Chapter 64 The Patient with a Mental Health Disorder Discussion
IntroductionThe first visit you had with this 19 year old unmarried women was six months ago. At that appointment she confided to you that she was pregnant and her parents had broken off any contact with her. Her parents told her they wanted nothing to do with her because she was pregnant, not married, and she was in a bi-racial relationship. Her boyfriend had no interest in the baby or in getting married. At today’s appointment she brings her three month old daughter with her. When you tell your patient how beautiful her daughter is she does not acknowledge the compliment nor does she look at her baby. What do you think this patient is experiencing? Should you address this issue? If so, what should you do?Remember: All posts and responses should contain proper grammar, be free of spelling errors, be substantial, and reflect critical thinking.
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DEH2806 Ch64
Chapter 64, The Patient With a Mental Disorder. Throughout this PowerPoint we’re going to
discuss various mental health disorders. One of those is schizophrenia.
For you art buffs, this is a self portrait of van Gogh. He is said to have suffered from
schizophrenia. He’s famous for cutting off his ear and sending it to a woman in a brothel that he
was in love with. While this was a self portrait, he was looking in a mirror. He actually cut off
part of his left ear. But in this portrait, it shows that a cut off part of his right ear. Just a little
extra knowledge to take away.
The American Psychiatric Association, they classify more than 200 types of mental disorders.
We won’t be covering 200 types in this PowerPoint. But again you’re going to see the Diagnostic
and Statistical Manual of Mental Disorders, the acronym for that is that DMS-5. That is an
acronym you need to know.
When referring to somebody that has either a mental disorder or a disability or a chronic disease,
the politically correct way to refer to that person is a person that has schizophrenia or an
individual that has schizophrenia. You don’t refer to them as a schizophrenic or a diabetic. It’s
more correct to say the person suffers from whatever it is.
We’ll start the power point discussing anxiety disorders, because they’re the most common class
of mental disorders in the general population. Everybody suffers from anxiety at one point in
their life. It’s kind of a normal reaction when you have stress. But in anxiety disorders, the
anxiety is exaggerated. And it results in excessive worry and avoidance of behavior. And it can
impact your day to day functioning.
There’s a fine line between some of these anxiety disorders. But the first one discussed here is
generalized anxiety disorder. And this person who suffers from this would have anxiety about
pretty much everything. They go through their life with persistent, pervasive anxiety and
excessive worry. They don’t have a particular life threatening attack or fear of something.
They’re pretty much anxious about everything.
Obsessive compulsive disorder. Breaking that down, is there is a thought, it’s an obsession with
something, and then that’s acted upon, which is the compulsion. They have an overwhelming
urge to do whatever it is that they’re thinking about. What happens is there’s repeated routines or
rituals that are practiced over and over again. When it becomes a true problem, a true obsessive
compulsive problem, is when they can’t function in their daily life. They can’t leave the house
unless they do certain things. Let’s say somebody has an obsessive compulsive need to wash
their hands. They’ll do that maybe 50-100 times a day. It interferes with their life events.
Panic disorder. This is a sudden attack, an extreme fear of something. It can be cued or it can be
uncued. Uncued would mean that it just occurs, that a person is walking down the street and they
have a panic attack. Situationally bound or cued means that something triggers that. For
example, if a person’s sitting at a stoplight and they have their first panic attack, from there on
out each time they come to a stop light, that stop light might trigger that panic attack.
Many times when persons suffer from panic attacks or they have panic disorder, they have a fear
of being out of control. They have a fear of being in a situation from which they cannot get out
of. This may occur in the dental chair. And I think we have several patients in the clinic that
suffer from panic attacks. Listed here are some of the symptoms that you would look for.
Most persons are familiar with post traumatic stress disorder, because you see it on the TV or
you read about it. Most persons associate that with going to war, which most definitely there are
a lot of soldiers that suffer from PTSD. But it can also be triggered by life events such as a
hurricane or somebody was in danger, somebody’s imprisoned, they’re tortured, they’re raped,
they’re sexually or physically abused. All those type of situations can bring on post traumatic
stress disorder.
What occurs to persons that are suffering from post traumatic stress disorder is they have
flashbacks of living that event over and over again. So they may avoid places, events, or objects
that trigger those attacks.
Listed here are the signs and symptoms of PTSD. The symptoms for adult are slightly different
than they are with children.
Treating somebody with an anxiety disorder. What’s first done is to try and change that person’s
lifestyle, meaning try and get them to have physical activity, eat better, sleep better, and avoid
drugs and alcohol. Drugs would be street drugs, not prescription drugs. Classically, persons that
have an anxiety disorder or any type of mental disorder, they try and self medicate with alcohol
and drugs. So that’s one of the first steps is to try and get that person to get away from that, to
avoid those.
The next three slides are the pharmacologic treatment. I’m assuming that this is just a review
from pharmacology.
Along with prescription drugs, there most often is psychotherapy, which is cognitive behavioral
therapy. And that combines the cognitive functions, the behavioral functions, and the emotional
components that go along with anxiety disorder.
Oral implications. You know from the list of medications, a lot of those side effects are
xerostomia. And with xerostomia comes a very high risk for dental caries. Persons with anxiety
disorders also have a higher risk for tooth loss and periodontal disease. If the patient has OCD,
Obsessive Compulsive Disorder, one of those compulsions they have maybe to brush their teeth,
extensively throughout the day. Well, this would be a result of abrasion that you would see in
recession with somebody who has obsessive compulsive disorder.
As far as appointment interventions, dental hygiene appointments, one of the major things that
you want to do when a person has an anxiety disorder is let them know that they can get up and
walk around or take a restroom break, if they would just let you know. So you also want to be
alert to symptoms and signs they’re are going to show in the chair. Set the chair up. Let them take
a breath. And let them know that they are actually in control.
The next group of mental disorders that we’re going to review in the PowerPoint are depressive
disorders. Depression is the leading cause of disability worldwide. Women tend to suffer from it
more than men do. Onset is usually in the 20s. But it can occur at any age.
Major depressive disorder. Most everybody has experienced some type of depression in their
life, whether it’s a death in the family, whether it’s a disappointment. What happens in major
depressive disorder, where the line gets crossed over, is a person cannot function in their life.
They are so depressed that they cannot either hold a job or go to family events. It severely affects
their life.
Postpartum depression. As the name suggests, it occurs after a woman has a baby. And it is
different from the baby blues that many women have after they have a baby. Hormones are
changing. It’s a big life event. And some women have baby blues. The difference here, again,
where the line is crossed, is this takes over their life where they cannot function. They cannot
function with the new baby. They cannot do in life what they need to do. It occurs in about 10%
to 15% of the women where they need to get help with the depression that they’re suffering from.
Signs and symptoms that may occur when a person has postpartum depression is they are totally
disengaged from that infant. They are not having that mother child bonding going on. It is critical
to identify a woman that has postpartum depression. It can lead to abuse of the infant. It can lead
to infanticide, suicide, or both. This woman needs directed to a physician, as soon as possible.
Listed here are common symptoms associated with a person who has a depressive disorder. You
can read through them. They’re kind of classic. Usually, that person can’t sleep. They have
appetite issues. Usually, they don’t eat well. They’re very tired all the time. They have memory
problems. So just take a read through these.
As far as treatment, the person with a depressive disorder, the physician will analyze whether
that person is at risk for suicide. If they are, they may be hospitalized until the physician can get
those feelings under control.
The next two slides list the pharmacotherapy for somebody with a depressive disorder. Again,
this should be a review from pharmacology.
The basic therapeutic approach. Again, we’re going to try and get that person to exercise, sleep
right, avoid drugs and alcohol.
Psychotherapy. It’s often combined with pharmacotherapy. And again, we’re looking at cognitive
behavioral therapy, problem solving therapy, and interpersonal psychotherapy.
Electroconvulsive therapy has been frowned upon in previous years. It was thought of as kind of
barbaric, because you put electrodes on a person’s head and you shock them. But what is
occurring, is it is kind of short circuiting the bad memories or bad events that this person is
reliving. So it is really very effective for about 70% to 90% of the people that suffer from
depressive disorders. If somebody has some type of cardiovascular issue, it would not be used
especially, if they have some type of cardiac arrhythmia, because that’s shocking may set off a
problem with their heart.
Oral health implications. Somebody who is suffering from severe depression, oral health habits
may have been neglected for a very long time. Also, if they’re on medications, you know that
many of those medications a side effect is xerostomia which is going to increase their risk for
demineralization and dental caries.
The next mental health disorder we’re going to discuss as bipolar disorder. It was formerly called
manic depressive disorder. What occurs with this person is they have extreme highs, known as
mania, and extreme lows, which would be depression. It’s more prevalent in women. The
average age of onset is in the mid 20s.
When a person is in the manic phase, they are not in control of what they’re doing. They have
very inflated self esteem. They may talk continually. They’re going to tell you all the stuff that
they’re going to do. They rarely sleep. They’re very irritable. They have risky behavior often,
meaning they might gamble all the time or they might go on shopping sprees where they spend
thousands of dollars. They have excessive energy and activity. The person with bipolar disorder
is harder to treat than the person with depressive disorder, because there’s highs and lows. And
what the physician is trying to do is get them level.
The next three slides list the pharmacotherapy that is used, the medications that are used. What
occurs when a person has bipolar disorder is in those highs, they feel good. They like how that
feels. So persons with bipolar disorder tend to be noncompliant with their medication. Persons
with depressive disorders tend to be compliant because that medication makes them feel better.
Also with schizophrenia, that we’ll discuss at the end of this PowerPoint, noncompliance is a
huge problem for them, also.
Hopefully, the next three slides are just reviews from pharmacology.
Oral health implications. Their tissues may be very abraded or lacerated, because they’re doing
these grandiose brushing motions.
As far as medication, again, we’re looking at xerostomia, very common with all these
medications. What I do want you to take note of is when persons take lithium, they have a
metallic taste in their mouth. That’s kind of a classic symptom.
The next section is feeding and eating disorders. Identification and referral of a patient that has a
eating disorder can be lifesaving for that person. Anorexia nervosa is a life threatening eating
disorder. Pica is the eating of non food items. And children, children would eat dirt or eat things
that are not food. But what occurs in adults with mental disorders, sometimes they do this same
behavior, which is not normal for an adult.
Anorexia nervosa. It is characterized by a refusal to maintain a body weight that would be an
average weight for the person’s age and their height. Usually the cut off is 15% below their
normal weight. You don’t need to know that for any exam. But you do need to know that the
classic symptom that separates them as far as this disorder is they refuse to maintain a normal
body weight.
This is a picture of a woman from Fort Myers, Florida. I don’t know if she’s still alive, because
anorexia nervosa has the highest mortality rate of any mental disorder. It is a life threatening
disorder.
As shown in this picture, a person with anorexia nervosa when they look in the mirror, they have
a very distorted body image. They see themselves as being overweight, when in actuality they’re
extremely thin. In women, which is the majority of people that have anorexia nervosa, their
menstrual cycle will cease altogether, because what’s occurring is their body is trying to keep
them alive. And so they’re continually shutting down different organs until actually that person
dies.
There are two types of anorexia nervosa, restricting and binge eating, purging. In the restricting
type, the person does not regularly engage in binge eating or purging behavior. Purging can be
vomiting. It can be the misuse of laxatives, diuretics, or enemas. Binge eating, purging the
person engages in binge eating or purging. Again, purging would be self induced vomiting,
laxatives, diuretics, or using enemas. So there’s two different types.
Bulimia nervosa. It’s a mental disorder that is marked or diagnosed by recurrent episodes of
uncontrolled binge eating that occurs on an average of once a week for three months. So it’s not
just going out on the weekend and eating two pizzas. It’s when that becomes a continual
behavior. There are two types of behaviors that are seen with people with bulimia nervosa. There
is the purging and then non-purging.
When persons have bulimia nervosa, classically people think that they eat and then vomit. Not
all persons that have bulimia nervosa do that. There is a purging type that will vomit or misuse
the laxatives, diuretics, or enemas. But there is also a non-purging type. So when they binge,
they try and compensate for that by very excessive exercising. Or they may have periods of
fasting with that. But they do not engage in this self induced vomiting, laxatives, diuretics, or
enemas.
So what categorizes a binge eating episode? It’s eating within any two hour period an amount of
food that’s definitely larger than most people would eat in that time frame. Also there’s a sense of
lack of control over what that person is eating. They cannot stop eating.
A person with bulimia nervosa is usually average weight. They can even be slightly overweight.
That is in comparison to somebody with anorexia nervosa, who is below average weight.
And the last eating disorder is binge eating disorder. This person binge eats without the
compensating. behaviors, such as the exercise and vomiting and all of that. So this is a person
that just binge eats. And this would have to occur at least once a week for three months to be
diagnosed as somebody with a binge eating disorder.
A person with a binge eating disorder often has some other type of mental disorder, such as
depressive disorder or bipolar disorder or anxiety disorder. They are usually normal weight or
overweight or even obese, because they are not engaging in those behaviors of vomiting or
exercising. They also have very strong feelings of guilt, because they know what they’re doing is
not normal.
Depending on the type of eating disorder the person has, they may have some of these medical
complications.
As far as pharmacotherapy, usually anti-depressants are given to persons with eating disorders.
As far as psychotherapy, usually it’s done on an individual basis and also on a family basis,
because what the therapist is trying to discover is what the underlying problem is, why that
person has an eating disorder.
There are several oral implications if a person has an eating disorder. And of course it would
depend on the type of eating disorder. But if it involves vomiting, they’re going to have or
possibly have something known as perimolysis, which is the chemical erosion of the enamel and
tooth surfaces. When that occurs the restorations in the mouth appear to rise up because the tooth
structure is being dissolved.
Dental caries or demineralization can occur from the vomiting and the food choices. Xerostomia,
again, can be from the medications. And also when you vomit a lot you’re going to lose body
fluid. Angular kelosis can occur, especially if a person has a vitamin B12 deficiency. If a person
has an eating disorder, they’re not getting the nutrients that they need.
Persons with bulimia nervosa a kind of classic sign, is they have parotid gland enlargement. It’s
not known exactly why that occurs. There’s thought that it’s reduced salivary flow and electrolyte
imbalance. It Is also seen in persons that have alcohol problems.
Bruxism related to stress and tension. And there may be an impairment of a taste perception. The
person may have hypersensitivity in their teeth due to the excessive vomiting, because the
enamel is being worn away and so dentin is being exposed.
Oral trauma, self-induced vomiting. It can either be from a finger or some type of object that is
put down the person’s throat to induce vomiting. And so they may injure either their mouth or the
commisures of their mouth.
These are two classic signs in these pictures that are seen when there’s self induced vomiting.
There’s irritation and inflammation due to the chronic vomiting and also the erosion of the
lingual surfaces, because I think you know by now, when you vomit and that acid lays on your
tongue, that tongue lays against the maxillary teeth, so the lingual surfaces start to dissolve.
When a person vomits, I think you know by now, they’re not supposed to brush their teeth
immediately, because that acid needs to be neutralized. And that can be done with either a baking
soda rinse or milk of magnesia.
And the last mental disorder, we’re going to discuss schizophrenia. And it basically is a
disturbance in how a person feels, how they think, how they behave. And it greatly impairs
somebody’s life. Symptoms of schizophrenia fall into three basic categories. There are positive
symptoms, negative symptoms, and cognitive symptoms.
The difference between positive symptoms and negative symptoms is positive symptoms are
events that are actually occurring. A negative symptom is a lack of something that should be
occurring. So positive symptoms, a person can have one or all of these, hallucinations, delusions,
disorganized thinking, excessive body movements. The person basically loses touch with reality.
I want you to know the two terms that are listed here. And the difference between the two. A
delusion is a false belief in something, such as the person might say, I’m the Queen of England.
They think they’re the Queen of England. Well, that’s a delusionary thought. A hallucination is a
false sensory perception. It could be auditory. It could be visual. But they’re hallucinating.
A negative symptom is, as I said, a lack of something. So it can be referred to as a flat affect. The
person has no emotional response to things. That would be a negative symptom. A lack of
pleasure, an inability to start or carry out tasks, not communicating, difficulty functioning with
everyday tasks such as oral hygiene care.
Cognitive symptoms are less obvious. It would be something like the person is not able to pay
attention. They have challenges with memory. They might have challenges functioning or not
understanding information that’s being given to them.
As I said earlier in the PowerPoint, persons with mental disorders, they tend to use alcoho …
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