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Home , Panic attack

Two hours of CDE credit 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 , attack, iety disorders and there is no single bio- generalized , post-traumatic disorder and . logic or psychological cause for anxiety. Recent terrorist attacks in the U.S. have had a marked impact on the 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 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 consists of a sudden, medullary afferents, and serotonergic that may not have a focus. It is a state of unexpected, overwhelming 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, , faintness, trembling, plaining panic attacks and anxiety in- an internal psychological conflict, an en- sweating, , flushes or chills, clude lactate infusion, re- vironmental stress, a physical disease, or numbness or tingling sensations, and ceptors, the , 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, , , 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 , 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 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, , and mood mon among people seeking medical may result from past and present psycho- disorders, , or personality treatment. Approximately 9.0% of the logical conflicts; these conflicts or 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 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 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 , 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, , , 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 .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 , social phobias, and simple ic 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). Simple phobias include dent or act of physical violence that seri- higher rates of depression and PTSD the fear of snakes, heights, flying, dark- ously injures or kills another person(s).1,2 than among people with similar jobs who ness and needles. Needle phobia and Most men with PTSD have been in com- worked five miles or more from the during MRI or radiation bat; most women give a history of sexual World Trade Center.23 therapy may affect medical/dental care.1,9,15 or physical abuse.1 The three cardinal A study following the 1995 Oklahoma features of PTSD are hyperarousal, intru- City bombing examined 182 survivors six Panic attack sive symptoms or flashbacks of the initial months after the bombing and 141 sur- Nearly 15% of cardiology patients visit a trauma, and psychic numbing.1,2 PTSD vivors 12 months later. Of the survivors, doctor because of symptoms associated may follow traumatic events that are 33% were diagnosed with PTSD six with a panic attack. The onset can occur anticipated or not anticipated, constant months following the bombing; all of the at any age but usually does so between a or repetitive, natural or malevolent; it is cases evaluated after 18 months were patient’s late adolescence and their mid- diagnosed when the onset of symptoms chronic.18 30s.9 The adrenergic surge is a key feature occurs at least six months after a trauma Although women generally are diag- of panic and results in an exaggerated or when the symptoms have been present nosed with PTSD more often than men, sympathetic response known as the fight for longer than three months. the rate of PTSD is higher in male veter- or flight response. Diagnostic criteria for PTSD includes ans than in female veterans, although it Panic attacks may be cued or uncued. a history of traumatic experience; re-ex- is likely that female veterans are under- A is an example of a cued periencing the event through intrusive diagnosed.24 In 2002, Pereira reported attack. Many patients report that they are memories; disturbing dreams; “flash- that men experienced higher levels of unaware of any life stressors prior to the backs”; psychologic or physical distress combat stress. In addition, Pereira found onset of panic disorder; such attacks resulting from the reminders of the that increased PTSD symptomology was would be classified as uncued. The major event; and the avoidance of people, associated with increased exposure to

November-December 2003 563 hibitors, beta-adrenoreceptor antago- is the standard for antianx- Table 1. Commonly used .3 nists, and benzodiazepines, the most iety therapy, as it has demonstrated better commonly used drugs (see Table 1).1,9,15 efficacy against anxiety than any other Treatment options for phobias in- drug.9 These drugs often are clude systemic desensitization, in which administered for 7–10 days, followed by a Chlordiazepoxide a patient is exposed to the feared situa- period of two to three days without the Diazepam tion gradually, and flooding, in which drug to avoid the development of drug Lorazepam the patient is exposed to the anxiety-pro- tolerance. Anxiolytic drug treatment Oxazepam voking stimulus directly. MRI-associat- should continue for no more than four Aiprazolam ed claustrophobia can be managed with weeks. An early sign of drug tolerance a low dose of benzodiazepines and be- occurs when increased dosage is re- 1,15 Sedative-hypnotics havioral therapy. Sertraline was the quired. Symptoms of Flurazepam first and only FDA-approved include muscle aches, agitation, restless- Temazepam for treating PTSD, although paroxetine, ness, insomnia, confusion, , and, fluoxetine, and nefazodone have dis- on rare occasions, grand mal seizures. Trizolam played either well-controlled or replicat- Some patients may experience rebound ed open-label evidence of efficacy for anxiety after the drug treatment has been treating PTSD.25 Phenelzine has been ef- stopped.1,9,15,26,27 stress and that men and women exposed fective for symptoms of nightmares and A number of tricyclic and other anti- to similar levels of stress were equally flashbacks. Early intervention in pa- have additional sedative or likely to have PTSD symptoms, although tients with PTSD can shorten the dura- anxiolytic effects. They appear to be as men were more likely to be diagnosed tion and severity of anxiety.1,9,15 effective as benzodiazepines when treat- with PTSD.24 Drug treatment for men ing generalized anxiety and superior to and combat trauma-induced PTSD Antianxiety (anxiolytic) drugs benzodiazepines for treating panic disor- (among both men and women) is less ef- Benzodiazepines are used to treat the var- der and agoraphobia. SSRIs and MAO fective than it is for other woman veter- ious anxiety states. These drugs enhance inhibitors also are effective in phobic ans or for women with civilian trauma- gamma-aminobutyric acid neurotrans- states and panic disorders. The disadvan- induced PTSD.25 There is little data mission selectively but indirectly, the pos- tages of these drugs include their slow regarding the effectiveness of drug treat- sible result of their ability to increase rate of onset, the possibility that anxiety ment among children with either acute neuronal receptor sensitivity to gamma- symptoms will be exacerbated initially, stress reaction or PTSD.25 aminobutyric acid. The benzodiazepines and the fact that some are toxic in over- are the drugs of choice for generalized dose; even when administered in thera- Acute stress disorder anxiety disorders and are very effective putic doses, these drugs have many ad- Acute stress disorder is a new DSM-IV for treating short-lived reactive states of verse side effects.26 category of anxiety disorder that results tension and anxiety, anticipatory anxiety when a patient is exposed to a traumatic and other forms of anxiety associated Dental management event and has specific signs and symp- with panic disorders, and anxiety symp- Anxiety toms that resemble those of PTSD.2 The toms found in patients with phobic dis- The dentist may detect anxiety in patients symptoms of acute stress disorder are orders.1,9,15,26 Tricyclics and MAO in- based on physical appearance, speech, shorter in duration; in addition, onset hibitors are the drugs of choice for panic dress, and the presence of certain signs follows the trauma more rapidly and disorders. and symptoms. Anxious patients display symptomatic reaction is limited to the Side effects of the benzodiazepines in- symptoms that may include sitting for- occurrence of the stressful event and its clude daytime sedation, mild cognitive ward in a chair; moving fingers, arms, or immediate aftermath.2 impairment, and aggressive and impulsive legs; getting up and moving; pacing behavior responses. The benzodiazepines around the room; checking certain parts Treatment of anxiety disorders can potentiate the effects of opioids, bar- of clothing; and straightening ties or Psychologic, behavioral, and drug modal- biturates, and alcohol on the CNS and are scarves. Conversely, they also may display ities are used to treat anxiety disorders. hazardous or contraindicated for patients sloppy dress habits and other signs that Psychologic treatment involves psycho- who drive or operate machinery, patients suggest the opposite of perfectionism. therapy, which generally is used for more with depressive mood disorders or psy- Anxious patients may appear intent severe cases. Behavioral treatment in- chosis, moderate-to-heavy drinkers, preg- on trying to keep their possessions in cludes cognitive therapy for dealing with nant women, and the elderly. Therapeutic sight at all times. They may respond to distorted perceptions and interpretations doses of benzodiazepines can result in a questions quickly, often preventing the of fear-producing stimuli, , tolerance as well as a habitual and physical dentist from finishing a question; they hypnosis, relaxation imaging, desensiti- dependence. The benzodiazepines’ ac- also may speak mechanically and rapid- zation, and flooding. Drug treatment in- tions are additive and usually synergistic ly and may fail to block out or connect cludes the use of tricyclic antidepressants, with psychotropic agents. Drug interac- thoughts. These patients may complain selective reuptake inhibitors tions have been reported with cimetidine of an inability to sleep or may wake at (SSRIs), monoamine oxidase (MAO) in- and erythromycin.1,9,15,26,27 an early hour and be unable to go back

564 General Dentistry www.agd.org Table 2. Dental management of the anxious patient.3

Behavioral management Pharmaceutical management Preoperative Establish effective communication with the patient Oral sedation (benzodiazepines) Be open and honest; let the patient see who you are May be administered the night before an appointment Consistent verbal and nonverbal communication (to help the patient fall asleep) or the day of an appoint- ment (to reduce patient anxiety); select a fast-acting Explain procedures and answer any questions (explain drug and prescribe the lowest possible effective dosage when there may be discomfort with a procedure and what you will do to make procedures “pain-free”) Talk to the patient if he or she displays signs of anxiety (for example, “You seem tense today—Would you like to talk about it”?)

Operative Allow patient to ask questions about the procedure Effective local anesthesia: oral sedation (benenzodi- Keep patient informed to expect any discomfort azepines); inhalation sedation (nitrous oxide); intramus- cular sedation (midazolam, promethazine, meperidine); Reassure patient that the procedure is going well intravenous sedation (diazepam, midazolam, fentanyl)

Postoperative Explain what usually occurs after the procedure Select the most appropriate medication for pain control: Explain what the patient needs to do and what he/she analgesics (including NSAIDs, salicylates, acetamino- needs to avoid phen, codeine, , fentanyl, morphine); adjunc- tive (antidepressants, muscle relaxants, Describe complications that can occur (for example, pain, steroids, anticonvulsants, and antibiotics) bleeding, infection, and allergic reaction to medication) Tell patient to inform you if any complications develop

to sleep. Other signs include attacks of utilizing hypnosis, , and oral or loss of control; as a result, the dentist diarrhea, increased frequency of urina- parenteral sedation agents or nitrous ox- must attempt to establish communica- tion, sweating, muscle tension, in- ide (see Table 2). tion and trust with these patients. Pa- creased breathing, and a rapid heart Anxiety or a history of panic attacks tients with intravenous drug habits may rate. also may be associated with mitral valve carry the hepatitis B virus (HBsAg pos- Overall, anxious persons are overalert prolapse.1,2,17 Patients with mitral valve itive) or HIV, while those who drink and tense, feel apprehensive, and have a prolapse and valvular regurgitation re- heavily may have liver and bone mar- sense of impending disaster with no quire antibiotic prophylaxis for any den- row involvement and could be at an in- apparent cause. Insomnia, tension, and tal procedures that produce significant creased risk for infection, excessive apprehension lead to fatigue, making it bleeding.3,17,28 Based on 1997 guidelines bleeding, delayed healing, and altered even more difficult for the individual to provided by the American Heart Associa- drug metabolism.3,29 During the de- deal with anxiety.9 tion, antibiotic prophylaxis is not indicat- pressive stage of PTSD, patients often The dentist should talk with the pa- ed if no regurgitation is associated with show a total disregard for oral hygiene tient and demonstrate a personal inter- the mitral valve prolapse.28 If the patient procedures and are at an increased risk est; verbal and nonverbal communica- is unaware of his or her status regarding for dental caries, periodontal disease, tion must be consistent. The dentist valvular regurgitation, a medical referral and pericoronitis; these patients may should confront the patient with the ob- is indicated.3 complain of glossodynia, temporo- servation that he or she appears anxious Patients with uncontrolled hyperthy- mandibular joint (TMJ) disorder, and and ask if the individual would like to roidism also may have associated anxiety; .3,29 talk about his or her feelings; this can in- these patients must avoid , clude the patient’s attitude toward the including even the small amounts used in Drug interactions and dentist. During these discussions, the local anesthetics.1-3 Patients who display side effects dentist should allow natural pauses to signs and symptoms of Antianxiety drugs develop between ideas, producing a tem- should be referred for medical evaluation Important interactions can occur be- porary state of regression that will help and treatment.3 tween benzodiazepines and barbitu- restore the patient to a less-anxious rates, opioids, psychotropic agents, state. Some patients may respond well Management of PTSD patients cimetidine, and erythromycin. These to this approach without ever indicating Veterans with PTSD may view the den- agents generally will potentiate the de- the cause of their anxiety. If the patient tist as an authority figure, similar to pressive effects of benzodiazepines on remains anxious, the dentist may con- those who sent them to war.29 Veterans the CNS. Barbiturates and opioids used sider managing the dental treatment by may associate dental treatment with a for dental sedation or pain control must

November-December 2003 565 Table 3. Commonly Table 4. Clinical considerations for heterocyclic antidepressant drugs.3 used antidepressants.3 Common side effects Dry mouth; and vomiting; constipation; urinary Tricyclic derivatives retention; postural hypotension; nervousness; insomnia; Amitriptyline drowsiness; reflux; (women); erectile problems, Nortriptyline loss of libido, gynecomastia (men) Serious side effects , seizures, obstructive jaundice, leukopenia, , arrhythmias, , Desipramine Doxepin

MAO inhibitors Pheneizine Table 5. Drug interactions for heterocyclic antidepressant drugs.3 Tranycypromine Barbiturates CNS depression Isocarboxazid Benzodiazepines CNS depression Heterocylic derivatives Anticonvulsants Interferes with the action of anticonvulsants Clomipramine Antihistamines CNS depression Ainoxapine Warfarin Inhibits warfarin metabolism (can increase International Normal- Maproliline ized Ratio (INR)) Cimetidine Inhibits clearance; can lead to toxicity of antidepressant SSRIs Fluoxetine Erythromycin Interfers with the action of the antibiotic Paroxetine Epinephrine Actions are enhanced; use with caution Seitraline

Serotonin and noradrenergic reuptake inhibitors (SNRIs) Table 6. Clinical considerations for SSRIs.3 Nefazodone Venlafaxine Common side effects Dry mouth, nausea and vomiting, diarrhea, anorexia, weight loss, blurred vision, insomnia, nervousness, , Derivatives of other chemical classes sweating, sedation, akathisia Bupropion Serious side effects Mania, seizures, hypotension, anemia, bleeding (platelet effect), Trazodone hypothyroidism

be administered with caution and in de- Table 7. Drug interactions involving SSRIs.3 creased dosages for patients who are taking a benzodiazepine for an anxiety Benzodiazepines CNS depression disorder. The dentist may prescribe a Beta blockers Bradycardia benzodiazepine as a sedative to control Warfarin Inhibits warfarin metabolism (can increase INR) dental-related anxiety but individuals Cimetidine Inhibits clearance; may lead to toxicity of SSRI receiving psychotropic agents for a psy- chiatric disorder must be treated with care. Medication dosage usually can be reduced to avoid overdepression of the patients taking heterocyclic antidepres- tipsychotic medications, as severe hy- CNS. The dentist should consult with sant drugs to avoid a hypertensive potension can result, compared to hyper- the patient’s physician before adminis- episode. While it is safe to use small tension resulting from the heterocyclic tering these drug combinations. The pa- amounts (1:100,000) in local anesthetics, antidepressants. tient can be monitored during treatment stronger concentrations of epinephrine by utilizing a pulseoximeter.27,30-32 must be avoided.3 Conclusion Antidepressant drugs used to treat medications may be Anxiety is found in many dental pa- anxiety states (see Table 3) can result in used to treat certain patients with anxiety tients. The degree of anxiety is low for important side effects and potentially sig- (see Table 8). The significant side effects most patients. Dentists can manage nificant drug interactions with agents and drug interactions of these medica- such patients in the dental environment used in dentistry. Tables 4–7 present side tions are listed in Table 9. These drugs by showing a personal interest in them, effects and drug interactions of hetero- should be adminstered in reduced displaying concern for their feelings, cyclic antidepressants and SSRIs. Epi- dosages. Epinephrine must be used with and allowing them to ask questions re- nephrine must be used with caution in care when given to patients taking an- garding their dental treatment. The

566 General Dentistry www.agd.org dentist should answer all questions in a Table 8. Commonly used antipsychotic medications.3 direct and honest manner. Verbal and nonverbal communication must be Phenothiazines Butyrophenones Oxoidoles consistent. Aliphatics Haloperidol Molindone Chlorpromazine Hypnosis, oral/parenteral sedation Thioxanthenes Dibenzoxazepines agents, or nitrous oxide and oxygen can Piperazines Chlorprothixene Loxapine be used for patients who remain anxious Fluphenazine Thiothixene during dental treatment. Patients Perphenazine should be referred to their physician if Trifluoperazine they display severe adverse drug reac- Piperidines tions to agents used for treating anxiety Thioridazine disorders. The dentist must avoid drug interactions by reducing the dosage of certain sedative agents for patients being Table 9. Side effects and drug interactions of antipsychotic drugs.3 treated with benzodiazepines. Patients being treated with antide- Significant side effects Significant drug interactions pressant drugs are more sensitive to the Agranulocytosis Prolong and intensify effects of the effects of epinephrine, which must be Visual impairment following drugs, which may result in severe respiratory depression used with caution to avoid a hyperten- Cholestatic jaundice Sedatives sive episode; hypotension may result Excessive or abnormal involuntary Hypnotics when patients being treated with an- movements tipsychotic medications receive epi- Dystonia, akathisia Opioids nephrine. In both of these cases Parkinson-like symptoms Antihistamines 1:100,000 epinephrine can be used in the local anesthetic if no more than two Dyskinesia, tardive dyskinesia Produce hypotensive crisis (epinephrine) or three cartridges are used. Xerostomia No more than two cartridges of 2.0% Hypotension—Orthostatic hypotension lidocaine with 1:100,000 epinephrine Author information Tachycardia Avoid more concentrated forms of epinephrine Dr. Little is Professor Emeritus at the Seizures University of Minnesota in Minneapolis. Neuroleptic malignant syndrome References 1. Vogel LR, Muskin PR. Anxiety disorders. 8. Katerndahl DA. Factors influencing care 16. Reus V. Psychiatric disorders. In:Fauci In:Cutler JL, Marcus ER, eds. . seeking for a self-defined worst panic at- AS, Braunwald E, Isselbacher KJ, Wilson JD, Philadelphia: W.B. Saunders Co.;1999:105- tack. Psychiatr Serv 2002;53:464-70. Martin JB, Kasper DL, Hauser SL, Longo 127. 9. Goldberg RJ. Practical guide to the care of the DL, ed. Harrison’s principles of internal medicine, ed. 14. New York: McGraw-Hill; 2. Task Force on DMS-IV, American Psychiatric psychiatric patient. St. Louis: Mosby;1995. 1998:2485-2502. Association. Anxiety disorders. Diagnostic 10. Culpepper L. 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November-December 2003 567 22. CDC. Injuries and illnesses among New cy and therapeutics, ed. 2. London: 30. Winter JC. Antipsychotic drugs (antipsy- York City Fire Department rescue workers Churchill Livingston;1999:393-409. chotics). In:Smith CM, Reynard AM, ed. after responding to the World Trade Center 27. Smith CM. Antianxiety drugs. In:Smith Textbook of pharmacology. Philadelphia: attacks. MMWR Morb Mortal Wkly Rep CM, Reynard AM, ed. Textbook of phar- W.B. Saunders;1992:298-309. 2002; 51 Spec No:1-5. macology. Philadelphia: W.B. Saunders; 31. Judd L. The therapeutic use of psychotrop- 23. CDC. Impact of September 11 attacks on 1992:271-298. ic medications. In:Fauci A, Martin JB, Pe- workers in the vicinity of the World Trade 28. Dajani AS, Taubert KA, Wilson W, Bolger tersdorf RG, ed. Harrison’s principles of Center—New York City. MMWR Morb AF, Bayer A, Ferrieri P, Gewitz MH, Shul- internal medicine, ed. 12. New York: Mc- Mortal Wkly Rep 2002; 51 Spec No:8-10. man ST, Nouri S, Newburger JW, Hutto C, Graw-Hill;1991:2139-2154. 24. Pereira A. Combat trauma and the diagno- Pallasch TJ, Gage TW, Levison ME, Peter G, 32. van der Bijl P. The benzodiazepines in den- sis of post-traumatic stress disorder in fe- Zuccaro G Jr. Prevention of bacterial endo- tistry: A review. Compendium 1992;13:46- male and male veterans. Mil Med 2002; carditis. Recommendations by the Ameri- 52. 167:23-27. can Heart Association. JAMA 1997;277: 1794-1801. 25. Davis LL, English BA, Ambrose SM, Petty F. Reprints of this article are available in quantities Pharmacotherapy for post-traumatic stress 29. Friedlander AH, Mills MJ, Wittlin BJ. Den- of 1,000 or more. E-mail your request to Jo-Ellyn disorder: A comprehensive review. Expert tal management considerations for the pa- Posselt at [email protected]. Opin Pharmacother 2001;2:1583-1595. tient with post-traumatic stress disorder. 26. Ashton CH. Insomnia and anxiety. In: Oral Surg Oral Med Oral Pathol 1987;63: Walker R, Edwards C, ed. Clinical pharma- 669-673.

568 General Dentistry www.agd.org 1. Anxiety can be a purely psychological or 9. Which symptoms are considered the purely physical experience. Which of the cardinal features of PTSD? following symptoms is a physical manifesta- 1. Hyperarousal tion of anxiety? 2. Intrusive symptoms or flashbacks A. Tachycardia 3. Agoraphobia B. Agoraphobia 4. Psychic numbing C. Post-traumatic stress disorder (PTSD) A. 1, 2, and 3 only Exercise No. 131 D. Panic disorder B. 1, 2, and 4 only Subject Code: 750 C. 1, 3, and 4 only 2. What psychiatric problem is found most D. 2, 3, and 4 only Special Patient Care frequently in the general population? A. 10. Which three modalities are used most The 15 questions for this exercise are based B. Anxiety disorders commonly to treat anxiety disorders? on the article, “Anxiety disorders: Dental C. Schizophrenia 1. Pharmacologic implications,” on pages 562–568. This D. Depression 2. Behavioral 3. Physiologic exercise was developed by Leslie A. Hayes, 3. A phobia is an irrational fear that interferes 4. Psychologic DDS, FAGD, in association with the General with normal behavior. A panic attack is a A. 1, 2, and 3 only Dentistry DART Committee. sudden, unexpected, overwhelming feeling B. 2, 3, and 4 only of terror which peaks in approximately 10 C. 1, 2, and 4 only minutes and usually lasts for 50–60 minutes. D. 1, 3, and 4 only A. Both statements are true. B. The first is true; the second is false. 11. What is the only drug approved by the FDA C. The first is false; the second is true. for treating PTSD? D. Both statements are false. A. Sertraline hydrochloride Reading the article and B. Paroxetine hydrochloride 4. What is the approximate prevalence of C. Fluoxetine successfully completing this panic disorder in cardiac patients? D. Nefazodone hydrochloride exercise will enable you to: A. 2.5% B. 5.0% 12. In which case is diazepam contraindicated? • recognize signs of anxiety in patients; C. 7.0% A. Moderate-to-heavy smokers • understand the various components of D. 9.0% B. Patients taking clindamycin anxiety disorders; C. Children 5. What percentage of a community is likely D. Driving or operating machinery • review the side effects and drug interac- to experience an anxiety disorder? tions of medications used to treat anxiety A. 1.0–3.5 13. Which statement is true regarding tricyclic disorders; and B. 3.0–6.0 antidepressants? C. 2.5–5.0 A. They interact negatively with • learn dental management skills for use be- D. 4.0–7.0 cimetadine and erythromycin. fore, during, and after the appointments B. They exhibit a slow rate of onset. with anxious patients. 6. Panic disorders, phobic disorders, and C. They initially exacerbate anxiety obsessive compulsive disorders occur more symptoms. frequently among first-degree relatives of D. They are superior to benzodiazepines Answers for this exercise must be people with these disorders than among in treating panic disorder and received by December 31, 2004. the general population. If one first-degree agoraphobia. relative has a panic disorder, other relatives have approximately a 25% chance of devel- 14. Management of the anxious patient could oping a panic disorder. include all but which of the following A. Both statements are true. modalities? B. The first is true; the second is false. A. Hypnosis C. The first is false; the second is true. B. Oral or parenteral sedation D. Both statements are false. C. Avoiding direct eye contact with the patient 7. Approximately what percentage of cardiac D. Confronting the patient about patients see a doctor because of symptoms appearing anxious associated with panic disorder? A. 10 15. Important side effects of antipsychotic drugs B. 15 include all but which of the following? Select the most correct answer to C. 20 A. Tardive dyskinesia each question. You must answer D. 25 B. Hypertension at least 12 of the 15 questions C. Agranulocytosis 8. Patients with a history of panic attacks D. Neuroleptic malignant syndrome correctly (80%) to receive credit. have been reported to have an increased incidence of Be sure to keep a copy of this A. reflex sympathetic dystrophy. exercise for your records. B. chronic obstructive pulmonary disease. C. mitral valve prolapse. To register by phone, call toll-free D. coronary artery disease. 888/AGD-DENT (888/243-3368), ext. 5300.

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