Behavioral and Psychiatric Disorders Anxiety Disorders Mood Disorders Schizophrenia

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Behavioral and Psychiatric DisordersAnxiety
DisordersMood DisordersSchizophrenia

• Donald Falace, DMD
• Oral Diagnosis and Oral Medicine
• UK College of Dentistry

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Anxiety

• Emotional pain
• Feeling of impending disaster
• Psychological distress (often without a focus)
• State of apprehension that can be experienced
  with
• Internal psychological conflict
• Environmental stress (crowds)
• Disease state (mitral valve prolapse,
  hyperthyroidism)
• Drug induced (steroids, cocaine)
• Both emotional and physical symptoms
• May be experienced as a normal or abnormal
  response

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Acute Anxiety Universal experience from time to
time (normal)

• Big test coming up for which you are not prepared
• Giving local anesthetic injections to each other
  in your local anesthetic course
• Seeing your first patient
• Just received a letter notifying you of a tax
  audit
• Just got notice of an OSHA violation

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Chronic Anxiety (Beyond the normal experience of
anxiety)

• Classification of Anxiety Disorders
• Panic attacks
• Phobias
• Generalized anxiety disorder
• Post-traumatic stress disorder

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Panic Attacks

• Sudden, unexpected, overwhelming feeling of
  fear, pending doom, or terror also may be
  described as an extremely uncomfortable feeling
  or situation from which the individual wants to
  escape
• May be triggered or spontaneous
• Peaks in about 10 minutes
• Lasts 20 to 30 minutes
• Exaggerated sympathetic response
• Palpitations, tachycardia, chest pains
• Trembling, dizziness,
• Sweating, dyspnea
• Choking, numbness
• Accounts for 15 of patients seen by cardiologists

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Phobias

• An excessive and irrational fear of objects,
  situations or experiences that interferes with
  normal behavior
• Objects needles, spiders, snakes, elevators
• Situations heights, being among people, leaving
  home, being in a confined space
• Experiences public speaking, flying

heights
enclosures
snakes, spiders
needles
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Generalized Anxiety Disorder

• Persistent, diffuse form of anxiety that is
  frequently and persistently present and difficult
  to define a cause generalized unpleasant
  feeling accompanied by
• Muscle tension
• Sympathetic hyperactivity
• Apprehension
• No familial or genetic basis
• Better outcome than panic disorder
• Can lead to depression and substance abuse

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Post-Traumatic Stress Disorder

• Follows a traumatic event beyond the usual human
  experience
• Combat
• Holocaust
• Rape, physical abuse
• Witness to a murder
• A civilian disaster such as a hurricane, tornado,
  or earthquake
• Cardinal clinical features
• Hyperarousal (sympathetic symptoms)
• Flashbacks (replaying the event in their mind)
• Psychic numbing (flat affect)
• Intrusive symptoms (sudden feeling of fear,
  anger, etc)
• Onset at least 6 months after traumatic event and
  lasts longer than 3 months

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Treatment of Anxiety Disorders (Behavioral/Drug)

• Cognitive therapy
• Biofeedback
• Hypnosis
• Relaxation imaging
• Desensitization
• Flooding

• Short term Benzodiazepines
• alprazolam (Xanax)
• clonazepam (Klonopin)
• Long term
• tricyclic antidepressants
• selective serotonin reuptake inhibitors
• monoamine oxidase inhibitors
• beta-blockers

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Anxiety DisordersDental Management

• Be sensitive to the history and condition
• Establish effective communication
• Be open and honest
• Explain procedures and outcomes
• Answer questions
• Tell what you are going to do in order to make
  their experience as pain free and pleasant as
  possible
• Avoid phobic or anxiety triggers

• Anxiolysis/sedation
• Oral sedation caution if taking other sedative
  drugs may not need additional
• Triazolam (Halcion)
• Alprazolam (Xanax)
• Inhalational (N2O/O2)
• Parenteral sedation
• Midazolam (Versed)
• Effective local anesthetic
• Adequate post-op analgesia

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Drug Considerations

• Benzodiazepines
• Side effects sedation (drowsiness)
• Drug interactions potentiation of other sedative
  drugs such as opioids, barbiturates, alcohol
• TCAs
• Side effects sedation, dry mouth, orthostatic
  hypotension
• Drug interactions avoid excessive use of
  epinephrine limit to 2 carpules of 1100,000
  avoid use of levonordefrin (Neo-Cobefrin)
• MAOIs ok to use vasoconstrictors as usual
• Non-selective ß-blockers avoid excessive use of
  epinephrine limit to 2 carpules of 1100,000

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Mood Disorders

• Depression
• Major depression
• Bipolar Disorders
• Mood swings between mania and depression

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Major Depression

• 20-25 of women and 7-12 of men will have at
  least 1 major depressive episode in their
  lifetime
• More common in women than in men
• Depressed most of the time
• Decreased interest or pleasure in most activities
• Physical/oral neglect
• Weight gain or loss
• Insomnia or hypersomnia
• Episode may last 8 to 9 months if not treated
• Recurrences common
• Suicide common (70 of suicide victims have
  history of depression)

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Treatment of Depression

• Antidepressants
• Tricyclics (amitriptyline Elavil)
• Heterocyclics (maprotiline Ludiomil)
• Selective serotonin reuptake inhibitors (SSRIs)
  fluoxetine-Prozac paroxetine-Paxil
  sertraline-Zoloft citalopram-Celexa
• Serotonin and norepinephrine reuptake inhibitors
  (SNRIs) nefazodone-Serzone venlafaxine-Effexor
• Bupropion Wellbutrin
• Monoamine oxidase inhibitors (phenelzine Nardil)

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Mosbys GenRx Top 10Most prescribed drugs based
on sales volume
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Drug Considerations

• Antidepressants
• Side effects sedation, dry mouth, orthostatic
  hypotension
• Drug interactions
• avoid excessive use of epinephrine with
  tricyclics, heterocyclics, SNRIs, and bupropion
  limit to 2 carpules or less of 1100,000
• Additive effects with other sedative type drugs
• If the patient is taking multiple drugs with
  serotonin uptake blockade, be alert for signs and
  symptoms of serotonin syndrome

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Serotonin

• Serotonin plays a major role in the
  sleep-wakefulness cycle as well as the biology of
  mood, emotion, and other functions mediated by
  the limbic system.
• Involved in depression, euphoria, and anxiety.

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Serotonin Syndrome

• A potentially serious, drug-related complication
  that arises from the use of serotonergic agents
  or disease states that increase serotonin most
  likely seen with multidrug therapy
• Signs and symptoms
• Neuromuscular (myoclonus hyperreflexia muscle
  rigidity tremor)
• Autonomic (diaphoresis hyperthermia
  hypertension tachycardia
• Cognitive/behavioral (agitation confusion)
• Treatment (D/C meds, supportive care,
  cyproheptadine (Periactin), benzodiazepines

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Bipolar Disorder

• Recurrent manic and major depressive episodes
• Usually occur at different times
• May occur as a mixture at the same time
• Each episode may last up to 8 or 9 months
• Men have more manic episodes
• Women have more depressive episodes
• Length of each episode decreases with age
• Frequency of episodes increases with age

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Bipolar Manic Component

• Mood is elevated, expansive or irritable
• Unceasing enthusiasm for interacting with people
• Symptoms
• Inflated self-esteem
• Grandiosity
• Decreased need for sleep
• Excessive speech
• Flight of ideas
• Excessive involvement in pleasurable activities
• Poor judgment can lead to financial and legal
  problems

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Bipolar Depressive Component

• Same as for major depression

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Treatment of Bipolar Disorder

• Mood Stabilizing Drugs
• Lithium
• Valproate (Depakote Valproic acid)
• Carbmazepine (Tegretol)
• Antidepressants
• Electroconvulsive therapy
• (for refractory cases)

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Drug Considerations

• Lithium
• Side effects dry mouth, orthostatic hypotention
• Drug interactions avoid NSAIDs (they can
  increase blood levels of lithium)
• Carbamazepine
• Side effects sedation, leukopenia, aplastic
  anemia, Stevens-Johnson syndrome
• Drug interactions avoid erythromycin (it can
  increase blood levels of carbamazepine)

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Oral Complications Mood Disorders

• Manic patients
• Abrasion of teeth (excessive brushing)
• Gingival injury (brusing, flossing)
• Depressed patients
• General oral neglect
• Poor oral hygiene

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Dental Management

• Determine current status
• Confirm drugs patient is taking and degree of
  control
• Patients often do not report a history of
  depression but will be taking antidepressant
  medications ask why they are taking them
• Refer severely depressed patients to physician
  be alert to any ideation about suicide
• Management of xerostomia due to antidepressants
  (frequent water, ice chips, Biotene products)
• Avoid drug interactions (opioids, sedatives,
  hypnotics)

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Schizophrenia (See the movie A Beautiful Mind
a story about John Nash starring Russell Crowe)

• Disordered thinking
• Catatonic (disorganized) behavior
• stupor, excitement, impulsive behavior
• Inappropriate emotional responses
• Flat affect
• Hallucinations
• Delusions (thought broadcasting, controlled by
  dead person)
• Bizarre behavior
• Deterioration of social or occupational
  functioning

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Treatment

• Antipsychotic drugs
• Chlorpromazine Thorazine
• Haloperidol Haldol
• Risperidone Risperdal
• Psychotherapy
• Psychosocial therapies
• Develop social skills
• Educate patient about the illness
• What to expect
• Provide support

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Drug Considerations

• Chlorpromazine (Thorazine)
• Side effects xerostomia, orthostatic
  hypotension, tardive dyskinesia (elderly),
  sedation, cognitive impairment, leukopenia
• Drug interactions additive with other sedative
  like drugs, codeine effects decreased
• Haloperidol (Haldol)
• Side effects xerostomia, orthostatic
  hypotension, tardive dyskinesia
• Drug interactions avoid macrolide antibiotics
  (increased blood levels of haloperidol)
• Risperidone (Risperdal)
• Side effects xerostomia, orthostatic
  hypotension, dysphagia, tardive dyskinesia

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Tardive Dyskinesia

• A common late side effect of antipsychotics
• Risk is 20 to 40
• Involuntary movements of the lips, tongue, mouth,
  jaw, and extremities
• Chewing and sucking movements of the mouth and
  jaw
• Darting (flycatchers tongue, bonbon sign)
  and writhing, wormlike tongue movements
• Treatment relatively ineffective
• May be permanent and is socially disabling

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Tardive Dyskinesia
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Dental Management of Schizophrenia

• Patient should be under medical management often
  will not be compliant with their medicines
• May need to have family member or attendant
  accompany the patient
• Morning appointments
• Avoid confrontation and authoritative attitude
• Sedation may be indicated, consult with patients
  physician
• Be alert for drug side effects (sedation,
  xerostomia, orthostatic hypotension, tardive
  dyskinesia)