JADA Continuing Education
Hypnotizability, Absorption and Negative Cognitions as Predictors of Dental Anxiety
Two Pilot Studies
Jeannie D. DiClementi, PsyD,
Jennifer Deffenbaugh and
Daniel Jackson, BA
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ABSTRACT
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Background. The authors conducted two pilot studies that investigated the roles of hypnotizability, absorption (defined as the ability to maintain focused attention on a task or stimulus) and state versus trait anxiety as predictors of dental anxiety. One of the studies also examined the effectiveness of hypnosis in managing dental anxiety.
Methods. Participants in study 1 completed measures of hypnotizability and anxiety, viewed a video of a dental procedure either under hypnosis or not, and completed dental anxiety questionnaires. Participants in study 2 were told either that the video showed major dental work or a routine polishing. All subjects watched the video and then completed measures assessing their perceptions of the video and their anxiety.
Results. The authors found a positive relationship between hypnotizability and scores on the Dental Anxiety Scale (DAS) (F1,290 = 3.45, P = .06), as well as an interaction between hypnotizability and hypnosis (F1,290 = 6.55, P = .01). An analysis of covariance found a relationship between trait and dental anxiety (F1,290 = 11.50; P = .001). A two-way analysis of variance found a main effect for hypnosis (F1,290 = 3.20, P = .07). The authors found an effect for group on the DAS (F1,228 = 3.67, P = .057), such that subjects in the negative-cognition group scored higher on the DAS. The authors found an interaction between absorption and cognition in perceptions of pain experienced by the patient in the video (F1,228 = 3.70, P = .05) and in ratings of one’s own pain level if in the same situation (F1,228 = 4.38, P < .05).
Conclusions. Hypnotizability or absorption, pre-existing anxiety and cognitions about dental procedures predict dental anxiety, and hypnosis may be helpful for some, but not all, patients.
Clinical Implications. Characteristics such as hypnotizability, trait anxiety and negative cognitions predict which people develop dental anxiety and who will be more responsive to hypnosis. The authors provide suggestions for dentists treating anxious patients.
Key Words: Dental anxiety; hypnotizability; cognitions; anxietyAbbreviations: BSI: Brief Symptom Inventory • DAS: Dental Anxiety Scale • GSI: General Severity Index • HGSHS: Harvard Group Scale of Hypnotic Susceptibility • STAI: State-Trait Anxiety Inventory • TAS: Tellegen Absorption Scale
As many as 75 percent of adults experience some anxiety about dental treatment,1 and as many as 25 percent of the population avoids dental care altogether until symptoms force them to seek help.2 In some cases, dental anxiety evolves into a more extreme phobic reaction, and estimates of extreme dental fear are as high as 15 percent of the population.1
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DENTAL ANXIETY
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Attempts to delineate specific antecedents of dental anxiety and phobia have been only moderately successful. Some authors report that women have more dental anxiety than do men.3,4 Others point to multiple invasive dental procedures,5 fear and dislike of the dentist,2 and psychological and conditioning variables as causing dental anxiety.6 Ost7 discussed a classic example of vicariously learned dental fear. A teenager sitting in the dentist’s waiting room heard another patient yell in pain; the teenager ran from the clinic and subsequently developed a lifelong dental phobia.7 It is clear that dental anxiety likely results from a combination of factors.
Anxiety is a future-oriented mood state typified by high negative affect accompanied by a fear component.8 In other words, the anxious person fears a future, rather than a current, event. In the cognitive literature, anxiety is assumed to be the result of cognitions about a real or perceived threat. If people believe that an event is going to be uncomfortable or painful, their anxiety and perception of discomfort or pain increase. People who are particularly anxiety-prone also may tend to engage in highly selective attentional processes, as research on panic disorder has shown.8,9 According to this research, people with panic disorder tend to focus their attention selectively on interoceptive cues, to the exclusion of external or peripheral information.8
Other researchers refer to this tendency to sustain focused and undivided attention as being part of the process of absorption, a component of hypnotizability. People who are more hypnotizable become more absorbed in tasks.10–12 Highly hypnotizable people may become so absorbed in a task or stimulus that they are not even aware of other tasks or stimuli.11,13 For example, students who were more hypnotizable were found to be more absorbed in, and adherent to, a complex task regimen than were students with low hypnotizability.14 Other researchers have found that highly hypnotizable people, or people with high absorption, pay greater attention to their own physical sensations and/or changes.15,16 The mechanisms for absorption and anxiety appear to overlap, in that both are associated with greater vigilance to interoceptive cues.
Hypnotizable people preparing to go to a dental appointment may be so focused on their physiological responses (for example, their experience of the pain or recall of the pain stimuli, such as the drill) that they may not recall anything else. Patients with low hypnotizability, on the other hand, may be more engaged in processing other information, such as remembering what the dentist said to them. If the more hypnotizable person also is highly anxious, then the appointment could be very uncomfortable for both the patient and the dentist.
We conducted two pilot studies to investigate the role of hypnotizability, absorption (a component of hypnotizability), beliefs and anxiety in predicting patients’ responses to dental care. In the first study, we also investigated the role of hypnosis in attenuating people’s responses to dental procedures.
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STUDY 1
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The hypotheses for this study were the following:
- – Participants who were higher in hypnotizability would be more anxious in response to cues associated with dentistry.
- – The sound of the dental drill would increase anxiety.
- – Hypnosis would attenuate dental anxiety.
- – State anxiety would increase the level of dental anxiety.
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SUBJECTS AND METHODS
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This study used two manipulated variables (hypnosis versus no hypnosis and sound versus no sound) and two covariates (hypnotizability and pre-existing anxiety). The score on a measure of dental anxiety served as the dependent variable. Participants were 291 undergraduate psychology students (196 women and 95 men) attending the regional campus of a Midwestern university system.
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MEASURES AND PROCEDURES
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Harvard Group Scale of Hypnotic Susceptibility (HGSHS).17
This structured technique measures behavioral, perceptual and cognitive responses to suggestions. It is begun in the form of an imagery technique guided by an examiner. We presented this measure on a tape recording to ensure standardized administration. The procedure includes a relaxation induction followed by suggestions of floating, arm levitation and immobilization, eye catalepsy, rigidity and head falling. At the conclusion of the taped session, participants completed a response booklet in which they reported their responses to the suggestions (for example, their physical sensations, perceptions of dissociation and involuntariness of actions).
The measure of 12 objective behaviors consisted of forced-choice responses for each item. For example, for the eye catalepsy item, participants were asked what an onlooker who had been observing might have seen. The responses were either that the participant’s eyes remained closed (scored as a plus) or that they had opened (scored as a minus). The total score is the number of plus responses out of a maximum of 12.
State-Trait Anxiety Inventory (STAI).18
This self-report questionnaire consists of 20 questions that measure how participants feel "right now" (that is, state anxiety), as well as 20 questions that measure how people "generally feel" (that is, trait anxiety). The STAI has been used extensively in research and clinical applications and has good reliability and validity.
Corah’s Dental Anxiety Scale (DAS).19
This scale, our dependent measure, is used to assess a person’s perceptions of dental procedures or other situations viewed as threatening. It consists of four questions, each with five multiple-choice responses ranging from 1 (relaxed) to 5 (completely anxious). Total scores range from 4 to 20. This scale is used widely in clinical practice, as well as in research.
Video.
In this study, we used a video of a dental procedure filmed by a dentist consultant. Viewers see gloved fingers of the dentist, as well as three instruments: a dental probe, a drill and a suction hose. There are no bodily fluids (including saliva or blood). The video is benign in nature, suggesting no particular procedure to the naïve viewer.
We randomly assigned participants to one of two hypnosis conditions and to one of two sound conditions. All participants completed the STAI and the HGSHS. Two of the authors (J.D., D.J.) administered to participants in the hypnosis condition a brief hypnotic induction adapted from the tape-recorded HGSHS. They presented this induction on a tape recording to ensure standardization. The recording instructed participants to close their eyes and relax, and it then gave them suggestions of floating and arm levitation. In addition, the recording suggested that they would remain in a relaxed state while viewing the video, and then instructed them to raise their heads and open their eyes when they were awake and ready to view the video.
We instructed participants in the no-hypnosis condition to take a 20-minute break until it was time to view the video.
Participants in the sound condition viewed a 30-second slice of the video that contained sounds of the drill. Participants in the no-sound condition viewed the same 30-second slice of video without the sound. All participants then completed the DAS and dental history form to control for previous experiences with dental care. We then debriefed participants.
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RESULTS
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Participants.
The mean age of participants was 22.75 years (standard deviation [SD], 7.47 years). There were no significant differences in age (F1,289 = 1.10; P = .29) between men (mean age = 22.08 years; SD = 5.52 years) and women (mean age = 23.07 years; SD = 8.25 years). There were no significant between-group differences in age (F3,287 = 1.33, P = 0.27) for the experimental conditions.
Experimental conditions.
A two-way analysis of variance showed a marginal effect for hypnosis (F1,290 = 3.20, P = .07), such that participants in the hypnosis groups (that is, those receiving the hypnotic induction before viewing the video) scored lower on the DAS than did those in the no-hypnosis groups (Table 1
). There was no main effect for the sound condition.
Hypnotizability.
Scores on the HGSHS determined the participant’s level of hypnotizability. We found a relationship between hypnotizability and scores on the DAS (F1,290 = 3.45, P = .06), such that participants who were more hypnotizable were more dentally anxious than other participants (Table 2). We also found a significant interaction effect between hypnotizability and experimental group (F1,290 = 6.55, P = .01), such that participants with high hypnotizability who were in the hypnosis groups, particularly the hypnosis/no-sound group, scored lower on the DAS than did subjects with lower hypnotizability who were in the no-hypnosis groups. In other words, the relationship between hypnotizability and scores on the DAS was enhanced by the hypnosis and sound experimental conditions.
We used a frequency analysis of the HGSHS to divide participants into high- versus low-hypnotizability groups (using a median split). We categorized participants with scores of 0 to 5 (n = 145) as "low hypnotizables" and particpants with scores of 6 to 12 (n = 146) as "high hypnotizables." When correcting for pre-existing anxiety, as indicated by scores on the STAI, we found that the interaction between hypnotizability and hypnosis condition remained significant (F1,290 = 5.90, P = .02) (Table 3, page 1246).
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TABLE 3 Study 1 group means on Corah’s DAS* for hypnosis by hypnotizability interaction after correcting for scores on the STAI.
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Anxiety measures.
We used scores on the STAI as covariates and scores on the DAS as the major dependent variable. An analysis of covariance showed a significant effect of trait anxiety on DAS scores (F1,290 = 9.19; P = .003), such that participants who were higher in trait anxiety scored higher on the DAS. We also found an interaction between trait anxiety and experimental condition; thus, subjects high in trait anxiety who were in the no-hypnosis groups scored higher on the DAS (F1,290 = 9.15; P = .003) than other subjects (Table 4, page 1246).
The results showed no differences in either trait or state anxiety between men and women. In addition, we found no relationship between scores on the STAI and age.
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STUDY 2
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In the literature on task absorption, researchers have reported a relationship between absorption and hypnotic susceptibility. Task absorption is influenced by setting and situation.13 It may be that people who are more susceptible to hypnosis are capable of becoming more absorbed in a task to the exclusion of peripheral distractions, especially when instructed to attend to the task. Evans11 asserted that people who are highly hypnotizable are more easily absorbed in tasks associated with daily living, often to the neglect of other tasks. Furthermore, we posit a link between absorption and anxiety in that both involve greater attention to internal physiological cues.
The purpose of our second study was to investigate the role that absorption plays in dental anxiety, particularly the interaction between absorption and beliefs or cognitions about dental procedures. We predicted the following:
- – Trait anxiety would predict dental anxiety, as demonstrated in the first study.
- – A higher level of absorption would predict greater dental anxiety.
- – Negative cognitions (beliefs) about the dental video would predict greater anxiety.
- – The negative cognition group would overestimate attributes of the video and would endorse greater levels of personal discomfort in response to the video.
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SUBJECTS AND METHODS
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We used a between-subjects design with participants randomly assigned to one of two cognition conditions: negative cognition or positive cognition. Participants consisted of 250 undergraduate psychology students (172 women and 78 men). Their mean age was 23.18 years (SD = 8.66 years). We found no significant between-group differences in age for either sex or experimental condition. We conducted this study during different semesters from the first study to avoid dual participation by students.
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MEASURES AND PROCEDURES
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In addition to the STAI and DAS, we administered three scales:
Tellegen Absorption Scale (TAS).20
This 34-item paper-and-pencil inventory is reported to correlate highly with hypnotizability21 and, in fact, measures one specific aspect of hypnotizability. Items are scored on a five-point Likert scale (0 = never, 4 = always). We used this measure to separate out the construct of absorption.
Brief Symptom Inventory (BSI).22
This is a 53-item self-report measure of cognitive, emotional, somatic and perceptual symptoms. It has well-established psychometric properties. The inventory converts raw scores to scaled scores, making it easier to compare individual results with population norms. There are nine clinical scales, plus scaled scores for numbers of symptoms (Positive Symptom Index) and severity of symptoms reported (General Severity Index [GSI]).
Recall and rating measures.
We administered a paper-and-pencil questionnaire asking participants for their estimation of the duration of the video, for their estimation of the number and type of sounds they heard, if the dentist said anything to the patient, if blood was present and for their estimation of the number of instruments used in the video. Participants completed written ratings of the discomfort they believed the patient was experiencing and of their own discomfort if they had been the patient (1 = very comfortable, 5 = very uncomfortable), the degree of pain the patient was experiencing and how much pain they would be experiencing if they were the patient (1 = no pain at all, 5 = a great deal of pain).
We randomly assigned participants to a negative-cognition or positive-cognition condition. Each participant completed the STAI, TAS, a dental history questionnaire and BSI. For participants in the negative-cognition condition, two of the authors (J.D., D.J.) gave an oral description of the video, portraying the dental procedure as a major procedure involving drilling into the cavity of the tooth. They told participants in the positive-cognition condition that the video simply showed a routine tooth polishing. Participants in both conditions viewed a two-minute slice of the same video used in study 1. All participants then completed a recall measure to assess their recall of the video, a rating scale of their perceptions of discomfort on the part of the dental patient in the video and Corah’s DAS.
At the conclusion of the study, we debriefed participants regarding the nature of the study and the reason for the minor deception. We asked them to complete a second consent form granting us consent to use the data obtained through deception.
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RESULTS
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Cognitions.
Belief about the dental procedure in the video was the primary independent variable. The results showed a significant effect for group on the DAS (F1,228 = 3.67, P = .057), such that subjects in the negative-cognition group reported having higher anxiety. Recall of the video and ratings of the patient’s reactions and one’s own reactions were the dependent variables. The results also demonstrated that the participants in the negative-cognition group overestimated the amount of pain the patient in the video was experiencing (F1,228 = 4.48, P < .05) and the number of comments made by the dentist to the patient (F1,228 = 11.93, P = .001) (Table 5). Male participants in the negative-cognition group overestimated the number of instruments seen in the video (F1,228 = 4.35, P < .05) and significantly rated their own level of discomfort as greater than that reported by female participants (F1,228 = 5.90, P = .02) (Table 6).
Absorption.
The mean score on the TAS was 59.74 (SD = 24.61). The study results showed no between-group differences on the TAS for cognition condition or sex. We found an absorption-by-cognition interaction with regard to perceptions of pain experienced by the patient in the video (F1,228 = 3.70, P = .05) and ratings of one’s own level of pain if he or she were in the same situation (F1,228 = 4.38, P < .05). Thus, people in the negative-cognition condition with higher levels of absorption rated the patient’s pain and their own pain significantly higher than did participants with low absorption and/or participants in the positive-cognition group. We also found that elevations in absorption predicted overestimations of the number of procedure-related sounds in the video (F1,228 = 7.07, P < .01), comments made by the dentist (F1,228 = 6.10, P = .01) and number of instruments (F1,228 = 7.18, P < .01), as well as elevated estimates of one’s own pain if he or she were in the same situation (F1,228 = 3.68, P = .05).
Psychological symptoms.
We used the GSI of the BSI, a measure of symptom severity, as a covariate, and we found that it predicted perceptions of greater pain on the part of the patient in the video (F1,228 = 16.10, P < .001), such that participants reporting more severe psychological symptoms in themselves perceived the patient to be experiencing greater pain. In an analysis of covariance, we also found a significant relationship between state anxiety and scores on the DAS (F1,247 = 4.61, P < .05), but we found no relationship between trait anxiety and scores on the DAS.
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DISCUSSION
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The data from these two pilot studies support our hypothesis that people higher in hypnotizability also would be more anxious in response to the video, as measured by the DAS. Our hypothesis in study 1 that hypnosis would attenuate anxious responses to the video also was supported. The sound of the drill alone did not affect significantly the anxiety experienced on seeing the video, so our second hypothesis was not supported. We found a relationship between trait anxiety and dental anxiety, such that people high in trait anxiety demonstrated more anxiety in response to seeing the dental video.
The results of study 2 were mixed. We found that greater levels of absorption predicted greater anxious responses to the dental video. The data failed to support the results of the first study with regard to state-trait anxiety. In study 2, we found that state anxiety predicted greater dental anxiety on viewing the video than did trait anxiety; this is surprising because both participant samples were drawn from the same student population. The data supported our hypothesis that the type of cognition or belief about dental procedures would affect the type of response to the dental procedures (that is, if the subject believed that the procedure was major surgery, he or she was more anxious than if he or she believed that the procedure was routine). Negative cognitions also resulted in distorted perceptions about what occurred in the video when, in fact, nothing actually took place.
Results of the two studies point to a particular characteristic of the patient with dental anxiety that has not been investigated previously: that of hypnotizability or, more specifically, absorption. The hypnotizable person is characterized as one who engages in highly selective attentional processes to the exclusion of peripheral, albeit relevant, information.10,14 In the dental situation, this is demonstrated by patients who are so focused on the perceived discomfort of the procedure that the actual experience of discomfort is increased.
Distracting patients.
Attempts to talk patients out of their anxiety once the procedure has begun may be difficult, because many of these patients cannot shift their focus to the peripheral stimuli. Stopping momentarily to talk with the patient, shifting his or her focus, may help alleviate his or her anxiety. At the least, by talking directly to the patient during the procedure, the clinician may distract him or her. Knowing in advance which patients are more hypnotizable would put the dental provider at an advantage, because he or she could apply interventions earlier. This is not always practical, however, because most dental practices do not routinely employ psychologists to provide pretreatment assessment. The dentist can, however, use relaxation techniques with all patients on a routine basis.
Hypnosis.
These data support the use of hypnosis to attenuate anxiety, particularly among those who are highly hypnotizable. Therefore, clinicians easily can add to dental appointments a routine application of techniques that are similar to hypnosis but do not require hours of training. For example, the dentist can ask patients to recall favorite places from childhood or vacations that evoke feelings of safety or relaxation. He or she then can use the images to guide the patient in a relaxation session. A psychologist with expertise in guided imagery and/or hypnosis easily can train and supervise the dentist. Evans11 reported that both highly hypnotizable and nonhypnotizable people responded to therapeutic interventions, including standard "talk" psychotherapy and repeated hypnosis sessions; the differences between them were in the rates of response. The nonhypnotizable subjects did not respond as quickly, but once they began to respond, they maintained a steady increase in response over several months.
Dentists should keep in mind that these techniques should be used during every appointment so that patients can expect them. For example, instead of conversing with the dental assistant or not conversing at all, the dentist can shift his or her focus to the patient and help the patient form some soothing mental images. This is a skill that needs to be learned by both the dentist and the patient.
Identifying those who are anxious—whether about a specific situation or as part of their character—is an easier task. A number of paper-and-pencil anxiety inventories can be administered when the patient comes in for an appointment that assess more of the nondentalcare–related aspects of anxiety than does the DAS. At the very least, routine use of the DAS would help the dentist prepare for potential adverse reactions by the patient.
We also found that negative beliefs about the dental procedure predicted anxious responses to the video. A basic tenet of cognitive theory is the principle that people’s beliefs about an event affect their feelings about the event. Central to cognitive theory regarding adverse reactions to events is people’s tendency to "catastrophize" the event. Beliefs about dental procedures have an effect on patients’ responses to the dental situation. If patients are left to decide for themselves what should be expected, they are likely to imagine the worst. This tendency is something that dental providers can respond to. By talking with the patient and describing carefully the planned procedures, the dentist can alleviate imagined catastrophes and head off many anxious or even phobic reactions.
Study limitations.
One flaw in the first study is the lack of a manipulation check to determine if the hypnotic induction had indeed worked. However, the fact that we did obtain significant results for the hypnosis groups versus the no-hypnosis groups lends support to the idea that at least some participants were hypnotized or were responsive to the relaxation in a way that attenuated their reaction to the video. In neither study did we ask participants if they felt that the video replicated the experience of actually being in the dental chair. The use of a nonrepresentative sample (that is, college students), plus the use of a laboratory rather than a real-life situation, require us to exercise caution in interpreting these results.
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CONCLUSION
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These study results indicate that there are some individual characteristics that may be predictive of dental anxiety, such as hypnotizability and its specific component, absorption; pre-existing anxiety; and beliefs about dental procedures. Dentists should assess their patients for these attributes before performing dental procedures. Some training—and supervision by or consultation with a psychologist trained in cognitive techniques for anxiety management—will aid the dentist in helping the anxious patient.
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FOOTNOTES
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Dr. DiClementi is an associate professor, Department of Psychology, Indiana University—Purdue University Fort Wayne, 2101 E. Coliseum, Fort Wayne, Ind. 46805, e-mail "diclemej{at}ipfw.edu". Address reprint requests to Dr. DiClementi.
Ms. Deffenbaugh is a research assistant, Department of Psychology, Indiana University—Purdue University Fort Wayne.
Mr. Jackson is a research assistant, Department of Psychology, Indiana University—Purdue University Fort Wayne.
The authors thank Heidi Krider, DDS, for her assistance in creating the video used in these studies and Renee Centers and Daysha Jackson for their assistance with data collection.
An earlier version of study 1 was presented at the annual meeting of the Midwestern Psychological Association, Chicago, May 4, 2006. An earlier version of study 2 was presented at the annual meeting of the Association for Psychological Science, New York City, May 27, 2006.
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ABSTRACT
DENTAL ANXIETY
