AMOS Psychiatry

27/4/2023
Drugs causing organ problems
• Can be idiosyncratic
• Unpredictable
• Dose independent
• E.g. paeds pt – some drugs have a risk (drugs are never free of complication)
• Or intrinsic
• Predictable
• Dose dependent – drug accumulation
• E.g. use of drugs in a known disease
Liver Changes
• Cholestatic changes – means bile in liver, can see color changes, S & S
will be jaundice
• NAFLD – fatty changes
• All eventually leads to cirrhosis (which is a fibrosis)
• Hepatomegaly in psy patient:
• Can affect management due to change in liver function – bleeding etc.
• Not due to drugs but due to chronic liver disease
CNS problems – find out why
• Parenchymal issue – shrinking
• Circulation – bleed or clot present as stroke
• Electrical – epilepsy or seizure (e.g. due to poorly controlled HTN)
• Neurodegeneration – Alzheimer’s or dementia, which can be
exaggerated by drugs
• Cognitive/learning/behavioral problems – ADHD or autism
• Acute infections e.g. meningitis – but usually we won’t see in dental
settings
Dementia can be due to Alzheimer’s (one of
the causes of dementia)
• Brain is affected by neuron, vessels
• Dementia is caused by damage to or loss of nerve cells and their connections in the
brain
• Age related, gradually worsens
• Alzheimer is due to neurodegeneration
• Can also be intrinsic drug reactions - Benzodiazepines and haloperidol (mood stabilizers) can
cause neurodegeneration
• Cognitively the patient is not sharp – consent issue, so need somebody else be there or a 2nd
specialist
• e.g., we see during cellulitis which trigger patient to go into psychosis spell again
• Check the baseline before procedure by Global Deterioration Scale (GDS)
• Other problems: oral hygiene maintenance and xerostomia
Delirium
• Cognitive problem, will have behavioral and personality problems
• Electrolyte/deficiency problem
Heart Changes
• TCA (used in depression) causes electrical changes, can be idiosyncratic
• Lithium (commonly used in psy - use in bipolar, is a mood stabilizer but
retraction/withdrawal risk is high) interact LA – affect CVS and heart
• Also patient may have other heart problems which is exaggerated by mood
problems e.g. cardiomegaly due to
• Dormant lifestyle
• Frequent snacking and unhealthy
• Social history – alcoholism and smoking
• DM, poorly controlled HTN, IHD – Heart failure
• Emergency is cause sudden collapse, need to manage by BLS and see if pt is
shockable or not
Kidney Changes
• When a patient presents with CKD – need to find out cause and try to
reverse it
• CKD which can be caused by drugs or DM – will have sign and
symptoms of fluid overload
• Find out stage
Other changes
• Skin allergy/rashes – beware as patient may be taking steroids for it
• Clonazepam causes bone marrow suppression
Psychological Problems
• E.g. behaviour of psychology patients: patients don’t look at you, sometimes refuse to disclose
• But remember to rule out all organic problems before diagnose as psychiatry
• Depression – emotional problems
• Beware sometimes flare up after surgery (e.g. worry about orthognathic surgery)
• Patient can swing into depression because its usually a cycle and depression happens when patient do not go out
of the cycle and progressively worsen
• Need to have a plan to deal with the patients, especially if presence of suicide presentation such as not normal
behaviour e.g. do not work, stop bathing, become unkempt, drop in grade, stop eating
• Assess the social support, such as living with parents all the time then less worry, more worry if living alone
• Bipolar – also emotional problems
• Swing in mood
• Funny and bizarre actions (doing things in the mall during mania phase)
• Something went wrong with the coping mechanism, which exists in everybody and if it fail it becomes a
psychology problem
• E.g. Azmin Ali’s brother
• Schizophrenia
• Has hallucination
Schizophrenia
• Is a chronic mental disorder - psychosis
• Usually a known case – because not easy to diagnose, usually referred
from psychiatry
• To assess control:
• Ask hallucination – but not specific
• Ask how’s work, social, interpersonal skills, self care and behavior – ask about
the time and amount of doing it as checkpoint
• Most important is positive and negative symptoms
• Any admission for relapse in psychiatry wards or need dental treatment under
GA – resistant
Positive Symptoms Negative Symptoms (5a)
• Jerky movements • blunted affect
• Talking • alogia (reduction in quantity of words spoken)
• Extrapyramidal – parkinsonism (can be due to • avolition (reduced goal-directed activity due to
drugs also) decreased motivation)
• Sudden slapping • Asociality
• Sudden movements – so they can’t sit still in • anhedonia (reduced experience of pleasure).
chair for treatment, need GA
• facial grimaces
Mood Cognitive
• Depress • Problem with senses manipulation - Delusional or
hallucination
• Irrational things
• Speak incoherently
Compliance - Treatment of Schizophrenia
• Counselling – cognitive behavioural therapy (CBT) – is a well
controlled case if only treatment is CBT
• Pharmacotherapy
• Physical treatment:
• electroconvulsive therapy (find picture to show patient) – sedate with
midazolam and then shock the brain but not good in long term (hence
banned in US)
• Ask if patient had this means bad control/severe/refractory/danger to themselves
• Magnetic resonance therapy
Complications - Emergency
• Psychosis episode – suicide or do weird things
• Drug side effects – effects to organs
Psy Drugs Interactions
• Depression and Mania is a cycle – drugs treatment make patient go in other
direction that’s why overlap in several diseases
• Many antipsychotic drugs (e.g. haloperidol) block LA vasoconstrictor effect
and cause vasodilatation, so shorter effect of LA, pt become painful faster,
and then if give more LA, can cause LA toxicity so be warned – can use lower
dose of LA
• LA with adrenaline interact with TCA (antidepressants) and cause HTN and
arrythmias
• SSRI (commonly used for depression or bipolar) – also increase bleeding risk
(affect platelets function) if used with NSAIDs, blood thinners and steroids
• But beware some interactions are weak evidence except SSRI cause bleeding
Psy Drugs Interactions
• Metronidazole and antipsychotic drugs
• Also metabolized by liver and slower removal in kidney – can cause increased toxicity of psy drugs
(e.g. lithium)
• Lithium + NSAIDs – lithium toxicity
• A sudden increase in concentration cause affect CVS by arrythmia
• Long term – kidney effect and cause CKD
• Opiods (tramadol) and psy drugs - seizures and serotonin syndrome (MAOI)
• neuromuscular hyperactivity – clonus, myoclonus, tremor, hyperreflexia, rigidity
• autonomic hyperactivity – fevers, tachycardia, diaphoresis, tachypnoea
• altered mental state.
• Tramadol require cytochrome P450 for conversion to an active opioid agonist. However,
many antidepressants are inhibitors (fluoxetine, paroxetine, and to a lesser extent
duloxetine, fluvoxamine, sertraline, desvenlafaxine and escitalopram). This means
combinations of codeine or tramadol with these antidepressants may lead to reduced
analgesia, that’s why don’t work
Pain Control
• Pain can be due to:
• objective reasons – scratch or pulpitis
• Subjective reasons – emotional and depend on type of disorder:
• Depression – less pain felt, PCM enough
• Manic/Anxiety – pt not cognitively sound, more pain felt as serotonin affected, PCM not
enough and wont work
• Poorer and not effective – may cause patient to go into mood disorder
• Can ask psychiatrist to suggest
• Panadol won’t work
Bipolar - Control
• Ask when is it diagnosed and determine what is the type
• BP 1
• Difference is manic behaviour is more pronounced than BP 2, find control by psy
referral and ask when is last manic episodes, how to control it
• Financial loss control, pt will feel rich and powerful and so different like VIP –
small problems can become big in dental chair (medicolegal issue)
• BP 2
• More depressive and hidden symptoms and is dangerous for dental
• Find the depression and suicidal tendency – beware if you do not achieve their
expectation and induce suicide
• Affects dental treatment and beware of drug interactions also
Depression - Diagnose
• Find the reason
• Find out if it is self-standing or associated with other psy disorders
• Ask how to manage stress
• Check scratch marks or scars on hand – pain make them feel alive
• Notice any behavioural changes
• Ask how many admission pt had
• Ask any physical therapy done (ECT means severely depressed or had
extreme behavior)
Depression - Control
• While doing invasive or aesthetic procedures, be warned if patient
report of problem with appearance and social interactions (some
component of life affected, causing pt no confidence)
• Check susceptibility –
• dangerous in those that may try to hide it
• those who try to get the treatment done
• Beware if they don’t achieve what they want
Suicide Risk – “SAD PERSON” to see if
need referral or admission
Autism
• Can happen if mum used valproic acid for epilepsy during pregnancy
• Depends on what age, ability to cooperate and what type of surgery to do
• Presurgery - Autism kids are fixed on routine, prepare by ask caregivers by pre appointment call
• Find ways to get them to cooperate
• Find out their routine (e.g. mix low dose midazolam sedative in their favourite drinks)
• Find if they are aggressive and situation
• Find out what triggers and sooth them – environment, touch on face, light, moving people etc. (have a check list of
things to avoid)
• Intrasurgery
• Ensure good pain control as unable to tell if pt is in pain – ask parents usually how child communicate if
uncomfortable, not using scale as pt will not be able to tell
• Beware of comorbidity such as T1DM
• If doing GA – ensure time from admission to operation is fast to increase cooperation
• Postsurgery – beware of T1DM and its effect
• Overall – in low functioning children, can use storyboards with picture or description, can start from
home, so try to let them see the same thing as expected to prevent sudden change in environment
e.g. his toys
ADHD
• ADHD kids has short attention span
• Behavioural component:
• How to prevent aggressiveness - Their senses are sharp so usual start with
scaling might not work
• How to keep them still in chair
• How to keep good OH