Psychiatry Flashcards
1. Recognise signs and symptoms of common psychiatric conditions 2. Be aware of management stratergies for anxiety, affective disorders including depression and bipolar affective disorder, schizophrenia, eating disorders and alcoholism 3. Be aware of dental relevance of common psychiatric conditions and implications of their management 4. Be aware of integral role of anxiety and depression in aetiology of non-odontogenic orofacial pain
What is neurosis and give examples
- Excessive degrees of normal phenomena
- Common
- Quantitively different
Anxiety, depression, somatisation (where people experience different body parts)
What is psychosis and give examples
- Thought dissorder
- Rare
- Qualitatively different
Schizophrenia, manic depressive illness, delusions, hallucinations
What is anxiety neuroses/ anxiety disorder
A combination of psychological and physical manifestations of anxiety, not attributable to real danger
Signs and symptoms are due to sympathetic overactivity and can occur as panic attacks
Typically begins in early adult life and is more common in females
Describe types of anxiety
Persisting state (generalised anxiety disorder = anxiety trait)
Due to specific trigger = phobia
Outline the clinical features - psychological symptoms and signs of anxiety
- Fearful anticipation
- Irritability, restlessness
- Noise sensitivity
- Repetitive worrying
- Poor concentration
- Subjective reports of poor memory
Outline the clinical features - physical symptoms of anxiety
- RS = difficulty inhaling, chest constriction, hyperventilating
- CVS = cardiac discomfort, palpitations
- GI = XS wind, aerophagy, difficulty swallowing, dry mouth, loose stools
- Neurological = tinnitus, dizziness, blurred vision, paraesthesia (related to hyperventilation)
- Musculo-skeletal = aching and stiffness
- Sleep disturbance = difficulty sleeping, tight terrors, intermittent waking
What are panic disorders
Recurrent episodic severe panic attacks occurring unpredictably and lasting minutes
Typically onsetting at 25-44 and more common in females
What are the psychological and physical symptoms of panic disorders
Psychological
- intense fear, impending doom, impaired concentration
- fear of losing control, going crazy/ dying
Physical
- chest tightness, palpitations, tachycardia, trembling, paraesthesia
- sweating, dry mouth, shortness of breath
What is generalised anxiety disorder
Generalised, persistent excessive anxiety about everyday circumstances lasting > 6 months - prolonged waxing and waning course
What organic causes present similarly to generalised anxiety disorder
Thyrotoxicosis
Phaechromocytoma
Hypoglycemia
How is anxiety treated
Psychological
- reassurance, counselling, psychotherapy
- behavioural therapy
Pharmacological
- anxiolytic agents (BZ = short term)
- antidepressants
- beta blockers (symptomatic relief)
What is a simple specific phobia
Specific phobia for stimuli characterised by anxious thoughts in anticipation of an encounter and avoidance habits - this is managed through CBT (exposure and anxiety management with flooding)
What is agoraphobia
Fear of open spaces or situations from which escape may be difficult (crowds) - the person progressively avoids situations which provoke anxiety and may be confined to their home
What is social phobia/ social anxiety disorder
Anxiety provoked by social performance situations and the fear of behaving in a manner that will be humiliating/ embarrassing
How is social phobia/ social anxiety disorder treated
- MAOI
- SSRIs
- Systematic desensitisation
- Cognitive therapy
What are obsessions and compulsions
Obsession
- unwelcome, persistent ideas, thoughts or impulses which are intrusive, senseless and recognised as absurd
Compulsions
- the motor component of an obsessional thought used to relieve the associated anxiety
- performed in a stereotyped fashion
- activity is excessive and not connected to thought in a realistic way
Typically associated with the anankastic personality trait = cleanliness, orderliness, rigid, checking
What is OCD
Obsessive-compulsive disorder = absurd, time consuming obsessions and compulsions that interfere with the individuals everyday function
How is OCD managed
CBT
- exposure and response prevention which tackles dysfunctional emotions, maladaptive behaviours and cognitive processes
- thought stopping
- habituation training
Drug therapy
- clomipramine
- serotonin uptake inhibitors (fluoxetine)
Which of the following symptoms is most suggestive of anxiety:
a. Audible wheeze
b. Difficulty exhaling
c. Palpitations
d. Pill-rolling tremor
e. Severe chest pain
C
What is psychosis
When contact with reality is lost and normal mental processes are suspended, the patient may encounter
- hallucinations
- delusions
- thought disorder
- loss of insight
This is found in bipolar affective disorder (mania/depression), schizophrenia, paranoia, organic disorders
Define delusions
Fixed, false beliefs which are out of keeping with the persons religious and cultural background which is maintained even in the face of evidence to the contrary
Define hallucinations
False sensory perception in absence of real external stimuli
What is schizophrenia
Disintegrative psychosis involving loss of contact with reality - splitting of normal links between perception, mood, thinking, behaviour and contact with reality
There is a social drift with this affecting classes IV and V
Outline the 5 classifications of schizophrenia
- Paranoid = prominent persecutory/ grandiose delusions, auditory hallucinations and may appear normal
- Hebephrenic/disorfanised = silly childish behaviour, thought incoherence and disorganised behaviour
- Catatonic = motor immobility, rigidity, posturing, excitement copying speech and behaviour
- Undifferentiated, simple = insidious social withdrawal, deterioration, defect state, absence of delusions, hallucinations
- Residual = at least one acute schizophrenic episode but currently no positive psychotic symptoms - will have negative symptoms such as withdrawal from society
What is type I schizophrenia classified by
Acute onset, positive symptoms
- delusions, hallucinations
- thought disorder
- speech
What is type II schizophrenia classified by
Chronic, negative symptoms
- lack of drive
- withdrawn
- depression
- poverty of speech
- poor attention span and memory
Describe Schneider’s first rank symptoms
- Auditory hallucinations
- third person arguing about subject and commentary on subject’s actions
- audible thoughts - Delusions
- thought insertion/ withdrawal
- thought broadcasting
- somatic passivity (movement controlled by external source)
- delusional perception
What are the treatments for schizophrenia
Antipsychotics (neuroleptics/ major tranquillisers)
- Orally = chlorpromazine, fluphenazine, risperidol
- IM with long acting depot injections (those refusing oral)
Psychotherapy
How do antipsychotics work
They alter the dopamine/ cholinergic balance in basal ganglia
What are the extrapyramidal and anticholinergic effects of antipsychotics
- Dystonia/ Dyskinesia = abnormal movements
- Akathisia = restlessness
- Parkinsinism - Tardive dyskinesia (involuntary movements involving lips and tongue)
What is the dental relevance of schizophrenia
- Neglect of dental care - caries and periodontitis
- Smoking - dental staining, oral precancer and cancer
- Hard to communicate
- Delusional oral symptoms
- Side effects of neuroleptics - haloperidol and clozapine can cause hyposalivation causing candidiasis and caries
What are affective disorders and list examples
- Disorders characterised by mood disturbances (depression/ elation)
- Accompanied by abnormalities in thinking an perception
Bipolar affective disorder, Unipolar affective disorder, Mixed affective states
Outline 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
- Hopeless/ helplessness
- Suicidal ideation
Outline biological features of depression
- Sleep disturbance: early waking, insomnia, unrefreshed
- Change in appetite, change in weight, constipation
- Change in psychomotor activity - retardation
- Diurnal variation in mood (worse in AM)
- Loss of interest in work and pleasure activities
- Loss of energy and libido
- Amenorrhoea
Outline how the appearance and speech of a patient with depression is different
- Dishevelled, neglected dress and grooming
- Facial features: down-turning corners of mouth, furrowing brow
- Reduced rate of blinking
- Reduced gestural movements
- Shoulders bent, head inclined forwards, downwards gaze
- Poverty of speech, slow and hesitant
What are the psychotic features of depression
- Delusions = concerned with ideas of worthlessness, guilt, ill health and poverty
- Hallucinations = second person auditory confirming patients ideas of worthlessness
How can depression be diagnosed
Loss of interest or pleasure or depressed mood for > 2 weeks, plus 4 =< clinical signs of depression
How is depression managed
- Antidepressants (takes 4 weeks for onset):
- TCAs = amitriptyline, dolesupin
- SSRI’s = fluoxetine, paroxetine, citalopram (less side effects)
- St John’s wort - Lithium / carbamazepine for mood stabilisation between depression and elation
- Electroconvulsive therapy (severe cases)
What are the dental aspects of depression
Treatment should be deferred until depression is controlled
Oral symptoms
- disturbed taste
- persistent idiopathic facial pain
- burning mouth syndrome
- TMJ dysfunction
- delusions (discharge from mouth, halitosis)
Adverse effects of treatments
- dry mouth (TCAs, lithium)
- altered taste sensation
What is bipolar disorder
Sustained episodes of an elevated/ agitated mood which alternated with episodes of depression
- affects ability to function in life
- increased mortality
Outline what happens in manic episodes of bipolar disorder
- Grandiosity: dressed in gaudy colours
- Diminished need for sleep, untidy, dishevelled
- XS speech or pressured speech
- Racing thoughts, flight of ideas
- Distractibility + overactivity casing exhaustion
- XS pleasurable activities: overspending, uninhibited sexual behaviour and risk taking
What are manic episodes in bipolar disorder
Hypomanic episodes characterised by elevated expansive, or irritable mood of at least 4 days duration
How is bipolar disorder managed
- Antipsychotics: chlorpromazine, haloperidol, respiridone, olanzapine (rapidly brings symptoms down)
- Sedatives for rapid tranquillisation (lorazepam)
- Lithium and carbamazepine prophylaxis (prevents mania relapse)
- ECT
What are the dental aspects of medications given for bipolar disorder
- Lithium toxicity with GA
- Long term potential to induce hypothyroidism
What is anorexia nervosa
Deliberate weightless where the person chooses not to eat and there is extreme avoidance of ‘fattening’ foods
- weight is maintained 15% below expectation
- BMI = <17.5kg m^-2
- patient has body image distortion with fear of obesity
- associated with OCD, anxiety, mood disorders
Outline clinical features of anorexia nervosa
- Thin, emaciated
- Dehydration, dental erosion, caries
- Hair loss from scalp, fine downy langue hair on face and back
- Early onset causes short stature
- Osteoporosis, pathological fractures
- Hypokalaemia: muscle weakness, tetany
- Amenorrhoea/ loss of libido
How is anorexia managed
- Controlled weight gain: feeding if severe, build relationship and agree on weight targets
- Behavioural regime: bed rest which is relaxed as weight is gained
- CBT to identify and change cognitions
- 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
Repeated bouts of overeating (binge) with excessive preoccupation with body weight control and purging
- Bouts occurring >/= twice weekly for 3 months
What are the clinical features of bulimia nervosa
- Normal weight range
- Repeated vomiting - oesophageal tears, haematemesis, hypokalaemia, depression
- Sialosis = salivary gland swelling
- Dental erosion
- Calluses on dorsum of hand = Russell’s sign
- Ulcers on soft palate, angular chelitis
What methods are employed to counteract weight gain in patients with bulimia nervosa
- Self-induced vomiting
- Periods of starvation
- Purgative and laxative abuse
- Abuse of appetite suppressants, thyroid hormones and diuretics
- Neglect to use insulin in diabetics
What are the features of alcohol dependance
- Compulsion to drink
- Pre-occupation with alcohol
- Stereotyped drinking pattern
- Increased tolerance to alcohol
- Repeated withdrawal symptoms and relief drinking to avoid these, with persistence even after attempted withdrawal
- Loss of ability to regulate drinking g
What are the acute withdrawal symptoms experienced by patients with alcohol dependance (delirium tremens)
- 10-72 hours after last drink
- agitation and insomnia
- tachycardia and hypotension
- pyrexia
- confusion and fits
- visual tactile hallucinations
Managed by 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 causing maxillofacial trauma
