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Lecture 1: Anger and frustration

From the perspective of information processing, both anger and frustration are associated with the situation when the desired goal is blocked.
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Welcome back to the course Brain, Behaviour, and Dentistry. Now we will have the third class of the third session of the course, which will focus on the issues of emotion. After this class, you will learn more concepts about emotion and social interaction, which are closely associated with patient-dentist communication. Since we are talking about the negative emotions during dental treatment, we should not forget a major kind of ‘dark feeling’ from patients, i.e., anger and frustration. From the perspective of information processing, both anger and frustration are associated with the situation when the desired goal is blocked. Just like fear and anxiety, we need to get to know what’s the threat underneath.
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For anger and frustration, we need to understand what desire is thwarted from the patients’ perspective. While anger is usually described as a burst of emotion, like the volcano eruption, frustration is more long-lasting and reflects the disappointment when someone is continuously trying to achieve something but fails anyway. Finally, though anger is commonly associated with aggressive behaviour, they are very different concepts. There are other emotions associated with aggression, and fear is one of them. It may sound weird that fear is associated with anger or aggression.
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But just think about it: when we are fighting with some enemies for limited resources, we want to secure our survival, and so do they. It is not impossible that we would ‘strike first’ to get rid of the enemies as a threat. The fighting can be very bloody, not because we feel so angry, but because of fear – we have to fight on. Otherwise, our survival will be jeopardized. Ironically, the aggressive behaviour is not really for an offensive purpose, but for a protective purpose – we fight due to the fear of being eliminated. Now, back to dental practice, it is not really a serious live-or-die condition. However, it is not uncommon to see some patients behave more aggressively in their language.
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That does not mean they are getting mad about or they just hate all dentists. It is very often that patients are getting mad because they are too anxious about the situation. For example, patients with acute pulpitis just need emergent treatment. They would become angry when pain is not relieved by the treatment because to get pain relieved is the reason why they are here. In another case, an elderly patient is anxious about the making of a new denture. He feels difficult to understand all the jargon from dentists and has no idea what to do next. The fear and anxiety may potentiate his bad temper and impatience.
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So, when it comes to anger and frustration, it is very important to clarify what goals are not achieved from the patient’s perspective. The problem is that during dental practice, some patients may have a ‘big goal’ that cannot be solved immediately. For example, chronic orofacial pain is a major challenge to dental treatment. It would be unwise for a dentist to guarantee that everything can be fixed just in one visit. In fact, to alleviate patients’ frustration, what dentists need to do first is to reset the goal for patients – any good relief should be considered a success for this appointment.
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If unfortunately, patients just try again and again, and every appointment or every dentist fails to achieve their goal, they would get more and more frustrated. As I mentioned earlier, frustration refers to something long-lasting, when people continuously try to achieve something but fail again. This is indeed what we usually see in patients with chronic pain. There’s a term Paingry to describe such a condition. Anger and frustration are not that uncommon for patients suffering chronic illnesses, and we need to help them make a reasonable goal of treatment.
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Now let’s have a quick digression to brain science. We know fear and anxiety are closely associated with each other, and pain is one of the strongest threats to dental patients. We also know that fear and anger can be related, and anger and frustration may reflect the stress of chronic diseases. We may reasonably conceive that these mental experiences share some common brain mechanisms. Using neuroimaging methods, researchers have discovered that brain activation is associated with these experiences, and here is an outcome from the meta-analysis of these findings using the tool Neurosynth. You can see that the pattern of brain activation when people receive painful stimuli and feel fear or anxiety are very similar.
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One explanation is that the brain activation reflects the cognitive-affective processing of a threat. Interestingly, this pattern of activation is not that pronounced in chronic pain. The activation pattern of chronic pain, in contrast, is more similar to the activation pattern of anger and stress. The outcomes imply that chronic pain may be associated with the inability of coping with long-lasting suffering, which is also common to anger, frustration and stress.
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I have to make a statement here: violence against healthcare workers is not allowed in all medical settings. However, as dental professionals who are engaged with patients’ suffering, we need to understand why and how the ‘dark energy’ comes about. For example, as I mentioned earlier, sometimes anger does not mean immediate aggression. It can be a ‘signal’ that signifies patients’ confusion and fear. I want to share a story from my internship. A very elderly man living alone came to argue with a young dentist about his ill-fitting denture. He asked for a simple refit of his old denture, but the dentist insisted the whole denture should be remade. This soon turned into an intense argument.
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Later on, a nurse came in and asked the patient ‘Hi, is there any difficulty that makes you worried about your situation’ – and that’s the key question. Then further discussion disclosed the fact that the elderly man, living alone, got a huge financial burden and he was so worried about the cost of remaking a denture. He really had no money for that. His anger derives, partly, from his fear and anxiety.

In this session, we will focus on negative emotions.

After this class, you will learn more concepts about emotion and social interaction, which are closely associated with patient-dentist communication.

Before we look further into ‘dark feeling’ from patients, we need to get to know first what’s the threat underneath. Most of the time, those negative emotions don’t mean the patients hate all dentists. It is very often that patients are getting mad because they are too anxious about the situation.

Let’s put our thinking caps on!

Do you have any experience of patient-dentist communication that did go well? What did you do? When being a patient, what did you do to make yourself more comfortable? As a dentist, what did you do to improve your relationship with patients?

Please share your experience with us. You’re also encouraged to read and comment on the responses of other learners 🙂

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Brain, Behaviour, and Dentistry

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