PSYCHIATRY REVISION NOTES REVISION NOTES BASED ON LECTURE NOTES WITH PREVIOUS YEAR QUESTIONS WITH HIGH YIELD TOPICS ALCOHOL CAFFEINE NICOTINE COCAINE SUBSTANCE ABUSE DISORDERS NEET AIIMS PG PREPARATION

1. Substance abuse disorders
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2. Substance use continuum
• Experimental use
• Recreational use
• Dependance
• Harmful use
• Abuse
• Intoxication
• Transient condition d/t excessive intake
• Withdrawal TONY SCARIA 2010
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3. Dependance
• Presence of need for increased dosage and withdrawal symptoms occur on
absence of drug
• Main criteria to decide dependence are Tolerance & withdrawal symptoms.
• 3 out of 6 in past 1 year should be there for dependence from the list:-
• Tolerance
• Withdrawal symptoms
• Craving
• Compulsion
• Taking despite harm
• Prioritization. (Lack of alternate pleasure)
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4. Dependance
Physiological
• Tolerance
• Withdrawal
• Tobacco
• Alcohol
• BZD
Psychological
• Craving
• Inability to stop
• Taking substance @ social life
• Cannabis
• Cocaine
• Amphetamine
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5. Dependance
• Control lost
• Craving
• Tolerance
• Withdrawal
• Salience
• Harmful use
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6. TONY SCARIA 2010
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7. Psychological dependence Physical dependence
• First to appear
• Emotional distress if drug is stopped
• Accompanies or follows psychological dependence
• Physical symptoms if drug is withdrawn
Only psychological (no
physical dependence )
• Cannabis /marijuana
• Cocaine (strong)
• Drugs not causing
clinically significant
withdrawal symptoms
• No suicidal tendency as
there is no or mild
withdrawal symptoms
Minimal physical
dependence
• LSD (nil)
• Volatile solvents
• Phencyclidine
Both physical &
psychological
• Opiods (maximum)
• Alcohol ‘
• Amphetamine
• Barbiturates
• Nicotine
• Physical symptoms 
withdrawal symptoms
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8. Harmful use
• Excessive intake
• Causes harm (physical & mental health )
• But criteria for dependence is not met
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9. Abuse
• Pattern of use which leads to 1 or more of the following
• Failure to fulfil obligations at work school or home
• Use In situations physically hazardous (while driving)
• Legal problems
• Social or inter personal
• Abuse is when any substance use is associated with – legal, social or
physical or psychological problem. Cannabis cause max. no of
psychological problems i.e. why most common drug of abuse is
cannabis. TONY SCARIA 2010
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10. Teetotaller
Not at all using alcohol or smoking (or any substance of abuse)
Gate way drug
Nicotine
Substance first used or tried by most of them
Newer gate way drug
Cannabis
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11. Mc psychotropic substance used Caffeine
Mc psychotropic substance abused Nicotine
Mc illegal psychotropic substance abused Cannabis
Mc psychotropic substance causing dependency Alcohol
Mc nonpsychotropic substance abused NSAIDs
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12. Bio psycho social model to explain substance
use disorder
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13. Brain reward pathway in substance abuse
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14. NT involved
• Opiods
• Catecholamines
• GABA
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15. TONY SCARIA 2010
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16. TONY SCARIA 2010
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17. Substance abuse pathogenesis
• Dynorphin dopamine disinhibition (DDD)
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18. TONY SCARIA 2010
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19. Alcohol
CNS depressant
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20. Metabolism of alcohol
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21. Principle behind breath analyser
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22. TONY SCARIA 2010
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23. Reverse tolerance
• sensitization
• Intoxicating effects are seen progressively with lower dosages
• phenomenon of a reversal of the side-effects from a drug, the
reduction of insensitivity caused after drug tolerance has been
established, or, in some cases, an increase in specific effects of a
single drug existing alongside a tolerance to other effects of the same
substance.
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24. Causes of reverse tolerance
• use of additional medication or
• amphetamines and SSRIs
• abstinence from a drug for a period of time, known as a drug holiday.
• when the liver of the patient is damage and can not detoxify the
alcohol taken.
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25. Mellanby effect
• Intoxicating effects of alcohol are
greater at a given blood alcohol
concentration
• When it is increasing rather than BAC is
falling
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26. TONY SCARIA 2010
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27. Blood levels Symptoms
20 - 30 • Slowness of motor performance and decreased thinking
• 30mg/dl legal limit for driving in india
30 – 80 • Worsening of motor performances
• Further decrease in thinking ability
80 - 200 • Incoordination
• Judgement errors
• Mood lability
200 - 300 • Nystagmus
• Slurring of speech
• Alcoholic blackout (anterograde amnesia seen during intoxication /unable to recall events
at this level)
>300 Impaired vital signs & possible death
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28. Black out
• Acute alcohol intoxication or pathological drinking (even little amount
of alcohol  highly symptomatic )
• Anterograde amnesia
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29. Alcohol withdrawal
• After 6- 8 hrs
• Tremouslessness (earliest & most common sign) COARSE TREMORS
• GI symptoms  N V
• Sympathetic autonomic hyperactivity
• Arousal anxiety sweating HTn mydriasis tachycardia
• After 12-24 hours
• Alcoholic hallucinosis
• Auditory hallucination
• Consciousness is normal
• After 24-48 hrs
• Alcohol withdrawal seizures
• > 1 seizure in a span of 3-6 hrs  CLUSTER SEIZURE
• After 48-72 hrs
• Delirium tremens  medical emergency
• Disturbances of consciousness /disorientation/COARSE TREMORS /autonomic hyperactivity
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30. Onset of Symptoms after last drink of alcohol
1 day • Withdrawal symptoms
• Rebound REM
2 days • GTCS
3 days • Delirium tremens
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31. Delirium tremens
• Most severe form
• >72 hrs after stopping
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32. Lilliputan hallucination in delirium tremens
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33. TONY SCARIA 2010
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34. Alcohol induced neurocognitive disorders
Wernickes korsakoff syndrome Marchiafava bignami disease
Wernickes
encephalopathy
Korsakoff psychosis • Vacuolation & degeneration of corpus
callsoum
• Diorientation /epilepsy /ataxia
/dysarthria /hallucination/spastic limb
paralysis
• Global confusion
• Opthalmoplegia
• Ataxia
• Amnesia with
confabulation
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35. Marchiafava bignami disease
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36. Wernicke’s encephalopathy
• May progress in weeks to korsakoffs
syndrome
• a/c neurological complication
• Global confusion
• Ophthalmoplegia
• Usually 6th CN >>3rd CN
• Horizontal nystagmus & palsy
• Ataxia
• Completely reversible with Rx
• Residual ataxia & horizontal nystagmus
persist
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37. Korsakoffs syndrome
• c/c neurological
• Retrograde amnesia
• Inability to recall old memories
• anterograde amnesia
• Inability to form new memories
• Anterograde>>retrograde
• Confabulations
• Making of false stories to fill memory
gaps
• Irreversible
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38. Pathophysiology
• Both korsakoff & wenickes encephalopathy
• Thiamine deficiency
• Neuropathological lesion
• Symmetrically & involve mammillary bodies
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39. Rx
• WE
• Parenteral thiamine
• KS
• Oral thiamine
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40. TONY SCARIA 2010
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41. Wernickes encephalopathy Korsakoffs psychosis
Acute & emergency condition c/c condition
Global confusion
Ophthalmoplegia
Ataxia
Amnesia (anterograde >> retrograde)
Confabulation
Petechial haemorrhages in mammillary body &
peraqueductal grey matter
anterior thalamic nuclei
Medial mammillary nuclei
Rx  IV thiamine Rx  oral thiamine
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42. TONY SCARIA 2010
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43. Marchiafava bignami disease
• Long term alcohol use
• Demyelination & vacoulation of corpus callosum, optic tracts &
cerebellar peduncles
• Epilepsy ataxia dysarthria
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44. Screening test  CAGE
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45. • CAGE
• =/> 2 in of the above qstns  alcohol use disorder
• AUDIT (alcohol use disorders identification test)
• SADQ (severity of alcohol dependence questionnaire )
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46. Widmarks formula
• Widmark’s formula-
• A = P.R.C.,
• A= wt of alcohol in gms in body,
• P= body wt in kg,
• C= conc. of alcohol in blood in gm/kg,
• R= constant (0.6 for men, 0.5 for women).
• For Urine, formula is-
• A = ¾ P.R.Q,
• where Q is the conc. of alcohol in urine in mg/kg.TONY SCARIA 2010
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47. Diagnostic markers
• Blood alcohol concentration
• Using breath analyser  WIDMARKS FORMULA
• carbohydrate deficient transferrin (CDT)
• Most sensitive & specific
• Elevated in heavy drinking
• Gamma glutamyl transferase (GGT)
• Elevated in drinking
• CDT & GGT
• Return to normal with in days of stopping drinking
• MCV
• Elevated in alcoholis
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48. TONY SCARIA 2010
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49. Mc evans sign
• Used to differentiate alcoholic from other comatose patients
• On stimulation of alcoholic
• Pupils dilate initially  later return to normal size
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50. Rx
• Detoxification
• For 7 – 14 days
• BZD  DOC
• Chlordiazepoxide ***
• Carbamazepine
• Maintenance of abstinence
• Pharmacological
• Deterrent agents
• Anticraving agents
• Non pharmacological
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51. Deterrent agents
• Disulfiram ***
• Metronidazole
• Calcium carbimide
• Irreversible inhibitor of aldehyde dehydrogenase
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52. disulfiram like reactions
• Metronidazole
• Greisofulvin
• Nitrofurantoin
• Glipizide
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53. Disulfiram  elevated level of acetaldehyde
unpleasant signs & symptoms  disulfiram
ethanol reaction
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54. TONY SCARIA 2010
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55. Anticraving agents
• NAltrexone
• Acamprosate
• Baclofen
• Fluoxetine
• Decreases craving
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56. Nonpharmacological methods
• Cognitive therapy
• Motivational enhancement therapy
• Relapse model
• Cognitive therapy
• Alcoholic anonymous
• Self help group which follows 12 steps to quit alcoholism
• Include patients who have recovered / current alcoholics/volunteers
• Family therapy
• Group therapy TONY SCARIA 2010
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57. Opium
• Heroin
• Most commonly used opiod
• Smack/brown sugar
• Can be taken
• orally /snorted intranasally / IV /SC
• Intravenous abusers move from peripheral V to central V  MAINLINING
• SC abuse skin popping
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62. Mu receptor
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71. Symptoms of intoxication
• Intense euphoria  period of sedation (nodding off)
• Pinpoint pupil
• Hypotension
• Bradycardia
• Histamine release itching
• Respiratory depression
• Cyanosis
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73. Withdrawal
• Sudden stopping of opiods
• Intake of opiod antagonist  naltrexone
• sudden stoppage of noradrenaline  rebound noradrenaline
hyperactivity
• Th4 clonidine (a2 adrenergic receptor agonist )  used in Rx of withdrawal
symptoms
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74. Opiate withdrawal FLU LIKE SYNDROME
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75. Piloerection  cold turkey
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78. Overdose Rx
• Naloxone
• Short acting opiod antagonist
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79. Rx
• Detoxification
• Maintenance Rx
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80. Detoxification
• Substitute opiod with longer acting opiod
• Methadone
• Buprenorphine  produces ceiling effect
• Proxyvon- dextro propoxy phene
• Clonidine is used as a adjunct to decrease withdrawal symptoms
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81. Maintenance rx
• Naloxone  short acting  not preferred
• T1/2 = ½ hr
• Naltrexone  long acting
• T1/2 = 96 hrs
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82. Opiods
Rx of opioid over dose Rx of opiod dependence
Rx with opioid
antagonist to
overcome resp
depression
• IV naloxone followed by oral
naloxone
• IV nalmefene (may also be used)
Detoxification • Substitution with
long acting agonist
Methadone
• Substitution of
partial agonist
Buprenorphin
e
• Substitution by α2
agonist
Clonidine
Or naltrexone
+ clonidine
Maintenance
therpay
• Methadone
• LAAM
LAAM( levo alpha acetyl methadol ) not used
nowadays d/t toxicity(prolonged QT interval)
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83. Amphetamine
• CNS stimulant
• It acts on NE release in brain along with an action of release of
dopamine & serotonin
Acute Cardiovascular Tachycardia /HTN /cardiac failure/ cardiovascular
shock
CNS Euphoria seizures hyperpyrexia tremors ataxia
pupillary dilation
Neuropsychiatric Anxiety panic insomnia
Paranoid hallucinatory
syndrome
• Mimimcs paranoid schizophrenia
amphetamine psychosis
• Delsuion of persecution
• Auditory or visual hallucination in setting of
clear consciousness
Chronic • Severe & compulsive craving for drug
• Tactile hallucination
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84. Amphetamine
• No withdrawal symptoms
• Rx
• No medication needed
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85. Cannabis
• Derived from hemp plant cannabis sativa
• Most commonly used illegal drug in the world & india
• Active ingredient
• d-9 tetrahydrocannabinol (THC)
• Smoked / chewed
• Poor water solubility cant be given IV
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86. Cannabis indica= Indian hemp= Hashish =
Marijuana
• 1. Bhang=Siddhi=Subji-
• dried leaves and fruit shoots, has 15% of active pple
• 2. Majoon-
• sweet prepared from bhang
• 3. Ganja=pot=grass=marihuana-
• flower tops of female plant, used for smoking in cigarettes,
has 15-25% of active pple
• 4. Charas=Hashish=dope=shit-
• Resinous exudate from leaves and stems of the plant, mixed
with tobacco in a pipe or hukka, has 25-40% of active pple.
• 5. hash oil
• Lipid soluble plant extract
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87. Part of cannabis plant used
Bhang Dried leaves & fruit shoots
Majoon sweet prepared from bhang
Ganja Dried flowering tops
Charas (hashish) Resinous exudates from leaves or stem
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88. Bhang
Majoon Ganja
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89. Charas  dried resinous exudate
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90. Cannabis intoxication
• Red eye
• Dry mouth
• Synesthesia
• Stimulation of one sensory modality cause
sensation in another modality
• Increased appetite
• Depersonalization
• Derealization
• Bad trip
• Restlessness fear anxiety similar to panic
attack
• Also seen in hallucinogen
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91. TONY SCARIA 2010
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92. Cannabis related disorders
• Flash back phenomenon
• Recurrence of experience of cannabis use even in absence of current use
• Also seen in LSD /psilocybin/ psilocin
• d/t high fat solubility  stored in fat vesicle mobilised from fat vesicle later
flashback
• Run amok-
• the person may psychic disturbance marked by a period of disturbance
followed by violent attempts to kill people (impulse to murder).
• Hashish insanity /hemp insanity
• the victim may become insane
• show hallucinations, delusion of persecution.
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93. Cannabis related disorders (ctd)
• Amotivational syndrome
• Unwillingness to perform any task whether
at school or work
• Uninterested lethargic apathetic
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94. Cannabis
• Caused only mild dependence
• No Rx needed
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95. Hallucinogens /psychedelic drugs
• Lysergic acid diethylamide (LSD)
• King of psychedelic
• Phencyclidine => angel dust
• a/c schizophrenic reaction
• Dissociative anaesthesia
• Psilocybin
• Mescaline
• Ecstasy = ‘rave drug’.
• chemical name is methylene dioxy methamphetamine => MDMA.
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96. Symptoms of intoxication of LSD due to 5HT
• Pupillary dilation
• Derealisation
• Depersonalisation
• Synesthesia
• Illusions
• Hallucinations
• Bad trip
• Flash back phenomenon Rx with BZDTONY SCARIA 2010
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97. CF of LSD d/t increased 5HT
Perceptual disturbance in a clear consciousness • Depersonalisation
• Derealisation
• Synesthesia (colours are heard & sound is felt)
• Illusion
• Hallucination
Autonomic hyperreactivity( d/t central sympathetic
stimulation)
• Mydriasis
• Tachycardia
• Sweating
• Tremors
Others Anxiety
Panic
Depression
Confusion
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98. • Rx of choice for hallucinogen intoxication
• Diazepam
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99. Withdrawal symptoms
• No dependence for hallucinogens  no withdrawal
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100. Cocaine
• CNS stimulant
• Erythroxylum coca
• Reuptake blocker of all amines
• Increased concentration of dopamine
• Increase NEsympathomimetic effect
• Higher concentration block Na
• used as a LA in eye nose & throat sx
• snorting / smoking / IV injection
Sigmeund freud introduced cocaine and he was addicted to it
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101. Reuptake blocker of all amines
Increased concentration of dopamine
Higher concentration block Na
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102. TONY SCARIA 2010
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103. • Free basing
• Smoking cocaine
• Mixing street cocaine with free base (chemically extracted pure cocaine)
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104. Usually inhaled snorting vasoconstriction
• Septal perforation
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105. • jet black pigmentation tongue in long term users
• Cocaine + heroin = speed balls
• Crack = free base form of cocaine
• Even Single use  intensive craving
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106. Manifestation
• Paranoid ideas
• Auditory & visual hallucination
• Tactile hallucination
• Arterial blockade ischemic myocardial injury
• Vasoconstriction  HTn
• Seizures
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107. CF of cocaine
Acute Sympathetic hyper reactivity • Tachycardia
• Mydriasis
• Sweating
• N & V
Hypomanaic state • Increased psychomotor activity
• Grandiosity
• Elation
• Hypervigilance
Chronic Psychotic episodes • Persecutory delusions
• tactile hallucination  magnan symptom
Black pigmentation of tongue & teethTONY SCARIA 2010
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108. Cocaine
• “Touch (tactile) hallucination
• Magnus symptom (cocaine bugs or Tactile hallucination)
• This may take the form of small animals crawling over the body, so
called formication. This is not uncommon in acute organic states. In
cocaine psychosis this type of hallucination commonly occurs
together with delusions of persecution and is known as the ‘cocaine
bug’.”
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109. Cocaine induced psychotic disorder
• Intravenous users & crack users
• Similar to paranoid schizophrenia
• Paranoid delusions
• auditory hallucination
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110. • Withdrawal symptoms are mild
• Fatigue
• Dysphoria
• Disturbed sleep
• Cognitive behaviour therapy
• Group therapy
• Narcotic anonymous
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111. Amphetamines
• Increase performance in academics  euphoria
• Used in ADHD /narcolepsy
• Long term use psychosis
• Paranoid delusions (delusion of persecution)
• Auditory hallucination
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112. Tobacco
• Most commonly abused substance in india
• Smoking chewing applying and gargling
• Active ingredient nicotine
• Stimulant action
• Improves attention learning reaction time and problem solving ability
• Nicotine + CO  cardiovascular ds
• Withdrawal symptoms
• Appear with in hours of smoking
• Peak in 24 -48 hrs
• Bradycardia /craving /irritability /anxiety /paradoxical trouble sleeping
/increased appetite / weight gain
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113. • Rx of tobacco withdrawal
• Nicotine replacement therapy
• Nicotine gums / nicotine lozenges /nicotine inhalers/nicotine spray
• Relieve withdrawal symptoms by substituting nicotine tobacco
• Medications
• Buprepion
• Clonidine & nortryptilline
• Varenicline
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114. TONY SCARIA 2010
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115. Substance characteristic
Cocaine • Magnus symptom (cocaine bugs or Tactile hallucination)
• Delusion of persecution
Cannabis • Synesthesia
• Run Amok
• Amotivation syndrome
• Flash backs
Alcohol • Mc-Evan’s Sign
• Morbid jealousy
LSD • Synesthesia
• Bad trips
• Flash backs
Amphetamine Paranoid hallucinatory syndrome (like paranoid schizophrenia)
Phencyclidine (Angel dust) Dissociative Anaesthesia
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116. • Drugs with mild dependence Cannabis
• Drugs with no dependence  LSD ,Amphetamine
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117. Substances associated with seizures
• Cocaine >>> amphetamines
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