Psychiatric & Cognitive-Behavioral Treatments of Specific Phobias Using Dental Phobia as the Example Disorder

Psychiatric & Cognitive-Behavioral Treatments of Specific Phobias Using Dental Phobia as the Example DisorderWhat is it?

As a psychological or psychiatric problem Dental Phobia would be diagnosed as a Specific Phobia.
It is a marked and persistent fear of the Dentist or some aspect of the dental situation
The dental fear is excessive and unreasonable
Exposure to the dental situation invariably provokes an anxiety response
Imagining or being in the dental situation can even lead to panic attacks
The dental situation is avoided or endured with intense anxiety or distress
The avoidance, anxious anticipation, or distress regarding the fear of the dental situation significantly undermines the patient’s well-being in some way

Ramifications of Dental Phobia

In terms of dental health and overall well-being, Dental Phobia can have serious ramifications.
Besides chronically infected gums and teeth which can affect your medical status, the ability to chew and digest can be compromised.
Without healthy gums and teeth, speech can be affected, as well.
Sufferers may lose self confidence as they begin to feel insecure about their breath and smile.
In turn, this lack of confidence can lead to limitations in social and business environments.

Prevalence
It has been reported that 50% of the American population does not seek regular dental care.
An estimated 9-15% of all Americans avoid dental care due to anxiety and fear surrounding the dental experience.
Millions of people are so afraid of dental treatment that they avoid it all together.
Etiology

What causes dental phobia?

Consider a Biogenic cause
Substance abuse or physical condition might nourish an originally subclinical fear of the dentist to the clinical level.

Examples:
Caffeine Intoxication (or Withdrawal) can result in Substance-Induced Anxiety Disorder with Phobic Symptoms
Hyperthyroidism (anxiety, fine tremor, heat intolerance)
Hypoglycemia (anxiety, hunger, weakness, headaches, palpitations)
Tx = Remove substance or refer for medical diagnostic work up
Then hopefully, phobic symptoms will drop to subclinical levels and treatment can commence.
Considering Psychogenic Orgins of Dental Phobia
Interview the phobic patient to establish what took place in that patient’s learning history that originated the dental fear.

The following are common origins of dental fear
1. Previously painful or traumatic experiences during office visits
2. A severe discomfort with feeling helpless and/or out of control in the dental situation
3. A sense of embarrassment about dental neglect and fear of ridicule and/or belittlement from the dentist or staff
4. Scary anecdotes of negative dental experiences learned vicariously from family and friends
5. Negative, menacing portrayals of dentists in movies, TV, newspapers and magazines

These etiologic experiences generate the 4 psychological drivers of Dental Phobia
a. Fear of the dental situation
b. Avoidance of the dental situation
c. Anticipatory anxiety of the dental situation
d. Hyperarousal in the dental situation

Rapport
Rapport is vital to treatment success.  The dentist or therapist establishes good rapport with the client by:
1. Maintaining an I-Thou relationship with the patient2. Listening to the client deeply3. Communicating authentic regard for the patient4. And verbally and behaviorally demonstrating that the intents to protect the patient from narcissistic and physical harm
Phobia-busting rapport will be enhanced by allowing the patient a sense of control over treatment and total inclusion in the treatment process.

Treatment Goals
Three super points:
1. All good treatment of Dental Phobia will eventually impact physiology
2. Or diminish the subjective distress associated with sympathetic overactivation
3. Making it possible for the patient to endure the dental situation with subclinical levels of distress

Rationale: The autonomic nervous system controls the glands and the muscles of our internal organs and it is a duel system. The sympathetic nervous system arouse us for defensive action.  If something alarms you, the sympathetic nervous system will accelerate your heart rate, slow your digestion, raise your blood sugar, dilate your arteries and cool you with perspiration making you alert and ready for action.  

When the stress subsides, the parasympathetic nervous system produces opposite effects.  It conserves energy as it calms you by decreasing your heart beat, lowering your blood sugar, and so forth.  In everyday situations, the sympathetic and parasympathetic nervous systems work together to keep us in a steady internal state. (Myers, 202, p 40-41)

In dental phobia, the patient’s sympathetic nervous system locks on the coeval subjective distress.
Treatment involves shifting the client from the Fight/Flight Response (sympathetic activation) toward the Relaxation response (parasympathetic calming) with a decrement of subjective distress 

Treatments
1. Medicines –
Some phobic patients respond to anxiolytic medication like benzodiazapines and other medications
Anxiolytic pills and potions are excellent and should never be under utilized
Beware “pharmaceutical Calvinism”

2. Self Talk – 
Dental phobic patients engage in an internal monologue that emphasizes the danger of the dental situation
Examples of Dental Phobic self talk:“The dentist will harm me”“I cannot stay in this chair”“I am out of control”
Tx assists the patient to switch to anxiolytic self-talk, like:“The dentist really is helping me”“I have the strategies to tolerate this”“Our Signal System is in place; I can stop and start this when I wish”

How Anxiolytic self-talk works –
This extremely unsophisticated intervention cause measurable, exquisite changes in the brain of the dental patient.  Those changes are brilliantly therapeutic.

3. Cognitive Restructuring
Dental Phobia is often governed by deep-seated, distorted beliefs about dentist and dentistry
Phobic Cognition: “Dentists hurt and humiliate me”
Cognitive Distortion: Overgeneralization – Generalization of one pervious bad experience to the entire category of dentists

Restructured Cognition: “My dentist actually made it known that she wants me to feel no pain. And she’s been nice to me, not mean”
Probable Outcome: Decrement in catastrophic responses

4. Systematic Desensitization (SD)
SD involves pairing relaxation with imagined scenes of dental situations that trigger the patient’s fear
SD operates on the assumption that if the client is taught to experience relaxation rather anxiety while imagining dental scenes, the real-life situations will cause the clients much less discomfort

Success of SD depends on
a. The patient’s capacity to learn relaxation (via tapes, etc.)
b. Constructing appropriate hierarchy: as series of scenes or situations relating to the dental phobia which are ranked from mildly anxiety provoking to very anxiety-provokingc. The extent to which the patient can comprehensively reproduce in imagination the real-life feared dental situationd. The patient’s ability to maintain relaxation in the face of scary dental imagese. The patient’s willingness to enter the dentist’s office and sustain relaxation in the face of the real stimuli

5. Gradual Exposure
The theory behind this treatment is elegant and simple. Prevent phobic flooding by exposing the patient to the dental situation a little bit at a time

Here is a sample protocol.  Have the patient:
a. Walk in and out of the dentist’s officeb. Sit in the waiting room for about 2 to 5 minutesc. Sit in the waiting room for 15 minutesd. Sit in the dental chair for 5 to 10 minutes without the dentist in attendancee. Sit in the dentist’s chair for 10 to 20 minutes without the dentist in attendancef. Make an appointment with the dentist to just look in the mouth and not do any workg. Make an appointment with the dentist to clean teeth only. Make an appointment with the dentist to do more work

6. Flooding – When using flooding to eliminate the anxiety response, the client is exposed to the high anxiety-arousing dental situation for a prolonged period of time – usually 30 to 60 minutesIf the patient agrees to flooding in the dentist office, she or he must understand the importance of remaining in office until the F/F is exhausted or the time is up; avoidance behaviors must not be an optionUp to 70% of Agoraphobics who undergo flooding experience improvements for at least 4 years; treatment gains would be expected for dental phobic’s

7. Assertiveness – Assertiveness training is based on the assumption that assertive behaviors are incompatible with anxiety and, therefore, can be used to eliminate maladaptive anxiety reactions
Treatment could involve the dentist and the patient role playing various situations that the patient anticipates will be problematic
Once the patient has practiced assertiveness via role playing, confidence and mastery will subvert fear and vulnerability

8. Distraction – Diverting the mind from unpleasant stimuli is a basic treatment for pain and anxiety symptoms
Dental phobic’s will be successfully distracted by visual and auditory stimuli via walkman or Discman or Virtual Reality glasses

9. Clinically Standard Meditation (CSM)CSM was developed by Herbert Benson at Harvard Medical School and Deaconess Hospital
His 9 step protocol will act as a general preventative against the Fight/Flight response and increases autonomic calm

a. Pick a focus wordb. Sit comfortablyc. Close eyesd. Relax musclese. Repeat focus word internally; when mind wonders return to focus word and continue to repeatf. Do this for 20 minutesg. Stop; wait a minute, open eyesh. Practice 2 times a day
Predicted immediate and long term outcomes:
a. Decrease in metabolism, blood pressure, heart rate, rate of breathing, muscle tensionb. Increase in slow brain waves

10. Four additional Treatments Include
a. Aroma Therapy – Certain fragrances have been proven to decrease anxiety in weight loss and pain control groups
Consider “ambient” relaxing fragrances to phobia-proof offices
b. Positive Role Modeling – Patients who watch films attractive role models successfully negotiate dental phobia will be more likely to experience successful treatment outcomes
This treatment is grounded in Social Learning Theory
c. Incorporation of the Auxiliary Ego – Phobic’s whose disorder is co morbid with dependent personality disorder and agoraphobia may experience declines in phobic responses when accompanied by their “safe” person
d. EMDR – treatment for patients whose fear has a PTSD component
This treatment is noted for its desensitization and its robust placebo effect