Title: Behavioral and Psychiatric Disorders Anxiety Disorders Mood Disorders Schizophrenia
1Behavioral and Psychiatric DisordersAnxiety
DisordersMood DisordersSchizophrenia
- Donald Falace, DMD
- Oral Diagnosis and Oral Medicine
- UK College of Dentistry
2Anxiety
- 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
3Acute 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
4Chronic Anxiety (Beyond the normal experience of
anxiety)
- Classification of Anxiety Disorders
- Panic attacks
- Phobias
- Generalized anxiety disorder
- Post-traumatic stress disorder
5Panic 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
6Phobias
- 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
7Generalized 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
8Post-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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10Treatment 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
11Anxiety 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
12Drug 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
13Mood Disorders
- Depression
- Major depression
- Bipolar Disorders
- Mood swings between mania and depression
14Major 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)
15Treatment 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)
16Mosbys GenRx Top 10Most prescribed drugs based
on sales volume
17Drug 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
18Serotonin
- 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.
19Serotonin 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
20Bipolar 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
21Bipolar 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
22Bipolar Depressive Component
- Same as for major depression
23Treatment of Bipolar Disorder
- Mood Stabilizing Drugs
- Lithium
- Valproate (Depakote Valproic acid)
- Carbmazepine (Tegretol)
- Antidepressants
- Electroconvulsive therapy
- (for refractory cases)
24Drug 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)
25Oral Complications Mood Disorders
- Manic patients
- Abrasion of teeth (excessive brushing)
- Gingival injury (brusing, flossing)
- Depressed patients
- General oral neglect
- Poor oral hygiene
26Dental 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)
27Schizophrenia (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
28Treatment
- Antipsychotic drugs
- Chlorpromazine Thorazine
- Haloperidol Haldol
- Risperidone Risperdal
- Psychotherapy
- Psychosocial therapies
- Develop social skills
- Educate patient about the illness
- What to expect
- Provide support
29Drug 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
30Tardive 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
31Tardive Dyskinesia
32Dental 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)