29: Psychiatric Disorders

Chapter 29

Psychiatric Disorders

Mental disorders are common in today’s society. Approximately one third of the population in the United States will have at least one psychiatric disorder during their lifetime, and 20% to 30% of adults in the United States will experience one or more psychiatric disorders during a 1-year period. About 5% of the population suffers from serious affective or mood disorders. Schizophrenic disorders are reported in 1.1%.< ?xml:namespace prefix = "mbp" />14

Psychiatric problems, which can affect the clinical course in various medical illnesses, increase required duration of treatment, decrease the patient’s functional level, and have a negative impact on overall prognosis and outcome. Disorders related to drug and alcohol use account for a significant proportion of the treatment-related psychiatric issues. In the elderly population, a high prevalence of psychiatric complications is associated with medical illness. About 11% to 15% of these patients experience depressive symptoms, and between 10% and 20% have anxiety disorders, including phobias. Phobia is the most common psychiatric disorder in women older than 65 years of age. Approximately 20% of elderly persons have a substance abuse disorder.5 The prevalence of psychiatric disorders among adult dental patients seeking treatment at the Virginia Commonwealth University School of Dentistry was found to be 28% of a randomly selected patient group of 442.6 The most common disorder reported was depression.6

This chapter provides an overview of mood disorders, somatoform disorders, and schizophrenia, with an emphasis on drugs used to treat these conditions and their significant adverse reactions and interactions with drugs used in dentistry. Also discussed are specific considerations in the dental management of patients with these disorders.

Mood Disorders


Mood disorders represent a heterogeneous group of mental disorders that are characterized by extreme exaggeration and disturbance of mood and affect. These disorders are associated with physiologic, cognitive, and psychomotor dysfunction. Mood disorders, which tend to be cyclic, include depression and bipolar disorder.3,4,7,8


Incidence and Prevalence

About 5% of the adults in the United States have a significant mood disorder. Mood disorders are more common among women (Table 29-1). Major depression may begin at any age, but the prevalence is highest among elderly persons, followed by those 30 to 40 years of age and, in recent years, an increased number of 15- to 19-year-olds.9 Lifetime prevalence rates for major depressive disorders are 15% to 20%.4 Point prevalence rates for major depression in urban U.S populations are 2% to 4% for men and 4% to 6% for women.4 After the age of 55 years, depression starts to occur more commonly in men.9 About one third of depressed persons require hospitalization; 30% follow a chronic course with residual symptoms and social impairment.3,4,9,10

TABLE 29-1 Epidemiology of Mood Disorders

Variable Depressive Disorders Bipolar Disorders

Major depression

    Point prevalence:
       Men: 2.0-4.0%
       Women: 4.0-6.0%
       Older adults: 11-15%
    Lifetime prevalence:
       Overall rate: 15-20%
    More common in divorced or separated persons


    Point prevalence:
       Men: 5.0%
       Women: 8.0%

Bipolar illness

    Lifetime prevalence: 0.6-0.9%
    May be as high as 1-10% if all subtypes are included
    Annual incidence:
       Men: 9-15 cases per 100,000
       Women: 7.4-32 cases per 100,000
    More common in upper socioeconomic groups
    Equal among races
    High rates of divorce


    Lifetime prevalence: 0.4-3.5%
Age at onset

Late 20s or 30s

Childhood possible

May have much later onset

Higher rate and earlier onset for persons born after 1940 than for those born before

Late teens or early 20s

Childhood possible

Cyclothymia may precede late onset of overt mania or depression

Family and genetic studies

Unipolar patients tend to have relatives with major depression and dysthymic disorder and fewer with bipolar disorder.

Early onset, recurrent course, and psychotic depression appear to be heritable.

Bipolar patients have many relatives with bipolar disorder, cyclothymia, unipolar depression, and schizoaffective disorder
Twin studies

Concordance in monozygotic twins:

    Recurrent depression: 59%
    Single episode only: 33%

Concordance rate for identical (monozygotic) twins is 4 times greater than for fraternal (dizygotic) twins

72% concordance in monozygotic twins, 19% in same sex dizygotic twins

Data from Schiffer RB: Psychiatric disorders in medical practice. In Goldman L, Ausiello D, editors: Cecil textbook of medicine, ed 23, Philadelphia, Saunders, 2008; and Kahn DA: Mood disorders. In Cutler JL, Marcus ER: Saunders text and review: psychiatry, Philadelphia, Saunders, 1999.

The prevalence of major depression is fairly consistent across races and cultures. However, this disorder occurs with greater frequency among recent immigrants and the displaced.9 No evidence suggests significant geographic variability, except in seasonal affective disorder, which is due to limited exposure to the sun during the winter in the northern states. No clear association with social class has been found, but major depression is associated with poverty and unemployment as significant stressors.9 Risk factors include current stress burden; history of early trauma, neglect, abuse, or deprivation; personal and family history of mood and anxiety disorders; medical and psychiatric disorders; and personality disorder.10

The lifetime prevalence of dysthymia, a chronic, milder form of depression, is 2.2% in women and 4.1% in men.2 Approximately 0.4% to 1.6% of adults in the United States have bipolar disorder.2 In contrast with major depression, which is more than twice as common in women as in men, bipolar disorder occurs almost with equal frequency in both sexes. Bipolar disorders are much less common than major depression (see Table 29-1).4,8,10


Several theories have been presented to explain the origin of mood disorders. Reduced brain concentrations of norepinephrine and serotonin (neurotransmitters) for some time have been believed to cause depression. Increased levels of these neurotransmitters have contributed to the onset of mania. The causes of depression and mania now appear to be complex.4,8,10 Current research focuses on the interactions of norepinephrine and serotonin with a variety of other brain systems and on abnormalities in the function or quantity of receptors for these transmitters. Thyrotropin release of thyroid-stimulating hormone and cortisol release by corticotropin-releasing factor and adrenocorticotropin over a long period may be associated with the development of depression. This model suggests that depression is the result of a stress reaction that has gone on too long.3,4,9,10

Evidence for a genetic predisposition to bipolar disorder is significant. The concordance rate for monozygotic twin pairs approaches 80%, and segregation analyses are consistent with autosomal dominant transmission. Multiple genes are likely to be involved, with strongest evidence for loci on chromosomal arms 18p, 18q, 4p, 4q, 5q, 8p, and 21q.3

Positron emission tomography (PET) studies show decreased metabolic activity in the caudate nuclei and frontal lobes in depressed patients that returns to normal with recovery. Single-photon emission computed tomography (SPECT) studies show comparable changes in blood flow.3

Psychosocial theory focuses on loss as the cause of depression in vulnerable persons. Mania receives much less attention because it is thought to be more of a biologically caused disorder.3,4,8,10

Clinical Presentation and Medical Management

Depressive Disorders

The Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR), lists three types of depressive disorders: major depression, dysthymic disorder, and depression not otherwise specified (NOS).11 Major depression (unipolar) is one of the primary mood disorders. Patients with major depression are depressed most of the day, show a marked decrease in interest or pleasure in most activities, exhibit a marked gain or loss in weight, and suffer from insomnia or hypersomnia (Box 29-1). These symptoms must be present for at least 2 weeks before a diagnosis of major depression can be made. About 50% to 80% of persons who have had a major depressive episode will have at least one more depressive episode; 20% of these people will have a subsequent manic episode and should be reclassified as bipolar. A major depression usually will last about 8 to 9 months if the patient is not treated. Dysthymia represents a chronic, milder form of depression with symptoms that last at least 2 years (see Box 29-1). Depression NOS is a form of depression that falls short of the diagnostic criteria for major depression and has been too brief for dysthymic disorder.9,12 A form of depression called seasonal affective disorder may occur in areas of the country that have limited amounts of sunlight during the winter.9


Box 29-1 Diagnostic Criteria for Depressive Disorders

Major Depressive Episode Dysthymia

At least five of the following symptoms have been present during the same 2-week period (one of the symptoms must be depressed mood or loss of interest or pleasure):

    Depressed mood most of the day
    Marked loss of interest or pleasure in most or all activities most of the day
    Significant weight gain or loss when not dieting, or change in appetite
    Insomnia or hypersomnia nearly every day
    Psychomotor agitation or retardation nearly every day that is observable by others
    Fatigue or loss of energy nearly every day
    Feelings of worthlessness or excessive guilt feelings
    Inability to think or concentrate, or indecisiveness
    Recurrent thoughts of death, or suicidal ideation without a specific plan, or with a plan, or attempted

An organic factor did not initiate or maintain the disturbance.

The disturbance is not a normal reaction to the death of a loved one.

At no time during the disturbance have there been delusions or hallucinations for as long as 2 weeks in the absence of prominent mood symptoms (i.e., before the mood symptoms developed or after they have remitted.)

Not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or psychotic disorder; no other specific diagnosis

Depressed mood for most of the day for at least 2 years

Presence, while depressed, of two or more of the following:

    Poor appetite
    Insomnia or hypersomnia
    Low energy or fatigue
    Low self-esteem
    Poor concentration or difficulty making decisions
    Feelings of hopelessness

During the 2-year period, the person has never been without the symptoms for more than 2 months at a time.

No major depressive episode has been present during the first 2 years of the disturbance.

There has not been an intermixed manic episode.

The disturbance does not occur during the course of a psychotic disorder.

The symptoms are not caused by the physiologic effects of a substance.

The symptoms cause significant distress or functional impairment.

From Schiffer RB: Psychiatric disorders in medical practice. In Goldman L, Ausiello D, editors: Cecil textbook of medicine, ed 23, Philadelphia, 2008, Saunders.


Bipolar Disorder

The DSM-IV lists four types of bipolar disorder: bipolar I, bipolar II, cyclothymic, and bipolar disorder NOS (Figure 29-1).11 Figure 29-2, A shows the normal variation in moods. Bipolar I disorder consists of recurrences of mania and major depression or mixed states that occur at different times in the patient, or a mixture of symptoms that occur at the same time (see Figure 29-2, B). The essential feature of a manic episode is a distinct period during which the affected person’s mood is elevated and expansive or irritable (Table 29-2). Associated symptoms of the manic syndrome include inflated self-esteem, grandiosity, a decreased need for sleep, excessive speech, flight of ideas, distractibility, psychomotor agitation, and excessive involvement in pleasurable activities. During a manic episode, the mood often is described as euphoric, cheerful, or “high.” The expansive quality of the mood is characterized by unceasing and unselective enthusiasm for interacting with people. However, the predominant mood disturbance may be irritability and anger. Speech often is loud, rapid, and difficult to interpret, and behavior may be intrusive and demanding. Style of dress often is colorful and strange, and long periods without sleep are common. Poor judgment may lead to financial and legal problems. Drug and alcohol abuse also are commmon in this patient population.3,4,11,13


FIGURE 29-1 Mood disorders listed in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV-TR). Patients with bipolar disorder have had at least one episode of mania or hypomania. Cyclothymic disorder consists of recurrent brief episodes of hypomania and mild depression. Major depression usually is recurrent but sometimes happens as a single lifetime episode. Dysthymic disorder is mild depression that lasts at least 2 years.

image image image

FIGURE 29-2 A, Normal mood cycles. B, Bipolar type I disorder. C, Bipolar type II disorder.

(From Khalife S: Bipolar disorder. In Carey WD, et al, editors: Current clinical medicine 2009—Cleveland Clinic, ed 2, Philadelphia, 2010, Saunders.)

TABLE 29-2 Clinical Features of Hypomania and Mania

Feature Hypomania Mania
Appearance May be unremarkable
Demeanor may be cheerful
Often striking
Clothes may reflect mood state
Demeanor may be cheerful
Disordered and fatigued in severe states
Behavior Increased sociability and loss of inhibition Overactivity and excitement
Social loss of inhibition
Speech May be talkative Often pressured, with flight of ideas
Mild elation or irritability Elated or irritable
Boundless optimism
Typically, no diurnal pattern
May be labile
Vegetative signs Increased appetite
Reduced need for sleep
Increased libido
Increased appetite
Reduced need for sleep
Increased libido
Psychotic symptoms Not present Thoughts may have an expansive quality
Thoughts may have an expansive quality Delusions and second-person auditory hallucinations may be present, often grandiose in nature
Schneiderian First Rank (symptoms associated with schizophrenia) symptoms found in 10-20%
Cognition Mild distractibility Marked distractibility
More marked disturbances in severe states
Insight Usually preserved Insight often lost, especially in severe states

From Mackin P, Young A; Bipolar disorders. In Wright P, Stern J, Phelan M, editors: Core psychiatry, ed 2, Edinburgh, 2005, Elsevier.

Bipolar II disorder (see Figure 29-2, C) consists of recurrences of major depression and hypomania (mild mania). Cyclothymic disorder manifests as recurrent brief episodes of hypomania (see Table 29-2) and mild depression. Bipolar disorder NOS refers to partial syndromes, such as recurrent hypomania without depression. Patients with bipolar disorder have at least one episode of mania or hypomania.3,8,11,13

The diagnosis of bipolar disorder is made as soon as the patient has one manic episode, even if that person has never had a depressive episode. Most patients who become manic will eventually experience depression. However, about 10% of patients in whom bipolar disorder is diagnosed appear to have only manic episodes.14

Men tend to have a greater number of manic episodes and women, more numerous depressive episodes. Untreated patients with bipolar disorder will experience a mean of nine affective episodes during their lifetime. The length of each cycle tends to decrease, although the number of cycles increases with age (Figure 29-3). Each affective episode lasts about 8 to 9 months. Bipolar patients have a greater number of episodes, hospitalizations, divorces, and suicides compared with unipolar patients.15


FIGURE 29-3 Natural history of recurrent mood disorders: an integrated model. Genetic factors and early environmental stress may predispose to development of a mood disorder. Early episodes are likely to be precipitated by environmental stress; later episodes are more likely to occur closer together and spontaneously, without precipitants.

Treatment of Mood Disorders

Table 29-3 shows commonly used antidepressants. The first-line medication for major depression is a selective serotonin reuptake inhibitor (SSRI) such as citalopram. Sertraline, venlafaxine, and bupropion are second-line drugs that may be used in patients who fail to achieve remission with citalopram.3,4,911 These agents are used primarily to treat major depression, dysthymic disorder, and depression NOS and have a limited role in depression associated with bipolar disorder that responds to an antipsychotic medication and the standard antidepressant medication fluoxetine. Drug therapy is essential in bipolar disorder for achieving two goals: (1) rapid control of symptoms in acute episodes of mania and depression and (2) prevention of future episodes or reduction in their severity and frequency. Mood disorders have a tendency to recur. Affective episodes may occur spontaneously or may be triggered by adverse events. Persons with mood disorders and their families must become aware of the early signs and symptoms of affective episodes, so that treatment can be initiated. These patients also must be made aware of the need for medication compliance and of the medication’s adverse effects and possible complications.3,4,8,10

TABLE 29-3 Commonly Used Antidepressants (by Structural Group)

Drug Trade Name Comments
Amitriptyline Elavil  
Trimipramine Surmontil  
Desipramine Norpramin  
Doxepin Sinequan  
Imipramine Tofranil  
Nortriptyline Pamelor  
Protriptyline Vivactil  
Maprotiline Ludiomil  
Selective Serotonin Re-uptake Inhibitors
Escitalopram Lexapro  
Fluoxetine Prozac  
Fluvoxamine Luvox  
Paroxetine Paxil  
Sertraline Zoloft  
MAOIs   Patients taking these drugs must be on a tyramine-free diet.
Phenelzine Nardil  
Tranylcypromine Parnate  
Atypical or Nontricyclic
Nefazodone Serzone As effective as imipramine
Venlafaxine Effexor SNRI; may be effective in treatment of resistant depression
Amoxapine Asendin  
Bupropion Wellbutrin May be especially helpful for atypical depression
Mirtazapine Remeron Increase at 1- to 2-week intervals.
Trazodone Desyrel Helpful as a second drug for sleep disturbance
Duloxetine Cymbalta Additionally useful in pain syndromes

MAOIs, Monoamine oxidase inhibitors; SNRI, Serotonin-norepinephrine reuptake inhibitor.

Data from Schiffer RB: Psychiatric disorders in medical practice. In Goldman L, Ausiello D, editors: Cecil textbook of medicine, ed 23, Philadelphia, 2008, Saunders.

The mainstays of drug therapy for bipolar disorders are the mood-stabilizing drugs, which generally act on both mania and depression (Table 29-4). Drugs used are lithium, valproic acid or divalproex (valproate semisodium), lamotrigine, and carbamazepine.16 The most widely used mood stabilizer is lithium carbonate. Lithium is most helpful in patients with euphoric mania. When lithium is ineffective, or when medical problems prevent its use, one of the anticonvulsants (valproic acid or divalproex, lamotrigine, or carbamazepine), with mood stabilizing effects, can be used.8

TABLE 29-4 Initial Treatment Guidelines for Bipolar Disorder


Mixed depressive and manic episodes are difficult to manage. First the manic behavior needs to be stabilized, and then the depression is addressed. An atypical antipsychotic (olanzapine) or a mood stabilizer is administered to stabilize the manic behavior, and depression is addressed with a standard antidepressant drug (fluoxetine). Another approach is to use a mood stabilizer and a combination agent consisting of an antidepressant plus an atypical antipsychotic—the olanzapine-fluoxetine combination (OFC) drug available as Symbyax.8

Electroconvulsive therapy is an effective antimanic treatment.17 It may be used in cases of manic violence, delirium, or exhaustion. It also is appropriate for use with patients who do not respond to medication taken for many weeks. When antidepressant drugs are given for bipolar depression, they may cause a switch to mania or a mixed state, or they may induce rapid cycling. The most common treatment for bipolar depression is an antidepressant combined with a mood stabilizer to prevent a manic switch or rapid cycling.3,4,8

It takes about 7 to 10 days for lithium to reach full therapeutic effectiveness. With most antidepressant drugs, a delay (10 to 21 days) is noted before full therapeutic benefits are achieved.3,4

Patients who have had two or three episodes of bipolar disorder, including depressive episodes, usually are treated indefinitely because of the near certainty of relapse. Lithium is the treatment of choice. About one third of patients will not experience additional episodes and are considered cured; a third of those who take lithium will experience less frequent or less severe episodes and will function well; and the remaining third of patients will continue to have frequent and severe episodes with ongoing disability.3,4,8

An estimated 30,000 suicides occur each year in the United States. About 70% of these involve persons with major depression. The physician must consider suicidal lethality in the management of patients with depression. In general, the risk for suicide is increased in association with the following factors: alcoholism, drug abuse, social isolation, elderly male status, terminal illness, and undiagnosed or untreated mental disorders. Patients at greatest risk are those with a history of previous suicide attempts, drug or alcohol abuse, recent diagnosis of a serious condition, loss of a loved one, or recent retirement, and those who live alone or lack adequate social support. Persons with a suicide plan and the means to carry out that plan are at greatest risk for suicide. Once medical control is attained in the patient with a mood disorder, insight-oriented psychotherapy often is initiated as an adjunct for management of the patient’s condition.4,11,17,18

Somatoform Disorders


Persons with somatoform disorders have physical complaints for which no general medical cause is present. Associated unconscious psychological factors contribute to the onset, exacerbation, or maintenance of physical symptoms. The following conditions are regarded as somatoform disorders: somatization, conversion disorder, pain disorder, and hypochondriasis (Table 29-5). Patients with a somatization disorder experience multiple, unexplained somatic symptoms that may last for years.3,4,19

TABLE 29-5 Somatoform Disorders

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Somatoform Disorder Features
Somatization disorder Chronic multisystem disorder characterized by complaints of pain, and gastrointestinal and sexual dysfunction. Onset usually is early in life, and psychosocial and vocational achievements are limited.
Rarely affects men. Diagnostic criteria include four pain symptoms plus two gastrointestinal symptoms, plus one sexual-reproductive symptom, plus one pseudoneurologic symptom.
Conversion disorder Syndrome of symptoms or deficits mimicking neurologic or medical illness in which psychological factors are judged to be of etiologic importance. Patients report isolated symptoms that have no physical cause (blindness, deafness, stocking anesthesia) and that do not conform to known anatomic pathways or physiologic mechanisms. In a group of such patients followed over time, a physical disease process will become apparent in 10% to 50%.
Pain disorder Clinical syndrome characterized predominantly by pain in which psychological factors are judged to be of etiologic importance
Hypochondriasis Chronic preoccupation with the idea of having serious disease. This preoccupation usually is poorly amenable to reassurance.
May consist of a morbid preoccupation with physical symptoms or bodily functions. Can be described as “illness is a way of life.”
Body dysmorphic disorder Preoccupation with an imagined or exaggerated defect in physical appearance
Other somatoform-like disorders  
Factitious disorder Intentional production or feigning of physical or psychological signs when external reinforcers (e.g., avoidance of responsibility, financial gain) are not clearly present
Voluntary production of symptoms without external incentive
More common in men and seen in health care workers more often
Skin lesions more common than oral (oral lesions cannot be seen)
Oral lesions include those associated with self-extraction of teeth, picking at the gingiva with fingernails, nail file gingival injury, and application of caustic substances to the lips.

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Jan 4, 2015 | Posted by in General Dentistry | Comments Off on 29: Psychiatric Disorders

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