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Behavior Management of Patients with Mental Disorders

Behavior Management of Patients with Mental Disordes in the Dental Setting

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Behavior Management of Patients with Mental Disorders

  1. 1. Tania Herschdörfer AEGD Tania Herschdörfer AEGD Behavior Management of Patients with Mental Disorders in the Dental Setting “The scream” Edvard Munch
  2. 2. Tania Herschdörfer AEGD • Classification systems for Mental Disorders (MD) • Definition • DSM-5 diagnostic criteria • Causes of MD • Statistics and facts of MD • History • Behavior management definition • Important considerations in behavior management of patients with MD • Conclussions Outline “The scream” Edvard Munch
  3. 3. ICD-10 International Classification of Diseases (ICD-11 2018) DSM-5 Diagnostic and Statistical Manual of Mental Disorders CLASSIFICATION SYSTEMS FOR MENTAL DISORDERS WHO (World Health Organization) APA (American Psychiatric Association)
  4. 4. WHO: “Mental disorders comprise a broad range of problems, with different symptoms. However, they are generally characterized by some combination of abnormal thoughts, emotions, behavior and relationships with others. Most of these disorders can be successfully treated”. MENTAL DISORDERS Mental disorders WHO defiintion http://www.who.int/topics/mental_disorders/
  5. 5. DSM-5: "A mental disorder is a syndrome characterized by clinically significant disturbance in an individual's cognition, emotion regulation or behavior that reflects a dysfunction in the psychological, biological or developmental processes underlying mental functioning”. Mental disorder WHO defiintion http://www.who.int/topics/mental_disorders/ MENTAL DISORDERS
  6. 6. DSM-5 DIAGNOSTIC CRITERIA • Neurodevelopmental disorders (Autism, CP, ID) • Schizophrenia spectrum and other psychotic disorders • Bipolar and related disorders • Depressive disorders • Anxiety disorders • Obsesive-compulsive and related disorders • Trauma and stressor related disorders • Feeding and eating disorders • Elimination disorders • Medication-induced movement disorders and other adverse efects of medication Armando Reveron
  7. 7. • Sleep-wake disorders • Sexual disfunctions • Gender dysphoria • Disruptive, impulse control and conduct disorders (intermittent explosive disorder, conduct disorder) • Substance related and addictive disorders • Neurocognitive disorders • Personality disorders • Paraphilic disorders • Other mental disorders • Other conditions that may be a focus of clinical attention DSM-5 DIAGNOSTIC CRITERIA
  8. 8. CAUSES OF MENTAL DISORDERS • Hereditary (genetics) • Biology • Psychological trauma • Environmental stressors http://www.mayoclinic.org/diseases-conditions/mental-illness/basics/causes/con-20033813
  9. 9. CAUSES OF MENTAL DISORDERS • Hereditary (genetics) • More susceptible • Multiple genes involved • Interaction between these genes and other factors (psychologycal trauma and environmental stresors) http://www.mayoclinic.org/diseases-conditions/mental-illness/basics/causes/con-20033813
  10. 10. CAUSES OF MENTAL DISORDERS • Biology • Abnormal balance of neurotransmitters • Messages may not make it through the brain correctly • Defects or injury to certain areas of the brain http://www.mayoclinic.org/diseases-conditions/mental-illness/basics/causes/con-20033813
  11. 11. CAUSES OF MENTAL DISORDERS https://www.bu.edu/cte/about/what-is-cte/
  12. 12. CAUSES OF MENTAL DISORDERS • Psychological trauma (as a child) and environmental stressors • Severe emotional, phyical or sexual abuse • Significant early loss • Neglect • Disfunctional family life • Changing Jobs or schools • Substance abuse http://www.mayoclinic.org/diseases-conditions/mental-illness/basics/causes/con-20033813
  13. 13. STATISTICS AND FACTS OF MENTAL DISORDERS http://www.mayoclinic.org/diseases-conditions/mental-illness/basics/causes/con-20033813
  14. 14. HISTORY A depiction of trephanning from the painting cutting stone (Circa 1494) by Hieronymus Bosch.
  15. 15. HISTORY Cyber Museum of Neurosurgery http://www.neurosurgery.org/cybermuseum/pre20th/treph 5000 B.C. Supernatural phenomena Demonic possession treated with trephanation
  16. 16. HISTORY Cyber Museum of Neurosurgery http://www.neurosurgery.org/cybermuseum/pre20th/treph
  17. 17. HISTORY Ancient Greece • Stigma attached to mental illness • Divine punishment • Locked up or put to die Foerschner, Allison M. “The History of Mental Illness: From ‘Skull Drills’ to ‘Happy Pills’.”(2010). Drake, Robert E., et al. “The History of Community Mental Health Treatment and Rehabilitation for Persons with Severe Mental Illness.” Community mental health journal 39.5 (2003): 427-40. HISTORY
  18. 18. HISTORY Ancient egyptians • Recreational activities Leeman, Eve. “Mental Illness: Learning from the Foibles of Earlier Generations.” The Lancet” 351.9100 (1998): 457. HISTORY
  19. 19. Hippocrates Supersticious Medical “Four essential fluids”; blood, phlegm, bile, and black bile. Imbalances in the body. Phlebotomies, bloodletting, purging, and diets Changing the occupation and/or environment of the patient Leeman, Eve. “Mental Illness: Learning from the Foibles of Earlier Generations.” The Lancet” 351.9100 (1998): 457. HISTORY
  20. 20. Middle Age • Church • Supernatural causes (demonic possession). Dain, Norman, PhD. “The Chronic Mental Patient in 19th-Century America.” Psychiatric Annals 10.9 (1980): 11,15,19,22. HISTORY
  21. 21. Treatment: • Persuade the demon out • Insult the demon. • Torture the possessed so that demon would not want to remain there • Inmersion in hot water or sulphur Dain, Norman, PhD. “The Chronic Mental Patient in 19th-Century America.” Psychiatric Annals 10.9 (1980): 11,15,19,22 HISTORY
  22. 22. • First Mental Hospital: Baghdad (729 BC) • Aleppo and Damascus • Mass establishment of asylums and institutionalization occured much later Leeman, Eve. “Mental Illness: Learning from the Foibles of Earlier Generations.” The Lancet” 351.9100 (1998): 457. HISTORY
  23. 23. Asylums • Not aimed to help the mentally ill • Abandoned or sentenced by the Law • Inhumane treatment • Protect ashamed families and prevent disturbances in the community Leeman, Eve. “Mental Illness: Learning from the Foibles of Earlier Generations.” The Lancet” 351.9100 (1998): 457. HISTORY
  24. 24. • Early XV centhury • Madhouses or asylums HISTORY
  25. 25. La Bicetre (France) HISTORY
  26. 26. • Saint Marie of Bethelem “ Bedlam” (London, England) HISTORY
  27. 27. HISTORY • Wealthy families in the Renaissance HISTORY
  28. 28. Common treatments HISTORY
  29. 29. Reforms • Humanitarian movement • Phillipe Pinel (Paris) 1797 HISTORY
  30. 30. United States (early 1800s) Moral management Mentally ill Spiritual Moral Rehab
  31. 31. • State Psychiatric Hospitals • MHA 1909 • U.S. Community Mental Health Centers Act of 1963 • Improve the lives of the mentally ill in the United States HISTORY
  32. 32. • Increase in Psychoanalysis (Sigmund Freud) HISTORY
  33. 33. • Electroconvulsive therapy • Psychosurgery (1930-1950) • Purpose of lobotomy: calm uncontrollably violent or emotional patients • 25% death rate • Lethargic and immature HISTORY
  34. 34. • “Scale of Mental Retardation “ (in use until 1970s) • Morons, Imbeciles, and Idiots • Lunatics HISTORY
  35. 35. • Lunatics HISTORY
  36. 36. Pharmacology • 1800s (sedatives) • 1949: Lithium • Series of successful anti-psychotic drugs to control sympthoms HISTORY
  37. 37. • Deinstitutionalization • Incapable of living independently • Homeless (inadequeate housing and follow up care) • 1980s: 1/3 of homeless in America were considered severely mentally ill HISTORY
  38. 38. BEHAVIOR MANAGEMENT Process that guides people to change their actions within a specific context. American Academy of Pediatric Dentistry Reference Manual. Clinical Practice Guidelines V 37 / NO 6 15 / 16
  39. 39. BEHAVIOR MANAGEMENT Identifying the negative behavior changing the environment to reduce negative behavior offering positive reinforcement to encourage desired alternatives American Academy of Pediatric Dentistry Reference Manual. Clinical Practice Guidelines V 37 / NO 6 15 / 16
  40. 40. BEHAVIOR MANAGEMENT • Medical • Physical • Psychological • Social • Dental American Academy of Pediatric Dentistry Reference Manual. Clinical Practice Guidelines V 37 / NO 6 15 / 16
  41. 41. BEHAVIOR MANAGEMENT • Psychiatrist • Comprehensive assessment • Psychotropic drugs (interactions, contraindications, clearance) https://sharklearn.nova.edu/webapps/blackboard/execute/content/file?cmd=view&content_id=_4716379_1&course
  42. 42. BEHAVIOR MANAGEMENT • Nonpharmalogical and pharma- logical BGT • Control anxiety • Encourage positive dental attitude, • Perform quality oral health care safely and efficiently for infants, children, adolescents, and persons with special health care needs. American Academy of Pediatric Dentistry Reference Manual. Clinical Practice Guidelines V 37 / NO 6 15 / 16
  43. 43. BEHAVIOR MANAGEMENT • Start with the less stressful procedure (unless emergency) • Talk to parents/caregivers • Consistensy • Positive reinforcement https://sharklearn.nova.edu/webapps/blackboard/execute/content/file?cmd=view&content_id=_4716379_1&course
  44. 44. BEHAVIOR MANAGEMENT • Modeling and shaping • Voice control • One voice • T-S-D • Count to 5 • Breaks https://sharklearn.nova.edu/webapps/blackboard/execute/content/file?cmd=view&content_id=_4716379_1&course
  45. 45. BEHAVIOR MANAGEMENT • Use the least restrictive behavior technique • Patient stabilizers (papoose boards) • Sedation • OR https://sharklearn.nova.edu/webapps/blackboard/execute/content/file?cmd=view&content_id=_4716379_1&course
  46. 46. • Wide range of behavior guidance techniques • Tolerant • Flexible • Anticipate reactions
  47. 47. Most appropiate technique for each patient.
  48. 48. BEHAVIOR MANAGEMENT OF PATIENTS WITH MENTAL DISORDERS • Mental development • Past experiences • Current emotional status and level of understanding • Remain attentive to physical and or emotional indicatorr of stress American Academy of Pediatric Dentistry Reference Manual. Clinical Practice Guidelines V 37 / NO 6 15 / 16 Conversations with Dr. Steven Ellen
  49. 49. BEHAVIOR MANAGEMENT OF PATIENTS WITH MENTAL DISORDERS • Compliance to medication
  50. 50. BEHAVIOR MANAGEMENT OF PATIENTS WITH MENTAL DISORDERS GL (F21) 20 yo at the time of the comprehensive exam Psychiatric diagnosis Schizophrenia (DSM-5: Schizophrenia spectrum and other psychotic disorders) Homestead No transportation
  51. 51. BEHAVIOR MANAGEMENT OF PATIENTS WITH MENTAL DISORDERS
  52. 52. BEHAVIOR MANAGEMENT OF PATIENTS WITH MENTAL DISORDERS Behavior on the maintenance visit
  53. 53. BEHAVIOR MANAGEMENT OF PATIENTS WITH MENTAL DISORDERS Caregivers and environment influences American Academy of Pediatric Dentistry Reference Manual. Clinical Practice Guidelines V 37 / NO 6 15 / 16 Conversations with Dr. Steven Ellen Calkins, Susan D. et al. (2007). Caregiver Influences on Emerging Emotion Regulation: Biological and Environmental Transactions in Early Development. Handbook of emotion regulation , (pp. 229-248). New York, NY, US: Guilford Press, xvii, 654 pp.
  54. 54. Caregivers and environmental influences CH 54 yo white non hispanic female Ex husband and caregiver for comprehensive evaluation Psychiatric history: Depression ( DSM-5 Depressive disorders) Anxiety (DSM-5 Anxiety disorders) BEHAVIOR MANAGEMENT OF PATIENTS WITH MENTAL DISORDERS
  55. 55. Missing teeth Gingiva: edematous and inflamed Fractured #8, multiple arrested and active caries. Patient has been in this Group Home for the last 4 years. Caregiver was unaware of the existence of a lower RPD. Caregivers and environmental influences
  56. 56. Cancer screen not conclussive/ Lower RPD Bleeding, heavy calculus, tissue overgrowth about 30 mm extending in the lingual surfaces on the anterior área. Caregivers and environmental influences
  57. 57. • Profound mental disabilities • Wheel chair, G tube, deaf, blind
  58. 58. BEHAVIOR MANAGEMENT OF PATIENTS WITH MENTAL DISORDERS Psychiatric history Organic delusional disorder Psychosis Autism
  59. 59. BEHAVIOR MANAGEMENT OF PATIENTS WITH MENTAL DISORDERSImportance of detailed notes DC (M 28) Psyciatric history Autism (DSM-5: Neurodevelopmental disorder) Impaired vision and speech Breaks, negotiation Document it!
  60. 60. FROM OUR PERSPECTIVE… • Negotiation
  61. 61. • Evaluation FROM OUR PERSPECTIVE…
  62. 62. FROM OUR PERSPECTIVE… • Negotiation
  63. 63. Solution FROM OUR PERSPECTIVE…
  64. 64. FROM OUR PERSPECTIVE… • There is always a way!
  65. 65. FROM OUR PERSPECTIVE…• It is about much more than the oral cavity…
  66. 66. FROM OUR PERSPECTIVE… • Environment, parents and caregivers
  67. 67. BEHAVIOR MANAGEMENT • Early preventive care American Academy of Pediatric Dentistry Reference Manual. Clinical Practice Guidelines V 37 / NO 6 15 / 16 Conversations with Dr. Steven Ellen at SNC NSU 2017. Calkins, Susan D. et al. (2007). Caregiver Influences on Emerging Emotion Regulation: Biological and Environmental Transactions in Early Development. Handbook of emotion regulation , (pp. 229-248). New York, NY, US: Guilford Press, xvii, 654 pp.
  68. 68. http://www.mentalhealthamerica.net/about-us
  69. 69. #breakthestigma NSU College of Psychiatric and Neurologic Pharmacists (CPNP)

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