Psychiatric Conditions in Dentistry

• Psychiatric illnesses can present in dental patients
• Psychiatric issues may impact both dental and medical professionals
• Insights can be helpful in diagnosis and treatment

Diagnosing Psychiatric Disorders

• Ruling out organic causes is important when diagnosing psychiatric disorders
• Psychiatric diagnoses are based on the presentation and classification of specific conditions
• Psychiatric conditions can overlap with normality and other conditions
• Diagnosis relies heavily on speaking with the patient
• Psychiatric conditions are often syndromic

Acute Confusional State (ACPVU)

• Possible causes include:
  • Hypoxia
  • Infection
  • Epilepsy
  • Hypoglycaemia
  • Drug or Alcohol Withdrawal
  • Stroke/MI
  • Raised Intracranial Pressure

Depression

• Depressed mood can be a feature of normal emotional experience
• Depression is common:
  • 10% of men and 20% of women
  • Severe depression affects 1-3% of the population

Diagnosing Depression (DSM 5)

• Diagnosis requires 5 or more symptoms over a 2 week period
• One symptom must be either depressed mood or markedly diminished interest/pleasure

Symptoms of Depression:

• Depressed mood
• Markedly diminished interest or pleasure in activities
• Weight loss or change in appetite
• Insomnia or Hypersomnia
• Psychomotor agitation or retardation
• Fatigue/loss of energy
• Feelings of worthlessness or inappropriate guilt
• Diminished ability to think or concentrate
• Recurrent thoughts of death or suicide
• Symptoms must cause significant distress or functional impairment

Managing Depression (Primary Care)

• Antidepressant medications
• Supportive counseling
• Social prescribing can be beneficial

Managing Depression (Secondary Care)

• Medication review
• Formal therapies
• Community team support
• Additional strategies

Mania

• 1% of the population
• Elevated mood can range from normal to abnormal
• Patients with mania may also experience depression, indicative of bipolar disorder
• Risk is equal for males and females

Symptoms of Mania

• Elated or irritable mood for more than 1 week
• May result in hospital admission
• Overactivity
• Reduced need for sleep
• Risk taking
• Disinhibition
• Distractibility
• Inflated self-esteem
• Delusions
• Hallucinations
• Loud, rapid speech
• Racing thoughts

Managing Mania

• Acute presentations often require extensive community support and/or hospital admission
• Insight may be lost, potentially requiring detention if at risk
• Safe environment
• Anti-psychotic medication
• Extensive support and rehabilitation
• Psychoeducation
• Long term medication is often required

Anxiety Disorders

• Anxiety is a normal response to perceived threats or danger
• Anxiety enhances performance by increasing arousal

Yerkes-Dodson Law

• Arousal improves performance up to a point
• If arousal becomes too high, it can impair performance

Pathological Anxiety

• Anxiety becomes a disorder when it interferes with functioning

Psychological Symptoms of Anxiety

• Fear of loss of control
• Irritability
• Sense of dread
• Avoidance
• Panic

Somatic Symptoms of Anxiety

• Palpitations
• Shortness of breath
• Chest pain
• Butterflies
• Sweating
• Dry mouth
• Nausea

Generalized Anxiety Disorder (GAD)

• Anxiety is not confined to specific situations
• It is experienced on most days

Trait Anxiety

• "Trait anxiety" exists in individuals genetically predisposed to worry
• Anxiety levels tend to increase further during stressful times
• Can result in panic attacks

Hyperventilation Syndrome (Panic Attacks)

• Overwhelming feeling of panic leading to hyperventilation
• Often associated with avoidance
• Usually short lived

Treating Hyperventilation

• CBT
• Pharmacological management (beta-blockers to treat symptoms, not anxiety itself)

Managing Anxiety

• Psychoeducation
• Relaxation/breathing techniques
• Desensitization
• Flooding
• Short term benzodiazepines
• Antidepressants

Preventing Anxiety

• Empathy
• Education
• Calm clinical environment
• Confident and professional manner
• Avoidance is a common feature in anxiety
• Avoidance reduces anxiety in the short term, but reinforces it long term

Comparing Neurosis and Psychosis

• Psychosis means the patient lacks insight and loses contact with reality
• Neurosis means the patient retains insight and does not lose contact with reality

Phobias

• Phobias involve irrational fear that is disproportionate to the stimulus
• Fear cannot be reasoned away, linked to a particular stimulus
• Dental phobias are more anxiety than phobia
• Leads to avoidance

Obsessions

• Obsessions are intrusive and distressing impulses, thoughts, or images

Compulsions

• Compulsions are responses to obsessions, such as rituals
• Until compulsions are completed, anxiety increases

Managing OCD

• Antidepressants and behavioral therapy, which are often combined

Hychondriasis

• Abnormal preoccupation with a state of health or body part
• Interpretations of normal bodily sensations as a sign of a serious disease
• Difficult to convince patients that the issue is psychological.

Managing Hychondriasis

• Ensure organic diseases have been excluded
• Some patients will attend multiple practitioners
• Exclude organic causes
• Determine if there is an underlying mental illness
• Use care when performing investigations
• Get psychiatric help early
• Treatment is to deal with an underlying disorder
• May utilise psychological

Alcohol Abuse

• Excessive consumption/'binge' drinking
• Harmful use
• Dependency
• Detoxification involves drug protocols
• Multi-system problems
• Patients are often seen in hospital
• Nutritional deficiencies can occur

CAGE questionnaire

• C: Have you ever felt you should Cut down?
• A: Are you Annoyed if people comment on your drinking?
• G: Do you feel Guilty about the amount you drink?
• E: Do you ever have a drink first thing as an Eye opener?
• A score of 2+ indicates potential problem

Eating Disorders

• Morbid fear of becoming obese
• Distorted perception of body image
• Enamel erosion can occur

Eating Disorders: Anorexia and Bulimia

• Morbid fear of becoming obese
• Distorted body image
• Restriction for food intake
• Body weight is 15% below minimum for Anorexia
• Amenorrhoea (lack of menstrual cycle)

Bulimia

• Can include a preoccupation with eating and strong compulsion to eat
• Binge eating, followed by guilt and self-induced vomiting, Russell's Sign
• Medication abuse

Managing Eating Disorders

• Ensure adequate nutrition, may need admission or NG tube
• Treat complications, both physical and psychological
• Resolve underlying psychological issues

Body Dysmorphic Disorder (BDD)

• Constant worry over a small defect in the appearance
• Need for aesthetic medicine/surgery
• Can be seen in cosmetic dentistry, orthognathic surgery
• Refer to a liaison psychiatrist

Schizophrenia

• Serious psychiatric condition
• Onset is usually in early/mid adulthood, either early or late onset
• Males and females are equally affected
• Disturbances in thinking, perception, emotion and behavior that leads to disintegration of personality

Schizophrenia Symptoms

• NOT a split personality, it is a syndrome or disorder in thought
• Normal emotion may be disturbed
• Positive Symptoms: Contact with reality reduced, delusions often persecution, and Hallucinations
• Passivity
• Thought disorder (disturbed conceptual thinking)
• Negative symptoms: Poverty of Speech, Slow Thought and Movement (flat emotions)

Managing Scizophrenia

• Managing with neuroleptic drug
• Psychological (CBT, psychoeducation, family therapy, DBT)
• Social support (financial, OT, housing, employment)

Schizophrenia - Dental Aspects

• General health/hygiene
• Delusions
• Hallucinations
• Drug alcohol and smoking behavior
• Medication effects

Suicide

• Suicidal ideation
• Never ignore
• Accurate documentation
• Crisis team

Paranoia

• The person refers to events with little evidence of the case
• Psychotic implications
• Symptoms of other disorders (e.g., schizophrenia and depression)

Borderline Personality Disorder (BPD)

• Affects the individual's feelings, Thoughts, and Interactions
• The individual may experience impulsivity, instability, and upsetting thoughtss
• Worry about abandonmennt
• Aetiology uncertain (related to neglect/abuse|)

Borderline Personality Disorder (Treatment)

• Psychotherapy

Dementia

• Requires global congitive functions
• Progressive and irreversible issues

Conclusions

• Psychiatric disorders are common
• Disorders do mot necessarily impact on capacity
• Issues may result in dental management
• Outline knowledge of underlying disorders