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Behavioral and Psychiatric Disorders Anxiety Disorders Mood Disorders Schizophrenia

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alprazolam (Xanax) clonazepam (Klonopin) Long term: tricyclic antidepressants ... Alprazolam (Xanax) Inhalational (N2O/O2) Parenteral sedation. Midazolam (Versed) ... – PowerPoint PPT presentation

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Title: Behavioral and Psychiatric Disorders Anxiety Disorders Mood Disorders Schizophrenia


1
Behavioral and Psychiatric DisordersAnxiety
DisordersMood DisordersSchizophrenia
  • Donald Falace, DMD
  • Oral Diagnosis and Oral Medicine
  • UK College of Dentistry

2
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

3
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

4
Chronic Anxiety (Beyond the normal experience of
anxiety)
  • Classification of Anxiety Disorders
  • Panic attacks
  • Phobias
  • Generalized anxiety disorder
  • Post-traumatic stress disorder

5
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

6
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
7
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

8
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

9
(No Transcript)
10
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

11
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

12
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

13
Mood Disorders
  • Depression
  • Major depression
  • Bipolar Disorders
  • Mood swings between mania and depression

14
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)

15
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)

16
Mosbys GenRx Top 10Most prescribed drugs based
on sales volume
17
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

18
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.

19
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

20
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

21
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

22
Bipolar Depressive Component
  • Same as for major depression

23
Treatment of Bipolar Disorder
  • Mood Stabilizing Drugs
  • Lithium
  • Valproate (Depakote Valproic acid)
  • Carbmazepine (Tegretol)
  • Antidepressants
  • Electroconvulsive therapy
  • (for refractory cases)

24
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)

25
Oral Complications Mood Disorders
  • Manic patients
  • Abrasion of teeth (excessive brushing)
  • Gingival injury (brusing, flossing)
  • Depressed patients
  • General oral neglect
  • Poor oral hygiene

26
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)

27
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

28
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

29
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

30
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

31
Tardive Dyskinesia
32
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)
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