Psychiatry

Normal Personality• OCEAN

– Openness to experience– Conscientiousness– Extroversion– Agreeableness– Neuroticism

Personality Disorder•Maladaptive patterns of behaviour, modes of thinking and relating to oneself, the environment and others which causes impairment of social functioning to the individual or others•Features usually present in adolescence and persist through life•Not usually thought of as an illness•Largely unresponsive to Rx•Diagnosis doesn’t imply change from previous level of functioning (psychosis +neurosis imply change from previous level of functioning and development of symptoms)•Different categories•1)ODD•2) DRAMATIC•3) ANXIOUS

Personality Disorders• Majority never come in contact with psych services, those who do

generally do because of another psychiatric disorder• Predispose to other psych disorders, and affect presentation and

Rx• “severe disturbance in the personality and behavioural

tendencies of the individual not directly from disease, damage to the brain or other psych disorder. Usually involving several areas of the personality. Nearly always associated with considerable personal distress and social disruption.

• Usually manifest since childhood/adolescence • 3 clusters

– A: paranoid, schizoid, schizotypal (ODD)– B: antisocial, borderline, histrionic and narcissistic (DRAMATIC)– C: avoidant, dependent, obsessive-compulsive (ANXIOUS)

Personality Disorders• 10% population have personality disorders and up to 50% psych

inpts and outpts• More males, younger adults and those in urban communities• Aetiology: genetic factors and early life experiences e.g. Child

abuse• Impulsive behaviour linked to reduced CSF serotonin, more?• After a highly threatening experience personality disorders can

develop though normally personality is set from late childhood

Paranoid Personality Disorder• Pervasive distrust of others including friends and partner• Person is guarded, suspicious and constantly on the lookout for

clues to confirm his fears etc• Strong sense of self-importance & personal

rights• Overly sensitive to rebuffs and setbacks• Easily feels shamed and humiliated• Persistently bears grudges• Difficulty engaging in close relationships, tendency to withdraw

from others• M>F• PROJECTING – their way of coping may be to blame

others/society e.g. Get guilty, project it to partners and become morbidly jealous and suspicious

• Schizoid personality disorder: – Cold and aloof/ cold and callous– Incapable of expressing strong emotions– Cold, detached and flat. Lacks emotional response– Little capacity for intimate relationships. No desire for social/sexual r’ships– Few friends. Indifferent to others, social norms and conventions– Solitary pursuits– Natural tendency to direct ones attention to ones inner self– Prone to introspection and fantasy. – Function well so no Rx really given.

• Schizotypal personality disorder:– Oddities of appearance, behaviour, speech– Anomalies of thinking similar to schizophrenics. E.g. Odd beliefs, magical

thinking, suspiciousness and unusual perceptual experiences– Fear social interaction and see other people as harmful– Development of ideas of reference (not delusions) where they think

everything is related to them, even though they know it is irrational. High chance of becoming schizophrenic.

• Dissocial/antisocial personality disorder:– M>W– Callous unconcern for the feelings of others– Dangerous anti-social behaviour. No signs of remorse.– Disregards social rules and obligations, irritable and aggressive, acts impulsively and lacks

guilt– Lots of relationships but generally fiery, turbulent and short– Most highly correlated with crime– BEDWETTING, CRUELTY TO ANIMALS & PYROMANIA (macdonalds triad)– ? Underlying brain dysfunction

• Emotionally unstable/borderline personality disorder:– Lack a sense of self, feel empty and fear abandonment– Pattern of intense but unstable relationships, emotional instability, anger and violence– May have transient psychotic episodes due to intensity of emotions– May be involved in mutilating behaviour/ODs– Poor self control– Emotions experienced with unbearable intensity– Threats of suicide/self harm common– Often due to child sex abuse. W3:1M.

• Histrionic personality disorder– Lack a sense of self-worth, depend on attention and approval of others.– Often thought to be dramatising/”playing a part” to attract and manipulate

attention. SHALLOW, labile affect. – Self-absorbed and cannot form lasting r’ships– Great care of appearance and behave charmingly/seductively– Act on impulse, crave excitement. “ACTING OUT”– Superficial or insincere when dealing with people– Sensitive to criticism and rejection. React badly to loss or failure.

• Narcissistic personality disorder: – grandiose sense of self-importance– Sense of entitlement and a need to be admired. Envious of others and

expects people to be jealous of him– Lacks empathy and readily exploits others to reach his goal. May seem

controlling, self-absorbed, intolerant and selfish– Provoked into fit of anger and revenge seeking if slighted or ridiculed. Ego

defence: denial, distortion and projection.

• Anankastic personality disorder– Excessive preoccupation with details, rules, lists, order,

schedules. Cautious and anxious.– Perfectionism so extreme it prevents the task being completed– Expense of leisure and relationships: pedantic and stubborn– Doubting and cautious, rigid and controlling. View their

obsessions as rational.• Anxious-avoidant personality disorder– Constant feeling of apprehension and low self esteem– Fear of social inadequacy and inferior-ness– Fear of being embarrassed, criticised or rejected– May be linked to rejection in childhood, strong link with

anxiety disorders. Excessive monitoring of reactions to everything.

– HYPERSENSITIVE

• Dependent personality disorder: lack of self-confidence and excessive need to be taken care of. Need lots of help to make decisions. Greatly fears abandonment, go through extreme measures to secure and maintain relationships. Naive and child like attitude. Helplessness.

• DDx – affective disorders, substance misuse, psychotic disorders, anxiety disorders, OCD, learning disability, dementia and autism.

• Mx: lifelong but tend to mitigate in middle/old age as people grow and gain wisdom. Emotional and practical support, psychological therapies, monitoring and crisis intercention.

• Complications: depressive disorder, substance misuse, accidents, DSH and suicide. Socially unemployment, homelessness and criminal activity.

• Up to 75% prison inmates have personality disorders! Antisocial the most common one by far.

Eating Disorders• Markedly disordered eating due to profound emotional

disturbance in specifically predisposed people• Core features:

– Psychological: low self-esteem, over evaluation of weight/shape/eating control, drive for thinness, fear of weight gain/fatness, body image distortion, total preoccupation with food/weight/eating

– Behavioural: dietary restriction, overeating/binge eating, compensatory behaviours (purging/non-purging)

– Physical: weight loss, amenorrhoea, decreased libido, delayed growth• Anorexia Nervosa• Bulimia Nervosa• Eating disorder not otherwise specified e.g.:binge eating disorder

(associated with obesity. Binge but no compensatory behaviours). Disorders of eating that resemble AN/BN but do not meet specific diagnostic criteria

Aetiological Factors

• Lack of control in other aspects of their lives, want something they can take full control over

• Any age, Boys or Girls (more commonly girls but rising in males)• Low self-esteem: child abuse, bullying, lack of attention• Can be attention seeking• Not being able to cope with the pressures of life (control)• Emotional struggle: problems with family, relationships, finance, job,

unemployment• ProAna websites: give eachother inspiration and tips etc• Predisposing factors: genetics, FHx, early trauma, weight/dieting Hx,

personality/self-esteem• Precipitating: difficult transitions, adverse life events, extreme dieting• Prepetuating: starvation syndrome, vicous behavioural cycles,

stressors

Anorexia Nervosa• Deliberate dietary restriction leading to marked weight loss or

growth failure• BMI >17.5• Intense fear of gaining weight or becoming fat• Body image disturbance; overevaluation of weight/shape;

denial of seriousness of low weight• Amenorrhoea (absence of >3 menstrual periods)

Bulimia Nervosa•Recurrent binge eating (large amounts, 2hour period, lack of control)•Compensatory behaviours: self-induced vomiting, laxatives, diuretics, exercise•Binge eating and compensatory behaviours occur at least 2x/week for 3months•Overevaluation of body weight/shape

“Multi-impulsive” ED• Significant trauma histories and associated psycopathy• Selfharm/suicidality, substanse misuse, sexual promiscuity,

increased spending, stealing...• Symptoms more related to mood than dietary restriction• Link with borderline personality disorder etc

Common major co-morbidities of eating disorders• Depressive disorder• Anxiety disorder• OCD• PTSD• PD• Substance misuse• BDD

Consequences

• Individual– Physical:

• Starvation: hypothermia, lanugo hair, bradycardia, hypotension, GI disturbance, myopathy, anaemia, hypoglycaemia, infertility, OP

• Binge-eating: Russell’s sign ( calluses on the knuckles or back of the hand due to repeated self-induced vomiting over long periods of time.), electrolyte disturbance (hypokalaemia), arrythmia, parotitis, oesophageal tears, acute gastric dilatation, pancreatitis, rectal prolapse, perimyolysis

• Refeeding: electrolyte disturbance (hypophosphataemia), cardiac failure, acute pancreatitis, convulsions, coma

• Others: fluid overload/hyponatraemia (weight falsification), musculoskeletal injury/increased CK (overexercising)

• Family• Society• Services

AN associations • Premorbid personality– Anxious/avoidant– Anankastic/obsessional– Achievement-oriented/perfectionistic– Alexithymic (difficulty

experiencing/expressing emotion) or inhibited

– Autistic etc

IT SERVES A PURPOSE!!!•Avoided: negative emotion, frightening change, family disruption•Gained: control, safety, attention, regard, self-esteem, value, achievement, specialness, anxiety relief, mood lift•Expressed: anger, frustration, guilt, self-hatred (self-punishment)

Outcome:AN: Mortality 5%, full recovery 47%, partial recovery 34%, chronic illness 20%BN: recovery 50%, partial recovery 30%, chronic 20%

SCOFF questionnaire

• 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 FOOD dominates your life• 2+: further questioning

Assessment • Establish rapport• History-taking: chronology, core features: eating pattern,

compensatory behaviours, weight history, endocrine Hx. , complications, comorbidity, contact with services.

• Mental state examination• Physical Examination• Further investigations• Collateral Hx• Repeated interviews• Risk Assessment

– Physical: BMI (trend), medical complications– Psychiatric: suicidality, major comorbidity– Social: home situation, child protection issues– Services: appropriate care environment?

Anorexia And Bulimia• BMI:

– 19-25 Normal range– <17.5 Part criteria for AN– <15 Worrying (physical safety)– <13.5 Very worrying (?admission)– <12 extremely worrying (“critical”)

• NICE– AN: competent outpt psychotherapy, skilled inpt refeeding, specific

family interventions– BN: CBT, SSRI– ENDOS: treat similarly, CBT/SSRI for BED

• Management– Practical, General, Physical: (medical, nutritional, pharmacological),

Psychological, Social and Others

Starvation Syndrome

• Starvation effects can resemble/intensify primary features of anorexia nervosa and make it harder to recover

• Obsessionality, cognitive rigidity, preoccupation with food/eating, cravings, constriction of interests, social isolation, increased drive for thinness, body image distortion

• ***Hence priority of weight restoration

Anorexia Nervosa Bulimia Nervosa

Risk Management: history, examination, investigations

Risk Management: history, examination, investigations

Engagement: being non-judgemental, willing to listen, appreciate the complexity/severity, try instil some hope

Engagement: being non-judgemental, willing to listen, appreciate the complexity/severity, try instil some hope

Nutritional restoration: restore weight, watch electrlytes, normalise eating patter, practicalities of managing food, principles of healthy eating

CBT: specifically adapted for BN

Competent Psychotherapy: work through internal conflicts

SSRI: 60mg fluoxetine daily.

Competent psychotherapy Support for families/carers

Support for families/carers

Substance Misuse• Substance = alcohol, illegal drugs, prescribed drugs, OTC drugs

and chemicals such as solvents• Misuse = use that creates problems/harm to the individual or

others• SM =

– Taking drugs/alcohol in a way that adversely affects health: physical and psychological

– The use of prescribed drugs in a way other than intended by the prescriber

• Neurophysiology of addiction: psychoactive substance misuse characterised by reward, tolerance and neuroadaption, withdrawal and dependence

• Codeine misuse is a HUGE problem, opiates too

Clinical Assessment• Drug type, route and duration of use: symptoms with cessation and last use

(misuse diary for those in long term care)• Start using- when, what, why. Escalating – what else, more often, when,

withdrawal when stopped??• Social: relationships, forensic Hx• Risk factors, symptoms and previous testing for BBVs• PMHx and review of symptoms of chronic misuse: malnutrition, TB, trauma,

endocarditis and STDs• Mental Health Hx• Physical Exam: vital signs and cardiac status for signs of fever, murmur,

haemodynamic instability. SKIN for areas of scarring, atrophy and infection (SITE of injection: neck/groin- infection risk)

• Lab Evaluation: FBC, comprehensive chemistry panel, HIV, ECG, CXR, STD screening

• Urine drug screens and breath analysis of alcohol• Alcohol: AUDIT or SADQ questionnaires

Dependence

1) Craving2) Increased tolerance3) Salience of drug-seeking behaviour (getting drug most important

thing in daily life)4) Narrowing of repertoire of drug taking behaviour (routine)5) Repeated withdrawal symptoms6) Relief or avoidance of withdrawal symptoms7) Reinstatement of drug taking after a period of abstinence• Loss of control: difficulty with onset, termination or level of use

and continued use despite knowledge of harmClass A: Heroin, methadone, cocaine, ecstasy, LSD. Possession 7yrs, supply LIFEClass B: cannabis, amphetamines. Possession 5years, supply 14yrsClass C: diazepam, lorazepam, temazepam. Possession 2yrs, Supply 5yrs

• Cannabis: – smoked/oral– Onset within minutes – last hours– Detected in urine up to 3 weeks after use. Stored in FAT CELLS– Intoxication: dry mouth, red eyes, tachycardia, distorted passage of

time, perceptual abnormalities, paranoia, panic, dependence, respiratory disease

– Psychosis: x2 risk schizophrenia, more violent• LSD

– Act via serotonin systems in brain– Taken orally, last up to 12 hours– Intoxication: dilated pupils, tachy, HBP, distorted reality, visual

hallucinations, thoughts/memories can re-emerge vividly, panic and fear can develop (bad trip)

– Withdrawal: no physical dependence, no substitutes, JUST STOP, flash backs can occur for years of trips

– Psychosis: in a minority of users

• Ecstasy– Party drug, big in 80-90s– Oral, brings euphoria and empathy– Neurotoxic to serotonin neurones– A/Es: hyperthermia, polydipsia (why people die: overhydration),

hyponatraemia (cerebral oedema) , seizures and arrhythmias, jaw grinding (CHARACTERISTIC)

– Low mood, anxiety, poor concentration• Amphetamines “speed”

– Taken to get a “high”– Sudden withdrawal: crash, dysphoria and craving– Used as diet pills and for depression in the past. Now just narcolepsy– A/Es: agitation, insomnia, HBP, arrythmias, seizures, circulatory

collapse, positive on drug screen for 2-3days.– Can induce paranoid psychosis, similar to schizophrenia. Tends to

resolve after 3days

• Benzodiazepines– Diazepam (classical BDZ), lorazepam and temazepam– Varying half lives, taken orally– Taken for anxiolytic effect– Acute intoxication: forgetful, drowsy, decreased concentration and

coordination– Chronic use: low mood, problems with concentration and memory– Rapid development of tolerance in matter of weeks– Withdrawal can be complicated by seizures and delirium

Withdrawal: Psychological Symptoms•Excitability•Restlessness•Insomnia, nightmares•Increased anxiety, panic attacks•Depersonalisation/derealisation•Hallucinations•Depression•SERIOUS AND VERY UNPLEASANT

Withdrawal: Physical Symptoms•Tingling, numbness, altered sensation•Weakness and pain•Fatigue•Flu like symptoms•Muscle twitches, jerks, tics•Tremor•Dizziness, light headedness•Blurres/double vision•Tinnitus•Hypersensitivity: light, sound, touch, taste, smell

• Cocaine– Euphoria, increased activity– Hallucinosis: auditory and visual– Frank psychosis– Formication: feeling of insects crawling under skin– After high: crash dysphoria, depression/anxiety,

anorexia, exhaustion, HBP, tachy, arrythmias– Cardiac A/Es:

• vasoconstriction of coronary system: chest pain• long term use fibrosis and hypertrophy

• Crack cocaine– Powerfully addictive form of cocaine– Mixture of cocaine and bicarbonate of soda: base

so absorbed much more readily– Stronger, more addictive, typically smoked, rapidly

absorbed– Faster but shorter high– A/E same as cocaine

Stimulant Withdrawal:•Easier to stop abruptly•Rebound effects:• Tiredness• Depression• Hunger• Social

withdrawal•PSYCHOSIS

• Heroin:– Natural opiate (poppy)– Intoxication: pupil constriction, constipation, N&V, drowsy, RESPIRATORY

DEPRESSION– In urine for 1-2 days– Not associated with frank psychosis– NB other opiates e.g. Codeine– Physical issues:

• Purity is variable so can lead to accidental OD• Method of use: oral, snorting, smoking, injecting (late on will inject anywhere: bad!)• Neglect of functions: social, occupational, hygiene etc• Putting other people at risk

– Dangers of injecting: • can hit an artery and cause ischaemic damage• Can introduce infection: septicaemia, endocarditis, BBV• Can cause embolus• Vein becomes hardened• Abscess• OD (often accidental)

• Heroin Withdrawal– “cold turkey” – Withdrawal symptoms peak at 72hours but last 5-7days– Craving can persist for weeks– Very unpleasant but not life threatening (unlike using heroin!!!)– Restless, anxious, lacrimination, rhinorrhoea, sweaty, piloerection (hairs

stand up), N&V, diarrhoea, muscle cramps, insomnia – Lofexidine (britlofex)

• Used in opiate detoxification• 0.2mg• Alpha noradrenergic agonist (like clonidine)• Alleviates withdrawal symptoms• Not a substitute drug• A/Es: low BP, bradycardia (Needs daily monitoring)

– Symptomatic relief: • Buscopan 10mg 4-6hourly PRN for GI spasm• Lomotil 2tabs/6hours for diarrhoea• Chlorpromazine 25mg nocte for anxiety/insomnia

• Patients who have injected:– Counselling and testing for HIV, Hep B&C– Vaccination HepB if seronegative– Referral to liver specialist for HepC+ pts– Education about risks of injecting and sharing

• Harm minimisation– Clean needles and works – pharmacy exchange programme– Education on dangers, safe practice and safe sex– Motivational counselling– Consider substitution

• Nalorex: opiate antagonist– Naltrexone hydrochloride, blocks opiate receptors so low effect of opiate

drugs– Pt must have withdrawn for 7-10days– Non addictive, no high– Long term, need LFT monitoring– Reduces relapse risk by blocking “good” effect of opiates

• Abstinent Pts– Referral to specialist drug services for counselling and rehab– Support counselling to maintain abstinence– Relapse prevention techniques– Rehab issues: housing, jobs, different group of friends

• Triggers for relapse– Negative emotional states: anger, sadness, trauma, stress– Physical discomfort: pain or withdrawal symptoms– Positive emotional states: wanting to feel even better– Testing personal control: I CAN have only one drink...– Strong temptations or urges (cravings of use)– Conflict with others: argument with partner– Social pressures

Alcohol Abuse• 1 unit = 8g ethanol/ 10mls absolute alcohol• Men: 21units/week, 4 (6) in a day• Women: 14units/week, 2 (4) in a day• Alcohol related illness: GP visit x2 other pts• 1/3 men and 1/10 women drink above the maximum

recommended levels for a prolonged period of time• Men drink 3x that of females• ¼ men will be problem drinkers at some point of their lives• MALE: onset alcoholism late teens/20s. Often insidious course.

Recognition of alcohol dependence often not til 30s• FEMALE: onset later, more likely to drink alone and delay in seeking

help, higher rates of depression• Common in those whose jobs have unsociable hours, shift work

and easy access to workers

Aetiology• Genetics: x7 risk in alcoholism in firs degree relatives• Biochemical: changes in serotonin• Psychological: death wish, self-destructive behaviour• Sociocultural: peer group

1 unit:•½ pint ordinary strength beer/lager•1 glass wine•1 glass sherry•1 single measure spirits•Alcopops: 1 bottle = 1.5 units•1 can extra strong beer = 4units

Hazardous Drinking:•Male 22-50 units/week•Female 15-35 units/weekHarmful Drinking:•Male >50 units/week•Female >35 units/week

History• Pattern:

– Binge pattern compared to daily consumption– Type of alcohol– Time of day– Drinking alone/in company– Frequency of drinking– Intensity of drinking

• CAGE questionnaire– Have you ever thought you should CUT DOWN on

your drinking?– Has anybody ever ANNOYED you by criticising

your drinking?– Have you ever felt GUILTY about your drinking?– Do you take a drink in the morning to steady

yourself: EYE OPENER?

• AUDIT

Investigations• Physical examination• Lab Investigation

– AST– ALT– GGT– MCV– FBC– Blood tox screen

Treatments•Acute detoxification•Long term maintenance•Relapse prevention

History

• Dependence:1) A strong desire/sense of compulsion to take the substance2) Narrowing of drinking repertoire3) Withdrawal symptoms with relief drinking (in the morning)4) Evidence of tolerance5) Progressive neglect of other interests6) Difficulty controlling alcohol use despite evidence/awareness of

harm7) Reinstatement after abstinence-3 features over last 6 months = Alcohol Dependence Syndrome

• Past treatment– AA– Detox programmes: self/GP, home/hospital– Community addictions teams referral– Residential programmes

• Consequences– HEALTH: oesophagitis, mallory weiss tears, aspiration pneumonia,

pancreatitis, cardiac arrhythmias, liver damage/cirrhosis, peripheral neuropathy, hypoglycaemia, gastritis, CVA, HTN, infertility

– SOCIAL: relationships (divorce), family, children, violence and accidents, debts

– EMPLOYMENT: Monday absences, lunch time drinking, poor performance, dismissals

– FORENSIC: drunk driving, violence• Co-morbidity

– 47% alcoholics have another psychiatric disorder:• Depression• Anxiety• Anti-social personality• Drug dependence

– Suicide is more common: x50 risk!!!!!– DSH more common

Alcohol Withdrawal Syndrome• In 95% symptoms occur within

hours of last drink and peak within 24-48hrs

• Restlessness, tremor, sweating, anxiety, N&V, anorexia, insomnia, tachycardia and HTN

• Withdrawal seizures may occur within 24-36 hours

Detoxification•Alcohol withdrawal associated with significant morbidity and mortality•CHLORDIAZEPOXIDE (librium) 10-20mg QID (BDZ, similar family to alcohol, addictive so careful)•Reduce slowly over 1 weel•B1 thiamine replacement•Anti-epileptics may be required

CHLORDIAZEPOXIDE/LIBRIUM

Wernickes Encephalopathy• Acute syndrome• Caused by THIAMINE deficieny• Medical emergency, treated

with IV thiamine (PABERNAX) which reverses the encephalopathy

• Disorientation, confusion, ataxia, ophthalmoplegia, neuropathy

• Precedes Korsakov's

TRIADCONFUSION

ATAXIA

NEUROPATHY

Korsakov’s Syndrome•Chronic syndrome, following WE•Confabulation: make things up to fill gaps in memory•Normal digit span memory but impairment of short term memory•No new learning

Wernicke-Korsakov Outcome•High acute mortality: 17%•Amnesic syndrome:• ¼ recover• ¼ partial recovery• ½ no recovery

•Important to have early diagnosis•Important to give THIAMINE

Delirium Tremens• 1-4 days after selective/absolute withdrawal of

alcohol• 1-5% mortality• Trauma/infection present from outset in 50%

cases• Biochemical evidence of liver damage in 90%• Some present insidiously with night time

confusion• TREMOR AND CONFUSION• Vivid hallucinations, delusions, confusion,

inattention, agitation and autonomic changes (tachy, HTN)

• Rx: – Early diagnosis– IV diazepam– Fluid & electrolyte replacement– IV thiamine

Risk Factors for DTs and Seizures:•Severe alcohol dependence•PHx DTs•Long Hx alcohol abuse•Old age•Concomitant acute illness•Severe withdrawal symptoms at presentation

Alcoholic Hallucinosis• In clear consciousness

(compared to DTs)• Long standind drinkers• Derogatory auditory

hallucinations (like schiz)• Seen as substance-induces

psychosis• Prognosis GOOD• Responds to anti-psychotic

medications and abstinence• Small %, symptoms last 6m

Treatment of Alcohol Abuse•Disulfiram (antabuse)• Inhibits aldehyde

dehydrogenase that normally metabolises acetaldehyde

• If + alcohol: flushing, headache, N&V

• If ++ alcohol: hypotension and collapse

•Acamprosate (campral)• Decreases craving

•Naloxone• Opiate antagonist, stops

higher effects of alcohol•CBT•Motivational interviewing•AA

Addictions• Addiction is an attachment to, or dependence on, any

substance/thing/person/idea so single minded and intense that virtually all other realities are ignored or given second place – and consequences (even lethal ones) are disregarded

• Phases of drug addiction:– Initiation and development phase– Continuation phase– Relapse phase

• Routes of drug use: oral (sublingual), smoked, inhaled, sniffed/snorted, subcutaneous, IV, IM

• Dependence: – Compulsion– Impaired control– Withdrawal– Tolerance– Salience– Persistent use despite harm

• 3+ in last 12 months

Reward Pathways• Drugs of dependence release dopamine causing a reward

effect, linked to D2 receptor pathway. Drugs hijack normal reward pathways so things that used to make you happy no longer do

• All drugs of misuse except LSD and BDZs act on dopamine reward pathway

• Tolerance/adaptation:– Receptor levels increase or decrease– Transmitter production increases or decreases– Metabolism (enzyme inhibition/induction)

• Body tried to adapt while drinking etc so once you stop “withdrawal” symptoms are experienced