Psychiatric Psychiatric DisordersDisorders

Iwan Arijanto, dr., SpKJ, Iwan Arijanto, dr., SpKJ, MKesMKes

Psychiatric Disorder Psychiatric Disorder ClassificationClassificationPPDGJ III / 1994-2004PPDGJ III / 1994-2004Multiaxial DiagnosisMultiaxial Diagnosis

Axis I : Clinical disorders, other conditions that Axis I : Clinical disorders, other conditions that may be a focus of clinical attentionmay be a focus of clinical attention

Axis II : Personality disorders, mental Axis II : Personality disorders, mental retardationretardation

Axis III: General medical conditionAxis III: General medical conditionAxis IV: Psychosocial & environmental Axis IV: Psychosocial & environmental

problemsproblemsAxis V : Global Assessment of Functioning ScaleAxis V : Global Assessment of Functioning Scale

Axis IAxis I

F 00 – 09F 00 – 09Organic mental disorder Organic mental disorder behavior & mental disorder due to behavior & mental disorder due to general medical conditions, head general medical conditions, head trauma, neoplasm trauma, neoplasm brain dysfuntionbrain dysfuntion

F 10 - 19F 10 - 19Behavior & mental disorder due to Behavior & mental disorder due to psychoactive substance usepsychoactive substance use

F 20 – 29F 20 – 29Schizophrenia, Schizotipal disorder (axis Schizophrenia, Schizotipal disorder (axis II), delusional disorder, schizoaffective II), delusional disorder, schizoaffective disorder disorder Psychotic disorder Psychotic disorder

F 30 – 39F 30 – 39Mood disorder Mood disorder depression / elation with depression / elation with or without psychotic symptomor without psychotic symptom

Axis IAxis I

Axis IAxis I

F 40 – 48F 40 – 48Neurotic disorder, Somatoform & Stress Neurotic disorder, Somatoform & Stress related disorderrelated disorder

F 50 – 59F 50 – 59Behavior syndrome related to Behavior syndrome related to physiological disorder & physical factor physiological disorder & physical factor Psychosomatic disorderPsychosomatic disorder

F 99 F 99 Unclassified mental disordersUnclassified mental disorders

Axis IAxis I

F 80 – 89F 80 – 89Psychological developmental Psychological developmental disorder disorder autism autism

F 90 – 98F 90 – 98Behavior & emotional disorder with Behavior & emotional disorder with onset at child and adolescentonset at child and adolescent

Axis IIAxis IIF 60 - 69F 60 - 69

Personality disorderPersonality disorder

F 70 - 79F 70 - 79Mental retardationMental retardation

SchizophreniaSchizophrenia

• Thought / perceptional distortionThought / perceptional distortion• Inappropiate/dull affectInappropiate/dull affect• Clear consciousness, intelectual Clear consciousness, intelectual

capacity within normal limit. capacity within normal limit. • Prevalence 1-1,5% in family, 8% in Prevalence 1-1,5% in family, 8% in

sibling, 47% identic twins (US)sibling, 47% identic twins (US)• ♀♀==♂;♂; highest onset ♂ 15-25 years, highest onset ♂ 15-25 years, ♀ ♀

25-3525-35 yearsyears

DiagnosisDiagnosis- One or more symptoms :One or more symptoms :

a. Thought echo, Thought a. Thought echo, Thought insertion / insertion /

withdrawl, Thought broadcastingwithdrawl, Thought broadcasting

b. Bizzare delusionsb. Bizzare delusions

c. Auditory hallucinationsc. Auditory hallucinations

talking about patient’s behaviortalking about patient’s behavior

SchizophreniaSchizophrenia

- Two or more symptoms within Two or more symptoms within interval more than 1 month : interval more than 1 month : d. Other hallucinationsd. Other hallucinationse. disorganized speech (eg, frequent e. disorganized speech (eg, frequent

derailment or incoherence)derailment or incoherence)f. grossly disorganized or catatonic f. grossly disorganized or catatonic

behaviorbehaviorg. negative symptoms, i.e, affective g. negative symptoms, i.e, affective

flattening, alogia, or avolitionflattening, alogia, or avolition

SchizophreniaSchizophrenia

• Prodromal (weeks – months): Prodromal (weeks – months): – Decrease academic / work achievementDecrease academic / work achievement– Decrease social activityDecrease social activity– Decrease personal hygiene Decrease personal hygiene – AnxietyAnxiety– DepressionDepression

• Type :Type :– Paranoid typeParanoid type– Hebephrenic (Disorganised) typeHebephrenic (Disorganised) type– Catatonic typeCatatonic type– Redidual typeRedidual type– Undifferentiated typeUndifferentiated type

SchizophreniaSchizophrenia

Delusional Delusional DisorderDisorder• Nonbizarre delusions of at least 1 Nonbizarre delusions of at least 1

month's duration that cannot be month's duration that cannot be attributed to other psychiatric attributed to other psychiatric disorders. disorders.

• With or without auditory hallucinationWith or without auditory hallucination

• Onset at middle age.Onset at middle age.

Acute and Transient Acute and Transient Psychotic DisordersPsychotic Disorders• Acute stressor / ≤ 2 mg Acute stressor / ≤ 2 mg psychotic symptoms; psychotic symptoms;

complete remission within 2-3 months; complete remission within 2-3 months; schizophrenia like ≤ 1 monthschizophrenia like ≤ 1 month

1. An acute onset (less than 2 weeks) as the key criterion 1. An acute onset (less than 2 weeks) as the key criterion for the whole group. Acute onset denotes a change within for the whole group. Acute onset denotes a change within 2 weeks or less from a state without psychotic features to 2 weeks or less from a state without psychotic features to a clearly abnormal psychotic state (not necessarily at its a clearly abnormal psychotic state (not necessarily at its peak severity).peak severity).

2. The presence of typical syndromes. Those include, first, a 2. The presence of typical syndromes. Those include, first, a rapidly changing and variable state called polymorphic, rapidly changing and variable state called polymorphic, prominent in acute psychoses described in several prominent in acute psychoses described in several countries, and, second, the presence of typical countries, and, second, the presence of typical schizophrenic symptoms.schizophrenic symptoms.

3. The presence or absence of associated acute stress 3. The presence or absence of associated acute stress (within 2 weeks of the first psychotic symptoms).(within 2 weeks of the first psychotic symptoms).

Panic DisorderPanic Disorder• The occurrence of three or more The occurrence of three or more panic attacks panic attacks

within a within a 3-week period3-week period. . • These attacks cannot be precipitated only by These attacks cannot be precipitated only by

exposure to a feared situation, cannot be due to a exposure to a feared situation, cannot be due to a physical disorder. physical disorder.

• These attacks must be accompanied by at least These attacks must be accompanied by at least four four of the following symptoms: of the following symptoms: dyspnea, dyspnea, palpitations, chest pain, smothering or palpitations, chest pain, smothering or choking, dizziness, feelings of unreality, choking, dizziness, feelings of unreality, paresthesias, hot and cold flashes, paresthesias, hot and cold flashes, sweating, faintness, trembling or shakingsweating, faintness, trembling or shaking..

• Genetik factor (+)Genetik factor (+)

Generalized Anxiety Generalized Anxiety DisorderDisorder• Criteria for generalized anxiety disorder require the Criteria for generalized anxiety disorder require the

presence of presence of unrealistic unrealistic or or excessive anxiety excessive anxiety and worry, and worry, accompanied by symptoms from three of four categories: accompanied by symptoms from three of four categories:

(1) (1) motor tensionmotor tension, , (2) (2) autonomic hyperactivityautonomic hyperactivity, , (3) (3) vigilance and scanningvigilance and scanning, and , and (4) (4) apprehensive expectationapprehensive expectation. . • The anxious mood must continue for The anxious mood must continue for at least a month.at least a month.• The diagnosis is not made if phobias, panic disorder, or The diagnosis is not made if phobias, panic disorder, or

obsessive-compulsive disorder are present or if the obsessive-compulsive disorder are present or if the disturbance is due to another physical or mental disorder disturbance is due to another physical or mental disorder such as hyperthyroidism, major depression, or such as hyperthyroidism, major depression, or schizophrenia. schizophrenia.

• Etiology Etiology chronic stress, ♀ > ♂ chronic stress, ♀ > ♂

Dissociative disorder / Dissociative disorder / ConversionConversion• Partial / full loss of normal integration Partial / full loss of normal integration

between past memory, identity awareness, between past memory, identity awareness, & body movement control.& body movement control.

• Psychogenic → related to psychic trauma, Psychogenic → related to psychic trauma, unsolved problems. unsolved problems.

• Sudden onset & end, last within weeks – Sudden onset & end, last within weeks – months.months.

• Dissociative amnesia, dissociative fugue, Dissociative amnesia, dissociative fugue, dissociative stupor, trance, motoric dissociative stupor, trance, motoric dissociative, dissociative konvulsion, dissociative, dissociative konvulsion, anaesthesia dissociative, sensoric anaesthesia dissociative, sensoric dissociative.dissociative.

Somatoform DisorderSomatoform Disorderrecurrent somatic complaints + asking for recurrent somatic complaints + asking for physical examination even there’s no physical examination even there’s no abnormalityabnormality

• Somatisation DisorderSomatisation Disorder::

- ♀ > ♂, onset young adult age.- ♀ > ♂, onset young adult age.

- family history- family history

- Several somatic complaints, change - Several somatic complaints, change

of origin, chronic (≥ 2 years), of origin, chronic (≥ 2 years),

fluctuativefluctuative

•Hypochondric DisorderHypochondric Disorder- ♀ = ♂- ♀ = ♂

- Preoccupation with the fear of - Preoccupation with the fear of

developing a serious disease or the developing a serious disease or the

belief that one has a serious disease.belief that one has a serious disease.

•Somatoform Pain Disorder Somatoform Pain Disorder ( Psychalgia )( Psychalgia )- Chest pain, torturing, persistent, - Chest pain, torturing, persistent,

without organic / physiologic disorders without organic / physiologic disorders

- Psychic stressor background (+)- Psychic stressor background (+)

Mood DisorderMood Disorder• Principal symptoms Principal symptoms : mood changes : mood changes

(depression/elation) + appropriate (depression/elation) + appropriate behavior, +/- psychotic symptombehavior, +/- psychotic symptom

• Chronic relapsing diseaseChronic relapsing disease

• Depression :Depression :

- Bipolar I,II- Bipolar I,II

- Depressive episode- Depressive episode

- Repeated depressive disorder- Repeated depressive disorder

- Persistant mood disorders (cyclothymic, - Persistant mood disorders (cyclothymic,

dysthymic)dysthymic)

→ → depressive mood, retardation in depressive mood, retardation in thinking, speech and behavior, thinking, speech and behavior, retardate / agitate psychomotorretardate / agitate psychomotor

→ → personal hygiene ↓↓ → health personal hygiene ↓↓ → health problem, including dental health problem, including dental health

→ → suicide attempt, dyssomnia (mid and suicide attempt, dyssomnia (mid and terminal insomnia), decreased weight terminal insomnia), decreased weight 5% in a month, negative thought / 5% in a month, negative thought / pessimistic, etcpessimistic, etc

Psychiatric Problems in Psychiatric Problems in Dental HealthDental HealthPatient Patient dental treatment & nurserydental treatment & nursery

emotional factors (conscious - unconsious, emotional factors (conscious - unconsious, realistic/unrealistic, rational/irational) related realistic/unrealistic, rational/irational) related to teethto teeth reflection of fear, anxiety & prejudice to reflection of fear, anxiety & prejudice to figure of authorityfigure of authorityattitude to tooth ache / dentistattitude to tooth ache / dentist the influence of psychic factor in oral and the influence of psychic factor in oral and dental health dental health aware in therapeutic process aware in therapeutic process

Influence of Influence of Emotional FactorsEmotional Factors • SalivaSaliva

a.anxiety, fear→ saliva ↓↓a.anxiety, fear→ saliva ↓↓

→ → dry mouth, swallowing problem, dry mouth, swallowing problem,

taste↓, cavity risk ↑taste↓, cavity risk ↑

b.emotional expression ↑ (tense, angry) b.emotional expression ↑ (tense, angry) → salivation ↑→ salivation ↑

c. emotional inhibition, salivation ↓c. emotional inhibition, salivation ↓

b & c : b & c : fine singer sutherlandfine singer sutherland

•EndocrineEndocrineemotional conflict emotional conflict pituitary gland pituitary gland ↑↑ metabolism of Ca++, metabolism of Ca++, carbohydrate carbohydrate gingivitis gingivitis

•Resistency to infectionResistency to infectionemotional / psychic problem → emotional / psychic problem → resistency to infection ↓resistency to infection ↓(depression, weak, fatigue, tense, (depression, weak, fatigue, tense, restlestness,restlestness, stress)stress)

oral infection oral infection oral flora ↑ oral flora ↑

• Blood circulationBlood circulation- anxiety, tense → blood flow ↑ - anxiety, tense → blood flow ↑ bleeding bleeding tendencytendency- depression →blood flow ↓ - depression →blood flow ↓ gingival gingival condition↓condition↓

• Chewing & SwallowingChewing & Swallowing- final phase of swallowing → conscious / - final phase of swallowing → conscious / unconscious unconscious swallowing disorder (swallowing disorder (globus hystericus globus hystericus etc), etc), nausea, vomitting with psychiatrical nausea, vomitting with psychiatrical background (tense, rejection, aggressivity, background (tense, rejection, aggressivity,

hostility)hostility)

The Psychologic The Psychologic Meaning of Teeth :Meaning of Teeth :

- Related to oral hygiene - Related to oral hygiene

- Threat of loss of teeth- Threat of loss of teeth

ChildrenChildren

(+)(+) (-)(-)Oral hygiene awareness ↑ Guilty feeling, angerOral hygiene awareness ↑ Guilty feeling, anger(family support)(family support) (rejection, family (rejection, family punishment)punishment)

Sense of well being,Sense of well being, Self worth, self careSelf worth, self care self blameself blame

Self destructive Self destructive

behaviorbehavior

AdultAdult

• Loss of old friendLoss of old friend

Morphologic abnormalityMorphologic abnormality

→ → heavy emotional consequence for the heavy emotional consequence for the

patient (low self-esteem → antisocial patient (low self-esteem → antisocial

behavior)behavior)

→ → therapytherapy : recovered self-esteem : recovered self-esteem

Anxiety ↑↑ Anxiety ↑↑ pratherapy evaluation pratherapy evaluation

Psychiatric Aspects of Psychiatric Aspects of Some Oral and Dental Some Oral and Dental PathologyPathology1.1.Resistency to treatment of oral Resistency to treatment of oral

hygienehygiene • Kebiasaan & didikan higiene oralKebiasaan & didikan higiene oral• ““SymbolSymbol” of anti authority & rejection ” of anti authority & rejection

of sexual activityof sexual activity• Mental disorder: psychotic, depression, Mental disorder: psychotic, depression,

MR, acute anxietyMR, acute anxiety• ““RationalisationRationalisation” : other lack in self ” : other lack in self

that cause socialization difficulties.that cause socialization difficulties.

2. Phantom teeth2. Phantom teeth- unable to receive reality - unable to receive reality lost lost

of of

teeth and senility process. teeth and senility process.

3. Implanted teeth3. Implanted teethcould stimulate the wish to go could stimulate the wish to go

back to back to

infant phase (regression)infant phase (regression)

4. Thumb sucking4. Thumb sucking• Related to unsatisfactory oral phase Related to unsatisfactory oral phase

(less experience of breastfeeding, (less experience of breastfeeding, less pleasure)less pleasure)

→ → ““sucking time” sucking time” = infant’s right= infant’s right

→ → too early discontinuation of too early discontinuation of breastfeeding : excessive optimism,breastfeeding : excessive optimism,

narcissism, pessimism, envy, narcissism, pessimism, envy, jealousy, excessively dependent and jealousy, excessively dependent and require others to give to them and to require others to give to them and to look after themlook after them

• Last till age > 4 years → bad early Last till age > 4 years → bad early rearing.rearing.

• Early intervension, strong, suddenly Early intervension, strong, suddenly → stuttering, delinquency, enuresis, → stuttering, delinquency, enuresis, sticking out the tounge, nail bitingsticking out the tounge, nail biting

• Therapy:Therapy: the child talk about the child talk about his/her feeling, good rearing, his/her feeling, good rearing, chewing training (food, drink), social chewing training (food, drink), social contact & better attention (for lonely contact & better attention (for lonely child)child)

• ResidueResidue in adult : smoking, candy in adult : smoking, candy chewing, mustache playing. chewing, mustache playing.

5.5. CariesCaries- stress → increase of intake - stress → increase of intake

(carbohydrate)(carbohydrate)

6.6. GingivitisGingivitis- Need of oral dependency >> + - Need of oral dependency >> + anxiety anxiety → precipitation : acute → precipitation : acute anxietyanxiety

7.7. Morphologic abnormalityMorphologic abnormalitySocial stigma → impulsive and asocial Social stigma → impulsive and asocial behaviorbehavior

corrective action could help corrective action could help patient’s patient’s

personality development personality development (decrease (decrease

anxiety, and low self esteem)anxiety, and low self esteem)

8.8. BruxismBruxism• SeparationSeparation

movement in tongue – jaw ≈ movement in tongue – jaw ≈ movement of breatfeeding in infantmovement of breatfeeding in infant

• AnxietyAnxiety

contact / pressure within teethcontact / pressure within teeth

→ → self confidenceself confidence

• AngerAnger

““displacement” of restrained angerdisplacement” of restrained anger

9. TMJ (Temporo-mandibular-9. TMJ (Temporo-mandibular-joint) syndromejoint) syndrome

• Severe pain – change places Severe pain – change places jaw, jaw, teeth, tongue feel like burning, teeth, tongue feel like burning, paraesthesia / paraesthesia / electric shockelectric shock in jaw in jaw and head, bad taste, shaky teeth.and head, bad taste, shaky teeth.

• Previous depression due to threat Previous depression due to threat separation with someone who was separation with someone who was very important in patient’s life.very important in patient’s life.

• The use of symptoms :The use of symptoms :

- escape from problems. - escape from problems.

- way to find substitution of - way to find substitution of missing missing

personperson

10.10. Oral painOral painPatient with complaint of pain without Patient with complaint of pain without organic origin :organic origin :a. repression & anger denial emerged from a. repression & anger denial emerged from

doctor-patient relationship. doctor-patient relationship. b. Displacement / escape from certain b. Displacement / escape from certain problemproblem

→ → pain :pain : - family support- family support

- doctor-patient relationship - doctor-patient relationship substitutionsubstitution- disturbed real relationship- disturbed real relationship

c. Fail to control anger / aggresivity to c. Fail to control anger / aggresivity to another personanother person

→ → hyposensitive to “hyposensitive to “self inflicted self inflicted painpain””

but hypersensitive to pain but hypersensitive to pain caused by caused by

other person (dentist)other person (dentist)