Iatrosedation by Dr Nathan Friedman

A common thread seems to weave through most histories of fearful patients. It is an unholy quartet of feelings consisting of:

The specific fear (needle, pain, drill etc.) invariably combined with
  • distrust
  • an intensified fear of helplessness and dependency
  • an intensified fear of the unknown; a sense of being unsafe and unprotected from the perceived threat or danger.

The variations on this theme seem endless. The following history is quite typical. It is not as obscure as the last two, but more complicated than the report preceding them.

Doctor: “Good morning, Mrs. Brown.”

Mrs. B: “Good morning, Doctor.”

Doctor: “Are you having any difficulties?” Open-ended question.

Mrs. B: “Yes, my gums bleed and I think I have pyorrhea.”

Doctor: “You think you have pyorrhea?” Facilitation by reflection

Mrs. B: “Yes, I’ve heard that bleeding gums is the beginning of pyorrhea and can cause teeth to loosen and they have to be pulled. And this makes me very nervous.” It is best not to take for granted what “makes me very nervous” means, therefore facilitate the cue.

Doctor: “What is it that makes you nervous?” The “what” question is combined with reflecting “makes me nervous”.

Mrs. B: “Well, the idea that I might lose my teeth and the kind of treatment I might need.” The “what” question yields a new clue… closer to the specific fear we want to uncover.

Doctor: “What kind of treatment are you referring to?”

Mrs. B: “Surgery… that some cutting might have to be done.” This seems to be the dominant problem and more specific.

Doctor: “What is there about the surgery that disturbs you?” The “what” is an attempt to learn the specific fear.

Mrs. B: “The whole idea… I was told to have a gall bladder removed 3 years ago and I refused to do it.” What is behind “the whole idea?”

Doctor: “Is there some reason why you feel this way about surgery?” An “on target” question designed to uncover the specific fear or fears surrounding the surgery. It may elicit information of its origin as well.

Mrs. B: “Yes there is. When I was about 5 or 6 years old I had my tonsils removed. Although I do not remember anything specific about it, I was not prepared for this and the experience left me fearful. (The origin begins to unfold as does an important element of the fear – the unknown) When I was 8 years old I went to an orthodontist who looked at my teeth but nothing was done. A few months later my mother said she was going to take me to a party the orthodontist was giving for all of his patients. I put on my party clothes and we went. (Distrust of the mother … authority … based on deceit) When we arrived I was immediately grabbed, forced into the dentist’s chair, held down and given gas. I was terrified. When I came to, I found that I had wet myself and was crying bitterly. (Distrust of the dentist, exaggerated fear of helplessness and dependency, and fear of the unknown probably are intensified.)

Fear of surgery is not the totality of the problem. It may be viewed as a vehicle carrying the powerful feelings of distrust, helplessness and the unknown with it. For this reason the maxim, “Fear is soluble in trust” seems credible. The promises, therefore, made in the commitment are important since they tend to initiate a feeling of trust and security with an attendant drop in the fear level. It remains for the iatrosedative encounter to fulfill the promises made and the hopes raised.