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Anxiety Disorders: Dental Implications

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Anxiety Disorders: Dental Implications Two hours of CDE credit Anxiety disorders: Dental implications James W. Little, DMD Anxiety disorders are the most frequently found psychiatric problem in the general No single theory fully explains all anx- population. The most common anxiety disorders are phobias, panic attack, iety disorders and there is no single bio- generalized anxiety disorder, post-traumatic stress disorder and acute stress disorder. logic or psychological cause for anxiety. Recent terrorist attacks in the U.S. have had a marked impact on the mental health Anxiety might be explained as a combi- status of individuals directly affected by the attacks as well as those who were far nation of psychosocial and biological from the scenes of destruction. To provide effective dental care, the dentist must processes. The locus coeruleus is a brain be able to identify anxious patients and deal with their anxiety. This process may stem structure that contains the majority involve referring the patient for medical evaluation and treatment of very of noradrenergic neurons in the central Special Patient Care Special Patient severe cases of anxiety. In most cases, the dentist can manage the patient nervous system (CNS); it appears to be by using behavioral and/or pharmacologic means. involved in panic attacks and anxiety. Panic and anxiety may correlate to the Received: November 19, 2002 Accepted: December 31, 2002 dysregulated firing of the locus coeruleus, resulting from multiple sources of input, including peripheral autonomic afferents, Anxiety is a sense of psychological distress A panic disorder consists of a sudden, medullary afferents, and serotonergic that may not have a focus. It is a state of unexpected, overwhelming feeling of ter- fibers.1 apprehension that may involve the fol- ror with symptoms of dyspnea, palpita- Other neurobiologic theories for ex- lowing (either alone or in combination): tions, dizziness, faintness, trembling, plaining panic attacks and anxiety in- an internal psychological conflict, an en- sweating, choking, flushes or chills, clude lactate infusion, benzodiazepine re- vironmental stress, a physical disease, or numbness or tingling sensations, and ceptors, the amygdala, and synaptic the effect of a medicine or drug. While chest pains. The panic attack peaks after responses from the brain. Lactate infu- anxiety can manifest as a purely psycho- approximately 10 minutes and usually sion causes peripheral somatic sensations logical experience with few somatic man- lasts for a total of 20–30 minutes.1,2,7,8 resembling those of natural panic attacks. ifestations, it also can appear as a purely Panic disorder, phobic disorders, and Dysfunction in the benzodiazepine re- physical experience (for example, tachy- obsessive-compulsive disorders occur ceptor may be responsible for some com- cardia, palpitations, chest pain, indiges- more frequently among first-degree rela- ponents of anxiety. The amygdala, a tion, and headaches) with no psychologi- tives of people with these disorders than brain structure that influences fear, vigi- cal distress other than concern about the among the general population.1,2 The lance, and rage, may play a role in anxiety physical symptoms. It is not clear why prevalence of panic disorder among car- by interacting with various hypothalamic some individuals experience anxiety as a diac patients is approximately 9.0%. and brain stem structures.1 psychological manifestation while others Generalized anxiety disorder has a com- Another theory suggests that stressors experience it in physically.1 munity prevalence of 2.5–5.0%; the induce protein c-fos, a class of immediate prevalence of post-traumatic stress disor- early proteins that act near the beginning Epidemiology: der (PTSD) among the general popula- of the neural process and can induce Incidence and prevalence tion is 4.0–7.0%.1,9-14 long-lasting biochemical and neurobio- Anxiety disorders constitute the psychi- logic changes through cascades.1 States atric problem diagnosed most frequently Etiology of anxiety also may be associated with in the general population. Simple phobia Anxiety represents the possible emer- other psychiatric disorders, organic dis- is the most common anxiety disorder, al- gence of painful, unacceptable thoughts, eases, the use of certain drugs, hyperthy- though panic disorder is the most com- impulses, or desires into consciousness. It roidism, mitral valve prolapse, and mood mon among people seeking medical may result from past and present psycho- disorders, schizophrenia, or personality treatment. Approximately 9.0% of the logical conflicts; these conflicts or feelings disorders.1,9,15,16 population experiences at least one panic stimulate physiologic changes that lead to attack during their lives and approximate- clinical manifestations of anxiety.1,15 Anx- Clinical presentation ly 3.0% have recurrent panic attacks.1,2 iety disorders may occur among persons and medical management A phobia is defined as an irrational under emotional stress or those with cer- From a psychological aspect, anxiety can fear that interferes with normal behavior. tain systemic illnesses; they also may be defined as an emotional pain or a feel- Phobias are fears of specific objects, situ- appear as a component of various psychi- ing that all is not well—a feeling of im- ations, or experiences that have taken on atric disorders. Panic disorders tend to be pending disaster. The source of the prob- a symbolic meaning for the patient; both found in families: if one first-degree rela- lem usually is not apparent to the person unconscious wishes and fears have been tive has a panic disorder, the chance that with anxiety. Patients with fear experi- displaced from an original goal onto an other relatives will develop panic disor- ence a similar feeling but they are aware external object.1-6 ders is approximately 18%.1,15 of the problem and why it affects them. 562 General Dentistry www.agd.org The physiologic reaction to anxiety complication of repeated panic attacks places, and objects associated with the and fear is the same. The reaction is me- involves adopting a restricted lifestyle to trauma. PTSD symptoms include sleep diated through the autonomic nervous avoid situations that might trigger an at- problems; irritability; an inability to con- system and may involve both sympathet- tack. Some patients develop agorapho- centrate; hypervigilance; startle respons- ic and parasympathetic components. bia, an irrational fear of being alone in es; psychic numbing, consisting of de- Symptoms of anxiety resulting from an public places that can result in patients tachment from others; a diminished overactivated sympathetic nervous sys- becoming housebound for years. A sud- capacity for intimacy; and a decreased in- tem include an increased heart rate, den loss of social supports or a disrup- terest in sex.1,2,9,15 sweating, dilated pupils, and muscle ten- tion of important interpersonal relation- Recent terrorist attacks in the U.S. sion; symptoms of anxiety resulting from ships appear to predispose an individual have affected the mental health status of stimulation of the parasympathetic sys- to develop a panic disorder.1,2,15 It has individuals involved directly in the at- tem include urination and diarrhea.1 been reported that patients with a history tacks, as well as others who were far away Most individuals experience some of panic attacks have an increased inci- from the actual scene.14,18-20 In a national anxiety. Low levels of anxiety can in- dence of mitral valve prolapse.17 survey of 560 adults conducted three to crease attention and improve perform- five days after the 2001 attacks on the ance. Anxiety leads to dysfunction when Generalized anxiety disorder World Trade Center and the Pentagon, it either is constant or results in episodes Some patients develop a persistent, dif- Schuster et al found that 44% of them of extreme vigilance, excessive motor ten- fuse form of anxiety with symptoms of displayed one or more substantial symp- sion, autonomic hyperactivity, or im- motor tension, autonomic hyperactivity, toms of stress.19 In a survey of 2,273 paired concentration. For many patients and apprehension. No familial or genet- adults performed one to two months with psychiatric disorders, anxiety is part ic basis for the disorder exists. Patients after the attack, Schlenger et al found that of the clinical picture; patients with with generalized anxiety disorder re- individuals in New York City displayed a mood disorders, dementia, psychosis, spond more favorably to treatment than prevalence for PTSD nearly three times panic disorder, adjustment disorders, and those with panic disorder, although gen- greater than respondents from the rest of toxic and withdrawal states often com- eralized anxiety disorder can lead to de- the country.14 Of 414 residents of Lower plain of anxiety.1 pression and substance abuse.1,2,15 Manhattan surveyed between October 25, 2001 and November 2, 2001, 39.9% Phobias Post-traumatic stress disorder displayed a potential for PTSD.21 A study There are three major groups of phobias: PTSD is a syndrome of psychophysiolog- of stress-related illnesses among New agoraphobia, social phobias, and simple ic signs and symptoms resulting from ex- York City Fire Department rescue work- phobias. Agoraphobia is a fear of display- posure to a traumatic event outside of the ers found that 1,277 such incidents were ing distressful or embarrassing symp- usual range of human experience, such as reported in the 11 months following the toms outside of the home; it often ac- a serious threat to one’s life or physical attacks, compared to 75 such incidents in companies panic disorder. Social phobias integrity; a serious threat to one’s chil- the 11-month period prior to the at- may be specific (for example, a fear of dren, spouse, or other loved ones; the tacks.22 A 2002 study of workers at a high public speaking) or general (for example, sudden destruction of one’s home or school and a college within five miles of a fear of being embarrassed in front of community; or the witnessing of an acci- the World Trade Center indicated much other people).
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