Mental state examination

Question 1

Steps in mental state exam?

Answer 1

1. Appearance 2. Behaviour 3. Speech 4. Mood and affect 5. Thought 6. Perception 7. Cognition 8. Judgement

Question 2

What are the assessment tools we can use?

Answer 2

• DASS21
• (or SODA40)

The Depression subscale of the DASS-21 is reported to have a sensitivity of 57.0% and a specificity of 67.0%

The Anxiety subscale of the DASS-21 is reported to have a sensitivity of 86.0% and a specificity of 64.0%.

Question 3

Examples of psychiatric presentation that are actually systemic disorders?

Answer 3

hypothroidism, may present with depression

. Panic disorder (or acute anxiety) may be mistaken for an acute myocardial infarction

Question 4

What questions do we need to ask if patient has a psychiatric disorder?

Answer 4

• Present or past
• Duration
• Any precipitating events – not always
• Treatment pharmacological and non pharmacological
• Antipsychotics can have long term side effects

Question 5

What are mood disorders?

Answer 5

Extreme exaggeration of mood and affect

• Depressive disorders
• Bipolar disorder
• Secondary to systemic conditions, medications (65%)

Question 6

Depressive Disorder types and stats?

Answer 6

•major, persistent, postpartum

• MDD lifetime prevalence about 12%
• Age 15-25yrs F:M 2:1
• >15% above 65ys, higher in nursing homes
• Etiology variable – NT disturbance, emotional stressor, Altered HPA axis
• Lost of interest, fatigability, disturbed sleep and or appetite, loss concentration, attention, self esteem

Question 7

Dental Considerations for Depressive disorders?

Answer 7

• Lack of interest – poor oral hygiene, dental caries, reduced salivary flow rate + output, periodontal disease (Fiedlander et al 2001)
• Low serotonin- increased carbohydrate craving, impaired taste perception
• Common presentation - Chronic facial pain, burning sensation of the oral mucosa (often tongue) or TMD (Brown et al, 2010; Fiedlander et al 2001)
• lower tolerance for pain or discomfort associated with dental conditions or treatment
• uncooperative irritable during tx (Brown et al, 2010; Fiedlander et al 2001)
• No contraindication to tx in depressive episode but best to postpone complex surgeries until stable

Question 8

What is Bipolar disorder?

Answer 8

Manic/depressive. The exact cause of bipolar disorder isn’t known, but a combination of genetics, environment and altered brain structure and chemistry may play a role.

• 1 in every 100 adults, M:F 1:1; late adolescence – early adulthood
• Etiology ill-defined, neurochemical abnormalities?

Question 9

Types of Bipolar?

Answer 9

Bipolar 1

• Mania – disinhibited, talkative, excitable, elated, irritable, display grandiosity, maybe demanding and intrusive
• Alcohol and drugs a common problem

Bipolar 2

• Hypomania

Question 10

Dental implications of Bipolar?

Answer 10

• Xerostomia, stomatitis, metallic taste, lichenoid reactions (Clark 2003)
• Manic phase abrasion due to rigorous brushing
• Depressive phase presentation similar depressive disorder

Question 11

What is Schizoprenia?

Answer 11

• Mean age of onset mid to late 20s M:F = 1:1
• Lifetime prevalence 1%
• Delusions, hallucinations, erratic or bizarre behavior, disorganized speech, poverty of thought
• Can be confused, withdrawn, anxious, pace about
• Etiology – disturbance in dopamine mediated neuronal pathways

Early identification and intervention:

There appears to be a long-term advantage for the early identification and treatment of psychosis. The most difficult part in this is the identification of young people experiencing psychotic symptoms. Health and community agencies have an important role in the prompt identification of psychosis and early referral.

Question 12

How is schizophrenia diagnosed?

Answer 12

Diagnosis:

Psychosis needs early identification and treatment; however, it is good clinical practice to delay definitive diagnosis at the first presentation of a psychotic episode, as bipolar disorder and schizophrenia may be indistinguishable initially. Relevant investigations for possible organic aetiologies are required and specific attention should be paid to possible comorbid conditions (eg substance abuse, depression). The longitudinal course of illness will help clarify the diagnosis.

Question 13

Management of Schizophrenia?

Answer 13

Tailored treatment:

Treatment should be carefully tailored to the unique needs of the individual, taking into consideration the patient’s age, gender, ethnicity, psychosocial maturity, stage of illness, style of recovery, personality, coping style, cognitive abilities, natural aptitudes, living situation, medical risk factors and socio-cultural environment. Because of difficulties with insight and poor motivation, care may sometimes need to be assertively provided with the assistance of a community mental health team.

The role of the family:

Families have a central role in the treatment of young people with schizophrenia through the provision of social and emotional support, financial assistance and a stable, secure living environment.

Psychosocial interventions:

Pharmacological treatment is only one part of a comprehensive management approach that also includes a range of psychosocial interventions. Intensive multimodal interventions with assertive follow-up should be pursued for 3 to 5 years from the onset of the first psychotic episode. This gives the patient the best opportunity possible to achieve stable remission and maximise their levels of functioning in the community. Longer-term psychosocial interventions will be required for most people with a chronic psychotic illness.

Pharmacological treatment:

Antipsychotics are the cornerstone of the management of schizophrenia

Overactivity and aggression should be treated with appropriate and safe containment. Antipsychotics or benzodiazepines can be of use

Ongoing treatment of the psychotic illness should be considered separately to the treatment of the behavioural emergency.

The prevention of relapse by maintaining antipsychotic therapy is a crucial element in caring for people with schizophrenia.

Concordance with antipsychotic therapy is perhaps the biggest challenge in treatment, with nonconcordance being the largest single cause of relapse, especially in young people with recent-onset disease

Question 14

Dental Implications of Schizophrenia?

Answer 14

• Mild schizophrenic features (which are often unrecognized) include loss of social contact, flatness of mood or inappropriate social behaviour, which may appear at first as mere tactlessness or stupidity. Thus the patient, when asked to sit down in the surgery, may sit in the operator’s rather than the dental chair. Attempts at communication are met by a response that indicates a failure to get through or are interrupted by totally irrelevant remarks. Such patients may have delusional oral symptoms and psychiatric help must be sought.
• Phenothiazines can cause adrenaline (epinephrine) reversal in patients given in LA (there is vasodilatation instead of the anticipated vasoconstriction because of the alpha-adrenergic blocking activity of phenothiazines).
• Conscious sedation is safe.
• Tramadol: there is a risk of seizures.
• Haloperidol and phenothiazines may cause orthostatic hypotension.
• Haloperidol and droperidol reportedly block the vasoconstrictor activity of adrenaline (epinephrine).
• GA, especially with intravenous barbiturates, can lead to severe hypotension and should therefore be avoided if possible.
• The long-term use of neuroleptics can lead to xerostomia (with susceptibility to candidosis and caries, and, occasionally, ascending parotitis), oral pigmentation and severe extrapyramidal symptoms.
• Muscular rigidity or tonic spasms (facial dyskinesias), frequently involving the bulbar or neck muscles, with subsequent difficulties in speech or swallowing. Alternatively, there may be uncontrollable facial grimacing (orofacial dystonia), which may start after only a few doses. This may be controlled by stopping the neuroleptic and giving anti-parkinsonian antimuscarinic drugs.
• Haloperidol and clozapine can cause hypersalivation. 


Question 15

What are the common comorbidities of schizophrenia?

Answer 15

Comorbid disorders:

Depression and anxiety require specific enquiry as they are frequently missed. They may settle with the treatment of acute psychotic symptoms

Psychological therapies for depression also have a valuable place in treatment.

People with schizophrenia often have problems associated with comorbid abuse of alcohol, nicotine and/or illicit drugs. This requires careful clinical assessment and a therapeutic approach that incorporates the treatment of both substance use and schizophrenia concurrently

Question 16

What is Anxiety?

Answer 16

5% to 6% , presneting in early adulthood to 50s.

Anxiety is often a healthy response to uncertainty and danger, but constant worry and nervousness may be a sign of generalized anxiety disorder. excessive activation of fight or flight

• Excessive levels of apprehension, anxiety or even terror
• Panic disorders, generalized anxiety, OCD, phobia

Physical symptoms — racing heart, dry mouth, upset stomach, muscle tension, sweating, trembling, and irritability

Question 17

What is OCD?

Answer 17

•OCD – present with excessive preoccupation with structure or functioning of any part of oral cavity

Question 18

Phobia specific anxiety in the dentasl practice?

Answer 18

•Site of needle, dental chair, vibration and sounds

Question 19

Issues with anxiety in the dental practice?

Answer 19

• May appear hostile in their responses, or be on the edge
• Usually avoid dentist, visit in an emergency requiring invasive tx, further exacerbates fear-> vicious cycle (Armfield et al, 2006 & 2007)

Question 20

Managment of Anxiety?

Answer 20

• Need to be very patient
• Good communication and rapport
• Early morning appointments – no wait time
• Anxiolytics
• Effective LA, distraction and relaxation techniques
• Nitrous, IV sedation
• GA in dental phobic patient
• Management of panic attack in chair

Question 21

what are somatoform disorder?

Answer 21

• Physical complaints without underlying physiological abnormalities
• If disorder present doesn’t’t explain nature or extent of symptoms
• •Multiple recurrent changing physical complaints
• •Abnormal sensations/ pain present for months or years

Question 22

What are example of somatoform disorders?

Answer 22

•Hypochondriacal disorder – insistent on a underlying serious disorder

• •Severe distressing persistent pain – no underlying cause

•Body Dysmorphic Disorder

• a persistent preoccupation with a presumed defect or deformity, which is out of keeping with reality and causing significant personal and social dysfunction
• Demands for unnecessary Complex dental reconstructive procedure
• more common in women

Question 23

How to manage somatic disorders?

Answer 23

• Repeated requests for examination and investigations
• Need to be empathetic, give assurance
• Fail to accept reassurance that no physical basis of problem
• Must not perform dental treatment until cause can be found
  
  • Don’t let patient pressurize you into treatment
• Management challenging – early identification and referral to psychiatrist
• Can be very demanding
• Important that you actually rule out all etiological factors prior to attributing symptoms to psychiatric disorders
• Will be very skeptical about psychological basis of disease/referral
  
  • need to stay involved

Question 24

Indication for referral for somatic disorder?

Answer 24

(1) A thorough search from a clinical standpoint has failed to provide any evidence of a disease process that could explain the symptoms;
(2) the symptoms have been present long enough that if they were related to a disease process, a lesion would have developed;
(3) symptom localization does not reflect known anatomic distribution of nerves; and
(4) underlying systemic conditions that could produce the symptoms have been ruled out by laboratory tests or by referral to a physician

•Exclude Malingering and factitious disorder

Question 25

What is an eating disorder?

Answer 25

Disturbed body image

usually to lose weight

Question 26

What are two mains of eating disorder?

Answer 26

• Anorexia Nervosa – excessive dieting +/- vomiting, purging
• Bulimia Nervosa – binge eating -> vomiting, purging

Question 27

Signs of eating disorder?

Answer 27

• Erosion on palatal surfaces of teeth
• Erythema, periodontitis
• Calluses on dorsum of fingers (Russell’s sign)
• Bilateral sialadenosis – cessation of vomiting usually results in resolution of parotid gland

Question 28

Referral to psychiatrist for eating disorder indication?

Answer 28

•Malnutrition, vit deficiency, profound electrolyte disturbances -> fatal arrhythmias, esophageal tears, suicide risk, hypotension, loss of bone density, hypotension

GP –medicare gives 10 free sessions if referred by them, but can refer independatly. Can be different in the hospital, multi dis for chronic pain so those specialists are already present

Question 29

What is an organic brain disorder?

Answer 29

• Brian dysfunction-> cognitive impairment, memory loss or disorientation
• Delirium – acute brain syndrome
• Confusion, clouding of consciousness, disorientation, agitation, poor memory, inattention emotional upset

•Dementia – chronic brain syndrome

• Loss of memory especially short term, loss of orientation, deterioration in social functioning and behavioral control
• >65yrs of age, can have early onset <65yrs
• “Do you know how long you’ve been here? What day it is?”

“Ask them something you spoke about 3-5 minutes ago”

Question 30

What is the management of organic brain disorders?

Answer 30

• Maybe on antidepressants, antipsychotics to manage other symptoms – depression, hallucination, anxiety insomnia agitation
• Undiagnosed – identify signs + symptoms – refer
• Trauma de to falls, caries, perio, xerostomia
• struggle to follow advice
• Cooperation during dental treatment is a problem
• Pain and infection may exacerbate confusion and cognitive impairment
• Consider anxiolytics to mange behavior

Question 31

What drugs are used in depression?

Answer 31

• Tricyclic antidepressants- nor/amitriptyline, imi/clomipramine
• SSRIs – fluoxetine (prozac), escitalopram (lexapro), setraline (zoloft)
• MAOIs – phenelzine, tranylcypromide
• Atypical antidepressants

SSRI and AA increase extrapyramidal levels of serotonin, thereby inhibiting dopaminergic pathways that control movements

Question 32

What drugs are used in bipolar managment?

Answer 32

• Lithium, lamotrigine, carbemazepine, valproate – mood stabilizing
• combination of antidepressants
• Antipsychotics/ neuroleptics

Question 33

What medications are used in schizophrenia?

Answer 33

• Antipsychotics – olanzepine, risperidone, clozapine
• mood stabilizers – lithium, valproate carbemazepine

Question 35

Issues with medications used in phsychiatric disorders?

Answer 35

• SSRIs & AA – bruxism + clenching
• TCAs – increase Carbohydrate craving
• SSRIs, AAs TCAs –increase xerostomia – block parasympathetic stimulation
• Alcohol or drug abuse – LFTs
• Antipsychotics + some mood stabilizing drugs can cause agranulocytosis, thrombocytopenia, leukopenia
• MAO + SSRIs, antipsychotics – postural hypotension
• LA safe
• NSAIDs – prolonged use lithium toxicity – Short Term use nil problem

Question 36

What are consent issues around psychiatric patients?

Answer 36

1. Capacity to consent? informed consent
2. gaurdian ship/carer, finacial as well as risks?
3. If in doubt, ask psychiatrist’s opinion regarding patient’s medico- legal competence to sign a consent form

Question 37

Issues with suicide?

Answer 37

• Men more successful, women more likely to attempt
• Enquire about it “ have you ever thought about ending it all?”
• “Do you ever feel like going to sleep and never waking up?”
• Questions about it do not prompt the act in patients
• Immediate medical care

Question 38

Consideration for pts with PTSD?

Answer 38

• Sexual/childhood abuse and PTSD
• Always have another staff in the room
• Patient and calm manner

Question 39

Issues for patients with substance abuse disorders?

Answer 39

• Poor physical coordination
• Looking unkempt
• Unusual body odors
• Blood shot or glazed eyes

Question 40

Phenotypes and disorders?

Answer 40

• Psychiatric disorders -> complex interactions between multiple genes the environment
• Behavioral phenotypes - Known chromosomal and genetic abnormalities -> mental disorders
• Behavioural phenotypes – cognitive personality and behavioural patterns -> may characterize psychiatric disorders or syndromes
• Down syndrome – depression (most common)
• •Schizophrenia and bipolar low
• Dementia common

•Prader-Willi syndrome – mood swings, depression

Question 41

Treatment modifications we can use?

Answer 41

May be better to try medication and then return instead of procedure straight out or use staged procedures so you can build that rapport with them.

Be aware hypersentive patients/ depressive - anterior region consideration

Question 42

Dental consideration of personality disorders?

Answer 42

• Personality disorders may make unreliable patients
• They are unlikely to have any conscience about missing appointments or to pay much attention to oral health-care instructions.
• Treatment plans may be argued about or frankly refused.
• Payment may be withheld and litigation threatened.
• Dental staff may also have personality disorders and find themselves in conflict with others, including colleagues – often to the dental staff’s disadvantage, and may find it difficult not to antagonize patients and colleagues.
• The lifetime prevalence of alcohol use problems at 43% to 77% and with other drug use problems affecting about 50% to 60%
• When people with personality disorders present in a crisis, clinicians often feel the need to offer them something to assist and hence may feel compelled to offer medication because there is no apparent alternative.

Question 43

Extra medication or aprehensive patients?

Answer 43

Premed: depends on medications already on, benzo – use to use diazepam but now more common to use temazolam, etc (have table with half life doses), need consent prior (have chap in room which is good, cant take care of children, drive, or go on public transport legally). and escort to leave as well as payment to be done prior. Have written out instructions for prior, during and afterwards.

Antitriptoline (50 verse 100) low doeses more for neuropathic pain but high doses have sedative effect (past 80mgs)

Question 45

What is the HPA axis symptoms?

Answer 45

Axis I: All psychological diagnostic categories except mental retardation and personality disorder

Axis II: Personality disorders and mental retardation (more appropriately termed “intellectual disability”)

Axis III: General medical condition; acute medical conditions and physical disorders

Axis IV: Psychosocial and environmental factors contributing to the disorder

Axis V: Global Assessment of Functioning or Child Global Assessment of Functioning [cGAF]

Question 46

How does diagnosis on the HPA scale change pain sensation?

Answer 46

When the HPA axis is activated repeatedly, like in periods of chronic stress or pain, more cortisol ends up circulating through the body. To compensate, the body attempts to regain equilibrium by reducing hormone levels. It can suppress the adrenal gland’s ability to produce cortisol.

Patients with chronic pain have been shown to have lowered baseline levels of cortisol. In other words, when they are not actively feeling pain, they have less cortisol in the body than healthy individuals

However, as the HPA axis is a negative feedback loop, it relies on its product to eventually turn off the reaction. When there isn’t enough cortisol to reach the hypothalamus, the system continues producing hormones, lengthening and enhancing the stress response.

As expected, individuals suffering from chronic pain have been found to have lower baseline levels of cortisol and higher levels following stress than healthy subjects

Question 47

5 axes of mental health?

Answer 47

• Axis I provided information about clinical disorders
• Axis II provided information about personality disorders and mental retardation
• Axis III provided information about any medical conditions that were present which might impact the patient’s mental disorder or its management
• Axis IV was used to describe psychosocial and environmental factors affecting the person
• Axis V was a rating scale called the Global Assessment of Functioning; the GAF went from 0 to 100 and provided a way to summarize in a single number just how well the person was functioning overall. 100 fine, 10 self danger