The nature of stress

Stress is an inevitable fact of life. Having stress is an experience that cannot be eschewed by the living. Perhaps stress should be viewed as the price we pay for being alive.

When an individual experiences, through physical sensation or psychologic perception, a need for a sudden adjustment or response, he/she might perceive the event as being stressful. The demands placed on the individual to adjust in the face of a dynamic situation may set into motion physical and internal reactions and sensations. The term “stress” has generally encompassed the adjustive demands or press placed on the individual and that individual’s biologic response to those demands .

Stress is experienced by the individual as a physical or psychologic tension that places his/her system into some level of disequilibrium. The perceived experience of stress should spur the individual to adjust to the attending challenges that the stressor or stressors engender. The efforts the individual undertakes to escape the tensions stimulated by stressors are often referred to as coping strategies or coping mechanisms. Neufeld conceptualizes stress as the consequence of inadequate or inferior coping skills or coping interventions. He suggests that the experience of stress and the attempts undertaken to cope with the felt stress are intertwined in an almost inverse fashion; the more efficient one’s coping skills, the less one’s perceived sense of stress is expected to be. Selye dichotomized the concept of stress by differentiating between the tensions that arise when positive life events demanding adjustments occur (eustress) and the adjustments undertaken in the face of perceived negative life events (distress). Being conferred the status of valedictorian might stimulate eustress; having an insurance company delay payment for an approved, complicated dental procedure may engender a feeling of distress. Whether the individual faces eustress or distress, he/she has to draw on his/her capacity to implement successful coping mechanisms; nonetheless, a cumulative history of distressful experiences has been correlated with the development of deleterious health consequences.

Butcher and colleagues point out three categories of stressors: frustrations, conflicts, and pressures. Frustrations can derive from either internally perceived or externally perceived obstacles, which can serve to thwart or stymie an individual’s goals or plans. A dentist, for instance, who cares little about engaging in certain procedures or, perhaps, views him/herself as unskilled in certain techniques endures frustrations springing from internal factors; not being permitted to expand a dental practice because of inadequate capital represents an external or an environmental source of frustration. Conflicts arise when an individual is presented or confronted with two concurrent and vying needs, motives, demands, or plans of action. Pursuing or fulfilling one’s need or plan of action precludes fulfillment of the other or competing need (opportunity cost). This phenomenon dovetails nicely with Festinger’s classic description of cognitive dissonance. For example, an established general dentist who wishes to pursue advanced training in orthodontics or in some other specialized training but weighs this path against the compromises to personal and professional obligations that such training will require experiences internal angst or conflict. One’s experience of stress may originate not only from frustrating or conflicting situations but also from the pressure to reach or meet particular sought-after goals or perceived imposed expectations. When pressure is experienced, the individual may feel compelled to work harder, longer, or more intensely than he/she normally would, which might overload his/her existing coping skills and lead to a concentrated experience of stress and even such maladaptive or self-destructive behaviors as self-medicating through drug ingestion to escape pressure. A dentist who expands his/her practice simply to please his/her spouse (external pressure) or because it will lead to greater recognition from colleagues (internal pressure) might experience prolonged stress as a consequence of these ill-conceived undertakings.

Physiologic aspects of stress

Whether stress stems from a biologic stimulus or from perceived psychologic press that demands a response or an adjustment from the individual, several physiologic processes, including the release of stress hormones, are activated. To appreciate why the stress we experience leads to sympathetic nervous responses such as tachycardia, increased perspiration, muscle contractions (especially in the trapezius and frontalis areas), the psychologic perception of apprehension and the release of corticosteroids and epinephrine and norepinephrine, one has to understand the stress response first described by Cannon and dubbed the “fight or flight” response. This stress response, or alarm reaction, directly results from the activation of the sympathetic division of the nervous system and from select glands in the endocrine system that are sensitive to stress. When the individual perceives an event as stressful, the adrenal glands, mediated by the pituitary gland, stimulate the production of corticosteroids and catecholamines, which activate the sympathetic response, alluded to earlier. Specifically, Selye pointed out that the anterior pituitary–adrenal cortex system is activated when stressors are perceived by the individual. Adrenocorticotropic hormone, released from the anterior pituitary, stimulates, in turn, the release of glucocorticoids from the adrenal cortex. The glucosteroids engender within the individual many of the sensations experienced during the stress response . In fact, the amount of circulating glucosteroids serves as a physiologic marker of the individual’s stress level. At the same time that the adrenal cortex stimulates the release of glucocorticoids in the system, the sympathetic response of the adrenal medulla releases higher levels of epinephrine and norepinephrine .

Selye advanced the concept of the general adaptation syndrome(GAS), which arises in the face of extended or extensive stress. Selye proposed that the GAS sets into motion an alarm response that does not cease until the energy turned on by the stress response is exhausted. Any perceived stressor, whether it is an internal response such as inhibition of inflammation, or a response to environmental stressors, such as a letter arriving from the Internal Revenue Service or a dentist interacting with a difficult patient, may set off the initial stage of the alarm reaction of the GAS. The alarm reaction, in turn, concurrently activates the sympathetic division of the autonomic nervous system and the segment of the endocrine system that responds to stress, which, again, is the essence of the fight or flight response. Although this response is functional during an actual or genuine threat to the individual, it is not functional when a situation bears no actual threat. Moreover, when an actual threat to the individual is removed, the parasympathetic division of the autonomic nervous system takes over and mediates a moderating influence, effectively halting the stress response. However, when personal and professional demands and stressors seem overwhelming and unremitting, we tend to adapt to a living pattern in which the stress alarm remains activated. In time, with the continued hyperarousal of the sympathetic nervous system, the individual may succumb to a stress-related illness or disorder.

In describing the GAS, Selye explained that when a stressor is experienced in prolonged fashion, the individual eventually enters into a phase of adaptation referred to as the resistance stage. During this stage, the endocrine system continues to emit stress hormones and sympathetic nervous system responses remain highly activated, notwithstanding the removal of the perceived threat. That is, our stress response remains at high alert when it should not. In further applying the GAS model, the individual will eventually reach an exhaustion stage, in which bodily resources are depleted and, by default, the parasympathetic division of the autonomic nervous system takes over. Despite the operations of the GAS, if the individual perceives that certain stressors serve as an ever-present threat (eg, work or monetary pressures, anticipation of difficult dental procedures or patients), the individual may be at risk for diseases of adaptation, such as heart disease. Cohen and colleagues emphasize that the buildup of cortical steroids in the system may account for why prolonged stress can contribute to the development of stress-related disorders and other issues. Although corticosteroids have usefulness in assisting the body cope with the physical aspects of stress, frequent cortical steroid deposits into the system will eventually debilitate the immune system because they tend to inhibit antibody protection, rendering the individual prey to opportunistic diseases .

One can anticipate that the dental practitioner who experiences frequent psychologic stressors, including dreading interaction with difficult patients, will tend to have increased levels of glucocorticoids, epinephrine, and norepinephrine. Such elevations in stress hormones are linked to the promotion of an array of physical disorders . Research has even shown that the experience of presurgical anxiety, especially of an exaggerated nature, has been linked to slow postsurgical recuperation and wound healing .

Physiologic aspects of stress

Whether stress stems from a biologic stimulus or from perceived psychologic press that demands a response or an adjustment from the individual, several physiologic processes, including the release of stress hormones, are activated. To appreciate why the stress we experience leads to sympathetic nervous responses such as tachycardia, increased perspiration, muscle contractions (especially in the trapezius and frontalis areas), the psychologic perception of apprehension and the release of corticosteroids and epinephrine and norepinephrine, one has to understand the stress response first described by Cannon and dubbed the “fight or flight” response. This stress response, or alarm reaction, directly results from the activation of the sympathetic division of the nervous system and from select glands in the endocrine system that are sensitive to stress. When the individual perceives an event as stressful, the adrenal glands, mediated by the pituitary gland, stimulate the production of corticosteroids and catecholamines, which activate the sympathetic response, alluded to earlier. Specifically, Selye pointed out that the anterior pituitary–adrenal cortex system is activated when stressors are perceived by the individual. Adrenocorticotropic hormone, released from the anterior pituitary, stimulates, in turn, the release of glucocorticoids from the adrenal cortex. The glucosteroids engender within the individual many of the sensations experienced during the stress response . In fact, the amount of circulating glucosteroids serves as a physiologic marker of the individual’s stress level. At the same time that the adrenal cortex stimulates the release of glucocorticoids in the system, the sympathetic response of the adrenal medulla releases higher levels of epinephrine and norepinephrine .

Selye advanced the concept of the general adaptation syndrome(GAS), which arises in the face of extended or extensive stress. Selye proposed that the GAS sets into motion an alarm response that does not cease until the energy turned on by the stress response is exhausted. Any perceived stressor, whether it is an internal response such as inhibition of inflammation, or a response to environmental stressors, such as a letter arriving from the Internal Revenue Service or a dentist interacting with a difficult patient, may set off the initial stage of the alarm reaction of the GAS. The alarm reaction, in turn, concurrently activates the sympathetic division of the autonomic nervous system and the segment of the endocrine system that responds to stress, which, again, is the essence of the fight or flight response. Although this response is functional during an actual or genuine threat to the individual, it is not functional when a situation bears no actual threat. Moreover, when an actual threat to the individual is removed, the parasympathetic division of the autonomic nervous system takes over and mediates a moderating influence, effectively halting the stress response. However, when personal and professional demands and stressors seem overwhelming and unremitting, we tend to adapt to a living pattern in which the stress alarm remains activated. In time, with the continued hyperarousal of the sympathetic nervous system, the individual may succumb to a stress-related illness or disorder.

In describing the GAS, Selye explained that when a stressor is experienced in prolonged fashion, the individual eventually enters into a phase of adaptation referred to as the resistance stage. During this stage, the endocrine system continues to emit stress hormones and sympathetic nervous system responses remain highly activated, notwithstanding the removal of the perceived threat. That is, our stress response remains at high alert when it should not. In further applying the GAS model, the individual will eventually reach an exhaustion stage, in which bodily resources are depleted and, by default, the parasympathetic division of the autonomic nervous system takes over. Despite the operations of the GAS, if the individual perceives that certain stressors serve as an ever-present threat (eg, work or monetary pressures, anticipation of difficult dental procedures or patients), the individual may be at risk for diseases of adaptation, such as heart disease. Cohen and colleagues emphasize that the buildup of cortical steroids in the system may account for why prolonged stress can contribute to the development of stress-related disorders and other issues. Although corticosteroids have usefulness in assisting the body cope with the physical aspects of stress, frequent cortical steroid deposits into the system will eventually debilitate the immune system because they tend to inhibit antibody protection, rendering the individual prey to opportunistic diseases .

One can anticipate that the dental practitioner who experiences frequent psychologic stressors, including dreading interaction with difficult patients, will tend to have increased levels of glucocorticoids, epinephrine, and norepinephrine. Such elevations in stress hormones are linked to the promotion of an array of physical disorders . Research has even shown that the experience of presurgical anxiety, especially of an exaggerated nature, has been linked to slow postsurgical recuperation and wound healing .

The interplay between psychologic stress and somatic disorders

We have significantly distanced ourselves from the dualistic notion, espoused by Descartes during the 17th century, that the mind and body are distinct and separate spheres. Much research is available that relates the impact of psychic stress to bodily dysregulation and illness. The diathesis-stress model has been posited as a theory designed to elucidate the mind–body relationship as it impacts the development or course of disease. A diathesis is conceived as a biologic or genetic predisposition, propensity, or vulnerability that places the individual at risk for falling prey to a specific disorder or disease syndrome. This theory further assumes that the burgeoning of a disorder hinges on the type and intensity of the stressors the individual encounters or sustains. The stressor or stressors that the individual experiences may run the gamut from prenatal or early developmental influences, physical or psychologic trauma, significant illness, familial pressures or dysfunction, the death of significant persons, working in an inhospitable environment, to, for the dentist, engaging a difficult or noncompliant patient.

The diathesis theory further asserts that an individual who harbors a diathesis for a specific disease or disorder may escape the illness if the degree of stress to which the individual is subjected is kept to a minimum, especially through applying effective coping strategies or techniques. Notwithstanding this point, it is also the case that the more forceful or vigorous the diathesis, the lower the level of stress needed to stimulate the manifestation of the disorder or dysfunctionality. The diathesis-stress theory has been presented frequently as a significant factor in the development of clinical depression . Lewinsohn and colleagues point out that the diathesis-stress model does not solely limit itself to biogenic factors; psychologically based diathesis is believed to be instrumental in accounting for the genesis of certain disorders during stressful life periods. Specifically, psychologic diatheses such as dogmatically adhering to irrational or faulty cognitions, having an anxious or inadequate personality structure, or experiencing emotional upheavals such as divorce, death, or familial strife, places the individual at greater risk for exogenous or reactive depression, which, in turn, can serve to compromise the immune system’s integrity.

The experience of prolonged stress has been closely linked to many physical or somatic disorders. It may not be the case that a particular psychologic disturbance such as depression or an anxiety-related disorder is causative to a disease process; nevertheless, psychologic factors often serve as contributory factors in the formation or exacerbation of physical disorders. For example, extant research presents evidence that stress can give rise to chronic headaches because it stimulates contractions to the muscles of the neck, scalp, face, and shoulders . In fact, when electromyogram biofeedback is used in stress management programs to treat nonmigraine or tension-related headaches, sensors are attached to either the frontalis or trapezius areas because both emit increased microvolts of energy when the individual feels tense. Sorbi and colleagues concluded that the cumulative experiences of so-called “minor,” albeit irritating, life stressors, combined with either a “quick-trigger” excitable or irascible temperament, or even sleep deprivation, may serve as significant factors in the development of different types of migraine headaches.

Cardiovascular disorders, such as coronary heart disease and hypertension, are tied to psychologic disturbances caused by stress and the individual’s characterological makeup. The intense or hard-driving lifestyle of the type A personality, with his/her concomitant characteristics of aggressive competitiveness and an inner or outward sense of hostility, is thought to be more prone than his/her non–type A (type B) counterpart to the development of cardiovascular disorders .

In more recent times, Denollet , through extensive research, was able to isolate the specific damaging emotions inherent within the type A personality that appear most linked to coronary heart disease and hypertension. Thus, the type A was refined into the current type D personality. Individuals who rank high on Denollet’s type D (distress) scale, especially by endorsing items suggestive of high levels of anxiety, hostility, and hopelessness, have a more than 400% greater probability of experiencing a cardiac attack or death within 6 to 9 months of undergoing angioplasty with stent placements, compared with non–type D peers who have received similar cardiac treatment.

Krantz and colleagues suggested that the demands of stressful occupations or professions (eg, dentistry) can be tempered by such personality traits as psychologic hardiness or flexibility. A wholesome professional outlook can, thus, moderate the effects of occupational stress and, in consequence, can lower the risk of developing coronary heart disease. Jorgensen and colleagues found that high levels of anxiety, anger, and depression, which are emotions often experienced during periods of stress, are correlated with the incidence of hypertension, a precursor of heart disease.

Although Helicobacter pylori ( H Pylori ) bacterium has been implicated in the development of many gastric ulcers, much evidence exists that supports the hypothesis that stress serves as a contributory factor or plays a maintenance role in the development, exacerbation, or perpetuation of a peptic ulcer . Thus, even in instances in which a bacterium is thought to give rise to an individual’s ulcer, stress may impede the healing process in the mucosal lining of the stomach or duodenum.

Although it might be dubious to advance the notion that stress is directly linked to the formation of malignant cancer cells in systems or organs, evidence is persuasive that psychologic states of depression may compromise the efficacy of the individual’s immune system, which, in turn, can influence the proliferation of cancer cells . Sklar and Anisman actually present evidence from animal and human studies that unchecked stress might serve as a contributor to the proliferation of tumors. Of course, if such research findings can be held up consistently, it would imply that proper stress management could serve to promote remission.

Research provides evidence that acute stress (eg, being in an anxious state when engaged in a difficult patient encounter) or chronic stress (eg, ongoing marital conflict) can negatively affect the integrity of the immune system. Prolonged or unmitigated stress may hamper phagocytosis, or the process by which phagocytes are able to engulf foreign microorganisms such as viruses. Some correlational studies suggest an existing linkage between sustained stress and susceptibility to infectious disease .

The foregoing segment essentially serves as a brief overview of some suspected consequences of long-term, or unchecked, stress. What follows serves as a “spotlight” on the stress that the dental practitioner experiences in dealing with different types of challenging patients, with an eye on better management of the stress.

What makes certain patients difficult to treat or interact with? Why are some patients noncompliant with the proposed treatment plan that was explained with due time and effort? How is the dentist best able to cope with the stresses and strains of an obstinate or incommodious patient? How does the dentist proceed with necessary treatment that a patient may needlessly turn into an Augean task?

The essence of cognitive behavioral psychology hinges on the basic tenet that it is not the “things, people, and places” we come across in life that disturb us; rather, it is the way we perceive or react to them. If we alter these perceptions, our feelings and actions become more rational. As we approach our challenges more calmly and realistically, we will discover that our reactions to the vicissitudes of life are experienced with less stress and struggle.

What makes a patient difficult? Some common explanations include:

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  Patient fear or anger

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  Faulty attributions or projected motivations or characteristics placed onto the practitioner

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  Inappropriate hostility displaced onto the dentist

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  Misinterpretation of what treatment is needed, or poor provider–patient communications leading to poor patient comprehension of treatment

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  Ingrained patient issues with perceived authority figures

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  Lack of patient trust in the practitioner

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  Clash between the inherent respective personality traits of the patient and dentist

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  Patient’s perception of the dentist’s lack of sympathy or caring regarding the patient’s plight

The difficult patient encounter

Concerning ourselves with the so-called “difficult patient” actually places the focus in the wrong place. What is difficult is the relationship, per se, between the patient and the dentist, and, for treatment to have the chance to succeed, the patient–dentist relationship requires change or improvement. Studies undertaken in the medical profession estimate that as many as 15% to 25% of the patient population are viewed as difficult .

When attempting to discern what contributes to a difficult patient–dentist encounter, it is necessary to ascertain which patient and practitioner characteristics contribute to the challenging interaction.

Patient characteristics

The following patient behaviors, perceptions, or traits appear to contribute to difficult encounters:

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  A patient who demands that treatment should proceed according to his/her understanding or predilection

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  A patient who is manipulative with respect to the dentist’s or staff’s time either through prolonging his/her visit or by cajoling staff for accommodations not provided to others

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  A patient who presents with vaguely expressed dental complaints

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  A patient who has dental complaints that have no biologic grounding or physical basis (somatization)

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  A patient who does not follow through with prior recommendations, or is otherwise noncompliant

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  A patient who minimizes the gravity or severity of his/her dental problems

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  A patient who provides “socially desirable” responses to questions posed by the dentist, thereby minimizing the true extent of his/her dental issues or degree of treatment compliance

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  A patient who assigns or transfers complete responsibility of care and treatment follow-up to the dentist

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  A patient who presents a multiplicity of complaints, many perhaps irrelevant, that stymie diagnosis or treatment focus

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  A patient who “straps” the dentist with his/her personal problems, confusing dental therapy with psychotherapy

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  The addicted patient who views the dentist as a ready source for benzodiazepine or opioid prescriptions

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  The chronic pain patient whose dental complaints tend to be diffuse or ambiguous and for whom sundry modifications in procedures need to be contemplated

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  A patient who clearly presents with either subtle or frank psychopathology, ranging from schizophrenia to bipolar to anxiety-related disorders

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  A malingering patient who is actively involved or seriously weighing the filing of a disability or workers’ compensation claim

If the dentist responds to any of these patient behaviors or presentations with anger, resentment, avoidance, dysphoria, deflation, or a sense of futility or helplessness, he/she will experience some level of stress and will view the interaction as difficult. It is clear that the most important first step is for the dentist to be cognizant as to why he/she perceives the patient encounter as difficult, and then he/she needs to use an appropriate coping strategy. This strategy might require a conscious effort to alter the perception of the patient or experience, effectively rendering the interaction with the patient as less stressful. Elder and colleagues , in a study surveying physicians on how they manage difficult patients, found that those who mentally braced and prepared themselves by taking inventory of their personal attitudes, biases, and expectations (in tandem, if need be, with the use of breathing and relaxation exercises) were better able to handle such difficult patient encounters.

Medical studies have shown that difficult, demanding, or troubled patients may actually be manifesting some level of psychopathology, which may range from mild to moderate to severe intensity . Highly anxious patients, for example, tend to express multiple complaints or might comment that the dentist or his/her staff is inattentive or unresponsive to his/her needs, which, in fact, is not the case. Another subset of patients may be diagnosed with a personality disorder and will present with such intractable, characterological issues as manipulativeness, obduracy, dependency, or narcissism. Bodner has previously addressed the psychologic aspects of chronic pain patients and the various personality traits and styles they adopt which parallel, in many respects, patients who engender difficult encounters.