Psychiatric Conditions Flashcards
What is neurosis and name some symptoms of neurosis
- Excessive degrees of normal phenomena
- Common
- Quantitatively different
- Anxiety
- Depression
- Somatisaiton
What is psychosis and name some symptoms of it
- Thought disorder
- Rare
- Qualitatively different
- Schizophrenia
- Manic depressive illness
- Delusions
- Hallucinations
What are anxiety neuroses
Various combos of psychological and physical manifestations of anxiety, not attributable to real danger - extensions of normal emotions
What are the signs and symptoms of anxiety neuroses caused by and what can they present as
Caused by sympathetic overactivity can occur as panic attacks or as a persisting state could result from a specific trigger = phobias
What are the psychological symptoms and signs of anxiety neuroses
- Fearful anticipation
- Irritability
- Restlessness
- Sensitivity to noise
- Repetitive worrying
- Poor concentration
- Subjective reports of poor memory
What are the respiratory symptoms of anxiety neuroses
RS - difficulty inhaling (exhalation in asthma), feeling of chest constriction, overbreathing
What are the cardiovascular symptoms of anxiety neuroses
Cardiac discomfort, Palpitations
What are the Gastrointestinal symptoms of anxiety neuroses
XS wind Aerophagy Difficulty swallowing Dry mouth Loose stools
What are the genitourinary symptoms of anxiety neuroses
Increased frequency of micturition
What are the neurological symptoms of anxiety neuroses
- Tinnitus
- Dizziness
- Blurring of vision
- Paraesthesia
What are the muscle-skeletal symptoms of anxiety neuroses
Aching
Stiffness
What are the sleep disturbance symptoms of anxiety neuroses
- Difficulty in getting off to sleep
- Night terrors
- Intermittent waking
What are some of the psychological symptoms of panic disorders
- Intense fear
- Impending doom
- Impaired concentration
- Depersonalisation
- Fear of losing control
- Going crazy or dying
What are some of the psychological symptoms of physical disorders
- Chest tightness
- Palpitations
- Tachycardia
- Trembling
- Paraesthesias
- Sweating
- Dry mouth
- Shortness of breath
What is generalised anxiety disorders
- Generalised, persistent, excessive anxiety about everyday circumstances lasting > 6 months
- Prolonged waxing and waning course
What must be excluded when diagnosing generalised anxiety disorders
Organic causes like thyrotoxicosis, phaechromocytoma, hypoglycaemia
What psychological treatment is there for generalised anxiety disorders
- Reassurance, counselling and psychotherapy
- Behavioural therapy once avoidance behaviour established
What pharmacological treatment is there for generalised anxiety disorders
- Anxiolytic agents e.g. benzodiazepines (short term)
- Antidepressants may be helpful owing to anxiolytic properties
- Beta blockers (symptomatic relief)
What management can there be for simple specific phobias e.g. spiders, darkness, heights
Cognitive behaviour therapy - exposure
Anxiety management training - flooding
What is agoraphobia and who is most likely to develop it
Fear of open spaces or situations from which escape might be difficult e.g. crowd, bus, train. Severe cases patients may be confined to home
Most common in females
What is social phobia
- Anxiety provoked by social performance situations
- Fear of behaving in a manner that will be humiliating or embarrassing
What are some treatment methods for social phobia
- Monoamine oxidase inhibitors, selective serotonin reuptake inhibitors (anxiolytics)
- Exposure by systematic desensitisation
- Cognitive therapy
What are obsessions
Unwelcome, persistent, recurrent ideas, thoughts, impulses or images that are intrusive senseless and recognised and absurd
Can occur as thoughts, ruminations, doubts, impulses, phobias
What are compulsions
Repetitive, purposeful, behaviours performed in response to an obsession in a stereotyped fashion -
70% of patients will have an anankastic personality trait - involves cleanliness, hand washing, touching, checking
What is OCD
Obsessive-compulsive disorder
- Absurd, time-consuming (>1hr/day) obsessions and compulsions that interfere with individual’s everyday functioning
What management options are there for OCD
Cognitive-Behaviour therapy: - Exposure and response prevention - Thought stopping - Habituation training Drug Therapy - Clomipramine - Serotonin uptake inhibitors e.g. fluoxetine
Describe Cognitive Behaviour Therapy (CBT)
- Patients challenge their patterns and belief
- Replaces errors in thinking with more realistic and effective thoughts
- Encourages patients to take a more open, mindful and aware posture towards them to diminish their impact
Describe psychosis and name some key features
- Contact with reality is lost
- Normal mental processes suspended
- Normal constraints abandoned
Features: - Halluncinations
- Delusions
- Thought disorder
- Loss of insight
What disorders can psychosis be associated with
- Bipolar affective disorder
- Schizophrenia
- Paranoid state
Define delusion
Fixed, false belief which is out of keeping with person’s religious and cultural background and which is maintained even in the face of evidence to the contrary
Define hallucination
False sensory perception in absence or real external stimulus
Describe what schizophrenia is
- Disintegrative psychosis involving loss of contact with reality
- Splitting of normal links between perception, mood, thinking, behaviour and contact with reality
What classes can be schizophrenia be split into
- Paranoid
- Herbephrenic or Disorganised
- Catatonic
- Undifferentiated, simple
- Residual
- Type I
- Type II
Describe the paranoid class of schizophrenia
Prominent persecutory or grandiose delusions and auditory hallucinations may appear normal until abnormal beliefs uncovered
Describe the Hebephrenic/Disorganised class of schizophrenia
Silly and childish behaviour, thought incoherence, disorganised behaviour
Describe the Catatonic class of schizophrenia
Motor immobility, rigidity, posturing, excitement, copying speech and behaviour
Describe the undifferentiated, simple class of schizophrenia
Insidious social withdrawal deterioration, defect state, absence of delusions, hallucinations. Will have negative symptoms such as withdrawal
Describe type 1 schizophrenia and symptoms
Acute onset, positive symptoms:
- Delusions, hallucinations
- Thought disorder
- Speech
Describe type II schizophrenia and symptoms
Chronic, negative symptoms
- Lack of drive
- Withdrawn
- Depression common
- Poverty of speech
- Poor attention and memory
What are the clinical features of schizophrenia
Auditory hallucinations:
- 3rd person arguing about the subject
- 3rd person commentary on subject’s actions
- Audible thoughts
- Thought insertion/withdrawal
- Thought broadcasting
- Somatic passivity
- Delusional perceptions
What are the treatment options for schizophrenia
Antipsychotics - neuroleptics/major tranquillisers
- Orally e.g. chlorpromazine, fluphenazine, risperidol
- IM with long acting depot injections
- Psychotherapy
What is the action and side effects of antipsychotics that treat schizophrenia
- Alter dopamine/Cholinergic balance in basal ganglia
- Extrapyramidal and anticholinergic effects frequent
- Dystonia/Dyskinesia
- Akathisia
What are the oral effects of schizophrenia
- Neglect of dental care - caries and periodontal disease
- Smoking - dental staining risk or oral precancer and cancer
- Difficulties with communication
- Delusional oral symptoms
- Side effects of neuroleptics - haloperidol and clozapine can cause hyposalivation - decreased salivary flow = cadidosis and caries
What are affective disorders
- Characterised by mood disturbances - inappropriate depression or elation
- Usually accompanied by abnormalities in thinking and perception out of mood disturbance
Give some examples of affective disorders and describe them a likkle
- Bipolar affective disorders (BAD) - recurring attacks of mania and elation
- Unipolar affective disorders - recurring attacks of depression only
- Mixed affective states - manic and depressive symptoms occur simultaneously
What are the clinical features of depression
- Depression of mood
- Loss of enjoyment (anhedonia)
- Reduced attention and concentration
- Poor memory
- Ideas of guilt and worthlessness
- Lowered self esteem
- Reduced energy (anergia)
- Hopelessness, helplessness
- Suicidal ideation
What are some of the biological features of depression
- Sleep disturbance
- Change in appetite/weight
- Change in psychomotor activity
- Diurnal variation in mood, worse in am
- Loss of interest in work and pleasure activities
- Loss of energy
- Loss of libido
- Constipation
- Change in menstrual cycle - amenorrhoea
Describe the appearance and speech of a person with depression
- Dishevelled, neglected dress and grooming
- Facial features - down-turning of corners of mouth, furrowing of brow
- Reduced rate of blinking
- Reduced gestural movements
- Shoulders bent, head inclined forwards, downwards gaze
- Poverty of speech
- Speech slow and hesitant
What are some of the psychotic features of depression
Delusions:
- concerned with ideas of worthlessness, guilt, ill-health, poverty
- Persecutory which patient feels to be justified
Hallucinations:
- Usually second person auditory confirming patients ideas of worthlessness
What is required to diagnose someone with depression
Loss of interest or pleasure or depressed mood for > 2 weeks + 4 or more of the following:
- Appetite change of weight change
- Insomnia or hypersomnia
- Early morning waking with diurnal mood variation
- Psychomotor retardation or agitation
- Decreased sexual drive
- Reduced ability to concentrate
- Ideas of worthlessness
- Recurrent thoughts of death/suicide attempts
What management options are there for depression
- Cognitive behaviour therapy (CBT)
- Antidepressants - take at least 4 weeks to start working:
- Lithium/carbamazepine for mood stabilisation
- Electroconvulsive therapy ECT - severe cases
What are types of antidepressant are used for depression and give some examples
- Tricyclic antidepressants - amitriptyline, dolesupin
- SSRI’s - fluoxetine, partoxetine, citalopram - fewer adverse effects, less dry mouth
What are the dental aspects of depression
- Defer treatment until depression is controlled - care with analgesics
Oral symptoms of depression: - Disturbed taste
- Persistent idiopathic facial pain
- TMJ dysfunction
- Delusions - discharges/slime from mouth, halitosis
What are the adverse effects of treatment
Dry mouth (TCAs, lithium) Altered taste sensation
Describe what bipolar disorder is
Spectrum of mood disorders includes bipolar I, bipolar II, cyclothymia (oscillating high and low moods, and major depression
What happens in bipolar affective disorders (mania)
Sustained period of elevated, euphoric or irritable mood
What happens in the individual episodes of bipolar affective disorders (mania)
- Brief depressive episodes
Manic episodes: - increased speech, pressure of speech
- decreased need for sleep, absence of fatigue
- overspending, uninhibited sexual behaviour
- insight impaired
- 10-20% of patients have schneiderian first rank symptoms of schizophrenia
What symptoms are there of manic episodes
- Grandiosity
- Diminished need for sleep
- Excessive talking or pressure speech
- Racing thoughts or flight of ideas
- Clear evidence of distractibility
- Increased level of goal-focused activity at home, at work, or sexually
- Excessive pleasurable activities, often with painful consequences
Describe the appearance and behaviour of people with bipolar disorders/mania
- Dressed in bright gaudy colours
- Untidy and dishevelled
- Over-activity leading to physical exhaustion
- Excessive activity in risk taking pursuits, social indiscretion
What management options are there for bipolar disorders
- Antipsychotics - chlorpromazine, haloperidol, respiridone, olanzapine
- Sedatives for rapid tranquillisation (lorazepam)
- Lithium and carbamazepine prophylaxis - prevents relapses into mania
- ECT
What are the dental aspects of bipolar disorder
- Lithium toxicity with GA
- Long term potential to induce hypothyroidism
What are 2 common eating disorders
Anorexia Nervosa
Bullimia Nervosa
What is anorexia nervosa
Deliberate weight loss, person chooses not to eat leading to potentially serious weight loss
Weight maintained at least 15% below that expected
What are the clinical features of anorexia nervosa
- Thin, emaciated
- Dehydration
- Dental erosion and caries
- Hair loss from scalp
- Fine, downy lanugo on face and back
- Early onset - shorter stature
- osteoporosis, pathological features
- Hypokalaemia - muscle weakness, tetany
- Amenorrhoea/loss of libido or ED
What management options are there fore anorexia nervosa
- Need for controlled weight gain should be agreed
- Admit for feeding if severe, rapid weight loss, depression
- Build relationship
- Agree on weight targets
- Behavioural regime - starting with bed rest which is gradually relaxed as weight is gained
- Cognitive therapy - aims to identify and change inappropriate cognitions regarding eating behaviour, body weight and shape
- Family therapy
What are the dental aspects of anorexia nervosa
- Caution during GA
- Parotid enlargement
- Erosion of teeth
- Oral ulcers and abrasions
What is bulimia nervosa characterised by
- Repeated bouts of overeating with an excessive pre-occupation with control of body weight
- Extreme measures to counteract fattening effects of ingested foods
- bouts occurring>/= twice weekly for 3 months
Who is most likely to get bulimia nervosa
Young women - 1-2%
Rare in males
Usually present in 3rd decade
1/3 have had anorexia
What are the clinical features of bulimia nervosa
- Weight in normal range
- Repeated vomiting = oesophageal tears, haematemesis, hyperkalaemia, depression
- Sialosis - salivary gland swelling
- Dental erosion
- Calluses on dorsum of hand - Russell’s sign
- Ulcers on soft palate, angular cheilitis
What methods do bulimic patients use to counteract weight gain
- Self induced vomiting
- Periods of starvation
- Purgative and laxative abuse
- Abuse of appetite suppressants, thyroid hormones or diuretics
- Neglect to use insulin in diabetics
Describe the epidemiology of suicide
- More common in males
- More common over 45 years
- Highest rates in those who are divorced, single or widowed
- Highest rates in social class I and V
- Associated with lack of employment
- Highest rates in spring and early summer
What are the aetiologies of suicide
Psychiatric disorder
Physical illness - chronic painful illnesses and epilepsy
Parasuicide
What psychiatric disorders are associated with suicide and how common are they
Present in 90% of those who comment suicide: depressive episodes, alcohol dependence, illicit drug use, personality disorder, chronic neuroses, schizophrenia
What is parasuicide and what can this event do to the risk of suicide
An attempt at suicide/ a suicidal gesture where there is no result of death/no aim of death - often attention seeking
Risk of committing suicide in following year ~ 100xs
Describe the epidemiology of Deliberate self harm
- More common females
- Aged 15-25
- Highest rates in divorced, single or teenage wives
- Highest rates in lower social classes
- Associated with unemployment
- More common in urban areas
What is a dental aspect of self harm
Care in prescribing analgesics
What are psychosomatic disorders
- Patients with physical symptoms for which no cause can be found
- Very common
- Simple reassurance and explanation may be all that is needed
What is an alcoholic
Someone whose repeated drinking leads to harm in his work or social life
What are the recommended safe limit of alcohol consumption for men and women in 2011 btw
Men - 0-21 units a week
Women - 0-14 units a week
Now men is same as women
What are the features of alcohol dependence
- Compulsion to drink
- Pre-occupation with alcohol
- Stereotype drinking pattern
- Increased tolerance to alcohol
- Repeated withdrawal symptoms
- Loss of ability to regulate drinking
- Relief drinking to avoid withdrawal symptoms
- Persistence even after attempted withdrawal
What gastrointestinal complications are associated with alcohol
- Gastritis
- Hepatitis
- Cirrhosis
- Oesophageal varices
- Peptic ulcer
What haematological complications are associated with alcohol
- Anaemia
- Thrombocytopenia
What cardiovascular complications are associated with alcohol
- Cardiomyopathy
- Hypertension
What neuropsychiatric complications are associated with alcohol
Wernicke’s encephalopathy - secondary to thiamine deficiency
What social complications are associated with alcohol
- Family/marital problems
- Jobl oss
- Accidents-Alcohol related road accidents
- Criminal activities
- Absenteeism from work
- Vagrancy
What are some associated features of fatal alcohol syndrome
- Epicnathal folds
- Low nasal bridge
- Minor ear abnormalities
- Micrognathia
- Flat midface
- Thin upper lip
What is the CAGE questionnaire for drinking and alcoholism
- Cut down?
- Annoyed by criticism of drinking?
- Guilty about drinking
- Do you ever drink a morning Eye opener
What are some acute withdrawal symptoms of alcoholism
- Starts 10-72 hours after last drink
- Agitation and insomnia
- Tachycardia and hypotension
- Pyrexia
- Confusion and fits
- Visual or tactile hallucinations e.g. formication or animals crawling over skin
- Mortality - 5%
What are the management options of acute alcohol withdrawal
- Rehydration
- Vitamins
- Sedation
- Chlormethiazole
- Chlordiazepoxide
What are the dental aspects of alcohol misuse
- Poor oral hygiene
- Malnutrition and anaemia
- Liver disease/cirrhosis - bleeding tendency and altered drug metabolism
- Problems with drug administration (metronidazole)
- Accidents and fights leading to maxillofacial trauma
What are some major classes of drugs used in psychiatry and give examples
- Benzodiazepines (diazepam)
- Phenothiazines (chloramine)
- Tricylic antidepressants (amitriptyline, imipramine)
- Selective serotonin rey-take inhibitors (fluoxetine-prozac, sertraline-zoloft)
- Monoamine oxidase inhibitors (isocarboxazid-marplan)
What psychiatric drug interactions might vasoconstrictors and LA have
- with TCAs, MAO and SSRIs - hypertensive reaction
- CNS depressants used for analgesia - enhanced effects
- Lithium - NSAIDs, metronidazole and tetracyclines
What can cause TCAs, MAO and SSRIs cause in the oral cavity
Xerostemia
Candidosis
Periodontal pathology
