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The Fear Reaction
You know that the fear response (or "fight-or-flight" reaction) has been triggered if you experience some or all
of the following:
OK, so the fear has "returned". Three possibilities (maybe more):
a) something about the circumstances has changed. Time to go back to the drawing board and figure out what's wrong and
how it can be rectified. Are there any needs which were met in the past that aren't being met now? Go figure out a solution.
Or ask on our message board.
b) if you have solely relied on methods of anxiety control involving memory loss for the procedure (IV or more profound
oral sedation), your brain hasn't had the chance to learn that dental treatment needn't be unpleasant. You may have felt great
afterwards, but fear is more likely to return to baseline levels where behavioural methods of anxiety control aren't used.
c) the "fear" appears to be coming "out of nowhere", there's no real reason you can come up with as
to why you'd experience the symptoms associated with fear or panic.
c) is more common than one might think - and results from the way the human brain is wired. See lengthy explanations (followed
by practical tips) below!
Fear Conditioning
Conditioning someone to experience fear (or to develop a phobia) is surprisingly simple. You can condition anyone to develop
a phobia of virtually anything by repeatedly exposing the person to a neutral stimulus (such as a dentist) and pairing that
neutral stimulus with an unconditioned (reflexive) stimulus (such as pain), which by itself elicits fear. Do this often enough,
and the neutral dentist stimulus by itself will elicit fear. Actually, we're so evolved that it may take as little as one
bad encounter to change the wiring in your brain forever, provided the event is traumatic enough. While pain is the most obvious
example, human beings are a bit more complex, and something seemingly innoculous like negative remarks can lead to conditioned
fear.
Fear conditioning is both rapid and long-lasting. In fact, it's been shown that the rewiring which occurs in the brain
during fear conditioning is permanent (but - see below!).
Extinction Learning
This may sound like bad news - and it is bad news ;) ! Fortunately, a counter mechanism exists, and it's called "extinction
learning". For example, in rats, conditioned fear responses to a tone paired with a footshock rapidly disappear when
the tone is presented in the absence of the shock. Similarly, if you're repeatedly exposed to a dentist in the absence of
any negative events (or, preferably, in the presence of positive events), the fear response will all but disappear. Unfortunately,
this effect doesn't always last very long.
With rats, the newly learnt "extinction memory" will have completely disappeared after 14 days, as if the extinction
learning had never happened. They show little or no fear response for about 6-10 days after learning that there's nothing
to fear. But quite suddenly, the fear response "recovers", and they're back to square one. Though not quite - the
memory trace still exists, and the next time the tone isn't coupled with an electric shock, the rat will relearn that there's
nothing to fear more quickly than the first time round. The reemergence of the fear response doesn't occur because extinction
memory has been lost, but rather because the rat fails to retrieve it.
It is now thought that rather than erase fear conditioning, extinction involves the formation of new memories, and that fear
conditioning and extinction learning are two separate learning mechanisms which coexist. Basically, this means that extinction
learning cannot wipe out existing fear conditioning. Instead, it's a separate mechanism which can offer an alternative way
of interpreting things.
The memory and primitive emotional systems of our brains are very similar to those of rats. As a result, the above has
some important implications for people who've been fear conditioned.
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What You can Do
(1) Spacing of Appointments:
Especially at the start, it might be a good idea not to have your appointments scheduled too far apart. I reckon one week
to 10 days is about ideal (not because of the rats - this is a purely personal observation =) - though the rats sort of confirm
it). A lot of people find that they actually wouldn't mind having another appointment (or are even looking forward to it)
when they've just had one successful appointment, but if left too long, some degree of fear returns (or rather, extinction
memory wears off). If it's not possible to schedule appointments close together, especially at the start, try tip (2) below.
Once they've finished treatment, some people also find it helpful to schedule the first check-up somewhat sooner than the
"usual" 6 months (unless they're on more frequent recalls, anyway).
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Reward Learning
Reward learning is a more powerful mechanism than extinction learning. Rewards, and especially social rewards such as praise,
are powerful motivators which make us feel good. Like fear conditioning, reward learning is an example of classical condition,
where a neutral stimulus (such as a dentist) is repeatedly coupled with a positive event (such as receiving praise). Unlike
extinction learning, rather than the mere absence of negative events, reward learning involves the presence of positive events.
Even though reward learning is thought to happen in the same part of the brain (the amygdala) as fear conditioning, again
they involve separate "circuits". As an interesting aside, these two systems may not be completely separate - which
may explain phenomena such as masochism, where fear and pleasure coexist and are activated simultaneously. But let's not go
there ;) ... the point was that the memories formed during reward learning can provide a powerful counterpoint (or what NLPers
call an "anchor") to coexisting memory traces of conditioned fear.
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What You can Do
(2) Repeating positive experiences:
Pick out anything positive about a dental appointment, and "relive" it. Replay past positive dental encounters at
regular intervals (in your head - no need to splash out on PlayMobil ;)), starting as soon as possible after the positive
encounter. This helps to strengthen the new memories you've learnt. Try to ignore any "bad bits". You only want
to replay positive aspects. Do this in as much detail as possible, and do it often, especially at the start.
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I said earlier that the rewiring which occurs in the brain during fear conditioning is permanent. When brain cells fire together
(as in the case of, say, a dentist paired with a painful stimulus), they wire together. But when cells fire apart, they wire
apart. So having a number of good experiences with a dentist can actually change the wiring in your brain. There may be differences
between individuals in how easily this rewiring is accomplished - some people's brains may have more plasticity than others'.
So it might take some people a longer time to "rewire" their brains. Some of the rewiring that takes place during
fear conditioning may permanently alter the connections in your brain, but that doesn't mean that new connections being made
may not prove stronger! It simply means that for many ex(ish)-phobics, re-conditioning them to experience dental fear tends
to be easier than fear conditioning an adult who's never experienced fear in the dental chair before.
One could also speculate that children and teenagers, whose brains have more plasticity than the fully developed brain,
are more easily fear conditioned than adults.
The Misattribution of Fear
Even if you work on strengthening extinction memory and memories of rewards, you may find that the fear response surfaces
regardless, especially if some time has passed since your last visit or if the context is somehow different. On the other
hand, some individuals who've overcome a dental phobia find that the fear response doesn't resurface at all. Again, brain
mechanisms can help to explain what's going on.
Not only does fear conditioning involve a memory system separate from the systems for reward learning and extinction learning.
In addition, the brain circuitry underlying the fear response has two different pathways. The older, more primitive pathway
(dubbed the "low road") carries nerve impulses from clusters of nerves which act as relay stations for sensory perceptions
directly to the amygdala (the brain's "fear centre"). The more evolved pathway (the "high road") sends
nerve impulses on to the sensory cortex (a region of the brain that conducts sophisticated analysis of inputs), where they
are evaluated. The brain then deciding whether or not the potentially dangerous stimulus warrants a fear reaction - or whether
it's in fact harmless.
Human beings, much more than any other animals, have a large amount of this "intelligent" cortex. As a result, in
the normal way, we're quite adept at not overreacting when presented with uncertain stimuli. However, the "low road"
is crucial for survival, and will kick in when there's not much time to think, e. g. when confronted with a sabre-toothed
tiger. The fight-or-flight response will kick in straight away. Speed is of crucial importance when faced with a threat to
survival.
When a person has been fear conditioned and developed a phobia, s/he may undergo behavioral treatment and seem to be cured.
It's been suggested that this is because the signal pathways from the thalamus to the amygdala and sensory cortex have been
normalized. The person is able to critically evaluate the stimulus (e. g. the dental environment, dental instruments, etc.)
through the "high road". They no longer automatically trigger fear by going the "low road".
However, during a period of high stress, the phobia may suddenly reappear, without an apparent reason. It has been suggested
that one of the reasons why it's so difficult to exert conscious control over fear is that the cell projections from the amygdala
to the prefrontal cortex (the area of the brain most responsible for planning and reasoning) are far more numerous than those
from the prefrontal cortex to the amygdala. Basically, once the amygdala "thinks" that danger might be present,
it will then "tell" the prefrontal cortex that a dangerous situation has indeed been "detected". And the
prefrontal cortex promptly falls for it, causing us to experience the feeling of fear.
What's really happening is that the physiological fear response induces a "feeling of fear", rather than fear triggering
the fear response. In other words, we misinterpret physiological changes such as an increased heartrate, sweating, or feeling
faint (which are controlled by rather primitive brain mechanisms) as sure-fire signs that danger must be present. The physiological
changes preceed the sense of impending doom, rather than the other way round, and fool us into experiencing fear. And because,
once fear mechanisms have been activated, it's hard to use the much less numerous nerve connections leading from our rational
thinking parts to the amygdala, a full-blown panic attack may result.
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What You can Do
(3) Be aware that the fear reaction is NOT the same as fear:
The fear REACTION is a purely physiological response which can happen without any conscious intervention. For example, you
may not feel particularly fearful and something may still trigger the fear reaction. It's easy to misinterpret physical changes
such as a racing heart, sweaty palms, feeling faint to mean that you're experiencing fear.
Simply being aware of the distinction between fear and the fear reaction may help. It's just your body reacting in a way
it's been programmed to react, it's not dangerous, and the feeling will pass.
By being aware and accepting that you may never be able to fully get rid off the fear reaction, but that the positive
emotions you've learnt since then are just as powerful and can co-exist with the engrained fear reaction, you may be able
to "shrug off" feelings of panic and see them for what they really are: remnants of past fears.
(4) The "pre-emptive strike":
One of the salient features of the fear response is that, once fear has reached a certain extent, the harder you try to suppress
it, the worse it gets - and may result in a full-blown panic attack. The best cure is to share your fear (by telling your
dentist you're fearful or terrified, depending on what extent of fear you're experiencing). It's been shown time and time
again that this will have the effect of making you feel calmer.
Even if you're not particularly worried, it can help to "pretend" and tell your dentist that you're nervous
at the start of a visit. This can have the paradoxical effect of making you feel more relaxed.
(5) Anchoring:
If you can catch the fear reaction before it escalates, simple techniques such as making a conscious effort to relax your
muscles, concentrating on your breathing, and thinking back to similar situations in the past when you felt calm (see (2))
will probably do the trick. Alternatively, some people prefer to visualize a pleasant situation such as lying on a beach or
similar.
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The idea that fear may be misattributed is by no means new. Even though my waffle above is based on rat research findings
dating from the late 1980s (using sophisticated tissue staining and tracing techniques), apparently the idea itself existed
much earlier. Or so I've been told (by a psychologist, no less! - read on, cos she explains it much better, and it all ends
on a juicy note):
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"In 1962, two psychologists by the names of Schachtner and Singer, introduced their " misattribution of fear"
theory to their colleagues. Personally, I think this theory was quite exciting, since it formed the cornerstone of many subsequently
developed theories, like the "excitation transfer theory".
The premise of Schachtner & Singers theory is that it examined the origin of fear from a novel approach. Usually,
fear was presumed to be the response to - or the result of - an emotional stimulus. For example: sighting of vicious tiger
= triggers fear = triggers physical response ( adrenaline rush = accelerated heartbeat, sweating, nausea, dizziness, etc.).
Nothing unusual about that.
But what if - Schachtner & Singer asked - emotion (fear) wasn't the instigating agent of the physical symptoms? What
if the emotional experience was actually the result of the (preceding) physical signs? Therefore, if you could block the physical
symptoms, you would eliminate the fear.
Obviously, the researchers didn't apply their theory to the above "vicious tiger" example. In this instance,
fear is a healthy, innate response to a threatening stimulus. Ignoring it would be detrimental to our survival as a person
or as a species. Viewed from an evolutionary perspective. But frequently, they argued, the source of our fear isn't clear.
Or necessary. Nor healthy. Indeed, frequently there IS no source. Because it somehow gets "misattributed" by the
preceding physical symptoms.
Anyway, they did a whole bunch of experiments which were all "de rigeur" in the 60's and then this theory, for
a variety of reasons, fell out of favour (psychologists are like toddlers, they get bored quite easily!). But in the early
70's, Wolf Zillman and his fellow researchers expanded on it with his "excitation transfer theory". They argued
that any physical arousal (produced by fear, sex, joy, vigorous exercise, grief, anger, anything) "transfers" to
any subsequent stimulus of arousal, thereby augmenting the subsequent emotion. According to that premise, that's why sex is
better after a hefty argument! Or why we respond with considerably more joy/anger/emotion after any preceding arousing event.
And it's true. The moment we release adrenaline it has an undeniable impact on any subsequent emotional event on that day,
or rather, in its immediate temporal vicinity. It heightens ALL our emotions, both positive and negative. Think about it.
The next time something trivial really annoys you - or really thrills you, for that reason - take an inventory of what happened
before. I'll guarantee you, there was something which aroused ( "arousal", in this instance, obviously refers to
any emotional response, and has no sexual connotation in this context) you earlier and which accounts for this apparently
"unusual" and excessive response.
Now how does all this relate to dental phobia and falling in love with one's dentist? Quite brilliantly, I think. Since
the person is already highly aroused (by fear = arousal 1) it will augment the arousal of the perceived subsequent stimulus
(= understanding, sympathetic dentist = arousal 2). And the result is romantic attachment! Or, if the subsequent stimulus
(dentist) is perceived as unsympathetic or in any way negative, the patient then REALLY loathes the guy/woman with venom.
Because the emotions are distorted by the original stimulus (fear)."
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Eh, don't ask how we ended up there... all I asked was what "excitation transfer theory" was and how it related
to dental phobia... honestly (I think ;) - my memory may be letting me down)! She's got a point, though... In any event, there
are lessons to be learnt from the above (apart from "pick a good-looking dentist of your preferred sex", that is
;)):
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What You can Do
(6) Reinterpret physiological changes:
Physiological changes, such as a pounding heart or sweaty palms, can be interpreted in different ways - as "negative"
arousal such as fear, or "positive" arousal such as feeling excited. If you're good at self-deception, you may find
it quite easy to reinterpret a rapid heartbeat and other symptoms of autonomic nervous system arousal as meaning that you're
actually quite excited and interested in what's going on. Sort of a "roller-coaster" effect (it helps if you like
roller-coasters or adventure sports).
Another trick which can work quite well: during or after receiving local anaesthetic, you may feel your heart beating
faster. True enough, this can be due to anxiety (and usually is, but who cares). But it can also be caused by epinephrine
(adrenalin) contained in the anaesthetic entering your bloodstream. Some people find it helpful to attribute autonomic nervous
system arousal to the effects of adrenalin entering their system, rather than fear causing raised adrenaline levels. If you
find the thought comforting (not everyone does), it may help to attribute arousal to having been given adrenaline. (To anyone
scared of the effects of adrenaline: it's impossible to be allergic to it, since our bodies produce it all the time).
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What You can Do
(7) Credit where credit is due:
A lot of people seem to fail to realize how remarkable their achievement is. Confronting your greatest fears is such a difficult
thing to do. Perhaps even the most difficult thing you've ever done. There's no point in beating yourself up over "what
might have been" had you confronted your fear earlier. What matters is that you've done it now! It may sound clich�d,
but it's true... there's no point in crying over spilled milk - and you deserve to feel very proud of yourself for your achievement!!
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