Management of complicated, high-risk patients with psychiatric comorbidities
The dental practitioner is likely to encounter complicated patients throughout his or her career regardless of clinical setting or specialty. Experiences with complicated patients range from a difficult clinical relationship to a treatment-resistant case, or even a patient with significant medico-legal risk. Patients with psychiatric comorbidities are among the most demanding in these ways. This chapter reviews common psychiatric diagnoses that are encountered with the complicated patient. An awareness of diagnostic criteria, screening, effective management, and referral likely improves dental outcomes and offers the patient optimal care.
Psychiatric disorders are as common in primary care dentistry as they are in general medical practice, with some reports suggesting that as many as one out of four patients present with mediating mental health issues. 1 With the expanding role of dentistry in health care, there is an increased awareness that the general dentist must take on the responsibility to assess, refer, and manage complicated patients. Indeed, the practicing dentist makes contact with a regular patient more frequently than other healthcare providers, a status that places dentistry in a unique position to positively impact public health.
Within dental practices, self-reported depression is second in frequency only to hypertension. 1,2 Substance abuse, anxiety, anorexia nervosa, bulimia nervosa, insomnia, bipolar disorder, and posttraumatic stress disorder follow in frequency of reports. Anxiety disorders are also particularly common in general practice. With the volume of a typical dental practice, the general clinician may see at least one patient with an anxiety disorder per day, and only one out of four receiving proper mental health care. Patients with these untreated disorders are likely to be less compliant, miss follow-up appointments, and have poorer outcome over a range of dental treatments.3
Some clinicians may elect to forgo a comprehensive medical and psychosocial assessment within their practice, based in the belief that an effort of this sort is not within their domain of responsibility. Indeed, some clinicians intentionally avoid asking difficult questions where mental health issues are concerned. The dentist may also fail to collect data from other sources, for example, primary care, other subspecialists, or family members, in part because of his or her own discomfort with asking sensitive questions. However, this approach may do a disservice to the patient as well as expose the clinician to medico -legal risks as dentistry continues to have an expanded role in the healthcare field.
Anxiety disorders can interfere with both the professional relationship and adherence to dental treatment. Of these, none can compromise care as much as posttraumatic stress disorder (PTSD).4,5 Dental-related phobia, panic disorder, and generalized anxiety disorders are also commonly encountered, while treatments for the related symptoms are addressed at greater length in other chapters of this book.
For a diagnosis of PTSD, there are two criteria for an event to be considered traumatic: (1) the event must involve actual or threatened death, serious injury, or a threat to the physical integrity of the person or others, and (2) the person experiencing or witnessing the event must respond with intense fear, helplessness, or horror.6 Common precipitating traumatic events include physical or sexual assault, natural disasters, and motor vehicle accidents. Some have argued that particular dental or medical procedures might be considered sufficient to precipitate PTSD, though data appear to offer little support for this. It is more likely that dental or medical procedures “trigger” an anxiety response that has been generalized from an earlier traumatic event.
The PTSD patient also shows a persistent reexperiencing of the event, that is, “flashbacks.” This can take the form of intrusive thoughts, dreams of the event, reliving of the event, and an intense psychological or physiological response to cues that resemble aspects of the event (p. 468).6 Although symptoms typically begin within the first 3 months of the traumatic event, there are cases when the onset of symptoms may be delayed months to years after the time of the event.6
To deal with the distressing reexperiencing of the event, the person may display a number of avoidance and “numbing” behaviors. Patients may avoid conversations about their trauma and make concerted attempts to avoid situations that evoke memories of the trauma. Hence, dental settings may be particularly problematic for patients with PTSD if the sounds, smells, tastes, or other cues are related to the traumatic event. Often, aspects of the traumatic event become generalized for the patient; the traumatic event did not have to occur in a dental setting for aspects of the dental office to evoke memories of the trauma. These patients may have difficulty falling or staying asleep, increased irritability and anger outbursts, concentration problems, and an exaggerated startle response. Depression is a common comorbid condition, and some patients attempt to ameliorate symptoms with alcohol or other substances. Sometimes those with PTSD cannot maintain employment, housing, or relationships with family.
Awareness of PTSD is particularly important given the growing populations of veterans who have experienced combat or torture, are victims of physical and psychological abuse, survivors of disasters, such as Hurricane Katrina, and refugees exposed to terrorism or war. These patients may be at higher risk for developing PTSD.5 PTSD can occur at any age and the severity, duration, and proximity of a person’ s exposure to the traumatic event are significant factors influencing the development of this disorder.6 The lifetime prevalence of PTSD is estimated at 8–14%,6 and even higher estimates for U.S. veterans.7 PTSD is estimated to be the fourth most common psychiatric illness in the United States.8 Most notably, cooccurrence of PTSD and domestic violence is quite high, with more than 80% of domestic violence patients suffering from the disorder. This should be of special importance, as many states require that all healthcare providers review basic abuse and violence risk issues for their patients.
PTSD can be followed by the development of pain conditions, such as chronic orofacial pain. Estimated prevalence of PTSD in orofacial pain populations is 15% compared with an average estimate of 10% in the general population, while some report even higher numbers.9 Some investigators have also suggested that permanent central processing changes may occur at the level of the brain when the trauma occurs. To date, the data appear to support the notion that trauma-induced vulnerability in the central nervous system may be a precursor to the development of a treatment resistant pain problem, while genetic factors also may play some role.8 Given the above prevalence with persistent facial pain, PTSD symptoms should be considered in the differential diagnosis of patients who present with significant head or facial pain.
The general dentist might not observe the patient’s flashbacks or avoidance behaviors. However, the dentist can be aware of common symptoms, including a phobic response associated with any devices placed in the mouth, or even a panic attack associated with observing the dentist with a mask. In contrast to a simple dental phobia, these patients present with severe anxiety and other psychiatric comorbidities. Hence, management by simple relaxation or desensitization techniques within the dental office would likely be ineffective as a sole focus of treatment. As a result, identification of PTSD for referral and collaboration with other providers remains important. During the clinical interaction with the patient, the dentist may be able to notice the signs of elevated anxiety, including insomnia, poor concentration, heightened startle response, hypervigilance for danger, and irritability.10 The medical and psychiatric history also may reveal a history of PTSD, and the dentist has an obligation to query the patient with respect to any precipitants and triggers that might occur in the dental setting. A patient presenting with a complicated regimen of psychiatric medications may offer a similar cue for the dentist to proceed with a more in-depth assessment of the patient’s symptoms.
After recognizing the presence of a PTSD diagnosis, the dentist should convey his or her empathy and understanding of the patient’s symptoms. Assurance and query about potential triggers should be direct with the patient, while some patients may be reluctant to discuss such triggers. Where possible, a family member can be included in the assessment.8 Communication with the patient’s mental health provider also may assist with patient adherence. In cases where the patient has no mental health provider in place, referral should be considered. While not as simple as the management of dental phobias, anxiety management techniques that maximize the patient’s control and reduce anxiety around the treatment setting offer the best options. In some cases, premedication for particular dental procedures can be considered, while care should be taken to coordinate such pharmacotherapy management strategies with the patient’s other treating providers.
Other anxiety disorders
While posttraumatic stress disorder can present a challenging diagnosis for primary dentist, most clinicians have a certain level of comfort in managing the patient with more generalized anxiety.11 As anxiety becomes severe or reaches the level of a psychiatric disorder, commonly associated symptoms include autonomic arousal and increased somatic complaints, such as chest pain. The patient may also report diagnoses of the stress-related medical disorders, such as irritable bowel syndrome.11 As with PTSD, common comorbidities can include major depressive disorder and substance use disorders,11 and the dentist should assess for their presence.
Panic attacks can be common with any anxiety disorder, while a specific psychiatric diagnosis of “panic disorder” also may be present. Approximately one-third of the population will experience a panic attack in the course of his or her life.12 A panic attack is the abrupt onset and escalation of a number of somatic and cognitive symptoms that usually peak within 10 min. 6 A list of these symptoms is presented in Table 7.1, and a minimum of four must be present.
|Possible cognitive symptoms||Possible somatic symptoms|
|Fear of losing control or going crazy||Palpitations/accelerated heart rate|
|Fear of dying||Sweating|
|Shortness of breath|
|Feeling of choking|
|Chills or hot flushes|
After the experience of recurrent and unexpected panic attacks, the patient must also experience persistent concern about a forthcoming attack, worry about the implications of the attack, or display significant changes in behavior related to the attacks.6 Hence, the patient becomes anxious “about being anxious.” Panic disorder can co-occur with agoraphobia, a strong fear of public or open places, which can lead to seclusion in the home.6,12 The worry that an unexpected panic attack will occur in a shopping center, grocery store, or at a dental office can lead one to avoid these places.
Depending upon the individual, a person with panic disorder may avoid coming to the dental office, or avoid returning if a panic episode occurs in the context of his or her dental care. However, the patient may feel less worry in coming to the appointments than elsewhere if he or she believes that there would be available assistance if an attack were to happen at the clinic. The patient with panic disorder may premedicate or employ other nonpharmacological strategies to ease the anxiety prior to coming to the dental appointment.13 With a proper assessment of the patient early in the treatment process, the dentist can adequately prepare the patient for their return visit with such strategies.
Patients with specific dental-related phobias are rarely seen in psychiatric settings, and are often managed solely by the practicing dentist. These patients are often less impaired than those with other anxiety disorders outlined above.14 A specific phobia is a persistent fear that is excessive or unreasonable, and that is cued by the presence or anticipation of the specific object or situation. Exposure to the situation invariably provokes an immediate anxiety response, which may include many of the somatic symptoms described in panic. In contrast to the panic attack, the person with a phobia does recognize that the fear is excessive or unreasonable, and the object or situation is avoided. Dental-related anxiety is a significant problem for both patients and practitioners,15 and the prevalence of severe dental phobia is estimated between 8 and 15%.15
|Needles, injections (trypanophobia)|
|Instruments (appearance, sounds)|
|Objects in the mouth, sharp objects, and instruments (aichmophobia)|
|Odors associated with dental office and treatment|
|Small rooms (claustrophobia)|
|Social settings, medical settings|
|Members of the same/opposite sex|
|Gagging or vomiting or just dentists|
For patients with dental-related phobia, it is important to know what aspect of a dental visit is the distressing part. The assessment is the same as with more severe anxiety disorders, while management may be easier for the practicing dentist. Common dental phobias are listed in Table 7.2.
Strategies for management of dental phobia are outlined elsewhere in this book, while the mainstay of treatment involves behavioral and pharmacologic strategies.16,17 These aim to reduce the patient’s pre-visit anticipatory anxiety, as well as instituting desensitization procedures that reduce anxiety within the dental setting once the patient’s specific fears are identified.
Operant conditioning principles also are paramount for success. For example, a patient presenting with a panic attack while in the dental chair should not be managed by an abrupt cancellation of the appointment. The act of leaving the dental setting would then result in the reduction of the patient’s anxiety, thereby reinforcing “escape” or avoidance behavior. Alternatively, the dentist is advised to keep the patient within the setting, for example, the dental chair, employ anxiety management strategies, and only discharge the patient after the anxiety subsides. Otherwise, the dentist would successfully reinforce the patient’s phobia and avoidance response.
When considering healthy mood, there is a neutral baseline from which we all experience periods of time above and below. The range of these peaks and valleys, however, is limited for most individuals. For some patients, the depth of depression and related symptoms are sufficiently severe that they meet criteria for a diagnosis of a major depressive disorder (MDD). Severe depression is typically marked by a sense of hopelessness about the future. Without any hope, motivation is lost, and life looks very bleak.6 The common cognitive and behavioral symptoms of a major depressive episode are listed in Table 7.3. While a depressive episode can be difficult to distinguish from the typical responses to life events, such as bereavement or substance use, failure to recognize a major depression carries the risk of high patient morbidity, with as many as 13% of patients committing suicide. Risk of suicide is of particular concern, and more completed suicides occur for those aged 65 or older, and among men.18,19
|Must have one or both of these symptoms||Depressed mood most of the day|
|Diminished interest or pleasure in activities|
|Can have any of these symptoms for at least five total||Feelings of worthlessness/excessive guilt||Psychomotor agitation or slowing|
|Thoughts of death or suicide||Fatigue/loss of energy|
|Significant weight change|
The bipolar depressive disorders, type I and type II, are considered variants of a major depressive disorder. Bipolar depression criteria includes periods of depression that alternate with periods of mania.20 As with any other psychiatric disorders noted above, these patients can lead normal, productive lives with appropriate pharmacotherapy and other adjunctive nonmedication approaches. While bipolar symptoms may vary from person to person, manic episodes are generally characterized by extreme irritability, feeling unusually “high” or overly optimistic. Patients may speak rapidly, that is, present with “pressured speech.” They may maintain extreme energy despite minimal sleep. They may have periods of grandiose beliefs about their abilities or powers, have extreme spending sprees, and act out in impulsive ways with notably impaired judgment. In more severe cases, delusions or hallucinations may be present. When symptoms of mania are less severe, the term “hypomania” is used. Differential diagnosis often includes ruling out substance use or other medical factors impacting the patient’s mental status, including particular pharmacological agents that can place the bipolar patient at greater risk for a manic episode. Some of these possible precipitants for the at-risk patient are listed in Table 7.4.
While the practicing dentist should not be expected to diagnose the patient with a major depression, bipolar disorder or manic episode, recognizing these symptoms remains a critical role within the dentist’ s scope of practice. Since the range of pharmacotherapy approaches employed by the dentist is expanding, the possible psychiatric consequences of those medications in the at-risk patient must be recognized. As noted, the dentist also sees the patient at a greater frequency than many other healthcare providers, and readily becomes familiar with the patient’s history and typical demeanor. For the long -term patient, changes in mental status may alert the dentist, allowing for cross-communication with the patient’s primary care physician or mental health provider. In many patients who develop depression, reports of medically unexplained somatic symptoms, such as pain or sleep disruption, precede reports of cognitive or emotional symptoms.21 The dentist should not hesitate to review the common symptoms of major depression noted above with patients. In the rare cases where the patient admits to suicidal ideation with a plan, the dentist also has an obligation to immediately refer the patient to an emergency facility for full assessment and care. If the dentist feels that there is an impending risk of harm, disclosure of the patient’s status to other treatment professionals, the patient’s family, or legal authorities does not place the dentist at legal risk.
|Tricyclic and other antidepressants|
Patients with temporomandibular disorders have higher rates of psychiatric comorbidities than the general population, and they can be notoriously difficult to manage in a general dental setting. 22 The era of narrowly assessing the patient’s occlusion, palpating muscles, and examining joint mobility has passed and falls below the standard of care with such complicated patients. While the practicing dentist can manage chronic pain conditions, there often is a requirement of co-management with other disciplines.
The history of orofacial pain management mirrors the early beginnings of care for other persistent pain conditions. In the historical context, headache, trigeminal neuralgia, atypical pain, temporomandibular disorders, and countless other complex disabling disorders have never ceased to ignite controversy among practitioners. For temporomandibular disorders, treatments have ranged across disciplines and include interventional a/>