Psychiatry Flashcards
1
Q
What does the Mental Health Act (Scotland) 2003 consider?
A
- concerned purely with management and treatment of psychiatric disorders
- compulsory detainment of patients
- no provision for compulsory treatment of physical problems
- patient choice once reality is restored
- can detain patients in the community on “Leave of Absence”
- can be in hospital
- may be allowed leaves of absence into population
- can be in community under compulsory treatment order
2
Q
What are the detainment periods under the Mental Health Act (Scotland) 2003?
A
- emergency detention: 72 hours
- short term detention: 28 days
- compulsory treatment order: 6 months
3
Q
Who is involved in the detainment of a patient?
A
- police
- removal of patient to place of safety
- doctor
- assessment for detention within 2 hours
- mental health guardian
- assess whether detainment and treatment are appropriate
- in case of emergency detention powers
4
Q
What are the conditions of the application of the Mental Health Act (Scotland) 2003?
A
- the person has a mental disorder
- medical treatment is available
- to stop condition deteriorating
- to treat some symptoms
- some conditions (personality disorders) do not apply - risk to individual or others in lack of treatment
- in absence of medical treatment - decision making is impaired
- because of mental disorder
- cannot make decision on medical treatment
- if lucid and refuses, treatment cannot be provided in a compulsory nature - the use of compulsory powers is necessary
5
Q
How are psychiatric illnesses categorised and what do they mean?
A
- neurosis
- contact with reality retained
- aware of surroundings and can function within them
- anxiety states and phobias
- psychosis
- contact with reality lost
- aware of surroundings but perceives them differently
- unable to interact appropriately
6
Q
What other psychiatric conditions are present in dentistry?
A
- eating disorders
- personality disorders
7
Q
What is normal dental anxiety?
A
- patient is anxious about accessing dental treatment
- may be from previous experiences
- may not behave rationally
- from dentist’s perspective
- does not have a psychiatric diagnosis
8
Q
What are the 5 ways in which neuroses can be categorised?
A
- anxiety
- phobic
- obsessional
- hypochondriacal
- depressive
- part of a spectrum of mood and social disorders
- patient with unstable emotions will experience a variety of symptoms
- related to intrinsic personality as well as circumstantial changes
9
Q
What are the anxiety states and what characterises each?
A
- the anxious patient
- concerned about dental treatment
- reasonable anxiety
- anxiety neurosis
- concerned about everything
- can be disabling for patient
- ask if worried about everything or just the dentist
10
Q
What are the anxiety disorders and what characterises each?
A
- generalised anxiety disorder
- presents in a wide variety of circumstances
- free-floating anxiety
- phobic anxiety
- intense anxiety
- specific situations
- panic disorder
- unpredictable extreme anxiety
- triggers can vary between episodes
- can simulate other issues such as MI
11
Q
What are somatoform disorders?
A
- repeated presentation of physical symptoms and persistent requests for medical investigations in spite of negative findings and reassurance that the symptoms have no physical basis
- problem does not exist medically or pathologically
- may be physiological/psychiatric symptomatology
- potentially depression
- commonly seen within dentistry
12
Q
What are the management strategies for anxiety disorders?
A
-psychological treatment
- psycho-education
- anxiety management strategies
- cognitive behavioural therapy
- usually more successful as target problem
- drug treatment
- self medication (alcohol)
- prescription medication
13
Q
what medications can be used to manage anxiety disorders?
A
anxiolytic drugs
- alcohol
- self medicated
- benzodiazepines
- diazepam
- midazolam
- temazepam
- lorazepam
- highly addictive medication
- antidepressants with anxiolytic features
- tricyclic antidepressants (noradrenaline + 5HT)
- amitriptyline
- dosulepin
- nortriptyline
- imipramine - mirtazapine
- SSRI
- selective serotonin reuptake inhibitor (5HT)
- fluoxetine
- sertraline
- citalopram
- tricyclic antidepressants (noradrenaline + 5HT)
14
Q
How does anxiety neurosis present in dentistry?
A
- TMJ pain
- parafunctional clenching
- oral dysesthesias
- changed sensation perceived in mouth and face
- dry, burning, painful
- anxiety is major aetiological factor in oral somatisation
- treat anxiety neurosis as well as symptoms
- medications
- CBT
- underlying anxiety must be manages or treatment of symptoms will be ineffective
15
Q
What are phobias?
A
- fear out of proportion to the treat
- individual experience, sometimes related to past experiences
- common for children of 50/60s to have dental phobia
- phobias in dentistry
- dental phobia
- phobias affecting access to dental environment
- management
- determine trigger
- determine when in contact with trigger
- psychological therapy
16
Q
What is OCD?
A
- neuroses
- Obsessive Compulsive Disorder
- fear of something happening
- in dentistry can be infection, dirty oral environment
- rituals and acts
- performed to manage anxiety
- OCD cycle
- obsessions (unwanted distressing thoughts)
- anxiety (distress, fear, worry, disgust)
- compulsion (behaviour performed to reduce anxiety)
- relief (temporary relief from negative feeling)
- increased risk of depression
- if patient has insight to fact behaviour is abnormal or has no bearing
- difficult to break the OCD cycle
17
Q
In what ways does perfectionism differentiate from OCD?
A
- perfectionism
- personality trait
- may follow habits or rituals rigidly
- performed due to desires, not anxiety avoidance
- OCD
- mental health disorder
- repeated unwanted thoughts or urges that cause anxiety
- compulsive action or ritual to prevent anxiety development
- ritual often not related to anxiety
18
Q
What are adjustment disorders?
A
- neuroses
- maladaptive response to severe past or continuing circumstances
- occur during adaption to new circumstances
- bereavement
- separation
- loss
- PTSD requires stress of exceptionally threatening or catastrophic nature
- managed by physiological intervention
- often accompanied by mood disorders (medication)
- does not respond solely to medication
- highly trained counsellor
19
Q
What are mood disorders and how to they present to the dentist?
A
- affective disorders
- rarely present to dentist
- may notice change to general demeanour over time
- oral effects (somatiform disorders)
- dysesthesias
- facial pain
- consider the necessity of dental treatment
- important decisions should not be made
20
Q
What is the mood disorder spectrum?
A
A chart showing the ways in which moods can change with circumstances (intrinsic or environmental)
- mania with psychosis on one end
- normal mood central
- severe depression with psychosis on the other end
21
Q
What is cyclothymia?
A
normal changes to mood
elation - normal mood - dysthymia
22
Q
What is depressive disorder?
A
- mostly neuroses with variable severities
- patient has contact with the reality of their environment
- can become psychosis in extreme depression
- unipolar, only experiences low mood
- can be persistent or recurrent (include before /)
normal mood - dysthymia - / - mild depression - moderate depression - severe depression - severe depression with psychosis
23
Q
What is bipolar depressive disorder?
A
- patient experiences both high and low moods
- Type I:
- extreme mood swings
- severe depression to mania
- Type II
- mostly depressive states
- some periods of normal and high moods
- never reaches mania
24
Q
What is cyclothymic temperament?
A
-exaggerated mood swings from high to low
- if more pronounced considered cyclothymic disorder
25
Q
What is monopolar mania?
A
- swings from normal to high moods
- sometimes reaches mania
- very few depressive points
26
Q
What are puerperal mood disorders?
A
- post natal depression
- relatively common
- response to large life change
- unable to enjoy the moment
- if experienced of first pregnancy, prone after subsequent
27
Q
What are the common symptoms of depression?
A
- low mood
- reduced interest and motivation
- lethargy and tiredness
- sleep disturbance
- appetite disturbance
- poor concentration
- loss of confidence/self-esteem
- recurrent thoughts of death and suicide
- unreasonable self-reproach and guilt
- any form of anxiety
28
Q
What are the common symptoms of mania and hypomania?
A
- increased productivity and feeling of wellbeing
- reduced need for sleep
- gradual reduction in social functioning and occupational functioning
- increase in reckless behaviour
- feeling of invincibility
- followed by period of depression
29
Q
What are the euphoric signs of elevated mood disorders?
A
- upbeat
- more talkative
- inflated self esteem
- feeling everything is possible
30
Q
What are the dysphoric signs of elevated mood disorders?
A
- irritable
- agitated
- aggressive energy
- rage
31
Q
What are common signs for both euphoric and dysphoric mood disorders?
A
- rapid speech
- restlessness
- reckless behaviour
- excessive energy
- decreased sleep
32
Q
How are mood disorders treated?
A
a combination of treatment is likely to be most effective
- psychological
- cognitive therapy
- CBT effective
- unusual perception of worth and ability - interpersonal psychotherapies
- cognitive therapy
- drug treatment
- antidepressant
- prescribed for 2 years
- allows brain to adjust to new norm and avoid relapse - mood stabilising
- antidepressant
- physical
- exercise
- phototherapy
- effective for seasonal affective disorder - ECT
- electro-convulsive therapy
- rarely used, potentially postnatal depression
33
Q
What types of drugs are used in the management of mood disorders?
A
- acute phase antidepressants
- act to take patient from low to normal mood, can overshoot to mania in some patients, must be monitored
- selective serotonin reuptake inhibitors (SSRIs)
- venlafaxine/mirtazepine
- tricyclic antidepressants (TCA)
- monoamine oxidase inhibitor (MAOI)
- act to take patient from low to normal mood, can overshoot to mania in some patients, must be monitored
- mood stabilising drugs
- good for mood cycling patients
- lithium
- carbimazepine
- valproate
- lamotrigine
- good for mood cycling patients
34
Q
Discuss selective serotonin reuptake inhibitors (SSRIs) as antidepressants
A
- most commonly used antidepressant
- patient may have to try several to find one that works
- types
- fluoxetine
- paroxetine
- fluvoxamine
- citalopram
- sertraline
- side effects
- acute anxiety disorders
- dry mouth
- sedation
- gastrointestinal upset
- disadvantages
- promotes anxiety between starting and stopping
- withdrawal experience, feels like addiction
- benzodiazepines used to aid stopping
35
Q
Discuss venlafaxine and mirtazepine as antidepressants
A
- venalfaxine
- serotonin reuptake inhibitor
- noradrenaline reuptake inhibitor
- mirtazepine
- complect 5HT actions
- presynaptic alpha 2 agonist
- second line antidepressants
- used when SSRIs have not worked
- prescribed by psychiatrist
- likely combined with other antidepressants
36
Q
Discuss tricyclic antidepressants (TCA) as antidepressants
A
- older but still prescribed to some patients
- less effective at treating depression
- effective at treating anxiety
- prescribed in conjunction with SSRIs to manage anxiety
- original types
- amitriptyline
- nortriptyline
- dosulepin
- new types
- imipramine
- doxepin
- side effects
- new have more side effects
- dry mouth
- sedation
- weight gain
- dangerous in overdose (not good for depression)
- precautions
- careful with glaucoma (raises eye pressure)
- prostates (blocks urine outflow)
37
Q
Discuss monoamine oxidase inhibitors (MAOI) as antidepressants
A
- 5HT (serotonin) and norA (noradrenaline)
- types
- phenelzine
- isocarboxazid
- selegeline
- only prescribed by psychiatrists
- only when other methods have failed
- interactions
- indirect acting sympathetomimetic amines
- ephedrine and noradrenaline
- enhanced vasoconstrictor effect
- cough and cold remedies
- issues with LA previously when noradrenaline - food stuffs
- tyramine containing foods
- beer, alcohol, bovril, marmite, cheese, herring, beans
- patient must understand limitation on life
- indirect acting sympathetomimetic amines
38
Q
Why are antidepressants used?
A
- to treat depression
- to treat anxiety disorders
- OCD
- panic attacks
- pain relief
- TCA and mirtazepine
- noradrenaline boosted in brain
- pain transmission in CNS reduced
- help psychological treatments
- SSRIs increase success of psychological treatments
- prescribed to promote learning of new behaviours
39
Q
Discuss lithium as a mood stabilising drug
A
- K+ substitute
- disadvantages
- toxicity risk
- interacts with NSAIDs and metronidazole
40
Q
Provide examples of antipsychotic medications used to treat episodes of mania
A
- aripirazole
- olanzapine
- quetiapine
- risperidone
- act to reduce tendency to mania and psychosis but do not act as antidepressants
41
Q
What are the dental manifestations of antidepressant drug treatments?
A
- direct drug effects
- dry mouth
- sedation
- facial dyskinesias (uncontrolable facial twitches)
- drug interactions
- drug metabolism
- local anaesthetics
42
Q
Provide examples of psychoses and the effects of the drug treatment
A
- manic depression
- schizophrenia
- Korsakoff’s psychosis (alcohol induced brain degeneration)
- drug effects
- dry mouth
- drug interactions
- dyskinesias
- difficult to treat during acute episodes
43
Q
What is schizophrenia?
A
- thought disorder
- distortions to thinking and perceptions
- auditory and visual delusions
- auditory are often threatening or derogatory
- cannot differentiate between delusions and reality
- relapsing and remitting periods of acute psychosis
- cumulative, chronic deficits
- affect motivational, affective and social domains
- even in deficit, auditory delusions will persist
- multifactorial abnormality of dopaminergic neurotransmission
- genetic susceptibility (multigene)
- environmental (perinatal risk factors)
- drug abuse (cocaine, amphetamine, ecstasy, opiate)
44
Q
How is schizophrenia managed?
A
- psychological therapy
- CBT
- cognitive remediation
- family intervention
- drug therapy
- oral medications
- poor compliance as patient does not see illness
- IM injections
- depot injections
- long lasting, delivered monthly - dopamine antagonist drugs
- blocks dopamine everywhere
- extrapyramidal side effects (pyramidal systems)
- movement control altered, Parkinson’s like
- dry mouth and sedation - atypical antipsychotics
- less likely to cause extrapyramidal side effects
- oral medications
45
Q
What are the different types of antipsychotics?
A
- butyrophenones
- haloperidol
- droperidol
- commonly used in 1990s
- phenothiazines
- chlorpromazine
- thioridazine
- sometimes still used
- thioxanthenes
- flupenthixol
- zuclopenthixol
- used for depot injections
- new atypical antipsychotics
- sulpiride
- respiridone
- clozapine
- quetiapine
- aripiprazole
- olanzapine
- referred to as atypical as do not act as dopamine antagonist
- fewer extrapyramidal side effects
46
Q
What are the extrapyramidal side effects of antipsychotics?
A
- akathisia
- restlessness
- finger tapping, rocking, crossing/uncrossing legs
- dystonia
- involuntary contraction of muscles
- contortion leads to painful positions/movements
- visible ot dentist in neck and intraoral muscles
- Parkinsonism
- Parkinson’s symptoms
- tremor, slow thought processes, difficulty speaking
- tardive dyskinesia
- uncontrollable facial movements
- lip-smacking, sticking tongue out, repeated blinking
- develops slowly
- unlike other side effects, stays after medication is stopped
47
Q
How are extrapyramidal symptoms managed?
A
- usually there is a normal balance of dopamine and acetylcholine
- when dopamine is reduced acetylcholine effects are increased
- drugs can be used to balance activity
- use of atypical antipsychotic instead
- fewer extrapyramidal symptoms
- beta-adrenergic blockers
- non-selective
- propranolol
- metropolol
- anticholinergics
- reduce effect of acetylcholine
- potential for dry mouth (in addition to antipsychotic)
- procyclidine*
- benztropine*
- diphenhydramine
- pramipexole
48
Q
Briefly outline some common eating disorders
A
- anorexia nervosa
- altered perception of body image
- refrain from eating
- oral manifestations (dry mouth, ulcers, infection)
- bleeding due to deficiencies
- often underweight
- bulimia
- normal weight
- cycles of binging and vomiting
- dental erosion (palatal aspect of teeth smoothed)
- oesophageal stricture (acid in upper GI tract)
- comfort eating
- coping mechanism for anxiety
49
Q
What are personality disorders?
A
- chronic peculiarities of character
- maladaption to life
- characterised by antisocial behaviour
- can be difficult for all to deal with
- knowledge of having disorder does not help and can result in mood disorders
50
Q
What are the symptoms of borderline personality disorder?
A
- deep fear
- usually abandonment
- take extreme measures to avoid rejection
- unstable relationships
- changes in self image
- frequent
- change goals and values in a rapid manner
- stress paranoia
- periods of stress related paranoia
- disconnect from realist
- impulsive behaviour
- sabotage success
- suicidal threats
- actions of self injury
- excessive mood swings
- wide range of moods over a few hours/days
- intense happiness, irritation, anxiety, fear, shame
- feelings of solitude
- feelings of emptiness
- loss of temper
- sarcasm, bitterness, intense anger
