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Psychiatrie Disorders in
Dental Practice
M. David Enoch FRCPsych, DPM
Emeritus Consultant Psychiatrist
Royal Liverpool University Hospital
Past Senior Clinical Lecturer
University of Liverpool
Honorary Visiting Consultant Psychiatrist
Cardiff Dental Hospital

Robert G. Jagger BDS, MScD, FDSRCS

Senior Lecturer and Honorary Consultant in Prosthetic Dentistry
Dental School
University of Wales College of Medicine

With a Foreword by
R. M. Green BDS, PhD
Professor of Conservative Dentistry,
University of Wales College of Medicine

WRIGHT
Wright
An imprint of Butterworth-Heinemann Ltd
Linacre House, Jordan Hill, Oxford OX2 8DP

A member of the Reed Elsevier pic group

OXFORD LONDON BOSTON

MUNICH NEW DELHI SINGAPORE SYDNEY
TOKYO TORONTO WELLINGTON

First published 1994

© Butterworth-Heinemann Ltd 1994
All rights reserved. No part of this publication
may be reproduced in any material form (including
photocopying or storing in any medium by electronic
means and whether or not transiently or incidentally
to some other use of this publication) without the
written permission of the copyright holder except in
accordance with the provisions of the Copyright,
Designs and Patents Act 1988 or under the terms of a
licence issued by the Copyright Licensing Agency Ltd,
90 Tottenham Court Road, London, England W1P 9HE.
Applications for the copyright holder's written permission
to reproduce any part of this publication should be addressed
to the publishers

British Library Cataloguing in Publication Data

A catalogue record for this book is
available from the British Library.

ISBN 0 7236 1006 1

Library of Congress Cataloguing in Publication Data

A catalogue record for this book is
available from the Library of Congress.

Typeset by P&R Typesetters Ltd, Salisbury, Wiltshire

Printed and bound in Great Britain by Biddies Ltd, Guildford, and King's Lynn
Foreword

The origins of Dentistry have ensured that it has a firm base in

tangible physical conditions and in technically precise means of
treating them. It is only quite recently that Behavioural Science
has been included in the undergraduate curriculum with the
intention of producing dentists who are better prepared to look at
their patients as whole human beings. Dentists have needed to be
encouraged to recognize that the occurence of dental caries and
periodontal disease is influenced by psychological and social
factors as well as the physical conditions in the patient's mouth.
Similarly facial pain and temporomandibular joint dysfunction
were for many years regarded as purely mechanical problems.
Treatment frequently involved extensive surgery or restorative
dental care but the lack of awareness of the psychological/
psychiatric components of the problem led to very variable
results being achieved.
A number of texts have been published in the last ten years
dealing with the relationships of Psychology and Sociology to
Dentistry but there have not been comparable texts associating
Psychiatry and Dentistry, the authors have attempted to fill this
niche with the current volume. They are to be congratulated on
addressing the difficult task of concisely outlining the range of
psychiatric conditions from which individuals may suffer and
clearly demonstrating how some of these can present as
orofacially related conditions.

R. M. Green
Professor of Conservative Dentistry
University of Wales College of Medicine
In memory of Joyce
Preface

We are aware of the need for dental students and practising

dentists to know the significance of psychological disturbances
and disorders in dental practice. This book services such a need.
In Section A of the book the scene is set. An outline of
psychiatric disorders is given and the resources available to treat
the variety of disorders is described.
Section Β describes the psychiatric syndromes. It provides an
up-to-date, detailed yet condensed description in a form which is
not readily available for dentists in other texts. Section Β is of
great importance in giving a clear description of the psychiatric
illnesses that the dentist will inevitably see in his patients in
clinical practice. It must be emphasized that in gaining insight it
will make management easier and more effective and also help to
inform the dentist when to refer to a clinical psychologist or
psychiatrist; to refer early is to avoid unnecessary suffering for
both patient and clinician.
In Section C, the psychiatric conditions particularly relevant to
the dentist are discussed in detail. Dental phobias, facial pain and
facial deformity are considered in separate chapters because of
their importance to dentists. The reader may well turn to Section
C before Section Β to get an idea of the nature of these conditions
and will gain a great deal of understanding merely by reading
these chapters. For greater depth of understanding, however, it is
necessary to refer to Section B. Sections Β and C are very much
complementary to one another.
The final section of the book describes treatment methods and
looks forward to the future, hoping that there will be increased
understanding of the nature of psychiatric disorders by dentists
and better liaison, when necessary, between dentists and
psychiatrists and clinical psychologists.

M. David Enoch
Robert G. Jagger
Acknowledgements

We are indebted to all those who have given encouragement and

advice in the preparation of this book. Professor Derek Stafford,
Head of the Department of Prosthetic Dentistry at the Dental
School, Cardiff, has encouraged us by his constant interest and
support. Dr Sujata Unnithan and Professor Richard Green have
been particularly helpful in suggesting important refinements to
the text. Mrs Shelagh Thompson, Dr Mike Lewis, Professor
Malcolm Jones and Dr Joseph Marbach have been helpful in
commenting on specific sections of the book. One of us (MDE)
thanks colleagues at the Liverpool Dental Hospital and School
especially Mr Lawrence Finch and Ms Eileen Theil. We appreciate
the diligence and patience of Mrs Lynda Hartles who typed the
several drafts and Mrs Gwen Allison for additional secretarial
assistance. We thank Mary Seager of Butterworth-Heinemann for
her enthusiastic encouragement. RGJ thanks Daryll for her
tolerance and understanding during the preparation of the book.
Chapter 1

Psychiatry in dental practice

Preclinical and clinical dental students have long been taught

medicine and surgery. However psychological illnesses have
usually been given scant attention. The recent mandatory
introduction of the behavioural sciences into the dental curricu-
lum has remedied this and caused us to address some important
problems long ignored.
The aim of this book is to give an outline of the major
psychiatric disorders and diseases while highlighting those
conditions of particular importance to the practising dentist.
Oral disorders that are usually associated with psychiatric
disorders and disturbances, or which have a significant
psychological component, are also described.
Most dentists appear to have little understanding of the
nature or scope of psychiatric disorders and disturbances. As
a result they may feel ill at ease at having to understand and
manage disturbed behaviour in patients and find it difficult
to recognize the presence of psychopathology or assess its
significance. Although dentists might have the view that
some patients' problems are 'all in the mind', they are poorly
equipped to communicate the nature of the problem with
medical practitioners or psychiatrists. The psychiatrists remain
distant to the dentist and the nature of their work is poorly
understood. They are sometimes perceived as having more
serious problems to deal with than those relatively mild
problems of some dental patients with psychiatric disorders;
there is in some instances justification for this view. Apart from a
few notable exceptions, liaison between dentists and psychiatrists
is poor.
There are several other important reasons why dentists should
be aware of the nature of psychological medicine:

1 Psychological disorders are very common and do not just

affect an odd few people. In fact, vast numbers are affected in
the UK in the course of a year. According to the Mental Health
Foundation (1990):
• Around six million people suffer from mental illness
4 Psychiatrie disorders in dental practice

• One in 12 of the population receives psychiatric treatment

of some kind
• One in 22 of the population suffers from depressive illness
• One in 100 of the population suffers from schizophrenia
during his/her lifetime
• Around one million people are alcoholics
• No-one is immune from mental illness and no family is
exempt.
Therefore it is inevitable that many patients attending for
routine dental treatment will be suffering from and presenting
with signs and symptoms of a psychological illness.
2 Psychological disorders may produce many problems relating
to dental treatment. Poor motivation may lead to lack of
compliance or unreliable attendance. Phobic patients, for
example, are notoriously bad at keeping dental appointments
and may often cancel at the last minute. Such behaviour is a
source of frustration and sometimes bewilderment, resent-
ment and hostility to clinicians, apart from being a waste of
time and a strain on limited NHS resources.
3 Many psychiatric disorders which commonly occur, such as
anxiety and depression, are often accompanied by oral
symptoms such as facial pain or preoccupation with
dentures. Unusually, oral symptoms are the only manifesta-
tion of the psychiatric disorder. These problems are discussed
in detail in Section C.
4 Many drugs used in the treatment of psychological disease
have important side-effects which cause symptoms related to
the mouth.

The information in this book should lead to improved early

recognition of psychological illness by the dental surgeon. Such
recognition leads to accurate assessment and diagnosis which is
the first step to correct management and treatment. Knowledge of
behaviour problems associated with psychological illnesses
enables the dentist to prepare treatment plans with realistic
goals and to tailor the treatment plan to the patients' needs.
Recognition of physical symptoms associated with psychological
illnesses helps to avoid inappropriate investigations and un-
necessary treatments that are a waste of time and a source of
frustration and resentment for clinicians.
Clearly, not all patients identified or suspected by the dentist as
having a psychiatric disturbance or disorder will need to be
 Psychiatry in dental practice 5

referred. For the majority of dentists working in dental

practice the psychological component seen in their patients
will be associated with underlying personality disorders or
neuroses. The supportive psychotherapy or counselling this
requires can in large part be provided by the dentist himself,
especially with the additional knowledge which such a book
as this supplies. The reader is particularly encouraged to
take note of the description of supportive psychotherapy in
Section D. This treatment is a form of counselling and is certainly
practised knowingly or unknowingly by most dentists when
dealing with anxious or 'difficult' patients. If the dentist
establishes a working relationship with professional detach-
ment, yet with an understanding warmth, patients will respond
by being more relaxed and open to management and treatment,
whatever their initial problems or fears. Some patients, for
example those with severe dental phobias, may require additional
treatment that may also be provided by the dental surgeon, such
as relaxation therapy, hypnosis, antianxiety drugs or relative
analgesia.
There is, however, a boundary beyond which referral becomes
essential because the dentist does not have the necessary expertise
to treat the patient; the dentist must be able to recognize the
patients who require such referral to a psychiatrist or clinical
psychologist. The information in this book will aid recognition of
those disorders and enable the dentist to communicate more
effectively with colleagues. If, as is usual, the patient remains
under the care of the dentist for dental treatment, supportive
psychotherapy by the dentist remains an important component of
the overall dental management.
A few dental centres in the UK have established liaison
psychiatry within their clinical practice. This implies close contact
of dentist with psychiatrist and is regarded as being superior to
mere referral, which entails loss of contact. An increased
awareness of the massive psychopathology within dental
practice and dental hospitals should encourage an increase in
liaison psychiatry.
In summary, it is hoped that this book will:

1 Aid the dentist to recognize psychological factors and

psychological illness in his patients
2 Enable the dentist to prepare dental treatment plans with
more realistic goals for affected patients
3 Provide a wider understanding of orofacial manifestation of
psychiatric disorders
6 Psychiatrie disorders in dental practice
4 Emphasize that the majority of patients with psychological
illness may be treated successfully within general dental
practice with the appropriate knowledge and insight while
there are also patients who require referral for specialist help
from psychiatrist and clinical psychologist
5 Illustrate the advantages of liaison psychiatry in relation to
dentistry
6 Indicate the urgent need for further research into the nature of
orofacial manifestations of psychiatric disease
7 Prove the need for a team approach to the management of
dental patients, of which the preparation of this book is a
practical example.

Reference
Mental Health Foundation (1990) Mental Illness: Fundamental Facts, Mental Health
Foundation, London.
Chapter 2

Outline of psychiatry

Definition of mental illness or disorders

To produce a clear definition of mental illness is surprisingly
difficult, as with other commonly used terms such as health,
normality and disease. In everyday speech the word 'illness' is
loosely used and in psychiatric practice the terms 'mental illness'
and 'mental disorders' are also used with little precision. Not
even the Mental Health Act of 1983, the most important
legislation dealing with the mentally ill, defines mental illness.
An obvious way of tackling the subject would be to examine
the concept in general medicine and to look for any worthwhile
analogies with mental illness. In the former an important
distinction is made between disease and illness; disease referring
to objective physical pathology and illness to subjective aware-
ness of distress or limitation of function. A person can have a
disease without being ill, as with a benign tumour, or one can be
ill without having a disease, as with the loss of a limb by trauma.
However, this distinction bears little relevance to psychiatric
disorders since the vast majority have no demonstrable physical
pathology. Thus, most psychiatric disorders are best regarded as
illnesses.
Continuing the analogy with general medicine, mental illness
may be regarded as having three ingredients: absence of health,
presence of suffering and pathological process (physical and/or
psychological). The difficulty of this definition is that, as already
stated, health is even more difficult to define. Some patients may
not experience suffering; for example those suffering from mania
have no demonstrable physical pathology or gross structural
pathology, whereas there are genetic and biochemical grounds for
supposing that schizophrenia and depressive disorders may have
a physical basis.
The psychiatrist more crucially has to make sense of the wide-
ranging phenomena related to disturbed or distorted thinking,
feeling and behaviour encountered, so that he/she can manage to
treat them rationally and improve the outcome. To this end the
psychiatrist has realized that the best way of doing so is to
8 Psychiatrie disorders in dental practice

commence with presenting basic data, that is the symptoms and

signs, and to group them into syndromes, that is a constellation of
symptoms occurring frequently together and having implications
for treatment and prognosis.

Classification of psychological disorders

Mental handicaps (now known as learning difficulties) are
usually separated from mental illness and will not be dealt with
in this book. Mental illness can be divided into the following
groups:

1 Neuroses
2 Personality disorders
3 Psychoses
4 Others (deviant behaviours).

Neuroses are regarded as 'breakdowns', the milder form of mental

and emotional disorders, although the symptoms can be quite
disabling to a patient's life. Neurotics have insight and are in
touch with reality. For example, phobic states are a neurotic
illness where a person will have a fear of a specific object but will
know that it is nonsensical.

Personality disorders are those conditions in which various traits

which may be present in normal persons come to dominate and
colour the whole personality. For example, in obsessional
personality disorder the obsessional part dominates the condi-
tions. Personality disorders resemble neuroses in that the persons
have insight and are in touch with reality. On the other hand,
psychopathic personalities, the most extreme of the personality
disorders, are aggressive, impulsive, show no guilt and fail to
learn from their past mistakes.

Psychoses, on the other hand, are what the layman terms insanity
or madness in which the patients suffer from severe symptoms
such as delusions or hallucinations. Such patients lack insight and
are divorced from reality. Personality and behaviour are more
severely damaged than in the neuroses. The main differences
between neuroses and psychoses are detailed in Table 2.1.

Other disorders are largely deviant behaviours and include

alcoholism and addiction, which are increasingly seen in clinical
practice and are described in Chapter 4.
 Outline of psychiatry 9

Table 2.1 Characteristics of neurosis and psychosis

Neurosis Psychosis
'Breakdowns' Madness, insanities
Has insight Partial or no insight
In touch with reality Divorced from reality
Little deviation from normal personality Radical change of personality
Thinking usually coherent Thinking disordered (though it can be
in a limited sphere)
Behaviour grossly deviant
Feelings persistently severely disturbed

Subclassifications of the neuroses, psychoses and personality

disorders are described in detail in Chapter 3. It is particularly
important for the dentist to be aware of the existence and nature
of the neuroses and personality disorders because they are
conditions which commonly occur and, inevitably, dentists will
meet them in patients. In being aware of their presence the dentist
will be in a better position to decide on appropriate treatment
plans. Though the dentist will have far less contact with
psychotics, knowledge of the types of psychoses will, again, be
of assistance in dealing with them more effectively, if necessary.
In discussing the classification of psychiatric disorders, mention
must be made of two major international classifications, namely
The Diagnostic and Statistical Manual of Mental Disorders, 3rd
Revision, DSM-III-R of the American Psychiatric Association
(1987) and the very recently updated International Classification of
Diseases ICD10 (World Health Organization, 1993). A simplified
classification of mental disorders based on these classifications,
which illustrates the diversity of mental illness, is given in
Appendix 1.

Demography (Mental Health Foundation, 1990)

Contrary to public conception, psychological medicine does not

embrace merely small, homogeneous groups of people. In fact,
psychological illness constitutes a vast problem. In the UK, about
six million people suffer from mental illness during the course of
a year; this represents one in ten of the population. Even this
figure is an underestimate of the true prevalence, for it is based on
the number of people identified by general medical practitioners
as suffering from mental illness according to the official
International Classification of Diseases mentioned above.
10 Psychiatrie disorders in dental practice

Mental illness is to be found largely in the adult population.

More women (55%) than men are victims. Of those affected the
great majority (4-5 million people) are in the 50-64 age range
within the working population. A further 1-2 million are over the
age of 65. In addition, 300 000 children under the age of 15 suffer
from mental illness.
Mental illness ranks alongside heart and circulatory disease as
one of the nation's biggest health problems: before 1989 it was
estimated that there were more than six million sufferers of each
of these diseases. By comparison, cancer affects two million,
mental handicap one million and AIDS can be counted in
thousands, although this number is increasing.
Mental illness is not regarded as a killer in the same way as
heart disease and cancer. Yet, in addition to the massive extent of
suffering caused by mental illness, it does result in the death of
substantial numbers of people. It is estimated that some 20 000
people die each year as a result of mental illness, including 4500
suicides, 1800 as a result of alcohol and drug misuse and 13 500
from causes attributable to chronic mental disorders of the
elderly. Thus, mental illness annually kills four times as many
people as die in road accidents (5300).
It was estimated that of all mentally ill patients visiting their
general medical practitioners in 1989, 3-6 million (60%) suffered
from neurotic conditions - mainly depression and anxiety states.
A further 1-9 million (33%) had behavioural or acute stress
disorders and 410 000 (7%) were suffering from psychotic illness.
Whilst severe mental illness is difficult to estimate it can be seen
that in 1989 4 % of the population, that is 2-3 million people,
suffered from major depressive illness. At least 410000 suffered
from a psychotic illness and a million more individuals were
severely affected by acute anxiety, stress disorders and addictive
disorders such as alcohol and drug misuse. Therefore, severe
major mental illness may well affect a minimum of four
million people every year. These statistics and the vast numbers
involved in the general population makes it inevitable that a
dentist will treat a significant number of patients with
psychological illness.

Psychiatric resources
Psychiatric resources to deal with the vast and various problems
of the mentally ill comprise personnel and material.
 Outline of psychiatry 11

Personnel

Personnel include psychiatrists, psychiatric nurses, psychiatric

social workers and clinical psychologists; these act more
effectively as a team. The patient has direct access to each
individual member of the team, and especially to the psychiatrist,
who specifically in the case of a compulsorily detained patient
under the Mental Health Act (1983) becomes the responsible
medical officer with special duties and responsibilities towards
the patient. The psychiatrist is usually the leader of the team. It is
therefore essential that any patient referred to the psychiatrist
knows that he of she is being referred to a physician.
A psychiatrist is a qualified medical doctor who undertakes
further training in the speciality of psychological medicine
(psychiatry). After basic training in psychiatry usually he/she
sits an examination for membership of the Royal College of
Psychiatrists and after further supervised work at a higher level
applies for the post of consultant psychiatrist. Again, it must be
stressed that the psychiatrist is first and foremost a medical
doctor - a physician with a basic medical qualification and a
further higher qualification in psychological medicine.
Psychiatric nurses are those men and women who have trained
and gained appropriate qualification as nurses in this field of
managing and caring for men and women suffering from
psychiatric disorders. Some have also qualified as general nurses
in the medical/surgical field and they are said to be 'doubly'
qualified. Increasing numbers of these nurses now work
exclusively or for a greater part of their time in the community
and are known as community psychiatric nurses. They usually
undertake additional training in community psychiatric nursing
and an additional qualification after about a year's training. They
work closely with patients and their families in their homes or in
institutions within the community.
Psychiatric social workers also play a considerable role in
psychiatry. To be able to fulfil all their duties in the field,
including statutory duties, they must become 'approved' social
workers. This means that they must have additional expert
training and experience in the field of psychological medicine. In
addition to having expert knowledge about welfare rights,
practical aids and community facilities, they have practical
powers and duties under the Mental Health Act (1983) and
other legislation. Though the vast majority of psychiatric social
workers are employed by and are the responsibility of the
Director of Social Services of that area or district, they may be
12 Psychiatrie disorders in dental practice

based in local authority offices as well as in psychiatric units or

hospital.
Clinical psychologists have a degree in psychology, following
which they undergo a further 2 or 3 years of clinical psychology
training. Some also do some research and gain a higher
qualification such as a PhD and then are able to use the prefix
'doctor' as a title. This, together with the emphasis on clinical
psychology, can be confusing to patients who may wrongly
believe that clinical psychologists are medical doctors. Initially,
clinical psychologists assessed mental states (especially intelli-
gence) and devised personality and IQ tests for patients. Recently,
they have become involved more in management and treatment,
especially of certain kinds of conditions such as neuroses, using
specific treatments such as behaviour therapy. They are restricted
to the use of psychological methods of management treatment
and may not prescribe drugs or other physical treatments such as
electroconvulsive therapy or any medical procedures. Dentists
should be aware of this important distinction, and if any medical
treatment needs to be given or continued it is essential that
patients are referred to the psychiatrist. However, if measures
such as relaxation therapy or hypnosis are needed the patients
could be appropriately referred to the clinical psychologist.
Discussion of the team would not be complete without the
mention of occupational therapists who play a very important
part in the management of many of these patients, especially
long-standing patients who need a great deal of rehabilitation.
Occupational therapists have developed expert techniques in
assessing the chances of rehabilitation, and apply them in the
occupational and industrial spheres, helping people to return to
full employment.
It is important that dentists know of the existence of the local
mental illness team, the point of contact and who to refer patients
to for various kinds of illnesses or disorders. It is useful to create a
working relationship with specific personnel so that quick, clear
advice can be given when necessary. Sometimes, the need for
such advice is urgent whilst at other times the need is for a more
long-term commitment of support, especially to such patients as
chronic schizophrenics and the mentally handicapped.

Material, sites and settings

The main inpatient facility for the mentally ill is still the unit
within the district general hospital, although many of the large
mental institutions still exist, albeit in a reduced state. The
 Outline of psychiatry 13
inpatient facility is required from time to time for all kinds of the
mentally ill. It is certainly needed in the case of acute psychotic
episodes and sometimes for disturbed neurotics, as well as
personality disorders. Sometimes, the patient may be referred to
day hospitals or units for assessment and then for daily
attendance at these units.
Outpatient facilities involve regular outpatients and both new
and long-stay patients. There are usually general adult outpatient
clinics as well as special clinics held, for example, for addicts and
those with psychosexual problems. The emergence of community
psychiatric nurses, facilities in the community, outpatient and day
hospitals and day centres reflects the change in emphasis that has
occurred in the last thirty years in the UK where community
psychiatry has played an increasingly important part.
In addition to the facilities mentioned, there is increasing
liaison between psychiatrists and general medical practitioners.
The general practitioners will have their own psychiatric staff and
psychiatrists may visit health centres or surgeries regularly to see
patients or to discuss cases with the general practitioners. Dentists
may refer patients for psychiatric advice and assessment direct to
psychiatrists or to certain other members of the psychiatric team
when appropriate, or they may refer them via their general
practitioners. Again, if an acute problem arises in a patient who is
being treated for some time then it is possible to call for assistance
from a community psychiatric nurse or psychiatric social worker.
One of the dangers of the new emphasis on community care is
that there are groups of people within the community who are
not in touch with any of the Mental Health or Social Services.
These people will fall through the net of community care with
resulting deterioration in physical and mental state.

References
American Psychiatric Association (1987) Diagnostic and Statistical Manual of Mental
Disorders, 3rd edn (revised), American Psychiatric Association, Washington DC.
Mental Health Foundation (1990) Mental Illness: Fundamental Facts, Mental Health
Foundation, London.
World Health Organization (1993) International Classification of Diseases ICD, 10th
revision. World Health Organization, Geneva.
Chapter 3

Psychiatric disorders

A classification of psychiatric disorders is given in Chapter 2.

Three important categories of psychiatric syndrome are recog-
nized, namely neuroses, personality disorders and psychoses.
These disorders are discussed in detail in this chapter.
It is important to distinguish neuroses and personality
disorders from the other major category of mental disorders,
the psychoses. These latter conditions are those recognized by the
layman as insanity or madness. In contradistinction to the
neuroses and personality disorders, persons with psychoses lack
insight and are divorced from reality. They hold false beliefs
impervious to reason which are termed delusions. They may also
have other severe symptoms such as hallucinations where they
will hear 'voices' which do not exist or see 'visions' which have no
basis in reality.

NEUROSES
Neuroses or psychoneuroses are minor mental disorders in which
the patients suffer or complain of unpleasant symptoms, during
the course of which they retain contact with reality and have
insight. For example, they may say they have a fear that prevents
them leaving the house, yet they know it is absurd. The neuroses,
as shown earlier, occur commonly and a great number of people
suffer from various neuroses to a varying degree. Though they
are regarded as minor mental disorders, often labelled Ijreak-
downs' or 'nervous illnesses' they are, nevertheless, in their most
severe state very crippling and the cause of a great deal of
suffering. Because those who suffer from neuroses appear and
look quite normal it is difficult for people to understand how
much they do suffer. To tell them to 'pull themselves together' is
most inappropriate.

Morbid anxiety
Anxiety is a universal emotion. It is an unpleasant feeling or
affect, an experience of unease, or of fearful anticipation. There is
18 Psychiatrie disorders in dental practice

Table 3.1 Types of anxiety

Normal

Morbid
Generalized (anxiety neurosis)
Intensive/episodic (panic attacks)
Focal anxiety (phobic states)
Obsessional neurosis ^
Hysterical neurosis I Morbid anxiety
Neurotic depression neurosis | 'transferred'
Mixed neurosis )
Minor stress disorders
Post-traumatic stress disorders

acknowledged normal anxiety which can be used for good effect.

For example, a mother's anxiety regarding a child's safety will
cause her to warn the child that a fire can burn and harm.
However, if this so-called normal anxiety becomes excessive it
can have a negative or ill effect on a person and his or her
behaviour. Such an anxiety is termed morbid anxiety; this morbid
anxiety underlies neurotic states. There are several types of
morbid anxiety neurosis (Table 3.1).
Morbid anxiety is a predominant feature of the anxiety
neuroses. The anxiety is excessive and experienced as a free-
floating, undirected emotional state, (the cause of which the
victim is unable to explain) in an otherwise mentally normal
individual. Intense episodic anxiety is known as panic attacks.
During these, actual physical symptoms predominate, accompa-
nied by fear of a serious consequence such as a heart attack.
Where the intense anxiety is focused on a specific item, e.g. an
object such as spiders, or situations such as open spaces, it is
termed phobic anxiety disorder. Thus, phobic anxiety disorders
have the same core symptoms as generalized anxiety disorders,
but these symptoms only occur under particular circumstances.
Morbid anxiety also underlines other neurotic states such as
obsessional neurosis, hysterical neurosis and depressive neurosis,
but the morbid anxiety is 'transferred' into characteristic
symptoms which give these neuroses their names.

Anxiety neurosis
In generalized anxiety neurosis there is an undirected or
misdirected free-floating anxiety which is inappropriate or out
of proportion in intensity and severity or duration to the stimulus.
 Psychiatrie disorders 19

When this results from some specific identifiable danger it is

called fear rather than anxiety. Significantly, anxiety and
depression can be differentiated but there is much overlap of
the two emotions. This is seen most clearly in a mixed anxiety-
depressive state and often in neurotic depression, where a large
element of anxiety is often present. Again, anxiety and irritability
can be differentiated though they too often coexist.
Anxiety neurosis comprises both physical and psychological
symptomology. These can be mixed though one can predominate
in a specific patient. The psychological symptoms consist of a core
generalized free-floating anxiety, a feeling of unease, undirected
with no known cause or accompanied by restless concern and
anticipatory fear. Associated with this central anxiety are other
psychological symptoms such as inability to concentrate,
sensitivity to noise and general restlessness. As these symptoms
persist, lack of concentration worsens and the patients feel that
they are losing their memory. As a result of this the patients will
begin to believe and perhaps say that they are going out of their
minds and often add that no-one understands how they feel.
Physical symptoms and signs of anxiety neuroses are in the
main the result of an arousal of the autonomic nervous system. As
a result of such arousal patients complain of palpitation, dry
mouths, panting, shortness of breath, pallor, cold extremities,
gastric and intestinal discomfort, churning, choking, tightness in
the throat and trembling.
Often, patients worry excessively about their physical state,
believing that they have some severe physical condition; hence
the need for a medical opinion in order to be able to effectively
reassure them. Often sleep is disturbed. They suffer from initial
insomnia and find it difficult to go off to sleep. Appetite is poor
and there is often accompanying weight loss. Sometimes the
psychological and physical symptoms occur together, but not
necessarily so. Sometimes the general anxiety is prominent with
little somatic manifestation.
Behaviour can be affected to a significant degree. The patients
may not be able to perform at work, college or school to their
usual standards so their work suffers, adding further fuel to the
fire and making them more anxious. Some young people, at this
point, tend to 'run away' from the situation and stay away from
school or college.
Anxiety states can also be assessed according to the time factor.
Acute anxiety states come on quickly, are quite severe and of
short duration, while chronic anxiety states are persistent and
long standing. Sometimes an acute on chronic state may occur
20 Psychiatrie disorders in dental practice

when an exacerbation of anxiety symptoms occurs in the chronic

state.

Panic disorders
Panic disorders are forms of anxiety states which have been
recognized for over a century but are only now being given a
classification of their own. They are essentially discrete episodes
of anxiety, sudden in onset, in which physical symptoms
predominate and are accompanied by fear of serious conse-
quences such as heart attacks. As they respond effectively to drug
therapy they are usually treated by psychiatrists or other doctors.
Special forms of psychotherapy also help to reduce the intensity
and frequency of attacks.

Phobic anxiety disorders

Phobic anxiety disorders have the same core symptoms as
generalized anxiety states but they occur only in particular
circumstances. In some the circumstances are rare, in others
frequent. Two other features characterize the condition: the
person avoids circumstances which provoke anxiety and he or
she experiences anticipatory anxiety when there is a possibility of
encountering such circumstances.
Anxiety phobic states are provoked by objects such as spiders,
situations such as crowded spaces or natural phenomena such as
thunder. They are usually a continuation of childhood phobia.
It is usual to recognize three principle phobic states: simple,
social and agoraphobia. Simple phobias are usually fear of objects
such as needles and/or situations such as visits to the dentist.
Social phobias occur when inappropriate anxiety results from
situations in which the person is observed or could be criticized.
The individual, therefore, avoids going into such groups and
avoids conversation or speaking in public. The third form of
phobic anxiety disorders is agoraphobic, where people are
anxious when they are away from their home or in crowds or
situations from which they cannot escape easily. Agoraphobia
occurs in the early or mid twenties, though there is a further
period of high onset in the mid thirties. The onset of agoraphobia
tends to be at a later age than the average onset of simple phobias
and social phobias. Typically the first episode occurs while the
individual is waiting for public transport or shopping in a
crowded store. Suddenly, he or she becomes extremely anxious
and fearful of fainting and experiences palpitation. There is no
 Psychiatrie disorders 21

obvious reason for the acute anxiety. The person rushes away
from the place and either goes home or to the doctor's surgery or
a hospital where there is rapid recovery. On returning to a similar
situation or place, there is increased tension and anxiety again,
and recurrence of the somatic symptoms. As the fear of
recurrence grows then the individual becomes more dependent
on members of the family; there is a tendency to isolate, requiring
others to carry out tasks.

Obsessional neurosis
Underlying the obsessional anxiety neurosis is a morbid anxiety
which cannot be controlled. The outstanding feature is a feeling of
subjective compulsion - which the victim feels must be resisted -
to carry out some action, or to dwell on a specific thought or idea
or to recall an experience and ruminate over it. The intruding
thoughts and the ruminations are perceived by the victim as
unwanted, inappropriate and nonsensical. The obsessional urge
or idea is recognized as alien to the personality but as coming
from within the self. The obsessional actions may be quasiritual
performances designed to relieve the anxiety. For example, the
victim may wash his hands 200 times a day to deal with apparent
contamination. If he or she touches anything in the course of this
ritual then the washing must start again. Thus, it is extremely
time-consuming and a cause of great tension within the person,
preventing the completion of daily tasks appropriately and in
time.
Attempts to dispel unwelcome thoughts or urges lead to severe
inner struggles as well as increasing tension and anxiety, until the
victim usually 'gives in' and allows the thought to intrude, or
reverts to repetition of the action. With this, relief is gained but
only temporarily and soon the urge begins to build up again with
the associated tension.
Clinically, there is obsessional thinking and compulsive
behaviour associated with various degrees of tension, anxiety,
depression and depersonalization. Obsessional thoughts consist
of single words or phrases or rhymes, usually unpleasant or
shocking to the victim. Obsessional imagery is vivid, imagined
scenes often of a violent or disgusting kind involving, for
example, sexual practice or violent acts. Obsessional ruminations
are internal diatribes in which arguments for and against see the
simplest everyday actions reviewed endlessly. Obsessional
doubts concern actions that may not have been completed
adequately, such as turning off gas taps, or securing doors;
22 Psychiatrie disorders in dental practice

others may consider actions that have harmed other people or

might in the future harm somebody like a child. Sometimes
doubts are related to religious convictions and observances,
obsessional impulses or urges to perform acts usually of a violent
or embarrassing nature, for example leaping in front of a car,
injuring a child or shouting blasphemies in church. Obsessional
rituals include both mental activities, such as counting repeatedly
in a special way, repeating certain formal words or repeating
senseless behaviours such as needlessly washing the hands. Some
have understandable connections with obsessional thoughts that
precede them, for example repeated washing following some-
thing dirty. Other rituals have no such connection, for example
routines with laying out of clothes in a complicated or set pattern
before dressing and in a certain specific order. Some patients are
compelled to repeat such actions a certain number of times in a
distinct form and if something goes amiss they have to start the
whole sequence all over again.
Patients have insight and do realize that their rituals are
illogical and hence try to hide them. Some fear that these
obsessional symptoms are a sign that they are going mad and are
greatly helped by the reassurance that it is not so and that their
odd behaviour is understandable. Obsessional personality and
obsessional neurosis disorders do not have a simple one-to-one
relationship. The fact is that some obsessional personalities do
develop obsessional personality disorders, but others develop
depressive illnesses. Two-thirds improve spontaneously within a
year; some cases last more than 1 year, usually taking a
fluctuating course with periods of partial or complete remission
lasting for months or several years. These cases may be
exceedingly persistent and cause a great deal of suffering for
the person and especially a partner and any children. It really can
cause tremendous tensions within families and relationships,
though there is no evidence that there are any greater break-ups
amongst such marriages than in the average family.

Hysterical neurosis
Hysterical neurosis is an important clinical problem and is thus
discussed here in depth. It is a disorder characterized by either
mental dissociation leading to psychological manifestations such
as amnesia and multiple personality, or more frequently by a
conversion to somatic symptoms such as convulsions, paralysis
and sensory disturbances occurring in the absence of organic
disease of the nervous system and employed for some kind of
 Psychiatrie disorders 23

secondary gain. The basic psychological mechanism present in

hysterical states are unconscious conflicts, although these are often
difficult to determine.
Hysterical symptoms (conversion or dissociative symptoms)
can occur in association with several other psychiatric disorders
such as anxiety states, depressive illness or organic states.
Although conversion or dissociative symptoms are not produced
deliberately they often represent ideas the patients have
concerning illness they might have seen in others, or which they
themselves have suffered from previously. The reproduction of
such symptoms will be more accurate in people with special
knowledge, such as nurses and doctors. However, there are
obvious discrepancies between the signs of hysterical disorders
and those of organic disease. For example, the pattern of
anaesthesia produced by a patient suffering from conversion
disorder may not correspond to anatomical innervation of the
part.

Conversion symptoms
An example of this hysterical state is a young trombonist who
suddenly developed difficulty in using her mouth to produce the
right sound because of difficulties in her personal life. It was only
after the unconscious conflicts had been resolved that the specific
difficulty of opening her mouth and using it appropriately
returned to normal.
These conversion symptoms may be encountered in dental
practice. It has been emphasized that the face, mouth and teeth
are closely linked with the emotions. Disturbance of emotion can,
therefore, clearly be converted into physical symptoms related to
these parts of the body. Dental intervention such as extractions,
fillings and other procedures of this kind can cause stress to
patients, which leads to both physical and psychological sequelae,
the latter taking the form of conversion symptoms. An example of
such symptoms is a hyperaesthesia which may be felt after dental
intervention and would be described as painful and burning.
Though it is often said that extravagant descriptions support a
hysterical or psychogenic origin for such symptoms, this is not a
safe diagnostic point because patients with histrionic personalities
may describe symptoms of organic disease in equally florid terms.
Diagnosis of psychogenic pain (described in Chapter 7) can
only be made after a thorough search and exclusion of organic
causes. The condition known as globus hystericus, when a patient
has difficulty in swallowing or a persistent feeling of a lump at
24 Psychiatrie disorders in dental practice

the level of the upper oesophageal stricture, has often been

classified as hysterical. However, cineradiology has shown that
there is frequently abnormality in the oesophageal mechanisms
involving swallowing. Such conditions emphasize the need for a
thorough knowledge and understanding of both the physical and
psychological mechanisms involved.

Dissociative disorders
Dissociative disorders confine mainly to psychological manifesta-
tions such as amnesia and multiple personalities. Patients may
present with certain fears which are so intense that they will have
an accompanying psychogenic amnesia. As a result they will not
be able to give any history themselves or only a partial history
and, therefore, are difficult to treat. It is again important to note
that a proportion of those patients who present in this way have
concurrent organic disease, especially epilepsy, multiple sclerosis
or the effects of head injury.
An extreme example of the dissociative state is the multiple
personality, where there are sudden alterations between two
patterns of behaviour in a person, each of which is forgotten by
the patient when the other is present. Each 'personality' is a
complex and integrated scheme of emotional responses, mem-
ories, attitudes and behaviour; the new one usually contra-
striking with the patient's normal state. Fiction in the form of Dr
Jekyll and Mr Hyde is an excellent example of this phenomenon.

Physical disease and hysterical elaboration

Physical disease may provide a non-specific stimulus to hysterical
elaboration of symptoms by a patient of histrionic personality.
The psychiatrist must guard against confusing dissociative and
conversion disorders with extravagant behaviour of a histrionic
or hysterical personality. People under stress who are anxious
and fearful with this kind of personality or, indeed, an anxious
personality often display exaggerated emotions and tend to react
in a demonstrative way that attracts attention and demands their
own way. This is a reaction which is common to all kinds of
physical symptoms that they might suffer. Such over-reaction to
organic disease can often be mistaken for the wholly psycholo-
gical hysterical disorder or dissociative or conversion disorders.
Exaggeration of physical symptoms is frequently termed
'hysterical overlay' or 'functional overlay'. In managing these
cases it is essential to get an independent history and to note
whether there has been any past history of exaggerated
 Psychiatrie disorders 25

behaviour. It is important to note also whether there is any

significant stress present in the life of the individual. Secondary
gain may be the main underlying motive for the presentation and
sustaining of the symptoms. Age is important in considering this
diagnosis since conversion or dissociative disorders seldom
appear for the first time after age 40.
It is also important to realize that often these hysterical
symptoms may be the result of both conscious and unconscious
mechanisms. If it is purely conscious and deliberate then the term
malingering is most appropriate. However, very often there is a
mixture of both conscious and unconscious motivation and in this
case the primary diagnosis would be one of hysteria or
dissociative disorder.
The prognosis among dissociative and conversion disorders
varies. Those of recent onset seen in hospital emergency
departments and general practice recover quickly in the main.
However, those that last over a year are likely to persist for a long
time. About a third of the patients in a neurological hospital
diagnosed as having hysteria developed definite organic illness
within 7 to 11 years; a further third developed depression or
schizophrenia (Slater and Glithero, 1965).

Neurotic depression
The mild kind of depressive illness is often termed neurotic
depression or reactive depression. It has as its central feature a
depressive mood which is mild in degree, worse in the evenings.
Often there is an associated marked anxiety, irritability and an
inability to relax. Agitation ranges from mild plucking of fingers
and restless movements of legs to more severe states of being
unable to sit for long, and pacing up and down. The patient often
reacts adversely to environmental or emotional stress and is
reluctant to deal with major problems. He or she loses interest in
activities or hobbies normally enjoyed and feels no zest for living
and no pleasure in everyday things which used to give pleasure.
The patient tends to withdraw from social encounters. There is
general reduction in energy and instead feelings of lethargy so
that everything is an effort; thus, tasks remain unfinished. The
patient maintains partial insight but is not able to explain fully the
lack of energy and zest.

Mixed neurotic state

It must be emphasized that the neurotic states described here are
rarely met with in pure form. For example, anxiety and
26 Psychiatrie disorders in dental practice

depressive symptoms may coexist. If one is predominant the

appropriate label is given, for example if depression is the more
prominent it is labelled neurotic depression with anxiety.

Minor stress reactions

Acute reactions
Stress can cause various kinds of psychological and physical
symptoms which are not severe or prolonged enough to justify
referral to a psychiatrist. However, they are met commonly in
general practice. Goldberg and Huxley (1990) studied 88 patients
from a general practice in Philadelphia and found that complaints
of anxiety and worry were most frequent but that despondency
and sadness were almost as common. Somatic symptoms were
also present in half the cases and excessive concern with bodily
function in about a quarter. These somatic symptoms are
autonomic features of anxiety but the patients were preoccupied
with the bodily sensations. This may have been due to their belief
that they would receive more sympathetic treatment than if they
presented with an emotional complaint. Again, they may have
felt concern for their physical health and needed examination and
reassurance. Often, these patients do have symptoms related to
the mouth and teeth, hence dentists will see them frequently. The
fact that they tend to have persistent early morning wakings
suggests that the condition may be in the early stages of an
endogenous depressive disorder. This means that in addition to
reassurance regarding their dental conditions it is essential for
them to be under the care of a physician and receive
antidepressant medication. These patients also often complain
of obsessional thoughts and mild compulsions and hence are
difficult to manage and treat. They often complain of poor
appetite and nausea and difficulty in swallowing. It is essential
that all the physical symptoms are thoroughly investigated but if
these are found to have a psychological basis they will need
psychological treatment.

More prolonged minor stress reactions

More prolonged stress reactions can occur. It is known that the
amount of stress is largely dependent on the amount of change
which is produced in our lives. Holmes and Rahe (1967)
developed the social readjustment rating scale, by which stress
in life could be measured in life change units (LCU): the death of
 Psychiatrie disorders 27

one's husband, wife or child was assigned 100 LCU; marital

separation rated 75 LCU; marriage 5 LCU; beginning a new child
39 LCU; obtaining a house mortgage and losing it 30 LCU. It is
possible with the use of such a scale to measure the recent
changes in a patient's life and to add up how many of these LCU
have been acquired in the previous 6 or 12 months. Then one may
predict the likelihood of illness affecting the patient during the
subsequent 12 months. Certainly as a result of these changes,
transient disorders of varying severity can occur in people with
no previous history of mental disorders. These stress reactions are
mild, last longer than the acute reaction yet are transient. They
occur in people without past history of mental disorder.
Symptoms are varied with a combination of worry, anxiety,
depression, poor concentration, irritability and short temper.
These last only a few months and are usually reversible. They
relate in time and quantity to the stimulating event. Treatment
consists of brief psychotherapy or counselling designed to help
the patient face the changing situation.

Post-traumatic stress disorder

Post-traumatic stress disorder is a recently introduced diagnosis.
The disorder is quite common yet often unrecognized and leads
to significant morbidity or mortality. The term denotes an intense
and usually prolonged reaction to intense stress caused by natural
catastrophes, such as earthquakes, floods and fires, man-made
disasters, the effects of war or personal assault or injuries such as
muggings, rapes, and road traffic accidents. Symptoms typically
include vivid flashbacks, nightmares, episodes of tense anxiety
and sweating. Initially these symptoms are severe and frequent.
Usually they subside but may persist for many years in lesser
form.
Drug therapy in the form of an antidepressant such as
amitriptyline, together with behavioural psychotherapy, is the
most effective treatment.

PERSONALITY DISORDERS
Personality disorders are the second major group differentiated in
the classification of mental disorders. It is undoubtedly the most
unsatisfactory grouping, occupying as it does an uneasy position
in the classification system, being vaguely defined and diagnosed
by medical clinicians only with reluctance. However, the
28 Psychiatrie disorders in dental practice

practising clinician cannot escape them because several surveys

(Hare, 1983; Kosten, 1982) reveal that between a third and a half
of the psychiatric population are likely to meet the current criteria
for personality disorder. Further, their difficult, if not disruptive,
behaviour makes management of any accompanying clinical
condition, either physical or psychological, additionally difficult.
The extreme subtype, i.e. those with psychopathic or sociopathic
personality disorders in particular, are associated with aggressive
if not violent behaviour. Thus, the recognition of such a condition
is of help in deciding on the form of management and is
important because of the disruptive potential.
The classification of personality disorders embraces two
approaches: firstly, descriptive using terms such as 'dependent'
or 'aggressive' and secondly, both descriptive and aetiological
referring to resembled mental disorder syndromes. For example,
obsessive-compulsive personality disorders have much in
common with obsessive-compulsive neuroses.
The six commonest personality disorders will be described in
detail. The first three - obsessive-compulsive, histrionic and
affective - resemble mental disorder syndromes and the neurotic
conditions already described. The second three have descriptive
labels - schizoid, paranoid and antisocial (psychopathic).

Obsessive-compulsive personality disorder

Earlier in this chapter were discussed the main features of the
obsessive-compulsive neurosis, which is closely related to
obsessive-compulsive personality disorder. People with obses-
sional personality may well develop depressive illness rather than
obsessive-compulsive neurosis.
The normal personality may have so-called obsessional traits,
namely dependability, preciseness, punctuality, high standards
and a tendency to keep to the rules. In obsessive-compulsive
personality disorder, these features, which make up for a 'strong'
personality, are met with to an extreme degree, and lead to
rigidity and inflexibility. As a result the individuals become tense
and uptight in the face of change and their stifling perfectionism
is a source of delay in their work. A high standard leads to
exaggerated concentration on details and moral standards. Hence
they are often preoccupied with guilt over minor misdemeanours.
They tend to lose their sense of humour and be ill at ease with
innocent foibles. They become indecisive and delay completing
tasks because of a fear of making mistakes. Such personalities are
sensitive to criticism and show undue concern how other people
 Psychiatrie disorders 29

view them and their behaviour. Superficially, they appear firmly

in control but underneath often experience a smouldering
resentment and anger as a result of believing that other people
have failed them or interfere unnecessarily. Many obsessional
people experience sexual difficulties and often have a great deal
of guilt about possessing sexual thoughts and fantasies. The
obsessional personality can be very difficult to treat.

Histrionic personality disorder (hysterical, psycho-infantile

personality)
In many ways this diagnosis is synonymous with that of
immature personality, being characterized by affectedness,
dependence upon others, craving for appreciation and attention,
suggestibility and theatricality. Much hysterical symptomology is
reminiscent of childish behaviour and most adults are capable of
behaving in a regressive fashion if they are sufficiently frustrated.
In a normal personality, minor histrionic traits can be socially
advantageous, for such people can be lively and engaging
company and do well in amateur dramatics.
Hysterical individuals display a great deal of emotion but this
is usually superficial and inconsistent. Typically, these people
cannot form deep and lasting relationships with others. They are
fond of proclaiming their undying affections until they are put to
the test and then there is often a rapid retreat from the emotional
commitment. They demand a great deal of attention and affection
from others and, in the absence of such a reaction, will stir the
feelings of everyone else for their own satisfaction. Individual
methods for gaining such notice will vary from constant
badgering to sulks and tantrums to threatened suicide attempts
(which are dangerous sometimes and can be fatal though are
probably not intended to be so). Their proclivity for manipulating
others, including the professional who might be treating them,
can be quite marked. Under stress, frank hysterical symptoms
(neuroses) may well develop and they will convert their
difficulties into physical symptoms as was described under
hysterical neuroses. In more severe cases the hysterical person-
ality disorder may shade into other forms or more serious
psychiatric maladies such as psychopathy and into various forms
of antisocial behaviour such as pathological lying (pseuodologica
fantastica) and confidence tricks.
In histrionic personality disorder there is often sexual
provocation combined with frigidity. They engage in spates of
affection and are flirtatious, but they are often incapable of deep
30 Psychiatrie disorders in dental practice

feelings. Their immature response and exaggerated reactions can

complicate matters considerably; hence the need to be aware of
the existence of such personalities.

Affective personality disorder (cyclothymic, depressive person-

ality)
The depressive personality disorders are comparatively common.
At times a good deal of anxiety is admixed with the depression.
Crises are poorly coped with; there is a tendency to retreat from
any sort of difficulty, thereby preventing the individual needing
to make a decision or take some form of relevant action.
It is important when seeing someone with what appears to be a
depressive personality disorder not to miss a true depressive
illness. Some relatively mild depressive conditions may be very
chronic and last for several weeks on end, so that after a time the
patient and his or her family come to accept the depression as the
normal mood state. Some of these cases respond well to
antidepressant medication. However, if hypochondriacal com-
plaints are frequent, some of these chronically depressed
individuals are indefatigable swallowers of patent medicines
and seek after-treatment constantly. With some of these persons it
is important to recognize their basic personality disorder and
remember that it may be safer to allow them to keep their
depression and their constant grumbling because it is their only
adequate defence against life's everyday problems. It is also
particularly important not to intervene by carrying out multiple
physical treatments.

Schizoid personality
In this personality disorder there is a withdrawal from affection,
social and other contacts and autistic preference for fantasy and
introspective reserve. They may be slightly eccentric or avoid
competitive situations. Apparent coolness and detachment may
mask an incapacity to express feelings. The schizoid personality is
often found in the relatives of schizophrenics and may occur in
some schizophrenics prior to the actual onset of their illness.
The schizoid individuals are shy and aloof and often with-
drawn into a world of their own, tending to prefer their own
company. They are ill at ease socially and often appear to be
rather humourless and oversensitive to criticisms, tending to
brood on slights and to magnify their significance. At times, the
social behaviour reaches the point of eccentricity and they may be
 Psychiatrie disorders 31

regarded as cranks or fanatics. We can probably recognize

amongst our acquaintances some who fulfil a number of these
criteria but, it must be remembered that the great majority of shy
and sensitive people are not psychologically disturbed. It is
important to encourage schizoid individuals to attend for the
necessary dental treatment as it decreases their isolation and
helps them gain social skills to mix with others.

Paranoid personality disorder

Paranoid personality disorder often has some features in common
with schizoid personality disorders. These individuals may
believe that people dislike them because of some feature of their
appearance, or because they belong to a minority group, or
because they are cleverer than other people. In all cases there is an
excessive self-reference.
Other individuals with this disorder become chronic hypo-
chondriacs, convinced that they have some serious disease, and
go from one specialist to another, never believing a negative
result and ignoring the obvious fact that a potentially fatal illness
(of which they have complained for so long) would have killed
them long ago. One must be sympathetic with these individuals if
they are ill and have trouble. The clinician must be very careful to
carry out the necessary examination and investigations. But, it is
essential not to be persuaded to side with these persons in their
unfounded complaints and allow them to dictate. It is useless in
most cases to try to argue sense into them, though their
grievances are obviously unfounded. If a patient proves
unusually obstructive or difficult it is advisable for the clinician
to consult with a psychiatrist colleague regarding the diagnosis of
the case, otherwise one may find oneself involved in some
extremely tangled situations of the patient's making, and this can
go on interminably.

Psychopathic personality disorder

The personality disorders described so far are fairly readily
acceptable as illnesses, especially in their extreme forms when the
patient is often tense and unhappy and unable to enjoy normal
social relationships. On the other hand the psychopathic
personality disorder is a condition in which the individuals
usually appear to suffer little from their abnormality but certainly
make other people suffer as a result of their conduct. The
psychopathic personality disorder is often referred to as antisocial
32 Psychiatrie disorders in dental practice

personality; sufferers are often actively antisocial and are

sometimes called sociopaths because of their strong tendency to
clash with society. It is the psychopath, in particular, who tends to
make psychiatrists dismiss these personality disorders from their
area of responsibility. However, there is also little doubt that the
psychopath does show evidence of psychological disturbance and
considerable social disruption leading to legal involvement.
Persons with this disorder show a bewildering variety of
abnormal features, antisocial actions, lack of guilt and failure to
learn from past adverse experiences. Indeed, in the extreme form
the person may inflict cruel, painful and degrading acts on others.
This lack of feeling is often in striking contrast to a superficial
charm enabling the individual to make quick, shallow and
passing relationships. Sexual activity is carried on without
evidence of tender feeling. Marriage is often stormy, with a
great deal of aggression and violence, both verbal and physical,
followed by periods of excessive wooing. There are consistent and
constant episodes of compulsive behaviour which are often
aggressive in nature, towards both loved ones and casual
acquaintances. There is an inability to keep contracts, hence, the
break-up of marriages and dismissal from places of work. They
demand treatment and yet will not keep appointments; they
complain aggressively about various aspects of treatments.
This kind of behaviour starts in adolescence if not in childhood
with delinquency, lies and vandalism. Behaviour is accentuated
by the effects of alcohol or drugs and is not readily modified by
experience, even punishment. Tolerance to frustration is nil and
these individuals blame others or offer plausible rationalizations
for their continued antisocial behaviour, which brings them into
conflict with society. They also tend to be poor attenders, and
exhibit aggressive behaviour if they are frustrated in any way,
while at other times they might appear superficially charming.
It is clear that the clinician must be on guard against the
antisocial behaviour of such personalities. Certainly, all staff must
be protected against any such physically aggressive behaviour.
To be aware of this psychopathic personality is to be forewarned.

PSYCHOSES
Psychosis refers to a more severe form of mental illness in which
there is lack of insight and the patient is divorced from reality.
They are subdivided into: firstly, functional psychoses such as the
mood (affective) psychoses (i.e. mania, depression, manic-
 Psychiatrie disorders 33

depressive psychoses), and schizophrenia and allied states; and

secondly, organic psychoses such as acute and chronic illnesses.
Chronic progressive organic illness is termed dementia.

Functional psychoses
Affective (mood) psychoses
Psychotic depression (endogenous depression)
Severe depressive illness, (endogenous depression or psychotic
depression) is fundamentally different from neurotic depression.
The latter has been dealt with in detail earlier with the neuroses.
Endogenous depression has the essential symptom of a central
depressive mood with diurnal variation, i.e. being worse in the
mornings and improving as the day goes on. There are associated
biological symptoms such as sleep disturbance. Typically, the
patients have early morning waking when they wake regularly at
2 or 3 a.m. and usually cannot go back to sleep. There may well be
loss of appetite, loss of weight, constipation and loss of libido.
When the patients get up in the morning they feel unrefreshed
and believe that the tasks of the day ahead of them are a great
burden. They look and think about the coming day with
pessimism and ponder gloomily about their future. In addition,
they may have feelings of self-guilt and brood about past failures.
It should be noted that some depressive patients, however, sleep
excessively but still wake unrefreshed.
Usually, weight loss is prominent and is greater than that
which can be accounted for merely by the patients' loss of
appetite. Sometimes, patients will eat excessively and gain weight
and the eating brings some temporary relief. Ideas of suicide may
be present. Often there are additional symptoms of anger and
irritability, as well as an inability to concentrate and to carry out
their work properly. Relationships with members of their family
or their fellow employees at work also suffer.
Complaints about physical symptoms are common in depres-
sive disorders. These take many forms and any system of the
body may be implicated. If there is any pain or discomfort
already present, for example in the mouth or teeth, then these
patients will experience an exacerbation and amplification of pain
related to these areas; it is well known that chronic facial pain
may be due to a depressive illness and responds to antidepres-
sants. Complaints about any pre-existing physical disorder or
34 Psychiatrie disorders in dental practice

symptom usually increase and hypochondrial preoccupations are

common.
Other psychological symptoms may occur as part of a
depressive disorder, and occasionally one of them comes to
dominate the clinical picture. These include depersonalization,
obsessional symptoms, phobias and hysterical symptoms - such
as loss of sensation or function in some part of the body. Patients
may often complain of poor memory; this is often the result of
poor concentration. If the patient is encouraged to make a special
effort they can usually recall facts which may be essential to make
a full assessment of the case. However, in a case of severe
endogenous depression it may well be that the loss of permanent
memory is so severe that the clinical presentation resembles that
of dementia.
In very severe depressive illness, delusions and hallucinations
occur; these are usually of the same kind and themes as the non-
delusional thinking of the more moderate depressive disorders.
These themes include worthlessness, guilt, ill-health and moral
impoverty. The patients may be preoccupied with some minor
misdemeanour in the past and hold the belief and feeling so
firmly that it can be regarded as a delusion of guilt. Patients with
hypochondriacal delusions may be convinced that they have
cancer of the mouth or some parasitic disease. Patients with
delusions of impoverishment may believe that they have lost all
their money in business failure. Delusions of persecution may
also occur where patients believe that people are discussing them
in a derogatory way or want to harm them, but believe that they
are worthy of such accusations and judgement and even
punishment.
In severe depressive illnesses perceptual disturbances may also
occur and are usually of the auditory type and take the form of
voices addressing repetitive words and phrases to the patient.
The voices seem to concentrate on the ideas of worthlessness or to
make derisive comments. A few patients do experience visual
hallucinations, sometimes in the forms of scenes of destruction or
death.
The term agitated depression is often used in clinical medicine
and is applied to depressive disorders in which agitation is
prominent. However, it more commonly occurs among middle-
aged and elderly patients and there is no reason to suppose that it
differs in any essential ways from other depressive disorders.
Retarded depression is the name applied to depressive
disorders in which psychomotor retardation is especially
prominent. It is a descriptive term and its most severe form
 Psychiatrie disorders 35

shades into depressive stupor. There is no evidence that this

condition is a separate depressive illness.

Mania
The central feature of the syndrome of mania is an elevation of
mood associated with increased activity and disinhibition. The
mood is elevated above the normal high spirits when things are
going well or in response to some happy event. It is characterized
by feelings of exhilaration or even exaltation, even if there is no
adequate reason for it. In the more severe cases the mood tends to
be further elevated by positive reinforcement such as social
stimulation. Though these individuals may appear very euphoric
superficially, any rebuff may cause them to become angry.
Irritability is a common feature and this may be intermingled
with transient depressional mood.
The content of thought reflects this elevation of mood with
increased self esteem, marked subjective feelings of well-being
and of great personal power. These may at first be fleeting and
held only half seriously but later develop into complete delusions.
There may be delusions of special ability: of being great healers,
or writers; some delusions of grandeur of identity such as relation
to royalty or some great leader; delusions of wealth, having
untold riches, owning lands; or delusions of special missions of
being on earth for a grandiose purpose to end wars. In addition,
these patients may develop non-specific delusions of reference or
persecution. Persecutory delusions are more typical of patients
who are irritable rather than euphoric. Some patients with mania
have marked religious colouring to their thoughts, believing that
they have special messages from God.
There is increased activity both in thought and in behaviour.
Patients are more talkative than usual and there is what is termed
pressure of speech; they are full of exciting ideas - one idea
leading rapidly to another, and this is known as flight of ideas.
Speech is rapid and loud with rapid change of topics, and in
extreme cases speech becomes incoherent and unintelligible. This
increased activity may also be seen in voluminous writing. There
is an increase in motor behaviour initially and this activity might
show increased efficiency. But soon this becomes unproductive
because the patient is easily distractable and eventually is active
all night long. The patient has both insomnia and early morning
waking but this is not associated with fatigue on waking initially.
There are increased drives particularly for sex, food and alcohol
but, in view of the overactivity, the patients tend to lose weight.
36 Psychiatrie disorders in dental practice

Concentration is impaired. Patients are easily distractable and

attention is drawn to unimportant or irrelevant stimuli. There is
excessive activity in uncharacteristic and risky pursuits, for
example spending sprees without the money to pay, unwise
business ventures. Disinhibition also leads to the removal of
social constraints which leads to both socially embarrassing
behaviour and to extravagant behaviour to which the patients'
grandiosity predisposes. This extravagant behaviour may well
put the patients at risk socially, for example when they give away
most of their money, have a tendency to wear outrageous clothes
or form wild, inappropriate sexual liaisons.
Cognition may also be altered, especially in severe cases. The
patients may become disorientated as a result of their extreme
distractability and may also exhibit impaired memory. Hallucina-
tions also occur. They are usually consistent with mood, taking
the form of voices speaking to the patients about their special
powers, or occasionally of visions, sometimes with a religious
content. Insight is invariably impaired. The patients may see no
reason why their grandiose plans should be restrained or their
extravagant expenditure curtailed. They seldom think of
themselves as ill or in need of treatment and this is the main
reason why it is extremely difficult to manage the manic patient.

Manic-depressive psychosis
Manic-depressive psychosis is a term which has been greatly used
in medical literature and reminds us that patients can suffer from
periods of both mania and depression.
Those patients who experience both manic and depressive
illnesses are described as suffering from bipolar affective
disorder. There should be history of at least one episode of
mania and one episode of depression. Repeated episodes of
mania without depression are also classified as bipolar. This is
because most authorities agree that patients with recurrent mania
will eventually develop a depressive illness sometime during
their life, or have experienced depressive episodes which have
gone undetected.
The term manic-depressive illness (manic-depressive psycho-
sis) does not have precisely the same meaning as bipolar affective
disorder. The former is, however, an outdated term best avoided.
The diagnosis of mania is usually made easily and presents few
problems, bearing in mind the above description. However, there
is a difficulty in diagnosing hypomania, which is an illness where
there is an elevation of mood which is so mild that it is hard to
 Psychiatrie disorders 37

distinguish it from a lively or active personality. In contrast, those

who experience depressive illness alone are described as suffering
from a unipolar affective disorder; there should be a history of at
least three separate episodes of depression, with complete
recovery in between and no evidence of mania.

Schizophrenia and allied states

Schizophrenia is a major psychosis as well as a major public
health problem. In the UK 300 000 people have had a diagnosis of
schizophrenia at some time and the point prevalence is around
150 000. It is an illness of the young and presents between the age
of 16 and 22 years. Since it can become chronic it means that it can
become a heavy burden on the health resources. In some parts of
the world such as the USA there is a tendency to overuse the
diagnosis 'schizophrenia'. On the other hand, the diagnosis has
often been missed because of clinical imprecision and social
management is often neglected. While it must be acknowledged
that there are many widely divergent concepts of schizophrenia,
increasingly clinicians have come to accept two basic concepts -
acute and chronic schizophrenia.
Essentially, in acute schizophrenia the predominant clinical
features are delusions, hallucinations and interference with
thinking. These kinds of features are called 'positive' symptoms.
Some patients recover from acute illness, whilst others progress to
the chronic syndrome. It is paradoxical that sometimes the most
severe and bizarre presentations are the ones that might clear up
completely. By contrast, the main features of chronic schizo-
phrenia are slowness, apathy, lack of drive and increased social
withdrawal. These features are called 'negative' symptoms. The
establishment of chronic symptoms is a poor prognostic sign.

Acute schizophrenia
A short case history will give an idea of the kind of patient who
presents in the clinical setting:

A 19-year-old student with no past previous history of mental

disorder presented with increasing withdrawal. His friends and
tutor related the fact that he was increasingly aggressive and
informing them that he was being persecuted. At other times he
was seen to be laughing for no apparent reason. Along the months
he became preoccupied with his own thoughts and his academic
work deteriorated. When interviewed he was reluctant to talk but
eventually revealed that he believed that his actions had been
38 Psychiatrie disorders in dental practice

affected with powers from without, and that police and others
were conspiring with his teachers to harm him. He believed that
some of his acquaintances were putting poison in his food. He
admitted to hearing voices commenting on his actions - they were
abusive.
This apparently healthy male, therefore, exhibited prominent
persecutory ideas with hallucinations in clear consciousness,
together with increasing social withdrawal and inability to cope
with his work or his relationships.
In the early stages of the illness the patients' appearances and
behaviour may appear quite normal but increasingly the patients
become more awkward in social behaviour as they become more
preoccupied and withdrawn; others may call them and their
behaviour 'odd'. There is disorder of thought. Schizophrenia is a
misrepresentation of a term which literally means 'split mind' and
refers, in fact, to a splintering or disintegration of the various
mental functions which allow us to lead fulfilling, purposeful
lives, rather than a division of the personality into two opposing
types.
Speech may reflect the underlying thought disorder which
presents as an indistinct abnormality of the construction and use
of language, resulting from a basic disturbance in thinking. In its
early stages thought disorder may be apparent when the patient
converses and the listener realizes that he or she has understood
little of what is being said. Unclear or irrelevant answers to
questions where the individual constantly wanders off the point
is known as Knight's move thinking, or derailment. In very severe
forms of thought disorder the patient is completely incompre-
hensible, talking jumbled nonsense referred to as word salad.
Other forms of thought disorder which have been described
include concrete thinking, or inability to explain abstract ideas.
This becomes clear when the patient is asked to explain some
well-known proverbs. There is also over-inclusiveness, failure to
maintain boundaries around topics so that irrelevant information
intrudes into the conversation. Schizophrenic patients may also
use ordinary words in unusual ways or invent entirely new
words, i.e. neologisms.
The patient's moods may appear normal or entirely incon-
gruous; they may greet bad news, for example, with inappropri-
ate laughter. A common mood is one of perplexity or fear which
is present even before the individual becomes tormented by his
delusions or hallucinations. Schizophrenic patients also have
periods of depression and this must be diagnosed because it calls
for appropriate treatment with antidepressants.
 Psychiatrie disorders 39

Disorders of stream of thought include pressure of thought,

poverty of thought and thought-blocking. Pressure of thought
occurs when ideas arrive in unusual variety and abundance;
poverty of thought is when the patient has only few thoughts,
which lack variety. The observer of the schizophrenic may notice
a sudden interruption in the flow of conversation. Minor degrees
of this effect are common, particularly in patients who are tired or
anxious. By contrast, thought-blocking, particularly abrupt,
complete interruption, is strongly suggestive of schizophrenia;
because it is such an important feature in the diagnosis it is
essential it should be identified only when there is no doubt about
its presence. The diagnosis of schizophrenia is strengthened if the
patients also interpret the experience in an unusual manner,
stating that their thoughts have been taken away by some person
who is persecuting them.
This thought-blocking and thought withdrawal are examples of
passivity experiences. They are of particular significance in a
diagnosis of schizophrenia and can include delusional beliefs that
impulses, actions, emotions or sensations which the patients
experience are not their own, but are imposed upon them by
some outside force or influence against their will. Other forms of
passivity include thought insertion, when subjects experience
thought which they do not recognize as a product of their own
fear, which they believe has been put there by some outside force
or agency. Thought broadcasting is where the patients believe
that their unspoken thoughts are known to or shared by those
around them, so that these thoughts are not contained within
their own minds. Often passivity experiences are of the emotions,
for example sudden rages or depressions; 'made' intentions;
'made' acts where the patients experience their acts as being
completely under control or where external influence initiates or
directs the movements throughout. The patients appear like
robots, the passive observers of their own actions.

Delusions are highly characteristic symptoms of schizophrenia.

This is especially true of primary delusions. It is thus termed
because the abnormal belief appears suddenly and fully formed
in the mind and its development is not understandable in terms
of previous thoughts or other experiences. For example, the
patient may see a cat ninning across the road and immediately
believe that this means that he or she is a subject of a death
plot by conspiring FBI agents. In this case the normal perception
of a cat running across the road is followed immediately by
40 Psychiatrie disorders in dental practice

an abnormal interpretation, namely the false belief that the

patient is the subject of a conspiracy and no amount of argument
will dissuade this individual. A delusional perception is
sometimes preceded by delusional mood in which the
subjects have conviction that there is something going on
around them which concerns them, but they do not know
what it is. Delusional mood often dissipates following the
occurrence of the delusion perception. The delusions are often
of persecutory nature though these are not specific to schizo-
phrenia. Less common but of greater diagnostic value are
delusions of reference and of control and delusions regarding
the possession of thought. The latter are delusions of thought to
be inserted into or withdrawn from one's mind or 'broadcast' to
other people.
Insight is usually impaired. Most patients do not accept that
experiences result from illness but usually ascribe them to the
hostile actions of other people. This lack of insight leads to an
accompanying unwillingness to accept treatment or to continue
with it.

Hallucinations are also primary symptoms of acute schizophrenia.

Auditory hallucinations are among the most frequent symptoms.
They may take the form of noises, music, single words, brief
phrases or whole conversations. They may be unobtrusive or so
severe as to cause great distress. In clear consciousness the
subjects hear a 'voice' or 'voices' speak about them, referring to
them in the third person. To be pathognomic, the content must
not be congruent with any depressive or grandiose mood. The
voice(s) may appear to come from within the subject's head,
within his or her body or from outside. It is sometimes difficult to
distinguish this from delusions of reference in which the subjects
think that other people are talking about them. They may then
misinterpret half-heard remarks or misapply overheard ones.
Some voices seem to give commands to the patient. Some patients
hear their own thoughts apparently spoken out loud, either as
they think them or immediately afterwards. Some voices seem to
discuss the patients in the third person. Others comment on the
patients' actions. These last three symptoms are of particular
diagnostic value.
Visual hallucinations are less frequent and usually occur with
other kinds of hallucination. Tactile, olfactory, gustatory and
somatic hallucinations are reported by some patients. They are
often interpreted in a delusional way.
 Psychiatrie disorders 41

Chronic schizophrenia
Any of the above symptoms can occur and persist in chronic
schizophrenic patients. In addition, it has been increasingly
accepted that part of the schizophrenic process consists of the
establishment of negative symptoms. They mostly follow an
episode of acute florid symptoms for which the diagnosis is not in
doubt. Rarely, negative symptoms develop in the absence of any
history of florid symptoms, when a diagnosis of simple
schizophrenia is often made. Negative symptoms are contrasted
with florid symptoms because they are the absence of normal
behaviour and by their very nature have major implications for
social functioning, with poor social relationships, poor inter-
personal relationships, uncommunicativeness, solitariness and
apathy. Work performance suffers early. Eventually the patients
may neglect themselves, their own appearance, hygiene and
general self-care.
An expression to describe this state is one of 'lack o f . There is
lack of initiative related to lack of motivation rather than the
inability to form drives into actions. Proof of this is the fact that
under supervision, with encouragement, the schizophrenic can
raise his or her performance. There is lack of energy; movements
are slow and the patient feels that everything is a great effort.
There is a lack of alertness with poor concentration, poor
attention spans and self-absorption. There is a general lack of
interest especially with demanding tasks such as reading and
study. Many patients are adherents of tasks which call for little
effort of their own, such as watching TV. If this progresses then
there may well be lack of emotional response and the patient can
progressively exhibit emotional blunting which is severe,
affecting face, voice and gesture. He or she generally withdraws
from social encounters; their behaviour may deteriorate to such
an extent as to embarrass people.
It must be emphasized that these two subgroups, i.e. acute
schizophrenia and the chronic syndrome, may well overlap.
Patients exhibit features of both acute and chronic symptoms.
Again, it must also be emphasized that different features may
predominate within a syndrome, for example in the acute, one
patient may have predominantly paranoid delusions while
another may well have mainly thought disorder.

Paranoia
Paranoia is an illness closely related to schizophrenia, in which
the delusions are the sole symptoms. Examples of paranoia are:
42 Psychiatrie disorders in dental practice

Psychotic jealousy (Othello syndrome)

Erotomania (De Clerambaut's syndrome)
Induced psychosis (folie-a-deux)
Monosymptomatic hypochondriacal psychosis (MHP).

MHP is of importance to dentists because orofacial symptoms

may be the presenting delusion. Particular examples are Ekbom's
syndrome and phantom bite syndrome (described in Chapter 5),
and a dysmorphophobic subgroup (described in Chapter 8).
These syndromes are dealt with in detail in Uncommon Psychiatric
Syndromes (Enoch and Trethowan, 1992).

Organic syndromes
The organic syndromes (organic disorders or reactions) can be
divided into three subgroups, namely acute organic states,
chronic organic states and dysmnesic syndrome. In addition,
psychological symptoms can be associated with head injury,
epilepsy, acquired immunodeficiency syndrome (AIDS) and drug
reactions.

Acute organic states or reactions

Irrespective of their cause, acute organic states produce
remarkably constant clinical features. These are usually defects
of cognition reflected in impairment of orientation, grasp of
general knowledge, attention, concentration and memory. In
addition, there is an impairment of consciousness to varying
degrees.
In acute organic syndromes there is an impairment in the levels
of consciousness and the onset of the condition is usually rapid
and tends to run a fluctuating course, lasting at most a few weeks.
Often, the patient also exhibits a perplexity, perceptual abnorm-
alities and changes in mood, and when this occurs the disorder is
known as delirium. Evidence of specific underlying structural
brain damage is uncommon. In most cases the disorder resolves
spontaneously, although some can progress to chronic irrever-
sible stage. There are many causes of acute organic syndromes
including trauma, infection, neoplasms, neurological disorders
and drugs including cannabis, amphetamines, cocaine and
heroin. In addition to these illicit drugs, withdrawal symptoms
can occur with prescribed drugs, especially the benzodiazepines
such as diazepam and Ativan.
 Psychiatrie disorders 43

It should be noted that the very young, the elderly, post-

operative cases and those with pre-existing physical illnesses are
particularly susceptible to cerebral disturbance.

Chronic organic reactions (dementia)

Chronic organic reaction states are otherwise referred to as
dementias. Dementia is defined as an acquired global impairment
of memory, intellect and personality without impairment of
consciousness. In dementing illness deterioration can sometimes
extend over several years, often with profound consequences for
patients and their families.
The onset is gradual and the condition tends to run a
progressive, irreversible course. There is frequently evidence of
structural brain damage. Dementia usually has an insidious onset
and in the initial stages there might be little evidence of disability
other than the occasional absence of recent memory, which is
often interpreted as normal forgetfulness. Premorbid personality
traits are sometimes exaggerated, for example the person who has
always been rather aggressive becomes even more so. Insight
(partial insight) is often retained during the early phase so that the
sufferers become perplexed, anxious and also depressed with the
realization of their failing mental faculties. With further
deterioration, diminishing intellectual capacity and memory loss
are more apparent. This can sometimes lead to development of
persecutory delusions, particularly if misplaced articles are
assumed to have been stolen.
Wandering, especially at night, neglect of personal hygiene,
diet and clothing are an increasing concern for relatives or carers.
Other changes occur in speech and behaviour including
perseveration (inappropriate repetition of words or actions),
confabulation (a falsification of memory), nominal aphasia (the
inability to name objects) and catastrophic reactions, i.e. explosive
displays of emotion in response to normal stress. Thinking
becomes slower and also restricted and there is a general
diminution of activities. The later stage of the illness is
progressive deterioration of personality, associated with lack of
emotional response and increased apathy and loss of insight.
Socially unacceptable behaviour such as aggressiveness, sexual
disinhibition and incontinence often occurs at this time, as well as
the general deterioration of physical health. Ultimately, death is
frequently the result of physical illness.
It is crucial in the elderly to differentiate dementia from
depressive illness. This can sometimes be difficult, especially if a
44 Psychiatrie disorders in dental practice

patient suffering from depressed mood is withdrawn or

uncommunicative. Furthermore, the symptoms already de-
scribed, such as the poor concentration and disordered affective
state, together with psychomotor sedation may well be inter-
preted as being due to memory impairment, intellectual deficit
and personality deterioration, whereas in fact these are symptoms
of a depressive pseudodementia. It is estimated that 10% of
individuals initially diagnosed as suffering from dementia turn
out to suffer from depressive illness. Hence, independent history
from a close relative or friend or a carer is essential. Treatment
with antidepressant medication may help to resolve the dilemma.
It must be pointed out that depression and dementing illness are
not mutually exclusive and can coexist. As already implied,
depressive illness can be an early presenting sign of dementia.
Senile dementia and multi-infarct dementia are the commonest
forms of the disorder. In senile dementia progressive decline in
intellect, memory and personality may be accompanied by
wandering, self neglect and socially unacceptable behaviour. In
multi-infarct dementia, deterioration tends to be stepwise with
intermittent periods of relative stability.
The presenile dementias occur much earlier in life and include
Alzheimer's disease, Creutzfeld-Jacob's disease, Pick's disease
and Huntington's chorea. Parkinson's disease, which results from
degeneration of dopamine-producing cells in the basal ganglia, is
commonly associated with depressive symptoms, and occasion-
ally dementia.
It is estimated that the underlying pathology is only treatable in
5-10% of cases of dementia. In such instances early intervention
may arrest the dementing process.

Dysmnesic syndrome
The third group of organic reactions or psycho-organic syn-
dromes is the dysmnesic syndrome. It is characterized by
prominent disorder of recent memory and disordered time
sense, in the absence of generalized intellectual impairment. The
condition usually results from lesions to the posterior hypothal-
mus and nearby midline structures, but occasionally is due to
bilateral hyppocampal lesions. Two such examples are Korsakoff
syndrome and Wernicke's syndrome.
In 1889 Korsakoff, a Russian neuropsychiatrist, described a
chronic syndrome in which memory deficit was accompanied by
confabulation and irritability. In addition, his patients suffered
from peripheral neuropathy. They had either abused alcohol or
Other documents randomly have
different content
 BEAVER COUNTY 575 of justice of the peace in 1898, and is
still holding that position. In March, 1910, he was appointed burgess
and is now serving that term. Mr. Cargo has always been an ardent
Republican, and cast his vote for Abraham Lincoln. He is a
stockholder in the Beaver County Telephone Company, and is the
owner of much real estate in Rochester. He and his wife are
members of the Methodist Episcopal Church, and he holds
membership in Post No. 183, Grand Army of the Republic, in which
he held the office of Post commander, and the Union Veterans'
Legion, Camp No. 72, of Rochester. Mr. Cargo married (first) January
7, 1867, Laura L. Rhodes, of Allegheny City, and had children:
Charles, married Ada and lives in Burlington, Vermont; Jane,
deceased, married George Musser, and left children: Grover, Laura
and Mildred; William, a resident of Rochester, married Hattie Blaine,
and has one child ; Warren, resides in Buffalo, New York, married
Clara , has no children; Lida, resides with her father. Mr. Cargo
married second) Annabell Graham, but has no children by this
marriage. Alexander Kennedy, who was born in Ireland, came to
KENNEDY this country as a young lad more than a century ago. He,
in company with his brother, located in Beaver county, Pennsylvania,
but they soon separated, each going his own way. Alexander
remained in Beaver county, wiiere he married at Links Bridge,
Emeline McMertrie, who was born there. Her father was Colonel
McMertrie, and he and his wife were among the early settlers of the
section, coming there when it was still almost a wilderness. Colonel
McMertrie brought his possessions to the place on a wheelbarrow,
built a log cabin, and cleared the land for farming purposes. (II)
John Kennedy, son of Alexander and Emeline (McMertrie) Kennedy,
was born at Seventysix, Beaver county, Pennsylvania. He received
his education in the schools in Green Garden, being obliged to walk
from six to seven miles daily. He became the owner of almost seven
hundred acres of land at Seventysix, the greater part of which he
cleared. He bought four hundred acres near Green Garden, cleared
and broke it, and erected a log house there, but subsequently
removed to Pittsburgh, where he was in business as a live stock
dealer. He lived in Pittsburgh and its vicinity for about seven years,
then removed to Allegheny county, where he purchased eighty-five
acres, and there his death occurred. He was of unusually large
stature and of great strength. His political affiliation was with the
Democratic party, and he was a member of the Methodist Episcopal
Church. He married Elizabeth, daughter of David and Polly (Philips)
Alexander, who were also among the early settlers of the county.
Children : William, David A., see forward ; Emeline Jane, Sadie,
Matilda, Mary, John, Louise. (III) David Alexander Kennedy, son of
John and Elizabeth (Alex 
 576 PENNSYLVANIA ander) Kennedy, was born at
Seventysix, Beaver county, Pennsylvania, July 30, i868. He was
educated in the public schools of Beaver county, remaining with his
father until he was fifteen years of age. He then entered the employ
of the Standard Oil Company, for whom he had charge of the wells
located between Sheffield and Burgettstown. After some time spent
at Imperial, Allegheny county, Pennsylvania, also in the employ of
the Standard Oil Company, he resigned his position with them, and
formed a connection with the Ohio Valley Oil Company, with whom
he remained for a period of eight years, in the states of Ohio and
West Virginia. In T907 he purchased two hundred and twelve acres
of land in Hanover township, Beaver county, Pennsylvania, and
devotes his entire time now to farming and stock raising, in which
fields he has achieved a very satisfactory amount of success. He has
never taken a very active part in the political affairs of the
community, but gives his support to the Democratic party. He is a
member of the Methodist Episcopal Church. Mr. Kennedy married.
May 5, 1891, Emma Cain, born in Beaver county, Pennsylvania, in
which she has always lived, and who was one of a family of fourteen
children. Mr. and Mrs. Kennedy have children: Elizabeth, married
Straus Keifer, and lives in West Virginia; Eva, who is at home with
her parents. In the earlier half of the nineteenth century William
Glenn GLENN with his wife and family crossed the mountains and
settled for a time in Washington county, Pennsylvania. In 1835 he
removed to Greene township, Beaver county, Pennsylvania, where
he purchased a large tract of land. Returning to Washington county
alone for a time, he died and was buried there. He married Mary
Chapman and had several children. (II) David Glenn, son of William
and Mary (Chapman) Glenn, was born in the eastern part of
Pennsylvania, and crossed the mountains with his parents. He was
probably old enough to have acquired his education before this
journey was undertaken. Between 1835 and 1840 he purchased two
hundred acres of land in Beaver county, in association with his
brother, but later he owned it alone, having bought his brother's
interest. He cleared a portion of the land and erected the necessary
dwelling house as well as barns and outhouses, and was engaged in
general farming and stock raising very successfully. He was sixty
years of age at the time of his death. In political matters he was a
Republican. He married Mary Conkle, whose parents were pioneers
near Hookstown, and who died at the age of eighty-six years. They
were members of the United Presbyterian Church, at first going as
far as Hanover to attend, but later going to Hookstown. Of their nine
children the following named grew to maturity: Margaret Conkle,
bom m 1840; Mary Jane Conkle, William, Thomas C. (III) Thomas C.
Glenn, son of David and Mary (Conkle) Glenn,
 BEAVER COUNTY 577 was born on the Glenn homestead in
Beaver county, Pennsylvania, April 26, 1850. He was educated at the
public schools which he was obliged to leave at an early age in order
to assist in the support of the family. He has always resided on the
homestead farm, having purchased one hundred acres of this
homestead and has improved it in many directions. Among these
improvements are a number of fine buildings which have been
erected by his direction and at his expense. The farm is still
cultivated for general produce, and is now under the personal
management of a nephew of Mr. Glenn, although his is still the
guiding spirit. For many years he has been a factor to be reckoned
with in the councils of the Republican party of that section of the
country, and it has greatly profited thereby. He has served as auditor
and supervisor of Greene township, and is a member of the
Republican county committee. His religious affiliation is with the
Presbyterian Church. The Whitehills are of Scotch descent, and were
first WHITEHILL found in America in 1723. The founder of the family
in this country, James Whitehill, was born in Scotland, February i,
1700, and came to America in 1723, at which time he settled in
Pennsylvania. He obtained his first warrant for land on December 2,
1734, his tract being situated near the head of Pequea creek,
Lancaster county, Pennsylvania. For more than one hundred years
this creek was known as Whitehill's Run, and is now called
Henderson's Run. He appears to have prospered and later made
other large purchases of land. (I) James Whitehill, a lineal
descendant of the immigrant ancestor, was bom on the family
homestead, a little below Kendall, Hanover township, Beaver county,
Pennsylvania, and there his marriage took place. Shortly afterward
he purchased a farm of four hundred acres in Hanover township, on
which he built a house, but about 1850 removed to the Ewing place
in Greene township ; he retained his ownership of the farm in
Hanover township, later returned to it, and died there in 1856. He
was an active member of the Whig party, and served as township
assessor and as constable. Both he and his wife were members of
the Mill Creek Presbyterian Church. He married Martha Ewing, and
had children: James, a farmer who died in Ohio; John, a farmer, died
in West Virginia; Robert, died on the homestead; Deborah, married
William Ramsey, and died in Washington county, Pennsylvania ;
Joseph McCready, see forward ; David, was killed at the battle of
Hatcher's Run during the Civil War ; William Ewing, see forward. (H)
Joseph McCready Whitehill, son of James and Martha (Ewing)
Whitehill, was born on the homestead below Kendall, Hanover
township, Beaver county, Pennsylvania, and there he was educated.
He engaged in farming independently when he attained man's
estate, becoming the owner of one hundred and seventeen acres.
This he improved in many directions, and in addition to general
farming was extensively engaged in sheep raising. All his life he was
a member of the Tomlinson's Run United Pres 
 578 PENNSYLVANIA byterian Church. He married Mary Kerr,
born near Comettsburg, Washington county, Pennsylvania, daughter
of Andrew T. Kerr. They had children: Minnie Luella; John Telford,
see forward; Thomas Ewing. (Ill) John Telford Whitehill, son of
Joseph McCready and Mary (Kerr) Whitehill, was born in Hanover
township. Beaver county, Pennsylvania, April 30, 1879. He was
educated in his native township, and was a student at the Frankfort
Academy, from which he was graduated with honor. He then entered
the employ of the railroad company, with which he remained six
years, then farmed for a time. At the present time he is on the
Hookstown to Industry Star Route. He also cultivates ninetysix acres
of land for general farming purposes. His political affiliations are with
the Republican party, and he is a member of the Mill Creek
Presbyterian Church. Mr. Whitehill married (first) April 29, 1904, Nora
Iradell Ewing, and had one child: Joseph Ewing. He married
(second) June 21, 191 1, Cora Louise Cameron, daughter of John O.
and Minerva Ellen (Tindall) Cameron, natives of Hancock county,
West Virginia, and Columbiana county, Ohio, respectively, and has
one child, Elizabeth Ellen. (II) William Ewing Whitehill, son of James
and Martha (Ewing) Whitehill, was bom on the farm on which he
now resides, August 27, 1847. John Ewing, his maternal grandfather,
was an old resident of Greene township, where he was the owner of
one hundred and fifty to two hundred acres of land, which he
farmed. He had children: John, died on the homestead in Greene
township, was a farmer; James, same as preceding; Martha, married
James Whitehill, and became the mother of William E. Whitehill;
Sarah, married Joseph Moore, and died in Beaver county ; Mary,
married Dr. Coburn, and died in Ohio ; Belle, married James Moody,
and died in Greene township. William Ewing Whitehill received his
education in the public schools, and from an early age assisted his
father in the management and cultivation of the homestead farm.
He, together with his brothers, Robert and Joseph McCready,
purchased the interests of the other heirs ,and he now owns one
hundred and forty-three acres. He has erected a fine dwelling house
and a barn, and made many other improvements. He also devotes
considerable time to stock raising. He and his wife are members of
the Mill Creek Presbyterian Church, in which he has served as a
trustee for more than a quarter of a century. His political allegiance
is given to the Republican party, and he has served as road
commissioner and as supervisor. Mr. Whitehill married, in 1870,
Jennie Stephenson, born in Greene township, daughter of Thomas
and Belle (Stewart) Stephenson, and granddaughter of William and
Elizabeth (Henderson) Stewart, of Scotch descent, who were early
settlers in Hancock county, West Virginia, near the Pennsylvania line,
where he was a farmer, and erected a brick house which is still
standing, and where both died. Thomas and Jane (Smith)
Stephenson, the paternal grandparents of Mrs. Whitehill, were old
settlers near Hookstown, where he was an extensive land owner;
they had eleven or twelve children. WilHam Ewing
 BEAVER COUNTY 579 and Jennie (Stephenson) Whitehill
had children: Belle, married E. H. Swearingen, has no children, and
lives with her father on the homestead; Mary, was graduated from
Slippery Rock Normal School, and is a teacher in East Liverpool,
Ohio. George Hartzel was born in Bucks county, Pennsylvania,
HARTZEL and removed to Marion township, Beaver county,
Pennsylvania, about 1830. He located on a farm which is now known
as the Michael Young farm, where he cleared the land and prepared
it for farming purposes. He died at Brush Creek, Cranberry township,
Butler county, Pennsylvania, while living with a daughter. He married
Catherine Cron, born in Germany, and they had children: George,
John, see forward; Jacob, Michael, Betsey, Catherine, Hannah,
Sarah, Maria. (II) John Hartzel, son of George and Catherine (Cron)
Hartzel, was born in Bucks county, Pennsylvania. He was a farmer all
his life, and the owner of about three hundred and six acres of land,
all in Marion township. He cleared and improved the land and
became a man of influence in the community. He affiliated with the
Democratic party, and served as supervisor and school director for a
number of years. He married Dolly Knauff, born in Germany, who
came to this country at the age of three years with her parents,
Michael and Knauff, about 1820. They bought a farm in Jackson
township, Butler county, Pennsylvania, and put up the first log
buildings. They had ahogether one hundred and thirty acres. Their
children were: Michael, Nicholas, Dolly, married Mr. Hartzel;
Margaret, Barbara, Casper. Children of Mr. and Mrs. Hartzel: George,
see forward; Michael, Catherine, now Mrs. Wolf; John, Henry,
Margaret, Herman, Jacob, Andrew. (III) George (2) Hartzel, son of
John and Dolly (Knauflf) Hartzel, was born in Marion township,
Beaver county, Pennsylvania, March 24, 1839. He was educated in
the old log schoolhouse, and has been engaged in farming all his
life. At first he resided on a fifty-acre farm in Marion township, then
removed, July 2, 1889, to the farm on which he is residing at the
present time, this consisting of one hundred and one acres. He put
up excellent buildings, and has made many improvements in the
place. He gives his political support to the Democrats, and is a
member of the German Lutheran Church. Mr. Hartzel married (first)
about 1858, Mary Lutz, and had children: George, John W., see
forward; Albert, Amos and Mary, twins. He married (second) 1868,
Anna Lutz, a sister of his first wife, and had children: Edward and
Harry. He married (third) in January, 1884, Elizabeth Luntz, and has
one child, Charles P., born December 15, 1887; he has always been
engaged in general farming; he married, March 4, 1908, Laura R.
Blinn. (IV) John W. Hartzel, son of George (2) and Mary (Lutz)
Hartzel, was born in Marion township, Beaver county. Pennsylvania,
March 13,
 58o PENNSYLVANIA 1863. He was reared in Butler county,
Pennsylvania, attending the common schools there, later becoming
an attendant at the night schools and at Peirsol's Academy in
Rochester. He served his apprenticeship to the tinning and plumbing
trade, then established himself in that business in Rochester, in
1886, and is still identified with it very successfully. He has been
prominent in local political circles as a Republican, and served as
sheriff of the county from 1908 to 191 1. He has also been a
member of the school board of Rochester. As a business man he is
held in high esteem, and he is a stockholder in the Beaver County
Telephone Company and the First National Bank of Rochester. Mr.
Hartzel married, in 1888, Kate A. Blaine, a relative of the noted
statesman, James G. Blaine. They have had children: Ethelinda,
Paul, deceased; Gale, Mary, Merle. The family attends the Lutheran
Church at Rochester, and Mr. Hartzel is a member of the
Independent Order of Odd Fellows, Woodmen of the World, Knights
of Pythias and Junior Order of United American Mechanics. Scotland
and the close of the eighteenth century are the two NICKLE
essentials with which this story of the Nickle family of Beaver county
begins, for it was from that land that David Nickle and his wife came
to the United States. (I) David Nickle, the head of the line herein
traced, was born in Scotland in 1 78 1, died in Hanover township,
Beaver county, Pennsylvania, March 6, 1847. After his marriage in
Scotland in 1807, he came to Beaver county, Pennsylvania, where
the remainder of his days were spent. He married Mary Murray, born
in Scotland in 1790, died in Beaver county, Pennsylvania, May 18,
1861, and was the father of: James, born in Scotland, January 7,
1808; George, William, David, Matthew, of whom further; Alexander,
Eliza, Margaret, all born in Pennsylvania. (ID Matthew Nickle, son of
David and Mary (Murray) JMickle, was born in Hanover township,
Beaver county, Pennsylvania, July 7, 1822, died in that county,
September 3, 1904. He was educated in the public schools, and
early in life began farming, becoming the owner of a tract of four
hundred and fifty acres, much of which he and his sons cleared. On
this large farm he at some times grazed several hundred sheep,
being one of the most extensive dealers in the vicinity, also
conducting general farming. His church was the United Presbyterian,
and there were few more earnest workers among the members of
that organization than he, the amount of his beneficences reaching
far beyond the contribution of even a generous man of his means.
Nor were his church works entirely material, for he held the position
of elder in that church, taking active part in its varied activities and
by the splendid example of his Christian life daily preaching the
gospel of right living and love for God and man. In public life he was
also active, taking a keen interest in politics, his sympathies being
with the Democratic party, and holding the offices of road supervisor
and school
 BEAVER COUNTY 581 director. The devotion of his life to
reHgious works is at once plain when it is learned that for forty-
seven years he was a member of the session of the United
Presbyterian Church, and for many years superintendent of the
Sunday sciiool. He married (first) August 26, 1847, Margaret,
daughter of John Patterson, of Carroll county, Ohio, born January 8,
1828, died May 6, 1868. After her death he married (second)
October 8, 1868, a widow, Jane (Bigger) Hall, of Beaver county,
Pennsylvania, died December 5, 1895. Children of Mlatthew and
Margaret (Patterson) Nickle: John Bryan, born July 28, 1848;
Thomas M., of whom further; David Franklin, born September 3,
1852; Alexander Murray, of whom further; James, born May 20,
1856; Mary, born July 3, 1857; Jeanette, born July i, 1861 ; Margaret
Robena, born March 18, 1865; William P. Scott, born July 13, 1867.
(HI) Thomas M. Nickle, son of Matthew and Margaret (Patterson)
Nickle, was bom in Greene township, Beaver county, Pennsylvania,
October 30, 1849. His early life was spent on the farm where he was
born, and he attended the public schools of the vicinity, living on the
homestead until his marriage, when he moved to his present farm,
about one mile from the place of his birth. His land is two hundred
acres in extent, and at the present time, in addition to conducting
operations general in character, maintains a large flock of sheep and
considerable cattle. His church is that of his father, and he is a
Democrat in politics, steadfastly refusing political preference of any
kind. In his business life, agriculture and stock raising, he has been
successful with unusual consistency, escaping the hardest blows that
occasionally fall upon an agricultural community, and has realized a
moderate competence. Mr. Nickle married, in 1891, Jennie M.
Stewart, of Allegheny county, Peimsylvania. Children: Maggie
Berdella, Lolo Ethel, Alena Gertrude, Mabel Patterson, Maude
Stewart. (HI) Alexander Murray Nickle, son of Matthew and Margaret
(Patterson) Nickle, was born near Hookstown, Greene township,
Beaver county, Pennsylvania, November 24, 1854. His excellent
education was obtained in the public schools of the locality, Frankfort
Academy, Edinboro, Pennsylvania, State Normal School, and Grove
City College. After leaving the latter institution he was for a time a
teacher in the public schools of Beaver county, then in Washington
county, Pennsylvania, and finally in Hancock county, West Virginia,
his entire pedagogical career covering a period of twelve years. In
April, 1887, he went to East Liverpool, Ohio, and entered the office
of Robert Hall, a lumber dealer, and served for fifteen years, the
business being incorporated at the end of that time as the Robert
Hall Lumber Company, when he was made general manager. This
position he held for three years, being compelled to resign at that
time because of an increasing nervousness which threatened a
nervous breakdown, and for two years he took almost complete rest.
In 1906 he accepted a position in the service of the Limoges China
Company as correspondence agent, in April, 1908, moving to Grove
City, Pennsylvania, where
 582 PENNSYLVANIA he has since followed the trade that he
learned earlier in life, that of carpenter. He and his wife are members
of the United Presbyterian Church, and his political convictions are
strongly in favor of the Prohibition party. While a resident of East
Liverpool, Ohio, he served for one year as a member of the board of
education of that place, and for eight years on the board of
examiners for teachers' certificates. Mr. Nickle married, February 15,
1888, Jennie Wills Bigger, born near Bavington, Robinson township,
Washington county, Pennsylvania, daughter of James and Sarah
(Donaldson) Bigger. James Bigger was a life-long farmer; his
children: Jennie Wills, of previous mention, married Alexander
Murray Nickle ; Isaac Donaldson ; James Walker ; Ida Margaret, twin
of James Walker; Esther, married a Mr. McBride; Richard; William;
John McBride. William Chapman, a prominent citizen and prosperous
CHAPMAN farmer and dairyman of Hookstown, Pennsylvania, is a
member of a Pennsylvania family, and was born at Kendall, Beaver
county, in that state, August 16, 1867. His paternal grandfather, one
of three brothers, was Samuel Chapman, who in early years settled
near Raccoon Station, Beaver county. William Chapman, son of
Samuel Chapman, was born near Washington, Pennsylvania, and
came to Beaver county about 1840, where he engaged in farming in
Hanover township. He married (first) Joanna Hoag, and by her had
four children. He married (second) Margaret Nickle, daughter of
David Nickle, and a sister of Matthew Nickle. Of this union there was
but one child, William, of whom further. Mr. Chapman Sr. was an
active man in the community during his life, and held the position of
road commissioner. He had a farm of about forty acres near Kendall,
Beaver county, and there lived and died. William Chapman was
educated in the local schools of Kendall, and took up farming upon
completing his studies in the same. In the year 1905 he bought the
old Nickle farm, which had been in his mother's family, and which
contained two hundred and fifty-two acres, and upon this he now
lives and conducts a large dairy. The farm lies in Greene township
and might serve as a model for dairymen. Mr. Chapman has made
extensive improvements upon, and highly developed his property.
His herd consists entirely of fine specimens of the Short Horn and
Red Poll cattle. Mr. Chapman married, in 1892, Ella Andrews, a
resident of the environs of Kendall, Beaver county, Pennsylvania, and
a daughter of Joseph Andrews. To them have been born two
children, George and Harry Chapman, both residing at home. Mr.
Chapman is a Republican in politics. He and his family are members
of the Mill Creek Church.
 BEAVER COUNTY 583 The date of the arrival of the Cooley
family in this country COOLEY cannot be established with any degree
of certainty, owing to the destruction in various manners of early
records. They have, however, been resident in America for a number
of generations. (I) Frank Cooley, who was a farmer in Allegheny
county, Pennsylvania, died in that county, and had been a highly
respected member of the community in which he lived. (II) Robert S.
Cooley, son of Frank Cooley, was born in Allegheny county,
Pennsylvania, and removed to Beaver county, in the same state, at a
very early day. He located on a farm a little below the one on which
Joseph Cooley Jr. now resides, and all the active years of his life
were spent in farming. He owned two hundred and fifty acres of
land, which he cleared and provided with log buildings for all
necessary purposes. He was an elder in the Presbyterian Church. Mr.
Cooley married Jennie Smith, also a native of Allegheny county,
Pennsylvania. Among their children were : Joseph, see forward ;
Frank, who served in a cavalry regiment during the Civil War, and
who died in the state of Kansas. (III) Joseph Cooley, son of Robert
S. and Jennie (Smith) Cooley, was born in Beaver county,
Pennsylvania, where he was educated in the district schools. He
learned the carpenter's trade, which he followed all his life, and was
also engaged extensively in farming. He owned two hundred and
fifty acres of land, a large portion of which was devoted to the
raising of sheep, in which he was very successful. Like his father, he
was an elder in the Presbyterian Church. Mr. Cooley married Matilda
Anderson, born in Beaver county, Pennsylvania, daughter of Charles
and Matilda (Blackamore) Anderson, who were early settlers in the
county. Mr. and Mrs. Cooley had children: Joseph, see forward; Mary
Ann, Elizabeth, Robert S., Letitia, Matilda. (IV) Joseph (2) Cooley,
son of Joseph (i) and Matilda (Anderson) Cooley, was born in
Hanover township, Beaver county, Pennsylvania, in May, 1849. Mr.
Cooley received the usual education of a farmer's lad, in the public
schools, a goodly portion of his time, even as a young lad, being
spent in assisting in the farm labors. When he was but three weeks
of age he had been taken by his grandparents to the farm on which
he is living at the present time. He is now the owner of three
hundred and fortyfive acres of land, which he has under general
cultivation, and he utilizes a large portion of it for the purpose of
raising sheep, in which he has been successful. He has made many
improvements on this farm since it has come into his possession,
installing the most modern farm implements, and made many
innovations which simplify the ordinary work. As a supporter of the
Republican party, he has been honored by election to membership in
the election board. Like his forefathers, he is a staunch supporter of
the church, his membership being in the Presbyterian Church. Mr.
Cooley married, in 1873, Elizabeth Chambers, and has had children:
I. Laura, married Charles B. McMillan, of Frankfort Springs; have
 584 PENNSYLVANIA five children : Helen M., Elizabeth J.,
Margaret A. L., Viola J., Charles C. 2. Chambers, killed by horse
running away and throwing him from the cart; was in his twentieth
year. 3. Edna. 4. Dwyte, married Laura B. Stevenson, and they reside
on the farm. 5. Leola, died while at play about an oil derrick; was six
years of age. The present generation of the Jackson family, of
Rochester, JACKSON Beaver county, Pennsylvania, has been
distinguished in public life as well as in religious and social circles. (I)
James Jackson, a native of Ireland, emigrated to the United States
and settled at North Sewickley, Beaver county, Pennsylvania, in the
early part of the eighteenth century. He followed his calling as a
farmer, and died there, after having married. (II) Hugh Jackson, son
of James Jackson, was bom in North Sewickley, Beaver county,
Pennsylvania. His education was as good a one as the public schools
of that early day afforded. He learned the carpenter's trade and
followed that calling for some time, later became identified with the
building of boats in Bollesville, where he died in May, 1862. He was a
devout member of the Presbyterian Church, and a Democrat in
political matters. Mr. Jackson married Ann Ferguson, born in North
Sewickley township, daughter of John and Elizabeth Ferguson, the
former a native of Ireland ; he emigrated to America and was a
farmer in North Sewickley township. Mr. and Mrs. Jackson had
children: Albert; George, deceased; Even, deceased ; Andrew,
deceased ; Samuel F., deceased ; Leander Whistler, of further
mention ; William, deceased ; Sarah E. (III) Leander Whistler
Jackson, son of Hugh and Ann (Ferguson) Jackson, was born in
Bollesville, Beaver county, Pennsylvania, November I, 1853. He
received his education in the public schools of Rochester township,
and from an early age commenced a self-supporting career.
Ambitious and energetic he made every effort to acquire the
necessary knowledge for the responsible work of a stationary
engineer, and followed this calling for a period of twenty-five years.
He then became superintendent for the S. Barnes Company Brick
Works, at Bollesville, retaining this position ten years. In 1910 he
was one of the organizers of the firm of Jackson & Gibson, wholesale
dealers in paper and paper products, in Rochester, and this has
proved a very profitable enterprise, and is successfully conducted up
to the present time. Mr. Jackson is connected with a number of other
important business enterprises, among them being the Central
Building & Loan Association, of which he is president. He has always
given his consistent support to the Republican party, and has served
as a member cf the common council of Rochester. His religious
affiliation is with the Methodist Episcopal Church, in which he has
been a trustee since 1888, and secretary of the Sunday school for
the past twenty-one years. Fraternally he is a member of the
Woodmen of the World. Mr. Jackson married, in 1881, Lauraucha
Roberts, bom in New Orleans, Louisiana, who came to Rochester
with her parents. Children : George R., William M., Mildred.
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