CHAPTER
29 
Mental disorders are common in today’s society. Approx-
imately 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%.1-4
Psychiatric problems, which can affect the clinical
course in various medical illnesses, increase required
duration of treatment, decrease the patient’s functional
level, and have a negative impact on overall prognosis
and outcome. Disorders related to drug and alcohol use
account for a significant proportion of the treatment-
related psychiatric issues. In the elderly population, a
high prevalence of psychiatric complications is associ-
ated 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 elderly persons have a substance abuse disorder.5 The
prevalence of psychiatric disorders among adult dental
patients seeking treatment at the Virginia Common-
wealth University School of Dentistry was found to be
28% of a randomly selected patient group of 442.6 The
most common disorder reported was depression.6
This chapter provides an overview of mood disorders,
somatoform disorders, and schizophrenia, with an
emphasis on drugs used to treat these conditions and
their significant adverse reactions and interactions with
drugs used in dentistry. Also discussed are specific con-
siderations in the dental management of patients with
these disorders.
MOOD DISORDERS
DEFINITION
Mood disorders represent a heterogeneous group of
mental disorders that are characterized by extreme exag-
geration and disturbance of mood and affect. These dis-
orders are associated with physiologic, cognitive, and
540
Psychiatric Disorders
psychomotor dysfunction. Mood disorders, which
tend to be cyclic, include depression and bipolar
disorder.3,4,7,8
EPIDEMIOLOGY
Incidence and Prevalence
About 5% of the adults in the United States have a sig-
nificant 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 elderly persons, followed by those 30 to 40 years
of age and, in recent years, an increased number of 15- to
19-year-olds.9 Lifetime prevalence rates for major depres-
sive disorders are 15% to 20%.4 Point prevalence rates
for major depression in urban U.S populations are 2%
to 4% for men and 4% to 6% for women.4 After the
age of 55 years, depression starts to occur more com-
monly in men.9 About one third of depressed persons
require hospitalization; 30% follow a chronic course
with residual symptoms and social impairment.3,4,9,10
The prevalence of major depression is fairly consistent
across races and cultures. However, this disorder occurs
with greater frequency among recent immigrants and the
displaced.9 No evidence suggests significant geographic
variability, except in seasonal affective disorder, which is
due to limited exposure to the sun during the winter in
the northern states. No clear association with social class
has been found, but major depression is associated with
poverty and unemployment as significant stressors.9 Risk
factors include current stress burden; history of early
trauma, neglect, abuse, or deprivation; personal and
family history of mood and anxiety disorders; medical
and psychiatric disorders; and personality disorder.10
The lifetime prevalence of dysthymia, a chronic,
milder form of depression, is 2.2% in women and 4.1%
in men.2 Approximately 0.4% to 1.6% of adults in the
United States have bipolar disorder.2 In contrast with
major depression, which is more than twice as common
in women as in men, bipolar disorder occurs almost
with equal frequency in both sexes. Bipolar disorders
are much less common than major depression (see
Table 29-1).4,8,10
 CHAPTER 29  Psychiatric Disorders 541

TA B L E 2 9 - 1 Epidemiology of Mood Disorders

Variable Depressive Disorders Bipolar Disorders

Prevalence Major depression Bipolar illness
• Point prevalence: • Lifetime prevalence: 0.6-0.9%
Men: 2.0-4.0% • May be as high as 1-10% if all subtypes are
Women: 4.0-6.0% included
Older adults: 11-15% • Annual incidence:
• Lifetime prevalence: Men: 9-15 cases per 100,000
Overall rate: 15-20% Women: 7.4-32 cases per 100,000
• More common in divorced or separated persons • More common in upper socioeconomic groups
Dysthymia • Equal among races
• Point prevalence: • High rates of divorce
Men: 5.0% Cyclothymia
Women: 8.0% • Lifetime prevalence: 0.4-3.5%
Age at onset Late 20s or 30s Late teens or early 20s
Childhood possible Childhood possible
May have much later onset Cyclothymia may precede late onset of overt mania
Higher rate and earlier onset for persons born after 1940 or depression
than for those born before
Family and genetic Unipolar patients tend to have relatives with major Bipolar patients have many relatives with bipolar
studies depression and dysthymic disorder and fewer with disorder, cyclothymia, unipolar depression, and
bipolar disorder. schizoaffective disorder
Early onset, recurrent course, and psychotic depression
appear to be heritable.
Twin studies Concordance in monozygotic twins: 72% concordance in monozygotic twins, 19% in
• Recurrent depression: 59% same sex dizygotic twins
• Single episode only: 33%
Concordance rate for identical (monozygotic) twins is 4
times greater than for fraternal (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; and Kahn DA: Mood disorders. In Cutler JL, Marcus ER: Saunders text and review: psychiatry, Philadelphia, Saunders, 1999.

Etiology
Several theories have been presented to explain the origin
of mood disorders. Reduced brain concentrations of nor-
epinephrine and serotonin (neurotransmitters) for some
time have been 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.4,8,10 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 transmit-
ters. Thyrotropin release of thyroid-stimulating hormone
and cortisol release by corticotropin-releasing factor and
adrenocorticotropin over a long period may be associ-
ated with the development of depression. This model
suggests that depression is the result of a stress reaction
that has gone on too long.3,4,9,10
Evidence for a genetic predisposition to bipolar disor-
der is significant. The concordance rate for monozygotic
twin pairs approaches 80%, and segregation analyses are
consistent with autosomal dominant transmission. Mul-
tiple genes are likely to be involved, with strongest evi-
dence for loci on chromosomal arms 18p, 18q, 4p, 4q,
5q, 8p, and 21q.3
Positron emission tomography (PET) studies show
decreased metabolic activity in the caudate nuclei and
frontal lobes in depressed patients that returns to normal
with recovery. Single-photon emission computed tomo­
graphy (SPECT) studies show comparable changes in
blood flow.3
Psychosocial theory focuses on loss as the cause of
depression in vulnerable persons. Mania receives much
less attention because it is thought to be more of a bio-
logically caused disorder.3,4,8,10
CLINICAL PRESENTATION AND
MEDICAL MANAGEMENT
Depressive Disorders
The Diagnostic and Statistical Manual of Mental Disor-
ders, fourth edition, text revision (DSM-IV-TR), lists
three types of depressive disorders: major depression,
dysthymic disorder, and depression not otherwise speci-
fied (NOS).11 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
542 CHAPTER 29  Psychiatric Disorders
BO X 2 9 - 1 Diagnostic Criteria for Depressive Disorders
Major Depressive Episode
• 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
From Schiffer RB: Psychiatric disorders in medical practice. In Goldman L, Ausiello D, editors: Cecil textbook of medicine, ed 23, Philadelphia, 2008, Saunders.
gain or loss in weight, and suffer from 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.
Dysthymia represents a chronic, milder form of depres-
sion with symptoms that last at least 2 years (see Box
29-1). Depression NOS is a form of depression that falls
short of the diagnostic criteria for major depression and
has been too brief for dysthymic disorder.9,12 A form of
depression called seasonal affective disorder may occur
in areas of the country that have limited amounts of
sunlight during the winter.9
Bipolar Disorder
The DSM-IV lists four types of bipolar disorder: bipolar
I, bipolar II, cyclothymic, and bipolar disorder NOS
(Figure 29-1).11 Figure 29-2, A shows the normal varia-
tion in moods. Bipolar I disorder consists of recurrences
Dysthymia
• 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.
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 Figure 29-2,
B). The essential feature of a manic episode is a distinct
period during which the affected person’s mood is ele-
vated 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 agita-
tion, 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 demand-
ing. 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 commmon in this patient
population.3,4,11,13
Bipolar II disorder (see Figure 29-2, C) consists of
recurrences of major depression and hypomania (mild
 CHAPTER 29  Psychiatric Disorders 543

Mood Disorders

Bipolar Disorders Depressive Disorders

Cyclothymic Major Dysthymic

Bipolar I Bipolar II Bipolar NOS Depression NOS
disorder depression disorder

Manic Mixed Depressed Hypomanic Depressed Single Recurrent

FIGURE 29-1  Mood disorders listed in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (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.

TA B L E 2 9 - 2 Clinical Features of Hypomania and Mania

Feature Hypomania Mania

Appearance May be unremarkable Often striking
Demeanor may be cheerful Clothes may reflect mood state
Demeanor may be cheerful
Disordered and fatigued in severe states
Behavior Increased sociability and loss of Overactivity and excitement
inhibition 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 Increased appetite
Reduced need for sleep Reduced need for sleep
Increased libido Increased libido
Psychotic Not present Thoughts may have an expansive quality
symptoms Thoughts may have an Delusions and second-person auditory hallucinations may
expansive quality 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.

mania). Cyclothymic disorder manifests as recurrent
brief episodes of hypomania (see Table 29-2) and mild
depression. Bipolar disorder NOS refers to partial syn-
dromes, such as recurrent hypomania without depres-
sion. Patients with bipolar disorder have at least one
episode of mania or hypomania.3,8,11,13
The diagnosis of bipolar disorder is made as soon as
the patient has one manic episode, even if that person has
never had a depressive episode. Most patients who become
manic will eventually experience depression. However,
about 10% of patients in whom bipolar disorder is diag-
nosed appear to have only manic episodes.14
Men tend to have a greater number of manic episodes
and women, more numerous depressive episodes.
Untreated patients with bipolar disorder will experience
a mean of nine affective episodes during their lifetime.
544 CHAPTER 29  Psychiatric Disorders
A B
FIGURE 29-2  A, Normal mood cycles. B, Bipolar type I disorder.
C, Bipolar type II disorder. (From Khalife S: Bipolar disorder. In Carey
WD, et al, editors: Current clinical medicine 2009—Cleveland Clinic,
ed 2, Philadelphia, 2010, Saunders.)
The length of each cycle tends to decrease, although the
number of cycles increases with age (Figure 29-3). Each
affective episode lasts about 8 to 9 months. Bipolar
patients have a greater number of episodes, hospitaliza-
tions, divorces, and suicides compared with unipolar
patients.15
Treatment of Mood Disorders
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.3,4,9-11 These agents are used
primarily to treat major depression, dysthymic disorder,
and depression NOS and have a limited role in
C
depression associated with bipolar disorder that responds
to an antipsychotic medication and the standard antide-
pressant medication fluoxetine. Drug therapy is essential
in bipolar disorder for achieving two goals: (1) rapid
control of symptoms in acute episodes of mania and
depression and (2) prevention of future episodes or
reduction in their severity and frequency. Mood disor-
ders have a tendency to recur. Affective episodes may
occur spontaneously or may be triggered by adverse
events. Persons with mood disorders and their families
must become aware of the early signs and symptoms of
affective episodes, so that treatment can be initiated.
These patients also must be made aware of the need for
medication compliance and of the medication’s adverse
effects and possible complications.3,4,8,10
The mainstays of drug therapy for bipolar disorders
are the mood-stabilizing drugs, which generally act on

EXPERIENTIAL PREDISPOSITIONS
MANIA
DEPRESSION
Birth
Genetic Stress, Minor dysphorias
predisposition separation,
loss
FIGURE 29-3  Natural history of recurrent mood disorders: an integrated model. Genetic factors and early environmental stress may predis-
pose 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.
both mania and depression (Table 29-4). Drugs used are
lithium, valproic acid or divalproex (valproate semiso-
dium), lamotrigine, and carbamazepine.16 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 dival-
proex, lamotrigine, or carbamazepine), with mood sta-
bilizing effects, can be used.8
Mixed depressive and manic episodes are difficult to
manage. First the manic behavior needs to be stabilized,
and then the depression is addressed. An atypical anti-
psychotic (olanzapine) or a mood stabilizer is adminis-
tered to stabilize the manic behavior, and depression is
addressed with a standard antidepressant drug (fluox-
etine). Another approach is to use a mood stabilizer and
a combination agent consisting of an antidepressant plus
an atypical antipsychotic—the olanzapine-fluoxetine
combination (OFC) drug available as Symbyax.8
Electroconvulsive therapy is an effective antimanic
treatment.17 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.3,4,8
It takes about 7 to 10 days for lithium to reach full
therapeutic effectiveness. With most antidepressant
drugs, a delay (10 to 21 days) is noted before full thera-
peutic benefits are achieved.3,4
Patients who have had two or three episodes of bipolar
disorder, including depressive episodes, usually are
treated indefinitely because of the near certainty of
relapse. Lithium is the treatment of choice. About one
CHAPTER 29  Psychiatric Disorders 545
Conditioned compensatory
response of hypomania
Full-blown Stereotypic Faster onsets Spontaneity
depression recurrences and recurrences with rapid
cycling
third of patients will not experience additional episodes
and are considered cured; a third of those who take
lithium will experience less frequent or less severe epi-
sodes and will function well; and the remaining third of
patients will continue to have frequent and severe epi-
sodes with ongoing disability.3,4,8
An estimated 30,000 suicides occur each year in the
United States. About 70% of these 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 retire-
ment, 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. Once
medical control is attained in the patient with a mood
disorder, insight-oriented psychotherapy often is initi-
ated as an adjunct for management of the patient’s
condition.4,11,17,18
SOMATOFORM DISORDERS
DEFINITION
Persons with somatoform disorders have physical com-
plaints 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 disor-
der, pain disorder, and hypochondriasis (Table 29-5).
546 CHAPTER 29  Psychiatric Disorders

disorder, and hypochondriasis appear to be more

TA B L E 2 9 - 3 Commonly Used Antidepressants
common than somatization disorder.3
(by Structural Group)

Drug Trade Name Comments Etiology

Tricyclic In this group of disorders, physical symptoms suggest a
Amitriptyline Elavil
physical disorder for which no underlying physical basis
Trimipramine Surmontil
Desipramine Norpramin can be found. Symptoms are linked to psychological
Doxepin Sinequan factors. Somatization therefore is defined as the manifes-
Imipramine Tofranil tation of psychological stress in somatic symptoms.
Nortriptyline Pamelor A conversion reaction results when a psychological
Protriptyline Vivactil conflict or need is expressed as an alteration or loss of
Tetracyclic physical function, suggesting a physical disorder. A
Maprotiline Ludiomil person who views a traumatic event, for example, but
Selective Serotonin Re-uptake Inhibitors has a conflict about acknowledging that event may
Escitalopram Lexapro develop a conversion disorder of blindness. In this
Fluoxetine Prozac instance, the symptom of blindness has symbolic value
Fluvoxamine Luvox and is a representation of and a partial solution to the
Paroxetine Paxil
underlying psychological conflict. By contrast, patients
Sertraline Zoloft
Patients taking these drugs with hypochondriasis or a factitious (self-inflicted) dis-
MAOIs order are aware of the nature of their problem but may
must be on a tyramine-
free diet. be unable to control it. Many patients with pain disorder
Phenelzine Nardil describe a history of a physical injury that precedes later
Tranylcypromine Parnate onset of pain. The onset of pain is accompanied by envi-
Atypical or Nontricyclic ronmental stress or emotional conflict.3,4,19
Nefazodone Serzone As effective as imipramine
Venlafaxine Effexor SNRI; may be effective in
treatment of resistant
CLINICAL PRESENTATION AND
depression
MEDICAL MANAGEMENT
Amoxapine Asendin
Bupropion Wellbutrin May be especially helpful Somatization Disorder
for atypical depression
Somatization consists of multiple signs and symptoms
Mirtazapine Remeron Increase at 1- to 2-week
intervals.
and usually begins before the age of 30 years. Patients
Trazodone Desyrel Helpful as a second drug experience multiple, unexplained physical manifesta-
for sleep disturbance tions of illness or disease, which may include pain, diar-
Duloxetine Cymbalta Additionally useful in pain rhea, bloating, vomiting, sexual dysfunction, blindness,
syndromes deafness, weakness, paralysis, or coordination problems.
MAOIs, Monoamine oxidase inhibitors; SNRI, Serotonin-norepinephrine Somatization disorder is a serious psychiatric illness.
reuptake inhibitor. Many patients have concurrent anxiety, depression, or
Data from Schiffer RB: Psychiatric disorders in medical practice. In Goldman personality disorder.3,4,19
L, Ausiello D, editors: Cecil textbook of medicine, ed 23, Philadelphia, 2008,
Saunders.
Conversion Disorder
Conversion disorder is a monosymptomatic somatoform
disorder that affects the voluntary motor system or
Patients with a somatization disorder experience multi- sensory functions. The patient may experience blindness,
ple, unexplained somatic symptoms that may last for deafness, paralysis, or an inability to speak or to walk.
years.3,4,19 Symptoms suggest a physical condition, but the cause
is psychological. The somatic manifestation, which is
not intentionally produced, typically is a symbolic
EPIDEMIOLOGY representation that relieves an underlying emotional
conflict.3,4,19
Incidence and Prevalence
The prevalence of somatoform disorders is 5%.3 Most
Pain Disorder
of these occur in women. Patients with symptoms that
do not meet the full criteria for somatization disorder Pain disorder causes the patient significant distress in
are much more common. Conversion disorder, pain important areas of functioning such as social and
 CHAPTER 29  Psychiatric Disorders 547

TA B L E 2 9 - 4  Initial Treatment Guidelines for Bipolar Disorder

Step 1 Step 2 Step 3

Drug/Indication
Category Starting Dose Target Drug Starting Dose Additional Options
Depression
Lithium 300-450 mg twice Serum level OFC* 6 mg/25 mg at Combinations of lithium,
daily >0.8 mEq/L bedtime OFC, quetiapine
Lamotrigine 25 mg once a day Dose Quetiapine (pending FDA 100 mg at Add traditional
Initial and target 50-200 mg/ approval for bipolar bedtime; antidepressant† to one or
doses may be day disorder type 1 and type increase to more of these (Step 1 or
affected by 2 depression) 300 mg at Step 2)
concomitant bedtime by ECT
medications day 3
Mania
Lithium 300-450 mg three Serum level Choose two of the Other two-drug combinations
times a day generally following in (choose from lithium, VPA,
1.0- combination: Lithium AAPs, carbamazepine,
1.5 mEq/L VPA or divalproex oxcarbamazepine,
AAP (excluding olanzapine topiramate)
and clozapine)
VPA 500 mg three times
a day
Divalproex 750 mg at bedtime
AAP (excluding Initial dosing varies ECT
clozapine and Clozapine
aripiprazole) Triple-drug therapy
*FDA-approved for bipolar disorder type 1 depression.
†
Traditional antidepressants include selective serotonin reuptake inhibitors, serotonin-norepinephrine uptake inhibitors, bupropion, venlafacine, and mirtazapine.
AAP, Atypical antipsychotic [agent]; ECT, Electroconvulsive therapy; FDA, U.S. Food and Drug Administration; OFC, Olanzapine-fluoxetine combination; VPA,
Valproic acid.
From Khalife S, Singh V, Muzina DJ: Bipolar disorder. In Carey WD, et al, editors: Current clinical medicine 2009—Cleveland Clinic, Philadelphia, 2009, Saunders.

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 second-
ary gain in the form of increased attention and sympathy
from others.3,4,19
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.3,4,19
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 respon-
sibility or financial gain. 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 psy-
chotherapy 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. Unneeded medical or surgical
treatment must not be rendered and will not correct the
problem. Such treatment is costly and may lead to sig-
nificant associated complications.3,4,19
SCHIZOPHRENIA
DEFINITION
Disordered thinking, inappropriate emotional responses,
hallucinations, delusions, and bizarre behavior charac-
terize schizophrenia. The lifetime prevalence rate for
schizophrenic disorders is about 1% to 1.5% (across all
cultures and both genders). Worldwide, the prevalence
is 0.85%.3 Onset usually is during adolescence or early
adulthood. Studies have suggested an earlier onset in
men than in women.3
548 CHAPTER 29  Psychiatric Disorders

TA B L E 2 9 - 5 Somatoform Disorders

Somatoform Disorder Features

Somatization disorder
Conversion disorder
Pain disorder
Hypochondriasis
Body dysmorphic disorder
Other somatoform-like
disorders
  Factitious disorder
  Malingering
  Dissociative disorders
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.
Chronic multisystem disorder characterized by complaints of pain, and gastrointestinal 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 gastrointestinal symptoms, plus
one sexual-reproductive symptom, plus one pseudoneurologic symptom.
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%.
Clinical syndrome characterized predominantly by pain in which psychological factors are judged to be of
etiologic importance
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.”
Preoccupation with an imagined or exaggerated defect in physical appearance
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.
Intentional production or feigning of physical or psychological signs when external reinforcers (e.g., avoidance
of responsibility, financial gain) are present
Disruptions of consciousness, memory, identity, or perception judged to be due to psychological factors

are caused in part by a disturbance in dopamine-mediated

EPIDEMIOLOGY
Etiology
The cause of schizophrenia is not known, but it appears
to involve the interaction of genetic and environmental
factors. Evidence for a genetic relationship has come
from family, twin, and adoption studies. Family studies
have shown a 13% risk for schizophrenia in children
with one parent with schizophrenia. If both parents are
schizophrenic, the risk increases to 46%.20 The risk of
developing schizophrenia for first-degree relatives is 5%
to 10%, and for second-degree relatives, it is 2% to 4%.
Concordance in twins for schizophrenia is 46% for iden-
tical twins and 14% for nonidentical twins. However,
89% of persons with schizophrenia do not have a parent
with the disease, and 81% do not have a parent or a
sibling with the disease.3,4,21 Despite evidence for a
genetic causation, the results of molecular genetic linkage
studies in schizophrenia are inconclusive. Major gene
effects appear to be unlikely.3
The predominant biologic hypothesis for a neuro-
physiologic defect in schizophrenia is the dopamine
hypothesis, which states that symptoms of schizophrenia
neuronal pathways in the brain. This theory is supported
by the blocking effect that most antipsychotic drugs have
on postsynaptic dopamine receptors. The disease is more
common among persons of lower socioeconomic status.
A separate risk factor is the chronic stress of poverty,
which may have an adverse effect on the outcomes of
the illness.20
Schizophrenia appears to be triggered by certain envi-
ronmental events in a genetically predisposed person.
Drugs, medical illness, stressful psychosocial events, viral
infection, and family situations characterized by conflict-
ing and self-contradictory forms of communication have
been reported to precipitate schizophrenia in susceptible
people.20 A hypothesis that has gained support relates
to the cytokine activity associated with inflammatory
immune processes, the cytokine hypothesis.22
CLINICAL PRESENTATION AND
MEDICAL MANAGEMENT
According to the DSM-IV definition, schizophrenia can
be diagnosed in patients who have two or more of the
following symptoms for at least 1 month: hallucinations,
 CHAPTER 29  Psychiatric Disorders 549

TA B L E 2 9 - 6 Schizophrenia and Other Psychotic Disorders

Diagnostic Features of Schizophrenia

Schizoaffective and Substance/General
Characteristic Social/Occupational Mood Disorder Medical Condition
Symptoms Dysfunction Duration Exclusion Exclusion
At least two of the following, For a significant portion Continuous signs of the Schizoaffective disorder The disturbance is
each present for a major of the time since disturbance persist for at and mood disorder not due to the
portion of the time during the onset of the least 6 months. This 6-month with psychotic direct effects of
a 1-month period (or less disturbance, one or period must include at least features have been a substance (e.g.,
if successfully treated):* more major areas 1 month of characteristic ruled out because (1) drugs of abuse,
Delusions of functioning (e.g., symptoms as described no major depressive medication) or a
Hallucinations work, interpersonal above (i.e., active-phase or manic episodes general medical
Disorganized speech (e.g., relationships, self-care) symptoms) and may include have occurred condition.
frequent derailment, are markedly below periods of prodromal concurrently with
“jumping from one the level achieved or residual symptoms. the active-phase
topic to another,” or before onset (or, when During these prodromal symptoms or (2)
incoherence) onset is in childhood or residual periods, signs if mood episodes
Grossly disorganized or or adolescence, failure of the disturbance may have occurred
catatonic behavior to realize the expected be manifested by only during active-phase
Negative symptoms (i.e., level of interpersonal, negative symptoms or two symptoms, their total
affective flattening, academic, or or more of the characteristic duration has been
alogia, or avolition) occupational symptoms present in an brief in relation to
achievement). attenuated form (e.g., odd the duration of the
beliefs, unusual perceptual active and residual
experiences). periods.
*NOTE: Only one characteristic symptom is required if delusions are bizarre or hallucinations consist of a voice keeping a running commentary on the person’s
behavior or thoughts or involve two or more voices conversing with each other.
From Schiffer RB: Psychiatric disorders in medical practice. In Goldman L, Ausiello D, editors: Cecil textbook of medicine, ed 23, Philadelphia, 2008, Saunders.

delusions, disorganized speech, grossly disorganized or
catatonic behavior, or negative symptoms such as affec-
tive flattening, alogia (poverty of speech, lack of addi-
tional unprompted content), or avolition (lack of desire,
drive, or motivation). In addition, the patient’s social or
occupational functioning must have deteriorated.21
Patients with schizophrenia show psychotic symp-
toms consisting of delusions, hallucinations, incoher-
ence, catatonic behavior, or flat or grossly inappropriate
affect. Delusions and hallucinations are referred to as
“positive” symptoms, and withdrawal and reduction of
affective expression as “negative” symptoms. Delusions,
such as thought broadcasting or being controlled by a
deceased person, usually are bizarre. Hallucinations are
prominent and occur throughout the day for several days
or several times a week for several weeks (Table 29-6).
The four types of schizophrenic disorders are catatonic,
disorganized, paranoid, and undifferentiated. Patients
with schizophrenic disorders show deterioration in their
level of functioning at work and in social relations and
self-care. They often are confused, depressed, withdrawn,
anxious, and without emotion. Physically, they may
grimace and pace about, or they may be rigid and cata-
tonic. Vulnerability to a schizophrenic disorder is inher-
ited, and life stresses appear to trigger the disorder.20,21
In schizophrenia, two types of thought disturbances
are seen: formal thought disorder and disorder of thought
content. Formal thought disorders affect relationships
and associations among the words used to express
thought. Thoughts may be strung together by incidental
associations, or they may be completely unrelated.
Thought blocking is common with psychotic patients.
Disorders of thought content involve the development of
delusions, which are fixed ideas that are based on incor-
rect perceptions of reality. Delusions, which commonly
are paranoid or persecutory, also may be bizarre, somatic,
grandiose, or referential (as to events that the patient
believes have special significance). Perceptual distur-
bances in schizophrenic patients include auditory, visual,
tactile, olfactory, and gustatory hallucinations. Auditory
hallucinations consist of sounds heard by the patient in
the absence of any real auditory stimulus. Patients may
hear sounds of bells, whistles, whispers, rustlings, and
other noises. The most commonly heard sound is that of
voices talking. Often, visual, tactile, or olfactory hallu-
cinations occur.20,21
The most common emotional change in schizophrenia
is a general “blunting” or “flattening” of affect. The
patient seems to be emotionally detached or distant, may
appear wooden and robot-like, and may lack warmth or
spontaneity. Paranoid patients may feel frightened or
enraged in response to a perceived threat or a delusion
of persecution. They can be very hostile and guarded to
any perceived slight.20,21
550 CHAPTER 29  Psychiatric Disorders
The long-term course of illness is variable. About
25% of patients experience full remission of symptoms.
Another 25% have mild residual symptoms. The
remaining 50% continue to have moderate to severe
symptoms.23
DRUGS USED TO TREAT PSYCHIATRIC
DISORDERS
Drug treatment has had the most dramatic impact on
control of symptoms and improvement in quality of life
of patients with schizophrenia. Psychotherapy and other
psychosocial treatments also are important because they
provide patients with the human connection that helps
them develop social skills, educates them about their
illness and what to expect, and offers support through-
out a long, difficult course of illness. Drug treatment of
schizophrenic disorders consists of antipsychotic medica-
tions that act selectively against specific target symp-
toms. These drugs are effective for “positive” symptoms
such as hallucinations and psychotic agitation but are
noneffective for “negative” symptoms such as social
withdrawal or anhedonia (inability to get pleasure from
or find interest in activities). The newer atypical antipsy-
chotic medications (clozapine, olanzapine, risperidone,
and quetiapine) are quite effective for control of both
“positive” and “negative” symptoms of schizophrenia
and are associated with minimal movement adverse
effects. Antipsychotic drugs are described later in this
chapter.20,21
Antidepressant Medications (Excluding
Those for Bipolar Depression)
Tricyclic Antidepressants.  The group of drugs that are
used primarily to treat depression are the tricyclic anti-
depressants (see Table 29-3). The first tricyclic used to
treat depression was imipramine. Tricyclics inhibit neural
reuptake of norepinephrine and 5-hydroxytryptamine
(5-HT), resulting in downregulation of their respective
receptors. All tricyclics are equally effective in the man-
agement of depression, but these agents differ in their
associated adverse effects.16 Amitriptyline and doxepin
are the most sedating, and this adverse effect is put to
advantage by patients who take these drugs just before
bedtime. Two combinations of drugs are available for
treating depression and other psychotic symptoms.
Triavil (amitriptyline plus perphenazine) is used to treat
patients with depression and agitation or psychotic
behavior. Limbitrol (amitriptyline plus chlordiaze­poxide)
is used to treat patients with depression and anxiety.2-4
Table 29-3 summarizes the drugs used to treat
depression.
Adverse effects associated with tricyclics include dry
mouth, constipation, blurred vision, cardiac dysrhyth-
mias such as tachycardia, hypotension, blurred vision,
allergic reactions, and important drug interactions
(Table 29-7). Tricyclic drugs should be used with caution
in patients with cardiac conditions because of the associ-
ated risk for atrial fibrillation, atrial ventricular block,
or ventricular tachycardia. Tricyclics can lower the
seizure threshold and must be used with care in patients
with a history of seizures. They can increase intraocular
pressure in patients with glaucoma. Urinary retention
may be increased in patients with prostate hypertrophy.
Erectile or ejaculatory disturbances occur in up to 30%
to 40% of patients. If used in some patients with bipolar
disorder, tricyclics can reduce the time between episodes,
induce manic episodes, and cause rapid cycling of the
clinical course of the disorder.2-4
Drug interactions reported with the use of tricyclic
antidepressants include the following: (1) Tricyclics may
potentiate the effects of other central nervous system
(CNS) depressants such as ethanol and benzodiazepines;
(2) they may potentiate the actions of anticholinergic
drugs such as antihistamines; (3) their levels are reduced
with use of oral contraceptives, alcohol, barbiturates,
and phenytoin sodium (Dilantin); and (4) they may cause
other drug interactions, including potentiation of the
pressor effects of sympathomimetic agents such as epi-
nephrine and levonordefrin, blockade of the antihy­
pertensive effects of guanethidine, and induction of a
hypertensive crisis if taken with or soon after an MAO
inhibitor (see Table 29-7). Overdosage with a tricyclic
antidepressant can cause death from cardiac arrhythmia
or respiratory failure.2-4
Monoamine Oxidase Inhibitors.  Traditional mono-
amine oxidase (MAO) inhibitors, which are both nonse-
lective and irreversible, were the first effective drugs used
for the treatment of depression. Only two drugs now on
the market are included in the group of MAO inhibitors:
phenelzine (Nardil) and tranylcypromine (Parnate).
These drugs act by inhibiting the two forms of MAO—
type A and type B. Inhibition of type A MAO results in
the antidepressant effects seen with MAO inhibitors.
More than 80% of type A MAO must be bound to serum
proteins before adverse effects can be seen clinically.
Resynthesis of new enzymes takes 10 to 14 days. If a
patient is changing from an MAO inhibitor drug to a
tricyclic drug, 2 weeks or more must elapse after the
MAO inhibitor is stopped and the tricyclic agent is
begun. Significant drug interactions may occur between
MAO inhibitors and opioids and sympathomimetic
amines. MAO inhibitors potentiate the depressant activ-
ity of opioids. They can produce a hypertensive crisis if
combined with specific sympathomimetic amines (see
Table 29-7).4,10,24
Phenylethylamine and phenylephrine must not be
given to patients who are taking MAO inhibitors. MAO
metabolizes these agents, and their use with an MAO
inhibitor could lead to significant potentiation of their
pressor effects (see Chapter 4). These adverse effects are
not seen with epinephrine and levonordefrin. Many
OTC cold remedies contain phenylephrine and should
 CHAPTER 29  Psychiatric Disorders 551

TA B L E 2 9 - 7  Adverse Effects and Drug Interactions of Antidepressant Drugs

Category of
Complications Tetracyclics MAO Inhibitors SSRIs SNRIs
Adverse effects Dry mouth Dry mouth Dry mouth Dry mouth
Nausea and vomiting Nausea and vomiting Nausea and vomiting Nausea and vomiting
Constipation Constipation Diarrhea
Urinary retention Urinary retention Anorexia Constipation
Postural hypotension Drowsiness Weight loss Somnolence
Nervousness Confusion Blurred vision Weight loss/ gain
Insomnia Anorexia Insomnia
Drowsiness Weight gain Nervousness Blurred vision
Sleepiness Tremor Sexual dysfunction Dizziness
Reflux Fatigue Sweating Anorexia
Anorgasmia (women) Insomnia Sedation (paroxetine) Impotence
Erectile problems (men) Anorgasmia (women) Akathisia Loss of libido
Loss of libido Erectile problems (men)
Gynecomastia (men)
Serious adverse effects Mania Mania Mania Mania
Seizures Hypertensive crisis Seizures Hypertension
Obstructive jaundice Orthostatic hypotension Orthostatic hypotension (venlafaxine)
Leukopenia Peripheral edema
Tachycardia Anemia Anemia
Arrhythmias Leukopenia Bleeding (platelet effect)
Myocardial infarction Thrombocytopenia
Stroke Agranulocytosis Hypothyroidism
Drug interactions
Barbiturates CNS depression CNS depression
  Benzodiazepines CNS depression CNS depression CNS depression
  SSRIs Dangerous—do not use Dangerous—do not use Serotonin syndrome
Seizures
  SNRIs Dangerous—do not use Dangerous—do not use Dangerous—do not use
  MAO inhibitors Anticholinergic toxicity Do not use two or more Dangerous—do not use
agents
  Heterocyclics Dangerous—do not use Dangerous—do not use Dangerous—do not use
  Anticonvulsants Interferes with action of Interferes with action of
anticonvulsants anticonvulsants
  Antihistamines CNS depression CNS depression
  Beta blockers Anticholinergic toxicity Sinus bradycardia Bradycardia
  Warfarin Warfarin metabolism Warfarin metabolism
inhibited—can lead to inhibited—can lead to
increased INR values increase in INR values
  Cimetidine Inhibits clearance—can Inhibits clearance—can
lead to toxicity lead to overdosage
  Erythromycin Interferes with action of
the antibiotic
  Opioid analgesics Increase sedative effect
  Vasoconstrictors Actions are enhanced Actions are enhanced
  • Epinephrine Use with caution Use with caution
  • Levonordefrin Best to avoid
  • Phenylephrine Avoid
Interactions involving
foods and beverages
  Tyramine Avoid Hypertension/arrhythmias;
must avoid these agents
  Caffeine Avoid
  Ethanol CNS depression CNS depression
CNS, Central nervous system; INR, International normalized ratio; MAO, Monoamine oxidase; SNRIs, Serotonin-norepinephrine reuptake inhibitors; SSRIs,
Selective serotonin reuptake inhibitors.
552 CHAPTER 29  Psychiatric Disorders
not be prescribed for patients who are taking MAO
inhibitors (see Table 29-7).
Tyramine is a naturally occurring amine that releases
norepinephrine from sympathetic nerve endings. Dietary
tyramine is deaminated by gastrointestinal MAO-A. In
the presence of MAO inhibitors, dietary tyramine is
rapidly absorbed into the circulation, and a hypertensive
crisis may result. Patients taking these agents must there-
fore avoid foods that contain high concentrations of
tyramine. Such foods include aged foods such as cheeses,
red wines, and pickled fish, as well as bananas and
chocolate.4,10,24
Second-Generation Antidepressant Drugs.
Selective Serotonin Reuptake Inhibitors.  The group
of drugs known as selective serotonin reuptake inhibitors
(SSRIs) includes fluoxetine (Prozac), sertraline (Zoloft),
paroxetine (Paxil), escitalopram (Lexapro), and fluvox-
amine (Luvox); these agents now are considered first-line
drugs for the treatment of depression. As a group, these
drugs are just as effective as the tricyclics, but they are
not more effective. These drugs typically are better toler-
ated than the tricyclics. The tricyclics generally are more
lethal in overdose than the newer antidepressants. The
SSRIs are considerably more expensive than the tradi-
tional tricyclic agents. Nausea, which occurs in up to
25% of patients who use these drugs, is the most fre-
quent problem associated with their use. Higher doses
of the SSRIs more often are associated with nervousness
and insomnia (see Table 29-7). Many physicians con-
sider SSRIs to be first-line drugs for the treatment of
depression.2-4,10
Atypical or Nontricyclic Antidepressant Agents.  hypothyroidism, arrhythmia, T wave depression, and
Amoxapine (Asendin), bupropion (Wellbutrin), trazo-
done (Desyrel), maprotiline (Ludiomil), nefazodone
(Serzone), mirtazapine (Remeron), venlafaxine (Effexor),
and duloxetine (Cymbalta) are other nontricyclics that
are used as antidepressants.16 Bupropion has a greater
tendency to produce seizures than the other antidepres-
sants. Nefazodone does not cause sexual adverse effects.
Mirtazapine was one of the first antidepressants to dem-
onstrate a significantly improved toxicity profile after
overdose. However, blood dyscrasias have been reported
with its use. Venlafaxine and duloxetine are drugs that
belong to a newer class of antidepressants—the serotonin-
norepinephrine reuptake inhibitors (see Tables 29-3 and
29-7). Venlafaxine has an adverse effect profile similar
to that for the SSRIs. It also has been reported to increase
blood pressure at higher doses. Duloxetine and SSRIs
have been shown to cause sexual side effects in some
patients, both male and female. Although usually revers-
ible, these sexual side effects can sometimes last for
months, or years, even after the drug has been com-
pletely withdrawn. This disorder is known as post-SSRI
sexual dysfunction.2-4,10 Table 29-3 shows some of the
second-generation antidepressant drugs.
Bipolar Depression Drugs.  There are many more FDA-
approved options for the treatment of mania than for
treatment of bipolar depression.8 The combination agent
OFC (i.e., the atypical antipsychotic olanzapine plus the
antidepressant fluoxetine) is the only FDA-approved
drug for treatment of acute bipolar depression.8 Antide-
pressants, when prescribed alone, are not effective in
bipolar depression. Olanzapine has been associated with
weight gain and hyperglycemia. Dosing of OFC as
Symbyax starts with the 6/25 formulation (olanzapine
6 mg and fluoxetine 25 mg) daily and is adjusted as
needed to the 12/50 formulation (see Table 29-4).8 Other
atypical antipsychotics may serve as potential antide-
pressant agents for management of bipolar depression.8
Mood-Stabilizing Drugs
Lithium.  Lithium has some antidepressant effects, but it
is primarily used for the treatment of patients with
bipolar disorder. Its mode of action is unclear. Lithium
is used to treat acute manic episodes and to prevent
manic episodes in patients with bipolar disorder. It is
effective when used alone in 60% to 80% of patients
with classic bipolar disorder (see Table 29-4). Lithium
should not be used if renal disease is present. Lower
doses must be used in older patients. The dose ranges
from 600 to 3000 mg/day, and full therapeutic effect is
attained in 7 to 10 days. The patient who is on mainte-
nance therapy should be evaluated every 3 to 6 months
for serum levels of lithium, sodium, potassium, creati-
nine, thyroxine (T4), thyroid-stimulating hormone,
and free T4 index. Medical complications associated
with long-term lithium use include nontoxic goiter and
vasopressin-resistant nephrogenic diabetes insipidus. All
of these complications are related to the effects of lithium
on adenylate cyclase activity. Drugs that interact with
lithium include erythromycin and nonsteroidal anti­
inflammatory drugs (NSAIDs), which increase serum
lithium levels, possibly leading to toxicity.3,4,8,13
Carbamazepine.  Carbamazepine, an anticonvulsant
drug, has been successfully used in the treatment of
manic episodes in bipolar patients who do not respond
to lithium or who cannot take lithium because of associ-
ated complications. The dose is 600 to 1600 mg/day.
Adverse effects include nausea, blurred vision, ataxia,
leukopenia, and aplastic anemia.3,4,8,13
Valproic Acid and Divalproex.  Valproic acid is used as
an anticonvulsant and mood-stabilizing drug, primarily
in the treatment of epilepsy and bipolar disorder. It is
marketed under the brand names Depakote, Depakote
ER, Depakene, Depacon, Depakine, and Stavzor. It is
used when lithium cannot be tolerated by the patient.
Starting dosage for valproic acid is 500 mg three times
a day.8 Common side effects are dyspepsia and weight
gain. Less common are fatigue, peripheral edema, acne,
dizziness, drowsiness, hair loss, headaches, nausea,
sedation, and tremors. Rarely, valproic acid can cause
blood dyscrasias, impaired liver function, jaundice, and

thrombocytopenia. Valproic acid should not be used
with the benzodiazepine clonazepam and aspirin, to
avoid adverse effects.8 Divalproex sodium consists of
valproate semisodium, a compound of sodium valproate,
and valproic acid in a 1 : 1 molar relationship in an
enteric-coated tablet form.
Lamotrigine.  Lamotrigine is a anticonvulsant drug used
to treat epilepsy and bipolar disorder. It is marketed as
Lamictal. It is an effective mood stabilizer and is the only
drug approved for this purpose since the FDA approved
lithium about 30 years ago.8 Lamotrigine is approved by
the FDA for the maintance treatment of bipolar disorder
type 1. The starting dosage of lamotrigine ranges from
25 mg to 300 mg daily.8 Common side effects include
headaches, body aches and cramps, hysteria, muscle
aches, abdominal pain, back pain; dizziness and lack of
coordination; acne, rash and skin irritation; sleepiness,
insomnia, vivid dreams or nightmares, night sweats; dry
mouth, mouth ulcers, damage to tooth enamel; fatigue,
memory and cognitive problems; blurred or double
vision; irritability, weight changes, hair loss, changes in
libido, frequent urination, nausea, fever, tremor, appetite
changes, and other side effects. In rare cases, lamotrigine
has been known to cause the dangerous drug eruptions,
Stevens-Johnson syndrome and toxic epidermal necroly-
sis. Drug interactions include those with hormonal
forms of birth control, carbamazepine, divalproex,
oxcarbazepine, phenobarbital, phenytoin, rifampin, and
valproic acid.
Antipsychotic (Neuroleptic) Drugs.  The introduction
of chlorpromazine in the 1950s revolutionized the prac-
tice of psychiatry. Other agents have been introduced
since chlorpromazine, but none represents any real
improvement beyond this prototypical agent.16 The pop-
ularity of these drugs is highlighted by the fact that two
thirds of all prescriptions for antidepressant and antipsy-
chotic (neuroleptic) drugs are written by physicians other
than psychiatrists. Antipsychotic drugs appear to work
by antagonizing the effects of dopamine in the basal
ganglia and limbic portions of the forebrain. Because of
significant adverse reactions associated with their use,
these agents should be used only when they are clearly
the drugs of choice4,24,25
The antipsychotic drugs are categorized as first-
generation (typical) or second-generation (atypical). The
following are examples of typical antipsychotic drugs:
chlorpromazine (Thorazine), thioridazine (Mellaril),
fluphenazine (Prolixin), and haloperidol (Haldol). Clo-
zapine (Clozaril), risperidone (Risperdal), olanzapine
(Zyprexa) and quetiapine (Seroquel) are examples of
atypical antipsychotic drugs.16 In general, the typical
antipsychotic drugs are more likely to cause extrapyra-
midal symptoms of all types. Although the atypical drugs
are much less likely to cause such symptoms, their use is
not without risk for these and other adverse effects.26
Antipsychotic drugs sedate, tranquilize, blunt emo-
tional expression, attenuate aggressive and impulsive
CHAPTER 29  Psychiatric Disorders 553
behavior, and cause disinterest in the environment. They
leave higher intellectual functions intact but ameliorate
the bizarre behavior and thinking of psychotic patients.
All of these drugs have significant anticholinergic adverse
effects and produce dystonias and extrapyramidal symp-
toms. Commonly used antipsychotic drugs are shown in
Table 29-8.4,24,25
Adverse effects of the antipsychotic drugs are numer-
ous and often significant (Table 29-9). Patients become
sedated, lethargic, and drowsy when first placed on these
drugs; however, after several days, tolerance to these
effects emerges. The anticholinergic actions produced by
these drugs include dry mouth, postural hypotension,
constipation, and urinary retention. Other adverse
effects observed are obstructive jaundice, retinal pigmen-
tation, lenticular opacity, skin pigmentation, and male
impotence.3,4,13
The extrapyramidal adverse effects (motor or move-
ment disorders) include acute and chronic conditions.
During the first 5 days of treatment with an anti­psychotic
agent, acute muscular dystonic reactions or a Parkinson-
like syndrome may occur. Akathisia, or extreme motor
restlessness, also may develop early in treatment. Clinical
manifestations consist of involuntary repetitive move-
ments of the lips (lip smacking), the tongue (tongue
thrusting), the extremities, and the trunk. This risk
increases for patients older than 60 years of age and for
those with preexisting CNS disease (70% risk). Many
of the acute extrapyramidal adverse effects are reversible
if the drug is stopped, or if anticholinergic agents are
given.3,4,26
Tardive dyskinesia is the most common late extrapy-
ramidal adverse effect associated with the use of antipsy-
chotic drugs.3,4,26 It usually occurs after antipsychotic
medication has been used for several years. The chief
sign is involuntary movements of the lips, tongue, mouth,
jaw, upper and lower extremities, or trunk. Classic
tardive dyskinesia affects the buccal, lingual, and masti-
catory muscles, leading to “flycatcher’s tongue,” “bon-
bon sign,” grimaces, or chewing movements. Flycatcher’s
tongue refers to darting of the tongue into and out of
the mouth. The bon-bon sign is the pushing of the tongue
against the cheek wall, so that it looks as though a piece
of candy is pressed against the cheek. An early sign of
tardive dyskinesia is wormlike movement of the tongue
within the mouth. Tardive dyskinesia develops in about
20% of schizophrenic patients who receive antipsychot-
ics over a period of years. Patients treated with such
agents will develop tardive dyskinesia at the rate of
about 4% per year. Elderly patients appear to be at much
higher risk for the development of tardive dyskinesia
early in their treatment.23,27,28
Additional adverse effects of the anticholinergic anti-
psychotic drugs include hormone-related changes, pos-
tural hypotension, and photosensitivity (see Table 29-9).
These hormonal changes are primarily the result of the
effect of these drugs on prolactin and may include
 TA B L E 2 9 - 8 Commonly Used Antipsychotic Medications

Class Drug Trade Name Side Effect(s)

Phenothiazine/aliphatic Chlorpromazine Thorazine EPMD
Phenothiazine/piperazine Perphenazine Trilafon EPMD
Fluphenazine Prolixin EPMD
Trifluoperazine Stelazine EPMD
Phenothiazine/piperidine Thioridazine Mellaril EPMD, risk for retinal degeneration
Mesoridazine Serentil EPMD, risk for retinal degeneration
Butyrophenone Haloperidol Haldol EPMD, dysphoria
EPMD, dysphoria
Thioxanthene Chlorprothixene Taractan
Thiothixene Navane
Dibenzoxazepine Loxapine Loxitane
Dihydroindole Molindone Moban Less likely to reduce seizure
threshold
Benzisoxazole Risperidone Risperdal Low incidence of EPMD effects
Dibenzodiazepine Olanzapine Zyprexa Fewer EPMD effects,
agranulocytosis
Clozapine Clozaril Fewer EPMD effects,
agranulocytosis
Diphenylbutylpiperidine Pimozide Orap
Phenylindole Quetiapine Seroquel Low incidence of EPMD effects
Ziprasidone Geodon Low incidence of EPMD effects
Piperazinil/dihydrocarbostyril Aripirazole Abilify Hyperglycemia
EPMD, Extrapyramidal movement disorder.
Data from Schiffer RB: Psychiatric disorders in medical practice. In Goldman L, Ausiello D, editors: Cecil textbook of medicine, ed 23, Philadelphia, 2008, Saunders.

TA B L E 2 9 - 9  Adverse Reactions of Antipsychotic Drugs Based on Type of Neuroreceptor Affected

Neuroreceptor Adverse Effects

Anticholinergic Dry mouth
Urinary hesitancy
Constipation
Urinary retention
Dry eyes
Sexual dysfunction
Blurred vision
Mild tachycardia
Closed angle glaucoma
Impaired memory and confusion
Antiserotonergic Weight gain (antihistaminergic mechanisms also proposed)
Antiadrenergic Dizziness
Postural hypotension (may lead to falls and hip fractures in older patients)
Sexual dysfunction
Antidopaminergic Hyperprolactinemia (causes hypoestrogenemia)
• In men: gynecomastia, impotence, loss of libido, impaired spermatogenesis
• In women: amenorrhea, altered ovarian function, loss of libido, risk for osteoporosis
Extrapyramidal syndromes (least frequent with atypical drugs—olanzapine, quetiapine, risperidone, and
ziprasidone)
Acute dystonia:
• Parkinsonism
• Akathisia
• Tardive dyskinesia
Combination of receptors Neuroleptic malignant syndrome—rigidity, fluctuating consciousness (delirium, stupor), and autonomic
lability (hyperthermia, tachycardia, hypotension or hypertension, sweating, pallor, salivation, and urinary
incontinence)
Other adverse effects Agranulocytosis
Cholestatic jaundice
Seizures
With some agents, increased risk of suicide/suicidal behavior (during induction of drug)
From Wright P, Perahia D: Psychopharmacology. In Wright P, Stern J, Phelan M, editors: Core psychiatry, ed 2, Edinburgh, 2005, Elsevier.
 CHAPTER 29  Psychiatric Disorders 555

galactorrhea, missed menstrual periods, and loss of
libido. Orthostatic hypotension is a potentially serious
adverse effect that is most common with low-potency
agents. Dehydrated patients are at greatest risk for this
complication.3,4,27
Several atypical antipsychotic drugs, including clo­
zapine (Clozaril), risperidone (Risperdal), olanzapine
(Zyprexa), and quetiapine (Seroquel), are available for
the treatment of schizophrenia. Clozapine does not cause
extrapyramidal adverse effects or carry a risk for tardive
dyskinesia. It also can be effective for decreasing the
negative symptoms of schizophrenia. Unfortunately, use
of clozapine is associated with a 1% to 2% incidence of
agranulocytosis. Patients treated with clozapine must be
monitored weekly with complete blood cell counts. Clo-
zapine is effective in some schizophrenic patients who do
not respond to standard antipsychotic drugs. Risperi-
done is a combined serotonin-dopamine antagonist. In
contrast with the standard neuroleptics, which have little
or no effect on the “negative” symptoms, risperidone is
effective for both “negative” and “positive” symptoms
of schizophrenia. All of the atypical antipsychotics have
a lower affinity for binding to D2 dopamine receptors
and a lower risk for extrapyramidal adverse effects.20,26,27
Important drug interactions may occur in patients
who are being treated with antipsychotic drugs (Table
29-10). Antacids can diminish the absorption of neuro-
leptic drugs from the gut. Neuroleptic drugs can decrease
blood levels of warfarin sodium. Neuroleptics and tricy-
clic antidepressants reduce the metabolism of each other,
allowing for increased plasma concentrations of both
drugs. Thioridazine can prevent the metabolism of phe-
nytoin, allowing buildup of toxic blood levels. Smoking
can decrease the blood levels of antipsychotic agents.
When neuroleptic drugs are used with tricyclic antide-
pressants or antiparkinsonian drugs, a powerful anticho-
linergic effect may result. Sympathomimetics such as
epinephrine can result in hpotension when given to
patients taking antipsychotic drugs.3,20,21,27
Malignant neuroleptic syndrome represents a rare but
very serious adverse effect of antipsychotic drugs. This
syndrome combines autonomic dysfunction, extrapyra-
midal dysfunction, and hyperthermia. The patient devel-
ops tachycardia, labile blood pressure, dyspnea, masked
facies, tremors, muscle rigidity, catatonic behavior,
dystonia, and marked elevation in temperature (up to
106° F). The syndrome was first reported in 1960; since
that time, more than 200 cases have been described. It
occurs after neuroleptic drugs are given in therapeutic
doses. Malignant neuroleptic syndrome is most common
in young male adults with mood disorders. Symptoms
continue 5 to 10 days after the drug has been stopped.
Reported mortality rates range from 10% to 20%.
Treatment consists of stopping all neuroleptic medica-
tion, body cooling, rehydration, and treatment with bro-
mocriptine (a dopamine agonist).3,20,21,27

DENTAL MANAGEMENT

TA B L E 2 9 - 1 0 Significant Drug Interactions Medical Considerations

with Antipsychotic (AP) Agents
Interacting Drug/
Drug Class Complication
Alcohol Increases risk of hypotension
and respiratory depression
Anesthetics Increase risk of hypotension
Antiarrhythmics Increase risk of arrhythmias
Anticonvulsants Reduce effects of AP drug
Tricyclic antidepressants The AP drug will increase the
serum level of the tricyclic
agent
Antihypertensives Increase risk of hypotension
Anxiolytics Increase risk of sedation
Increase risk of respiratory
depression
Cimetidine Increases the antipsychotic
effects of the AP drug
Opioids Increase the sedative effects of
the opioids
Increase risk of respiratory
depression
Erythromycin Increases the serum level of the
AP drug, risk of convulsions
Sympathomimetics Increase risk of hypotension
(epinephrine)
Depression.  During a deep depressive episode, signifi-
cant impairment of all personal hygiene, including a total
lack of oral hygiene, is likely. Salivary flow may be
reduced, and patients may report dry mouth, with an
increased rate of dental caries and periodontal disease.
In addition, complaints of glossodynia and various facial
pain syndromes are common.29
Signs of low-grade chronic depression include tired-
ness even after getting enough sleep; difficulty getting up
in the morning; restlessness; loss of interest in family,
work, and sex; inability to make decisions; anger and
resentment; chronic complaining; self-criticism; feelings
of inferiority; and excessive daydreaming. Signs of more
severe depression include excessive crying, change in
sleeping habits, a sense of nausea precipitated by thoughts
of food, weight loss without dieting, strong feelings of
guilt, nightmares, thoughts about suicide, feeling unreal
or in a “fog,” and an inability to concentrate.29
Depressed patients often have poor oral hygiene
because they lack interest in caring for themselves. The
effects of poor oral hygiene may be compounded by
xerostomia, which is an adverse effect of medications
that the patient may be taking. Only small amounts of
epinephrine should be used in local anesthesia, because
556 CHAPTER 29  Psychiatric Disorders
more concentrated forms of epinephrine can cause severe
hypertension when given to patients on antidepressive
drugs. Sedative medication may have to be given in
reduced dosages to avoid overdepression of the CNS. No
medical contraindication to dental treatment during a
depressive episode has been recognized. Most depressed
patients, however, may be best served by addressing only
their immediate dental needs during the depressive
episode. Once the patient has responded to medical
treatment, more complex dental procedures can be per-
formed29 (Box 29-2).
Patients with severe depression must be referred for
medical evaluation and treatment. If the patient is not
responsive to this recommendation, the problem should
BO X 2 9 - 2 Dental Management
Considerations in Patients with Depression, Bipolar Disorder, and Schizophrenia
P Consultation
Patient Evaluation/Risk Assessment (see Box 1-1)
• Evaluate and determine whether psychiatric disorder exists.
• Obtain medical consultation if patient’s condition is poorly con-
trolled, if signs and symptoms point to undiagnosed condition, or
if diagnosis is uncertain.
Potential Issues/Factors of Concern
A in management of the patient’s dental
Allergy No issues.
Analgesics Avoid sedative agents or use in reduced
dosage (see drugs) in patients taking
antidepressant and/or antipsychotic drugs.
Anesthesia The use of epinephrine should be limited in
patients taking antidepressants or
antipsychotic drugs, because hypertensive
reaction (with antidepressants) or
hypotensive reaction (with antipsycotics) can
occur. Limit to two cartridges of 1 : 100,000
epinephrine (also avoid more concentrated
forms of epinephrine in retraction cord or
used to control bleeding).
Antibiotics Not indicated unless acute infection is present.
Anxiety No issues.
B hypothermia may occur. Some psychiatric
Bleeding Thrombocytopenia and leukopenia may occur
as side effects of medications used to treat
these patients. Examine for signs of these
conditions.
Breathing No issues.
Blood pressure Check blood pressure, because hypotension
may occur as result of some medications
(antidepressant and antipsychotic drugs).
C
Cardiovascular No issues.
Chair position Patients taking tricyclic antidepressants or
MAOIs may be prone to postural
hypotension with sudden changes in chair
position. Support patient getting out of the
dental chair.
be shared with a family member and every attempt
made to get the affected person in for medical attention.
During severe depression, suicide is an ever-possible
outcome; however, medical treatment can reduce this
possibility.29
Bipolar Disorder.  From a dental standpoint, lithium,
which is used to manage bipolar disorders, can cause
xerostomia and stomatitis. However, no adverse drug
interactions occur between lithium and other agents used
in dentistry other than NSAIDs and erythromycin, which
can cause lithium toxicity.24
Patients who do not respond to lithium and those who
can no longer take lithium usually are treated with a
phenothiazine type of drug. Phenothiazines can cause
Patient’s physician should be consulted to
confirm medications and the status of
control of the illness. Elective dental
treatment may have to be deferred for
patients with severe symptoms of mania,
depression, or schizophrenia until the
condition is better controlled. Confirm the
need to reduce the dosage of drugs required
problems. If severe xerostomia is found,
request the physician to change medication
if possible. Refer patients found to be
developing chronic extramedullary
movement complications related to
antipsychotic medications.
D
Devices No issues.
Drugs Avoid or, use in reduced dosage, sedatives,
hypnotics, and narcotic agents in patients
taking antidepressants or antipsychotic
drugs. Avoid NSAIDs, tetracycline, and
metronidazole in patients taking lithium,
because lithium toxicity may occur. Also,
diazepam should be avoided, because
drugs may cause xerostomia.
E
Emergencies With patients who are depressed and have
shared thoughts of suicide, a relative and
the patient’s physician should be contacted
immediately.
Equipment No issues.
F
Follow-up Ensure that patient is seeking routine follow-up
for the condition.

bone marrow suppression and fluctuations in blood pres-
sure. The dentist must be aware of these adverse effects
and should examine the patient for signs of thrombocy-
topenia and leukopenia (see Chapters 23 and 24), which
can lead to serious problems with infection and/or exces-
sive bleeding. Phenothiazine drugs potentiate the seda-
tive action of sedative medications, and serious respiratory
depression may result with use of these agents at normal
dosage. Therefore, if these agents must be used, the
dosage must be reduced. The dentist should consult with
the patient’s physician regarding this point. Epinephrine
used in normal amounts in local anesthetic solutions
(1 : 100,000) usually will not produce adverse effects
in patients who are taking phenothiazine-type drugs
(see Box 29-2). The primary effect of epinephrine-
phenothiazine interaction—hypotension—should be a
consideration in management; monitoring of blood pres-
sure is therefore indicated.24,30
Somatoform Disorder.  The characteristics of a somato-
form disorder include the following:
•
No identifiable lesion or pathologic condition can be
found.
• The disorder or reaction has an emotional cause.
• The disorder is not dangerous to the patient.
• The disorder is a defense for the patient in terms of
reducing the level of anxiety.
Reducing anxiety by converting it into a symptom is
called primary gain. Patients also may have secondary
gains as a result of their condition—for example, because
of their symptoms, they may not be able to work, or they
may receive increased attention from their family.
Examples of oral symptoms that can be produced by
somatoform disorders are burning tongue, painful
tongue, numbness of soft tissue, tingling sensations of
oral tissues, and pain in the facial region. The diagnosis
of a somatoform disorder should be made only after the
following criteria have been met: (1) A thorough search
from a clinical standpoint has failed to provide any evi-
dence of a disease process that could explain the symp-
toms; (2) the symptoms have been present long enough
that if they were related to a disease process, a lesion
would have developed; (3) symptom localization does
not reflect known anatomic distribution of nerves; and
(4) underlying systemic conditions that could produce
the symptoms have been ruled out by laboratory tests or
by referral to a physician. Systemic conditions that must
be ruled out are anemia, diabetes, cancer, and a nutri-
tional deficiency (vitamin B complex).19,30
The process of establishing the diagnosis of somato-
form disorders is slow and time-consuming. Dental treat-
ment should not be provided on the basis of a patient’s
symptoms unless a dental cause can be found. Many
patients have undergone needless extractions, root canal
treatments, and other procedures in an attempt to address
somatoform symptoms. Complex dental care should not
be attempted until the somatoform problem has been
CHAPTER 29  Psychiatric Disorders 557
appropriately managed. The diagnosis of a somatoform
disorder should not be reached until a thorough search
has been made over time that fails to uncover pathologic
findings that could explain the symptoms.
After the diagnosis of an oral somatoform disorder
has been established, the following management
approach is recommended: First, the findings should be
discussed with the patient in the presence of a close rela-
tive or spouse. During this discussion, the dentist should
point out that no organic source for the patient’s problem
could be found, that the patient does not have oral
cancer, and that the pain or symptom is real to the
patient. Next, the possibility that feelings of unhappiness
or other distress are the source of the symptoms should
be pointed out; this correlation often will be difficult for
the patient to understand and accept, but it is important
to establish this “groundwork.” Complex or unneces-
sary dental procedures should not be performed, even if
the patient demands them in the belief that this will cause
the symptoms to disappear.
Dentists should pay close attention to their feelings
toward the patient. Symptoms may be viewed only as a
device to gain attention and sympathy, and this may
cause feelings of hostility and anger on the part of the
dentist, which will not enhance proper management of
the patient. The dentist should try to feel empathy
toward the patient and to understand the cause of the
problem and then should react in a positive manner.
An attempt should be made by the dentist to provide
effective management for the patient with a mild somato-
form disorder (mild in the sense that the patient remains
able to function at a reasonable level, the patient’s psy-
choaffective status appears to be stable, and the patient
has shown or expressed no suicidal tendencies). Such
patients should be assured that they do not have a life-
threatening disease such as cancer. A series of regular
short appointments should be scheduled to reexamine
the patient for possible signs of disease, to discuss symp-
toms, and to provide reassurance that tissue changes are
not clinically evident.
Patients with a severe somatoform disorder should be
referred to a psychiatrist; however, once a patient has
been referred, the dentist should be willing to remain
involved. The patient may need to be reexamined and
the psychiatrist consulted regarding the findings. If
patients feel that the dentist only wants to “get rid of
them,” the suggestion of referral will not be helpful or
effective.
Schizophrenia.  Consultation with the patient’s physi-
cian is recommended before dental treatment is started,
to establish the patient’s current status, medications the
patient is taking, and the ability of the patient to give a
valid consent for treatment.31 It is suggested that the
dentist ask the psychiatrist’s opinion regarding the
patient’s medicolegal competence to sign a consent
form.31 Also, the dentist should inquire about the ability
of the patient to perform preventive hygiene procedures.31
558 CHAPTER 29  Psychiatric Disorders
Routine dental treatment of the schizophrenic patient
should not be attempted unless the patient is under
medical management. Even then, these patients may be
difficult to manage. An attendant or family member
should accompany the patient to maximize comfort
and familiarity. Patients should be scheduled for morning
appointments. Preventive dental education is important,
although the importance of good oral hygiene and
appropriate technique is more difficult to convey to
this group of patients. Oral instructions, modeled
demonstrations (hygienist brushes and flosses his or her
own teeth), and descriptive posters showing proper
toothbrushing and flossing techniques can be used to
communicate to the patient what needs to be done and
how.31 For patients who are not able to perform oral
hygiene procedures, or who lack the motivation, a family
member or attendant should be instructed on the proce-
dures. The dentist may use artificial saliva products,
antimicrobial agents (chlorhexidine gluconate), and fluo-
ride mouth products to promote good oral hygiene.31
Patients should be recalled at 3-month intervals for
examination, oral prophylaxis, and application of a fluo-
ride gel or varnish.31
Confrontation and an authoritative attitude on the
part of the dentist should be avoided. If the standard
approach does not allow for proper dental management,
the dentist should consider sedation or tranquilization,
which should be provided in consultation with the
patient’s physician. Chlorpromazine (Thorazine), chloral
hydrate, diazepam (Valium), or oxazepam may be con-
sidered.32,33 Antipsychotic medications may add to or
potentiate the actions of other CNS depressants such as
narcotic analgesics and barbiturates. When these agents
are used, caution must be exercised to avoid excessive
CNS depression, hypotension, orthostatic hypotension,
and respiratory depression. Epinephrine must be used
with caution in patients taking antipsychotic drugs as
severe hypotension may result. The small amount of
epinephrine used in local anesthetics is safe, however
more concentrated forms of the drug should not be used.
Patients who are treated with clozapine can develop
bone marrow suppression; the most recent white blood
cell count should be reviewed before dental treatment is
started.31
Suicidal Patient.  Suicide is one of the leading causes
of death among persons younger than 45 years of age.
It also is far too common in the elderly population. Since
1980, a dramatic increase has occurred in the rate
of suicide in persons 5 to 19 years of age and in persons
65 years or older. In fact, in some countries, the suicide
rate has increased by 60% during the past 45 years.18
Men are three times more successful in their suicide
attempts than women. However, women are 10 times
more likely to attempt suicide. The most common
methods of suicide include hanging, overdose of medica-
tion or poison, carbon monoxide poisoning through car
exhaust systems, jumping from a height (building, cliff),
FIGURE 29-4  In the United States during 2001, about 55% of all
suicides were committed with the use of firearms.
jumping in front of a moving vehicle, and the use of
firearms18 (Figure 29-4).
Physician-assisted suicide occurs when a physician
administers an agent that will end the patient’s life.
The patient has given previous consent for the procedure
and usually has a terminal condition such as advanced
cancer that is not responding to treatment. Only a very
few countries in the world (Belgium, Luxembourg,
Netherlands, and Switzerland) and three states (Oregon,
Washington, and Montana) in the United States have
endorsed this practice.18,34,35
Patients with suicidal symptoms often say that they
feel frustrated, helpless, or hopeless. They frequently are
angry, self-punishing, and harshly self-critical. The
potential for suicide is high among persons who suffer
from any of the following conditions: chronic physical
illness, alcoholism, drug abuse, and depression. Suicide
statistics show that men, adolescents, and elderly persons
are at greatest risk. A history of a previous suicide
attempt greatly increases the risk, as does a history of
recent psychiatric hospitalization. Recent diagnosis of a
serious condition such as cancer or AIDS also may
increase the risk of suicide. The recent loss of a loved
one or recent retirement may increase this risk as well.
Occurrence of any of these events is associated with
increased risk for suicide in people who live alone or
have little or no social support. Patients most likely to
attempt or complete suicide are those who are perturbed,
who state a plan for suicide, and who have the means to
carry it out.18,36
The dentist should ask whether the very depressed
patient has had any thoughts about suicide. Studies have
shown that questions about suicide do not prompt the
act in these patients. Patients who state they have had
these thoughts must be referred for immediate medical
care. If possible, members of the family should get
involved.18,29

Drug Interactions and Adverse Effects
Tricyclic Antidepressants.  Many of the heterocyclic
antidepressants can cause hypotension, orthostatic hypo-
tension, tachycardia, and cardiac arrhythmia. When
sedatives, hypnotics, barbiturates, and narcotics are used
together with the heterocyclic antidepressants, severe
respiratory depression may result. If these agents must
be used, the dosage should be reduced. Atropine should
be used with care in these patients because it may increase
intraocular pressure. Small amounts of epinephrine
(1 : 100,000) can be used in patients who are taking
heterocyclic antidepressants if the dentist aspirates before
injecting and injects the anesthetic slowly. No more than
two cartridges should be injected at any appointment
(see Box 29-2). Other, more concentrated forms of epi-
nephrine must be avoided.9,28,37
Monoamine Oxidase Inhibitors.  Patients who are
taking MAO inhibitors can receive small amounts of
epinephrine in local anesthetics, as described previously.
Other forms of epinephrine (retraction cord, topical for
control of bleeding) are best avoided. Phenylephrine
must not be used in patients who are taking MAO
inhibitors. MAO inhibitors may interact with sedatives,
narcotics, nonnarcotic analgesics, antihistamines, and
atropine to prolong and intensify their effects on the
CNS (see Table 29-7).9,28,37
Antipsychotic Drugs.  Several important drug interac-
tions may occur in patients who are taking neuroleptic
drugs. Extreme care is indicated with use of sedatives,
hypnotics, antihistamines, and opioids in patients who
are taking neuroleptic agents, which will increase the
respiratory depressant effects of these drugs. This poten-
tiation can be dangerous, particularly in patients with
compromised respiratory function. If these types of
drugs must be used, the dosage must be reduced. The
dentist should always consult with the patient’s physi-
cian before using these agents.25,28,37
Epinephrine must be used with great care in patients
who are receiving a neuroleptic drug because a severe
hypotensive episode may result. Small amounts of epi-
nephrine (1 : 100,000) can be used in patients who are
taking neuroleptic drugs if the dentist aspirates before
injecting, injects the anesthetic solution slowly, and, in
general, uses no more than two cartridges. Use of
epinephrine-impregnated retraction cord or as a topi-
cally applied agent for control of bleeding is contraindi-
cated (see Box 29-2).
With older patients who are taking antipsychotic
drugs, several important problems arise in terms of drug
usage. These patients usually have decreased levels of
serum albumin; hence, many of them have a higher per-
centage of the drug in an unbound state. This free drug
increases the risk for toxic reactions. In addition, many
of these patients have marginal liver function; hence,
drugs metabolized by the liver may remain in the circula-
tion for longer periods and in increased concentrations.
CHAPTER 29  Psychiatric Disorders 559
Treatment Planning Considerations
The goals of treatment planning for patients with psy-
chiatric disorders are to maintain oral health, comfort,
and function, and to prevent and control oral disease.
Without an aggressive approach to prevention, many of
these patients will be susceptible to dental caries and
periodontal disease. Susceptibility to such diseases
increases because of the adverse effect of xerostomia,
which is associated with most of these medications, and
the fact that some of the psychiatric conditions for which
these patients are being treated are asociated with
reduced interest in performing or impaired ability to
perform oral hygiene procedures. Also, many of these
patients, consume an improper diet containing foods or
drinks that increase the risk for dental disease.29
The dental treatment plan should contain the follow-
ing elements. Daily oral hygiene procedures must be
identified. The treatment plan must be realistic for the
patient’s psychiatric disorder and physical status. The
plan must be both flexible and dynamic, to take into
account variability in energy level and other uncertain-
ties associated with major depression or bipolar disorder.
During affective episodes, emphasis should be placed on
maintenance and prevention. Complex dental proce-
dures should be performed only when the patient is in a
stable condition in terms of the mood disorder. The treat-
ment plan should minimize any stress associated with the
dental visit. This can best be accomplished through effec-
tive patient management efforts and the use of nonverbal
communication.
The dental team should communicate to the patient
and family members a positive, hopeful attitude toward
maintenance of the patient’s oral health. The dental team
should determine whether the patient is legally able to
make rational decisions. This issue should be discussed
with the patient and a close relative or spouse. Treatment
planning often involves input and permission from a
significant other so that decisions can be made.
The last aspect of the treatment plan deals with selec-
tion of medications to be used in dental treatment.
Certain agents may have to be avoided, and others may
require a reduction in their usual dosage. Medical con-
sultation is suggested to establish the patient’s current
status, confirm medications the patient is taking, identify
possible complications, and confirm dental medications
and doses that will minimize the chance or severity of
drug interactions.
Oral Complications and Manifestations
Antipsychotic drugs may cause agranulocytosis, leuko-
penia, or thrombocytopenia. Oral lesions associated
with these reactions may occur. If the dentist notes
oral lesions, fever, or sore throat in a patient who is
taking antipsychotic drugs, the patient must be evaluated
for possible agranulocytosis. The mood-stabilizing
560 CHAPTER 29  Psychiatric Disorders
FIGURE 29-5  Agranulocytosis. The dentist should be aware that
agranulocytosis may be associated with the drugs used to treat
psychoses. (From Sapp JP, Eversole LR, Wysocki GP: Contemporary
oral and maxillofacial pathology, ed 2, St. Louis, 2004, Mosby.)
drugs—carbamazepine and valproate—also may cause
agranulocytosis, leukopenia, or thrombocytopenia
(Figure 29-5).
Patients who are taking antipsychotic agents may
develop muscular problems (dystonia, dyskinesia, or
tardive dyskinesia) in the oral and facial regions. If the
dentist observes such initial symptoms of dysfunction,
the patient should be referred to the primary care physi-
cian or psychiatrist for evaluation and appropriate
management.25
Patients with psychiatric disorders may engage in
painful self-destructive acts. Acts of orofacial mutilation
such as eye gouging, pushing sharp objects into the ear
canal, lip biting, cheek biting, tongue biting, burning of
oral tissues with the tip of a cigarette, and mucosal injury
with a sharp or blunt object have been reported.
Patients with severe psychiatric disorders may not
have an interest in caring for themselves or the ability to
do so. Hence, oral hygiene is poor, and increased dental
problems develop. Most of the medications used to treat
psychiatric disorders contribute to increased dental
problems in such patients because xerostomia is one of
their primary adverse effects. This unfavorable oral envi-
ronment may create conditions leading to an increased
incidence of smooth-surface caries and candidiasis.
Stiefel and colleagues38 reported on the oral health of
persons with and without chronic mental illness in com-
munity settings. Patients with chronic mental illness were
found to have a significantly greater incidence of dry
mouth, mucosal lesions, and coronal smooth-surface
caries, as well as increased severity of plaque and calcu-
lus buildup.
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