psychiatry - mood disorders and psychoses Flashcards
example of mood disorder
mood disoder
how can mood disorder affect pt
May present to the dentist (RARE)
- Oral effects (somatiform disorders)
- Dysaesthesias
- Facial pain
Patient’s general demeanor – particular if familiar with pt/staff
should you tx pt during period of depression?
any important decision – extraction, appearance etc – may be better to delay if pt not in best reflection on themself
mood disorder spectrum
Change depend on circumstances (environment and within ourselves)
- Cyclothmia – normal mood swing
Different severities of depression – most not psychotic (still have contact with environment - neuroses)
- At extremes of depression, psychoses can take over and pt have a psychotic view on world/reality
Depressive disorder can persist for some time or return to normal mood (be recurrent depressive disorder)
cyclothemia
normal mood swing
unipolar disorder
moves only in one direction on mood spectrum
(usually low mood)
bipolar affective disorder
moves in both directions
natural changes in mood progression
Normal mood swings
Cyclothymic
- Temperament - quite common
- Disorder –exaggerated mood swings
Bipolar type II
- more depressed – never reach mania
Monopolar mania
- does span into depression, just normal to mania
Bipolar type I a.k.a true
- range from mania with psychosis to depression with psychosis (returning to euthymic state)
two classess oc cychlothymic issues
- Temperament - quite common
- Disorder –exaggerated mood swings
bipolar type II
more depressed – never reach mania
monopolar mania
does span into depression, just normal to mania
bipolar type I
true
range from mania with psychosis to depression with psychosis (returning to euthymic state)
mood disorders prevalance
common
Female: Male
2-3 : 1
unipolar point prevalence
6%
bipolar life prevalence
1.2%
puerperal mood disorder a.k.a
post natal depression
prevalence of puerpral mood disorder
0.5/1000 in one month
1/1000 in one year
Prone to have with next pregnancy if had already
effect of puerperal mood disorder
inability to enjoy the moment - thinking of months and years ahead with baby
Prone to have with next pregnancy if had already
common types of depressive disorders (7)
- major depressive disorder
- persistent depressive disorder
- bipolar depression
- postpartum depression
- premenstrual dysphoric disorder
- seasonal affective disorder
- atypical depression
major depression disorder
extent
can reach severe and psychotic depression
persistent depression disorder
extent
pt runs at low mood, never returning to normal or reaching depths of depression
10 common symptoms of depression
- Low mood
- Reduced interest and motivation – in people and environment
- inc things that used to be enjoyable for them
- Lethargy and tiredness
- Sleep disturbance
- Appetite disturbance – eat excessively or lose all interest in food
- Poor concentration
- Loss of confidence and self esteem
- Recurrent thoughts of death and suicide
- pt may not want to carry them out – scary for them
- Ask if they have thought about how to carry out
- pt may not want to carry them out – scary for them
- Unreasonable self-reproach and guilt
- Any form of anxiety
clinical criteria for major depressive disorder
5 or more with depressed mood and interest loss, for at least 2 weeks
S sleep changes
I interest loss (anhedonia
G guilt (worthless)
E energy lack
C concentration reduced
A appetite change
P psychomotor change
S sucidide ideation/thoughta
2 types of bipolar on bipolar spectrum
Bipolar 1
- Mania – normal to high mood
Bipolar 2
- Cyclothymia, Hypomania (with psychosis) and then down into depressive state
5 mania and hypomania symptoms
- Increased productivity and feeling of wellbeing
- Reduced need for sleep
- Gradual reduction in social functioning and occupational functioning
- Increase in reckless behaviour
- Thinking downsides of behaviour will not happen to them – speeding, drugs
- Followed by a period of depression
2 ways elevated mood disorders can present
euphoric
dysphoric
(some overlap)
soley euphoric characteristics
upbeat
more talkative
inflated self esteem
felt everything was possible
soley dysphoric characteristics
irritable
agitated
aggressive energy
restlessness
rage
characteristics that can be seen in both euphoric and dysphoric (elevated mood disorders)
rapid speech
restlessness
reckless behaviour
excessive energy
decreased sleep
3 tx modalities for mood disorder
- psychological
- drug treatment - usually 2 years tx
- physical
best is combination
psychological tx for mood disorders (2)
cognitive behavioural therapy
- particular depressive - as unusual perception in own worth and ability
interpersonal psychotherapies
drug families that can be used in mood disorder tx
antidepressant
mood stabilising
why does drug tx for mood disorders last 2 years
Even if returned to ‘normal’ before then as the ‘normal’ they are in is due to drugs so need to have a while before the brain will accept the new eqm and biochemistry as normal
- Withdrawal too soon - replase
3 physical tx options for mood disorders
- exercise
- phototherapy (SAD)
- ECT less now, post natal
examples of acute phase antidepressants that can be used in mood disorders
- selective serotonin reuptake inhibitor (SSRI)
- venlafaxine/mirtazapine
- second line if SSRI not worked
- tricyclic antidepressants (TCA)
- monoamine oxidase inhibitor (MAOI) - last resort
TCA use in mood disorders
older - more effective with anxiety than SSRIs but less effective with depression
why are MAOI last resort for drug tx of mood disorder
many side effects
issue with drug tx for mood disorder
- Possible to overshoot – go from low up to hypomania
- Not always predictable
Assess each individual to see how they are managing
4 reasons why a pt may be taking an ‘antidepressant’
- Treating depression
- Treating anxiety disorders
- Includes OCD and panic attacks
- Pain relief
- TCA and mirtazapine, boost NorA in brain and reduce pain transmission in CNS
- Help psychological treatments
4 examples of mood stabilising drugs that can be used in mood disorders
- lithium
- carbamazepine
- valoproate
- lamotrigine
pts who are prone to mood cycling
tricyclic antidepressants examples
original
- amitriptyline
- nortiptyline
- dosulepin
new TCAs
- imipramine
- doxepin
issue with TCAs
side effects
- dry mouth, sedation, weight gain (reduction in feeling full)
- more side effects in older drugs
Dangerous in overdose - caution with depression pt
Use with caution in
- glaucoma (rise in eye pressure), prostatism (blockage in urine outflow)
- not common
SSRIs examples
‘prozac’ type drugs
- fluoxetine
- paroxetine
- fluovoxamine
- citalopram
- sertraline
most common
variety - try to find best suited to pt
SSRIs side effects
- acute anxiety disorders
- some pts similar to TCAs - sedation, dry mouth
- gastrointestinal upset
Can cause anxiety when starting and ending
- Negative withdrawal syndromes – can feel addicted to them (need control and maybe use of benzodiazepines)
monamine oxidase inhibitors (MAOI) examples
(5HT and norA)
- phenelzine
- isocarboxazid
- selegeline
interactions of MAOIs
Indirect acting sympathetic amines (e.g. ephedrine and noradrenaline)
- Enhanced vasoconstrictor effect (adrenaline containing LA no problem appears)
- Cold and cough remedies
Foodstuffs – tyramine containing, alcohol/low alcohol
- Bovril/oxo/marmite, cheese, herring, beans
ensure pt aware
4 other drugs that can be used as antidepressant but usually started by psychiatrise (not GP)
- Venlafaxine (mixed SRI/NRI)
- Mirtazapine (complex 5HT actions presynaptic alpha2 antagonist)
- Nefazadone (SSRI/5GT blockade)
- Reboxetine (SNRI)
4 drugs used in bipolar mood disorder
as mood stabilisers
lithium
carbamazepine
lamotrigine
valporate
lithium
mood stabiliser
K+ substitute
avoid - NSAID, metronidazole
medicines used to tx episodes of mania
antipsychotic medicines
- Aripiprazole
- Olanzapine
- Quetiapine
- Risperidone
- Not antidepressants*
- Reduce tendency to mania and psychosis*
antidepressant drugs impact on dentistry
Direct drug effects
- Dry mouth – caries may result in extreme (lithium)
- Sedation
- Facial dyskinesias – uncontrollable facial twitches
Drug interactions
- Drug metabolism (none significant to dental)
- Local anaesthetics
psychoses is
3 conditions
Perceptual abnormalities
- Manic depression
- Schizophrenia
- Korsakoff Psychosis – Alcohol induced brain degeneration
psychoses acute episodes
difficult to tx
no insight to trouble
antipsychotic drug effects
- Dry mouth
- Drug interactions
- Dyskinesias – tonic or dystonia (tardive) – larger problem
schizophrenia
Thought disorder
- ‘fundamental and characteristic distortions of thinking and perception’
- Various types of delusions – sometimes bizarre
- Visual hallucinations
- Auditory hallucinations
- often threating or derogatory – gnaw at pt conscious
Relapsing and remitting periods of acute psychosis
Multifactorial abnormality of Dopaminergic neurotransmission
Prevalence – 1-2%
factors which can cause abnormality in dopaminergic neurotransmission in schizophrenia
- Genetic Susceptibility – multigene
- Environmental – perinatal risk factor
- Drug abuse – cocaine, amphetamine, ecstasy, opiate (cannabis and alcohol)
how may a person with schizophrenia appear to behave
Person usually behave appropriately for the situation they find themselves in
However, their reality not the same as actual reality so behaviours seem unusual
effects of schizophrenia
Cumulative, chronic deficits in motivational, affective and social domains
2 types of schizophrenia management
psychological therapy
drug therapy
3 psychological therapy options for schizophrenia
- CBT
- cognitive remediation
- family intervention
- everyone involved as affects everyday life
2 drug types for schizophrenia
Dopamine antagonist drugs
- Block affects of dopamine receptors in brain
- cause ‘extrapyramidal’ side effects (distressing), dry mouth and sedation
- don’t just block dopamine in areas of concern in brain but also elsewhere in brain
Atypical antipsychotics
- less likely to cause extrapyramidal side effects - preferred
pyramidal controls and link to dopamine
pyramidal – control of movement
dopamine shortages in Parkinson
similar side effects in extrapyramidal side effects of dopamine antagonist drugs
drug therapy regime options for schizophrenia pts
Oral or depot IM injection
- compliance, frequency of requirement
pt doesn’t see issue (their reality they feel is correct and normal) – can affect compliance as see no need to take medicines
- long lasting injections may be more appropriate rather than daily oral tablets until pt has recovered
4 groups of antiphsycotic drugs
butryrophenones
phenothiazines
thioxanthenes
new ‘atypical’ antipsychotics
2 butryrophenones
(antipsychotics)
haloperidol
droperidol
4 phenothiazines
(antipsychotics)
chlorpromazine
thioridazine
prochlorperazine (depot injections)
fluphenazine (depot injections)
2 thioxanthenes
(antipsychotics)
fluphenthixol
zucleopenthixol
new ‘atypical’ antipsychotic drugs (6)
advantage
Do not act by being dopamine antagonist
Less side extrapyramidal side effects
- sulpiride
- repiridone
- clozapine
- quetiapine
- aripipraxole
- olanzapine
4 extrapyramidal side effects of antipsychotics
akathisia
dystonia
parkinsonism
tardive dyskinesia
when are extrapyramidal side effects of antipsychotics seen
Not always present at initial commencement of drugs
- Can take a while to manifest
Most will settle if drug withdrawn (not last tardive dyskinesia)
akathisia
extrapyramidal side effect of antipsychotic
- feeling of restlessness, making it hard to sit down or hold still
- Symptoms include tapping your fingers, rocking, and crossing and uncrossing your legs
dystonia
extrapyramidal side effect of antipsychotic
- muscles involuntarily contract and contort leading to painful positions or movements (can be neck, intraoral – dentist present)
parkinsonism
extrapyramidal side effect of antipsychotic drug
- the same symptoms as someone with Parkinson’s disease, but your symptoms are caused by medications, not by the disease
- may include tremor, slower thought processes, slower movements, rigid muscles, difficulty speaking, and facial stiffness.
tardive dyskinesia
extra pyramidal side effect of antipsychotic
- uncontrollable facial movements such as sucking or chewing, lip-smacking, sticking your tongue out or blinking your eyes repeatedly
- Do not go away if medicine is stopped (develops over many months and years and persists – devasting for pt)
how to treat extrapyrimdal symtoms
3 strategies
- Use an ‘atypical’ antipsychotic instead
- beta adreniagic blockers (non-selective)
- Anticholinergics
how does beta-adrenergic blockers (non-selective) tx extra pyramidal side effects
- Tip towards ACh – so nerve effects increased*
- Reduce disbalance with drugs*
2 beta-adrenergic blockers (non-selective)
propranolol
metropolol
how does anticholinergics tx extrapyramidal syptoms
- Tip towards ACh – so nerve effects increased*
- Reduce disbalance with drugs*
4 anticholinergics and issue when using to tx extrapyramidal symptoms of antipsychotic
inc dryness - cumulative effect with antipsychotic
- procyclidine
- benztropine
- diphenhydramine
- pramipexole
types of eating disorders (6)
anorexia nervosa
bullimia
avoidant/restrictive food intake disorder (ARFID)
other specified feeding or eating disorder (OSFED)
Binge eating disorder (BED
comfort eating
anorexia nervosa
- altered perception of body image
- don’t eat - oral effects of malnutrition seen
anorexia nervosa
dental appearnce
oral effects of mallnutrition
- ulcers
- dry mouth
- infections
- bleeding
bulimia
- normal weight - binge/vomit
- ‘comfort eating’ - stress reaction?
- dental erosion & oesophageal stricture
dental signs of bulimia
dental eroision and oesphageal stricture
- recurring flow of acid from stomach into tissue not made to cope with it – palatal surfaces eroded, labial surfaces normal
comfort eating
is eating disorder used as a coping strategy for anxiety
core pychopathology of eating disorder
“morbid fear of fatness” & self-perception of being too fat
Characteristically young females
actions of individual with eating disorder
- restriction of food intake
other behaviour aimed at losing weight:
- self-induced vomiting,
- excessive exercise
- use of laxatives, appetite suppressants, diuretics
personality types
variation exists
can be hard to define where personality type ends and disorders begin
personality disorders tx
many have no effective tx
hard to tell how they arise - genetic or learned behaviour?
boderline personality disorder
instability in interpersonal relationships, self image and affects and marked impulsitivity
antisocial personality disorder
disregard for and violation of the rights of others
histrionic personality disorder
excessive emotionality and attention seeking
narcisstic personality disorder
gradiosity, need for admiration and lack of empathy
dependent personality disorder
submissive and clinging behaviour related to an excessive need to be taken care of
schizoid personality disorder
detatchment from social relationships and restricted range of emotional expression
personality disorders comon characteristics
- ‘chronic perculiarities of character’
- ‘maladaptation to life’
- Often ‘antisocial’ behaviour
can be Dentist or pt
8 symtpoms for boderline personality disoder
- deep fear (of getting abandoned)
- unstable relationships
- changes in self image
- stress paranoia (disconnect with reality and practicality)
- impulsive behaviour
- suicidal threats
- excessive mood swings
- feelings of solitude
black and white thinking
- Great fears – drives behaviour*
- Disguise the person’s anxiety of being isolated*
- knowing has doesn’t help due to lack of understanding of others - emotional centres brain outweighs logical*
hallmark of boderline personality disorder (BPD)
finding it hard to regulate emotions - lead to intense mood swings, impulsivity and behavioural problems
subtypes of BPD
discouraged boderline (clingy, fear alone/rejection)
impulsive boderline (seeks attention/ thrills)
petulant boderline (unpredictable, pessimistic)
self-destructive boderline (bitterness)
BPD link to other psychiatric disorders
- bipolar disorder
- depression
- self-harm and suicidal thoughts - higher rate
- anxiety
- subtance misuse
- eating disorder
not individual problem but overall BPD
some see advantages in having BPD
signs of BPD
- patterns of ups and downs
- disturbed cognition
- relationship or interpersonal difficulties
- identity disturbances, including poor self esteem and poor body image
- impulsivity and being highly reactive
