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Ministry of Health of Ukraine Bukovynian State Medical University




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Ministry of Health of Ukraine

Bukovynian State Medical University


“Approved”

on the methodical meeting

of the Department of neurology, psychiatry

and medical psychology nm. S.M.Savenko

“____” ___________ 2009 (Report № __).

Chief of the Department

_______________________

Professor V.M. Pashkovsky


Methodical INSTRUCTION

for 4-th year students of medical faculty №2

(the speciality “medical affair”)

for independent work during preparing to practical class


Theme 18: Mental and behavioural disorders due to psychoactive substance use


MODULE 2. SPECIAL (NOSOLOGY) PSYCHIATRY


Topical module 4. Mental and behavioural disoders due to

psychoactive substances use.


Сhernivtsi, 2009

Theme 6: Mental and behavioural disorders due to psychoactive substance use

Module2. Special (nosology) psychiatry

Topical Module 4. Mental and behavioural disorders due to psychoactive substance use


1. Actuality Aim

Psychoactive (psychotropic) substance is any substance which after absorption has influence on mental processes both cognitive and affective.

  1. stimulative

  2. suppressive

  3. hallucinogenic

To the student, future doctor, which begins to obtain knowledge, practical skills and abilities in clinics, it is necessary to master the basic forms of mental and behavioural disorders due to psychoactive substance use, able them to diagnose, to give urgent help at the extreme states.

^ 2. EDUCATIONAL PURPOSE

2.1. To know:

  • Mental and behavioural disorders due to psychoactive substance use.

  • Mental and behavioural disorders due to use of opioids.

  • Mental and behavioural disorders due to use of cannabinoids

  • Mental and behavioural disorders due to use of sedatives or hypnotics.

  • Mental and behavioural disorders due to use of cocaine.

  • Mental and behavioural disorders due to use of other stimulants, including caffeine.

  • Mental and behavioural disorders due to use of hallucinogens.

  • Mental and behavioural disorders due to use of tobacco.

  • Mental and behavioural disorders due to use of volatile solvents.

    1. Able:

  • Describe acute intoxication due to psychoactive substance use.

  • Describe harmful use.

  • Describe dependence syndrome.

  • Describe withdrawal state.

  • Describe psychic disorders due to psychoactive substance use.




    1. To capture practical skills:

  • to collect subjective and objective anamnesis;

  • to find out beginning of psychical disease;

  • to describe symptoms of alcoholic psychosis;

  • to organize retaining of patient at excitation for introduction of medical

preparations;

  • to find out a suicidal conduct for patients.


^ 3. EDUCATE PURPOSE.

On practical tutorial a teacher comes into notice of students on practical activity of doctor, improvement of own qualities, necessities, interests and ideals. Consciousness of man not only represents reality but also creates it. A doctor not only finds out ту or other pathology (diagnostics), he treats a patient, deprives him sufferings. Must a doctor be peculiar independence in working out problems, self-control and self-possession in the moments of unexpected complications, unforeseen obstacles.


^ 4. INTERSUBJECT INTEGRATION (base level of preparation).


Names of previous disciplines

Skills are got

1. Anatomy.


2. Physiology.


3. General psychology.



  1. To know an anatomy and topographical anatomy of cerebrum.

  2. To know the basic cork functions of cerebrum. Able to define the type of higher nervous activity.

  3. To know psychology of will and attention.


^ 5. PREPARATION STAGE.

A teacher acquaints students with the theme of practical lesson. Determines its actuality for practical activity of doctor of any profession. Motivation for subsequent purposeful educational activity of students is formed. A teacher acquaints students with concrete aims and plan of practical lesson.


^ 5.1. CONTENTS OF THEME.

    • Drug abuse has a wide range of definitions related to taking a psychoactive drug or performance enhancing drug for a non-therapeutic or non-medical effect.

    • Some of the most commonly abused drugs include amphetamines, barbiturates, hallucinogens, cocaine, methaqualone, opium alkaloids, and minor tranquilizers.

    • A transient condition following the administration of psychoactive substance resulting in disturbances in level of consciousness, cognition, perception, affect or behaviour, or other psychophysiological functions and responses

F11.x Mental Disorders Due to Use of Opioids

  • Morphine, heroin (diacetylmorphine), codeine, pethidine, methadone

  • Heroin:

    • dependence develops within two weeks of daily use

    • overdose may lead to death

    • withdrawal symptoms are extremely unpleasant

    • needle-sharing represents a serious risk of transmission of HIV and hepatitis B + C viruses

    • treatment of the withdrawal state – buprenorphine, benzodiazepines, spasmolytics; in serious cases of dependence heroin is replaced by methadone

F12.x Mental Disorders Due to Use of Cannabinoids

  • Marijuana (marihuana) is a colloquial term for dried leaves and flowers of cannabis plant (Cannabis sativa L.)

  • ?9-tetrahydrocannabinol (?9-THC) is responsible for the psychoactive properties of the cannabis plant

  • Complex physiological functions of the cannabinoid system: motor coordination, memory procession, control of appetite, pain modulation and neuroprotection




  • Summary of adverse effects:

    • acute: anxiety, panic, impaired attention, memory, reaction time and psychomotor performance and coordination, increased risk of road accident, and increased risk of psychotic symptoms among vulnerable persons

    • chronic: chronic bronchitidis, a cannabis dependence syndrome, subtle impairments of attention, short-term memory and ability to organize and integrate complex information

F12.x Mental Disorders Due to Use of Cannabinoids

Effect of cannabinoids on central nervous system:

  • Euphoria, enhancement of sensory perception, tachycardia, antinociception, difficulties in concentration, impairment of memory

  • Cannabis use may exacerbate symptoms of schizophrenia and may precipitate disorders in persons who are vulnerable to developing psychosis; heavy cannabis use may increase depressive symptoms among some users

  • Tolerance develops; the relatively long half-life and complex metabolism of cannabis may result in a low intense withdrawal syndrome

  • Marijuana use tends to impair executive function in the brain, e.g. higher risk for all types of injuries is associated with cannabis use

  • Cannabis abuse and dependence were highly associated with increasing risks of other substance dependence

F14.x,15.x Mental Disorders Due to Use of Stimulants

  • Cocaine, amphetamine, metamphetamine (pervitine), phenmetrazine, methyphenidate, MDMA (ecstasy, methylenedioxymetamphetamine)

  • Positive mood, activity, planning, diminished need of sleep

  • Tachycardia, arrhythmia, hypertension, hyperthermia, intracerebral haemorrhage

  • Withdrawal symptoms: severe craving, depression, decreased energy, fatigue, sleep disturbance

  • Prolonged use can trigger paranoid psychoses, impulsivity, aggressivity, irritability, suspiciousness and anxiety states

F16.x Mental Disorders Due to Use of Hallucinogens

  • Lysergid acid diethylamide (LSD), psilocybin, mescaline, phencyclidine

  • Acute intoxication: distorted perception (optic hallucinations and illusions); unpredictable and dangerous behaviour

  • Withdrawal syndrome has not been described

For most addicts, their problem is a mixture of both physical and psychological aspects. There are some instances when it's difficult to distinguish between the two.

The stimulants cocaine and amphetamine are classic examples of this - people coming down after using these drugs feel very low and lack energy. When they take cocaine, they feel very high and use up lots of energy. Their feelings afterwards could be partly because of feeling tired and adjusting to a normal mood again, but there are other theories that suggest these feelings are because the body is re-establishing its chemical balance.

The receptors in these two organ systems mediate both the beneficial effects, and the undesirable side effects. There are a number of broad classes of opioids:

  • natural opiates, alkaloids contained in the resin of the opium poppy including morphine, codeine and thebaine, but not papaverine and noscapine which have a different mechanism of action;

  • semi-synthetic opiates, created from the natural opioids, such as hydromorphone, hydrocodone, oxycodone, oxymorphone, desomorphine, diacetylmorphine (Heroin), nicomorphine, dipropanoylmorphine, benzylmorphine and ethylmorphine;

  • fully synthetic opioids, such as fentanyl, pethidine, methadone, tramadol and propoxyphene;

  • endogenous opioid peptides, produced naturally in the body, such as endorphins, enkephalins, dynorphins, and endomorphins.

Although the term opiate is often used as a synonym for opioid, it is more properly limited to the natural opium alkaloids and the semi-synthetics derived from them.

Some minor opium alkaloids and various substances with opioid action are also found elsewhere in nature, including alkaloids present in the Kratom, Corydalis, and Salvia plants and some species of poppy aside from ^ Papaver somniferum, and there are strains which produce copious amounts of thebaine, an important raw material for making many semi-synthetic and synthetic opioids. Of all of the more than 120 poppy species, only two produce morphine.

It has been discovered that the human body, as well as those of some other animals, naturally produce small amounts of morphine and codeine and possibly some of their simpler derivatives like heroin and dihydromorphine, in addition to the well known endogenous opioids. Some bacteria are capable of producing some semi-synthetic opioids such as hydromorphone and hydrocodone when living in a solution containing morphine or codeine respectively.


^ 5.2. QUESTIONS OF CONTROLS:

  1. Biological and psychological mechanisms of addiction.

  2. Mental and behavioural disorders due to psychoactive substance use.

  3. Mental and behavioural disorders due to use of opioids.

  4. Mental and behavioural disorders due to use of cannabinoids

  5. Mental and behavioural disorders due to use of sedatives or hypnotics.

  6. Mental and behavioural disorders due to use of cocaine.

  7. Mental and behavioural disorders due to use of other stimulants, including caffeine.

  8. Mental and behavioural disorders due to use of hallucinogens.

  9. Mental and behavioural disorders due to use of tobacco.

  10. Mental and behavioural disorders due to use of volatile solvents.


^ 6. MATERIALS OF METHODICAL PROVIDING OF EMPLOYMENT (MATERIALS OF CONTROL OF BASE (INITIAL LEVEL) PREPARATION OF STUDENTS):

6.1. Additions. Facilities for control:

Questions of controls:

  1. Biological and psychological mechanisms of addiction.

  2. Mental and behavioural disorders due to psychoactive substance use.

  3. Mental and behavioural disorders due to use of opioids.

  4. Mental and behavioural disorders due to use of cannabinoids

  5. Mental and behavioural disorders due to use of sedatives or hypnotics.

  6. Mental and behavioural disorders due to use of cocaine.

  7. Mental and behavioural disorders due to use of other stimulants, including caffeine.

  8. Mental and behavioural disorders due to use of hallucinogens.

  9. Mental and behavioural disorders due to use of tobacco.

  10. Mental and behavioural disorders due to use of volatile solvents.


Tests and tasks:

1. A male patient, 37 years old, became too cheerful for no particular rea-son, he has a subjective feeling of high creative abilities, enthusiasm, elation and increased productivity, in spite of manifest disability to concentrate (im­paired attention); his speed of thinking processes is too high. He is uncritical to his state, and finds it normal.

^ Name the syndrome:

A. Manic (non-psychotic) syndrome

B. Syndrome of dysphoria

C. Hypomanic (non-psychotic) syndrome

D. Obsessive syndrome

E. Depersonalization syndrome


2. A male patient 22 years old, complained of the decrease of physical and mental productivity, as well as increased fatigue, weakness, increased need for rest after easy work. He became irritable, impatient and less toler­ate towards people, it is difficult for him to wait even for a short time; he often has headache, sweats easily, feels prickling sensations in the heart re-gion when worries.

^ Name the syndrome:

A. Depressive syndrome

B. Hypochondriac syndrome

C. Asthenic syndrome

D. Paranoia syndrome

E. Obsessive syndrome


3. After a head injury that the patient had 5 years ago he developed affec-tive disturbances: suddenly and for no serious reason he feels anger. His mood during these periods is characterised by tension, depression combined with anger or even rage, high irritability with a tendency to aggressive actions.

^ Name the syndrome:

A. Phobic syndrome

B. Dysphoric syndrome

C. Depressive syndrome

D. Manic syndrome

E. Asthenic syndrome


4. At the inpatient department of a psychiatric hospital a female patient is passive, inert and is never involved in any activities on her own accord. Does some primitive work (makes cardboard boxes), but constantly needs induce­ment and activation. She is completely indifferent to the situation in the de­partment, to the members of her family and her own situation, does not care about being discharged from the hospital or left at the department for a longer time.

^ Name the probable syndrome:

A. Asthenic syndrome

B. Apathetic and abulic syndrome

C. Organic brain syndrome

D. Encephalopathic syndrome

E. Depressive syndrome


5. In a month after having flu the patient began to complain of persistent headaches, sleep and eating disorders; other complaints were irritability for no serious reason and emotional instability. Gets exhausted quickly, feels tired even after 20 or 30 minutes of conversation with the psychiatrist. Practically isn't able to read books, because can not concentrate, is easily distracted to other subjects. Is critical to the state of his health, understands that is ill and needs treatment.

^ Name the probable syndrome:

A. Apathetic syndrome

B. Neurotic syndrome

C. Hysterical syndrome

D. Asthenic syndrome

E. Organic syndrome


6. The observed patient's movements are retarded, she doesn't react to the attempts to contact her, answers no questions. Sometimes she spontane­ously stays in strange postures. It is possible to set (form) her body and limbs into different positions artificially. For instance, if the psychiatrist lifts her arm or leg, so that she remains standing on the other leg, the patient can stay in such an inconvenient position for quite a long time.

^ Name the probable syndrome:

A. Depressive stupor

B. Apathetic stupor

C. Psychogenic stupor

D. Catatonic stupor

E. Neurotic stupor


7. At the psychiatric department the patient monotonously walks along a corridor wall, doing a certain number of paces. Then he stops, makes a decisive gesture with his hand, calls out a senseless phrase and sharply turning round walks the same number of paces along the corridor and again re­peats the same gesture and phrase. He repeats this type of behavior several times, and it is impossible to stop him because he shows resistance. Name the probable syndrome:

A. Catatonic syndrome

B. Manic syndrome

C. Hebephrenic syndrome

D. Heboid syndrome

E. Hysterical syndrome

8. At the psychiatric department the patient has no motivation, no incen­tive, and no wishes. She doesn't speak to anybody, spends all her time in bed, fencing herself from others with a blanket. Eats only if she is led to the table under compulsion and fed with a spoon. Often urinates in bed and has no initiative to ask someone to change her bedclothes.

^ Name the probable syndrome:

A. Organic syndrome

B. Apathetic-abulic syndrome

C. Asthenic syndrome

D. Depressive syndrome

E. Catatonic syndrome


9. A male teenager (15 years old) with a normal level of intelligence and no conduct disorders before the age of 14, is characterized by rudeness, neg­ativism, perverted emotional reactions and drives with antisocial tendencies. His attitude to others, especially members of his family, is often cruel, he seems to enjoy hurting people. At school he sometimes bites or pinches girls painfully, and says that he does this because he "likes them." He often of­fends and beats his grandmother and mother, when they "irritate" him.

^ Name the probable syndrome:

A. Hebephrenic syndrome

B. Hyperkinetic syndrome

C. "Wildness"

D. Alienation

E. Heboid syndrome


10. A male patient, 51 years old, is sure that he has a serious incurable illness. He presents several physical complaints (unpleasant feelings in his chest and stomach, constipation, etc.) and regularly consults all the medical specialists in the outpatient department. He doesn't believe them, when they assure him that the results of investigations are normal. The patient is sure that a horrible diagnosis is being concealed from him. Demands more addi­tional investigations and a professor's consultation.

^ Name the probable syndrome:

A. Hysterical syndrome

B. Hypochondriac syndrome

C. Depressive syndrome

D. Paranoia

E. Overvalued ideas


11. The patient consulted a psychiatrist with a complaint of being what he called "too pedantic." He told the doctor that he simply couldn't begin doing any work without putting all his instruments symmetrically. "Recently I had to repair my car, but was putting the wrenches and screw drivers sym metrically instead." Conflicts often occurred in the family about trifles: the patient insisted that all the things had to lie symmetrically. Otherwise he felt discomfort and nervous tension.

^ What is the probable syndromal diagnosis?

A. Depressive syndrome

B. Obsessive-compulsive syndrome

C. Asthenic syndrome

D. Cotard's syndrome

E. Dysmorphomanic syndrome


12. A 17-year-old girl, after her mother's serious illness became anxious and irritable. Waited impatiently for the classes to be over, then ran home as fast as possible, imagining the horrible picture of her mother's death. Her heart palpitated, she felt heaviness in the stomach and trembled all over. The girl got calm again only when she saw that her mother was well.

^ What is the syndromal diagnosis?

A. Cotard's syndrome

B. Asthenic syndrome

C. Depressive syndrome

D. Obsessive-phobic syndrome

E. Syndrome of overvalued ideas


13. The patient had consulted the psychiatrist several times. During this visit the complaints were as follows: the state occurred acutely, she felt that her body had changed "as if it was not hers", her voice became "somehow different." As she stood at night near the window, she suddenly saw her body as if from aside, and "felt the experiences and sensations of both bodies si­multaneously." The patient told the psychiatrist that all night she seamed to "live double life."

^ What is the syndromal diagnosis?

A. Apathetic syndrome

B. Derealisation syndrome

C. Depersonalisation syndrome

D. Paraphrenic syndrome

E. Visual hallucinosis syndrome


14. At the psychiatric department the patient is lively and cheerful, her eyes shine, and her mood is elevated almost all the time. Her clothes look rather extraordinary: the slippers are decorated with bows and a lot of cot­ton wool balls are sewn all over her jersey. Her hair is made into a strange coiffure, her lips are painted with bright lipstick. The patient is excessively energetic and restless, she intrudes into every activity going on at the depart­ment, dances, sings, makes sexually advances to male visitors of the depart­ment. Seems never to get tired, sleeps only for 3 or 4 hours at night, her appe­tite is increased. Speaks very quickly, with no pauses, can't keep one line of conversation, and constantly "skips" from one topic to another.

^ Name the syndromal diagnosis.

A. Catatonic excitation

B. Manic syndrome

C. Hebephrenic excitation

D. Hyperbulic syndrome

E. Hysterical syndrome


15. The patient is excited and restless, incessantly walks around the room, wrings her hands, weeps and groans. There is an expression of fear on her face. Asks the people around her to save her family, which is sure to be in great danger. Promises to give the people much money for rescuing her rela­tions. The personnel can't dissuade her: the patient stays extremely anxious. Couldn't sleep for two nights, and hasn't eaten any food for three days, say­ing, "How can I eat, when my dear ones are dying?" Tried to commit sui­cide.

Name the syndromal diagnosis.

A. Hypochondriac syndrome

B. Anxiety and depressive syndrome

C. Agitated depression syndrome

D. Masked depression syndrome

E. Catatonic syndrome


^ 8. RECOMMENDED LITERATURE IS:

8.1. Basic:

  1. Clinical Psychiatry from Synopsis of Psychiatry by H.I.Kaplan, B.J.Sadock. – New York: Williams @ Wilkins. – 1997.

  2. Psychiatry. Course of lectures. – Odessa: The Odessa State Medical University. – 2005. – 336 p.

  3. Lectures.

  4. Internet resource.

8.2. Additional:

  1. Морозов Т.В., Шумский Н.Г. Введение в клиническую психиатрию. – Н.Новгород: Изд-во НГМА, 1998.

  2. Попов Ю.В., Вид В.Д. Современная клиническая психиатрия. – М., 1997.

  3. Сонник Г.Т. Психіатрія: Підручник / Г.Т.Сонник, О.К.Напрєєнко, А.М.Скрипніков. – К.: Здоров’я, 2006.     


Prepared by assistant S.D.Savka

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