to pain, ataxia, muscle rigidity, hyperacusis, coma

pupil dilation

What is the DSM-5 criteria for diagnosing mild phencyclidine use disorder?

presence of 2-3 symptoms

What is the DSM-5 criteria for diagnosing moderate phencyclidine use disorder?

presence of 4-5 symptoms

What is the DSM-5 criteria for diagnosing severe phencyclidine use disorder?

presence of 6 or more symptoms

What is the DSM-5 criteria for diagnosing other hallucinogen use disorder?

same criteria as for PCP except for addition of specifying the particular hallucinogen

What are the sx included in the DSM-5 diagnosing criteria for hallucinogen intoxication?

pupillary dilation, tachycardia, sweating, palpitations, blurring of vision, tremors, incoordination

What is experienced in Hallucinogen persisting perception disorder?

following cessation of use of hallucinogen, the reexperiencing of one or more of the perceptual symptoms that were experienced while intoxicated

When is acute intoxication of inhalants experienced?

15-30 mins

What are the withdrawal symptoms associated with inhalants?

N, tremors, irritability, mood changes, insomnia

What are the sx of inhalant overdose?

respiratory depression, cardiac arrhythmias

How do you treat inhalant related disorders?

monitor ABCs

may nee O2 if hypoxic

EKG, CBC, CMP, phosphorus, Ca, cardiac/muscle enzyme analysis

OD may be fatal d/t respiratory depression, or cardiac arrhythmias

What are other effects/complications of inhalant use?

heart failure, death, seizures, choking, coma

long-term: liver damage, kidney damage, bone marrow damage, limb spasm secondary to nerve damage, brain damage due to hypoxia

What symptoms are seen with inhalant-related disorders withdrawal?

Nausea, tremors, irritability, mood changes, insomnia

What is the DSM-5 criteria for mild, mod, severe inhalant use disorder?

mild - 2-3 sx

mod - 4-5 sx

sev - 6 or more sx

What drugs are involved in stimulant-related disorders?

cocaine, classic amphetamines, substituted "designer," "club drugs" amphetamines

Which stimulants can cause formication?

cocaine and amphetamines

What are the dangerous and deadly symptoms of cocaine OD?

dangerous: seizures, cardiac arrhythmias, hyperthermia, paranoia hallucinations (esp tactile)

deadly: vasoconstrictive effect (MI, intracranial hemorrhage/stroke)

How do you treat cocaine OD?

mild-mod agitation: sc and benzos

severe agitation/psychosis: antipsychotics

hyperthermia, sx support (tx arrhythmias/HTN)

What do you not give a pt with cocaine use?

Beta blockers