Psychiatric Disorders

Definition

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.

Psychiatric problems are important to dentistry because they can affect the clinical course of various medical illnesses, increase required duration of treatment, decrease the patient’s functional level, and have a negative impact on overall prognosis and outcome. Of note, disorders related to drug and alcohol use account for a significant proportion of treatment-related psychiatric issues.

COMPLICATIONS: Bleeding, infection, hypotension (related to drugs) and postural hypotension, tardive dyskinesia, malignant neuroleptic syndrome (rare), depression with risk of suicide, and death.

Epidemiology

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%. In the older adult 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 older persons have a substance abuse disorder. 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. The most common disorder reported was depression.

Epidemiology

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%. In the older adult 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 older persons have a substance abuse disorder. 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. The most common disorder reported was depression.

Mood Disorders

Definition

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.

Epidemiology

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 older adults followed by those 30 to 40 years of age and, in recent years, an increased number of 15- to 19-year-old adolescents and young adults. Lifetime prevalence rates for major depressive disorders are 15% to 20%. Point prevalence rates for major depression in urban U.S. populations are 2% to 4% for men and 4% to 6% for women. After the age of 55 years, depression starts to occur more commonly in men. About one third of depressed persons require hospitalization; 30% follow a chronic course with residual symptoms and social impairment.

TABLE 29.1
Epidemiology of Mood Disorders
Variable Depressive Disorders Bipolar Disorders
Prevalence 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

Dysthymia

  • 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

Cyclothymia

  • 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.
Patients with bipolar disorder 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 four 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.

Etiology

Several theories have been presented to explain the origin of mood disorders. Reduced brain concentrations of norepinephrine and serotonin (neurotransmitters) are 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. 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. The interactions between thyrotropin and thyroid-stimulating hormone as well as 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 is prolonged.

Clinical Presentation and Medical Management

Depressive Disorders

The DSM-IV lists three types of depressive disorders: major depression, dysthymic disorder, and depression not otherwise specified (NOS). 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 have 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 (see Box 29.1 ).

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 disorders: bipolar I, bipolar II, cyclothymic, and bipolar disorder NOS ( Fig. 29.1 ). Fig. 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 Fig. 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 common in this patient population.

FIG 29.1
Mood disorders listed in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (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. NOS, Not otherwise specified.

FIG 29.2
A, Normal mood cycles. B, Bipolar type I disorder. C, Bipolar type II disorder.
(From Khalife S: Bipolar disorder. In Carey WD, editor: 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 Fig. 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.

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

Men tend to have a greater number of manic episodes and more numerous depressive episodes than women. 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 ( Fig. 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.

FIG 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.

Medical Management

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. 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.

TABLE 29.3
Commonly Used Antidepressants (by Structural Group)
Drug Trade Name Comments
TRICYCLIC
Amitriptyline Elavil
Trimipramine Surmontil
Desipramine Norpramin
Doxepin Sinequan
Imipramine Tofranil
Nortriptyline Pamelor
Protriptyline Vivactil
TETRACYCLIC
Maprotiline Ludiomil
SELECTIVE SEROTONIN REUPTAKE INHIBITORS
Escitalopram Lexapro
Fluoxetine Prozac
Fluvoxamine Luvox
Paroxetine Paxil
Sertraline Zoloft
MONOAMINE OXIDASE INHIBITORS 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
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. 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.

TABLE 29.4
Initial Treatment Guidelines for Bipolar Disorder
Drug or Indication Category Step 1 Step 2 Step 3
Starting Dose Target Drug Starting Dose Additional Options
DEPRESSION
Lithium 300–450 mg twice daily Serum level >0.8 mEq/L OFC * 6 mg/25 mg at bedtime Combinations of lithium, OFC, quetiapine
Lamotrigine 25 mg once a day
Initial and target doses may be affected by concomitant medications
Dose 50–200 mg/day Quetiapine (pending FDA approval for bipolar disorder type 1 and type 2 depression) 100 mg at bedtime; increase to 300 mg at bedtime by day 3 Add traditional antidepressant to one or more of these (step 1 or step 2)
ECT
MANIA
Lithium 300–450 mg three times a day Serum level generally 1.0–1.5 mEq/L Choose two of the following in combination: Lithium
VPA or divalproex
AAP (excluding olanzapine and clozapine)
Other two-drug combinations (choose from lithium, VPA, AAPs, carbamazepine, oxcarbamazepine, topiramate)
VPA 500 mg three times a day
Divalproex 750 mg at bedtime
AAP (excluding clozapine and aripiprazole) Initial dosing varies ECT
Clozapine
Triple-drug therapy
AAP, Atypical antipsychotic [agent]; ECT, electroconvulsive therapy; OFC, olanzapine–fluoxetine combination; VPA, valproic acid.
From Khalife S, Singh V, Muzina DJ: Bipolar disorder. In Carey WD, editor: Current clinical medicine 2009—Cleveland Clinic, Philadelphia, 2009, Saunders.

* Approved by the U.S. Food and Drug Administration (FDA) – for bipolar disorder type 1 depression.

Traditional antidepressants include selective serotonin reuptake inhibitors, serotonin–norepinephrine uptake inhibitors, bupropion, venlafaxine, and mirtazapine.

Electroconvulsive therapy is an effective antimanic treatment. 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.

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

An estimated 30,000 suicides occur each year in the United States. About 70% of them 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. After medical control is attained in a patient with a mood disorder, insight-oriented psychotherapy often is initiated as an adjunct for management of the patient’s condition.

An interesting potential is the role of celebrity suicides triggering others on an international basis. For example, after the railway suicide of the German national goalkeeper Robert Enke in 2009, a significant increase of railway suicides was observed nationally. Enke’s suicide in 2009 was also followed by increasing train suicide numbers in Europe. An international copycat effect or an increased overall awareness about this particular suicide method appears to be one likely explanation for the changes.

Somatoform Disorders

Definition

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.

TABLE 29.5
Somatoform Disorders
Somatoform Disorder Features
Somatization disorder Chronic multisystem disorder characterized by complaints of pain, and GI 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 GI symptoms plus one sexual or 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.
Malingering Intentional production or feigning of physical or psychological signs when external reinforcers (e.g., avoidance of responsibility, financial gain) are present
Dissociative disorders Disruptions of consciousness, memory, identity, or perception judged to be due to psychological factors
GI, Gastrointestinal.
From Schiffer RB: Psychiatric disorders in medical practice. In Goldman L, Ausiello D, editors: Cecil textbook of medicine, ed 23, Philadelphia, 2008, Saunders, and Scully C, Cawson RA: Medical problems in dentistry, ed 5, Edinburgh, 2005, Churchill Livingstone.

Epidemiology

The prevalence of somatoform disorders is 5%. Most of these occur in women. Patients with symptoms that do not meet the full criteria for somatization disorder are much more common. Conversion disorder, pain disorder, and hypochondriasis appear to be more common than somatization disorder.

Etiology

In this group of disorders, physical symptoms suggest a physical disorder for which no underlying physical basis can be found. Symptoms are linked to psychological factors. Somatization therefore is defined as the manifestation of psychological stress in somatic symptoms.

A conversion reaction results when a psychological conflict or need is expressed as an alteration or loss of physical function, suggesting a physical disorder. A person who views a traumatic event, for example, but has a conflict about acknowledging that event may develop a conversion disorder of blindness. In this instance, the symptom of blindness has symbolic value and is a representation of, and a partial solution to, the underlying psychological conflict.

Clinical Presentation and Medical Management

Somatization Disorder

Somatization consists of multiple signs and symptoms and usually begins before the age of 30 years. Patients experience multiple, unexplained physical manifestations of illness or disease, which may include pain, diarrhea, bloating, vomiting, sexual dysfunction, blindness, deafness, weakness, paralysis, or coordination problems. Somatization disorder is a serious psychiatric illness. Many patients have concurrent anxiety, depression, or personality disorder.

Conversion Disorder

Conversion disorder is a monosymptomatic somatoform disorder that affects the voluntary motor system or sensory functions. The patient may experience blindness, deafness, paralysis, or an inability to speak or to walk. Symptoms suggest a physical condition, but the cause is psychological. The somatic manifestation, which is not intentionally produced, typically is a symbolic representation that relieves an underlying emotional conflict.

Pain Disorder

Pain disorder causes the patient significant distress in important areas of functioning such as social and occupational activities. In patients with pain disorder, no organic disease can be identified. Often, a stressful event precedes the onset of pain. Pain often results in secondary gain in the form of increased attention and sympathy from others.

Hypochondriasis

Patients with hypochondriasis are preoccupied with the fear or belief that they have a serious disease. Their misinterpretations of normal bodily functions generally are to blame.

Factitious Disorder

Factitious disorder consists of intentional self-harm that is produced by infliction of physical, chemical, or thermal injury. It involves the voluntary production of signs and symptoms (physical injury or psychological symptoms) without external incentives such as avoidance of responsibility or financial gain. Many affected persons also have other mental disorders. Factitious disorder is more common among men and occurs more often in health care workers. The skin is the most common site for injury.

Treatment

Treatment of patients with somatoform disorders often requires multiple therapeutic modalities, including psychotherapy for their interpersonal and psychological problems. Medication for the treatment of underlying depressive disorder also may be needed. Group therapy is beneficial in some cases.

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