February 1, 2012
by Peter Nkansah, MSc, DDS, Dip. Anaes., Specialist in Dental Anaes. (Ont.)
As a child, I would spend the first half of each Saturday with my father (the second half was all about hockey). I don’t know if it was designed as bonding time, or if it was just a function of how the day worked out best for everyone (i.e. my parents). I never asked and it didn’t really matter to me. One of those Saturdays, I heard a news story on the car radio about someone who had exhibited what to me was very bizarre behaviour. Given that I was seated next to a psychiatrist (when children were allowed to ride in the front), I thought I’d engage my father in a topic sure to be in his wheelhouse. At the end of the report, to get the conversation rolling, I said, “Dad, what kind of problem would the guy in that story have?” Without missing a beat, my dad said, “Oh, he’s crazy.” That was it. And so I decided that psychiatry was off my potential-career list; it didn’t seem very challenging.
Recently, with a study group that I’m lucky enough to belong to, I’ve had the good fortune to attend three excellent lectures on mental health/illness. These lectures and my sedation/anaesthesia practice have led me to re-evaluate my stance on “crazy”.
First, there are my patients. Some of whom come to see me because unless they can be sedated for their dental procedure, they just aren’t going to have the dental procedure done. I only understand that as far as someone who is not a particularly anxious dental patient can understand that. It’s kind of like trying to understand where a drug addict might be coming from when you’ve never tried drugs; you can empathize, but you can’t really understand. For years I just sort of categorized my regular sedation patients as “crazy” in as dental-specific and nonperjorative a way as possible. I understood their situations, but I didn’t really understand their fear, especially after repeated successful appointments. I didn’t think less of these patients as people, I just didn’t really get it. Admittedly, beyond a point, I didn’t try.
Second, there are the team members in my office and at the University of Toronto, where I am a clinical demonstrator. Patients who require sedation for their dentistry are often somewhat difficult patients. For most of these people, when it comes time to have dental work done, their coping mechanisms break down. The reasons for this are many and all of them are valid, but again my teams and I would tend to clump them together, as “crazy”. This was/is as much our coping mechanism as it was/is laziness.
Third, there was the input from my dental brethren who practice sedation/anaesthesia dentistry at whatever depth. It means that a significant portion of their patients have dental anxiety of dental phobia. Conversations with these colleagues often lead to case reports of “crazy” patients.
Categorization and compartmentalization is a part of our normal life. You’re a child until you’re 18, then suddenly you can drink and smoke (in some provinces) legally. Black people may be from the Caribbean, the continent of Africa, the United States, Canada or any other part of the world, but they are still Black. The same type of classification is true of Asians and Whites. Compartmentalization may be convenient, but it’s also usually arbitrary and so it can get things really wrong too. I get my haircuts at a barber shop that is largely occupied by Jamaicans, and to be honest, unless I’m seriously paying attention, the conversations there may as well be in Italian or Spanish, because I understand very little of it. Still, I’m accepted there because I’m Black. I’m OK with the music that they play though. And how about the compartmentalization of music? Why is “West End Girls” by the Pet Shop Boys in the Pop or Rock section of the music store? It’s really a rap song. Conversely, “Gone Till November” by Wyclef Jean isn’t Hip-Hop, but that’s where you’ll find it. Paul Simon and Peter Gabriel both embrace World Music and sing with more soul than most R&B singers, but you won’t find them in either of those two sections. And where oh where should Queen really be? But I digress.
Let’s go back to the “crazy” section. This category may not always be wrong, but it is always incomplete. These lectures on mental illness helped to eliminate a blind spot in my approach to and treatment of some of my patients. Anxiety disorders are real, as are schizophrenia, personality disorders, bipolar disorders, major depression and a host of other mental illnesses. I don’t diagnose or treat or cure any of these maladies, but I have to work within their framework, and I’ve been doing some patients an injustice by not considering the implications of these conditions. Statistically speaking, all dentists in clinical practice encounter patients with mental illness, as the Public Health Agency of Canada estimates an annual prevalence of nearly one in five Canadian adults. Anxiety disorders lead the way with an estimated 12% prevalence. The crossover to dentistry is direct with an estimated 15% of the general Canadian population having dental fear ranging in severity from somewhat afraid to terrified.1 On a personal, basic, professional level, I would like to be able to identify and to react appropriately to mental illnesses. Even if I don’t know exactly what the specific problem is, encountering one should prompt an appropriate reaction. In a direct dental analogy: I take the time to look for lumps, bumps and nodules during my examination of patients. And I should be able to recognize major deviations from normal and then follow-up as appropriate. Given that I interview all of my new patients before I treat them anyway, shouldn’t I at least consider their mental health? In my defense, mental illness is invisible and it’s stigmatized. It also falls outside of my dental training, making it hard for me to identify. Still, I can learn and I owe it to my patients to make the effort.
I’m not sure how exactly I’m going to get better at this in my practice. More information seems like a pretty good starting point. The mental health handbook, The Diagnostic and Statistical Manual of Mental Disorders (DSM IV) is the central textbook, but it’s not an enjoyable read and it has issues, as does psychiatry (or maybe society) with the medicalization of the human condition. Maybe I’ll read some more books that include personal experiences. Jon Ronson’s The Psychopath Test was great; it was light and enlightening. Basketball Hall-of-Famer Jerry West discusses his battle with depression in his new book, West By West; that would speak to me (because of the basketball, not the depression). Or maybe What Disturbs Our Blood by James Fitzgerald. Each would teach me something that I don’t know now. That’s a win-win for me and my patients. Thanks to Drs. Scott Woodside, David Goldbloom, and Brian Hodges, I’m even further behind on my reading. I guess the new Jackie Collins book can wait. Hmm…if I’ve read all of her books, does that make me crazy? OH
Chanpong, B, DA Haas and D Locker. Need and demand for sedation or general anesthesia in dentistry: a national survey of the Canadian population. Anesthesia Progress, 52: 3-11. 2005.