Fundamentals of Psychiatry for the Dental Practitioner PDF

Fundamentals of Psychiatry for the Dental Practitioner September 18, 2023 Dara Wilensky, MD Director, Consultation-Liaison Psychiatry Fellowship Boston Medical Center/Boston University School of Medicine Agenda 1. The big picture: why are we here? 2. Review of psychiatric diagnostic criteria and...

Fundamentals of Psychiatry for the Dental Practitioner September 18, 2023 Dara Wilensky, MD Director, Consultation-Liaison Psychiatry Fellowship Boston Medical Center/Boston University School of Medicine Agenda 1. The big picture: why are we here? 2. Review of psychiatric diagnostic criteria and psychopharmacology pearls 3. Managing common psychiatric presentations in dental practice a. Depression and grief b. Anxiety and phobia c. Psychosis and delusions d. Eating disorders 4. Managing challenging patients Why Are We Here? Not only does geographic closeness beget a clinical relationship… Why Are We Here? Mental Health by the Numbers  In 2010, the number of primary care visits with psychiatric diagnosis as the primary dx: 63.3 million  26.2% of Americans ages eighteen and older suffer (57.5 million people) from a diagnosable mental disorder in a given year (2008)  5.1 million adults reported they needed but did not receive any mental health services in the past year (2013) Reasons :  24.6% “did not know where to go for services”  10.3% “might cause neighbors/community to have negative opinion”  7.8% “might have negative effect on job”  6.3% “did not want others to find out” Why Are We Here? Prevalence of Psychiatric Disorders One in four adults will experience mental illness in their lifetime. Alcoholism 13.7% Phobias 12.6% Social anxiety disorder 13% Drug abuse 6.1% Major depression 10% Antisocial personality disorder 2.5% Schizophrenia 1% Bipolar disorder 1% Prevalence of Psychiatric Disorders Why Are We Here? Morbidity  Comorbidity  50% of all psychiatric illness is diagnosed by age 14, and 75% by age 24  29% with a primary psychiatric diagnosis also met criteria for a substance use disorder  Common comorbidities: • Anxiety and depression • Schizophrenia and substance abuse disorder Borderline personality disorder and PTSD • Disability Claims – CDC Why Are We Here? ConsultationLiaison Psychiatry and Dentistry  CL Psychiatry: study of relationships among social, psychological, and emotional factors with bodily processes (physical symptoms are common in psychiatric illness)  Strong evidence that patients suffering from mental illness are more vulnerable to dental illness  Oral symptoms may be the first or only manifestation of mental illness– consider facial pain, preoccupation with dentures, bizarre or delusional thoughts about oral health Review of Diagnostic Criteria: The DSM Review of Diagnostic Criteria: The DSM Review of Diagnostic Criteria: Major Depressive Disorder  Major contributor to the burden of disease in high-income countries and lead all diseases as a cause for years of life lived with disability  Second leading cause of disability worldwide  Biological factors  Social factors  Psychological factors Contribute to risk  Gender (women 2x as likely)  Family or personal hx of depression  Substance misuse  Medical illness, pain  Social isolation Review of Diagnostic Criteria: Major Depressive Disorder *Two MAJOR symptoms (low mood and anhedonia) + 3-4 MINOR symptoms for at least 2 weeks = MDD Psychopharmacology Pearls: Treatment of Depression  Medications: SSRIs: fluoxetine, sertraline, paroxetine, citalopram, escitalopram, fluvoxamine • • xerostomia common SNRIs: venlafaxine, duloxetine • • xerostomia common TCAs: amitriptyline, nortriptyline • • xerostomia common • MAOIs: phenelzine, tranylcypromine, selegiline • Others: bupropion, mirtazapine Psychotherapy: cognitive behavioral therapy, psychodynamic psychotherapy   Neuromodulation: ECT, TMS, ketamine Review of Diagnostic Criteria: Bipolar Disorder One episode of mania is diagnostic for bipolar I disorder! However, bipolar disorder consists of episodes of mania, depression, AND periods of euthymia. Episodes of mania must last AT LEAST ONE WEEK. Diagnosis of bipolar II disorder requires one hypomanic and one depressive episode. Psychopharmacology Pearls: Treatment of Bipolar Disorder  Medications: • Mood stabilizers: lithium (xerostomia), valproic acid/depakote, lamotrigine, oxcarbazepine, carbamazepine • Antipsychotics commonly used as well (see next slides) Review of Diagnostic Criteria: Anxiety Disorders Review of Diagnostic Criteria: Anxiety Disorders 1/5/13 Review of Diagnostic Criteria: Anxiety Disorders Psychopharmacology Pearls: Treatment of Anxiety  Medication: • Long-term: • SSRIs: fluoxetine, sertraline, paroxetine, citalopram, escitalopram, fluvoxamine • SNRIs: venlafaxine, duloxetine ◦ Short-term:  Benzodiazepines: lorazepam, alprazolam, diazepam  Potential for physiologic dependence and abuse  Can also consider: hydroxyzine, clonidine  Psychotherapy: cognitive behavioral therapy, exposure and response prevention therapy Review of Diagnostic Criteria: Schizophrenia Case Mr N Mr N Is a 20yo college student who comes in distressed that “aliens are controlling me through a transmitter in my teeth; I want them out.” How do you respond? Psychopharmacology Pearls: Treatment of Schizophrenia Medication: ◦ First generation antipsychotics: haloperidol, perphenazine, chlorpromazine…  Risk for tardive dyskinesia with long-term use; frequently seen as oral-buccal-lingual movements  Some are anticholinergic  xerostomia; sialorrhea with clozapine ◦ Second generation antipsychotics: clozapine, risperidone, olanzapine, aripiprazole…  Less, but not zero, risk for TD  Some are anticholinergic  xerostomia  Other: family psychoeducation, cognitive enhancement  Review of Diagnostic Criteria: Eating Disorders Review of Diagnostic Criteria: Substance Use Disorders Review of Diagnostic Criteria: Personality Disorders Review of Diagnostic Criteria: Personality Disorders Cluster A: Paranoid, Schizoid, Schizotypal Common features: Acts peculiar or avoids social relationships but is not psychotic Suspicious of medical system, may focus on negative prior experiences Suspicion increases in times of distress (unhealthy coping mechanism) Review of Diagnostic Criteria: Personality Disorders Cluster B: Antisocial, Borderline, Histrionic; Narcissistic  Common features: Emotional, inconsistent, or dramatic Antisocial: Has no empathy or concerns for others, dishonest, criminality, charming Borderline: Erratic, unstable, intense, impulsive, seductive, feels empty, self-injury – cutting behavior, splitting (good v evil) Review of Diagnostic Criteria: Personality Disorders Cluster C: Avoidant, Dependent, Obsessive-compulsive Common features: Fearful and anxious Sickness = loss of control Identify with scientific process/theory Attention to detail with history taking and treatment compliance Common Psych Presentations in Dental Practice: Depression Common Psych Presentations in Dental Practice: Depression  GRIEF: this manifestation of depressive symptoms can come with diagnosis or treatment of oral cancers, which are often related to smoking, chewing tobacco, or EtOH use  Patients commonly experience pre-emptive grief as they process their diagnosis, and it can be difficult to differentiate this from a depressive disorder Common Psych Presentations in Dental Practice: Depression Common Psych Presentations in Dental Practice: Depression Oral cancer associated with increased risk of suicide  6x more likely to contemplate suicide than pts with other types of cancer  More than 3 times the rate of completed suicides than does the general population. Risk factors with head and neck cancers:  advanced stages of disease  comorbid substance abuse  decrease in quality of life because of disfigurement and a decline in the ability to speak, taste, smell, masticate and swallow Common Psych Presentations in Dental Practice: Depression  Knowing the risk factors for suicide and who is at risk can help reduce the suicide rate.        Sudden catastrophic event/failure Pre-existing mood disorder Shame and humiliation Family history of suicide Substance use disorder Veterans, history of incarceration Debilitating medical condition  Listen and take their concerns seriously. Don’t be afraid to ask questions about their plans. Let them know you care, and they are not alone Case: Dr F Dr F, an 83yo neurologist, presents with advanced oral cancer. He makes statements about not wanting to live any longer because of his unmanageable pain. Case: Dr F Dr F, an 83yo neurologist with advanced oral cancer: 1939 Sigmund Freud in his increasing frailty with oral cancer, turned to his doctor, friend, and fellow refugee, reminding him they had previously discussed his terminal illness: “Schur, you remember our contract not to leave me in the lurch when the time had come.” Common Psych Presentations in Dental Practice: Phobia  Response to a stimulus that is specific to the dental context  Adherence to dental care is affected by emotions  Emotions can be pathological when there is lack of balance between real and perceived danger  Perception, anticipation, expectations rather than the realities of the situation itself that is crucial for the development of dental anxiety Common Psych Presentations in Dental Practice: Phobia RISK FACTORS  Numerous caries  Missed appointments  Previous distressing experience with dental staff as a  Feelings of helplessness or embarrassment during treatment  Experiencing pain during treatment  Fearful attitude learned from parents  Perceived loss of control Common Psych Presentations in Dental Practice: Psychosis  Adherence to dental care/appointments in people with schizophrenia is half that of the rest of the population  Common delusional themes include infestation, implanted devices  Low threshold to refer to psychiatry for these patients Common Psych Presentations in Dental Practice: Eating Disorders  Eating disorders are the most lethal of psychiatric disorders with mortality rates from the complications up to 4%  Although the lethality of bulimia nervosa is much less than that of anorexia nervosa, the purging behaviors can lead to significant dental morbidity  Tooth wear including attrition, abrasion is caused by purging habits, in patients with bulimia and anorexia  Important to recognize signs of potential medical instability so as to know when to refer to ER Common Psych Presentations in Dental Practice: SUDs Common Psych Presentations in Dental Practice: SUDs Common Psych Presentations in Dental Practice: SUDs  Opioid-based pain medications will make cause physiologic dependence over time (withdrawal if medication decreased or stopped abruptly)  this is not the same as addiction  Most patients do not develop addiction on pain medication, even if they develop physiologic dependence.  How do you know who will have a problem, or how to spot it? Common Psych Presentations in Dental Practice: SUDs Spotting opioid misuse or overuse:       Analgesia (feeling no pain) Sedation Euphoria (feeling high) Respiratory depression (shallow or slow breathing) Small pupils Frequent early refill requests        Nausea, vomiting Itching or flushed skin Constipation Slurred speech Confusion or poor judgment Using for other reasons than analgesia Diverting prescriptions Common Psych Presentations in Dental Practice: SUDs  18% general US prevalence of smoking  Smoking prevalence of 50-85% among people with psychiatric disorders  Tobacco-related illnesses (COPD, CAD, lung cancer) are the leading cause of death in people with psychiatric illness, and they have shorter life expectancies than the general population.  High risk of oral cancers Common Psych Presentations in Dental Practice: SUDs Marijuana use – gum disease Methamphetamine – decay Cocaine- dental erosion, dry mouth Common Psych Presentations in Dental Practice: SUDs  Signs of substance misuse on exam:  Nasal irritation/septal perforation, conjunctival irritation, stained teeth or erosion, perioral rash, thrush, track marks, abscesses or cellulitis Common Psych Presentations in Dental Practice: SUDs Common Psych Presentations in Dental Practice: SUDs BRIEF MOTIVATIONAL INTERVIEWING:  Non-judgmental- avoid shaming patients  Identify pros and cons of using and not using  Identify long-term vs short-term goals (their goals are usually inconsistent with their behavior)  Express empathy  Avoid arguing  Roll with resistance  Support self-efficacy Miller and Rollnick Motivational Interviewing Have you ever felt angry, frustrated, or helpless when caring for a patient? What Makes a Patient Difficult?  Multiple somatic complaints  Anger or irritability  Frequent visits/calls  Noncompliance  Anxiety  Agitation  Drug-seeking behavior  Physically or verbally aggressive behavior  Sabotaging care Personality Style vs Personality Disorder  Personality style is a lifelong habitual way one thinks, feels, behaves, and copes  Personality disorder is an enduring pattern of inner experience and behavior that is inflexible, pervasive, and causes impairment  Under stress (such as with medical illness), personality style may become more rigid and maladaptive to the point where it is difficult to differentiate from personality disorder 4 Types of “Hateful Patients” Groves (NEJM, 1978) described 4 personality characteristics which invoke “helplessness in the helper” Type of Patient Illness Behavior Dependent Clingers Demanding, sticky, constantly ask for reassurance, rejection sensitive Entitled Demanders Needy, hostile, belittling Manipulative Help Rejecters Pessimistic, undermine treatment, yet demanding Self-destructive Deniers Hopeless, uncooperative + dependent, may continue self injurious behavior despite medical complications Groves, NEJM, 1978 Dependent Clingers  “Compliant, good patient”  These patients are completely helpless and needy, want attention  Utilize regression, passive-aggression and idealization  Physician may initially feel special, and then later feel depleted  Resemble those with dependent/histrionic personalities  Manage: Schedule appointments, consistent interactions, set limits Groves, JE. Taking Care of the Hateful Patient. NEJM. 1978; 298:883-887 Entitled Demanders  Arrogant, demanding, and devaluing others  Low self-esteem and the illness is a further insult.  May be confrontational and unable to problem solve. demand the “best of the best.  Manage: Acknowledge patient’s point of view. Attempt to cope w feeling frail/ill/flawed; focus on how you might help in the ways you are able  Accept the patient’s entitlement & redirect it to an expectation of appropriate medical attention Groves, JE. Taking Care of the Hateful Patient. NEJM. 1978; 298:883-887 Manipulative Help-Rejecters  Appear to want treatment and keep returning, yet will reject treatment solutions  Root cause is that the illness is more important to the patient than the treatment. Often diagnosable with borderline personality disorder  Utilize splitting, projective identification, idealizing/devaluing  Manage: Help patient limit demands & hostility; Help patient maintain sense of autonomy Self-Destructive Deniers  These patients often exhibit Cluster B, especially antisocial, characteristics  Lying, deceitful, and acting out  Arouse hatred, then guilt, and finally despair and hatred in the providers  Manage: Be compassionate & diligent; treat underlying depression; set limits, but don’t abandon patient The Therapeutic Relationship Based on psychodynamic principles Trust, rapport and collaboration  Alliance improves adherence to treatment outcomes, patient satisfaction and providers job satisfaction.  A strong therapeutic alliance reduces burnout and malpractice claims. The Therapeutic Relationship Transference: unconscious aspects of emotional relationships with early caregivers that are re-experienced with or transferred onto the physician   Countertransference: Unconscious feelings experienced by the physician in working with the patient.    In other words… the patient experiences the physician through the lens of all of their past relationships and life experiences. This “lens” is called the “transference.” In other words… the physician has a “lens” of prior relationships and life experiences through which they view the patient too. This is called “countertransference.” “When patients experience ambivalence about changing their maladapdtive behaviors, treaters often get angry, frustrated, and perhaps even malevolent.” Optimizing Therapeutic Relationships Issues to address: Trust Pain (physical and psychological) Fear/anxiety Treatment non-adherence Co-morbid substance use High risk behavior Your own feelings: fear, aversion, sympathy, attraction, frustration (yes, it’s ok to acknowledge your own feelings!) Working with Fearful, Anxious, and Phobic Patients–  When in doubt, ask your patient about possible fear or distrust  Explain procedures and their rationale. Schedule short, simple procedures first to give the patient an experience (graded exposure).  Listen to the patient. For many fearful patients, control over what happens in the dental office is very important  For distrustful or questioning patients, provide enough information.  Reassurance can be helpful for patients who are primarily anxious. Techniques of relaxation, distraction, breathing exercise, meditation can also be effective.  If the patient complains of pain, believe the patient and respond accordingly. Inadequate pain control can cause dental fear. Treating Fearful Dental Patients: A Patient Management Handbook. 2009 Case: Ms B Ms B, a 34yo woman, comes for a routine dental visit. She presents as simultaneously angry, dismissive, rejecting, and needy– although she reports a great deal of pain, she criticizes you and your office staff and complains that you have made several mistakes as you perform your exam. You are left feeling used, worthless, and angry. What is your response? Key Points  Psychiatric concerns are common among dental patients  Active screening, early recognition, and treatment or appropriate referral are key  Keen observation, being a listener, and empathy will enhance the therapeutic relationship Thank you!