3. Understanding Mental Health Pt. II

Question 1

Clusters of Symptoms in Mood Disorders
____ (e.g., sadness, euphoria)
____ (e.g., suicidal ideation, hopelessness, racing
thoughts, grandiosity)
____(e.g., fatigue, withdrawal, increase in activity, reckless behavior)
____ (e.g., disturbances in sleep, eating, physical complaints)

• If you think about mood, its a continuum of negative to positive
• All mood disorders range from very negative to very positive
• What separates the clinical presentations from sub clinical is the degree that it causes ____
to the pt and degree that it ____ their functioning. This holds true for both extreme positive
and negative
• These symptoms we will talk about today group into clusters of symptoms (dont think of
symptoms individually but as groups)

1. Most obvious for mood disorders. One end they have extreme sadness, the other end extreme euphoria
2. These go beyond just emotion, these are different thinking patterns associated with mood disorders. Hopelessness on the low end, racing or grandiose thoughts on the high end
3. Mood disorders are more than just thoughts and feelings. Also manifest in distinct motivational + behavioral patterns. On one end fatigue and withdrawal from activity. On the other an increase and recklessness
4. These are physical disturbances of mood disorders (reads in parenthesis). Will see some ____ differences here, when they experience depression they may be more likely to label the somatic symptoms. They may be more salient more prominent than labeling it as depression or an emotional symptom. This happens in ____ as well, sometimes its labeled as a somatic rather than depression or anxiety.
   These clusters are a good way to think about characterizing mood disorders. Some are more prominent depending on age, developmental, cultural considerations

Answer 1

emotional
cognitive
motivational/behavioral
somatic

distress
impairs
cultural
kids

Question 2

Classification of Mood Disorders

Depressive Disorders
Disruptive Mood Dysregulation Disorder
Major Depressive Disorder 
Persistent Depressive Disorder 
Premenstrual Dysphoric Disorder
Substance/Medication-Induced Depressive

Bipolar and Related Disorders
Bipolar Disorder I
Bipolar Disorder II Cyclothymic Disorder
Substance/Medication-Induced Bipolar

• Not going thru all oof these but wanted to show there are a lot that are characterized as mood disorders
• Left side is the ____ end of the emotional spectrum, negative emotions. AKA unipolar depressive disorders - they primarily experience the negative end of that spectrum
Primarily mostly only in children
Tied with substance use disorder
Quite controversial, experience of mood disorders on top of a normal experience in the
menstrual cycle
We will major focus on these 2 that you will see most common

• Right side is people who experience both sides of the spectrum, the extreme ____ and the extreme ____. You will see there are different manifestations of this.
• When someone says depression, there are a bunch of manifestations of it. Like last time we said most mental health disorders are far more heterogeneous than people think. Even within each of these categories there is a lot of inter individual variability, so we will try to look at the core features of this

Answer 2

low
lows
highs

Question 3

Implications of Mood Disorders for Dental Practice

Prevalence (any mood disorder) – lifetime (approx. ____%); within past year (approx. 10%)
• ____ is leading cause of ill health and disability worldwide (WHO)

Consequences
• Negative impact on oral hygiene and use of services (____ pathway)
• Chronic stress may influence immune response (____ pathway)

• Why is this important for dentists to understand? 2nd only to anxiety this will prob be what we come in contact with the most
• In our lifetime, statistics says 1 in 5 of you will meet the characteristics for one of these mod disorders. Within the past year is 10% which is pretty significant (independent of substance abuse and anxiety which are usually comorbid with this). Also keep in mind these are prob an underestimate, bc many ppl (at least half) do not get diagnosed/cant access treatment
• Reads bullet. These are not only common but debilitating and have a wide range of effects on a persons economic and social and health function
• For your purposes any of these disorders will have a negative impact on their oral health thru the ____ pathway
• They are less likely to engage in them/follow thru on what you recommend/less likely to access services
• Impacts the persons ability to maintain oral health and get services
• Things associated with chronic stress may have an affect on immune response and their oral
health

Answer 3

21
depression
behavioral
biological
biological

Question 4

Implications of Mood Disorders for Dental Practice
Other Factors

• ____ treatments can interact with dental procedures
• Associated with other behaviors affecting oral health (e.g., smoking,
substance use, poor diet)
• Less likely to ____ preventive care (no ____ -> no problem)
• Poverty and access to care

1. Talked a little bit about this last time
2. Most mental health conditions (mood disorders included) assoc with other behaviors affecting
   oral health. Higher rate of ____/substance use than the general public
3. They will label a need for services purely wether it is extremely painful. They wont go until then and you know at that point they’re already pretty far down the line. Dental care is viewed as
   ____ rather than proactive
4. Higher rate of poverty, still a disparity so they have problems accessing their access to mental
   healthcare and other types of healthcare. Multidimensional problem here

Answer 4

medication
access
pain
smoking
reactive

Question 5

Implications of Mood Disorders for Dental Practice
Stigma
• may cause ____ or avoidance of care
• worsens disease progression, reduces treatment compliance
• stereotypes by health professionals can lead to ____ care (e.g., not explaining procedures, blaming and shaming patients)

1. Lost of literature about people seeking medical/dental care reluctant to bring it up bc they think they will be treated differently
2. You’d be surprised in how many ways this impacts the day to day delivery of care
3. Very subtle things, being less likely to explain the procedure bc even subconsciously you
   know that they have the mental health condition. Or unintentionally blaming/shaming them for now maintaining their oral health out of good intention, but it can be read as blaming them for something out of their control. Aka if theyre battling thoughts of suicide/intense depression, flossing is probably low on their list so how you ____ it is very important

Answer 5

delay
substandard
encourage

Question 6

Mood Disorders and Oral Health
•Higher rates of ____ teeth/dental caries even after accounting for SES, hygiene behaviors, demographic characteristics, medication (Delgado-Angulo, et al., 2015)
•Higher rates of tooth ____ (Cademartori et al., 2018)
• Approx. 2.5x more likely to have failure of ____ treatment of dental caries; failure not more likely with amalgam restorations (Henn et al., 2019)

1. Seems to be some direct link, this may be that ____ pathway, between depression and oral health
2. Reads
3. People with depression/mood disorders have the higher failure with endo but not amalgam.
   You’re dealing with a higher rate of problematic issues and appears some interaction with this procedure. I’m not a dentist you guys are in a better position to decide why it might be for this certain procedure

Answer 6

decayed
loss/edentulism
endodontic
biological

Question 7

DSM 5 Classification: Mood Episodes
Major Depressive Episode Manic Episode
Hypomanic Episode

• Let’s talk about mood disorders and more what they look like, there are different manifestations of them
• Mood disorders are really distinguished form one another from a history of mood episodes - what is the ____ of mood episodes. These patterns are important for distinguishing one type from another
• They are largely ____ - periods when they are asymptomatic and periods of symptomatic.
• What kinds of episodes are there?
1. An intense period of severe depression lasting at least ____ weeks. Somewhat more acute and intense. They can last months and even a year
2. Experience of ____ - high end of the mood spectrum. Lasting at least ____ week.
3. Elevation in mood but ____ in duration and not necessarily impairing. Not as intense or severe
So which mood disorder someone has is distinguished by which episodes they have had and when, what is the pattern of episodes

Answer 7

pattern
episodic
2
euphoria
1
shorter

Question 8

Major Depressive Episode (≥ ____ Symptoms for ≥ ____ weeks)

1. Depressed ____
2. Diminished interest or pleasure
3. ____ loss/gain
4. Insomnia/Hypersomnia
5. ____ retardation/agitation
6. Fatigue or loss of energy
7. ____ or inappropriate guilt
8. Diminished ability to concentrate
9. Recurrent thoughts of death or ____ ideation

• Pt must have had at least 5 of these for at least 2 weeks.
• We have ____ symptoms (1+2), ____ symptoms (3+4), ____ symptoms (5+6), ____ symptoms (7+8+9)
• So those clusters that we started off with in the beginning we can see specifically here
• What’s interesting is, going back to the ____ of this, is the person may experience different ends of the spectrum
• Some ppl with depression may have difficult time sleeping, and some sleep too much. Some lose weight, others gain weight. Some have slowed movement (looks sluggish), or they may
appear very agitative and restless
• Regardless of which we see, we must see 5 of them. With children and some cultural
differences the person is more likely to label 3+4 as ____ symptoms than label it as depression. Men are also less likely to label some of these as depression when they experience it

Answer 8

5
2

mood
weight
psychomotor
worthlessness
suicidal

emotional
somatic
motivational/behavioral
cognitive

heterogeneity
somatic

Question 9

Manic Episode (≥ ____ Symptoms for ≥ ____ week*)

1. Inflated self-____ or grandiosity
2. Decreased need for sleep
3. More ____ than usual, pressured speech
4. Flight of ideas/racing thoughts
5. ____
6. Increase in goal-directed activity or psychomotor agitation
7. Excessive involvement in high-____ activities (e.g., buying sprees, sexual indiscretions, foolish investments)

• At least 3 of these for 1 week, the exception is if the symptom results in \_\_\_\_/ incarceration - this should give you some sense of the degree of impairment that can come with a manic episode
1. They are capable of doing a lot of things. Last class we talked about psychosis (hallucinations and delusions), in a manic episode or even major depressive they may have psychotic features associated. They feel like they’re on top of the world and can do anything
2. Could go 2-3 days only having slept 2-3 hrs/night. For dental students this may happen but you guys would feel it/be sluggish the next day, they however may feel like they are functioning optimally
3/4/5. Reads
6. Taking on and starting a lot of tasks but not necessarily \_\_\_\_ them. Lists like 12 chores to do around the house before breakfast. They make extensive plans that are far from realistic
7. The effects of 6 can ultimately manifest itself in high-risk activities. They can max out their credit card, take investment risks, sexual risks. One former student just disappeared for a weekend and told nobody, everyone was worried about him, and got into a little bit of trouble. That’s an example of a full blown manic episode - leads to impairment
-a hypomanic episode would be experiencing these symptoms for at least \_\_\_\_ days but does not lead to significant \_\_\_\_

Answer 9

3
1

esteem
talkative
distractibility
risk

hospitalization
finishing

4
impairment

Question 10

Depressive Disorders

Major Depression
• At least one ____ episode (≥ 2 weeks)
• No ____ episodes

Specifiers:
Single or recurrent episodes Severity (mild, moderate, severe) With Psychotic Features
In partial (or full) remission

Reads first 2 bullets defining major depression
• In the DSM, classification system for American Psychiatric Association, there are some of the heterogeneity again. They may have things listed like major depressive disorder single episode - meaning this is their first mood episode. Or different severities (mild/moderate/severe) depending on how many symptoms. Severe could mean with psychotic features
• From last class, ____ is often associated with schizophrenia but it is not exclusive to schizophrenia.
• Psychotic features can be present in a large amount of ____ conditions, mood disorders are one of the kinds
• In a severe enough major depressive episode the person may believe that they are the devil/ evil. In the midst of a manic episode they may believe they can control the wind/weather

Answer 10

major depressive
manic

psychosis
mental health

Question 11

Depressive Disorders
Persistent Depressive Disorder (Dysthymia)
• ____ symptoms (≥ ____ years; never > ____ months asymptomatic)
• No ____ episodes
• Can coexist with ____ (specify)

Specifiers:
Early or late onset (age 21) Severity (mild, moderate, severe) In partial (or full) remission

• Other common form of depression is persistent depressive and it is the more chronic form
1. There is a lower level of intensity of depression but there is never more than 2 months where
they aren’t symptomatic
2. Reads
3. Can have a low chronic level of depression and then in the midst of that they get a major depressive episode but then return to this low intensity chronic one
So the two most common forms of depression are:
Major depression: Intense and acute, more episodic Persistent depressive: More chronic, somewhat less ____

Answer 11

chronic depressive
2
2
manic
major depression

intense

Question 12

DSM 5: Bipolar and Related Disorders
Bipolar Disorder I
Bipolar Disorder II
Cyclothymic Disorder Substance/Medication-Induced Bipolar

• If you know someone with bipolar that has experienced a manic episode you will recognize the
symptoms i put up. Very ____ symptoms, not necessarily among people but the same person that you can recognize when they are beginning to enter this phase. It really does start to effect the people around them
• Last time said that distress and dysfunction are the 2 distinguishing factors of clinical disorders, major depression and persistent depressive tended to have both of those - they’re feeling stressed and its impairing function. In bipolar, at least in the manic episode, the person is often experiencing ____ but not necessarily ____ - it can feel good.
• Manic episodes are dysfunctional bc it may rip apart their lives in the inability to get work done and interfere with relationships and impact with help seeking services
• There are 2 different manifestations of bipolar disorder as well: bipolar 1 + 2

Answer 12

characteristic
dysfunction
distress

Question 13

Bipolar Disorders

Bipolar I
• At least one ____ episode (≥ ____ week*)
• May or may not have ____ episodes

Specifiers:
Current or most recent episode Severity (mild, moderate, severe) With Psychotic Features
In partial (or full) remission

• At least one manic episode and may of may not have had a major depressive episode
• This is kinda odd… if you only have 1 manic episode why do we still call it bipolar? Bc well over 90% of ppl that have a manic episode will go on to have a major depressive (MD) episode, so in terms of treatment and prognosis and understanding the course if there is a full manic episode the best course of action is to treat like they have ____.
• If they have both (any sequence of those) its bipolar
• If i say bipolar 1 last major episode is major depression, it means they’ve had a ____ episode before and gives you some of the history with the last episode
• Has the same kinds of specifiers, NOT so important you know them just to have an understanding of the ____ nature

Answer 13

manic
1
MD

bipolar
manic
heterogeneous

Question 14

Bipolar Disorders

Bipolar II
• At least one ____ episode (≥ ____ days)
• At least one ____ episode
• No ____ episodes

Specifiers:
Current or most recent episode Severity (mild, moderate, severe) In partial (or full) remission

Hypomanic - Experiencing manic symptoms, elevated mood, higher than usually but not impairing *reads 2nd and 3rd bullets
• People with bipolar 2 have had a major depressive (MD) episode and at least 1 elevated mood
but not to the criteria of flow blown maniac

Answer 14

hypomanic
4
MD
manic

Question 15

Bipolar Disorders

Cyclothymic Disorder
• Chronic ____ and ____ symptoms (see criteria; ≥ ____ years; never > ____ months asymptomatic)
• Don’t meet ____ for manic, hypomanic, or MD episodes

Specifiers:
With anxious distress

• This is the bipolar equivalent of persistent depressive disorder. Less intense
1. Reads
2. Reads. But they have significant symptoms. They may have 3 of the MD symptoms and 3 of
the manic episodes and cant meet the criteria for either one of those and seems to be chronic
• more ____ than the other 2 variations

Answer 15

hypomanic
depressive
2
2
criteria
rare

Question 16

Sample Bipolar Classifications
•Bipolar I, Single Manic Episode***
•Bipolar I, Most Recent Episode Hypomanic
•Bipolar I, Most Recent Episode Manic
•Bipolar I, Most Recent Episode Mixed
•Bipolar I, Most Recent Episode Depressed
•Bipolar II

• In mental health diagnosis is very important, but also limiting in many ways. We can place people into categories and the categories are pretty artificial
• These are possible diagnoses, and in a short amount of time you can infer a lot about someone
1. What do we know about their history? Just one ____ and ____
2. We know theres a history of full blown ____ (bc theyre BP1) but their most recent is
____. Don’t know for sure if they’ve had MD
3. Previous ____ episode and they’ve had at least one in the past. Likely the other one was MD
4. Should’ve taken this out. This is where the person experiences both ends of the spectrum.
PRETEND you didnt see this one
5. They’ve had a ____ and a ____ episode

From the classification and the specifiers, you can get a sense of the persons history, not complete but classification and diagnosis can be really informative

Answer 16

episode
manic
manic
hypomanic
manic
manic
MD

Question 17

Bipolar Disorder: Diagnostic Challenges

• If presence of psychosis, acute mania or schizophrenia?
• If MD episode occurs first… •Comorbidity
• Entire pattern of mood swings

With bipolar there are some really unique factors that come into play
1. If the person believes theyre being controlled by someone else or followed by the FBI.. is this
bipolar with psychosis or schizophrenia? Would make this decision by getting some ____ (bipolar has a family history) or getting a history of when the ____ features are happening (if only during a mood episode then more likely ____, ____ more likely if occurring outside of a mood episode).
2. You’re in your early 20s (most likely age of onset) and you have a MD episode.. how do i know if the MD was part of depression or if it is part of bipolar and MD was just your first episode? Its really hard.. can get family history again but difficult. Meds used for Major Depression is not the same as meds used for Bipolar.. some evidence that drugs used for depression may induce a ____ episode
3. Bipolar comorbid with substance use disorders, anxiety.
4. Range of things blending together for symptoms.. so really important to look at ____ swings.

Getting the family history you really want to see if they can identify any historical patterns and piece together what the history of mood swings tells up
-bipolar manic episode will often end in ____ bc they feel like they’re on top of the world and don’t need any intervention. They get intervention when arrested/in the hospital

Answer 17

family history
psychotic
bipolar
schizophrenia
manic
mood
hospitalization

Question 18

Depressive Disorders: Etiology/Contributing Influences
•Genetic Vulnerability
• Twin and adoption studies support heritability (general); higher for ____

•Neurotransmitter Systems
◦ Associated with low levels of ____ and Serotonin(ST)
◦ “Permissive hypothesis”– low levels of ST allow other ____ to vary more widely

Endocrine Systems
◦ “Stress Hypothesis”- overactive ____
◦ Produces ____ hormones (e.g., cortisol) in response to stress ful life events
◦ Prolonged exposure may interfere with neural functioning and development (e.g.,reduced neurogenesis in ____)

“Again this may be beyond our purpose here but..”

1. A general heritability for any mood disorder, not necessarily that parent having MD makes you more likely for MD, but you’re more likely to have any mood disorder. Studies show that heritability is higher for bipolar than the other mood disorders
2. Primarily serotonin, low levels are associated with depression. Not necesarily the serotonin per say but their low levels allow differences in other levels of neurotransmitters. Serotonin serves more as a mood regulator so when its low we see more variability in other NT levels. Our meds we use really target serotonin
3. When we experience stress we produce stress hormones that help us adapt to stress, problem is people that experience intense/chronic stress can have a ____ to them. Prolonged exposure may be linked to reduced neurogenesis in hippocampus. So we see stress effects endured long past the stressful event

Answer 18

bipolar
norepinephrine
NTs

HPA Axis
stress
hippocampus

hypersensitivity

Question 19

Medication Treatment: Depressive Disorders
• SSRI’s: inhibit re-uptake of ____ (Prozac, Zoloft, Paxil, Lexapro)
• SNRI’s: inhibit re-uptake of ____ (Effexor, Wellbutrin)
• Tricyclics: affects ____ activity (Tofranil, Elavil)
• MAOI’s: inhibit breakdown of ____ (Nardil)

We talked about some of these last class but the primary for unipolar depression are SSRIs

1. Prozac was the first one (idk how much its prescribed anymore). Serve as agonist of ST. This will most likely be the first class of meds used for someone with depression, may take 3-4 wks to get up to full therapeutic dose so not an immediate effect. Have to take them everyday
2. These are other likely treatment you see
   - Last 2 i really wont go into bc you wont really see these unless theres been failure of the other
3. Inhibit the breakdown of ____. Not that effective and have lots of complications with ____ and other things

Answer 19

ST
ST and NE
NE and ST
NE and ST
monoamine oxidase

Question 20

Medication Treatment: Bipolar Disorder

• Lithium Carbonate
• “Mood ____” effects
• Common side effects: increased ____, shakiness of the hands, and increased thirst
• Serious side effects: ____, diabetes insipidus, and lithium toxicity
• Requires close medical ____
• Non-compliance rates
• Other Common Meds – ____ (carbamazepine and valproate)
• Mood stabilizer with atypical antipsychotic (e.g., ____ + risperidone)

For bipolar still the most common (but its changing) in Li carbonate
Li affects the highs and the lows
These could affect you in a dental procedure
Have to get bloodwork to make sure theres no toxicity
They become less and less likely to take the meds when in maniac state
Commonly paired with anticonvulsants
And also paired with a mood stabilizer, especially if you’re ____ with psychotic features

Answer 20

stabilizing
urination
hypothyroidism
maintenance
anticonvulsants
lithium
bipolar

Question 21

Mood Disorders: Suicide

• 11th leading cause of death in U.S. (> 40,000 per year)
• 2-3x higher in ____, but women attempt more
• Risk factors: ____ of attempts, stressful life events, substance use
• Important to Screen for Symptoms
• Suicidal ideation, intent, plan?

Major consequence of mood disorders are suicide. Not unique to mood disorders but most common precipitating diagnosis of suicide
2. Men chose more lethal means (firearms)
3. Family history could be from heritability but also stress, if you have a family member that has had suicide ideation/attempts that can be extremely stressful on you too
5. Ideation - does the person have thoughts of suicide? Not that uncommon, many people think about it at least casually (in passing). If they think seriously about it its a much smaller percentage Intent - next level of risk, do they intend to do it?
____ - do they have a specific plan for how they would do it? Highest level. Make sure they get referred to a mental health professional

Answer 21

men
family history
plan

Question 22

ADHD

Beyond Hallmark Symptoms

____
____
____

The Specificity Myth

These are the 3 hallmark symptoms of ADHD
1. Distractability and difficult time focusing/eliminating out distractions
2. Excessive motor activity/movement. Can’t sit still/figidty
3. Hard time inhibiting behavior, interrupting others, blurting out, playing out of turn on a game
None of these are specific to ADHD, myth that if you have one of these you could have ADHD Inattention could be from: cell phone, bored, have to go to bathroom, bullied, difficult home life, physical pain/illness, anxiety, depression, learning disability, hunger, etc. so hard to determine when its part of ADHD and when its not
2 main clusters are ____ and ____. Kids that are hyperactive them to be impulsive so theyre grouped together

Answer 22

inattention
hyperactivity
impulsivity

inattention
hyperactivity+impsulvitiy

Question 23

Diagnostic Classification (DSM-5) - Current Presentation

• Combined Presentation •Predominantly Inattentive Presentation
• Inattentive Presentation (Restrictive):
• Predominantly Hyperactive/Impulsive Presentation

Like everything we’ve talked about there’s heterogeneity. They’re not called subtypes anymore but instead ____. Over the course of someone’s life it might change what it looks like

1. Child has both the inattentive and hyperactive+impulsive
2. Kids with this type likely to ____ through the cracks, girls typically have this one
3. Only inattentive symptoms
4. No/little inattentive

Most common question is what’s the difference btw ADD and ADHD? Distinction not used anymore but ADD referred to the more ____ ones and ADHD to more combined/ ____ ones

Answer 23

presentations
slip

inattentive
hyperactive

Question 24

DSM-5 Diagnostic Criteria for ADHD

Either (1) or (2)
1. ____ or more symptoms of inattention for at least ____ months
2. ____ or more hyperactive-impulsive symptoms for at least ____ months
Some evidence of symptoms before age ____
Several symptoms present in 2 or more ____
Significant ____
Rule-out other similar diagnoses

1. If they have both its combined or if just one they have just one, you get their presentation from this first criteria
2. ADHD classified as a neurodevelopmental condition, so if someone at age 18 suddenly has inattention/hyperactivity it probably isn’t ____. This doesn’t mean it has to be diagnosed before 12 though, it means theres a ____ over development (ex. child held back in kindergarten, having to switch classrooms). Some kids get pretty far along before they get services, especially if they’re bright bc it was masked since he was smart and wasn’t discovered until 3rd grade.
3. Home, school, peers, work. This shows that theres something more pervasive, its not just an artifact of the situation. So if the child’s inattention is just in math class, it could be from the classroom, the teacher, of their math skills. Maybe there’s a specific learning disability that is making math more difficult
4. We all see some element of ADHD in ourselves, you go to any preschool you’ll see kids bouncing off the walls. So how do we label it? Kids all do this but not where it starts to cause interference in school.

Answer 24

6
6
6
6
12
settings
impairment

ADHD
progression

Question 25

Implications for Dental Practice

• Research on prevalence of dental caries is ____
• May impact oral health in various ways:
• Poor ____ (e.g., not brushing long enough, brushing less frequently)
• ____ (e.g., ingestion of more sweets as rewards)
• Side effects of ____ (e.g., xerostomia)
• Managing behavior during the dental visit

1. Since kids lose their baby ____ it might hide some of their bad oral hygiene habits since it takes some time for dental caries to form
2. The main symptoms of ADHD can show up here. Now theres those toothbrushes that tell you how long to brush bc with ADHD staying sustained for 2 min is hard.
3. Indirect way bc they dont crave more sweets or anything but very often they are behavior problems and sweets can be an effective reward so they might be getting more than other kids
4. If you get them into the chair and they’re not anxious then the trick is to keep them there and focused as long as possible
   - kids with ADHD have a higher tendency of ____ that result in injury. Go to the ER more and more accidents once they start driving. The question is how much of that results in injuries to the teeth

Answer 25

inconsistent
hygiene
diet
medication
teeth
accidents

Question 26

When an Elephant is not an Elephant Diagnosing ADHD)
A. Problem Behavior Overlap
◦ \_\_\_\_, anxiety, stress, abuse
B. Co-\_\_\_\_
C. \_\_\_\_/Situational Influences 
◦ Is the problem real?

1. The problem behaviors of ADHD occur in other problems
2. Hard to diagnose bc its comorbid with lots of other things. Ex. Learning disabilities, dyslexia. Are they not focusing bc they cant ____ the material as well and are giving up and getting distracted
3. ADHD varies a lot on the context. Kids can focus on video games for a whole hour but not on math hw. This is similar to anxiety.. if I have a fear of spiders I’m not anxious all of the time, just when theres a spider. With panic attacks i also just get it from a specific physiological cue

Ex. Kids with ADHD have more difficult holding things in there working memory and processing it. So if everyone in the room has ADHD and i give a math problem, one half of the room gets scrap paper and one half has to do it in their head. The paper side will do better bc it has reduced the load on working memory. There are ways that highlight ADHD more than others. ADHD kids are hunters in a farmers world

Answer 26

depression
morbidity
contextual
read

Question 27

ADHD and Executive Function

ADHD as a disorder of impaired ____ control (self- regulation)
Delay or impairment of important executive functions:
• ____ – (holding info in mind)
• ____ an approach to a task
• ____ our performance
• tuning out ____
• Executive function and oral hygiene behaviors

Most research points to deficits in executive function and self-regulation
-its not that they cant pay attention they just have a harder time regulating their ability to do so
1. If they have a good question and i keep talking they will eventually blurt it out bc of poor
working memory
2. They dont think if i push billy over i will get in trouble
3. Paying attention to my emotions
4. There’s a gentle hum of the A/C in this room, and everyone typing hitting their keys. ADHD
kids have more trouble tuning those out. I keep saying kids but ADHD occurs throughout the
age span
5. All oral hygiene involves ____ function and a whole new set of procedures. ADHD is deficits in these kinds of functions that show up in certain situations more
-ADHD kids to develop and improve on these functions over time, ADHD less visible in adults than kids bc a lot of it has leveled out over development

Answer 27

inhibitory
working memory
planning
monitoring
distractions

executive

Question 28

ADHD: Etiology/Contributing Influences

Genetic Vulnerability
•Evidence from twin, adoption, and family (e.g., parent-child)
•Genes involved in dopamine regulation; ____ and ____

Neurobiological Factors
•Cortex reaches peak thickness about ____ years later in children with ADHD (esp. in pre-frontal cortex)
•Structural abnormalities in ____ associated with symptoms of ADHD
•Dopamine systems - related to psychomotor activity and reward seeking; ____ signals from external stimuli

1. Pretty strong evidence for heritability.
   2 most common genes are DAT1 and DRD4. There’s a couple others but those are the most frequently implicated
2. Not so much theres a true deficit but its just developing at a slower rate. Ex. A 12 yr old having working memory that is comparable to a 10 yr old
   Missing bullet that he reads
   Key areas: ____ cortex (working memory), ____ cortex (inhibition) and ____ cortex (emotional/cognitive control)
3. Read. There is some research that the overall size? (Listened 3x idk what word he says there) is 10% smaller in ADHD kids but idk about it
4. Dopamine systems are the ones that are most commonly implicated. Kids with ADHD have a harder time regulating their behavior in response to consequences

Answer 28

dopamine transporter (DAT1)
dopamine receptor (DRD4)

2-3
basal ganglia
decreasing

dorsolateral prefrontal
orbital prefrontal
anterior cingulate

Question 29

Approaches to Interventions for ADHD

Medication
◦ Stimulants
◦ Antidepressants & Other non-stimulants

Psychological Interventions
◦ Parent Interventions
◦ School-Based Interventions
◦ Intensive Summer Treatments

Non-conventional Treatments ◦ Dietary modifications
◦ Neurofeedback

1. ____ are most common ‘fix’ for ADHD. Stimulants are the most common used
2. ____ intervention, so you’re either going to work with the parents/schools or theres some intensive summer programs offered - learn behavior and self-regulation skills. Intervention is focused on parents and teachers bc they spend the most time with the kids and are most equipped to help
3. Wide range of these, most are garbage. ____ changes have not been shown to make any changes at large. ____ has shown some brainwaves modified when under certain stimulus (like a video game that has kids focus on a barrel and it explodes when they do). This gives immediate feedback on physiological process that are used in attention. Not widely used, shows some promise

Answer 29

meds
psychosocial
dietary
neurofeedback

Question 30

Medications for ADHD

Stimulant Medications - target ____ system and ____ (agonist)
◦ ____ forms (e.g., Ritalin, Focalin (XR), Concerta, Metadate)
–◦ short-acting (3-4 hours) and long-acting (8 – 12 hours)
◦ ____ forms (e.g., Adderall (XR), Dexedrine, Vyvanse)
–◦ Short-acting (3-4 hours) and long-acting (10 – 14 hours)

Non-Stimulant Medications
◦ Strattera (____ agonist)
◦ ____ (e.g., Wellbutrin)

1. These are ____-acting (unlike the SSRIs we discussed), but come in short and fast-acting forms. Short takes effect quickly, but the long will get them through the school day. Different from SSRIs bc you will see the effect relatively quickly and you can stop it and it leaves quickly (ex. Give it only on school days and not the weekends). This isnt possible with SSRIs bc it takes weeks to get up to full therapeutic dosage
2. Is an SSRI, typically not that effective - not first line of treatment. Good for if kid cant take a stimulant (ex. ____ condition). Parents want to stay away from stimulants bc amphetamine scares them but the method of action is a lot different

Answer 30

dopamine
norepinephrine

methylphenidate
amphetamine

norepinephrine
antidepressants

fast
cardiac

Question 31

Conceptualizing Psychosocial Interventions for ADHD

Antecedents -> Behavior -> Consequences

Think about child behavior:
Antecedents - what happens ____ the behavior occurs, the when/where. Give me an example of a high risk scenario (where you’re child is likely to act out) - those are the antecedents. We want to think when it happens.. doing math/etc

Consequences - what kinds of things ____ or discourage the behavior. Take the kid in class and struggles in math and he’s being distruptive. If he has to leave the room is he more or less likely to do it again? More if he really is bored and wants to get out of class.

We want to change what we ____ to make the behaviors more likely and how we ____ to them

Answer 31

before
encourage

do
respond

Question 32

Considerations for Dental Practice: ADHD

Modifying the Antecedents
◦ \_\_\_\_ of medication and appointment
◦ Prompts (post-it notes, smartphone alerts, etc.)
◦ \_\_\_\_ up procedures
◦ Vivid, simplified, direct instructions

Modifying the Consequences
◦ Reinforce ____ behaviors, token systems etc.
◦ Behavior Contracts
◦ Reinforce an ____ behavior (e.g., stress ball)

1. Time it based on when they took their meds, prob not at end of day when meds are wearing off
2. Any kind of visual stimulus to remind them, reduces demand for executive function
3. Break down the instructions so they understand
4. May help them stop fidgety
   This is the approach for most psychological interventions.. how can we set the classroom up so they behave differently, how do we set up different rewards

Answer 32

timing
breaking

positive
alternative

Question 33

Stress and Mental Health in Dental Students

Depression, anxiety and suicidal ideation are common among medical and dental students and may vary depending on stage of training.
• Dental students report higher levels of stress on several dimensions:
• “____” – feeling hurried, too many external demands
• “ ____” – feelings of discouragement, joylessness, worry (Montero-Marin, et al., 2014)
• 10% (moderate or severe depression) 37% (mild depression) among dental students; 6% suicidal ideation (Deeb et al., 2016)
• ____ attitudes about seeking mental health services are common (Ey et al., 2000)

1. Some years are more stressful than others
2. Part of the stress is you cant be in every place at once
3. Also are you enjoying what you’re doing. If you’re not, that’s a source a stress - bc you’re
   putting in a lot of work and not feeling like you’re getting enjoyment from it
4. Probably underreported
5. A reluctance to need help bc we pride ourselves on being able to help others

Answer 33

tenseness
frustration
negative

Question 34

Burnout

Components:
• ____ exhaustion - feelings of being emotionally overextended and exhausted at one’s work
• ____ - unfeeling and impersonal response toward recipients of one’s service, indifference or a distance attitude towards one’s work
• ____ – lack of personal accomplishment or feelings of competence and success in one’s work
• Combatting burnout?

If you ignore the signs of stress you eventually get burnout, no one starts out in their profession thinking they will get burnt out but it creeps up on us
1. Most commonly its emotional exhaustion
2. Distinsing of yourself from the people you’re working with, its an underlying part of burnout
3. You could be really busy but if you dont feel like you’re accomplishing something that can be a source of burnout. If part of your stress is not feeling accomplished this will be a problem.
4. People who successfully combat burnout are those who find ____ (focus on improvement
not competition) in their work and get ____ by others.

Answer 34

emotional
depersonalization/cynicism
inefficacy

meaning
recognized