52: Psychiatric Conditions: Assessment of Disease States and Associated Dental Management Guidelines


Psychiatric Conditions: Assessment of Disease States and Associated Dental Management Guidelines


Anxiety is a normal, healthy reaction to stress and it helps a patient deal with stressful situations. When anxiety becomes excessive or irrational it becomes a disabling disorder. The intensity of symptoms is directly related to the patient’s ability to cope.

Anxiety Disorder Classification

The five major types of anxiety disorders are:

1. Generalized anxiety disorder
2. Obsessive-compulsive disorder (OCD)
3. Panic disorder
4. Posttraumatic stress disorder (PTSD)
5. Social phobia, or social anxiety disorder

Generalized Anxiety Disorder (GAD)

GAD is associated with excessive, unrealistic anxiety that lasts six or more months. These patients also experience trembling, muscle aches, insomnia, bowel movement upsets, dizziness, and irritability.

Obsessive-Compulsive Disorder (OCD)

The OCD patient is plagued by obsessions due to increased anxiety or fears. The obsessions lead the patient to perform a ritual to relieve the anxiety caused by the obsession.

Panic Disorder

Patients with panic disorders go through a phase of extreme anxiety when faced with a specific situation—for example, fear of heights or closed spaces. They experience severe palpitations, chest discomfort, sweating, trembling, tingling sensations, feeling of choking, fear of dying, and fear of losing control.

Posttraumatic Stress Disorder (PTSD)

PTSD can follow an exposure to a traumatic event, such as an assault of any kind, unexpected death of a family member/spouse, or experiencing a natural disaster. The patient relives the traumatic event by experiencing flashbacks and nightmares. The patient avoids places related to the trauma and becomes emotionally detached from others. The patient also experiences difficulty sleeping, irritability, and poor concentration. Internal or external stimuli can trigger an attack of PTSD. Drug and alcohol abuse is a common occurrence with PTSD.

Social Anxiety Disorder (SAD)

SAD is associated with extreme anxiety about being judged by others or having extreme anxiety about behaving in a way that might cause embarrassment or ridicule. The patient experiences blushing, palpitations, and sweating. Good history-taking will show that the patient starts to avoid situations that will cause SAD.

Treatment of Anxiety Disorders

Anxiety disorders are treated as follows:

1. Psychosocial therapies
2. Medications
3. Both psychosocial therapies and medications

Anxiety Medications

Combination therapies are often utilized in the management of anxiety. Drugs used to treat anxiety disorders are:

1. Benzodiazepines
2. Beta-blockers
3. Monoamine oxidase inhibitors (MAOIs): an antidepressant with anxiolytic effects
4. Selective serotonin reuptake inhibitors (SSRIs): antidepressants with anxiolytic effects
5. Tricyclic antidepressants: antidepressants with anxiolytic effects

Anxiety Disorders and Alcohol Abuse

Patients with anxiety and alcohol abuse could present with the following complications:

1. These patients often have poor treatment compliance.
2. They have an increased risk of relapse into alcohol abuse following detoxification.
3. They can have severe drug interactions between prescription medication and alcohol.
4. Patients with social anxiety disorder (SAD), posttraumatic stress disorder (PTSD), generalized anxiety disorder (GAD), and panic disorder often abuse alcohol.
5. Substance abuse or alcohol abuse is treated with individual therapy or group therapy that utilizes the twelve-step programs birthed by Alcoholics Anonymous.
6. SSRIs are often prescribed in conjunction with therapy to assist with the recovery process. Common SSRIs prescribed are fluoxetine (Prozac), sertraline (Zoloft), fluvoxamine (Luvox), paroxetine (Paxil), citalopram (Celexa), and escitalopram (Lexapro).
7. Benzodiazepines should be avoided in these patients as they can increase the risk of abuse, tolerance, and physical dependence.

Anxiety Disorders and Suggested Dental Alerts

The following are dental alerts for anxiety disorders:

1. The anxious individual will tend to be very alert, quite hyperactive, and fidgety in the dental environment. It is best to address the anxiety with the patient before you begin treating the patient.
2. Always establish good communication and trust with these patients. Show genuine concern and offer stress management.
3. O2 + N2O or benzodiazepines can be used to control the anxiety with the following precautions: Use benzodiazepines for stress management only if approved by the patient’s physician, the patient is not on any medications to control the anxiety, or the patient is already on benzodiazepines to control the anxiety. Use O2 + N2O for patients on antidepressant medications.
4. An occasional physician may allow the use of low-dose benzodiazepines in conjunction with the patient’s anti-anxiety or antidepressant medications. You are advised, therefore, to always check with the patient’s MD.
5. Benzodiazepine use is contraindicated in the pregnant patient, the elderly patient, the obese patient, the alcoholic patient, the patient on centrally acting drugs, and the patient on H2 blockers for GERD, peptic ulceration, or gastritis. When benzodiazepines have to be used in the presence of H2 blockers, keep an interval of two hours between both the medications.
6. Anesthetics: Avoid epinephrine in the local anesthetic and epinephrine cords in the presence of TCAs and MAOIs. Epinephrine is not contraindicated with the SSRIs.
7. Patients suffering from anxiety often experience aphthous ulcerations, ulcerative gingivitis, TMJ problems, lichen planus, geographic tongue, and myofacial pain. These conditions should also be additionally addressed in the dental setting.
8. Xerostomia is a genuine concern in patients taking all kinds of psychiatric medications. Follow the suggested xerostomia management guidelines in Chapter 48.
9. Psychiatric medications cause postural hypotension. Assist the patient out of the chair to prevent a fall or collapse.

Anesthetics, analgesics, and stress management summary: Avoid sedatives, epinephrine (except with SSRIs), narcotic analgesics, sedating antihistamines, and epinephrine cords with psychiatric medications.


Depression is a condition where a patient feels sad, hopeless, and/or disinterested in life in general. Depression is an illness that affects the way a person thinks, feels, behaves, and functions. When these feelings last for more than two weeks and when the feelings interfere with daily living, it is called a major depressive episode.

Major Depressive Episode Symptoms

Symptoms experienced are persistent sadness, hopelessness, pessimism, worthlessness, decreased energy, fatigue, difficulty concentrating and making decisions, insomnia, early-morning awakening or oversleeping, decreased appetite and/or weight loss, overeating and weight gain, thoughts of death or suicide, suicide attempts, restlessness, and irritability. The patient experiences persistent physical symptoms such as headaches, digestive disorders, and pain for which no other cause can be determined. The patient does not respond to treatment for any of these symptoms.

Depression Disorder Classification

The three main types of depressive disorders can occur with any of the major anxiety disorders:

1. Major depression
2. Dysthymia/chronic depression
3. Bipolar disorder

Major Depression

Major depression is diagnosed when the patient is symptomatic for a two-week period. Major depressive episodes may occur once or twice in a lifetime, or may recur frequently throughout life. They may occur spontaneously and some patients may attempt suicide.

Dysthymia/Chronic Depression

Dysthymia is a less severe and more chronic form of depression. The patient mainly experiences decreased energy, poor appetite or overeating, insomnia or oversleeping, and extreme pessimism.

Bipolar Disorder/Manic-Depressive Psychosis

Understanding Bipolar Disorder

Bipolar disorder/manic-depressive illness causes extreme mood swings with episodes of mania and depression, or a mixture of both. People with depression may feel sad or have difficulty with activities of daily living.

The classic signs of depression include:

  • Alterations of sleep, difficulty falling or staying asleep, or sleeping too much.
  • Little or no interest in any activity previously found to be pleasurable.
  • Alterations in appetite, loss of appetite, or eating too much.
  • A low threshold for becoming irritated.
  • Fatigue, loss of energy, or sluggishness.
  • Feelings of worthlessness or guilt.
  • Difficulty concentrating and making decisions.
  • Recurring thoughts of death or suicide.

A patient in the manic phase may demonstrate a period of abnormally elevated or irritable mood for at least four days (for hypomania) to seven days (for mania) and display these symptoms:

  • Rapid, pressured speech; patient is more talkative.
  • Inflated ego or grandiosity.
  • Flight of ideas or complaints of racing thoughts.
  • Decreased need for sleep, such as two to three hours of sleep.
  • Distraction that occurs easily.
  • Psychomotor agitation or increase in goal-directed activity, like social or occupational activity.
  • Hypersexuality.
  • Overindulgence in pleasurable activities like sexual indiscretions, buying sprees, unwise business decisions.

A “mixed” episode is characterized by a period of a week or more in which the symptoms of both a major depressive episode and a manic episode are present daily. These episodes may last from a week to a few months. The patient may experience mixed episodes, manic, and/or depressive episodes over the course of the illness. A mixed episode may evolve from a manic or a major depressive episode, or it may emerge on its own. Besides extreme mood swings, patients with bipolar disorder can experience anger, panic attacks, agitation, anxiety, restlessness, suicidal thoughts, persecutory delusions, hallucinations, and confusion.

Bipolar Subtypes

Subtypes of bipolar disorder include:

  • Bipolar I Disorder: At least one episode of mania alternates with major depression. Mania may also include symptoms of psychosis.
  • Bipolar II Disorder: Episodes of hypomania alternate with major depression. This form of bipolar disorder, which is not as severe as bipolar I disorder, often increases the patient’s functioning when in the hypomanic state. Hypomania is a milder form of mania that lasts for at least four days at a time but tends not to interfere with the patient’s daily activities. The patient with hypomania tends to be euphoric, but suicidal tendencies are a particular risk for patients experiencing major depression.
  • Cyclothymia: Patients alternate between hypomania and minor depression for a period of at least two years.
  • Bipolar disorder not otherwise specified: Patients experience episodes of hypomania without major depression.

Bipolar Disorder Treatment

Treatment of bipolar disorder is very patient-specific. Health-care providers must use their expertise, time, and patience to find the correct combination of medications to attain satisfactory results.

The Role of Psychotherapy

After a patient is no longer in a state of mania, psychotherapy may be used to help the patient cope more adaptively to stressors and decrease the possibility of relapse. Pharmacology and psychotherapy are considered crucial during the continuation and maintenance phases of bipolar disorder.

Interpersonal and social rhythm therapy is another formalized therapy that has been tested in combination with pharmacologic interventions in randomized clinical trials as treatment for patients who are in the maintenance phase of bipolar disorder. This therapy focuses on factors that are related to recurrence of symptoms, including nonadherence, stress reduction, and support systems.


Lithium is a psychotropic agent with an established record of efficacy for treating acute manic episodes of bipolar I disorder, in addition recurrent manic and depressive episodes. It inhibits 80% of acute manic and hypomanic episodes within 10–21 days of the start of treatment. Lithium is not as effective for symptoms of mixed mania or for rapid cycling.

Lithium mechanism of action (MOA): MOA of lithium is not completely understood. Chemically similar to sodium and potassium, lithium is a positively charged ion that seems to affect electrical conductivity in neurons. According to one theory, bipolar disorder is caused by an overexcitement of neurons in certain parts of the brain; lithium interacts with sodium and potassium at the cell membrane to stabilize electrical activity.

Lithium improves mood in patients with bipolar disorder who are depressed, and it augments antidepressant therapy when antidepressants alone fail to improve mood in patients who are depressed. Lithium is also effective as prophylaxis against recurrent depression in patients with bipolar disorders.

Because lithium must reach a therapeutic blood level, it can take up to three weeks to control symptoms in patients with mania. Generally, the target serum level for acute treatment in adults is between 0.8 and 1.4mEq/L, and slightly lower levels (0.6–1.2mEq/L) are suggested for older adults, due to decreased renal clearance.

Adverse DDIs associated with Lithium

  • Drugs that decrease lithium levels by increasing lithium excretion: acetazolamide, alcohol, sodium bicarbonate, caffeine, urea, and xanthine derivatives.
  • Drugs that increase lithium levels and associated toxicity by increasing sodium excretion: angiotensin-converting enzyme (ACE) inhibitors and diuretics.
  • Calcium channel blockers (CCBs): CCBs and carbamazepine increase neurotoxicity in combination with lithium.
  • Fluoxetine: Fluoxetine may increase or decrease lithium levels.
  • Metronidazole: Metronidazole may cause lithium toxicity by reducing renal clearance of lithium.
  • NSAIDS: NSAIDS increase lithium levels by reducing renal clearance of lithium.

Lithium Side Effects

Fine hand tremors, polyuria, and mild thirst are common adverse reactions during initial treatment. The patient may also experience transient mild nausea and general discomfort during the first few days of lithium administration. These adverse reactions should subside shortly after initiation of treatment, but if they persist, a reduced dosage or cessation of therapy is indicated.

Lithium Toxicity Concerns

Lithium has a very narrow therapeutic window, so always be concerned about possible toxicity. Because of the risk for toxicity, serum lithium levels must be checked regularly throughout treatment. Serum lithium levels greater than 1.5mEq/L carry a greater risk of toxicity than lower levels. When signs and symptoms of toxicity appear, the patient must contact the health-care provider, withhold the medication, and obtain a lithium level as prescribed. The health-care provider can then reevaluate the dosage.

Early signs and symptoms of toxicity include nausea, vomiting, diarrhea, thirst, polyuria, lethargy or drowsiness, slurred speech, muscle weakness, incoordination, and fine hand tremor.

With serum levels between 1.5–2.0mEq/L (advanced toxicity), patients begin to experience coarse hand tremors, persistent gastrointestinal (GI) upset, mental confusion, muscle hyperirritability, electroencephalographic changes, incoordination, and sedation.

The patient may display ataxia, giddiness, serious electroencephalographic changes, tinnitus, and blurred vision, when serum lithium levels are between 2.0–2.5mEq/L (severe toxicity). Other signs include clonic movements, large output of dilute urine, seizures, stupor, severe hypotension, and coma. Severe toxicity may be fatal; death is usually secondary to pulmonary complications.

Lithium is not typically given to women who are pregnant due to the potential for harm to the fetus. Lithium is categorized as a Category D drug because of evidence of human fetal risk, but it may be used in the event of a life-threatening risk to the mother or threat of serious illness. Lithium is also contraindicated in women who are breast-feeding.

Lithium Alerts for Patients

Missing doses of lithium may increase the risk for a relapse in mood symptoms. Lithium may make the patient drowsy. Driving or operating machinery should be avoided particularly during the start of therapy. Avoid alcohol or recreational drugs while taking lithium.

The loss of too much water or salt from the body can lead to serious adverse reactions because of lithium. The patient must drink enough water at all times, especially during phases of vomiting and/or diarrhea. Taking lithium with food can help decrease or avoid stomach upset. A low-salt diet, leading to low sodium blood levels, can increase the risk of lithium toxicity.

Antiepileptic Drugs

Although classified as anti-seizure medications, antiepileptic drugs (AEDs) are also used to treat bipolar disorder. Under certain circumstances, AEDs such as valproate and carbamazepine are now being used as mood stabilizers.


Valproate products that are FDA-approved />

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Jan 4, 2015 | Posted by in General Dentistry | Comments Off on 52: Psychiatric Conditions: Assessment of Disease States and Associated Dental Management Guidelines
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