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The dental cognitions questionnaire in CBT for dental phobia in an adolescent with multiple phobias
Journal of Behavior Therapy and Experimental Psychiatry 34 (2003) 65–71
The dental cognitions questionnaire in CBT for dental phobia in an adolescent with multiple phobias Warren Mansella,*, Kathleen Morrisb a
Department of Psychology, Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK b Phoenix Children’s Resource Centre, Bromley, BR2 9JG, UK
Abstract A case of an adolescent boy with multiple phobias who was treated successfully for his dental phobia is described to illustrate the clinical utility of the Dental Cognitions Questionnaire (DCQ) in aiding effective cognitive-behavior therapy. The client showed drops in dental anxiety that coincided with the use of the DCQ in cognitive restructuring, and there was a close correlation between dental cognitions and degree of dental anxiety over the timecourse of therapy and follow up. r 2003 Elsevier Science Ltd. All rights reserved. Keywords: Anxiety disorders; Children; Cognitive-behavior therapy; Exposure; Comorbidity
1. Introduction Dental phobia is a significant clinical problem because of its great impact on physical health and quality of life, and its high prevalence, at around 5%, which peaks during early adolescence (Kent, 1997). It has been suggested by many authors that multiple fears maintain dental phobia (e.g. Kent, 1997; de Jongh, Muris, Schoenmakers, & ter Horst, 1995b; Chapman & Kirby-Turner, 1999). A comprehensive series of research studies have culminated in the characterization of dental fears using the Dental Cognitions Questionnaire (DCQ; de Jongh et al., 1995b). Patients’ scores on this scale have been shown to account for 70% of the variance in state anxiety while in the chair awaiting dental treatment. *Corresponding author. E-mail address: [email protected] (W. Mansell). 0005-7916/03/$ - see front matter r 2003 Elsevier Science Ltd. All rights reserved. doi:10.1016/S0005-7916(03)00020-X
66
W. Mansell, K. Morris / J. Behav. Ther. & Exp. Psychiat. 34 (2003) 65–71
The most effective treatment for phobias to date is graded exposure to the fear. provoking stimulus (Ost, 1996). Nevertheless, an important debate concerns the extent to which the mediation of change during therapy may involve cognitive processes (Mansell, 2000), and emerging evidence suggests that cognitive factors are indeed important in facilitating change (De Jongh et al., 1995a; Kamphuis & Telch, 2000). Indeed close inspection of some treatment protocols suggests that ‘graded . exposure’ may actually use cognitive methods. For example, Ost, Svensson, . Hellstrom, and Lindwall (2001) suggest that in graded exposure, ‘‘the guiding principle of treatment is the cognitive-behavioral analysis of the child’s catastrophic cognition concerning what will happen when encountering the feared object or situation’’ (p. 817). The following case study describes the assessment and treatment of an adolescent with incapacitating dental phobia. The aim of the study was to explore the effectiveness of CBT for dental phobia, in particular using the DCQ as a focus of cognitive intervention. The role of cognitive factors in change was assessed in two ways. First, changes in belief ratings across and during sessions were recorded to test whether the use of the DCQ was associated with a drop in dental anxiety, relative to periods where exposure-based techniques were used. Second, the relationship between changes in dental anxiety and DCQ was assessed by investigating the degree to which they correlated with one another across time.
2. Description of the case John was 14 years old and lived with his mother and younger sister. He was referred by the Dental Officer at the local special needs medical center following his refusal to receive either local anesthetic or gaseous sedation prior to dental treatment. He had been extremely anxious and highly resistant to any treatment involving injection or possible loss of consciousness. John’s dental phobia prevented him from getting five fillings, one of which was giving him pain. He also had a phobia of injections that had prevented him from receiving important vaccinations. He had a longstanding vomit phobia which led him to drastically limit his food and drink because of the belief that they would make him sick. He avoided taking lifts, also because of his anxiety. John developed his vomit phobia at around six years of age following a period when his father left home after a ‘breakdown’ with PTSD and depression, and John was sick at home in front of his mother and friends of the family. During the next year, John had an accident in which he damaged his front teeth, requiring prolonged emergency dental treatment on the top floor of a specialist hospital. John’s lift phobia emerged soon after this occasion. The treatment itself involved an injection into the gum at the base of each front tooth. After the operation, John’s mother told him that he had received injections and that the dentist was surprised that John wasn’t sick considering the amount of blood that he had swallowed. In the following year, when John was seven, he received a rubella injection. He had tried to refuse treatment but the nurse used physical constraint to force him to receive the injection,
W. Mansell, K. Morris / J. Behav. Ther. & Exp. Psychiat. 34 (2003) 65–71
67
and she insisted to John that the injection did not hurt. The next year marked the onset of a brief period of school phobia, after he witnessed another boy having an epileptic fit next to him in assembly. The school phobia was addressed by behavior therapy. John went to dental treatment over the next 6 years but he refused treatment when he required several injections for his fillings.
3. Treatment plan The treatment plan was broadly cognitive-behavioral, and incorporated elements from a number of published treatment studies (de Jongh et al., 1995b; Kent, 1997; Chapman & Kirby-Turner, 1999). It was formulated that John had a range of specific fears that led to the experience of anxiety, in anticipation of, and during the dental procedure. In response to these feelings, he would fear a complete loss of control, which would lead him to tense up which in turn maintained his feelings of anxiety. Alternatively, he would terminate the procedure and avoid it, thereby maintaining his fears, which would be left unchallenged. The elements of treatment were as follows: imaginal and in vivo exposure that was under the client’s control; timeline construction of the onset and progression of the dental phobia and other fears; psychoeducation on the anxiety response; information about the dental procedure; identification and restructuring of cognitions using the DCQ; and brief relaxation techniques.
4. Assessment measures The following standardized questionnaires were used: MDAS (Humphris, Morrison, & Lindsay, 1995); DCQ (de Jongh et al., 1995a,b); Beck Anxiety Inventory (BAI; Beck, Epstein, Brown, & Steer, 1988); Birleson Depression Scale (BDS; Birleson, 1981). Furthermore, the MDAS and the degree of belief in five ‘critical’ cognitions (those chosen by the client and therapist to be monitored because of their relevance for recovery) were assessed at several points during session seven: prior to a brief cognitive intervention (7.1); after the cognitive intervention (7.2); and after the first exposure to dental treatment (7.3).
5. Results 5.1. Dental cognitions The DCQ was used at the start of session six to identify the client’s key fears. The statements that were endorsed with a belief rating of over 80% were: ‘‘Everything goes wrong’’, ‘‘Something will surely go wrong’’, ‘‘I can’t stand this treatment for long’’, ‘‘This treatment will hurt’’, ‘‘The nerve will be touched’’, ‘‘I am helpless’’, ‘‘I have no control over what happens’’, ‘‘I can’t escape, I’m locked in’’, ‘‘The sound of
68
W. Mansell, K. Morris / J. Behav. Ther. & Exp. Psychiat. 34 (2003) 65–71
the drill frightens me’’, ‘‘I will panic during treatment’’, ‘‘I become sick’’ and ‘‘The dentist will lose control over the drill’’. Each of the key dental cognitions was addressed during session six using cognitive techniques. For example, the therapist asked him what made him believe that he would panic during the treatment. He explained that he experienced bodily sensations, such as shaking and feeling hot that he found frightening and meant that he was losing control. The therapist explained that these feelings were due to anxiety and the formulation (described earlier) was shared with the client so that he could see how his beliefs about his physical reactions could lead to a vicious cycle. He was also reminded of his experience during exposure therapy that the feelings of anxiety would gradually drop with time. The belief that the dentist will lose control of the drill was addressed by prompting the client to remember a particular event he had witnessed on an earlier session; the dentist had carved the client’s name on a pencil with the drill, indicating how precisely she could control it. The client was asked how he might have more control over what happened during the treatment. He suggested that one way would be for him to signal to the dentist by squeezing her free hand if he wanted to stop the procedure. This procedure was instigated. The belief that he would be locked in was addressed by simply explaining to the client that the door would not be locked behind him at any point.
5.2. Effectiveness of treatment The effectiveness of the treatment was assessed by change on the MDAS, and by the extent to which the client could tolerate each of the items on the fear hierarchy. The client started therapy with the maximum possible score on the MDAS (25), ended therapy with a score in the normal range (10) that was maintained at 1-, 6- and 18-month follow-up (see Table 1). He moved in a graded manner through the
Table 1 Changes in measures of psychopathology from pre-treatment to follow-up
Modified Dental Anxiety Scale Dental Cognitions Questionnaire— Frequency Dental Cognitions Questionnaire— Believability Beck Anxiety Inventory Birleson Depression Scale
Pre
Post
1-month follow-up
6-month follow-up
18-month follow-up
Clinical mean
Non-clinical mean
25
10
10
5
9
2272.9
1075.4
14
2
2
0
0
2376.7
1077.0
46
5
4
3
2
50716
19712
18
12
18
0
2
16713
7.378.4
5
1
0
1
1
21
6.371.3
W. Mansell, K. Morris / J. Behav. Ther. & Exp. Psychiat. 34 (2003) 65–71
69
following items on the fear hierarchy: imagining a stationary syringe; imagining a moving syringe; picture of syringes; syringe on table; syringe in hand; syringe in therapist’s hand near mouth; dental equipment; dental sounds; video of arm being injected; dental surgery; syringe with cap on in mouth; drills and other equipment; syringe in mouth with cap off; injection, drilling and filling; observe another patient having injection and treatment; observe mother having injection and treatment; further injections, drilling and filling. After the end of the psychological therapy, the client completed all his required dental treatment. 5.3. The role of cognitive change The scores on the DCQ before and after treatment are shown in Table 1. The dental cognitions dropped dramatically in frequency of endorsement and degree of belief rating after treatment. Inspection of the scores on the DCQ during the treatment itself indicated that most of the change had occurred by session eight. Fig. 1 illustrates this pattern of change for the five ‘critical’ cognitions. The figure
Fig. 1. The change in dental cognitions with exposure and cognitive treatment.
70
W. Mansell, K. Morris / J. Behav. Ther. & Exp. Psychiat. 34 (2003) 65–71
shows that the cognitive techniques used during session six and seven accounted for the largest drop in the degree of belief in the critical cognitions. The relationship between dental anxiety and dental cognitions was assessed by exploring the correlation between the MDAS and the DCQ mean belief ratings. The Pearson correlation coefficient was rð10Þ ¼ 0:91; po0:001: The correlation remained significant even when using session number as a covariate in the analysis, rð7Þ ¼ 0:69; po0:05: This indicates that the correlation between these measures was not merely a function of both of them dropping with time.
6. Discussion This study documents the successful cognitive-behavioral treatment of dental phobia in an adolescent with multiple phobias. The DCQ proved to be extremely useful in accessing, discussing and gently challenging and coping with the multiple fears that are present in dental phobia. It is very likely that the therapist would not have known in advance about several of the key dental cognitions without the use of the DCQ. Therefore, the fears may have been addressed before they led to significant interference in the dental treatment. The observed drops in dental anxiety after cognitive restructuring with the aid of the DCQ are strongly indicative of cognitive mediation. Furthermore, the extremely high correlation between the DCQ and dental anxiety supports their close relationship. However, further more controlled research would be necessary to fully test the cognitive mediation hypothesis. Although the DCQ was not designed with adolescents in mind, it proved highly appropriate in this case. We would recommend that other therapists, and psychologically trained dentists, could use this questionnaire in cases that appear to be resistant to other methods of intervention. The approach of graded exposure also proved to be important. For this individual, imaginal exposure was commenced before using in vivo stimuli because of the intense fear generated by real stimuli. It is clearly desirable to be flexible to the client’s level of anxiety, maintain the client’s own control over their treatment, and modify the hierarchy accordingly. It remains to be tested whether the kind of interventions described here could be provided in a single session, a method that recent studies have shown to be highly effective in . et al., 2001) and dental phobia in specific phobias in children and adolescents (Ost . adults (de Jongh et al., 1995a; Thom, Sartory, & Johren, 2000). In summary, this case study suggests that the DCQ can be helpful and effective in cognitive-behavior therapy for dental phobia.
Acknowledgements We would like to thank Sara Hutchinson for her support in the process of therapy, and Stan Lindsay for his help with providing materials for treatment and assessment.
W. Mansell, K. Morris / J. Behav. Ther. & Exp. Psychiat. 34 (2003) 65–71
71
References Beck, A. T., Epstein, N., Brown, G., & Steer, R. A. (1988). An inventory for measuring clinical anxiety: Psychometric properties. Journal of Consulting and Clinical Psychology, 56, 893–897. Birleson, P. (1981). The validity of depressive disorder in childhood and the development of a self-rating scale: A research report. Journal of Child Psychology and Psychiatry, 22, 73–88. Chapman, H. R., & Kirby-Turner, N. C. (1999). Dental fear in children—a proposed model. British Dental Journal, 187, 408–412. De Jongh, A., Muris, P., ter Horst, G., Van Zuuren, F., Schoenmakers, N., & Makkes, P. (1995a). Onesession cognitive treatment of dental phobia: Preparing dental phobics for treatment by restructuring negative cognitions. Behaviour Research and Therapy, 33, 947–954. De Jongh, A., Muris, P., Schoenmakers, N., & ter Horst, G. (1995b). Negative cognitions of dental phobics: Reliability and validity of the dental cognitions questionnaire. Behaviour Research and Therapy, 33, 507–515. Humphris, G. M., Morrison, T., & Lindsay, S. J. E. (1995). The modified dental anxiety scale: Validation and United Kingdom norms. Community Dental Health, 12, 143–150. Kamphuis, J. H., & Telch, M. J. (2000). Effects of distraction and guided threat appraisal on fear reduction during exposure-based treatments for specific fears. Behaviour Research and Therapy, 38, 1163–1181. Kent, G. (1997). Dental phobias. In: G.C.L. Davey (Ed.), Phobias: Handbook of theory, research and treatment. Chichester, UK: Wiley. Mansell, W. (2000). Conscious appraisal and the modification of automatic process in anxiety. Behavioural and Cognitive Psychotherapy, 28, 99–120. . Ost, L. (1996). Long-term effects of behavior therapy for specific phobia. In M. R. Mavissakalian, et al. (Ed.), Long-term treatments of anxiety disorders (pp. 121–170). Washington, DC: APP. . . Ost, L., Svensson, L., Hellstrom, K., & Lindwall, R. (2001). One-session treatment of specific phobias in youths: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 69, 814–824. . Thom, A., Sartory, G., & Johren, P. (2000). Comparison between one-session psychological treatment and benzodiazepine in dental phobia. Journal of Consulting and Clinical Psychology, 68, 378–387.
The dental cognitions questionnaire in CBT for dental phobia in an adolescent with multiple phobias Warren Mansella,*, Kathleen Morrisb a
Department of Psychology, Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK b Phoenix Children’s Resource Centre, Bromley, BR2 9JG, UK
Abstract A case of an adolescent boy with multiple phobias who was treated successfully for his dental phobia is described to illustrate the clinical utility of the Dental Cognitions Questionnaire (DCQ) in aiding effective cognitive-behavior therapy. The client showed drops in dental anxiety that coincided with the use of the DCQ in cognitive restructuring, and there was a close correlation between dental cognitions and degree of dental anxiety over the timecourse of therapy and follow up. r 2003 Elsevier Science Ltd. All rights reserved. Keywords: Anxiety disorders; Children; Cognitive-behavior therapy; Exposure; Comorbidity
1. Introduction Dental phobia is a significant clinical problem because of its great impact on physical health and quality of life, and its high prevalence, at around 5%, which peaks during early adolescence (Kent, 1997). It has been suggested by many authors that multiple fears maintain dental phobia (e.g. Kent, 1997; de Jongh, Muris, Schoenmakers, & ter Horst, 1995b; Chapman & Kirby-Turner, 1999). A comprehensive series of research studies have culminated in the characterization of dental fears using the Dental Cognitions Questionnaire (DCQ; de Jongh et al., 1995b). Patients’ scores on this scale have been shown to account for 70% of the variance in state anxiety while in the chair awaiting dental treatment. *Corresponding author. E-mail address: [email protected] (W. Mansell). 0005-7916/03/$ - see front matter r 2003 Elsevier Science Ltd. All rights reserved. doi:10.1016/S0005-7916(03)00020-X
66
W. Mansell, K. Morris / J. Behav. Ther. & Exp. Psychiat. 34 (2003) 65–71
The most effective treatment for phobias to date is graded exposure to the fear. provoking stimulus (Ost, 1996). Nevertheless, an important debate concerns the extent to which the mediation of change during therapy may involve cognitive processes (Mansell, 2000), and emerging evidence suggests that cognitive factors are indeed important in facilitating change (De Jongh et al., 1995a; Kamphuis & Telch, 2000). Indeed close inspection of some treatment protocols suggests that ‘graded . exposure’ may actually use cognitive methods. For example, Ost, Svensson, . Hellstrom, and Lindwall (2001) suggest that in graded exposure, ‘‘the guiding principle of treatment is the cognitive-behavioral analysis of the child’s catastrophic cognition concerning what will happen when encountering the feared object or situation’’ (p. 817). The following case study describes the assessment and treatment of an adolescent with incapacitating dental phobia. The aim of the study was to explore the effectiveness of CBT for dental phobia, in particular using the DCQ as a focus of cognitive intervention. The role of cognitive factors in change was assessed in two ways. First, changes in belief ratings across and during sessions were recorded to test whether the use of the DCQ was associated with a drop in dental anxiety, relative to periods where exposure-based techniques were used. Second, the relationship between changes in dental anxiety and DCQ was assessed by investigating the degree to which they correlated with one another across time.
2. Description of the case John was 14 years old and lived with his mother and younger sister. He was referred by the Dental Officer at the local special needs medical center following his refusal to receive either local anesthetic or gaseous sedation prior to dental treatment. He had been extremely anxious and highly resistant to any treatment involving injection or possible loss of consciousness. John’s dental phobia prevented him from getting five fillings, one of which was giving him pain. He also had a phobia of injections that had prevented him from receiving important vaccinations. He had a longstanding vomit phobia which led him to drastically limit his food and drink because of the belief that they would make him sick. He avoided taking lifts, also because of his anxiety. John developed his vomit phobia at around six years of age following a period when his father left home after a ‘breakdown’ with PTSD and depression, and John was sick at home in front of his mother and friends of the family. During the next year, John had an accident in which he damaged his front teeth, requiring prolonged emergency dental treatment on the top floor of a specialist hospital. John’s lift phobia emerged soon after this occasion. The treatment itself involved an injection into the gum at the base of each front tooth. After the operation, John’s mother told him that he had received injections and that the dentist was surprised that John wasn’t sick considering the amount of blood that he had swallowed. In the following year, when John was seven, he received a rubella injection. He had tried to refuse treatment but the nurse used physical constraint to force him to receive the injection,
W. Mansell, K. Morris / J. Behav. Ther. & Exp. Psychiat. 34 (2003) 65–71
67
and she insisted to John that the injection did not hurt. The next year marked the onset of a brief period of school phobia, after he witnessed another boy having an epileptic fit next to him in assembly. The school phobia was addressed by behavior therapy. John went to dental treatment over the next 6 years but he refused treatment when he required several injections for his fillings.
3. Treatment plan The treatment plan was broadly cognitive-behavioral, and incorporated elements from a number of published treatment studies (de Jongh et al., 1995b; Kent, 1997; Chapman & Kirby-Turner, 1999). It was formulated that John had a range of specific fears that led to the experience of anxiety, in anticipation of, and during the dental procedure. In response to these feelings, he would fear a complete loss of control, which would lead him to tense up which in turn maintained his feelings of anxiety. Alternatively, he would terminate the procedure and avoid it, thereby maintaining his fears, which would be left unchallenged. The elements of treatment were as follows: imaginal and in vivo exposure that was under the client’s control; timeline construction of the onset and progression of the dental phobia and other fears; psychoeducation on the anxiety response; information about the dental procedure; identification and restructuring of cognitions using the DCQ; and brief relaxation techniques.
4. Assessment measures The following standardized questionnaires were used: MDAS (Humphris, Morrison, & Lindsay, 1995); DCQ (de Jongh et al., 1995a,b); Beck Anxiety Inventory (BAI; Beck, Epstein, Brown, & Steer, 1988); Birleson Depression Scale (BDS; Birleson, 1981). Furthermore, the MDAS and the degree of belief in five ‘critical’ cognitions (those chosen by the client and therapist to be monitored because of their relevance for recovery) were assessed at several points during session seven: prior to a brief cognitive intervention (7.1); after the cognitive intervention (7.2); and after the first exposure to dental treatment (7.3).
5. Results 5.1. Dental cognitions The DCQ was used at the start of session six to identify the client’s key fears. The statements that were endorsed with a belief rating of over 80% were: ‘‘Everything goes wrong’’, ‘‘Something will surely go wrong’’, ‘‘I can’t stand this treatment for long’’, ‘‘This treatment will hurt’’, ‘‘The nerve will be touched’’, ‘‘I am helpless’’, ‘‘I have no control over what happens’’, ‘‘I can’t escape, I’m locked in’’, ‘‘The sound of
68
W. Mansell, K. Morris / J. Behav. Ther. & Exp. Psychiat. 34 (2003) 65–71
the drill frightens me’’, ‘‘I will panic during treatment’’, ‘‘I become sick’’ and ‘‘The dentist will lose control over the drill’’. Each of the key dental cognitions was addressed during session six using cognitive techniques. For example, the therapist asked him what made him believe that he would panic during the treatment. He explained that he experienced bodily sensations, such as shaking and feeling hot that he found frightening and meant that he was losing control. The therapist explained that these feelings were due to anxiety and the formulation (described earlier) was shared with the client so that he could see how his beliefs about his physical reactions could lead to a vicious cycle. He was also reminded of his experience during exposure therapy that the feelings of anxiety would gradually drop with time. The belief that the dentist will lose control of the drill was addressed by prompting the client to remember a particular event he had witnessed on an earlier session; the dentist had carved the client’s name on a pencil with the drill, indicating how precisely she could control it. The client was asked how he might have more control over what happened during the treatment. He suggested that one way would be for him to signal to the dentist by squeezing her free hand if he wanted to stop the procedure. This procedure was instigated. The belief that he would be locked in was addressed by simply explaining to the client that the door would not be locked behind him at any point.
5.2. Effectiveness of treatment The effectiveness of the treatment was assessed by change on the MDAS, and by the extent to which the client could tolerate each of the items on the fear hierarchy. The client started therapy with the maximum possible score on the MDAS (25), ended therapy with a score in the normal range (10) that was maintained at 1-, 6- and 18-month follow-up (see Table 1). He moved in a graded manner through the
Table 1 Changes in measures of psychopathology from pre-treatment to follow-up
Modified Dental Anxiety Scale Dental Cognitions Questionnaire— Frequency Dental Cognitions Questionnaire— Believability Beck Anxiety Inventory Birleson Depression Scale
Pre
Post
1-month follow-up
6-month follow-up
18-month follow-up
Clinical mean
Non-clinical mean
25
10
10
5
9
2272.9
1075.4
14
2
2
0
0
2376.7
1077.0
46
5
4
3
2
50716
19712
18
12
18
0
2
16713
7.378.4
5
1
0
1
1
21
6.371.3
W. Mansell, K. Morris / J. Behav. Ther. & Exp. Psychiat. 34 (2003) 65–71
69
following items on the fear hierarchy: imagining a stationary syringe; imagining a moving syringe; picture of syringes; syringe on table; syringe in hand; syringe in therapist’s hand near mouth; dental equipment; dental sounds; video of arm being injected; dental surgery; syringe with cap on in mouth; drills and other equipment; syringe in mouth with cap off; injection, drilling and filling; observe another patient having injection and treatment; observe mother having injection and treatment; further injections, drilling and filling. After the end of the psychological therapy, the client completed all his required dental treatment. 5.3. The role of cognitive change The scores on the DCQ before and after treatment are shown in Table 1. The dental cognitions dropped dramatically in frequency of endorsement and degree of belief rating after treatment. Inspection of the scores on the DCQ during the treatment itself indicated that most of the change had occurred by session eight. Fig. 1 illustrates this pattern of change for the five ‘critical’ cognitions. The figure
Fig. 1. The change in dental cognitions with exposure and cognitive treatment.
70
W. Mansell, K. Morris / J. Behav. Ther. & Exp. Psychiat. 34 (2003) 65–71
shows that the cognitive techniques used during session six and seven accounted for the largest drop in the degree of belief in the critical cognitions. The relationship between dental anxiety and dental cognitions was assessed by exploring the correlation between the MDAS and the DCQ mean belief ratings. The Pearson correlation coefficient was rð10Þ ¼ 0:91; po0:001: The correlation remained significant even when using session number as a covariate in the analysis, rð7Þ ¼ 0:69; po0:05: This indicates that the correlation between these measures was not merely a function of both of them dropping with time.
6. Discussion This study documents the successful cognitive-behavioral treatment of dental phobia in an adolescent with multiple phobias. The DCQ proved to be extremely useful in accessing, discussing and gently challenging and coping with the multiple fears that are present in dental phobia. It is very likely that the therapist would not have known in advance about several of the key dental cognitions without the use of the DCQ. Therefore, the fears may have been addressed before they led to significant interference in the dental treatment. The observed drops in dental anxiety after cognitive restructuring with the aid of the DCQ are strongly indicative of cognitive mediation. Furthermore, the extremely high correlation between the DCQ and dental anxiety supports their close relationship. However, further more controlled research would be necessary to fully test the cognitive mediation hypothesis. Although the DCQ was not designed with adolescents in mind, it proved highly appropriate in this case. We would recommend that other therapists, and psychologically trained dentists, could use this questionnaire in cases that appear to be resistant to other methods of intervention. The approach of graded exposure also proved to be important. For this individual, imaginal exposure was commenced before using in vivo stimuli because of the intense fear generated by real stimuli. It is clearly desirable to be flexible to the client’s level of anxiety, maintain the client’s own control over their treatment, and modify the hierarchy accordingly. It remains to be tested whether the kind of interventions described here could be provided in a single session, a method that recent studies have shown to be highly effective in . et al., 2001) and dental phobia in specific phobias in children and adolescents (Ost . adults (de Jongh et al., 1995a; Thom, Sartory, & Johren, 2000). In summary, this case study suggests that the DCQ can be helpful and effective in cognitive-behavior therapy for dental phobia.
Acknowledgements We would like to thank Sara Hutchinson for her support in the process of therapy, and Stan Lindsay for his help with providing materials for treatment and assessment.
W. Mansell, K. Morris / J. Behav. Ther. & Exp. Psychiat. 34 (2003) 65–71
71
References Beck, A. T., Epstein, N., Brown, G., & Steer, R. A. (1988). An inventory for measuring clinical anxiety: Psychometric properties. Journal of Consulting and Clinical Psychology, 56, 893–897. Birleson, P. (1981). The validity of depressive disorder in childhood and the development of a self-rating scale: A research report. Journal of Child Psychology and Psychiatry, 22, 73–88. Chapman, H. R., & Kirby-Turner, N. C. (1999). Dental fear in children—a proposed model. British Dental Journal, 187, 408–412. De Jongh, A., Muris, P., ter Horst, G., Van Zuuren, F., Schoenmakers, N., & Makkes, P. (1995a). Onesession cognitive treatment of dental phobia: Preparing dental phobics for treatment by restructuring negative cognitions. Behaviour Research and Therapy, 33, 947–954. De Jongh, A., Muris, P., Schoenmakers, N., & ter Horst, G. (1995b). Negative cognitions of dental phobics: Reliability and validity of the dental cognitions questionnaire. Behaviour Research and Therapy, 33, 507–515. Humphris, G. M., Morrison, T., & Lindsay, S. J. E. (1995). The modified dental anxiety scale: Validation and United Kingdom norms. Community Dental Health, 12, 143–150. Kamphuis, J. H., & Telch, M. J. (2000). Effects of distraction and guided threat appraisal on fear reduction during exposure-based treatments for specific fears. Behaviour Research and Therapy, 38, 1163–1181. Kent, G. (1997). Dental phobias. In: G.C.L. Davey (Ed.), Phobias: Handbook of theory, research and treatment. Chichester, UK: Wiley. Mansell, W. (2000). Conscious appraisal and the modification of automatic process in anxiety. Behavioural and Cognitive Psychotherapy, 28, 99–120. . Ost, L. (1996). Long-term effects of behavior therapy for specific phobia. In M. R. Mavissakalian, et al. (Ed.), Long-term treatments of anxiety disorders (pp. 121–170). Washington, DC: APP. . . Ost, L., Svensson, L., Hellstrom, K., & Lindwall, R. (2001). One-session treatment of specific phobias in youths: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 69, 814–824. . Thom, A., Sartory, G., & Johren, P. (2000). Comparison between one-session psychological treatment and benzodiazepine in dental phobia. Journal of Consulting and Clinical Psychology, 68, 378–387.