POST-TRAUMATIC STRESS DISORDER

1. POST-TRAUMATIC STRESS DISORDER IN A DENTAL ENVIRONMENT

2. Introduction • Results from a traumatizing event • Event is individually horrifying & had the potential to physically harm the person • Fear is triggered, then they re-experience the event even though the threat has been removed • Causes suffering & social dysfunction • Chronic PTSD- episodes occur more than 3 months • Clinician should be aware of different behavioral side effects to prevent discomfort or triggers • Clinician should be educated on managing these episodes in a clinical environment

3. Signs & Symptoms • Take proper precautions if you see the following signs • Social functioning difficulties • Self-neglect • Anger • Anxiety • The patient may experience • Intrusive recurrent thoughts, images, or flashbacks of their traumatic event • Sleep disturbances • Emotional numbing • Misinterpretation of other’s actions around them • Perception of a foreshortened future • Hyperarousal

4. Veterans & Emergency Service Personnel • Misinterpretation of external stimuli • Patient falls asleep during procedure- wake up to someone putting instruments in their mouth= Defensive response • Flashing overhead light=Danger response • Loud sounds (high volume vacuum suction or drill) • Prevent triggering an episode- tell them what you are planning to do in advance • Veterans & alcohol abuse is associated with PTSD • Oral hygiene materials not available in war zone

5. Experience with Cancer Treatment • This experience is an event that extends from the point of diagnosis until the end of treatment. • A child that has undergone chemotherapy may perceive gloves and masks as a sign of harm, and may react out of fear with irrational behavior. • Other chemotherapy patients may be scared of being exposed to radiation while receiving dental xrays.

6. Abuse • Children, youth, adults, & elderly • Neglect, trauma, sexual, emotional, or physical abuse • Suspects- who the victim trust the most • Overwhelmed with traumatic event causes feelings of helplessness, fear, and embarrassment leading to more severe issues, like PTSD • Patients try to avoid uncomfortable situations that could trigger reaction • Clinician- soft tone, no firm suggestions, avoid commanding, take precaution during physical contact

7. Sight of Blood • The clinician should grab gauze from the tray, apply pressure, stop the bleeding, and put the gauze out of sight to prevent the patient from seeing it. • There are different scenarios, but each are equally devastating to the patient. • Veterans & emergency personnel • Cancer patient • Abused children and adults • Women that has suffered a miscarriage

8. Keeping Your Distance • Proxemics- study of territory • Intimate zone: 1-18 inches away • Comfort zone: 4-12 feet away • Ease the discomfort- develop rapport • Patient’s with PTSD want more space • Clinician of the opposite sex more feared • Claustrophobia- feels trapped in small space • Lost trust in people & now have a fear of something bad happening again

9. Stop & Explain • Gain trust • Always explain what you will be doing before you actually do it • Tell them honestly what they will be feeling • There can be signals for communication while the clinician is working in the mouth • a wink, a sound, or raising their hand

10. Dental Management • “Improving my smile is the least of my concern compared to the other issues I’m dealing with”. • Clinicians should educate patient on oral hygiene & improve or modify their techniques • No improvement unless at-home tasks are done • Systemic diseases & medications should be reviewed at each appointment • Common PTSD drugs: beta-blockers, SSRIs, anti-anxiety agents, anticonvulsants, & antipsychotics • Dental considerations: monitor vital signs, chronic dry mouth, semi-supine position, may neglect self-care, short appointments, increased bleeding, poor healing, & frequent recall schedule to avoid periodontal infection

11. Conclusion • PTSD can effect someone that has had to fight cancer, or that has suffered from neglect, trauma, sexual, emotional, or physical abuse • There are steps clinicians can take to help make their dental treatment a little more comfortable • While some PTSD patients are open about their disorder, others may not be. We must be aware of the signs and symptoms so that we can take precautions if we believe the patient may be suffering from the disorder. • It is important to be aware of ways to handle a patient with PTSD and the dental implications that comes with the disorder.

12. References • Bush, N. (2009). Post-traumatic stress disorder related to the cancer experience. Oncology Nursing Forum, 36(4), 395-400. • Grogan, S., & Murphy, K. (2011). Anticipatory stress response in PTSD: Extreme stress in children. Journal Of Child & Adolescent Psychiatric Nursing, 24(1), 58- 71. • Jaffe, S., & Schub, T. (2011). Quick lesson about post-traumatic stress disorder. Cinahl Information Systems (Glendale, California), (2p) (5 ref) • Katsounari, I. (2011). Post-traumatic stress disorder and psychosis. Mental Health Practice, 15(4), 14-18. • McCarthy, E. (2010). Epidemiology and Management of Alcohol Dependence in Individuals with Post-Traumatic Stress Disorder. CNS Drugs, 24(12), 997- 1007. • Nield-Gehrig, J. S. (2010). Patient Assessment Tutorials Second Edition: A step-by- step guide for the dental hygienist. Philadelphia, PA: Lippincott Williams & Wilkins. • Pickett, F. A., & Terezhalmy, G. T. (2010). Dental Drug Reference with Clinical Implications Second Edition. Philadelphia, PA: Lippincott Williams & Wilkins. • Richardson, L., Frueh, B., & Acierno, R. (2010). Prevalence estimates of combat related post- traumatic stress disorder: critical review. Australian & New Zealand Journal Of Psychiatry, 44(1), 4-19.

13. Picture references • Stop sign: http://www.clker.com/clipart-6863.html • Drugs: http://www.writers-free-reference.com/10classaction.htm • Soldier: http://www.entheology.org/edoto/anmviewer.asp?a=266&print=yes • Cancer: http://abclocal.go.com/wabc/story?section=news/health&id=7696578 • Abuse: http://www.shutterstock.com/pic-66196585/stock-photo-conceptual-image-of-child-abuse-similar-available-in-my-portfolio.html

14. Questions?