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The basic principles of fear, anxiety, and phobia: past and present

Arthur A. Weiner

INTRODUCTION

In 1621, Robert Burton wrote:

Many lamentable effects this fear causeth in man, as to be red, pale, tremble, sweat; it makes sudden cold or heat to come all over the body, palpitations of the heart, syncope … it makes men amazed and astonished, they know nor what to do and where they are; it tortures them many days before, with continued affrights and suspicions. It hinders most honourable attempts and makes their hearts ake and be sad. They that live in fear are never resolute and secure, never merry but in continued pain. No greater misery, no rack, no torture unlike it, ever suspicious, anxious, solicitous, they are without reason or control, without judgment. …¹

The word “fear” stems from the Old English word fear, meaning sudden calamity or danger. In Middle English, as in today’s complex society, it denotes a normal, useful response to an active or imagined threat. For example, if an individual is confronted with an impending threat of fire, gunfire or very high winds, that fear can cause the individual to take lifesaving actions. Fear can also sharpen one’s wits, mobilize energies, and heighten reflexes. The physiological responses that emotional arousal causes are designed to prepare the body for the three Fs—“flight, fight, freeze.”

Fear is the emotional response to a perceived threat or danger. It is composed of physiological changes, an inner feeling, an outer behavioral actions. Fear can cause a variety of physiological changes, such as pallor, pilomotor erection, pupillary dilation, tachycardia, cardio or pylorospasm, hyperperistalsis, hyper/hypogastrointestinal secretions, and increased flow of adrenalin. It can also cause a number of unpleasant feelings such as an inner feeling of terror, paleness, pounding heart, muscular tensions, dryness of the throat and mouth, sinking feeling in the stomach, nausea, vomiting, diarrhea, irritability, difficulty in breathing, sensations of faintness, loss of appetite, insomnia, and an urge to run and hide. Changes in external behavior may be reflected as a pattern of startle, withdrawal or avoidance, or fleeing. It can cause the individual to remain mute or motionless.

Fear may be divided into two types:^1–6

• active or “real” fear = objective fear; and
• imagined or subjective fear.

Objective fear, or “real” fear, is that type of fear caused when a person is walking down a darkened street, and a large barking dog jumps out from behind the bushes. Immediately, a physiological chain reaction occurs, including an increase in the flow of adrenalin, muscle activity, and, the individual, without thought, takes flight. The heart rate has increased, breathing has increased, more sugar has been released into the blood stream, and all the necessary physiologic changes have occurred to preserve the integrity of the being.

Subjective or anticipated fear, the most common type of fear that affects most individuals, is the type of fear that Burton referred to back in 1621. The manifestations and feelings associated with it are unpleasant and do not disappear or resolve when the feared stimulus is removed, as in real objective fear. It afflicts individuals in varying degrees of intensity, and greatly influences their behavioral responses. For example, an individual might think that every time he or she visits the dentist, the dentist may slip and cut the tongue with the dental drill, or every time he or she rides in an automobile, he or she is at risk to hit the first telephone pole one encounters. When fear is learned as a response to a new situation, it is accompanied by a number of reactions that are either parts of the innate pattern of fear, or high in the innate hierarchy of response to fear. Fear can act as a cue to bring about responses that have previously been learned in other terrifying experiences, and can play a role in the development of varying degrees of anxiety, particularly affecting the outcome of dental care.

Anxiety is one of the most prevalent of all human emotions. It includes: (1) physical and mental awareness of being powerless; (2) presence of an impending threat; (3) a feeling of doom and danger that comes from within, the result of cognitive appraisal; and (4) an irresoluble doubt concerning the nature of the threat, the best means of reducing it, and one’s subjective capacity to effectively utilize those means. How a person appraises a situation depends on two sets of factors: (1) those factors inherent in the stimulus object or event itself, and (2) interpersonal variables. With regard to the first, some individuals are conditioned to react negatively to dental care and the many facets associated with it. Second, one’s ability to cope or manage a threatening situation governs the responses that will follow.

Both these factors are influenced by the individual’s past history, personality, and ability to deal with threatening events. Fear is also differentiated from anxiety on the basis of one’s ability to identify the threatening agent externally and to recognize the presence of behavior that will decrease or ameliorate the perceived danger. Anxiety can also be considered as an emotional state in which people feel uneasy, apprehensive, or fearful. People will often usually experience anxiety about events they cannot control or predict, or about events or situations they may consider threatening and harmful. There is a feeling of vulnerability, and severe anxiety can persist and eventually may even become disabling.

Stress is a word or term used to describe a change or disturbance in the psychophysiological equilibrium, and is most commonly associated with the response aspect. Stress is also a term most commonly used in association with the maladaptive aspects of response to the negative or aversive factors present.

All three—fear, anxiety, and stress—are negative or aversive states whose degree of severity of psycho- physiological symptoms is the result of the combination of the emotional response and the individual’s appraisal of the threat at hand, which determine the degree and make- up of the behavior that will follow. For example, whether or not to keep the upcoming dental appointment, which most likely could or will involve receiving an injection and its accompanying pain. This behavior will also depend on the affect or influence within an individual who suffers from panic disorders, general anxiety, depression, and neuroticism. Persons with these disorders have been found to be associated with higher levels of dental fear, anxiety, and phobia.^7–9

MAJOR ETIOLOGICAL MODELS TO EXPLAIN ANXIETY^{4–6,10–12,16}

Historically, three major etiological models have been postulated to explain anxiety, panic neurosis, and disorders:

• the psychological or psychosocial model;
• the behavioral model; and
• the biological model.

The psychological model considers anxiety the result of interplay between environmental stressors and internal conflicts, either past or present. The anxiety response is thought to be an action that attempts to adjust to the event or situation, to immobilize, ward off, and eventually avoid the anticipated overwhelming danger or threat. In the case of the dental visit, stress due to the thought of the associated pain, past experience, and encounter with the dental practitioner, weighted against the individual’s need for dental care, sets up an inner conflict. The degree of past anxiety/fear experience often dictates the outcome by heightening the level of anxiety as the appointment nears, leading to avoidance.

The behavioral model holds that anxiety can occur even without conflict. Following the laws of learning theory, the anxiety response is believed to be acquired. It may take the form either as a classic conditioned response to trauma or stress, or as a demonstrable behavior that has been strengthened by operant conditioning, or both. These first two models are the two most associated with dental anxiety and dental phobia.

The biological model views anxiety and especially panic disorder as a genetic and/or metabolic disease that is similar to other metabolic disorders. Therefore, the fear/anxiety/panic manifested by patients at any given time during the cycle of visits may stem either from purely psychosocial/emotional factors or as the result of a medical disease process to which there is attached a genetic vulnerability, thought to be a chemical imbalance within the central nervous system.⁹

Anxiety bears two distinct components, state and trait. State anxiety is the individual’s response to a specific object, event, or situation. It varies in intensity and fluctuates over time, increasing before dental treatment and decreasing afterwards. When anxiety occurs over a prolonged period and characterizes one aspect of the patient’s everyday personality and behavior, it is called trait anxiety. It is part of the personality, involving the individual’s predisposition to become anxious under a variety of circumstances. Patients who exhibit trait anxiety are also predisposed towards greater degrees of low pain threshold and pain intolerance. Corah in 1969 developed the Dental Anxiety Scale as a trait measure designed to assess a patient’s tendencies to appraise a situation that might be dangerous and threatening such as dental treatment.¹³ It is to this day still the most widely used scale to measure dental fear and anxiety. A recent study in the British Dental Journal by Fuentes and Gorenstein, examining the relationship between dental anxiety and trait anxiety, claimed that dental anxiety is specific and has its own features, and that its development is not necessarily associated with trait anxiety.^14,15

As dental practitioners, we are interested in a patient’s trait tendencies and how it affects the appraisal of a given situation that might be considered threatening, and its resulting effect on behavior and degree of sensitivity to pain and treatment. When those responses interfere with the ability to carry out everyday normal activities, such anxiety is said to be clinical, and the individual is usually referred for psychological intervention. When the patient is contemplating the aversive situation, and the current threat of pain, the practitioner can do much at this level to modify a patient’s perception of anxiety. The more a practitioner can respond to a patient’s current anxiety in a positive, compassionate and understanding manner, the less the patient is apt to consider the pain a threat. The practitioner’s proficiency in history taking is the key to this. Methods on how to do this will be discussed in a following section.

The major difference between anxiety and fear is the immediacy of the etiological agent. For purposes of this discussion, the term fear is used to denote the emotional response of the individual within the dental office, reserving anxiety for those responses or reactions in anticipation of the dental visit.

BEHAVIORAL INDICATORS OF ANXIETY^4,16–18

Outward manifestations of anxiety can be noticed in an individual in one of two instances. First, the office receptionist can play an important role as the first member of the dental team, since he or she has the earliest opportunity to detect any possible signs of aversive and negative behavior in the reception area. Some of these patient behaviors may be overtly visible:

• heavy breathing;
• facial grimaces;
• pacing;
• frequent changes in sitting position;
• frequency of urination;
• excessive conversation;
• accelerated heat rate;
• sweating and moist palms;
• informing the dental practitioner of their fears; and
• knowledge of preexisting emotional disorders.

An awareness of and ability to recognize these behaviors in an individual permits office staff to speak with the patient and make an effort to determine the possible cause of these reactions. Gaining early knowledge of the causes permits both staff and practitioner to respond in a manner that might alleviate some doubts or anxieties about pending treatment. Such insight might also help determine whether the patient’s anxiety stems from anticipation of treatment or from some other source, such as loss of employment, recent family tragedy, marriage problems, or a host of other factors. In addition, the presence of disorders such as depression, somatoform disorders, substance abuse, and posttraumatic stress disorder, all can affect the dental visit. Knowledge of these circumstances might persuade the practitioner to postpone the day’s visit, allowing the patient to deal with the present calamity without the added stress of the dental visit. Such an action on the part of the dental practitioner allows the patient to see his or her practitioner as someone who has the capacity to be understanding and compassionate, as well as a fine dentist. The frequent use of selfreporting questionnaires can yield much information and aid in predicting a patient’s levels of sensitivity to treatment, as well other anxiety- causing related events that might affect the dental visit.^13,19–25

Indirect indicators

Some overt behavior prior to dental treatment are symptomatic of anxiety over pending dental treatment. Taken individually, they may seem innocuous, but are obvious to the astute practitioner/staff. For example:

• frequent cancellations;
• frequent questioning;
• arriving late;
• multiple trips to the restroom;
• avoiding periodic check-ups;
• abnormal number of telephone calls;
• forgetting or missing appointments;
• multiple complaints;
• numerous different excuses; and
• unreasonable demands.

All these above actions are probably manifestations of anxiety/phobia to the dental situation. They may be the result of some personal past or present negative experience, or the result of some vicarious learning habits within the patient’s environment. When they continuously appear in an individual’s record, the practitioner must set aside a period of time to inquire about the cause of this behavior, and what can be done on the part of the practitioner/staff to ameliorate it. Understanding the root causes of such behavior allows the practitioner/staff to develop the means and behavioral modalities that will help assure treatment compliance and reduce existing stress on the part of all concerned. Sometimes, it may take only a brief explanation of upcoming procedures, a correction of false information, or the recognition of an underlying emotional disorder not yet successfully managed. Fear and anxiety is a multifaceted phenomenon, and the behaviors that practitioners and staff exhibit play an important role in a patient’s levels of fear and avoidance of care.

NATURE OF DENTAL ANXIETY

In order to identify and manage anxiety effectively, its nature must be clearly understood. Dental anxiety can be defined as a state of anxiety elicited by the provision of dental care. Anxiety is actually a multifaceted phenomenon that requires further analysis to guarantee its management. There are three characteristics essential in understanding dental anxiety: How fear and anxiety are manifested within the individual echelons of expression, timing, and severity.

(1) Echelons of expression;

• biological;
• psychological; and

(a) association;

(b) attribution; and

(c) appraisal

• sociological;

(2) timing; and

(3) severity.

ECHELONS OF EXPRESSION

At the biological echelon, anxiety is closely related to those physiological processes that mediate arousal. These processes are governed by certain mechanisms and systems within the brain, especially those involving subcortical regions and their connections with the higher cortical areas. At this level, anxiety is manifested in numerous ways, which include sweating, muscle tension, increased heart rate, hyperventilation and fearful facial expressions.

At the psychological echelon, anxiety is the result of a learning process that involves three features:

(1) Association refers to a process of learning in which pain eventually becomes associated with dental treatment, so that the dental treatment itself elicits a fearful/anxious reaction. This is a process of classic conditioning, whereby previously neutral stimuli (the needle, the sound of the drill, the sight of the instruments) become stimulants for arousal and anxiety through being paired with pain, one’s own past experiences, or similar negative experiences of others.

(2) Attribution is a process that occurs in response to a heightened biological arousal as discussed above. Here the patient must explain why such arousal has occurred, causing such unpleasant body symptoms and feelings. The individual may do so by attributing it to the fact that he or she is in the dental office, about to have a dental injection that is most likely to result in pain and discomfort. Therefore, the anxiety and accompanying unpleasant feelings must be due to this upcoming, potentially frightening experience.

(3) Appraisal is the process by which we think about past dental care. It involves the reconstruction of negative experiences rather than positive happenings that account for the accrual of anxiety —the pain of the injection, the ouch of the drilling. It is that appraisal in the role of cognition and how we think that is a very important aspect of anxiety. Such a cognitive appraisal may result in cancellations and avoidance. These characteristics can begin to operate early in life, even before contact with dental treatment, through vicarious learning experiences with family or friends. Many times, a family history of negative dental experiences, or instances of poor direct care will produce significant dental anxiety and avoidance. Other contributing factors also include the following:

• Some people do not visit the dentist very often and therefore do not have the opportunity to learn a different response other than negative thoughts, pain, and anxiety.
• There is sometimes a failure on the part of the dental practitioner to share information concerning treatment, limiting the ability of the patient to have any false ideas or cognitions dispelled. The patient’s knowledge frequently comes from his or her peers, who also may share negative associations about their dental experiences.
• Some individuals tend to remember the bad and negative experiences of dental treatment, often making it difficult to change memories and therefore modify aversive behavior.

Finally, it is also the process by which we think about past dental care, that sometimes causes us to form inaccurate or biased cognition about these past experiences, which then lead us to negative expectations about upcoming care. Such a cognitive appraisal may result in cancellations and avoidance. These characteristics can begin to operate early in life, even before direct contact with dental treatment, through vicarious learning experiences with family or friends. Often a family history of negative dental experiences, combined with a few instances of poor direct care, produce significant dental anxiety and avoidance. Psychological learning does not occur by itself; it has many root causes.

At the sociological echelon, anxiety is viewed as an outcome of interpersonal and social processes. For example, there is never a shortage of bad press concerning dentistry. One has only to pick up a newspaper or turn on the TV to see how often dentistry is at the core of a joke or portrayed as being painful and unpleasant. Although harmless by itself, this phenomenon demonstrates the generalized way in which dental anxiety is socially constructed. A less obvious example of the interpersonal process involves dental professionals themselves, in that they sometime unwittingly play a role in the development of dental anxiety through their behavior and attitude toward their patients. Anxious practitioners can create anxious patients, so the prevention of dental anxiety demands an awareness of one’s own feelings, as well as those of the patient during treatment.

TIMING OF DENTAL ANXIETY

The second characteristic associated with understanding the nature of anxiety is its timing. Frequently, dental anxiety is discussed only in term of its presence during treatment, but it also represents responses to situations that are sometimes somewhat vague, poorly defined and not immediately evident. This can be misleading because dental anxiety is often the result of a process that begins long before patients arrive in the reception room and continues long after they leave it. Therefore, the timing of dental anxiety can be also divided into three phases:

• pre-appointment;
• in-treatment phase; and
• posttreatment.

Pre-appointment anxiety refers to that anxiety that begins before the dental visit actually takes place. The thought and feelings of fear and anxiety are aroused within the individual in anticipation of the upcoming dental encounter. It is usually the most debilitating, since anxious patients often form inaccurate expectations about pain and discomfort before they receive treatment. During treatment, these evaluations do not differ from nonanxious patients, as both are capable of forming misconceptions of any facet of a visit. With this in mind, one can postulate that the identification and management of dental anxiety may need to occur before individuals begin treatment. Ideally, the collection of patient information should be an essential part of the initial appointment and history gathering. It should include past and present medical and dental history, both of the patient and patient’s family. An early assessment of any problem behaviors or psychosocial factors should be sought. Specific questions can be asked, which can help identify the complex patient behaviors, such as obsessive compulsive disorders, somatoform disorders, and/>