Complications of Intravenous Diazepam Adverse Psychological Reactions. (An assessment of 16,000 cases) N. Bruce Litchfield, M.D.S., F.R.A.C.D.S.

INTRODUCTION of schizophrenic disorders such as autism, paranoid The author is presently engaged in an assessment delusions and hallucinations. Another' found that of 16,000 cases overall, including seven detailed diazepam was more effective with patients in the psy- studies of 6,000 cases over a thirteen year period choneurotic category but found that the eight pa- where intravenous diazepam has been used in general tients examined with phobic reactions had the least dental practice in order to determine the incidence successful response. of complications. It is well established that diazepam causes depres- The benzodiazepines have been proved to be sion and 'suicidal tendencies in quite a high propor- relatively free of side effects compared with the tion of patients who are on long term oral diazepam phenothiazines, barbiturates and most other therapy5'8 It was even stated8 that diazepam no longer similar drugs. However, they do produce some can be recommended as a useful drug in psychiatric complications, which are related to their emotional illness, but is recommended for the alleviation of and prolonged central depressant effects. The limbic anxiety in those suffering from psyehoneuroses, and system of the brain contains many reverberatory must be used with special caution in psychotic or circuits and the benzodiazepines, by interfering with severely depressed patients. The effects of 30 mg. of transmission, can affect mood and memory. diazepam or 45 mg. of phenelyzine were compared' Of the benzodiazepines, diazepam, flunitrazepam in patients who were divided into depression sub- and lorazepami have been used intravenously. Mid- types instead of their responses and found that there azolam, a new product which shows promise, is still was a significant number of anxious patients who undergoing clinical trials. Diazepam is the onlv bein- responded to diazepam but it was a poor treatment zodiazepine available for intravenous use in Australia for hostile depressives. These patients were restless, and has been proved to be very useful in dentistrv anxious, negativistic, suspicious and irritable. Oxa- since 1967. zepam did not appear to provoke these reactions The complications of diazepamn, previously noted, and the potential of diazepam for provoking them largely relate to long term oral administration ancl might be related to its unusually slow metabolic con- most research has been devoted to this. Much less version to oxazepam in certain individuals. These research has been done relating to its parenteral untoward effects have also been observed in normal administration, particularly in the comparatively subjects. 1 12 large single doses commonlv used in dentistrv on Soon after diazepam was used intravenously in amlulant and reasonably healthy patients. It has i)een dentistry in 1967, it was found that adverse psycho- well stated recently bv Donaldson and Gibson' that logical reactions occurred at a relatively high fre- reports in the literature of complicationis of intra- quency in children, adolescents and those psycho- venous diazepam have been sparse, indicating its logically disturbed. These reactions made operating high therapeutic index. conditions difficult even though patients may have Diazepam is administered because of its sedating, been amnesic at the time. Carmichael and McDonald tranquilizing, amnesic aind relaxing properties. If an " found several cases in which intravenous diazepam opposite (paradoxical) reaction occurs, it is classified was ineffective in tranquilizing adult patients and that as an adverse psychological reaction anid it is these they were unable to claim a success rate of greater that the author reports on. than 60-70% of the age group 7-16 years and that there is a hard core of adults and children on whom REVIEW OF satisfactory operating conditions cannot be achieved LITERATURE with any of the currently available sedation tech- Adverse psychological reactions to oral diazepam niques. Foreman'4 commented that no single method were found SOOI1 after the drug was first produced. of sedation is a panacea and although the majority One report2 stated that (liazepamn (lid not help of difficult patients respond well to intravenous di- chronic schizophrenic patients when given in the azepam, there are some highly resistant, often psy- dosage of 30 mg. daily. Another3 found that while chological disturbed patients who can be treated diazepam was effective in 77% of all psvchiatric con- only with general anaesthesia and even this will not ditions it did not, however, affect the second order always be without problems. Brown et al15 examnined NOVEMBER-DECEMBER 1980 175 one hundred and eight patients for minor oral sur- ually aroused in the recovery room or at home. gery and found that 4.6% of cases gave poor results There was no admission of sexual arousal during the in the operator's opinion. Their experience using operative period. diazepam with children has been disappointing; even It is clear from this review of the literature that among adults there are those whom it is impossible reports of adverse psychological reactions to intra- to sedate satisfactorily with the drugs presently avail- venous diazepam in dentistry are scanty and scattered able. They were not able to change a person's basic and because of this it was decided to examine the attitude, especially those who were aggressively un- matter in greater detail. cooperative. Shane'16 mentions that diazepam alone or with methohexitone is unsatisfactory for long Material and Methods operations or for the surgical removal of impacted The occurrence of adverse psychological third molars because it creates restlessness and irrit- reactions during the thirteen year period when ability in teenagers and young children soon after intravenous diazepam was used in general dental its administration. Hodge'7 refers to "sedation- practice may be divided into three groups: resistant patients" and states that these may react 1. Immediately after injection during the operative quite violently and vocally to prevent the operator period, manifesting itself in talkativeness, obtaining reasonable operative conditions. He states emotional release, loss of inhibitions, excite- that there may be no obvious indication of the pa- ment, rage, abreaction and other paradoxical tient's sedation resistance until the treatment has reactions. commenced. 2. Immediately post-operatively and during the Sara'8 comments that the success rate of intrave- day of the operation. These manifest themselves nous diazepam would appear to be around 85%; as a continuation of the complications occur- children and adolescents do not react well. Success ring during the operative period, euphoria and with diazepam as a hypno-sedative depends firstly on a false sense of well being, depression, insomnia the faith and enthusiasm of the administrator in the and distortion of time, events and actions. medication and this attitude is then communicated 3. Extending beyond the day of the operation to the patient. Understanding the patient's problem which is seen in prolonged recovery of the com- and supplementing diazepam with the dentist's atti- plications already referred to, especially depres- tude is necessary for success. sion, excitability and hallucinations. Other com- In a survey of two hundred dentists, taught intra- plications of course can occur and are those venous sedation by Trieger'" and who had been given normally expected for diazepam. a questionnaire to complete which included various Another important factor which affects the oc- complications, it was found that of the 157 dentists currence of adverse phychological reactions is the who responded, 9% reported hyperexcitement as addition of other drugs. In most of the 16,000 cases one of the complications. Donaldson and Gibson' when intravenous diazepam was used by the author, assessed two hundred and twentv cases over a seven small amounts of metho hexitone were added. This year period of complications from intravenous di- resulted in much fewer adverse reactions during the azepam, which were reported to the United States operative period but as it wore off, being short Department of Health, Education and Welfare, of acting, adverse reactions appear and even extend patients from all different categories. Included among beyond the day of the operation. them was "hysteria" with an incidence of 9.5% of all The author has made a special study of diazepam the complications. They state that the delayed onset used alone in the first two of the seven studies un- of hysterical reactions and hallucinations make it dertaken. A part of the first study2' related to the use mandatory for out-patients receiving intravenous of diazepam alone in four hundred and forty-five diazepam to be escorted for the remainder of the cases in general dentistry, on patients ranging from day. 2-83 years. The average dose of diazepam was 20 mg. Campbell et al2" in examining 110 oral surgery pa- and it was used with atropine sulphate (0.5 mg.) fol- tients who had fentanvl, diazepam and methohexi- lowed by local anesthetic. tone sedation, found that in addition to having The second study22 involved one thousand oIne other complications, had adverse psychological re- hundred and forty-two oral surgery patients, the actions which did not involve violent physical and majority of whom were over fifteen years of age. emotional behavior during or after the surgery. In most cases, diazepam was used by itself but in However, during the surgery, in the recovery room some, a very small amount of metho- or after returning home, 15 out of the 110 adlmitted hexitone was added. These first two studies have to episodes of dreaming, hallucinations or sexual been used to determine the incidence of adverse arousal. Of these, nine stated that they seemed to phychological reactions to diazepam during the op- recall periods of intra-operative dreams. Two ad- erative period. Other studies also helped in the gen- ditional ones had similar responses at home, while eral assessment of adverse psychological reactions two patients had unpleasant hallucinationis in the re- during the operative period. A third studv was an covery room and two adInitted to having been sex- assessment of intravenous diazepam used onl the

176 ANESTHESIA PROGRESS very young and very old.23 A fourth study was an Full details of these first studies have been assessment of intravenous diazepam used on twenty- reported 21"22 and include details as to the procedure five severely handicapped patients."4 A fifth study in- adopted, age, dosage, duration of the operation, volved two hundred and sixty-seven patients who apprehensiveness of the patient, type of procedure underwent pedodontic treatment and all of whom involved, as well as the results, and will not be en- were under twelve years of age.25 larged upon here. It is the results of the sedation A sixth and major study of 2,470 cases investigated that are of special interest in this report. the incidence of prolonged recovery and an assess- ment of adverse psychological reactions occurring Results beyond the day of the operation was made. The The results of the sedation are shown in Tables complications examined were depression, excitabil- 1, 2 and 3. Averaging the results from the two studies ity, insomnia, and hallucinations. Other compli- showed that there was an overall incidence of ad- cations relating to prolonged recovery were also verse psychological reactions of 29.03%. While this examined. figure may appear to be high, it should be kept in Initially, the patient was carefully assessed den- mind that it included persons who exhibited only tally, medically and psychologically; had intravenous relatively minor adverse reactions. The incidence of sedation explained to them and precise pre-opera- poor results which indicated pronounced adverse tive and post-operative instructions given verbally psychological reactions was 6.9%. and in writing. An appointment was then made for In the first study, which was of four hundred and the patient to return for the intravenous sedation thirty-two patients who underwent general den- session. tistry, moderate and poor results appeared in one Throughout the series, the dosage of diazepam hundred and forty-nine which represents 34.5% and administered ranged from 5 to 50 mg. with an av- poor results appeared in forty-four which was erage of 20 mg. On larger treatment sessions, some- 10.2%. Moderate and poor results were highest in times a second increment of diazepam was injected the 12 to 19 year group at 36.58%, in the 20 year about one hour after the initial injection. If and over 34.0%, and lowest in the under 12 year methohexitone was used, 10-20 mg. was injected group at 33.33%. However, in the poor result cat- when required, to maintain the level of sedation egory, the incidence was highest in the under 12 year produced by the diazepam or to deepen the sedation for the administration of local anaesthetics or some other painful procedure, or to mask adverse Table 1 psychological reactions. Adverse Psychological Reactions to Diazepam During the operation, the patient was supine with a blanket covering the body from the neck down- First Study wards and remained in this position for thirty to Moderate and Poor Results and (Poor Results) sixty minutes post-operatively and was then taken to TOTAL - 432 PATIENTS, MODERATE AND the recovery room for a further similar period be- POOR RESULTS - 149 (34.5%) fore being assisted to a nearby waiting car to be POOR RESULTS 44 (10.2%) escorted home and properly cared for the rest of (PER CENT OF AGE GROUPS) that day and night. 1-11 The method of assessing the incidence of adverse years 12-19 years 20 and over psychological reactions in these first two studies was Males 11.1 ( 2.78) 17.07 (2.44) 9.87 (5.10) on the basis of categorizing the results of the se- Females 22.22 (13.89) 19.51 (8.54) 24.20 (4.14) dation into "good", "moderate" and "poor" work- Combined 33.33 (16.67) 36.58 (1.97) 34.07 (9.23) ing conditions with moderate and poor indicating Moderate and Poor Results and (Poor Results) varying degrees of adverse reactions. Good oper- ating conditions indicated that the patient was ideallv (PER CENT OF SEX) relaxed, sedated, amnesic and was pleased with the 1-11 technique. Moderate operating conditions were years 12-19 years 20 and over when the patient moved around and reacted a little Males 23.52 (5.88) 34.14 (4.88) 30.69 (15.84) to stimuli but nevertheless the procedure could be Females 42.10 (29.41) 39.02 (17.07) 35.68 (6.10) carried out satisfactorily without too much incon- venience. Poor operating conditions indicated that Apprehensiveness the patient reacted badly in the form of crying, Very Apprehensive excessive talking, movements of the body to even (PER CENT OF SEX) the slightest stimuli and other unusual psychologic behavior. In all cases the dentistry was completed 1-11 years 12-19 years 20 and over but only with great difficultv in some. Ini most in- NMales 70.58 43.90 25.74 stances the patients were amnesic during the pro- Females 57.89 43.90 32.86 cedure and were generallv satisfied.

NOVEMBER-DECEMBER 1980 177 Table 2 Table 3 Adverse Psychological Reactions to Diazepam Adverse Psychological Reactions to Diazepam Second Study, 1142 Oral Surgery Cases Related to Dosage (MG) Moderate and Poor Results and (Poor Results) (% of dose group) MODERATE AND POOR RESULTS, 269 (23.56%) 0-9 10-19 20-29 30-39 40-49 POOR RESULTS 40 (3.50%) (PER CENT OF AGE GROUP) STUDY 1 14.28 39.71 67.56 22.81 60.0 (454 cases) 3-11 years 12-19 years 20+ years STUDY 2 30.59 21.44 43.75 Males 25.58 (4.65) 11.66 (1.84) 7.53 (0.68) (1142 oral Females 23.26 (6.98) 13.50 (2.45) 12.33 (1.51) surgery cases) Combined 48.83 (11.63) 25.15 (4.29) 19.86 (2.19) Moderate and Poor Results and (Poor Results) had an incidence of 21.44% of adverse reactions (PER CENT OF SEX) which was less than the 10 to 19 mg. group. The second study did show that the 30 to 39 mg. of 3-11 years 12-19 years 20+ years diazepam group was the one that produced the high- Males 50.0 (9.09) 24.67 (3.90) 15.53 (1.41) est incidence of adverse reactions. Females 47.61 (14.29) 25.58 (4.65) 23.93 (2.93) In these earlier studies it should be mentioned that when an adverse psychological reaction oc- Very Apprehensive curred it was treated by increasing the dose of di- (PER CENT OF SEX) azepam which sometimes helped but often worsened the situation or by allowing the patient to emerge 3-11 years 12-19 years 20+ years somewhat from the sedation to become more Males 45.45 54.54 29.37 co-operative which often took quite some time. Females 47.61 51.16 34.57 Adverse psychological reactions occurred more with females than with males. This happened in each age group in the first study, culminating in a 16% group at 16.67% then the 12 to 19 year group at increase over males in the 20 year and over age 10.9% and the 20 year and over at 9.23% which rep- group. In the second study, females were 50% more resents the more typical picture. than males in the 20 year and over age group. As to In the second study which was of one thousand why this should be the case is not clearly understood one hundred and forty-two oral surgery cases, except that it appears to be related to the degree of moderate and poor results appeared in 267 (23.56%) apprehensiveness of the patient beforehand. The au- and poor results appeared in forty (3.5%). In both thor has found that during the series of 16,000 cases, the moderate and poor category incidence was approximately twice as many females attended for higher in the under 12 year group and then reduced intravenous sedation than males. Females apparently as age increased. are attracted more to pain and anxiety control tech- These results support what is being clinically ex- niques and to pain clinics. The dental practice where perienced by many in the past that adverse reactions the author carried out his research is in an outer appear most commonly in the young and adoles- surburban area which would also attract a higher- cents and reduces as the age increases. As to why proportion of married women who live in the vi- this should be it is not clear, except that it could be cinity. This may also have a bearing on the matter. due to an unstable developing nervous system and The correlation between the incidence of adverse emotional changes occurring in the young. reactions and the degree of apprehensiveness of the An attempt was made from these studies to see if patient was found in the first study where in the 20 there was any correlation between the incidence of year and over age group, females were 28% more adverse psychological reactions and the dosage of apprehensive than males and in the second they were diazepam but not a very clear picture emerged as can 18% more apprehensive. (Tables 1. 2) be seen from Table 3, except that there was a general These adverse psychological reactions often ex- increase in incidence of adverse reactions as the dos- tend into the post-operative period and even into age increased. In the first study, the highest incidence the following and subsequent days and remain as was in the group who received 20 to 29 mg. of long as the effects of the diazepam remain. The au- diazepam but for some reason it dropped to one thor, in the sixth study, has particularly studied pro- third of that figure in the 30 to 39 mg. group and longed recovery from intravenous diazepam ex- then climbed again in the 40 to 49 mg. group. In the tending beyond the day of the operation. The second study, a different picture developed where symptoms examined in order of the infrequency the group who received 20 to 29 mg. of diazepam were drowsiness, dizziness, depression, nausea, loss

178 ANESTHESIA PROGRESS of memory, excitability, poor vision, insomnia, and from the hospital was found who could speak the hallucinations. Of these,depression, excitability, in- Serbian language in order to communicate with the somnia and hallucinations were adverse psycholog- boy and reassure him. The child's mother who wit- ical reactions. Of the various complications ana- nessed this was very distressed and indicated that she lyzed, those relating to adverse psychological had never seen her son behave like that before. reactions will alone be referred to and are as follows: Case Report 2 This involved a paradoxical abreaction, which has Table 4 previously been reported by the author2" seen in a girl of fifteen years of age who had 20 mg. of diaze- Result of Sixth Study pam for an apicoectomy. The patient appeared nor- % of Totals mal at the commencement of the procedure but Extending Beyond soon after, she exhibited strange and unusual body Day After Day After movements and began to speak and act in an obscene Depression 7. 4 3. 9 manner, all of which resembled the person pos- Excitability 3 1. 1 sessed in the film, "The Exorcist". This behavior Insomnia 1. 8 1. 1 continued throughout the operation and for two Hallucinations 1. 3 0. 7 hours after. She did admit when questioned later to having seen the film, even though she was under age. A particularly interesting finding in this study was She had no recollection of her behavior afterwards. in relation to the young. Complications were high- Case Report 3 est in those under three years of age due to a higher A female aged thirty-three years of age received dosage being given in relation to their body weight 30 mg. of diazepam and 100 mg. of methohexitone to secure suitable sedation. Prolonged depression for twenty restorations involving two hours dura- (30%) on the one hand and excitability (38%) on the tion. The patient stated that she could not stop other were very high in this group. The study re- crying on and off for two days and mentioned that vealed that there was a general increase in compli- not take diazepam tablets as they depress cations as dosage increased especially when over she could 20 mg. was given but generally, complications her. lessened with an increase in age. In some, compli- Case Report 4 cations continued for up to nine days after the A female twenty-one years of age who was ex- operation. tremely apprehensive, received 40 mg. of diazepam The high occurrence of depression on the one and 300 mg. of methohexitone for fourteen resto- hand and excitability on the other appearing in chil- rations over one and a half hours. She stated, "the dren, created problems with post-operative care at effect of the sedation was one of extreme depres- the surgery and after they returned home. Those sion. The following day, I was on duty at 7 a. m. as who become hyperexcited were particularly a prob- a senior nurse in a busy hospital ward. The whole lem as they required constant supervision during the morning I kept on bursting into tears over mere day and after the day of the operation. Busy mothers trivialities. I forgot some very important had to devote much of their attention to the care procedures. of their child to prevent injuries and other irre- For example, I forgot to give a man his premed- sponsible behavior. ication for theatre and was later reprimanded by the The following case reports indicate the problems assistant matron. This was something I have never adverse psychological reactions can produce. omitted to do before. It took me a week to finally Case Report 1 understand why I was falling to pieces as a nurse and This involved a Serbian boy of thirteen years who I realized that I had had a lot of diazepam which left attended a Sydney hospital for the surgical exposure its effect without my knowledge". of two lower bicuspids. The patient was apprehen- Case Report 5 sive and did not speak English well. Intravenous A female, forty-two years of age, received 20 mg. diazepam (10 mg.) was given but the patient still re- of diazepam and 120 mg. of methohexitone for eight acted strongly to the local anaesthetic so it was restorations over a one hour duration. The patient therefore decided to give another 10 mg. Local an- stated, "life was not worth living for three days after esthetic was administered with difficulty but the pa- the sedation". tient still did not become sedated sufficiently enough to enable the surgical work to be done and became Case Report 6 very restless, abusive and violent. This worsened and A male, fifty years of age, received 20 mg. of di- he began speaking loudly with bad language, swing- azepam and 80 mg. of methohexitone for endo- ing his arm around and it required several persons dontia over a period of one hour and commented to prevent him from hurting himself. This behavior that he had "delayed reactions including hallucina- continued for one and a half hours until a staff dentist tions for twenty-four hours after the operation".

NOVEMBER-DECEMBER 1980 179 Case Report 7 Other adverse psychological reactions A female, aged 16, received 30 mg. of diazepam Some patients may experience hallucinations or and 20 mg. of methohexitone for one hour of res- develop excessive dependence on or emotional at- torative dentistry. The patient's mother stated that, tachment to the operator and this tends to occur "on returning home my daughter became very ex- more with the opposite sex. This may occur during cited and this lasted for two days. My daughter was the operative period or post-operatively. Several furious with all the other members of the household embarrassing situations have occurred with the op- and said that she was locked up in a barred room, erator and female patients and also with female staff and was quite irrational. She later realized that the and male patients. This highlights the need for a sec- sedation was the cause of her mood change". ond person to be in the surgery at all times during Case Report 8 the operative procedure. It has been stated27 that there is the possibility of a female patient experi- A female eighteen years of age, received 30 mg. encing an erotic dream while under the influence of of diazepam and 250 mg. of methohexitone for one an anesthetic, so much so, that upon recovery, she hour of restorative dentistry. Her mother said that, may have the impression of having been sexually her daughter "was very agitated, extremely overac- assaulted and thereby wrongly accuse the operator. tive and distraught. We experienced a very difficult Reyes-Guerra more recently referred to this prob- period with her extending into the following week. lem,28 commenting that exotic dreams are rare with Diazepam had a very bad effect on our daughter and intravenous diazepam but can occur as they do with we would like some other form of sedation in the nitrous oxide. He stated that "perceptual distortions future". and sexual fantasies can be elicited in a significant Case Report 9 number of patients, particularly females who re- A male, aged three, received 10 mg. of diazepam ceived nitrous oxide. This could be due to the fact and 40 mg. of methohexitone for 30 minutes of re- that some female patients may have certain fancied storative dentistry. His mother reported that he relations of trust, respect and even affection for their "developed severe asthma the evening after the doctor. The dentist who treats patients, whether sedation, which continued the next day and night under nitrous oxide analgesia or intravenous seda- and also he was very violent and upset during the tion, without a third party being present is being same period". foolhardy in the extreme. This precaution should extend itself to the recovery room as well as Case Report 10 the preoperative physical evaluation". The author A female, aged five years, received 8 mg. diazepam suggests that this problem is not so rare with and 80 mg. of methohexitone for thirty minutes of intravenous diazepam and probably equates that of restorative dentistry. Her mother reported that her nitrous oxide. daughter "was extremely hard to manage and cried Patients who are under psychiatric treatment or on and off for two days. It was an extremely who are emotionally unstable are at special risk and unpleasant experience for both my daughter it is recommended that consultation with their psy- and myself'. chiatrist or medical practitioner beforehand should be made and special care exercised during the Case Report 11 sedation session. A male, aged six years, received 10 mg. of diaze- The following two cases reports further illustrate pam and 50 mg. of methohexitone for thirty minutes the type of thing that has happened on several of restorative dentistry. His mother reported that occasions in the experience of the author over her son "became extremely violent after he came this thirteen year period. home and was thrashing, kicking and screaming which continued on and off during the following days as well". Case Report 12 These case reports are representative of the type A female patient, aged thirty-five years, received of adverse reactions that can occur from intravenous 20 mg. of diazepam for fifteen restorations over a diazepam. period of two hours. Immediately prior to the These reactions indicate that diazepam is a psy- injection, she seemed normal but as soon as chotrophic drug which can affect the emotions in the injection was given, she began speaking about various ways, causing strange and unusual com- a difficult domestic situation and often referred to plications. Hyperexcitement, anxiety, depression, the problems she had at home with her husband until hallucinations, anger and emotional breakdown all it was controlled by the addition of methohexitone. can occur. The addition of other drugs such as Whenever the methohexitone began to wear off, she methohexitone can prevent these occurring during resumed speaking about her domestic problems in the operative period but as the shorter acting drugs quite a distressed manner and also referred to it in wear off, the effects ofthe diazepam remain and these the immediate post-operative period. The author reactions can then appear. attempted to reassure her and encourage her in the

180 ANESTHESIA PROGRESS situation without becoming too much involved. portant in all medical therapy and is one of the great- However, the patient very much appreciated the est preventives against medico-legal problems.29 sympathetic interest shown to her and wrote a series There is increasing need for dentists to have a of letters to the author over several weeks and also greater understanding of psychology and behavior. came to see him on several occasions, making var- The author has previously reported3" on the neces- ious excuses for so doing, in order to further explain sity of fully utilizing the non-drug approach prior her problem and seek guidance and counselling. She to the use of drugs. The non-drug approach includes also loaned him books on counselling with appro- the production of a suitable atmosphere by the best priate sentences underlined, placed notes in his car, use of attitude, color and sound, reassurance, ed- and became increasingly dependent on and attached ucation, hypnosis, suggestion and total care of the to him. The author soon realized that there was no patient as an individual. The establishment of good point in continuing this and promptly brought the rapport, gaining the patient's confidence and co- matter to an end. It was later discovered that the operation, is essential to successful therapy. It has patient had undergone psychiatric treatment and had recently been stated3' that the effectiveness of drugs been to many marriage counsellors and psycholo- used to control anxiety and pain in dental patients gists in relation to her problems. is directly related to the effectiveness of the behav- ioral approach; moreover, the dividing line is be- Case Report 13 coming progressively harder to define and modern A very apprehensive female of thirty-eight years research indicates that certain behavioral techniques of age received 30 mg. of diazepam and 150 mg. can in themselves lead to the production within the methohexitone for twenty-five restorations. Every- patient of powerful pharmacological agents. The an- thing proceeded normally during the operation and swer to the problem of the anxious dental patient the recovery period was uneventful. However, the is multi-disciplinary, encompassing both iatroseda- patient did not return to have the restorations finally tion and pharmacosedation along with a thorough checked and polished. On inquiring why, some two understanding of the factors which affect intoleranice months later, she stated to the secretary that she was and how these may be modified by various behav- dissatisfied with the treatment and the dentist's be- ioral techniques. Giddon'2 referred to this and havior but would not give any details. She refused commented on the important role of behavioral to settle the outstanding account and when pressed scientists in the teaching of pain and anxiety control to do so again, further referred to her dissatisfaction in dentistry and refers to educational psychology, and eventually asked to speak to the dentist and motivation of doctor and patients, non-pharma- mentioned that her dissatisfaction related to her cological methods and psycho-physiological aspects being molested in the region of the upper part of of pain and anxiety control. her body during the operation. This was adamantlv The term "holistic" has been given'33 to describe refuted and she was informed that a nurse was in the the treatment of the whole person and it has been surgery during the whole operation and it was stated that "when we see our patient holisticallv, we explained to her that psychotrophic drugs, such do not see his parts as something existing and func- as diazepam, can cause distortion, exaggeration of tioning in isolation apart from him as a person. In actions and hallucinations which she finally accepted. this holistic frame of reference every doctor's task The author believes what may have triggered this off then is to keep in mind a patient's personalitv". in her mind was the proximitv of instruments to her Lambert34 states that psychological sequellae oc- chest and the fact that instruments are often wiped curring as a result of hypnosedatives in dentistry can on the napkin on the chest and some instruments be decreased by a better understanding of sugges- are placed on the napkin. Also, the movement of tion, personality and anxiety and particularly rec- the triplex syringe across the chest may have some ommends the use of suggestion and hypnosis. bearing on it. In a seventh study on over 500 cases over the past The dentist is particularly vulnerable in this regard 12 months, the author is investigating the value of in view of the fact that he works in the oral cavitv hypnosis prior to intravenous injection of diazepam and close proximitv to the head, neck, chest and as a means of increasing the non-drug approach and arms. The use of psychotrophic drugs makes the thereby enabling a lesser dosage of drug to be used dentist even more vulnerable because of their dis- and indirectly less complications. Because hypnosis tortionarv and halluciinatorv effects, particularlv with makes a patient more suggestible, reassuraince, ed- susceptible patients. It is quite possible for the ucation, relaxation and rapport can be more readilv patient to misunderstand, misinterpret or miscon- achieved. This study has not yet been completed but strue actions of the dentist while under the influence so far the results have been verv impressive. The of such drugs. method used is a simple one where the patient is This emphasizes the fact that dentists should be guided into a state of self-hypnosis, using various more concerned about the individual persoinalitv induction techniqlues. This takes some four or five than just treating a tooth or a mouth. The consid- minutes and it is not necessary to reach a deep level eration of the whole person is fundamiientallv im- of hypnosis for it to he successful. Suggestion can

NOVEMBER-DECEMBER 1980 181 be added when the patient is deeply relaxed in a light 8. All patients who have had intravenous diazepam or moderate hypnotic state to reassure and educate. should be assisted to a nearby car by a respon- This provides greater rapport which is much appre- sible nurse and escorted home by a friend or ciated by the patient and enables the operator to relative and cared for at home for the rest of have greater consideration for the patient as a that day and night and in the case of persons whole. As it also provides a more relaxed patient, who have had more than 20 mg. of diazepam, less diazepam can be used and therefore less com- the next day as well. plications, especially those of adverse psychological 9. Persons who have had large amounts of diaze- reactions and prolonged recovery. The author has pam (over 20 mg.) should be telephoned by the found that he has been able to reduce the amount trained nurse the following day to see how they of diazepam down to one half to two thirds of what are and to reinforce the post-operative instruc- he had been using formerly with a corresponding tions. reduction in complications. 10. A greater use of the non-drug approach, espe- cially that of hypnosis, is strongly recom- Recommendations for reducing the incidence of mended. adverse psychological reactions 11. As low a dose of diazepam as is practicable 1. Proper assessment of the patient medically, should be administered. Psychologically and dentally. Such screening CONCLUSION helps to separate the psychologically unstable Adverse psychological reactions to intravenous and very apprehensive patient who are more diazepam are common at the time of operation and likely to produce adverse reactions. Special care afterwards. An understanding of psychology, care of can then be used with these patients if diazepam the sedated patient, the prevention of possible is used or an alternative technique resorted to. sequellae, and the use of hypnosis are 2. The dentist will need to have postgraduate train- medico-legal ing in pharmacology, psychology, care of the recommended. sedated patient, practice management and medico-legal aspects. 69 BEECROFT ROAD, 3. The surgery premises should be adequate in- BEECROFT. N.S.W. 2119. cluding proper recovery space. AUSTRALIA. 4. Staff should also be properly trained and suit- able, keeping in mind their additional respon- sibility in caring for patients under sedation dur- REFERENCES ing the operative and post-operative period. In 1. Donaldson D and Gibson G Systemic complicationis with this regard, it is highly recommended that a intravenous diazepam Oral Surg 49 (2):126-130 1980. trained general nurse be employed to be 2. 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ANNOUNCEMENT TITLE: "18th Annual Basic Science Symposium on Anesthesiology and Critical Care Medicine". DATES: May 31 - June 5, 1981 SPONSORSHIP: Departments of Anesthesiology Montefiore Hospital and Medical Center Albert Einstein College of Medicine and the New York State Society of Anesthesiologists LOCATION: Barbizon Plaza Hotel 106 Central Park South New York, New York FOR INFORMATION CONTACT: Deryck Duncalf, M. D., Chairman Department of Anesthesiology Montefiore Hospital and Medical Center 111 East 210th Street Bronx, New York 10467 (212) 920-6307

NOVEMBER-DECEMBER 1980 183