Psychiatric Disorders Flashcards
DEPRESSION
More common in the (3) patients
Nearly 1 out of 3 patients presenting for
treatment of orofacial pain may have symptoms
consistent with — diagnosis (1)
— is a serious, potentially life
threatening situation which requires referral to
appropriate health care providers for treatment
along with care for the pain disorder (1)
elderly, teenagers, and
chronic pain
depression
MAJOR DEPRESSION: DSM-IV
Diagnostic Criteria
Diagnostic Criteria: At least one of the symptoms is
either:
…or …
3. 5 of more of the following symptoms > 2 weeks:
eight
- Low mood(Feeling blue)
- Anedonia (no longer enjoys pleasurable activities)
- Low energy
- Sleep changes: daily insomnia or hypersomnia
- Significant weight loss/ decreased Appetite
- Suicidal thoughts
- Psychomotor agitation/retardation
- Poor concentration
- Irritability
- Feeling worthless or inappropriate guilt
– out of 9 Symptoms > 2 weeks = major depression
Affects — function
5
social
Locus ceruleus- produces —
Raphe nucleus- produces —
Left frontal cortex & brainstem
Brain is either firing too fast or too slow in releasing (2)
norepinephrine (NE)
serotonin (SER)
norepinephrine and
serotonin
Depression-
less serotonin, more postsynaptic receptors, firing rates of
neurons are faster because they have a hypersensitive neurosynaptic
junction. Causes upregulation.
Anxiety-
–% of people with depression have anxiety
firing rates of neurons are too slow
100
PHYSIOLOGY
More common in individuals who as children experienced:
(5)
People in — personality positions have increased serotonin
Brain is either firing too fast or too slow in releasing norepinephrine and
serotonin
abuse, shyness, high rejection sensitivity, eagerness to please, introverts
alpha
SSRI’s
Selective Serotonin Reuptake Inhibitors (SSRI’s): i.e. Prozac, Paxil
MOA …
Initially this increases firing rate for — weeks
–% of people feel worse; SSRI’s take 4 weeks to work to down regulate
neurons
SSRI’s reduce —
Inhibit reuptake of serotonin at nerve junction
2-3
30
rejection sensitivity (i.e. spouse no longer cares if husband is
upset with her especially if it’s an abusive relationship)
DEPRESSION SYMPTOMS
Ask patient “how long have you been feeling down, had problems with sleep &
appetite?”
Early morning dysphoria-
Grieving individuals usually have their worst symptoms in the —.
The most sensitive symptom is —
— is the main symptom of depression & patient is typically unaware of
this
Family members or spouse is the best source to get the patient history for behavior
unless patient is being abused emotionally or physically
waking up in morning “feeling down” regularly. This is
the worst and pathognomic symptom.
evening
mild depression
Irritability
DEPRESSION SYMPTOMS
Mild depression begins to act like a chronic mild stressor:
MOA
Causes — if patient does not get immediate treatment
Platelets spike causing (2) over time
Cortisol affects NMDA receptor neuronal firing kills brain cells in amygdala & hippocampus
decreased brain mass
clotting & micro-clotting
DEPRESSION
BP is increased which destroys …
Immune system spikes initially then decreases
5 killers:
(5)
lining of blood vessels and causes plaques
Bacteria
Viral
Fungus
Cancer
Parasites
Depression is Major killer of immune system
PSYCHOTHERAPY:
(4)
Lifestyle changes- 5-10% compliance
Regular sleep- REM sleep replenishes
NE, dopamine, replenishes mood,
preserves neurotransmitters
Regular exercise
Sun in the morning
MEDICATIONS:
(2)
SSRI’s: Prozac, Lexapro, Zoloft,
Paxil, Luvox
SSNRI’s: Effexor, Cymbalta- work
better in severe depression
ECT (electroconvulsive therapy):
(3)
Helps if medications fail
Releases neurotransmitters
Down regulates post-synaptic neurons
GENERALIZED ANXIETY DISORDER
Diagnosed when a person has persistent & excessive
anxiety or worry ≥– months
At least 3 of the following
symptoms:
(6)
6
- Restlessness
- Fatigue
- Difficulty concentrating
- Irritability
- Muscle tension
- Sleep disturbance
The anxiety & worry are not
associated with another —
The symptoms cause significant
impairment of …
—% of the Orofacial Pain
population may be experiencing
generalized anxiety disorder
mental
disorder (i.e. obsessive-compulsive
disorder), substance use, or
another medical condition (i.e.
hyperthyroidism).
interpersonal
functioning or work performance.
10-30
PANIC DISORDER
Affects –% of population
Age-
Worsens with —
— may precipitate it
Brain: — fires spontaneously
–% suicide among panic
disorder patients
Post anxiety spells last
days
3
20’s – 30’s
age
Environmental stress
locus ceruleus
15
Diagnostic Criteria (DSM-IV):
1. Recurrent unexpected panic attacks
2. At least 1 attack has been followed by ≥ – month of 1 or more of
the following:
- Panic attacks are NOT due to substances (i.e. drug abuse,
medication, caffeine) OR a medical condition (i.e. hyperthyroidism) - May or may not have associated agoraphobia
1
(a) persistent concerns about having additional attacks
(b) worry about the implications of the attack or its
consequences (i.e. losing control, having a heart attack,
going crazy)
Caffeine Toxicity
When caffeine consumption climbs to 250 to 700 mg per day, people may
experience:
(3)
heart palpitations with more than — mg
Can be dangerous in adolescents even requiring hospitalization
nausea, headaches, sleep difficulties or increased anxiety.
1,000
“Habitual Caffeinated beverage consumption and
headaches among adults with episodic migraine: A
prospective cohort study”
MR Mittleman et al. Headache,2024:64: 299-305.
https://doi.org/10.1111/head.14673
“Abstract
Objective
To examine the relationship between habitual caffeinated beverage consumption and
headache frequency, duration, and intensity in a prospective cohort of adults with episodic
migraine.
Background
Caffeine is a commonly ascribed headache trigger in adults with migraine and clinicians
may counsel patients to avoid caffeinated beverages; however, few studies have examined
this association.
Methods
From March 2016 to August 2017, 101 adults with physician-confirmed episodic migraine
completed baseline questionnaires, including information about caffeinated beverage
consumption. For 6 weeks, they reported headache onset, duration, and pain intensity
(scale 0–100) on twice-daily electronic diaries. Ninety-seven participants completed data
collection. We examined associations between self-reported habitual caffeinated beverage
consumption at baseline and headache outcomes prospectively captured over the
following 6 weeks, adjusting for age, sex, and oral contraceptive use.”
“Results
The adjusted mean headache days per month was similar among the 20
participants reporting no habitual intake (7.1 days, 95% confidence
interval [CI] 5.1–9.2), the 65 participants reporting 1–2 servings/day
(7.4 days, 95% CI 6.1–8.7), and the 12 participants reporting 3–4
servings/day (5.9 days, 95% CI 3.3–8.4). Similarly, mean headache duration
(no servings/day: 8.6 h, 95% CI 3.8–13.3; 1–2 servings/day: 8.5 h, 95% CI
5.5–11.5; 3–4 servings/day: 8.8 h, 95% CI 2.3–14.9) and intensity (no
servings/day: 43.8, 95% CI 37.0–50.5; 1–2 servings/day: 43.1, 95% CI 38.9–
47.4; 3–4 servings/day: 46.5, 95% CI 37.8–55.3) did not differ across levels
of caffeinated beverage intake, though estimates were imprecise.
Conclusions
We found no association between habitual caffeinated beverage intake
and headache frequency, duration, or intensity. These data do not support
a recommendation that patients with episodic migraine should avoid
consuming caffeine. Further research is needed to understand whether
deviating from usual caffeine intake may trigger migraine attacks.”
PANIC ATTACK
Diagnostic Criteria for Panic Attack (DSM-IV):
1. A discrete period of intense fear or discomfort with ≥ 4 symptoms developing abruptly &
peaking within 10 minutes:
(13)
(1) Palpitations, pounding heart, accelerated heart rate
(2) Sweating
(3) Trembling or shaking
(4) Sensations of shortness of breath or smothering
(5) Feeling of choking
(6) Chest pain or discomfort
(7) Nausea or abdominal distress
(8) Feeling dizzy or faint
(9) Derealization (feelings of unreality) or depersonalization
(10) Fear of losing control or going crazy
(11) Fear of dying
(12) Parasthesias (numbness or tingling sensations)
(13) Chills or hot flashes
Panic disorders
TREATMENT
PSYCHOTHERAPY:
(2)
Avoid stimulants (caffeine,
theophylline)
Regular exercise
Panic disorders
MEDICATIONS:
(4)
SSRI’s: Prozac, Lexapro, Zoloft,
Paxil, Luvox
Treat aggressively with SSRI’s
Worsens panic for 2 weeks
Benzodiazepines: Xanax, clonopin,
versed (Intravenous)
Dental Care for Patients with Anxiety
1. Treat xerostomia with —
2. Help the patient feel in control
3. Keep dental appointments — because dental phobia is the #1 fear/phobia
4. Watch and be aware of symptoms of panic attack during appointment (i.e.
give patient breaks to walk around)
5. May prescribe — prior to appointment if patient has a driver
saliva substitutes
short
benzodiazepines
Agoraphobia
(3)
Fear of being alone in a crowded
space
Person becomes “clingy” and
dependent pushing family members
away
Spouse feels “smothered”
Agoraphobia
Diagnostic Criteria (DSM-IV):
(3)
- Anxiety about being in places or situations
from which escape might be difficult or in
which help may not be available if panic
attack occurs. Agoraphobic fears include
being outside of home alone, being in a
crowd, or public contact. - The situations are avoided (i.e. travel) or
endured with marked distress or with a
companion. - The anxiety or phobic avoidance is Not
better accounted for by another mental
disorder
POST-TRAUMATIC STRESS DISORDER
(PTSD) – DSM-IV
A. A person has been exposed to a
traumatic event in which both of the
following were present:
B. The traumatic event is experienced in
1 or more ways:
1. Recurrent intrusive thoughts of event
2. Recurrent distressing dreams of event
3. Reliving the experience
4. Intense psychological distress when
exposed to internal/external cues
that resemble the traumatic event.
5. Physiological reactivity on exposure
to cues that resemble traumatic
event.
- Experienced, witnessed, or was
confronted with event(s) that
involved actual or threatened
death or serious injury, OR a threat
to the physical integrity of self or
others; - Person’s response involved intense
fear, helplessness, or horror.
POST-TRAUMATIC STRESS DISORDER
(PTSD)
C. Persistent avoidance of stimuli
associated with the trauma &
numbing of general response in ≥3
ways:
(7)
- Avoidance of thoughts, feelings, or
conversations associated with the
trauma. - Avoidance of activities, places, or
people that cause recollection of
the trauma. - Amnesia of important aspect of the
trauma - Diminished interest or
participation in significant
activities. - Feeling detached or estranged
from others. - Change in affect (i.e. unable to
have loving feelings) - Sense of foreshortened future.
POST-TRAUMATIC STRESS DISORDER
(PTSD)
C. Persistent symptoms of increased
arousal in ≥2 ways:
(5)
E. Duration of disturbance ≥– month
F. Disturbance causes clinically
significant distress or impairment
in social, occupational or other
important areas of functioning.
- Difficulty falling or staying asleep
- Irritability or outbursts of anger
- Difficulty concentrating
- Hypervigilance
- Exaggerated startle response
1
skipped
POST-TRAUMATIC STRESS DISORDER
(PTSD)
(9)
Physical assault
Sexual assault/rape
Sudden death of a loved one
Transportation accident
Illness/injury
Weapon assault
Accident
Natural disaster
Terrorist attack
Medications for Treatment of Post-
traumatic Stress Disorder (PTSD)
(3)
SSRI’s (sertraline & paroxetine)
SNRI’s (venlaflaxine)
Cognitive Behavioral Therapy with
a pyschologist
EATING DISORDERS
DENTISTS ARE THE FIRST TO NOTICE
SIGNS OF VOMITING:
(4)
- Erosion of enamel esp. on lingual
surfaces of maxillary anteriors - Parotid gland induration-
“chipmunk face” - Halitosis
- Typically not identified until 5
years from onset
ANOREXIA
(7)
- Rare
- Difficult to treat
- High socioeconomic family
- 90% are FEMALE
- Amenorrhea is common (miss 3
periods in a row) - Onset is at puberty
- “Perfect family”
ANOREXIA SYMPTOMS
(7)
- “baby hair” on arms
- Dehydration
- Low protein levels
- Low fat levels
- Malnourished appearance
- Slow mental processing
- Difficult to talk to especially about weight
Diagnostic Criteria for Anorexia Nervosa
DSM-IV
(4)
- Refusal to maintain body weight at or above a minimally normal weight and
height (less than 85% for expected age & height) - Intense fear of gaining weight or becoming fat even though underweight.
- Disturbance in the way one’s body weight or shape is experienced or denial of
the seriousness of the current low body weight - Amenorrhea
Bulimia Nervosa
Starts later in life
–% of college students will purge at some time- not necessarily bulimic
Family life is typically chaotic or abusive
Features:
(5)
40
- Look for enamel erosion on lingual surface of maxillary anterior teeth- check
health history for GERD- acid reflux can also cause enamel erosion - Low potassium levels
- Esophageal tears due to vomiting
- Impulsive behavior
- “Chipmunk face” due to parotid gland irritation
Bulimia Nervosa:
DSM-IV Diagnostic Criteria
- Recurrent episodes of binge eating. An episode of binge eating is
characterized by both of the following:
(a) eating in a discrete period of time (i.e. within any 2 hour period) an
amount of food that is definitely larger than most people would eat
during a similar period of time and under similar circumstances.
(b) a sense of lack of control over eating during the episode (i.e. a feeling
that one cannot stop eating or control what or how much one is eating). - Recurrent inappropriate behavior in order to prevent weight gain, such as
self-induced vomiting, misuse of laxatives, diuretics, enemas or other
medications, fasting or excessive exercise. - The binge eating and inappropriate compensatory behaviors both occur on
average, at least twice per week for 3 months. - Self-evaluation is unduly influenced by body shape and weight.
- The disturbance does not occur exclusively during episodes of Anorexia
Nervosa
Bulimia Nervosa:
Treatment
(2)
- SSRI’s
- Approach patient carefully if you suspect bulimia by inquiring about
depression such as asking about low energy and poor sleep.
