Managing the Patient With Psychological Problems
Psychiatric disorders are expressed primarily as abnormalities of thought, feelings, and behaviors that either cause the patient emotional distress or result in impairment of function. These problems are common in our society, accounting for more than 30 million physician visits per year in the United States, even though it has been estimated that only 50% of persons with psychological problems seek care for their illness.1,2 The most recent epidemiologic studies indicate that 20% of the U.S. adult population experience signs and symptoms of a recognized mental disorder each year.3 Mental illness accounts for 15% of the burden of disease in developed countries.4 The most common psychiatric disorders in order of prevalence in the United States are phobias, substance abuse, major depression, and obsessive-compulsive disorders (OCD).1
These statistics suggest that at any point in time a large number of patients presenting for dental care may have a treated or untreated psychological disorder. Although the dentist will not be called upon to diagnose psychological disorders, practitioners should be able to recognize the signs and symptoms of undiagnosed or untreated disorders. The dentist also has an important role in managing the oral effects of the disorder or the side effects of medications used to control it. A patient’s self-destructive behaviors and lack of oral health care can cause significant problems in the oral cavity, which the dental team is expected to manage. Additionally, psychological problems may necessitate marked alteration in both the nature and scope of the patient’s plan of care. These issues are the focus of this chapter.
PATIENT EVALUATION
Scheduling enough time at the first visit with the patient is imperative. Some patients with psychological disorders need extra time to respond to questions or to assimilate information provided by the dentist. Imagine how a patient with an anxiety disorder might respond if placed in a situation that includes pressures to respond quickly to questions. Such a patient may just give up on dental care because he or she has not been afforded the opportunity to interact in a comfortable manner. In any clinical setting, there may be instances when the patient must be scheduled without adequate time for a slower paced interview. Developing rapport with the patient may be the best use of the time remaining following determination of the patient’s chief complaint.
Obtaining the Patient History
Some patients with psychological problems will be honest as the health history interview is completed, but many believe that a stigma is attached to psychological disorders and may be reluctant to provide all relevant information. The importance of establishing rapport quickly and effectively cannot be overstated. An effective way to open discussion when the dentist suspects that the patient suffers from a psychological disorder is to mention a physical finding that may relate to the disorder. For example, because some medications for psychological disorders cause dry mouth, a nonjudgmental, nonthreatening question such as “I notice that your mouth seems much drier than usual. Have there been any changes in your health that could account for this change?” may open a discussion in which the relationship between physical findings and psychological status can be described. From the initiation of the professional relationship, honest and open communication between the dentist and the patient can ease the discomfort of discussing mental disorders. The practitioner should reassure the patient that this information is necessary to ensure provision of the best possible treatment and that the inquiry is not meant to be intrusive or embarrassing. The patient will be more forthcoming if questions are framed in a nonjudgmental fashion with the understanding that overall health status can affect the delivery of dental care.
Patients with psychological problems are often less defensive and more open about divulging medication history than about psychological health history. Open discussion can be invaluable in assisting the dentist in understanding the nature of the psychological problem, the level of control, and the severity of the disease. Such discussion can also alert the dentist to possible oral side effects of medications and potential adverse drug interactions. For these reasons, when reviewing patient medi-cations, it is important to find out who prescribed a particular medication, its purpose, the dosage, whether any recent changes in dosing have occurred, and whether the patient has suffered any adverse reactions. The clinician must ensure that the same questions are asked for all medications taken by the patient. Many over-the-counter remedies (antihistamines, decongestants, herbal products, and homeopathic remedies) have significant oral side effects and can potentiate the adverse reactions of prescription medications. It is estimated that 70% of patients will not voluntarily report the use of homeopathic or herbal medications to their health care practitioner. Many patients do not consider herbal and homeopathic agents to be medications because they are “natural” substances, whereas others anticipate that reporting self-directed therapy will elicit a negative reaction from the health care practitioner.
Patient With a Diagnosed Psychological Disorder
Even the patient with a well-managed psychological disorder presents the clinician with the potential for related treatment planning modifications. It is essential that the dentist be knowledgeable about the diagnosis, the treatment, and the effectiveness of treatment of the psychological disorder before providing dental treatment. On numerous occasions a consultation with the patient’s physician will be indicated. The patient may provide the dentist with information that the physician has not been made aware of. Additionally, there are several oral changes that can result from medications that warrant discussion with the physician, such as dry mouth, a lichenoid drug reaction, or extrapyramidal effects. If the dentist concludes that contact with the physician is appropriate, consent needs to be given by the patient. In the vast majority of instances, the patient will grant consent. Many times, simply explaining the reason for contacting the physician will be sufficient to convince the patient to provide consent. However, there will be times when the patient refuses to provide consent, putting the dentist in a difficult position. The patient’s refusal to allow the clinician access to information that could affect not only the dental treatment but also the overall health of the patient makes it inappropriate for the clinician to proceed. In such situations, it will be important to explain to the patient that treatment cannot proceed without this information and that any dental treatment provided under such circumstances would fall below the standard of care. The clinician should avoid giving in to the patient’s wishes in this scenario. The risks to the patient and clinician far outweigh the benefits of acquiescing to the wishes of the patient. If the patient cannot be persuaded to grant consent, the doctor-patient relationship should be terminated.
Instances may occur in which the patient’s history and behavior suggest the presence of a psychological disorder, but there is no indication of treatment in the patient’s history. The explanation may be either that the patient is noncompliant or it may be that the physician and the patient are both aware of the problem, but the patient has chosen not to pursue therapy. In either case the treating dentist must have complete health and medication histories to effectively manage the patient with a diagnosed psychological disorder. In such instances the dentist may need to confront the patient about his or her concerns and request that the patient be reevaluated by a physician or other mental health care provider.
Patient With an Undiagnosed Psychological Disorder
Observing the patient’s behavior helps the clinician to recognize the patient with an undiagnosed psychiatric disorder. Although patients who display inappropriate behaviors or respond to questions in a strange way may simply be nervous, it also may be the case that they have an undiagnosed psychological problem. Obviously, behavioral changes will be more readily recognizable in an established patient whom the dentist has seen before. When such questions are raised in the dentist’s mind, it is appropriate to determine whether a primary care physician has evaluated the patient recently and, if not, to suggest that such an examination be pursued. It is possible that the patient is unaware that his or her behavior has been changing and may resent the implication that there is a “problem.” Addressing these issues can be stressful for both patient and dentist. Approaching the subject in the context of the impact of the patient’s overall health on the way that oral health care is delivered with expression of concern for the patient’s health will be helpful.
When the dentist suspects an undiagnosed psychological disorder, every effort should be made to convince the patient to see his or her primary care physician for a complete evaluation. Most patients will appreciate this demonstration of concern for their health. On the other hand, some patients may perceive such a referral as a refusal to treat. The patient needs to be reassured that the dentist will continue to provide care, but that a health status evaluation by a physician is necessary to ensure that the most appropriate oral health care is delivered. Although it is not ethical to withhold emergency care, a highly symptomatic patient must be made aware that definitive care may be deferred until the mental health problem has been addressed. It would be dangerous to provide dental treatment when it is unclear that the patient is reporting all current medications. The potential for an adverse drug interaction is greatly increased when dealing with psychotropic medications.
Patient With a Poorly Controlled Psychological Disorder
Poorly controlled psychological disorders manifest in the same manner as undiagnosed disorders, although the symptoms may be less severe. Several possible explanations may account for the behavior, including noncompliance secondary to a lack of “insight” by the patient. Insight refers to the patient’s awareness of his or her own mental illness. Patients with such insight are aware of their deteriorating mental health and will seek professional care when the condition worsens. Others, especially those who are psychotic, lack insight and tend to be noncompliant in terms of taking medications and seeing their physician on a regular basis.
Noncompliance may also relate to financial considerations associated with health care costs, the belief that a chronic disorder is “cured,” or the unpleasant side effects of prescribed medications. Providing the patient with a strategy to deal with the xerostomia associated with many psychotropic medications is one way for the dental practitioner to enhance compliance (see treatment of xerostomia later in this chapter).
By helping the patient recognize the deleterious oral and systemic effects of noncompliance and deal positively with the undesirable side effects of compliance, the dental practitioner may be able to encourage the patient to resume medication therapy. The patient should be encouraged to discuss problems relating to the drug’s effects and side effects and the cost of treatment and medications with the psychiatric care provider. If the patient remains unwilling to comply with the recommended therapy, it may be appropriate for the dentist to inform the medical, psychiatric, or psychological care provider of the problem. Some mental disorders are refractory to pharmacotherapy and the patient may never be asymptomatic despite the best available treatment.
GENERAL TREATMENT PLANNING CONSIDERATIONS FOR THE PATIENT WITH A PSYCHOLOGICAL DISORDER
Patient compliance is the major determinant of treatment success in both dentistry and medicine. Both long- and short-term prognoses are affected significantly by how well the patient maintains his or her physical, oral, and psychological health. The finest restorative or periodontal treatment will fail if the patient is unwilling or unable to maintain adequate oral hygiene. The dentist must communicate the importance of maintaining oral health and the ways in which the disease process or treatment can interfere with oral health (see the Ethics in Dentistry box). Once the dentist is comfortable with the patient’s ability to practice adequate oral hygiene, the prognosis for dental treatment may be the same as for any other dental patient.
Control of dental diseases should be pursued aggressively, but definitive treatment ideally should be deferred until the patient can demonstrate consistently adequate oral hygiene. For those patients with severe mental illness, this may be impossible, and limited definitive care (i.e., holding phase, see Chapter 17) may be the only option available to improve function and esthetics, especially for severely decayed and broken down teeth. It is particularly important that the oral hygiene of patients with psychological disorders is assessed at every appointment. Changes in oral hygiene status may result from medication changes or from a change in the patient’s psychological status. Drastic changes in oral hygiene should be discussed with the patient, with emphasis placed on the potential deleterious effects on the oral cavity.
The ability of the patient to cope with dental treatment should be ascertained before beginning each procedure. The patient must be compliant and cooperative and must give consent to proceed. Taking the extra time necessary to be sure that the patient is comfortable, well informed, and free of anxiety can ensure that treatment proceeds in predictable fashion.
After receiving permission from the patient, the dentist may wish to establish a professional relationship with the clinician treating the psychological disorder. Ongoing interactions between the dentist and mental health professional can only improve the care of the patient. The dentist needs to be aware of changes in treatment or medications so that no untoward events occur. The mental health clinician can provide insight concerning patient compliance and may characterize projected patterns of patient behavior. In turn, the dentist can provide the clinician with information about the effects of medication use on oral structures and offer possible solutions to counteract xerostomia, dysgeusia, and other intraoral side effects of psychotropic medications. Contact with a physician is especially important if the patient seems suicidal. Signs of suicidal ideation include verbalization of a plan, the potential for the plan to succeed, construction of a suicide letter, or an attempt to gain access to large quantities of medications with fatal overdose implications. In such a situation, it is very helpful to have already established rapport with the patient’s primary care physician or other clinician treating the psychological disorder so that a strategy for immediate and appropriate intervention can be developed.
MAJOR TYPES OF PSYCHOLOGICAL PROBLEMS
Although it is not practical or appropriate for the dental clinician to definitively diagnose psychological problems, it is helpful to have some background knowledge about the standard categorizations of mental disorders when discussing patient histories with other health care professionals. In addition, it is helpful for the dentist to be aware of the approach the clinician is likely to use to evaluate the patient. Psychological problems have been categorized in The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) published by the American Psychiatric Association.
In the following sections, the major psychological disorders are summarized. Dental treatment planning rami-fications are reviewed for each major category.
ANXIETY DISORDERS
Anxiety disorders are among the most common psychological illnesses encountered in clinical practice. The National Institutes of Mental Health (NIMH) estimate that more than 19 million U.S. adults are affected by disabling anxiety disorders each year.5 Unfortunately, most patients with anxiety disorders do not receive professional treatment. In general, these illnesses tend to be chronic, to develop before the age of 30, and to be more common in women and those with a family history of anxiety or depression.1,2
The terms fear and anxiety are often used interchangeably in the clinical setting, but they describe two separate entities. Fear is the sense of dread associated with the response to an external stressor. Anxiety derives from an internal response that is out of proportion to the reality of the external stressor. Everyone has experienced anxiety at one time, such as that associated with taking an examination or giving an oral presentation. This type of anxiety is transient and generally disappears once the stressful event is past. Pathologic anxiety is associated with greater intensity, longer duration of symptoms, autonomy from the external event, and the development of inappropriate behavioral responses to the event. The symptoms of anxiety disorders are listed in Box 14-1. The DSM-IV divides anxiety disorders into several categories. The categories relevant to dental practice are generalized anxiety disorder, panic disorder, phobias (specific and social), OCD, and posttraumatic stress disorder (PTSD). Dental phobias and anxiety are very important to the practicing dentist and are discussed in Chapter 13.
Generalized Anxiety Disorders
Generalized anxiety disorders are defined as excessive anxiety that has persisted for 6 months or longer and is out of proportion to situational factors. Symptoms include irritability, fatigue, sleep disorders, muscle tension, and inability to concentrate. Generalized anxiety disorders often occur with other conditions, such as depression, panic attacks, and substance abuse. Patients report a chronic level of anxiety that is heightened during stressful events. It is important to remember that the patient’s response to an external event is very personal and should not be discounted by the clinician.
Treatment for anxiety includes pharmacotherapy and some form of counseling, often cognitive-behavioral therapy (talk therapy), which helps patients learn techniques to help them cope with unpleasant situations. Strategies used in behavioral therapy include desensitization through graduated exposure to an unpleasant event, relaxation techniques, and altering the factors that place the patient in unpleasant situations.
Panic Disorder
Panic disorder affects approximately 2.4 million Americans each year6 and is defined as recurrent episodes of intense anxiety with manifestation of at least four symptoms of anxiety or autonomic stimulation with rapid onset and a peak in intensity within 10 minutes (Box 14-2). Persons who experience a rapid onset of anxiety with one or two of the symptoms listed in Box 14-2 are said to have limited symptom attacks. Persons who suffer from panic disorder may develop avoidance behaviors that render them homebound or completely dependent on others to perform the activities of daily living. Treatments for panic disorder include cognitive-behavioral therapy, antidepressants, and benzodiazepines.
Phobias
Phobias are subdivided into two groups: social phobias and specific phobias. Social anxiety disorder is the most common anxiety disorder.1 The essential feature of a social phobia is a persistent distinct fear of social or performance situations in which embarrassment may occur. Fear of public speaking is an example of “performance anxiety” that could potentially evolve into a social phobia. The response to the situation must be of sufficient intensity to produce notable anxiety and result in interference with normal daily activities. Treatments for social phobias consist of pharmacotherapy (selective serotonin reuptake inhibitors (SSRIs), anxiolytic agents, and β-adrenergic blockers), cognitive-behavioral therapies, or both.1,7
Specific phobias affect about 5.3 million U.S. adults each year8 and are manifested by excessive fear of a specific object or situation, such as heights, air travel, snakes, insects, and so on.1 Patients are asymptomatic unless in contact with the specific “trigger” to their anxiety. Although most patients simply avoid the feared object and do not seek professional care, treatment includes desensitization therapy and anxiolytic agents for acute situations.
Posttraumatic Stress Disorder
PTSD occurs in persons who have been exposed to a life-threatening situation and who experience flashbacks and/or autonomic symptoms when exposed to situations reminding them of the initial event. PTSD was once thought to be a disorder of war veterans only (approximately 30% of individuals who have spent time in a war zone manifest signs or symptoms of PTSD),9 but is now recognized in many different population groups, such as survivors of natural disasters and victims of mugging, rape, or automobile accidents. An estimated 5.2 million U.S. adults are affected by PTSD every year.9 The disorder may occur in early childhood, but can manifest at any age. Common symptoms include nightmares, avoidance of pleasurable activities, difficulty with social interactions, irritability, and aggression. This disorder is often associated with anxiety, depression, or substance abuse. Treatment includes pharmacotherapy to address specific symptoms and cognitive-behavioral therapy.
Obsessive-Compulsive Disorder
OCD is the fourth most prevalent psychiatric disorder and the most disabling of all the anxiety disorders.1 OCD affects approximately 3.3 million U.S. adults.10 Obsessions are defined as recurrent persistent ideas, thoughts, or images that the patient recognizes as inappropriate and that therefore produce significant anxiety. Common obsessions involve thoughts about contamination or repeated doubts. Compulsions are repeated, intentional, ritualistic behaviors, usually performed in response to an obsession.
Symptoms of OCD usually manifest in late adolescence or early adulthood. Most obsessive-compulsive patients exhibit both obsessions and compulsions and recognize that their thoughts and behaviors are irrational, but are unable to control them and thus the disorder becomes debilitating. Two major subgroups of OCD are cleaners and checkers. Checkers spend much of their day making sure that lights or the stove is turned off or that all of the doors and windows are locked. Cleaners may continually clean themselves or inanimate objects in an attempt to avoid contamination. This ritualistic cleansing may involve every waking hour.
It is important to understand that OCD commonly presents with other mental disorders. A recent study showed that 80% of the study population had a psychiatric disorder in addition to OCD.11 Cognitive-behavioral therapy is the treatment of choice for mild OCD. Many patients also require pharmacologic intervention in the form of potent SSRIs. Even with pharmacologic treatment, many OCD patients still suffer from lifelong disabling symptoms.
Medications Used to Treat Anxiety
Anxiolytic agents (Table 14-1) are used to reduce the severity, frequency, and duration of anxiety symptoms. Benzodiazepines are the most common and efficacious medications used for this disorder. All are equally efficacious, with pharmacokinetic parameters (onset, duration of action, degree of sedation) determining the choice of agent. Ideally the duration of benzodiazepine therapy should not exceed 4 months, although some patients may require continuous treatment.
Table 14-1
Common Anxiolytic Agents1,7,12
| Benzodiazepines | Select Adverse Effects |
| Alprazolam (Xanax) Chlordiazepoxide (Librium) Clorazepate (Tranxene) Diazepam (Valium) Lorazepam (Ativan) Oxazepam (Serax) |
Salivary gland effects range from ptyalism to xerostomia, depending on the particular agent. Uncommon effects: dysphagia, facial edema, and sore gums. All have CNS depressant effects, including sedation, psychomotor impairment, confusion, and memory problems. These effects are enhanced by the concomitant use of other CNS depressants, including narcotics, muscle relaxants, alcohol, and other sedativehypnotic drugs. |
| Miscellaneous | |
| Buspirone (Buspar) | May cause arthralgia, muscle cramps or stiffness, salivation, facial edema, and dysgeusia; additive effects with other CNS depressants. |
| Hydroxyzine (Vistaril, Atarax) | Sedation, transient drowsiness, xerostomia; additive effects with other CNS depressants. |
The short-term use of benzodiazepines by patients with anxiety disorders rarely results in abuse, although it may occur in patients with alcohol or sedative-hypnotic dependence. When taking the medication history, it is important to determine the prescribed regimen and duration of drug therapy and the actual drug usage. Patients should be counseled not to decrease or discontinue anxiolytic agents without contacting their physician.
To prevent dependency, antidepressants are prescribed for patients who require long-term pharmacotherapy for anxiety. Other nonbenzodiazepine agents include buspirone, hydroxyzine, and autonomic blocking agents such as propranolol.
A number of oral side effects can accompany anxiolytic medication, including excessive salivation, or ptyalism; dry mouth, or xerostomia; difficulty swallowing, or dysphagia; and abnormalities of taste, referred to as dysgeusia. Patients experiencing the central nervous system (CNS) adverse effects of these drugs, such as confusion or memory problems, may be unable to give adequate informed consent or to understand postoperative or oral hygiene instructions. When planning to sedate a patient for dental treatment, drug dosages may need to be altered to prevent oversedating patients already receiving multiple medications that depress the CNS.
Treatment Planning for Patients With Anxiety Disorders
Treatment planning considerations for dental patients who suffer from anxiety disorders (other than dental anxiety/phobia) are summarized in Box 14-3. The decision to sedate these patients for dental treatment should be made in consultation with the patient and his or her physician. The choice of appointment length is affected by the decision regarding sedation. Short, early morning appointments are preferred for the anxious patient who does not receive additional sedation. Long appointments are indicated when the patient will be sedated to accomplish as much treatment as possible. Allowing the patient some control over the timing of procedures during the appointment may reduce general anxiety and help make the experience less threatening. Postoperative information should be provided both verbally and in writing to prevent any confusion about the instructions.
DEPRESSIVE DISORDERS
Mood disorders, also referred to as affective disorders, are among the most common reasons for visits to health care professionals.1,2 These disturbances are divided into depressive (unipolar) and bipolar disorders. Bipolar disorders occur when a patient has had one or more episodes of mania or hypomania usually alternating with depressive episodes. Depressive disorders have an unknown etiology, but are understood to be the result of a complex interaction of life events, genetic predisposition, and alterations in CNS neurotransmitters. Patients with these disorders manifest symptoms associated with changes in the neurotransmitters norepinephrine (NE), serotonin (5-HT), and dopamine (DA). Most antidepressants exert their effects by altering the levels or effective concentrations of these neurotransmitters.1,7,12
Box 14-4 lists the more common psychological and physical symptoms of the depressive disorders. Initial episodes are often preceded by psychosocial stressors, such as the death of a loved one, loss of a job, or serious illness. The clinician must remember that depressive illnesses often are associated with the treatment or progression of chronic physical disease. The prevalence of depressive disorders surpasses 20% for patients with diabetes mellitus and heart disease, and approaches 50% for some cancers.13
Major Depressive Disorder
A major depressive disorder is a disabling, often recurrent, disease with patients exhibiting significant occupational, social, and physical impairment. For women, the lifetime risk for major depressive disorder ranges from 20% to 25%, whereas the lifetime risk for men is reported to be between 7% and 12%.1,2,13 The disorder is defined as a depressed mood or loss of interest and the occurrence of at least five of the symptoms listed in Box 14-4 almost daily for at least 2 weeks. Major depressive disorders are managed with a combination of medication, behavioral therapy, and occasionally, electroconvulsive therapy.
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