2. Biopsychosocial Principles of Clinic Flashcards
1
Q
What do we need to provide the best psychological care?
A
- knowledge of patient
- knowledge of common presenting psych problems
- understanding building blocks of psych theories
- ability to synthesise and reflect to fit theory to individual
2
Q
Explain ICE theory
A
- a mnemonic for consultations introduced by Pendleton
- IDEAS - what the patient thinks might be happening, whether there is a problem
- CONCERNS - what they’re worried about (may be condition, situational/making a fool)
- EXPECTATIONS - what they think is going to happen - tooth extracted vs check up
3
Q
Relevant info to look at for this as a dentist?
A
- info collected at intake
- talking to patient
- observing and reflecting on how they respond to you in appointment
- trying out theoretically-informed approaches (if appropriate, if dental fear)
- psychometric measures
4
Q
Define ‘fear’
A
- refers to here and now
- an emotion associated with danger
- strong urge to escape or fight
- often accompanied by physical response to ‘fight or flight’
5
Q
Define ‘anxiety’
A
- refers to the future
- emotion associated with anticipation of danger
- strong urge to avoid
- physical response less intense and longer-lasting
6
Q
Define ‘pain’
A
- unpleasant sensory and emotional experience associated with actual/potential tissue damage or described in terms of damage
- known to cause emotional distress and to be increased by distress
7
Q
3 behavioural science theories associated with fear, anxiety and pain
A
- behavioural learning theory
- cognitive factors
- social/environmental factors
8
Q
Define ‘classical conditioning’
A
two things that always occur together will become linked
9
Q
Examples of classical conditioning
A
- Pavlov’s dogs
- Little Albert
- dentist and unpleasant feelings/noises
10
Q
Terms of classical conditioning
A
- unconditioned stimulus and response - stimulus exerts certain response before any conditioning takes place like a sudden noise causes fear
- neutral stimulus - something which at first has no impact on response (e.g a rat)
- conditioned stimulus and response - a previously neutral stimulus is paired with the unconditioned one - conditioned stimulus comes to evoke same response as unconditioned through association
- generalization is when conditioned response also triggered by other stimuli similar to conditioned stimulus
11
Q
Implications of classical conditioning
A
- patients may react with fear to features of dental environment - smell of surgery, sight of staff in uniform etc
- elements of dental care may resemble past experiences of patients who experienced trauma/abuse
- helpful to pay close attention to env and interpersonal factors to reduce similarity with previous bad experiences
12
Q
Behaviour and … are often linked
A
- emotions
- approach behaviour and confidence, avoid behaviour and fear, aggressive behaviour and anger
13
Q
Skinner’s operant conditioning
A
- about re-inforcement (operant conditioning about behaviour being shaped by what happens immediately after behaviour)
- positive reinf is behaviour followed by rewarding outcome, negative reinf is beh followed by cessation of unwanted experience
- punishment - an unwanted experience
- extinction - behaviour is followed by no rewarding outcome - eventually stops
14
Q
For each of these reinforcement schedules, give the rate of learning and extinction
- continuous
- fixed ratio
- fixed interval
- variable ratio
- variable reinforcement
A
- slow, fast
- fast, medium
- medium, medium
- fast, slow
- fast, slow
15
Q
Explain cognitive model/impact of thinking
A
- anxious thoughts leads to feeling anxious leads back to anxious thoughts (cycle)
- feeling anxious makes it more likely that we’ll have anxious thoughts - may assume these thoughts are realistic and true
- anxious thoughts are characterised by ‘thinking the worst’ - often they’re not true
- important to recognise they aren’t facts and related to feelings - anxious thoughts can lead to anxious feelings
16
Q
How does escape, avoidance and expectations impact fear?
A
- at a triggering event, release of hormones for fight/flight/freeze
- then escape
- in expectations, arousal increases and enables imagined consequences of continued exposure
- if not there is the natural physiological trajectory remaining and the natural physiological trajectory of escaping (this flattens much quicker)
17
Q
What is vicarious learning?
A
- learning through the experience of someone else
- observing responses of another, hearing their experience or picking up on emotion of another in room
- a factor that shapes fear
18
Q
Explain the 5 areas model
A
- informs many psychological interventions
- provides framework for organising how we describe an experience with thoughts, emotions, physical sensation, behaviour and social context
- answers given within a circle
- each aspect is thought to influence the others and small changes in each aspect of model can add together and lead to significant changes
19
Q
What did Armfield say caused dental fear?
A
- some people who have had traumatic dental experimental experiences do not end up with dental fear
- some people with dental fear did not have a traumatic dental experience
- in a survey of 1084 Australian adults perceptions dental treatment as unpredictable, uncontrollable, dangerous and disgusting were more predictive of fear than previous dental experience
20
Q
Explain vicious cycle of dental fear
A
- dental fear/anxiety
- leads to delayed visiting
- leads to dental problems
- leads to symptom-driven treatment
- which leads back to dental fear/anxiety
- evidence shows interaction between patient and dentist when they do attend is important
21
Q
Psychologically informed treatment principles
A
- understand patient perspective
- provide info to address concerns, correct misconceptions, direct helpful strategies
- plan and apply appropriate behavioural techniques and strategies - dentist delivered and patient directed
- within a context of support
- people are individual - use reflection
22
Q
Explain how fear presents
A
- body sensations (heart racing, hot, trembling, muscle tension, butterflies, nausea)
- thoughts (needing to escape, something bad is going to happen, why am i like this)
- feelings (scared, terrified, nervous, overwhelmed)
23
Q
Explain fight/flight response
A
- activated when triggered by potential danger
- mostly caused by release of complex mix of hormones like cortisol and adrenaline
- fast breathing, fast heart rate, hot and sweaty, nausea, trembling, focus on danger and escape
24
Q
Why does fear apply to specific situations?
A
- usually where the danger is perceived or unlikely
- predisposed to fear certain things like spiders, heights, snakes as associated with genuine danger to humans
- but can acquire from bad experiences to specific things or learn it from others
25
How to help when treating fear?
- eliminate potential fear triggers like making the waiting room less clinical
- play music or ask patients to play their own
- pro-actively ask patients how they want to have a break etc
26
Explain Wolpe's behavioural treatment of fear
- systematic densensitization and reciprocal inhibition
- fear can be treated by exposing patients to things they fear and prevent escape/avoidance
- when patient doesn't experience anything bad, fear gradually reduces - unless own reaction is extreme enough to create fear
- systematic desensitization involved creating a 'hierarchy' of feared situations which gradually presented as patient becomes less fearful
- coping strategies like breathing techniques/distraction are taught
27
Cognitive principles in treating fear
- help patients to understand what is happening - treatment, own responses
- ask about their concerns and address them
- normalise reactions that may be ashamed of such signs of anxiety
28
How do interactions between dental team and patient increase/reduce anxiety over time?
- dental fear can be fuelled by cycle of attempts at escape and avoidance, stressful interactions, negative experience back to dental fear
- dental fear disuaded by support to approach treatment, supportive interactions/praise and then a positive experience reduces dental fear
29
Recommendations for working with mild fear and anxiety
- use general anxiety-reducing treatment style - provide safe secure situation to acknowledge feelings, assure patient they'll be fine and nothing will happen against their wishes
- make use of modelling, enable patients to feel in control and highly predictable treatment
- teach coping strategies - distraction/relaxation
- add in pharmacological support if needed
30
Recommendations for working with specific phobias
- systematic exposure
- start by teaching relaxation skills to patient
- construct hierarchy from least to most feared situation
- work through each level gradually until patient can tolerate it
- this helps patients face fears gradually
31
Recommendations for treatment of high treatment needs
- IV sedation or general anaesthetic for amount of work
- nothing to treat fears in above so need cognitive behaviour therapy for long term - rather than sedation alone
32
How to address psychological aspects
- keep calm
- let patient know they can signal to stop anytime
- tell them unpleasant feelings are from hormones and body can only release a certain amount of hormones
- help them slow breathing but not deeply - breath to 7 in, 11 out
- ask how you can help - follow existing coping strategies
- check consent at every stage
33
How to address social aspects of practice?
- ask how anxious people are, concerns and any way to help
- acknowledge what they've said without judgement
- address concerns by offering ideas
- respect, support and understand
- involve them in treatment plan
34
What is pain?
an experience including sensory, attitude, beliefs, emotional and motivational elements
35
First rule of understanding pain
- not always a sign of physical damage or injury
36
What is nociception?
- transmission of messages from peripheral tissues to the brain
- from specific nerve cells called nociceptors
- not pain messages - pain only experienced once stimuli interpreted in brain
- warning messages
37
Pain is influenced by what factors?
- situation
- interpersonal factors
- previous experience
- temperament
- response
- deliberate strategies
38
What kind of pain is present in dental settings?
- part of necessary procedures
- symptom like toothache
- long term persistant condition
39
Why is pain an alarm?
- shows something is happening
- human help needed
- may be dangerous
40
Why do we investigate pain?
- come up with likely explanation
- answer question 'is it safe to ignore this?'
41
What kind of anxiety management with also reduce pain?
- be friendly
- be calm
- briefly explain what you're doing
- discuss and agree stop signals
- discuss strategies
- ask how much patients want to know
- supporting staff can give emotional support
42
Onward referral regarding anxiety
- most dentists don't have access to bespoke psych services
- patients can self-refer to IAPT services and info on how to do so online
- patients can speak to GP to make referral to psych services
- psych therapist can educate and give coping srategies around dental fear
43
Personal impact of working with anxiety
- emotionally challenging
- need to seek self care and be professional about it
- can't care if you aren't caring for own needs
