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Managing Patient Anxiety - The Iatrosedative Process
by Dr. Nathan Friedman, DDS
PART 1 OF
4
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Part 4
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Dr.
Nathan Friedman, is the author of this paper, researcher and
developer of the Iatrosedative Process. Presently retired, he
was a Clinical Professor and Chairman Section of Behavioral
Dentistry, USC School of Dentistry. Dr. Friedman has taught this process to thousands
of dental students and practicing dentists. The outcomes
of the process have enormous benefits to the patient and
to the practitioner.
No part of this article is to be reprinted in any journal or newsletter without appropriate request and permission from Dr. Friedman. This paper originally appeared in "Emergencies in Dental Practice" by Frank McCarthy, MD, DDS.
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INTRODUCTION Avoidance of the dentist frequently results in extensive pathology. Consequently, such patients are driven to the dentist by some crisis-like situation; either pain, swelling, acute infection or the last-ditch need to have a badly destroyed dentition repaired. However, the dentist can not "get to" the teeth until the barrier of fear is removed in some way. Attempting to ignore the wall of fear usually leads to great frustration and stress for the dentist and a higher fear level for the patient. A recent survey of dentists indicates that 57% of those responding considered the "difficult patient" to be the most stressful single factor in their practices. It is clear that for both the doctor and the patient, fear must be viewed as a significant syndrome requiring treatment. In a sense, each time the dentist is faced with a fearful patient, he is dealing with an emergency; not a dental emergency, but the emergency of fear. For the dentist, facing the fearful patient may create considerable stress, a sense of inadequacy and frustration unless he is equipped to deal with the problem expertly. The dentist has a variety of ways to help the fearful patient. The use of drugs is the traditional modality. The techniques of inhalation, intravenous, intramuscular and oral sedation have been taught for years in dental schools and, postdoctorally, through continuing education channels. The techniques are well structured, the goals quite clear and the dentists using these modalities are confident of their effectiveness. However, it must be recognized that pharmacosedation does not reduce or eliminate fear; it temporarily circumvents it. Its value lays primarily in making dental treatment approachable for the patient by diminishing awareness and producing a temporary state of tranquility. Treatment of the fear syndrome requires a different technique, one with which the fear is eliminated or significantly reduced by means of a relearning process. The relearning process is the result of interactions initiated by the doctor designed for this purpose. Traditionally, sedation has been equated with the use of drugs to induce calmness. Although in a vague way it is conceded that the behavior of the doctor is helpful in calming the anxious patient, it is considered a haphazard, intuitive effort. The concept of fear treatment to be developed in the following pages is based on a system of simple behavioral techniques designed to accomplish the goal with maximum efficiency and minimum use of time. This system is Iatrosedation. TERMINOLOGY Pharmacosedation is defined as: the act of making calm with the use of drugs. Psychosedation is defined as the act of making calm though psychology. It is distinguished from organ sedation wherein some part of the body is calmed, e.g., cardiac sedation. Psychosedation, then, is the generic term for psychological calming and includes:
In treating the fearful patient, Iatrosedation is primary and Pharmacosedation secondary. The fear is reduced to the lowest level possible with Iatrosedation. If this level is not sufficiently low to permit the patient to cope with the dental experience, Pharmacosedation is used supplementally. In most instances, however, Iatrosedation alone will reduce the fear to a functional level. Components of Iatrosedative Process Iatrosedation has two components:
1. The Iatrosedative Interview The first meeting of doctor and patient is an interview in the literal sense of the word; that is, a view between two people. If in the course of this interchange the patient indicates either verbally or nonverbally that he/she is anxious, the doctor responds by initiating an iatrosedative interview. The procedure is designed to identify the fear problem, make a diagnosis and initiate treatment. The fear level will drop as the interview progresses so that a substantive decrease will be achieved at its completion. Usually, the interview does not complete the relearning process in which the fear is eliminated or maximally reduced. This occurs during the second phase of the iatrosedative process, the iatrosedative clinical encounters. 2. The Iatrosedative Clinical Encounters The first clinical encounter is crucial. This is the "firing line." The patient and the doctor are going to face together what the patient perceives as dangerous. The doctor’s behavioral technique must be structured to blend with his clinical techniques to provide the maximum feeling of safety for the patient. Often this first clinical interaction will result in a successful learning experience, eliminating the fear entirely; that is, dropping the level to what is considered within the normal anxiety range. If this does not occur, subsequent clinical encounters will continue to decrease the fear until the maximum effect of iatrosedation is achieved. There are instances where the iatrosedative interview does not drop the fear level sufficiently and the patient requires some pharmacosedation to face the first clinical encounter. The choice of modality is worked out together, based on the patient’s previous experiences and feelings about the use of drugs and the methods of administering them. Many people have anxieties about inhalation sedation because of imagined threat to breathing, some about intravenous sedation based on a feeling of loss of control, while others object to the use of drugs in any form. DENTAL FEARS Every dentist is familiar with the more obvious fears patients may have, for example:
This partial list will suffice. However, other fears invariably are combined with the above obvious ones. Frequently these are the more important fears that are not apparent to the patient or the doctor until they surface during the interview. These are fears that all people have normally but which are exaggerated when bound up with the dental fears listed above. They are:
Each of these heightened fears, when they exist must be dealt with in the iatrosedative process. As we shall see, there are specific techniques designed to deal with these components of the problem. HOW DENTAL FEARS ARE LEARNED Basically, fear of the dentist is learned. It can be learned in a variety of ways and is expressed in seemingly limitless kinds of experience. However, irrespective of how the fear was learned and what the central focus is, be it pain, the drill or needle, the ultimately important element in defusing that fear will be the behavior of the present doctor and the feelings generated in the patient as a consequence of such behavior.Fear may be learned as a consequence of direct or indirect experiences. A direct experience is one in which the individual has suffered some traumatic incident or threat of trauma in a dental or medical therapeutic situation. Traumatic experiences not related to medicine or dentistry can spread to the dental situation if there is some triggering reminiscent occurrence. An indirect experience is one in which the fear is learned vicariously. The most frequent vicarious source is the family; father, mother or sibling. The child may learn to be fearful as a consequence of observing a parent’s experience or hearing of it. The same would hold true for those of siblings or friends. Other vicarious experiences result from viewing motion pictures, television skits and cartoons portraying painful or threatening dental scenes. These experiences most frequently occur during childhood. The memories of the events and the feelings associated with them may persist throughout life unless relearning occurs. Fortunately, the ability to unlearn and relearn is resident in each individual. The Conditioning Aspect of Dental Fears Classical conditionin g Heightened fear of the dentist and the dental experience may be viewed as a conditioned response in some instances, similar to the response found in Pavlovian classical conditioning. A brief review of this paradigm is:
An example of a direct dental experience that can be likened to conditioning is as follows:
Although the above example is likened to classical conditioning, an overlay of interrelated variables may be conceptualized. The histories of many patients reveal fear-learning patterns, leading to an assumption that more is involved than the simple pairing of the dentist with the pain or the instrument causing the pain. The behavior of the dentist seems to be a powerful component of the traumatic experience. The normal fears of helplessness, dependency and the unknown are markedly intensified and become, with the pain, a part of the conditioned response that includes all of those fears. Yet the fear will be labeled simply "fear of pain." A simple example of such conditioning is reflected in the behavior of a 45 year old male patient who visited the dentist for an examination. He was extremely anxious and had been for two days prior to the visit. His history revealed that when he was about five years of age, he was taken to the dentist by his father to have a tooth extracted. He had a vivid memory of pain and of being pinned down by his father and the dentist. During the struggle the overwhelming experience of force, pain, injury and the total violation of trust and denial of any protection against frightening danger was imprinted on the child’s brain. His father’s behavior compounded that of the dentist’s and the conditioning was magnified in intensity. The fears of helplessness, dependency and the unknown clearly are integrated with the painful experience. One such traumatic event can result in a life-long conditioned response of high anxiety unless relearning or counter-conditioning takes place. Iatrosedation is designed to reduce or eliminate high anxiety through relearning (counter-conditioning). GENERALIZATION Conditioning also results in generalization; that is, its effects spread from the original traumatic circumstances to situations which have similar elements, e.g., medical experiences generalize to dental situations if similar cues are involved.Childhood experiences with surgery such as tonsillectomies are a common source of fear learning that may be generalized to the dental scene. This is true not only in relation to mutilation or pain but the experience with general or local anesthesia. Injections for immunization, for the administration of antibiotics or local anesthetics to dress or suture traumatic wounds may be originating circumstances for the heightening of fear and anxiety. An example of generalization is as follows: J.B., a muscular, vigorous looking man, 30 years of age during the initial interview, stated that he did not want local anesthesia for any restorative procedure. When asked if there was some reason for this he said that he feared injections; that in the past he reacted to them with nausea, palpitations and would turn white even at the thought of a "shot". Pain was not a factor but in the course of the interview it became apparent that the deep penetration of the needle, as in a mandibular injection, seemed to have been a disturbing experience. Pursuing this cue precipitated an association with childhood experiences. Between the ages of 7 and 10, Joe had suffered a number of accidental injuries such as scalp wounds and deep cuts about the face and legs. Each time these emergencies arose he was rushed to the physician or hospital amidst considerable anxiety and would have an injection for local anesthesia to permit suturing, followed by an injection of an antibiotic. Consequently, injections became associated with body injury, crisis, fear and pain, and a locked-in conditioned response developed. Each time Joe had to face an injection of any type, or in the area of the body, he would suffer acute anxiety. This was generalized to an intra-oral injection for dental anesthesia. In an attempt to avoid this anxiety when having dental restorative procedures, he refused to have injections of local anesthetics. MODELING Another method of learning is through modeling. This is an indirect or vicarious learning experience. Fears often arise in children because of their observations of traumatic experiences of parents, siblings, or friends, or hearing stories of these experiences. This kind of learning also may take place as a result of seeing traumatic dental scenes portrayed in television skits, motion pictures or cartoons.The parental scene is a common and powerful learning arena for fear as evidenced by the following history. Here the patient refuses injections for local anesthesia just as J.B did (above), but he fear is based on a modeling learning experience rather than a direct one. A woman, 45 years of age, refused injections for dental treatment stating that she feared them tremendously. When asked what there was about the injection that she feared, she responded that she didn’t know. She had not had any traumatic experiences at the hands of dentists or physicians as a child or as an adult/ Seemingly, there was no reason for the fear. When questioned about blood tests she replied that she would not have them. When asked about immunization injections as a child she said that neither she nor her sister had them because her mother, a nurse, "didn’t believe in them." The dentist interpreted this to indicate that a small child being told this by her mother (a nurse as well) would feel that "shots" were dangerous and must be avoided. He approached the solution to the problem using this interpretation as the starting point. In the above history, the fear was not linked with the behavior of a doctor or some other authoritative figure. This usually is not the case. In most instances the tales heard from others or scenes viewed on television will include the dentist’s unsympathetic behavior linked with the traumatic event. A small child accepts these impressions as real and universal and consequently may face the first dental experience with fear. A dentist who is cognizant of the symptoms of fear example of modeling based on observation of events portrayed on the screen is as follows: A 47-year-old male stated, "I have a terrible fear of the dentist." He characterized his mouth as a "disaster area", not having had attention for a number of years. He stated that he tolerated pain well and that he has had pain all his adult life since he was injured and disabled in service. "It’s probably more the anticipation than the actual act that worries me…I tolerate pain fairly well." The learning to fear the dentist started as a child because, as he stated, "…it seems to be part of our social syndrome to be afraid of dentists. I remember I used to see movies … comedies, you know … the guy gets in there, ‘this isn’t going to hurt’ and wow! You know. It's supposed to be funny but it scares you and you’re supposed to overcome that fear…" The story unfolded in a way that suggested that when he did go to the dentist he had high anticipatory anxiety, indulging a heightened fear of the unknown which he characterized as, "the strangeness of having a hand groping in there with sharp instruments and cutting away at things that normally are not cut upon…" Interrelated with the unknown was the potential body damage that the "strange hand" may create. Knowledge of the learning paradigms is essential to the effective use of the technique of iatrosedation. Similarly, it is important to understand the significance to the patient of the doctor’s behavior in all aspects of dental care. The significance of such behavior becomes even more consequential where anxiety is a dominant factor fear and its treatment can dispel this type of anxiety quite easily. If on the other hand, he is unaware or ignores it, a more powerful fear learning experience will occur, precipitated by the dentist’s inept behavior when trying to treat the teeth of a frightened child. Continued: Technique of the Iatrosedative Interview ...Click here for page 2 of this paper
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