Fear and anxiety normally reflect adaptive responses to stress. Biological responses to stress activate the hypothalamic-pituitary-adrenal axis and the central noradrenergic system. These neurochemical systems subserve important adaptive functions in preparing the organism to respond to a treat or stress by increasing vigilance, modulating memory, mobilizing energy stores, and elevating cardiovascular function.
Acute stress increases CRH, ACTH, cortisol, and central norepinephrine release. In addition, acute stress affects central GABAergic, serotonergic, and dopaminergic activity, which plays important roles in modulating stress responses and emotional behavior.2,7,9,12 These stress-induced biological responses, if chronically or inappropriately activated, can become dysregulated and result in generalized anxiety disorder (GAD).
Patient with GAD experience chronic anxiety about events and activities, which lead to physiologic symptoms characterized by restlessness, fatigue, difficulty concentrating, irritability, muscle tension, sleep disturbances, and a high-number of comorbidities such as depression and other medical problems (hypoglycemia, cardiomyopathy).13,14 GAD can cause marked, clinically significant impairment of social and occupational functioning.
SSRI, SNRI, norepinephrine reuptake inhibitors, and serotonin receptor agonists have emerged as first-line therapies for patients with GAD (Table 4).2,13,14 The primary advantage of these agents is their favorable ADR profile with long-term use. Benzodiazepines are also effective in the treatment of GAD, but their long-term use, especially in older adults is troublesome, and they are not effective in resolving unipolar depression (Table 2).
When providing oral healthcare to patients with GAD, the goals are to develop and implement timely preventive and therapeutic strategies. The anxiety, worry, or physical symptoms can cause clinically significant distress or impairment in the patient’s ability to perform optimal oral self-care, to participate in oral healthcare-related decision-making, to cooperate in their treatment, and they may perceive the dental setting as threatening.