Iain Macleod Stephen Potts

PSYCHIATRIC PROBLEMS IN DENTISTRY: 

PSYCHIATRIC PROBLEMS IN DENTISTRY By Iain Macleod & Stephen Potts

Slide2: 

Royal Bethlehem Hospital “Bedlam”c18th

Classification of psychological disorders: 

Classification of psychological disorders ‘Neurosis’ Psychosis Disorders of personality and behaviour Substance misuse Learning disability Organic problems

‘Neurosis’ v Psychosis: 

‘Neurosis’ v Psychosis Anxiety, Depression, Somatisation Quantitatively different Excessive degrees of normal phenomena Common Schizophrenia,Manic Depressive illness Qualitatively different Delusions Hallucinations Thought disorder Rare

Dental presentation - Psychosis: 

Dental presentation - Psychosis ‘Aliens are controlling me through transmitters implanted under my fillings…..’ ‘I want them out.’

Dental presentation – ‘Neurosis’: 

Dental presentation – ‘Neurosis’ ‘Look at my tongue. I’m really worried it’s cancer. I know you said before it’s not, and I felt better for a while, but I can’t stop thinking about it, especially since that man on the telly said it was on the increase. ‘I want you to check me out again and this time I want a scan.’

Anxiety and depression(emotional disorders): 

Anxiety and depression (emotional disorders) Both are extensions of normal emotions Signs and symptoms of anxiety are due to sympathetic overactivity : “fright/fight/flight” response Anxiety due to specific trigger = phobia Generalised anxiety = anxiety trait Severe form = panic attack Can get combined anxiety and depression

pathophysiology: 

pathophysiology TRIGGER SYMPATHETIC ACTIVITY HYPERVENTILATION RESPIRATORY ALKALOSIS BODY SENSATIONS CATASTROPHIC INTERPRETATION PANIC

Depression: 

Depression Various sub-types Unipolar and bipolar (with mania) Can be acute or chronic Genetic factors may be present (family history) Can lead to suicide Can be difficult to detect Patients may lack insight May not seek help “feel unworthy”

Ten key symptoms of depression: 

Ten key symptoms of depression Depressed mood (for>2weeks) Loss of interest and pleasure (anhedonia) Loss of confidence and self-esteem Self-reproach or guilt Recurrent thoughts of suicide or death Diminished concentration or indecisiveness Fatigue and loss of energy Agitation and psychomotor retardation Sleep disturbance (eg.early morning waking) Appetite and weight change (usually lost)

“STRESS”: 

“STRESS” Term used in different ways: To indicate presence of stressors To describe experience of “being stressed” To describe an emotional disorder associated with stress Used in a negative sense BUT can be positive What is stressful to one person may not be to another – coping skills

Life events scale: 

Life events scale

Somatisation: 

Somatisation Somatisation has been defined as “the expression of personal and social distress in an idiom of bodily complaints, with medical help seeking”

Common !: 

Common ! “In general medical practice,somatisation associated with psychiatric illness accounts for 20 - 30% of all consultations” Higher in specialist clinics (50% or more)

Why the mouth ?: 

Why the mouth ? Sensory cortex

Slide16: 

“Theoretically,every disease is psychosomatic,since emotional factors influence all body processes through nervous and humoral pathways” Franz 1950

PAIN: 

PAIN “Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage” “- pain is always subjective -” Int. Assoc. for the Study of Pain

PAIN: 

PAIN Pain is a complex sensation Pain can cause considerable distress “chicken and egg” situation Dental pain can be difficult to diagnose Beware of referred pain (sinuses,cervical spine,heart etc.)

KEY QUESTIONS: 

KEY QUESTIONS Is the pain present every day ? What is a normal day like ? How severe is the pain ? (score 0 – 10)

Rules of thumb !: 

Rules of thumb ! Dental pain gets better or worse ! Chronic pain is rarely dental If an experienced dentist “feels” the pain is not dental they are most often right

Assessment tools: 

Assessment tools Visual analogue scale 0 10 cm / No pain Severe pain - Verbal rating scale Eg. How are things at present ? 0= could not be better 10= could not be worse

Orofacial pain conditions: 

Orofacial pain conditions Atypical facial pain Atypical odontalgia Oral dysaesthesia Phantom bite syndrome (TMD) Syndrome of bizarre oro-facial symptoms

Atypical facial pain: 

Atypical facial pain Middle aged or older Mainly female Constant pain / discomfort Poorly localised May cross midline Does not waken patient from sleep Lack objective signs Investigations (-ve) Other symptoms (headaches,IBS,backache etc.)

Atypical facial pain: 

Atypical facial pain Demand physical treatment Often do not accept psychological explanation May have seen several specialists/practitioners May be obsessed with symptoms

Management: 

Management History Exclude organic disease HAD scale Life events – counselling medication / referral

Role of the dental practitioner: 

Role of the dental practitioner Explanation of these common conditions Allow patients to express their concerns and beliefs as to what is happening Reassure re. cancer phobia Reduce fear of the need for surgery Explanation of parafunction To refer appropriately

Role of psychologist/psychiatrist: 

Role of psychologist/psychiatrist Detailed history Explore connections to life events Assess for psych disorders (depression) Minimise iatrogenesis Treat – medication (antidepressants) Treat – psychological (CBT, CPN) Treat – social (support, links) Liaise – GDP, GMP, other specialists

Body dysmorphic disorder: 

Body dysmorphic disorder An obsessive concern about a body part or appearance Will seek physical intervention Unlikely to be pleased with results and demand further treatment May become depressed Will not accept a psychological explanation

Wrong !: 

Wrong ! The doing anything is better than doing nothing approach : this confirms the patients belief of a disease that is non-existent Beware of litigation !

Slide30: 

“The scream” Edvard Munch 1863-1944