PTSD- What to do with nightmares?

Nightmares associated with PTSD are a common occurrence in patients whom I see in my clinical and medico- legal practice as a Consultant Psychiatrist. And Prazosin is used as a medication to treat these. Evidence from a recent systematic analysis, (abstract presented in the 20th European Congress of Psychiatry) confirms its efficacy. In addition to this, in my clinical experience it is important to address the trauma memories by psychotherapy so that the memories become ‘narrative’ in quality as opposed to being emotionally laden and this brings about resolution of nightmares. This can be achieved by EMDR, which allows for the procession of the memories to eventually give them this quality. A common debate is whether use of medication can interfere with therapy, but this systematic analysis and current opinion highlights that Prazosin may actually be helpful when doing trauma work in Psychotherapy.

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Ecstasy

Ecstasy has been around for a very long time. Chemically it is 3, 4- methylenedioxymethamphetamine- MDMA. As the name suggests, it is a methamphetamine compound. It is taken orally usually in a tablet or capsule form and the effects start within 30- 60 minutes. Pharmacologically, there is a huge efflux of Serotonin in the brain along with effects on the Dopamine and Noradrenaline sytems as well.The acute effects can often lead to Hyperthermia (raised body temperature) which is compounded by its use in warm, humid climates typically found in the dance clubs and this can be life threatening. The euphoria that is often reported after its use seems to be more related to the contexts of the environment i.e. whether being used in isolation or with club goers and club environment. This has been seen in studies as reported in the 1st International Conference of Psychoactive Drugs in Budapest in March 2012.

Intoxication with Ecstasy has been described as occurring in three stages (Koesters et al, 2002; Parrott and Lasky, 1998)- initial stage of disorientation, second stage of ‘spasmodic jerking and tingling’ and the final stage of increased sociability, increased mental clarity, a feeling of emotional warmth and feeling close to others. Given the context dependent effects, higher doses can give rise to frank euphoria. In toxic doses it can lead to dehydration, hyperthermia (both these can be life threatening in club environment), raised pulse, hypertension, liver failure and/or renal failure (Jonas and Graeme- Cook 2001; Lester et al 2000). There may be anxiety, agitation and even confusion.

The post dose recovery time often leads to depressed mood, irritability, anxiety, sleep impairment, asociability. People who are regular users can experience mid week depression and there are reports of aggression as well.

The chronic effects after regular heavy use can be damaging. Several studies have now indicated that the SERT (Sertraline Transporter) is reduced with chronic use which highlights the diminution of Serotonin in various regions of the brain. As the effects of Ecstasy are on the Frontal Cortex (the part of the brain responsible for planning and executive function), cognitive and memory deficits can be significant. Interestingly, for me working as a Consultant Psychiatrist in Addictions in Wales, what I learnt new from the conference is also that heavy regular use can be associated with Sleep Apnea (serotonin being an important chemical in maintaining lung function).

Whilst experimenting with the drug may be tempting but it can lead to long lasting damage if it becomes persistent or heavy or dependent use.

 

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Legal highs and Novel Psychoactive Substances (NPS)- Beyond Cocaine, Ecstasy and Amphetamines

The debate regarding the legislating evolving new drugs persists for Addiction Psychiatry. Whilst ‘Legal Highs’ (so called as they are not yet under legislation and illegal) keep growing, the issue of legislation needs to be carefully balanced by the understanding of scientific effects of these drugs.

The 1st International Conference on Novel Psychoactive Substances in Budapest, Hungary on 12- 13 March 2012 was a very useful conference which highlighted its theme of the rapidly changing world of ‘Legal Highs’. The biggest challenge for Addiction Psychiatry seems to be keeping pace with this rapid developments where newer drugs are coming out along with newer market evolution and the trends that are transgressing national and international borders- an impact of globalisation and the internet becoming a massive global market. Also, the epidemiology of these is not yet clear as the new drugs have been not around with us long enough. Fortunately though, EMCDDA is reporting that there are some prevalence studies coming up which may be reflecting the wide variation of use of these substances in different regions and countries. Other information reported in this conference, that is useful to me as a Private Psychiatrist in Wales, UK is that the Novel Psychoactive Substances are not probably the first preference of drug users and that stimulants- Amphetamines, Cocaine, MDMA & Ketamine remain drugs of preference. From the reported results, it seems that the Mephadrone might be on the decline. From Dr Paul Dargan’s findings, the other challenge that faces us in Addiction Psychiatry is that there are no systematic data on toxicology, the ICD coding takes a long time to code for new drugs and when faced with acute presentations which may be in A&Es, general medical wards, Psychiatry Wards or in Addiction services, the analytic confirmation is still not up to speed to be able to confirm or refute the drug in the body. Whilst most NPS seem to be falling under the categories of Piperazine, Cathinone and Synthetic Cannabinoids- variations in these poses clinical management challenges. Piperadole derivatives like DPMP and D2PM have been on the increase as highlighted in the conference and people after having used these have developed neuropsychiatric syndromes.

Similarly, the  marketing of these has changed a lot and the newer social networking sites have been used a lot for advertising. Another MixMag survey had highlighted that the number of online shops has increased exponentially and the number of head shops have gone up as well. What struck me as well is that the products being sold with the same brand name such as ‘Ivory Wave’ has been found to be having no standardization, therefore the person buying the same brand may never be assured of getting the same drug on repeat orders. And Methoxetamine (Ketamine derivative) is being branded as “Bladder Friendly”.

What effects do these have in the long run is a difficult question to answer at the moment and a collaborative effort by clinicians, researchers, policy makers, criminal justice systems and governments is needed to address this new epidemic!

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