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WFDAQ KEY AND EXPLANATIONS |
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Responses to Questions 3,4,& 5 will highlight any avoidance patterns thereby aiding a diagnosis of a phobia. Anxiety, fear and phobia are words which often seem to be interchangeable however there are important differences. ANXIETY – Reaction to an unknown, ill-defined, or not immediately present danger. FEAR – Reaction to a known or perceived threat or danger. Leads to activation of the “fight or flight” response. “The things we fear the most have already happened to us”. Deepak Chopra. PHOBIA – Persistent, unrealistic and intense fear of specific stimulus, leading to the avoidance of the perceived danger. The avoidance often causes significant distress or interferes with social or role functioning. A phobia may be a social phobia or it may be a specific phobia. A social phobia may be a fear of being observed doing something humiliating or embarrassing, e.g. in a dental setting- a fear of vomiting as a result of excessive gagging. A specific phobia is a fear associated with a particular object or situation. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (American Psychiatric Association 1994), dental phobia (aka odontophobia, dentophobia, or dentist phobia) is one of the specific phobias. The diagnostic criteria of specific phobia include:
Question 6 highlights any history of a previous bad experience, and the possibility of a learning theory aetiology of a phobia. The Behavioural (or Learning) Theory – ‘a bad previous experience’. Bernstein et al, (1979) described a painful or unpleasant previous experience being a major cause of dental phobia. The dental phobia may be the result of learned association between pain and the dentistry. Multiple exposures to traumatic experiences may be needed for the development of a phobia. ‘Pavlovian (or classical) conditioning’ is widely accepted as a significant cause of phobia. (Lautch 1971, ter Horst & De Wit 1993.) How does this theory work? Initially innocuous stimulus – Conditional Stimulus (CS) followed by; Traumatic event – Unconditional Stimulus (US) Produces fearful response – Unconditional Response (UR) Following this pairing (especially if repeated) CS can then evoke a Conditional Response (CR) (similar to UR) even without US
In their classic demonstration of the acquisition of a phobia in an 11 month old boy (Little Albert) Watson & Rayner (1920) presented the child with a white rat (CS) that initially produced the positive response of reaching out to touch it. However, the experimenters then produced a loud noise (US) behind Little Albert’s back by hitting a metal bar with a hammer. Not surprisingly this startled the child and when the procedure was repeated for a second time the child began to cry and show signs of fear (UR). On subsequent occasions when the rat (CS) was shown to Albert, he showed a fear response (CR) and began to cry, trying to crawl away to escape. This acquired fear (phobia) was also said to have generalised to fur coats, and even the beard on a Father Christmas mask. It is easy to see how a process of this sort could lead to both general and specific phobias in dental settings. If aspects of the dental surgery or the procedures being carried out are associated with a traumatic event those formerly innocuous stimuli may become the focus for a later phobic response. For Example: CS : Dental procedure in dental surgery – (no fear from child with no previous painful experience or no expectations.) US : Painful experience with procedure. UR : Fearful response. Repeated exposure to CS (prospect of dental procedure in dental surgery) leads to CR – fearful response.
So why do learned fear responses (phobias) persist? If a CS is repeatedly presented without being paired with the US, a process of extinction takes place and the CS is no longer able to evoke the CR. For example if Little Albert was to have been repeatedly exposed to the white rat (CS) without reinforcing parings with the US (loud noise) the laws of Pavlovian conditioning would predict that the strength of the fear response (CR) to the white rat alone would diminish and disappear (extinguish) quite quickly. There is a similar problem with a more cognitive account of the phobia- surely each time the rat was presented there would be an opportunity for cognitions about it to change- it is not really dangerous, no disease has ensued, it doesn’t attack- in fact it is a perfectly harmless animal. Similarly for modelling – there would surely be occasions over time where other people would model perfectly calm and non-phobic reactions to the phobic object or situation. So why do phobias persist? The clue lies in the definition of phobia which says that the fear leads ‘to the avoidance of the perceived danger’. Extinction does not occur because the phobic individual avoids the feared object or situation and so does not have ant opportunity for extinction (or for changed cognitions or new modelling experiences). In fact the very act of avoiding is rewarding in its own right and so, learning theory would say, is continuously strengthened, not weakened. If the phobic individual is presented with the possibility of encountering the feared object or situation, anxiety rises to uncomfortable levels (which causes a reduction in the unpleasant feelings (negative reinforcement), which makes the avoidance response more likely on future occasions (and prevents exposure to the CS- thereby preventing extinction). Phobics in other words do not ‘reality-test’.
Question 7 will indicate whether there is a problem with an unrealistic expectation of the experience of pain. Expectation: Kleinknecht and Bernstein (1978) suggested that anxiety may lead to an increase in pain experienced and pain will heighten anxiety. Anxiety and expectation may therefore affect pain tolerance and threshold. Question 8 will indicate if modelling has been an aetiological factor Modelling A fear or phobia may develop by observing another individual’s fearful response to an object/situation (especially if the individual is ‘significant’ e.g. a family member). Fear is then associated when that person comes into contact with the object/situation. In this way, by a process of social contagion, whole groups (especially whole families) may develop a particular phobia. Forgione and Clarke (1974) reported that relatives of dentally anxious patients had more negative attitudes to dentistry themselves. Effect of Cognitions: Ideas, thoughts and beliefs about the phobic object may develop and be elaborated over time. In some cases, these cognitions can be the sole aetiology of the phobia. E.g. hearsay, hearing stories, reports etc. regarding extractions, fillings, other people’s accounts of painful experiences, anaesthetic not working etc. Also a similar process may occur with cartoons, TV programmes and films depicting a negative emotion in conjunction with dental treatment. Another example is the parent giving detrimental comments while their child is in the chair such as “I wouldn’t let you do that to me”, or “Sit still Albert or the dentist will use his big needle to give you an injection and pull out your teeth”, etc.
Question 9 may highlight any links with the theory of Preparedness. Prepardness. De Silva, (1988), suggested that fears such as heights, spiders, snakes etc may indicate an innate predisposition or preparedness to anxiety. We may be prepared by evolution to fear things which were or may be dangerous. By being naturally fearful of (for example) poisonous spiders, our ancestors survived to pass on their DNA (including the ‘prepared phobia’) to the next generation. It is unfortunate for dentistry that dental surgeries and procedures seem to incorporate some very potent ‘prepared’ stimuli and situations (instruments which could cause pain or injury, invasion of personal space and of bodily boundaries, surrender of control and submission to a dominant other). On this account dental phobias could be argued to be as ‘prepared’ as spider phobias. This would also explain why the majority of people have some level of anxiety regarding the stimuli and situations associated with the dental surgery.
Question 10 may reveal a biological sensitivity to pain or at least that the patient believes that this may be the case. It may also indicate a high expectation of pain. Due to biological differences: some people may have, or believe they have lower pain thresholds. Question 11 will reveal any uncertainty the patient may have regarding treatment and provide an opportunity for clarification of procedure. Uncertainty itself can provoke anxiety and ‘fear of the unknown’ (Epstein & Roupenian 1970). This anxiety usually does not progress to become a phobia if it is the only factor. Question 12 addresses the issues of expectation and mistrust. Mistrust of dental personnel is an important issue and includes the fear of unnecessary or wrong treatment. The importance of trust and other dentist-patient relationship interaction are discussed by Kroeger (1988) and Freeman (2000). Question 13 allows people with strong gag reflexes to be identified, it may also highlight a fear of catastrophe. Question 14 again highlights any history of a previous bad experience, and the possibility of a learning theory aetiology of a phobia. Question 15 indicates the possibility of a fear of catastrophe. ‘Fear of catastrophe’ whereby the patient incorrectly believes that the procedure may threaten their life. This includes fear of allergy, heart attack, cerebral aneurysm, gagging/choking to death, etc. They are hypersensitive about bodily sensations e.g. sweating, heart palpitations, breathing, etc. believing these to be symptomatic of whatever they fear, when in fact they are due to the panicking itself.
Key to Questions 16-21: Each Question (16-21) is marked: a)= 1 b)= 2 c)= 3 d)= 4 e)= 5 CORAH (Not incl. Q18 & 19): Non or slightly anxious = 4 to 12/20, Moderately anxious = 13 & 14/20, Highly anxious = 15 to 20/20. MODIFIED CORAH: Non or slightly anxious = 6 to 18/30, Moderately anxious = 19 to 21/30, Highly anxious = 22 to 30/30 Two questions are added in the Modified Corah DAS –(18 & 19) allowing more specific stimuli to be identified. The original Corah DAS would not aid diagnosis of dental needle phobia.
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