Definition
This chapter discusses anxiety disorders (panic, phobias, posttraumatic stress disorder [PTSD], and generalized anxiety disorder) and eating disorders ( Box 28.1 ). Adverse reactions and drug interactions associated with drugs used to treat anxiety states are covered, with an emphasis on the dental implications of these reactions. The dental management of patients with anxiety and eating disorders is covered in detail. Chapter 29 is devoted to mood disorders (depression and bipolar disorders), somatoform disorders (conversion, hypochondriasis, pain, somatization), and schizophrenia. Dementia is discussed in Chapter 27 and substance abuse in Chapter 30 .
Anxiety Disorders
- •
Panic disorders
- •
Agoraphobia
- •
Phobias
- •
Obsessive-compulsive disorder *
* Conditions not covered in this chapter or in Chapter 29 .
- •
Posttraumatic stress disorder
- •
Acute stress disorder
- •
Generalized anxiety disorder
- •
Anxiety disorder due to a general medical condition *
- •
Substance-induced anxiety disorder *
Mood Disorders
- •
Depressive disorders
- •
Major depression
- •
Dysthymic disorder
- •
Depression not otherwise specified
- •
Bipolar disorders
- •
Bipolar I—manic, mixed, depressed
- •
Bipolar II—hypomanic, depressed
- •
Cyclothymic disorder
- •
Bipolar not otherwise specified
Somatoform Disorders
- •
Body dysmorphic disorder *
- •
Conversion disorder
- •
Hypochondriasis
- •
Somatization disorder
- •
Pain disorder
Factitious Disorders
- •
Predominantly psychological signs and symptoms
- •
Predominantly physical signs and symptoms
- •
Combined psychological and physical signs and symptoms
Psychological Factors That Affect Medical Conditions *
Substance Abuse Disorders *
Cognitive Disorders *
Schizophrenia
- •
Catatonic type
- •
Disorganized type
- •
Paranoid type
- •
Undifferentiated type
Delusional (Paranoid) Disorder *
- •
Erotomania, grandiosity, jealousy, persecution complex, somatic delusions *
Problems may be encountered in the dental practice that stem from a patient’s behavioral patterns rather than from physical conditions. A good dentist–patient relationship can reduce the number of behavioral problems encountered in practice and can modify the intensity of emotional reactions. A positive dentist–patient relationship is based on mutual respect, trust, understanding, cooperation, and empathy. Role conflicts between the dentist and the patient should be avoided or should be identified and dealt with effectively. An anxious patient should be offered support that minimizes the damaging effects of anxiety, and an angry or uncooperative patient should be accepted and encouraged to share her or his reasons for feelings and behavior, allowing emergence of a more peaceful and cooperative state of mind. Patients with emotional factors that contribute to oral or systemic diseases or symptoms and patients with more serious mental disorders can be managed in an understanding, safe, and empathetic manner.
The American Psychiatric Association published the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 2013. It includes detailed descriptions of neurodevelopmental disorders, schizophrenia spectrum and other psychotic disorders, bipolar and related disorders, depressive disorders, anxiety disorders, feeding and eating disorders, sleep–wake disorders, substance-related disorders, addictive disorders, and other topics.
The authors are aware of the implications of applying the new fifth edition of the DSM. We decided to postpone the application. This was based on the need to see how well accepted it becomes. In this edition, the fourth edition of the DSM is used.
COMPLICATIONS: Inability to function, insomnia, secondary drug and alcohol abuse, starvation, suicide, and death.
Anxiety Disorders
Definition
Anxiety is a natural response and a necessary warning adaptation in humans. Anxiety becomes a pathologic disorder when it is excessive and uncontrollable, requires no specific external stimulus, and results in physical and affective symptoms and changes in behavior and cognition. Anxiety disorders occur in two patterns: (1) chronic, generalized anxiety and (2) episodic, panic-like anxiety. Several related psychiatric disorders often coexist with anxiety disorders, including PTSD, substance abuse, and depression.
Anxiety is a sense of psychological distress that may not have a focus. It is a state of apprehension that may involve an internal psychological conflict, an environmental stress, a physical disease state, a medicine or drug effect, or combinations of these. Anxiety can be a purely psychological experience, with few somatic manifestations. Alternatively, it can be experienced as a purely physical phenomenon encompassing tachycardia, palpitations, chest pain, indigestion, headaches, and so forth, with no psychological distress other than concern about the physical symptoms. The reason for the variability in physical responses is not clear.
An understanding of anxiety requires definitions of some related entities, phobia and panic attack. A phobia is defined as an irrational fear that interferes with normal behavior. Phobias are fears of specific objects, situations, or experiences. The feared object, situation, or experience has taken on a symbolic meaning for the patient. Unconscious wishes and fears have been displaced from an original goal onto an external object.
A panic attack consists of a sudden, unexpected, overwhelming feeling of terror with symptoms of dyspnea, palpitations, dizziness, faintness, trembling, sweating, choking, flushes or chills, numbness or tingling sensations, and chest pains. The panic attack peaks in about 10 minutes and usually lasts for about 20 to 30 minutes. A person who has repeated panic attacks is described as having a panic disorder.
Epidemiology
Anxiety disorders constitute the most frequently found psychiatric problem in the general population. Simple phobia is the most common of the anxiety disorders (up to 25% of the population will experience a phobia); however, panic disorder is the most common anxiety disorder in people who seek medical treatment (lifetime prevalence of 3.5%). Generalized anxiety disorder has a lifetime prevalence of 5% to 6%. PTSD has a lifetime prevalence of 5% to 10%, with a point prevalence of 3% to 4%. Panic disorder, phobic disorders, and obsessive-compulsive disorders occur more frequently among first-degree relatives of people with these disorders than in the general population.
Etiology
Anxiety represents a threatened emergence into consciousness of painful, unacceptable thoughts, impulses, or desires (anxiety may result from psychological conflicts of the past and present). These psychological conflicts or feelings stimulate physiologic changes that lead to clinical manifestations of anxiety. Anxiety disorders may occur in persons who are under emotional stress, in those with certain systemic illnesses, or as a component of various psychiatric disorders. Panic disorders tend to occur in families: First-degree relatives of a person with a panic disorder have about an 18% increased risk for development of a similar disorder.
The cause of panic disorder is unknown but appears to involve a genetic predisposition, altered autonomic responsivity, and social learning. Panic disorder shows a familial aggregation; the disorder is concordant in 30% to 45% of monozygotic twins, and genome-wide screens have identified suggestive risk loci on 1q, 7p15, 10q, 11p, and 13q. Acute panic attacks appear to be associated with increased noradrenergic discharges in the locus coeruleus.
No single theory fully explains all anxiety disorders. No single biologic or psychological cause of anxiety has been identified. Psychosocial and biologic processes together may best explain anxiety. The locus coeruleus, a brainstem structure that contains most of the noradrenergic neurons in the central nervous system (CNS), appears to be involved in panic attacks and anxiety. Panic and anxiety may be correlated with dysregulated firing of the locus coeruleus caused by input from multiple sources, including peripheral autonomic afferents, medullary afferents, and serotonergic fibers.
Anxiety states also may be associated with organic diseases, other psychiatric disorders, use of certain drugs, hyperthyroidism, and mitral valve prolapse. Anxiety also is associated with mood disorders, schizophrenia, or personality disorders.
Clinical Presentation
From a psychological perspective, anxiety can be defined as emotional pain or a feeling that all is not well—a feeling of impending disaster. The source of the problem usually is not apparent to persons with anxiety. The feeling is the same in anxious patients as that in patients with fear, but the latter are aware of what the problem is and why they are “fearful.”
Physiologic reactions to anxiety and to fear are the same and are mediated through the autonomic nervous system. Sympathetic and parasympathetic components may be involved. Signs and symptoms of anxiety caused by overactivation of the sympathetic nervous system include increased heart rate, sweating, dilated pupils, and muscle tension. Signs and symptoms of anxiety resulting from stimulation of the parasympathetic system include urinary frequency and episodic diarrhea.
Most people periodically experience some degree of anxiety in one or more aspects of their lives. Anxiety can be a strong motivator; low levels of anxiety can increase attention and improve performance. Anxiety leads to dysfunction when it is constant, or it may result in episodes of extreme vigilance, excessive motor tension, autonomic hyperactivity, and impaired concentration. Anxiety is part of the clinical picture in many patients with psychiatric disorders. Patients with mood disorders, dementia, psychosis, panic disorder, adjustment disorders, and toxic and withdrawal states often report feelings of anxiety.
Phobias
Phobias consist of three major groups: agoraphobia, social, and simple. Agoraphobia is a fear of having distressful or embarrassing symptoms on leaving home. It often accompanies panic disorder. Social phobias may be specific, such as fear of public speaking, or general, such as fear of being embarrassed when with people. Simple phobias include fear of snakes, heights ( Fig. 28.1 ), flying, darkness, and needles. The two phobias that may affect medical or dental care are needle phobia and claustrophobia, the latter during magnetic resonance imaging (MRI) or radiation therapy. Dental “phobia” is associated with more extreme anxiety than the “usual” level attending a visit to the dentist. Previous frightening dental experiences are cited as the major cause. Patients may specifically fear the noise and vibration of the drill, the sight of the injection needle, and the act of sitting in the dental chair, and they may experience muscle tension, fast heart rate, accelerated breathing, sweating, or stomach cramps. True phobic neurosis about dental treatment is rare.
Panic Attack
About 15% of patients who are seen by cardiologists come to the doctor because of symptoms associated with a panic attack. Onset usually is between late adolescence and the mid-30s, but it may occur at any age. A key feature of panic is the adrenergic surge, which results in the fight-or-flight response. This response is an exaggerated sympathetic response ( Table 28.1 ). Panic attacks may be cued or uncued. An example of a cued attack is that occurring in a person who is fearful of flying. Many patients report that they are unaware of any life stressors preceding the onset of panic disorder; such attacks are classified as uncued. The major complication of repeated panic attacks is a restricted lifestyle adopted to avoid situations that might trigger an attack. Some patients develop agoraphobia, an irrational fear of being alone in public places, which can cause them to be housebound for years. Sudden loss of social supports or disruption of important interpersonal relationships appears to predispose the affected person to development of panic disorder.
| Anxiety Disorder | Signs and Symptoms | Major Diagnostic Criteria |
|---|---|---|
| Anxiety | Motor tension
Autonomic hyperactivity
Vigilance and scanning
|
Some of the signs and symptoms of anxiety may be noted in persons who are under the daily stresses of life. This form of anxiety can be helpful in the sense of focusing necessary attention on a specific task, such as a school examination, driver’s test, or athletic event. Anxiety becomes a negative factor when signs and symptoms are present for longer periods and start having an effect on the person’s emotional and physical well-being. |
| Panic disorder | Sudden onset of intense fear, arousal, and cardiac and/or respiratory symptoms without provocation (panic attack); often confused with systemic medical illness such as angina pectoris or epilepsy Symptoms of anxiety listed above Fear of dying Fear of “going crazy” or doing something uncontrolled |
One or more panic attacks have occurred that were unexpected and were not triggered by situations in which the person was the focus of another’s attention. Either four attacks have occurred within a 4-week period, or one or more attacks have been followed by a period of at least 1 month of persistent fear of having another attack. |
| Generalized anxiety disorder | At least six of the symptoms of anxiety listed above must be present over a period of 6 months or longer. | Presence of unrealistic or excessive worry and apprehension about two or more life circumstances, for a period of 6 months or longer, during which the person has been bothered more days than not by these concerns |
| Posttraumatic stress disorder (PTSD) | Symptoms of PTSD arise only after an exceptionally threatening event that is outside the normal range of experience (e.g., combat, rape, attempted murder or torture, acts of terrorism, natural disasters):
|
Repeated reliving of trauma as daydreams, intrusive memories, flashbacks, or nightmares Persistent psychic numbness or “emotional bloating” Avoidance of thoughts about or reminders of the trauma, which may lead to marked detachment from personal involvement or relationships Symbols, anniversaries, or similar events often prompt exacerbation of symptoms. |
Generalized Anxiety Disorder
Some patients present with a persistent, diffuse form of anxiety characterized by signs and symptoms of motor tension, autonomic hyperactivity, and apprehension (see Table 28.1 ). No familial or genetic basis for this generalized anxiety disorder has been found. Outcomes typically are better than those with panic disorder; however, the persistent anxiety may lead to depression and substance abuse.
Posttraumatic Stress Disorder
Posttraumatic stress disorder is a syndrome of psychophysiologic signs and symptoms that develop after exposure to a traumatic event outside the usual range of human experience, such as combat exposure, a holocaust experience, rape, or a civilian disaster such as a hurricane ( Fig. 28.2 ) or eruption of a volcano ( Fig. 28.3 ). The traumatic event may represent a serious threat to the person’s life or physical integrity; a serious threat to the persons’ children, spouse, or other loved ones; or sudden destruction of home or community; alternatively, it may result when the person views an accident or an act of physical violence that seriously injures or kills another person(s). Other experiences that have resulted in PTSD or are associated with increased risk for the disorder include child abuse, weaning from mechanical ventilation, traumatic experience of myocardial infarction, and loss of a close relative or loved one to cancer.
Most men with PTSD have been in combat, and most women give a history of sexual or physical abuse. The three cardinal features of PTSD are hyperarousal; intrusive symptoms, or flashbacks to the initial trauma; and psychic numbing. PTSD may follow traumatic or violent events that are anticipated or not anticipated, constant or repetitive, natural or malevolent. For this reason, terrorist attacks often lead to PTSD ( Fig. 28.4 ). PTSD is further defined by onset of symptoms at least 6 months after the trauma, or a duration of more than 3 months (see Table 28.1 ).
Diagnostic criteria for PTSD consist of a history of a traumatic experience and reexperiencing of the event through intrusive memories, disturbing dreams, “flashbacks,” and psychological or physical distress in response to reminders of the event; another criterion is avoidance of things associated with the trauma (see Table 28.1 ). Signs and symptoms include sleep problems, irritability, trouble concentrating, hypervigilance, startle responses, and psychic numbing, seen as detachment from others, reduced capacity for intimacy, and decreased interest in sex. Avoidance and numbing appear to be the most specific symptoms for identification of PTSD.
Although women generally are given the diagnosis of PTSD more often than men, the rate of PTSD is higher among male veterans than among female veterans; however, some evidence suggests that the condition is underdiagnosed in female veterans. Pereira found that (1) men experienced higher levels of combat stress, (2) greater exposure to stress was associated with increased symptoms of PTSD, (3) men and women exposed to similar levels of stress were equally likely to experience PTSD symptoms, and (4) men were more likely to be given the diagnosis of PTSD. Unit cohesion may protect from PTSD regardless of the level of stress exposure. Drug treatment of men and persons with combat trauma–induced PTSD (men and women) is less effective than that provided to other veteran women or women with civilian trauma–induced PTSD.
Acute Stress Disorder
Acute stress disorder develops after exposure of the patient to a traumatic event, and specific signs and symptoms resemble those of PTSD. In acute stress disorder, however, symptoms are of shorter duration and emerge more rapidly after the trauma. The symptomatic reaction is limited to the period during which the stressful event is occurring and its immediate aftermath.
Medical Management
Psychological, behavioral, and drug modalities are used to treat anxiety disorders. Psychological treatment involves psychotherapy, which, in general, is used in more severe cases. Behavioral treatment includes cognitive approaches (anxiety management, relaxation, and cognitive restructuring), biofeedback, hypnosis, relaxation imaging, desensitization, and flooding. Drug treatment includes the use of tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase (MAO) inhibitors, benzodiazepines, antihistamines, β-adrenergic receptor antagonists, and sedative-hypnotics. The most commonly used drugs are the benzodiazepines and the SSRI buspirone, or a combination of medications ( Table 28.2 ). Most patients benefit maximally from a combination of therapies such as cognitive therapy plus medication.
| Drug Class | Drug | Trade Name | Comments |
|---|---|---|---|
| Sedative–hypnotics | Chloral hydrate | Noctel | Seldom appropriate |
| Meprobamate | Miltown | Seldom appropriate | |
| Antihistamines | Hydroxyzine | Atarax | Most useful at bedtime for associated sleep |
| Diphenhydramine | Benadryl | Most useful at bedtime for associated sleep | |
| Benzodiazepines | Lorazepam | Ativan | Also effective for generalized anxiety |
| Diazepam | Valium | ||
| Triazolam | Halcion | Abuse potential with many of the benzodiazepines! | |
| Chlordiazepoxide | Librium | ||
| Temazepam | Restoril | ||
| Alprazolam | Xanax | ||
| Clorazepate | Tranxene | ||
| Flurazepam | Dalmane | Higher risk of abuse potential with flurazepam | |
| Oxazepam | Serax | ||
| Clonazepam | Klonopin | Long duration of action permits once-daily dosing | |
| Buspirone | BuSpar | No dependence with prolonged use | |
| Zolpidem | Ambien | Most useful on an as-needed basis | |
| Beta-blockers | Propranolol | Inderal | Does not block the fear component of anxiety or panic |
Systemic desensitization (whereby the patient is gradually exposed to the feared situation) and flooding (by which the patient is exposed directly to the anxiety-provoking stimulus) are techniques used in the treatment of phobias. Claustrophobia associated with MRI can be managed with a low dose of benzodiazepines and behavioral therapy.
First-line treatment for PTSD consists of psychotherapy (exposure therapy, group therapy, patient and family education), cognitive-behavioral therapy, and eye movement desensitization and reprocessing (EMDR). EMDR is a newer, relatively novel treatment in which the patient focuses on movements of the clinician’s finger while maintaining a mental image of the traumatic experience.
Second-line treatment consists of a combination of psychotherapy and pharmacologic therapy. In cases with comorbid psychiatric disorders or with especially severe symptoms of PTSD, a combination of psychotherapy and pharmacologic treatment is recommended as the first line of treatment. The U.S. Food and Drug Administration has approved the SSRIs paroxetine and sertraline for the treatment of PTSD. Bupropion or other antidepressants are used when depression is a component of the clinical picture.
Benzodiazepines are used when anxiety is part of the symptom complex. Early intervention in patients with PTSD can shorten the duration and severity of anxiety. In some complex and treatment-resistant cases, mood stabilizers such as valproate or carbamazepine are indicated.
Anxiety Disorders
Definition
Anxiety is a natural response and a necessary warning adaptation in humans. Anxiety becomes a pathologic disorder when it is excessive and uncontrollable, requires no specific external stimulus, and results in physical and affective symptoms and changes in behavior and cognition. Anxiety disorders occur in two patterns: (1) chronic, generalized anxiety and (2) episodic, panic-like anxiety. Several related psychiatric disorders often coexist with anxiety disorders, including PTSD, substance abuse, and depression.
Anxiety is a sense of psychological distress that may not have a focus. It is a state of apprehension that may involve an internal psychological conflict, an environmental stress, a physical disease state, a medicine or drug effect, or combinations of these. Anxiety can be a purely psychological experience, with few somatic manifestations. Alternatively, it can be experienced as a purely physical phenomenon encompassing tachycardia, palpitations, chest pain, indigestion, headaches, and so forth, with no psychological distress other than concern about the physical symptoms. The reason for the variability in physical responses is not clear.
An understanding of anxiety requires definitions of some related entities, phobia and panic attack. A phobia is defined as an irrational fear that interferes with normal behavior. Phobias are fears of specific objects, situations, or experiences. The feared object, situation, or experience has taken on a symbolic meaning for the patient. Unconscious wishes and fears have been displaced from an original goal onto an external object.
A panic attack consists of a sudden, unexpected, overwhelming feeling of terror with symptoms of dyspnea, palpitations, dizziness, faintness, trembling, sweating, choking, flushes or chills, numbness or tingling sensations, and chest pains. The panic attack peaks in about 10 minutes and usually lasts for about 20 to 30 minutes. A person who has repeated panic attacks is described as having a panic disorder.
Epidemiology
Anxiety disorders constitute the most frequently found psychiatric problem in the general population. Simple phobia is the most common of the anxiety disorders (up to 25% of the population will experience a phobia); however, panic disorder is the most common anxiety disorder in people who seek medical treatment (lifetime prevalence of 3.5%). Generalized anxiety disorder has a lifetime prevalence of 5% to 6%. PTSD has a lifetime prevalence of 5% to 10%, with a point prevalence of 3% to 4%. Panic disorder, phobic disorders, and obsessive-compulsive disorders occur more frequently among first-degree relatives of people with these disorders than in the general population.
Etiology
Anxiety represents a threatened emergence into consciousness of painful, unacceptable thoughts, impulses, or desires (anxiety may result from psychological conflicts of the past and present). These psychological conflicts or feelings stimulate physiologic changes that lead to clinical manifestations of anxiety. Anxiety disorders may occur in persons who are under emotional stress, in those with certain systemic illnesses, or as a component of various psychiatric disorders. Panic disorders tend to occur in families: First-degree relatives of a person with a panic disorder have about an 18% increased risk for development of a similar disorder.
The cause of panic disorder is unknown but appears to involve a genetic predisposition, altered autonomic responsivity, and social learning. Panic disorder shows a familial aggregation; the disorder is concordant in 30% to 45% of monozygotic twins, and genome-wide screens have identified suggestive risk loci on 1q, 7p15, 10q, 11p, and 13q. Acute panic attacks appear to be associated with increased noradrenergic discharges in the locus coeruleus.
No single theory fully explains all anxiety disorders. No single biologic or psychological cause of anxiety has been identified. Psychosocial and biologic processes together may best explain anxiety. The locus coeruleus, a brainstem structure that contains most of the noradrenergic neurons in the central nervous system (CNS), appears to be involved in panic attacks and anxiety. Panic and anxiety may be correlated with dysregulated firing of the locus coeruleus caused by input from multiple sources, including peripheral autonomic afferents, medullary afferents, and serotonergic fibers.
Anxiety states also may be associated with organic diseases, other psychiatric disorders, use of certain drugs, hyperthyroidism, and mitral valve prolapse. Anxiety also is associated with mood disorders, schizophrenia, or personality disorders.
Clinical Presentation
From a psychological perspective, anxiety can be defined as emotional pain or a feeling that all is not well—a feeling of impending disaster. The source of the problem usually is not apparent to persons with anxiety. The feeling is the same in anxious patients as that in patients with fear, but the latter are aware of what the problem is and why they are “fearful.”
Physiologic reactions to anxiety and to fear are the same and are mediated through the autonomic nervous system. Sympathetic and parasympathetic components may be involved. Signs and symptoms of anxiety caused by overactivation of the sympathetic nervous system include increased heart rate, sweating, dilated pupils, and muscle tension. Signs and symptoms of anxiety resulting from stimulation of the parasympathetic system include urinary frequency and episodic diarrhea.
Most people periodically experience some degree of anxiety in one or more aspects of their lives. Anxiety can be a strong motivator; low levels of anxiety can increase attention and improve performance. Anxiety leads to dysfunction when it is constant, or it may result in episodes of extreme vigilance, excessive motor tension, autonomic hyperactivity, and impaired concentration. Anxiety is part of the clinical picture in many patients with psychiatric disorders. Patients with mood disorders, dementia, psychosis, panic disorder, adjustment disorders, and toxic and withdrawal states often report feelings of anxiety.
Phobias
Phobias consist of three major groups: agoraphobia, social, and simple. Agoraphobia is a fear of having distressful or embarrassing symptoms on leaving home. It often accompanies panic disorder. Social phobias may be specific, such as fear of public speaking, or general, such as fear of being embarrassed when with people. Simple phobias include fear of snakes, heights ( Fig. 28.1 ), flying, darkness, and needles. The two phobias that may affect medical or dental care are needle phobia and claustrophobia, the latter during magnetic resonance imaging (MRI) or radiation therapy. Dental “phobia” is associated with more extreme anxiety than the “usual” level attending a visit to the dentist. Previous frightening dental experiences are cited as the major cause. Patients may specifically fear the noise and vibration of the drill, the sight of the injection needle, and the act of sitting in the dental chair, and they may experience muscle tension, fast heart rate, accelerated breathing, sweating, or stomach cramps. True phobic neurosis about dental treatment is rare.
