2. Anxiety Disorders ✅

Life can be altered by what a patient:

“HAS” – diseases ---such a bipolar disorder, and major depressive disorder.

“IS” – dimensions --- such as intelligence and personality traits: openness, conscientiousness, extrovert/introvert, agreeable, worries.

“DOES” – behaviors --- such as excessive use of alcohol or drugs.

“ENCOUNTERS” - life-story --- such as grief due to the death of a loved one, fear after a rape, or demoralization after loss of a job.

biopsychosocial view

Overview

Anxiety, fear, and avoidance are normal and adaptive responses --- difficult to diagnose. Can be comorbid with e.g. mood disorders.

Anxiety-related emotions can be most predominantly experienced as somatic symptoms.

More than temporary worry or fear.

Does not go away and may get worse.

Symptoms may significantly impact daily activities such as school, relationships and work

Facts

Most common mental illness in the U.S., affecting 40 million adults
18 and older, or 18.1% of the population every year.

highly treatable, only 36.9% of those suffering receive treatment.

3-5xmore likely to go to the doctor and 6x more likely to be hospitalized for psychiatric disorders

Develop from a complex set of risk factors, epigenetics, brain chemistry,
personality, and life events.

To some degree useful and occasionally experienced by everyone.

Distinguished from fear– more transient, intense and focused response to an immediate threat.

More sustained and variable emotion developed in the fact of a more subtle threatening and prolonged situation

psychoeducation: the anxiety response

Cognitive Manifestations of anxiety

Thought processes range from generalized worry to overwhelming fear (focus on impending doom)

Behavioral Manifestations of anxiety

The avoidance of anxiety-provoking situation

Somatic Manifestations of anxiety

Physiological complaints due to activation of sympathetic nervous system (stomach aches, headaches, shakiness etc.)

Biological Explanation for anxiety

Fears may have an evolutionary basis (contribute to survival)

Genetic predisposition to fears and anxiety

Lack of GABA neurotransmitter

Cognitive Explanation for anxiety

Irrational beliefs regard feared stimulus

Behavioral Explanation for anxiety

Classical conditioning of fear

Avoidance relieves fear (negative reinforcement)

Biopsychosocial Model Explanation for anxiety

Anxiety has a biological involvement and learning component, both of which are influenced by culture

Types of Anxiety

Generalized Anxiety Disorder

Panic Disorder

Phobia-Related Disorders

Social Anxiety Disorder

Separation Anxiety Disorder

Generalized Anxiety Disorder (GAD)

Excessive anxiety and worry, more days than not for at least 6 months, about a number of events/activities (e.g. work or school performance).

Difficult to control the worry.

Feeling restless, wound up, or on edge

Being easily fatigued

Having difficulty concentrating

Being irritable

Having muscle tension

Difficulties controlling feelings of worry

Having sleep problems

Panic Disorder

Panic attack: sudden period of intense fear that comes on quickly and reaches panic in minutes.

People who have recurrent unexpected panic attacks.

Can occur unexpectedly or be brought on by a trigger, such as a fear object or situation.

6 million American adults.

People without panic disorder can have panic attacks.

More than one in five people will experience a panic attack in their lifetime

signs of a panic attack

Feeling of impending doom
Feelings or being out of control
Feelings of being out of your body

During a Panic Attack

Worries about when the next attack will occur and try to prevent future attacks by avoiding places, situations or behaviors associated with the attack.

These worries can be so severe it may cause people to stop driving, or to not leave their houses

how to approach someone During a Panic Attack

Get on their level

Speak slowly and confidently

Use a gentle, caring tone of voice.

Use short, clear sentences

Provide reassurance

Do not argue with or challenge the person.

Do not threaten.

Do not raise your voice or talk too fast.

Use positive words instead of negative words.

Stay calm and avoid nervous behavior.

Do not restrict the person’s movement.

Be aware of what may increase the person’s fear and aggression.

Take a break from the conversation

Grounding

Simple exercises to help you focus on the present moment and help you detach from painful emotions so you can return to the here and now.

Research has shown that practicing grounding exercises can;
• Lower blood pressure in the body
• Reduce inflammation
• Reduce stress
• Increase mood
• Improve immune response

how to ground yourself

Relax your body, slow your breathing, take note of how you’re feeling (sensations in your body and everything around you). Uncross your legs, put feet flat on the floor.

Find a good place for hands and arms to rest that is comfortable for you.

Ideally you can take off your shoes (at home) and take note of how your feet feel on the floor.

Notice how your body feels resting against the chair.

Take a deep breath and allow shoulders to drop and relax.

Continue to focus on your breath and allow body to relax or keep your mind in the present moment.

Visualize energy pulling your body and your feet deeper toward the ground.

Let your body feel heavy and grounded.

You can scan the room and notice your surroundings, take note of things you see in the room, colors, material anything in the room.

Notice how the room feels for you.

The air, the temperature, continue to breathe.

Focusing on breath and take this moment to be very present in the moment.

Present in your body, how you feel and your mind and begin to gently move around

Phobic-Related Disorders

Phobia: intense fear or --- an avoidance of specific objects or situations.

May have some basis in reality but is out of proportion to the actual danger of the feared object or situation.

People with a Phobia

May have an irrational worry about going to the dentist

Take steps to avoid going to the dentist

Experience immediate intense anxiety when encountering the dentist

Endure unavoidable objects and situations with intense anxiety – snakes, bugs

normal fears vs phobias

dentophobia

5 Elements of Dentophobia

Most people fear more than one

severe dentophobia may fear all or most simultaneously

1. the dentist

2. pain

3. numbness/gagging

4. sounds + smells

5. needles

5 Elements of Dentophobia: the dentist

Dentist is often cast as cold and unfeeling at best, or sadistic at worst.

If you have had a negative personal experience with a particular dentist, you may be more prone to this phobia

5 Elements of Dentophobia: pain

Completely painless dentistry was difficult or impossible.

Some procedures may involve a slight amount of pain.

Many people are extremely sensitive to mouth pain and fear that the pain may be excruciating

5 Elements of Dentophobia: numbness or gagging

Some people, particularly those who have experienced choking or difficulty breathing, are afraid of having their mouths numbed.

You might worry that you will be unable to breathe or swallow

5 Elements of Dentophobia: sounds + smells

Many people, particularly those who have had previous bad experiences with dentists, are afraid of the sounds and smells of a dentist’s office, particularly the sound of the drill

5 Elements of Dentophobia: needles

If you have a needle phobia, you might be extremely afraid of the injections that dentists use to numb the mouth.

The ranking of fears associated with going to the dentist are the following:

1. Extraction

2. Injection

3. Drilling

4. Prophy

Social Anxiety Disorder

People have a general intense fear of anxiety toward, social or performance situations.

People worry that others will negatively evaluate them, leading to embarrassment.

Avoid social situations

Separation Anxiety Disorder

Children and adults experience SAD

Fears about being parted from people they are attached.

Often worry that harm will happen to parent or spouse while they are separated.

Child who refuses to go to school has stomach aches.

Genetic and Environmental Factors

Temperamental traits of shyness or behavioral inhibition in childhood

Exposure to stressful life or environmental events in early childhood or
adulthood

A family history of anxiety or other mental illness

Prognosis

Early diagnosis and treatment can limit the problems caused by an anxiety disorder and improve the outlook.

Many anxiety disorders are not recognized and, as a result, not treated.

Anxiety and Dentistry

Survey of 6,000 people, 43% reported that they avoided going to the dentist unless they had trouble with their teeth.

Of these 43%, 58% said part of the reason was they were scared of the dentist.

One study found that visiting the dentist ranked 4th, behind fear of snakes, heights, and storms.

Phobic or intensely fearful dental patients suffered pain an average of 17.3 days before consulting a dentists, as compared with only 3 days for non-phobic patients.

Early signs include a sense of vigilance and tension.

With increasing anxiety, more uncomfortable states emerge:

Fatigue, persistent exhaustion, worry, agitation, distractibility, jumpiness, an odd state of derealization/depersonalization, a loss of mental and physical efficiency, increased heartbeat, stomach cramps, dry mouth, and lightheadedness.

Derealization

Sense of distance from activities going on in the world or feeling that one's surroundings are distorted or somewhat unrecognizable.

This may include:
• Feeling as if objects are the wrong size/color
• Feeling as though time is speeding up/slowing down
• Experiencing sounds as louder/softer than expected
• Feeling as though watching events and activities unfold in a movie/on a computer screen, rather than participating

Depersonalization

Sense of experiencing one's own behavior, thoughts, and feelings from a dreamlike distance.

Symptoms include:
• Feeling emotionally numb, as if the person is not controlling his or her words and actions
• Feeling detached from ordinary sensations, such as touch, thirst, hunger, and libido

Implications of Survey Data:

Dentists will see many patients who view them as someone who inflicts distress.

Dentists will meet with patients who require extensive restorative work and will not agree to have it

Key Principle of Patient Care

Your relationship with your patient is the strongest anesthetic and anti-anxiety agent

Treating the Anxious Patient

For children, the most important preventive measure is a setting in which
they feel safe and trusting.

Experienced dentists know that the actual accomplishment of treatment
is always secondary to the establishment of trust when a new patient enters the office.

Anxiety and Dentistry: fear over time

Show and experience anxiety in different ways

Not always possible to tell how anxious a patient might be.

Anxiety levels might be higher in the waiting room, so a receptionist’s judgment may be useful.

Anxiety can run in families, new child patient may experience a similar level of anxiety as the parent

Gradual introduction is often especially helpful.

Exposure to dental setting is increased gradually, so patient’s coping strategies are not overwhelmed.

Anxious patients often ashamed of difficulties and may be concerned about critical judgment of them.

Important to be accepting and non-evaluative

provide provide give

Recommendations

Mild cases of panic respond to cognitive-behavioral therapy, but many
patients need medication.

Serotonin reuptake inhibitors.

The agoraphobic patient should be gently encouraged to get out and explore the world.

Progress will only occur if patient confronts the feared places and situations

Patients should minimize their caffeine intake.

Sometimes behavioral techniques are useful.

Exposure, desensitization, relaxation training.

Therapy

Holistic Remedies

Practical Application

Ost’s applied relaxation technique

Jacobson’s progressive muscle- relaxation technique

Brief or functional relaxation therapy

The awareness that you will have to take your place in the dentist’s chair in a few minutes quite possibly provokes an unpleasant feeling over your body, leading to a hardening of your muscles.

This tension may be relieved by the technique of functional relaxation.

For this exercise, please try to feel your body more intensely.

Please perform and repeat each sequence of movements as described for 2–3 seconds.

Pause for a moment to register your body’s perception of changes from one sequence of movements to another.

Try to assume a comfortable position in your seat, and perform only small, almost imperceptible, movements

4S Rule/4S Principle

Anxious patients who must undergo restorative procedures are often managed this way

Based on eliminating four of the primary sensory triggers for dental anxiety when in the dental setting:

sight (air-turbine drill, needles)

sounds (drilling)

sensations (high-frequency vibrations [the annoyance factor])

smells

Tips for staying calm (for patients)

Share your fears. If you're tense or anxious, tell your dentist and the dental staff. Expressing your concerns will help your dentist adapt the treatment to your needs.

Focus on breathing regularly and slowly during dental procedures. When people are nervous they tend to hold their breath, which decreases oxygen levels and further increases feelings of panic. As in some meditation techniques, a focus on slow, regular breathing helps reduce stress levels.

Listen to music. If the sound of the drill bothers you, bring along your favorite music and earphones.

Watch what you eat and drink. Avoid caffeine before appointment. Eat high-protein foods which – unlike sugary foods – produce a calming effect.

Use hand signals. Empower yourself by agreeing on hand signals to communicate with your dentist. When you feel uncomfortable, signal the dentist to ease off or stop the procedure.

Choose a low-stress appointment time. Select a time for your dental visit when you’re less likely to be rushed or under pressure. This might mean a Saturday or an early morning appointment.