Psychiatry

• The text provides an overview of psychiatry for medicine and surgery in 2025, by Prof. Mark Greenwood.
• Up to 1 in 4 people will experience psychiatric illness.
• Individuals will come across psychiatric illness in dental patients.
• Psychiatric illness may affect dental and medical professionals.
• Having an insight into psychiatric illness is helpful.
• Diagnosis of psychiatric disorders is difficult.
• It is required to exclude organic causes when diagnosing psychiatric disorders.
• Presentation and classification of conditions makes diagnosing psychiatric disorders difficult.
• There is overlap between both 'normality' and with other conditions, making diagnosis difficult.
• There are few diagnostic tests to use.
• Psychiatric disorders are often 'syndromic'.

Acute Confusional State (ACPVU)

• ACPVU: Alert, Conscious, Pain, Vocal, Unresponsive
• Hypoxia, Infection and Epilepsy can cause Acute Confusional State
• Also Hypoglycaemia, Drug or alcohol withdrawal, Stroke/MI, Raised intracranial pressure

Depression

• Depressed mood is a normal feature of life.
• Depression is common, affecting 10% of men and 20% of women.
• Severe depression affects 1-3%.

Diagnosis of Depression - DSM 5

• 5 or more of the following symptoms over a 2-week period are required for diagnosis.
• One symptom must be depressed mood or markedly diminished interest or pleasure in all activities.
• Symptoms to consider are: -Depressed mood -Markedly diminished interest or pleasure in all activities -Weight loss or increased/decreased 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

Updated Guidelines – DSM-5-TR 2022

• Update of diagnostic text
• Disorders added: Prolonged Grief Disorder, Unspecified Mood Disorder, Stimulant-Induced Mild Neurocognitive Disorder

Depression - Management

• Primary care treatments include supportive counseling, social intervention, and antidepressant medication.
• Secondary care involves medication review, formal therapies, community team support, and additional strategies.

Mania

• Mania affects 1% of the population.
• Elevated mood can be 'normal'.
• Most patients with mania also experience depression, also known as bipolar disorder.
• The risk afflicts males and females equally.

Mania - Features

• Elated or irritable mood for more than 1 week may indicate mania.
• The mood may result in hospital admission.
• Other mania features include: -Overactivity -Reduced need for sleep -Risk taking -Disinhibition -Distractible -Inflated self-esteem -Delusions -Hallucinations -Loud, rapid speech -'Racing' thoughts

Mania - Management

• Acute presentations often require extensive community support and/or hospital admission.
• Insight can be lost; detaining may be necessary if at risk.
• A safe environment is important.
• Medication is used to manage mania.
• Extensive support and rehabilitation is needed.
• Education is of great importance.
• Long-term medication is often required.

Anxiety Disorders

• Anxiety is a universal and 'normal' response to a perceived threat or danger.
• Anxiety enhances performance by increasing arousal (sympathetic nervous system) according to Yerkes-Dodson.
• Anxiety becomes pathological when it interferes with the individual's functioning.

Yerkes-Dodson

• Performance vs Level of Arousal
• Performance has an optimal peak depending on Arousal level

Symptoms of Anxiety

• Psychological symptoms include: fear of loss of control, irritability, sense of dread, avoidance, panic
• Somatic symptoms include: palpitations, shortness of breath, chest pain, 'butterflies', sweating, dry mouth, and nausea

Generalized Anxiety Disorder

• Anxiety is not confined to a specific situation, and is experienced on most days in Generalized Anxiety Disorder.
• 'Trait anxiety' is said to exist in those who have always been prone to worrying.
• Anxiety levels typically rise further in stressful situations.
• Panic attacks may result from anxiety.

Hyperventilation Syndrome 'Panic Attacks'

• Hyperventilation Syndrome is caused by an overwhelming feeling of panic leading to hyperventilation.
• It is strongly associated with avoidance.
• Episodes are usually short-lived.
• Treatment plans involved CBT and pharmacological management.

Anxiety Management

• Treatments include: Education, Relaxation/breathing techniques, desensitization, 'Flooding', Short term benzodiazepine, Antidepressants
• Prevention involves Empathy, Education, Ambience of the clinical environment, Confident, professional but friendly manner
• Avoidance is a common feature
• Avoidance reduces anxiety levels but reinforces the avoidance

Neurosis and Psychosis

• Psychosis implies a lack of insight into the disorder such as some types of severe depression.
• Individuals with psychosis lose contact with reality
• In neurosis, there is insight, and contact with reality is never lost.

Phobias

• This involves an irrational fear, out of proportion to the stimulus.
• A phobia cannot be reasoned away, and is linked to a particular stimulus.
• An example of a phobia is dentistry, which causes 'odontophobia'.
• Phobias lead to avoidance.

Obsessive Compulsive Disorder

• Obsessions involve Intrusive and distressing impulses, thoughts, or images that come from within.
• Compulsions involve a Response to obsessions, such as rituals.
• Until the compulsion has been satisfied, levels of anxiety increase.

Obsessive Compulsive Disorder Management

• Utilizes Antidepressants and behavioral therapy, often in combination.
• May require services for psychiatric assistance.

Hypochondriasis

• This is an abnormal preoccupation with the state of health or body functions; this may be part of other conditions.
• Individuals often interpret something that is normal as a sign of disease, or exaggerate its severity.
• An example would be a dental abscess being interpreted as oral cancer.
• It is difficult to convince patients that they have a psychological component.
• Be very careful to ensure that organic disease has been excluded.
• Some patients will attend multiple practitioners.

Hypochondriasis Management

• Exclude organic' cause.
• Determine if an underlying mental illness is present.
• Care is needed with investigations, such as scans and blood tests, as they can reinforce hypochondriasis.
• Psychiatric help should be sought early.
• Treatment should deal with an underlying disorder, like anxiety or depression.
• Treatment may be pharmacological.
• Behavioral and cognitive techniques may be used.

Alcohol Abuse

• Alcohol abuse Excessive consumption/'binge' drinking.
• It indicates harmful use
• There is dependency
• Treatment involves Detoxification with drug protocols.
• Seeing patients with Alcohol abuse is not unusual to see in inpatients
• May be accompanied by Multi-system problems (especially cardiac, liver).
• Results in Nutritional deficiencies

Wernicke's Encephalopathy

• Wernicke's Encephalopathy is caused by a thiamine deficiency, leading to triad of Nystagmus, Ophthalmoplegia, Ataxia,
• Other signs include altered consciousness, confusion

Korsakov's Syndrome

• It causes a Decrease in ability to acquire new memories
• It may follow Wernicke's
• Individuals may confabulate.

Alcohol Abuse-CAGE Questionnaire

• Two out of four positive answers indicate potential problem: -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: Have you ever drunk early in the morning as an eye-opener?

Eating Disorders

• Morbid fear of becoming obese, where the patient goes to great lengths to avoid it.
• Distorted perception of body image.
• It can cause Enamel erosion, but beware of GORD and carbonated drinks
• Includes Anorexia nervosa and Bulimia nervosa

Eating Disorders - Anorexia Nervosa

• This may be indicated when there the patient has Morbid fear of becoming obese, in addition to a Distorted body image
• There will be Restriction of food intake and Avooidance of 'fattening' foods
• There will be a signifiant change in Body weight of at keasr 15% below normal
• Accompanied by Amenorrhoea
• Patients May use laxatives, diuretics, or exercise to excess

Eating Disorders - Bulimia Nervosa

• A Morbid fear of becoming obese
• Preoccupation with eating and strong compulsion to eat
• Patient will Binge eat, followed by guilt and self-induced vomiting, also known as (Russell's Sign)

Eating Disorders - Management

• It is vital to Ensure adequate levels of nutrition, sometimes May need admission and NG tube
• You must Treat complications, whether Physical, Psychological and attempt to resolve any Underlying psychological issues- group or individual

Body Dysmorphic Disorder (BDD)

• Involves Constant worry over a small defect in the appearance (or a perception of one)
• May be seen in aesthetic medicine,care will be needed
• Also with cosmetic dentistry, orthognathic surgery
• These patients must Refer to a liaison psychiatrist

Schizophrenia

• Indicates A serious psychiatric condition
• Age of onset is usually in early/mid adulthood
• Though some are Early and late onset cases
• The risk is equal, hence Male = female
• Disturbs thinking, perception, emotion and behaviour, tending to lead to a disintegration of the personality
• This is not a ‘split personality', it’s a Syndrome

'Positive' Symptoms of Schizophrenia may include

• Reduced Contact with reality. Also normal emotions may be disturbed.
• Delusions, often of persecution
• Hallucinations, often auditory
• Passivity such as thoughts inserted/withdrawn/thoughts made avaiable to others
• Thought disorder that disturbs conceptual thinking and thiscan be shown in the patient's speech

'Negative' Symptoms of Schizophrenia

• Poverty of speech
• Slow thought and movement
• Flat emissions. Apathy and social withdrawal
• Lack of Motivation

Schizophrenia - Management

• Medication like anti-psychotic drugs and depot injections, clozapine, and CBT is used.
• Social measures help too, by OT, finances and Housing.

Schizophrenia- Possible Dental Aspects

• General health/hygiene may be affected
• Also Delusions and Hallucinations, somatic (pain)
• Drug, alcohol and smoking behaviour can add to the problem
• Effects of Medication

Suicide

• Often 'Suicidal ideation'
• Never ignore suicidal thoughts
• Accurate documentation is required
• Contact the Crisis Team- have numbers to hand

Paranoia

• The person refers events to themselves, with no or very little evidence that this is the case
• Involves A psychotic implication
• May be a symptom of other disorders, e.g. paranoid schizophrenia, psychotic depression

Borderline Personality Disorder (BPD)

• This affects feelings, thought and interactions
• Involves Impulsivity, emotional instability, and upsetting thoughts.
• The patient is worried about abandonment
• The Aetiology is uncertain, but potentially related to neglect.abuse
• Can be treatd eith Psychotherapy

Dementia

• Dementia involves Acquired impairments of global cognitive function, usually progressive and largely irreversible
• This is covered in the Lecture on older people

ADHD (ADD)

• This is covered in the Lecture on Paediatrics

Conclusions

• Psychiatric disorders are common
• Does not necessarily impact on capacity
• May impact on dental management
• An outline knowledge of underlying disorders is required