Assessment of Dental Phobia and Anxiety
Thorough assessment and accurate diagnostics are important for both clinical and research purposes. A correct diagnosis will aid in the construction of an appropriate treatment plan and in the long run, lay the groundwork for optimal treatment. In terms of the cross-disciplinary treatment plan for dental phobia, a psychologist performs the diagnostics and the dentist undertakes the phobia treatment. The criteria for phobias in general and specific phobia in particular have changed over time and with new editions of both the American and European diagnosis manuals. In the first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) (APA 1952), specific phobia was categorized under ‘phobic reaction’, then ‘phobic neurosis’ in DSM-II (APA 1968), ‘simple phobia’ in DSM-III (APA 1980) and finally as ‘specific phobia’ in DSM-IV (1994).
Currently there are seven criteria that must be met in order to qualify for the diagnosis ‘specific phobia’ (300.29) in DSM-IV: The core characteristic of a specific phobia is a considerable and persistent fear in response to the presence or anticipation of a specific object or situation (Criterion A). Exposure to this stimulus will almost always evoke an immediate anxiety response (Criterion B). The individual recognizes that the fear is unreasonable or excessive (Criterion C). The phobic object/situation is either avoided or endured with strong anxiety (Criterion D). Clinical impairment must be present: The fear, anticipatory anxiety or avoidance behaviour must interfere with the person’s social or occupational functioning or daily routines, or there is considerable distress about having this phobia (Criterion E). In adults there is no requirement concerning duration but in individuals under the age of 18, the phobia must have lasted for at least six months (Criterion F). Finally, the symptoms cannot be better explained by any differential diagnosis (Criterion G). One must be aware that, in children, the anxiety and panic may manifest itself as anger, crying, clinging or freezing behaviour. They may also not be able to recognize that the fear is excessive or unreasonable.
In the diagnostic manual of the World Health Organization: International Classification of Disorders (ICD-10) (1992) specific phobias are labelled under F40.2 Specific (isolated) Phobias. Only three criteria are outlined in ICD-10 versus seven in DSM-IV. It states that the individual’s symptoms must represent ‘primary manifestations’ of anxiety rather than being symptoms of obsessional or delusional thought (a). Second, the anxiety must be circumscribed to a particular situation or object (b) and there must be avoidance whenever possible (c). This means that DSM-IV and ICD-10 differs in that the DSM-IV includes the role of anticipatory anxiety, degree of anxiety, recognition by the patient of excessiveness or unreasonableness of the fear and the impact the phobia must have on a person’s life in order to qualify for a diagnosis.
There are five subtypes in the DSM-IV: animal, environment, blood-injection-injury (BII), situational and ‘other’. In DSM-IV, dental phobia is categorized as a part of BII, since dental treatment is regarded as a medical procedure. The ICD-10 does not purposely state any subtypes.
The most relevant differential diagnoses for dental phobia are the other anxiety disorders: panic disorder with agoraphobia (F40.01/300.21); social phobia (F40.1/300.23); post-traumatic stress disorder (PTSD) (F43.1/309.81); and obsessive-compulsive disorder (F42/300.3). It is also essential to assess the BII phobia in its totality, of which dental phobia is a subcategory. In order to assess differential diagnoses, questions should be aimed at exploring which stimuli provoke fear, why the patient feels anxious or avoids the dental situation, and it can be helpful to include how the fear developed.
The unifying core emotion of these disorders is anxiety. The anxiety is circumscribed to specific objects or situations. Post-traumatic stress disorder is the only disorder that represents a fear of something that has happened in the past.
In a dental phobia, common negative cognitions are that the pain from the dental procedure will be so strong that it is experienced as intolerable; loss of control in the dentist’s chair; being subjected to negative behaviours from the dentist; being embarrassed in the treatment situation; and finally being subjected to serious treatment errors from the dentist (De Jongh, Aartman and Brand, 2003).
In intra-oral injection phobia, the focus is on the injection itself. Common fears are intolerable pain, dying from this pain, dying for some other reason due to the injection; going insane; bodily harm; and finally that the pain from the injection will become continuous (Öst et al. unpublished manuscript). This phobia differs from dental phobia as these patients would be fine if dental treatment could be done without the need for anaesthetic injections and only fear what could happen as a consequence of an intra-oral injection.
In extra-oral injection phobia, the primary fear is that one will experience such strong pain from the needle that one cannot stand the pain and lose control. Furthermore, these patients often fear that the injection or venipuncture will lead to permanent body damage, e.g. they will become ill or die from the injection, the vein will not stop bleeding. This differs from dental phobia in that injection phobics fear injections anywhere on the body but do not fear the typical dental stimuli.
In blood phobia, the primary fear is fainting. Cognitions related to fainting are: losing control (of one’s bodily functions); never waking up; losing one’s memory; and brain damage. The secondary fear is usually falling, being hurt and feeling pain because of that and that the wound will not heal and, thus, one would bleed to death. The blood phobics may also fear fatal consequences of fainting. The blood phobia can generalize and comprise situations concerning venipuncture, receiving injections and so on. This condition differs from dental phobia in that blood phobics fear fainting when exposed to blood stimuli and usually do not fear typical dental phobic fear stimuli.
The primary fear in claustrophobia is to be in an enclosed space and being unable to leave the situation when an anxiety reaction is experienced. This condition is different from dental phobia in that claustrophobic patients are fine with dental treatment as long as they can leave the situation when they find it necessary. They do not fear the typical dental stimuli.
In social phobia, the individual would be most concerned with the dentist’s or other personnel’s evaluation of him or her, especially if symptoms of anxiety could be detected. Thus, social phobics differ from dental phobics in that they do not fear the dental treatment stimuli but that the dental situation may become embarrassing if they cannot comply or if they show anxiety reactions.
In panic disorder with agoraphobia, the patient will be most afraid of having an unexpected panic attack and not being able to escape and/or carry out safety behaviours (idiosyncratic behaviours which reduce anxiety in the short term but maintain the disorder in the long run). This differs from dental phobia in that these patients do not fear the typical dental fear stimuli and will be fine as long as they know that they can leave the dentist’s chair if a panic attack occurs.
In obsessive-compulsive disorder (OCD), obsessions and compulsions can involve various themes. If the main theme is fear of contamination, this may translate to the dental treatment setting as well. OCD patients do not fear, however, the typical dental phobic fear stimuli. They are fine with dental treatment as long as they are convinced that they will not be contaminated by them.
In post-traumatic stress disorder (PTSD) one’s primary fear is linked to an event in the past. This disorder can manifest itself with difficulties receiving dental treatment, especially if the trauma concerns the mouth as in some forms of torture or molestation.
Any assessment of dental phobia should focus on assessing the severity of the anxiety (subclinical or clinical levels), and possible differential diagnoses in order to help the therapist arrive at an idiosyncratic functional analysis of the phobia. A functional analysis contains a description of which situations/stimuli represent danger to the patient and the maintaining factors (e.g. belief in catastrophic cognitions and avoidance behaviours). The level of anxiety can be assessed in various ways and the most relevant ones will be described in this section. Some of these are applied mostly in a research setting and others mostly clinically.
Behavioural and physiological assessments
A graded behavioural approach test before and after treatment is probably the measurement of best ecological validity and which can clearly illustrate what a patient is able to do in terms of dental treatment. This type of assessment is probably used mostly in a research setting but could represent a powerful assessment tool as well as a source of mastery for the patient when used after the phobia treatment is completed. This test should be performed by someone other than the treating dentist. Such a test can, for example, begin with entering the dental treatment room and end by filling a cavity (e.g. Haukebø et al. 2008). This measure has only been used in five randomized controlled trials (RCTs) so far (Gauthier et al. 1985; Haukebø et al. 2008; Jerremalm, Jansson and Öst 1986; Mathews and Rezin 1977; Wroblewski, Jacob and Rehm 1978).
Clinically, a structured rating of the patient’s overt behaviour during dental treatment by the treating dentist can easily be included. A scale such as the Dental Operatory Rating Scale (DORS; Kleinknecht and Bernstein 1978) can be utilized. This scale quantifies the patient’s activity according to general activity, specific activity (e.g., movement of arms, hands, feet and head) and postural status. Only three RCTs have utilized such a measure (Berggren and Linde 1984; Getka and Glass 1992; Jerremalm et al. 1986).
As anxiety is rooted in, and thus accompanied by, a wealth of psychophysiological responses, the level of anxiety can be assessed by changes in these. Mostly used in a research setting, five RCTs have utilized such methods (Getka and Glass 1992; Jerremalm et al. 1986; Lundgren, Carlsson and Berggren 2006: Miller, Murphy and Miller 1978; Thom, Sartory and Jöhren 2000). Measures of skin conductance, heart rate and electromyographic response are most widely utilized.
Structured clinical interviews
None of the above measures are used as diagnostic tools but rather supply supplementary information pre-and post-treatment. To date, the two most commonly used semi-structured interviews within the field of anxiety disorders, which arrive at a diagnosis, are the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I; First et al. 1996) and the Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV; Brown, DiNardo and Barlow 1994; DiNardo, Brown and Barlow 1994). These are also the diagnostic interviews of choice for dental phobia.
Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I)
This interview assesses many of the Axis I disorders in DSM-IV. It comes in a research version (patient and non-patient) and a clinical version which is shortened for use in clinical settings. Current diagnoses are assessed as well as the lifetime prevalence for a few of them. One can use the section concerning the anxiety disorders to arrive at the diagnosis of specific phobia and at the same time achieve an evaluation of relevant differential diagnoses: panic disorder with agoraphobia, social phobia, obsessive-compulsive disorder and post-traumatic stress disorder. It divides the severity of the phobia into three categories (mild, moderate and severe), as well as the course of the disorder (partial remission, full remission and fully restituted). Lobbestael, Leurgans and Arntz (2010) found moderate to excellent inter-rater reliability for the Axis I disorders. Williams et al. (1992) showed good test–retest reliability and acceptable inter-rater agreement concerning lifetime prevalence and current prevalence of the disorders. In terms of validity, there are studies showing superior validity of the SCID over standard clinical interviews at intake episode (Ramirez Basco et al. 2000; Fennig et al. 1994; Fennig et al. 1996; Kranzler et al. 1995; Kranzler et al. 1996).
Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV)
This semi-structured interview assesses the presence of DSM-IV anxiety disorders. There are two versions of the ADIS-IV available: a standard version assessing the current diagnoses and a lifetime version assessing both the current and lifetime prevalence of the diagnoses. It provides dimensional ratings of 17 situations/objects connected to specific phobias and 13 situations for social phobias. ADIS-IV also gives important information for a functional analysis of the anxiety disorders; more so than the SCID-I. Sections screening for mood, substance and somatoform disorders are included due to high comorbidity rates with />