Preparation for oral surgery: Evaluating elements of coping

Journal of Behavioral Medicine, Vol. 18, No. 5, 1995

Preparation for Oral Surgery: Evaluating Elements of Coping

Mark D. Litt, 1-3 Carrie Nye, 1 and David Shafer 1,2

Accepted for publication: May 17, 1995

Third-molar extraction patients (N = 231) underwent one of five preparatory interventions offering different levels of relaxation, control, and self-efficacy to evaluate the relative importance of each of these elements of coping in the context of an acute stressor. Prior to surgery subjects completed measures of monitoring and blunting. Results indicated that relaxation, perceived control, and self-efficacy were each significant, and roughly equivalent, contributors to coping, and operated in an additive way. Intervention type, and the interaction of intervention type with blunting score, significantly predicted distress prior to and during surgery. It was concluded that no single element is crucial to effective coping and that interventions that provide more coping elements are generally superior. Additionally, the interaction of coping style with intervention is as strong a contributor to coping outcome as the other factors. Those who prefer to distract themselves may benefit most from interventions that require the least possible personal investment of effort and attention.

KEY WORDS: coping; self-efficacy; control; preoperative distress; behavioral style; coping style.

INTRODUCTION

Invasive medical and dental procedures represent significant stressors for many patients. High levels of procedure-related anxiety have been as-

lUniversity of Connecticut School of Dental Medicine. 2University of Connecticut School of Medicine. 3"I"o whom correspondence should be addressed at Department of Behavioral Sciences and Community Health, University of Connecticut Health Center, Farmington, Connecticut 06030.

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0160-7715/95li000-0435507.50/0 O 1995 Plenum Publishing Corporation

436 Litt, Nye, and Shafer

sociated with adverse effects both preoperatively and postoperatively, including negative affective responses, prolonged and more difficult recoveries, and increased need for pain medication (Johnson et al., 1970; Auerbach, 1973; Spielberger et al., 1973; Sime, 1976; Gendzilov et al., 1977). An additional problem is that anxious patients may be less likely to return for postoperative care and additional procedures (Klepac, 1986; De- Martino, 1987).

Oral surgery represents an excellent example of a stressful medical or dental situation. It involves invasive procedures commonly performed on otherwise healthy, young people who have seldom had previous experience with surgery of any kind. As a result, oral surgery offers an ideal procedure in which to study cognitive and behavioral interventions to manage patients' preoperative anxiety and perioperative pain.

Among the behavioral interventions that have been used to manage procedural pain and anxiety are provision of social support, provision of information, modeling, hypnosis, and relaxation training (cf. Kendall and Watson, 1981; Gil, 1984). Although each of these interventions has found some success in some cases, the reasons for success with these strategies are not well understood (Klepac, 1986; Ludwick-Rosenthal and Neufeld, 1988). Different preparation strategies, with different theoretical rationales, have produced equivalent rates of success. In some studies, even treatments used as "controls" have produced anxiety reduction (see, e.g., Bernstein and Kleinknecht, 1982; Gatchell, 1980).

A variety of mechanisms has been assumed to account for the coping enhancement qualities of these various strategies. These potential elements of coping include relaxation plus exposure to cues, i.e., desensitization (Bernstein and Kleinknecht, 1982), lowered physiological arousal (e.g., Ben- son, 1975), or the development of certain kinds of cognitive coping responses, such as perceiving control in stressful situations or having confidence in the ability to cope with stress (Litt, 1988a; Bandura, 1982).

The desensitization hypothesis is a persuasive one. Klepac (1986) notes, however, that, even with desensitization, patients may still enter the dental setting extremely nervous yet cope well during the procedure. Like- wise, relaxation is a logical candidate for "final common pathway to effective coping." But if lowering of arousal were all that was necessary for coping, then oral premedication using sedative hypnotics should pro- duce results similar to the most effective behavioral interventions, yet there is no evidence of this (e.g., Pawlicki, 1987).

Perception of control, or attributing control of a situation to oneself, has demonstrated utility in predicting coping with laboratory stressors, but less evidence is available in clinical settings. In the dental setting, the provision of control has produced mixed results. Corah and his colleagues have

Evaluating Elements of Coping 437

conducted a number of studies of children and adults getting cavities filled, indicating that provision of control in some cases leads to reduction of behavioral indicators of anxiety (Corah, 1973) but not necessarily physiological indicators (Corah et al., 1978).

The issue of perceived control may also play a role when patients are administered anxiolytic medication to help them cope with stressful situations. The effects of attributing physiological or emotional responses to drugs or to oneself have been explored experimentally (e.g., Davison and Valins, 1969). Additionally, in a study of patient behavior during repeated periodontal surgeries, Croog et al. (1994) found that decreased patient distress during a second surgery was positively correlated with the belief that one's own actions (other than taking medication) can control discomfort after the surgery. This association was not found during the first surgery, however. To summarize, although the perception of control should play a role in the management of preoperative anxiety, the evidence for this is not clear.

Perception of self-efficacy may also be a key to coping effectiveness. In the dental setting, however, relatively little research exists on self-efficacy. Klepac et al. (1982) and Kent and Gibbons (1987) have produced data showing a relationship between self-efficacy and managing anxiety in dental situations, but only Litt et al. (1993) have manipulated self-efficacy to determine its causal role in dental coping. In that study self-efficacy enhancement was predictive of lower distress, but so was relaxation.

One possible reason for the inconsistency in results of different interventions for preoperative anxiety may be that whereas some interventions may work well for some, they may work poorly with others. Interventions may work best when they are matched to an individual's coping style, or the way a person characteristically deals with threatening situations. A number of researchers have demonstrated that behavioral interventions are most effective when they are congruent with the subject's dispositional coping style (Martelli et al., 1987; Miller, 1988; Shipley et al., 1978, 1979). The differentiation of avoidant versus attentional coping style has attained par- ticular importance, for example. In a meta-analysis of studies using attentional versus avoidant coping strategies in stressful circumstances, Suls and Fletcher (1985) concluded that avoidant strategies were generally superior in the short term.

In practical terms, dispositional avoidance has been successfully op- erationalized using a measure of repression-sensitization (Scott and Clum, 1984) and using Miller's measure of Monitoring vs. Blunting (Miller Be- havioral Style Scale; Miller, 1987). In general, it appears that those who characteristically want to have information and control do better with interventions that afford them more control and that individuals who prefer


not to have control fare better when control is not so available. This has been demonstrated effectively using Miller's measure (e.g., Gattuso et al., 1992; Miller, 1988).

Given this background, one question that presents itself is whether there is a key element that underlies all successful behavioral interventions for enhancing coping with acute stressors. In our previous study (Litt et al., 1993) we sought to evaluate systematically the contribution to coping of each of the mechanisms discussed above. Oral surgery patients undergoing extractions under intravenous sedation were assigned to one of four preparation conditions, each condition adding additional coping elements. It was discovered that each of the elements was additively contributing to coping effectiveness. No single element was seen to be key; those who received the most elements had the best outcomes. The most effective treatment was that in which patients received relaxation plus (false) feedback to the extent that their relaxation effort was effective (i.e., self-efficacy enhancement).

It was not known, however, whether this treatment would be equally effective for patients with different dispositional styles. Previous work by ourselves (Gattuso et al., 1992) and others has pointed to the utility of the blunting--monitoring dispositional style as a modifier of the effectiveness of anxiety control interventions. It remained to be seen whether congruence of style with intervention would be a more powerful predictor of outcome than any of the elements of the intervention itself. Will even a powerful intervention do poorly if it is poorly matched to the patient? If so, it would point to congruence as a potent element of the coping process.

Finally, given the fear that many patients were showing in response to the intravenous needle, we surmised that a self-efficacy enhancement intervention would be more effective if we more clearly specified a feared stimulus with which to cope, namely, the IV needle. We therefore wished to determine if desensitization to the most feared aspect of the procedure would also be an important element of the coping process.

Overview

Our purpose in the present study, then, was to replicate the results of the previous work regarding effective elements of coping with a stressful dental procedure. In addition, we wished to determine if the interaction of coping style with preparation was a significant element of coping. Finally, we wished to test if the addition of a specific IV needle desensitization component could also be a significant contributor to coping and improve


the effectiveness of the intervention that was most successful in the previous study.

To accomplish these aims, 231 third-molar extraction patients were recruited, administered a self-efficacy measure and a coping style measure, and randomly assigned to one of five surgery preparation conditions. The first four of these were exactly like those in our first study: (1) standard preparation; (2) oral benzodiazepine premedication; (3) relaxation; and (4) a relaxation + efficacy enhancing feedback condition in which subjects were given false skin conductance level (SCL) biofeedback leading them to be- lieve that they were highly skilled at relaxing. The fifth condition (5) was a self-efficacy enhancement preparation that included an IV needle desensitization imagery component. One to two weeks after randomization subjects presented for surgery. Prior to surgery they completed measures of preoperative distress and self-efficacy and were given the appropriate preparation. Behavioral and self-report measures of distress were taken during and after the surgery.

METHOD

Design

A dismantling design was used in which each succeeding preparation intervention added a further element that could contribute to coping success. Standard preparation offered minimal information plus some exposure to anxiety-producing cues in a nonthreatening context (i.e., a desensitization approach) and served as a control condition. Oral premedication patients received standard preparation (desensitization) plus a means of lowering physiological arousal, thus lowering anxiety. Relaxation group patients did not receive premedication but did receive desensitization, lowered physiological arousal via relaxation, and also an acquired sense of control, i.e., the belief that their anxiety reduction was a result of their own efforts. Thompson (1993) refers to this as an example of providing central control (a way to reduce the impact of the stressor). The self-efficacy enhancement patients received all the previously discussed elements but also received feedback that they were very good at relaxing, thus raising their confidence in their ability to cope. Finally, self-efficacy enhancement plus needle desensitization patients received relaxation plus feedback, in addition to a rehearsal procedure specifically designed for desensitization to placement of the intravenous line.

It was hypothesized that the addition of each element would have beneficial overall effects on patients' coping and that the best effects would

440 IAtt, Nye, and Sharer

Table 1. Experimental Design: Table Indicates Which Presumed Coping Mechanisms Are Present in Each Intervention

Preparation intervention group

Oral Relaxation Self-efficacy Standard preme- Relaxation + + IV desensi-

Coping mechanism treatment dication only self-efficacy tization

Information, cue exposure X X X X X Decreased arousal X X X X Self-control attributions X X X Self-efficacy enhancement X X Specific IV desensitization X

be seen for those patients who perceived control and who had high confidence in their ability to use that control. We also wished to test the hypothesis that coping style might interact with intervention to predict coping effectiveness. Table I shows the coping elements present in each of the interventions.

Subjects

The subjects were 231 first-time oral surgery patients (77 men and 154 women) who presented to the oral surgery clinic of a university dental school requesting uncomplicated extraction of third molars under intravenous sedation and nitrous oxide. Patients were excluded if they had any contraindications to surgery (as determined by the consulting oral surgeons following guidelines developed by the NIH consensus conference, 1979), previous experience with benzodiazepine or other sedative agents, or any previous experience with systematic relaxation or meditation. Pregnant women were also excluded, as were any patients diagnosed as having pri- mary depressive disorder or psychosis. Eligible patients were offered $50.00 ($20.00 on day of surgery, $30.00 upon completion of 1-week follow-up), to compensate for time involved in completing questionnaires and in being interviewed at future points in time. The mean age of the sample was 24.9 years (SD = 6.8 years). Thirty-nine percent had at most a high-school education, and the remaining 61% had at least some college. The ethnic composition of the sample was as follows: 77% Caucasian, 12% African American, and 9% Hispanic. None of the subjects had any experience with oral surgery or with any kind of intravenous sedation prior to this study. All but 10 of the subjects were scheduled for extraction of three or more teeth. On a scale of dental anxiety (to be described) the mean score was


2.41 (range, 0.9 to 4.8; SD = 1.16) of a possible score of 5, indicating that this was a moderately anxious sample.

Procedures and Measures

Potential subjects were identified by the oral surgery staff and ap- proached by the research associate (C.N.) on the day of initial consultation with the oral surgeon. Patients were told that the study involved examining patients' reactions to oral surgery under various conditions. Those patients who met eligibility criteria were asked to sign a statement of informed con- sent and 86% agreed to participate. Of those who declined, the majority did so because of scheduling problems. Subjects were then randomly assigned to one of the five preparation intervention groups. The oral surgery itself was scheduled for a time 2 to 5 weeks following the initial consultation. Subjects assigned to the oral premedication condition were given the medication by the clinic nurse at this time and instructed to take the medication 1.5 hr prior to the time of their surgery.

At the time of consultation the research associate administered measures of dental anxiety, oral surgery coping self-efficacy (a measure of subjects' confidence in their ability to cope with the stress of oral surgery), and coping style. A dental anxiety measure was used to provide a baseline measure of general anxiety that could be used as a covariate. Dental anxiety was measured using a modified version of the Dental Fear Survey (Kleinknecht et al., 1973). The survey includes 27 items tapping several dimensions of dental anxiety scored on 5-point scales (1 = never or a little to 5 = often or a lot). Evidence for its validity has been provided by Jo- hansson and Berggren (1992). The internal consistency reliability of the instrument, using Cronbach's alpha, was a = .96.

Coping self-efficacy was measured using the Oral Surgery Confidence Questionnaire: an ll-i tem self-report scale designed for the Litt et al. (1993) study to assess pretreatment self-efficacy regarding coping with oral surgery. The questionnaire was patterned after a measure devised by Gat- tuso et al. (1992) for judging self-efficacy for coping with gastrointestinal endoscopy. Items are scored from 0 to 9 (not confident to very confident) and include five questions regarding the confidence the individual has in his/her ability to exhibit behavioral coping (e.g., keeping mouth open, stay- ing relaxed) and six questions regarding the subject's expectations about tolerating potential sensory (e.g., pain) and affective (e.g., nervous) experiences, as well as a question asking the subject's confidence in his/her ability to do well generally during the procedure. The internal consistency reliability of the Oral Surgery Confidence Questionnaire was a = 0.90.

442 Litt, Nye, and Sharer

Coping style (monitoring vs. blunting) was measured using the Miller Behavioral Style Scale (MBSS; Miller, 1987). This measure presents four hypothetical problem vignettes and asks the subject to choose from a set of solutions that vary in the degree of information or distraction provided. In this way the measure assesses the extent to which a person seeks out or distracts him/herself from information about an aversive situation. Miller (1987) has produced data on the reliability and validity of the measure. In previous research with endoscopy patients receiving preparatory interventions requiring varying levels of involvement (Gattuso et al., 1992), the type of intervention patients received interacted with Miller's typology to predict coping. Miller herself presents a variety of data in which coping style as measured by the MBSS interacted with information provided to determine coping (see Miller, 1988). Internal reliability of the Monitoring subscale was ~t = .69; reliability of the Blunting subscale was tx = .66.

On the day of surgery subjects in the Standard Preparation and Oral Premedication groups reported to the oral surgery clinic 1 hr prior to their surgery time, and subjects in the other groups were asked to report 1.5 hr prior to surgery to undergo their assigned preparation intervention and to complete preoperative questionnaires. Descriptions of the preparation interventions follow. All interventions took about 20 min.

Standard Preparation + Attention (SP). Subjects in the standard preparation (n = 48) condition were given the same information as that received by patients normally, except that the patients received additional information regarding the study from the research associate to control for the attention given to subjects in the other experimental conditions. Prior to receiving any information, the subject was asked to sit quietly and was told that the research associate would monitor the skin conductance level (SCL). At this point the Ag/AgCI SCL electrodes, coated with a small amount of conducting gel, were attached to the palmar surfaces of the index and middle finger of the nondominant hand with Velcro strips. The SCL device was a J&J Instruments G-25A combined temperature-SCL portable biofeedback monitor. Skin conductance level as micromhos was read from an illuminated light bar on the front of the unit indicating degree of de- viation from baseline of the patient's current skin conductance. A baseline SCL reading was taken after the patient had been seated quietly for 5 min and the SCL reading had been stable for 1 min. When this baseline measure was completed the patient was asked to complete the preoperative questionnaires, after which he/she was asked to sit quietly and wait to be called (about 30 min). No information regarding the SCL was given to the subject, and no suggestions for coping with the oral surgery were made. Subjects in this condition were used as an overall control group.

Evaluating Elements ot" Coping 443

Oral Premedication (OP). Subjects in the oral premedication condition (n = 46), having been told that they were to receive a known anxiolytic drug intended to reduce anxiety prior to surgery, received the medication, 0.5 mg lorazepam in tablet form, from the clinic nurse on the day they were recruited for the study. This drug, used at this dosage, has been widely used as a preoperative medication. Patients were instructed to take the medication 1.5 hr prior to surgery with only a sip of water. The admini- stration of the drug was timed so that it would reach its maximum effectiveness by about the time surgery started. They were then instructed to report to the Oral Surgery Clinic 1 hr prior to surgery, accompanied by a responsible adult, for completion of questionnaires. Patients were asked at this time to verify that they had taken the medication by recording the time and circumstances when the medication was taken. When the patient arrived at the clinic he/she was taken to an unused operatory and a baseline SCL reading was taken. Patients listened to the same information as that given to the standard preparation subjects, again as a control on the amount of time the research associate spent with patients in each experimental condition. The information was followed by completion of the questionnaires, after which the person was asked to wait quietly until called.

Relaxation Onky (RE). Subjects in the relaxation-no feedback condition (n = 46) were seen in an operatory of the oral surgery clinic 1.5 hr before surgery. At this point the Ag/AgCI SCL electrodes were attached and a baseline SCL reading taken. Patients then listened to an introduction to the relaxation procedure. The subject was asked to sit quietly in a comfortable chair and told that the research associate would monitor the extent of their relaxation with the SCL apparatus.

Subjects were then given instruction by the research associate in a modified autogenic relaxation technique like that described by Benson (1975). Patients were asked to take deep breaths and suggestions were made to allow their arm and legs to get heavy and warm. Instruction was given for approximately 15 min. Following the relaxation training, subjects were instructed to practice the procedure for the next 30 min. After 30 min the subjects were asked to complete presurgery questionnaires. Prior to entering the operatory for the oral surgery, the research associate reminded the subject to try to use the relaxation to stay calm in the dental chair.

Relaxation Plus Self-Efficacy Enhancement (SE). Subjects assigned to the relaxation plus self-efficacy enhancement condition (n = 46) provided the same SCL baseline reading and received the same instructions as those in the relaxation-only condition, except that they were informed that the SCL monitoring would be used to help them relax more effectively by providing feedback in the form of a steady hum when they were relaxing correctly. For these subjects, the audio feedback feature of the monitor


was turned on and set so that subjects received almost-continuous (false) feedback as to their relaxation efficacy. In addition, statements were made by the research associate during the relaxation instruction emphasizing the subjects' success at relaxing as indicated by the continuous positive feedback from the monitor, e.g., "You are really doing well, you really seem to be able to get yourself relaxed!" After 30 min of relaxation with feedback and coaching, the subjects were asked to complete presurgery questionnaires. The research associate reminded the subject to continue practicing the relaxation during the surgery.

Self-Efficacy Enhancement Plus Intravenous Needle Desensitization (IV). Subjects in this condition (n = 45) provided an SCL baseline reading and received the same relaxation plus self-efficacy enhancement instruction as in the SE group. In addition, however, a needle desensitization component focusing specifically on coping with the IV injection was added. This was done to determine the effect of adding a specific salient imagery component to the more general procedure. Pilot work with these subjects had indicated that the placement of the intravenous needle was among the most fear evoking events in the operatory. During the relaxation instruction, the research associate prepared the subject for IV placement using IV-related imagery and reassuring statements regarding procedure outcome (e.g., '9~s you relax you can see the IV needle, but you don't feel afraid. You know the needle will only pinch you for a moment, and then the discomfort will be over."). As in the other groups employing relaxation, subjects in this group were coached and then reminded to practice their relaxation skills during the surgery.

Following the preparation intervention subjects were administered the Preparation Assessment Questionnaire, a four-item scale asking subjects to rate from 1 (not at all)-to 7 (very much) how logical the preparation procedure seemed to them and how much confidence they had in it. This was also a check on the placebo value of the interventions. The questionnaire was patterned after that developed by Borkovec and Nau (1972) to assess credibility of a variety of procedures used in analog outcome research. The scale has an internal reliability of a = .76 and is uncorrelated with self- efficacy (r = .03 in the present study). While assessing credibility of the intervention, the instrument also assesses a subject's "outcome expectations" (cf Bandura, 1977) regarding the preparation, i.e., the degree to which the intervention itself is useful in coping with the surgery stressor. Subjects were also asked to complete for a second time the Oral Surgery Confidence Questionnaire, which was used to determine extent of change in coping self-efficacy as a function of the preparation interventions. Upon being seated in the active operatory for the surgery a presurgery SCL was recorded after the reading had been stable for 1 min. This reading served


as a check on the degree of physiological arousal subjects were experienc- ing.

Dependent Variables. Dependent variables in this study were self-reported preoperative distress (measured after the preparation intervention), behavioral ratings of patient distress in the dental chair, and patients' ratings of their distress during the dental procedure, recorded immediately after surgery. Degree of preoperative distress, including state anxiety, prior to surgery was determined using five 100-mm visual analogue scales ranging from "not at all" on the left to "extremely" on the right. The items assessed the degree to which subjects' felt "tense," "serene," "on edge," "nervous," and "calm." This scale has successfully discriminated anxious from relaxed subjects in other studies (Gattuso et al., 1992; Litt, 1988b) and had an internal reliability in this study of c~ = .92.

Behavioral ratings of distress during the oral surgery were made by the oral surgeon and the dental assistant, both of whom were blind to the study conditions. 4 Ratings were made immediately after the procedure was completed using a rating scale adapted from the Patient Stress Response Index devised by Croog et al. (1994). The scale used here includes seven items judging the degree to which the patient appeared comfortable or distressed recorded on a 0 to 4 scale anchored at one end with "not at all" and at the other with "extremely." The seven items have an internal reliability of ct = .95. All clinical personnel connected with the study were trained to criterion reliability in the use of the rating sys- tem prior to the beginning of the study. Average interrater reliability between surgeons and dental assistants was • = .89. The score used in data analyses was the average of the scores of the surgeon and the assistant.

Patients' ratings of their perioperative distress was assessed using the same five 100-mm visual analogue scales used for assessment of preoperative distress. The scales were administered immediately postsurgery. The internal reliability of this scale administered postoperatively was ct = .90.

Immediately after surgery patients were administered a scale assessing control-related cognitions during surgery. The five items consisted of questions such as, "I was thinking I did as well as I did because I was in control of myself," and "I was thinking I was in control of myself." The five items had an internal reliability of o~ = .77.

4The only exception to this was for those subjects in the oral premedication condition, in which case the oral surgeon was informed that the patient had been given a sedative prior to the surgery. It was felt that this breach in the blinding procedure was necessary to ensure appropriate patient care.


RESULTS

Comparability of Intervention Groups

Analyses were conducted to determine whether the five preparation intervention groups were equivalent with respect to demographic characteristics. A one-way multivariate analysis of variance (MANOVA) with subject age and education as dependent variables yielded no significant effects for the group variable, indicating that the five groups were equivalent on these variables (Wilks' k = .97, p > .55). Chi-square analyses indicated that the distribution of males and females was equivalent throughout all groups [Z2(4) = 1.71, p > .75], as was the ethnic composition of the groups [Z2(9) = 12.82, p > .35]. A one-way analysis of variance (ANOVA) indicated that there were no between-group differences in general dental anxiety [F(4,226) = .96, p > .40]. A one-way ANOVA also indicated that there were no between-group differences on the Preparation Assessment Questionnaire, assessing credibility of the interventions [F(4,98) = .98, p > .40]. This finding indicates that no one intervention was seen as more credible than the others and that each group had equivalent outcome expectancies regarding the role of the preparation they received.

Manipulation Checks

Physiological Arousal. As a check on the ability of the interventions to lower arousal, a one-way analysis of covariance (ANCOVA) with planned contrasts (Rosenthal and Rosnow, 1985) was performed on the presurgery SCL reading, using the baseline SCL as a covariate. 5

Control-Related Cognitions. To examine the hypothesis that relaxation- based strategies would induce a greater sense of control than either the standard or the oral premedication condition, these data were analyzed using a one-way ANOVA with planned contrasts. A contrast compared the three conditions in which relaxation was used (RE, SE, and IV) against the SP and OP conditions. This contrast proved significant [F(1,225) = 3.96, p < .05]; subjects in the three relaxation conditions reported more control-related cognitions than subjects in the other two groups. Mean control cognitions scores for each group are shown in Table II.

Increases in Self-Efficacy. Change in self-efficacy was analyzed by means of a one-way (ANCOVA) with planned contrasts. The four con-

5Analysis of baseline SCL readings showed no between-group differences; all means were between 16.5 and 17.5 Izmho. A N C O V A was used in an effort to reduce some of the random error that can occur in analyses of physiological measures.


Table II. Manipulation Checks: Means and Standard Deviations of SCL, Self-Efficacy Ratings, and Control Cognition Scores by Intervention Group (N = 231)

Intervention group

Oral Standard p r e m e - Relaxation Self-efficacy IV +Self- treatment dication only enhancement efficacy

Variable M SD M SD M SD M SD M SD

SCL a 13.89 3.93 11.65 5.59 12.21 3.37 11.78 3.45 11.65 4.26 Control cognitions 15.27 5.08 15.89 4.59 16.37 4.59 16.77 4.85 17.71 5.02 Self-efficacy* 51.98 15.25 53.96 16.86 55.75 13.33 58.99 14.81 58.58 14.30

aMeans adjusted for covariates

trasts compared self-efficacy changes in each experimental intervention with change in self-efficacy in the standard preparation (control) condition. The contrasts indicated that only the relaxation + self-efficacy enhancement (SE) condition and the self-efficacy plus needle desensitization (IV) condition yielded pre- to postintervention changes in self-efficacy significantly greater than those from the standard treatment [SE vs. SP, F(1,225) = 4.73,p < 0 05; IV vs. SP, F(1, 25) = 3.96,p < .05]. Debriefing of subjects indicated that they believed the feedback they received. Mean self-efficacy ratings by group, adjusted for pretreatment self-efficacy, are shown in Table II.

Outcome Analyses

Preoperative Distress. Between-group differences in preoperative distress were analyzed by means of a one-way ANCOVA with planned contrasts in which general dental anxiety was the covariate. General dental anxiety was covaried to highlight effects attributable solely to the experi- menta l manipulat ion. The contrasts were planned to test the three between-group comparisons that would be predicted on the basis of self- efficacy and control theories. Namely, it was hypothesized that (1) each succeeding intervention, encompassing successively more coping elements, would result in successively lower preoperative distress (i.e., SP > OP > RE > SE > IV); (2) the relaxation-based interventions, which offer control attributions, would result in lower preoperative distress than the premedication or standard interventions (i.e., SP + OP > RE + SE + IV); (3) the relaxation + self-efficacy enhancement conditions would yield lower preoperative distress than the relaxation-only condition, thus demonstrating


Table III. Means and Standard Deviations of Outcome Variables by Intervention Group (N = 231) ~

Intervention group

Oral Self-efficacy Standard preme- Relaxation enhan- IV +Self- treatment dication only cement efficacy

Outcome variable M SD M SD M SD M SD M SD

Preoperative distress b'c'a 53.62 24.37

Behavioral ratings of distress during surgery b'c'a 11.10 4.48

Patients ratings of distress during surger)P 'c 46.81 23.03

42.25 26.25 42.82 19.61 40.91 22.34 40.82 19.40

9.37 3.93 9.36 4.19 8.88 4.25 9.18 3.49

39.43 21.46 36.19 21.24 34.45 23.24 35.26 24.19

aMeans adjusted for the dental anxiety covariate. bSignificant contrast: SP > OP > RE > SE > IV. cSignificant contrast: SP + OP > RE + SE + IV. dSignificant contrast: RE > SE + IV.

the contribution of self-efficacy enhancement (i.e., RE > SE + IV); and (4) the addition of desensitization to a specific fear was expected to be more effective than a more general approach (i.e., SE > IV). Means adjusted for dental anxiety and standard deviations on each outcome variable for each intervention group are shown in Table III.

The contrast analyses supported three of the four hypotheses. The first (linear) contrast indicated a trend in which each succeeding intervention yielded lower preoperative distress than the previous one [F(1,225) = 8.84, p < .01]. The second contrast, in which the standard and premedication groups were compared with the three relaxation-based groups, was also significant [F(1,225) = 6.04, p < .05]. The third contrast, comparing the relaxation-only group to the two self-efficacy enhancement groups was also significant [F(1,225) = 4.17, p < .05], indicating that the addition of self- efficacy enhancement yielded less distress than did relaxation alone. The fourth contrast, comparing the two self-efficacy enhancement groups, was not significant.

Behavioral Ratings of Distress During Surgery. Between-group differences in behavioral ratings of distress during surgery were analyzed by means of the same type of ANCOVA with planned contrasts as that described for analysis of preoperative distress. As was the case with preoperative anxiety, the linear contrast indicated a trend in which succeeding interventions produced less behavioral distress than the previous ones (i.e., SP > OP > RE


> SE > IV) [F(1,223) = 8.70, p < .01]. 6 Likewise, the contrast comparing the relaxation interventions (RE, SE, and IV) with the standard and premedication preparations (SP and OP) was also significant [F(1,223) = 6.09, p < 0.05]. The analysis also indicated that the self-efficacy enhancement subjects showed significantly less distress than the relaxation-only subjects (i.e., RE > SE, IV) [F(1,223) = 4.61, p < .05]. As in the previous analysis, the comparison of SE with IV was not significant.

Patient Ratings of Distress During Surgery. Patient ratings of distress during surgery were assessed by means of the same analyses as those just described. The linear contrast indicated that each of the succeeding experimental groups yielded successively less patient-rated perioperative distress [F(1,225) = 6.34, p < .05]. Additionally, the contrast comparing the two relaxation groups with the standard and oral premedication preparations was also significant [F(1,225) = 7.03, p < .01]. The contrast comparing the relaxation-only condition with the relaxation + self-efficacy enhancement conditions, however, was not significant, nor was the contrast comparing the SE and IV conditions.

Predictive Validity of Arousal, Control Cognitions, and Self-Efficacy Estimates

Correlational analyses were used to determine the extent to which skin conductance level (a measure of physiological arousal), the control cognitions score, and coping self-efficacy estimates made immediately postpreparation and presurgery predicted the three outcome measures in this study regardless of intervention group. The correlations are presented in Table IV, along with correlations of the other predictors of interest. SCL was not a significant correlate of any of the measures of distress in this study. Control cognitions did significantly and negatively correlate with behavioral ratings of distress, but the magnitude of this correlation was small, especially compared to that of general dental anxiety. Self-efficacy, however, was a strong correlate of distress, and only minimally correlated with dental anxiety (r = .21). Regardless of treatment condition, self-efficacy estimates were predictive of outcome.

Regression analyses were conducted to allow the various predictors to compete against one another to determine which of these might be most

6Two cases in the analyses of surgery related distress, one in the SE condition and one in the IV condition, met the criteria for being declared multivariate outliers [i.e., studentized residuals greater than 2.0 and Mahalanobis distance greater than 5.0 in within-group homogeneity analyses as per Norusis (1988), and Tabachnik and Fidell (1988)]. Results reported for these analyses are with the outlier cases removed.


Table IV. Correlations of Major Predictor Variables and Outcome Variables (DV1, DV2, and DV3) (N = 231)

Variable DV2 DV3 1 2 3 4 5 6

Dependent DV1. Preoperative distress DV2. Behav. rating DV3. Pt.-reported distress

Predictor 1. Dental anxiety 2. SCL 3. Control cognitions 4. Self-efficacy 5. Monitoring 6. Blunting

.28*** .54*** .49*** .11 -.07* -.63*** -.07 .13 - - .33*** .21"* - .02 - .04 - .29*** - .09 - .08

- - .37*** .05 - .16" - .49*** - .02 .08

.05 .02 .21"* .19"* .09 - - - .07 - .13" - .10 .06

- - .09 - .02 - .01 - - .04 - .02

- - - . 10

*p < .05. **p < .01.

***p < .001.

important to coping outcomes. Dental anxiety was entered first, to serve as a covariate, with the rest of the variables entered as a block. Results of these analyses are reported in Table V. Results are similar for each of the three dependent variables. General dental anxiety tended to be a strong predictor of outcome, except for behavioral ratings of distress. Self-efficacy was also a consistent predictor of distress, accounting for a significant amount of variance even after dental anxiety was entered. The control cognitions score was a significant predictor of patients' ratings of distress during surgery but did not predict the other two outcomes. Level of physiological arousal, as measured by SCL, was not at all predictive of distress outcomes.

Interaction of Coping Style with Preparation

Hierarchical linear regression analyses were conducted in which preparation condition, monitoring and blunting behavioral style scores, and the interaction of condition with behavioral style were used to predict the outcome variables. The purpose was to determine whether monitoring or blunting behavioral style played a role in the efficacy of the preparation interventions. Separate regression equations were used with monitoring and blunting because of their virtual independence from one another (r = -.10). An effects-coding scheme was used to code group membership. According to Cohen and Cohen (1975), effects coding is particularly appropriate when


Table V. Predictive Validity Analyses of Coping Elements: Results of Regression Equations Testing Effects of Arousal, Control Cognitions, Self-Efficacy, and Coping Style (N = 231)

Cumula- Dependent tive

variable Variable entered b SE of b 13 t R 2

Preoperative distress a Dental anxiety 4.25 1.24 .23 3.43*** .18 SCL (preop) .03 .21 .01 .16 .18 Control cognitions -.18 .27 -.04 -.68 .20 Self-efficacy -.69 .10 -.46 -.6.79*** .37 Blunting .71 .49 .08 1.44 .38 Monitoring -.71 .42 -.10 -.167 .39

Behavioral ratings of distress during surgery b

Patient-reported distress during surgery b

Dental anxiety .43 .27 .13 1.57 .04 SCL (preop) -.01 .05 -.02 -.31 .04 Control cognitions -.06 .06 -.07 -.92 .05 Self-efficacy -.07 .02 -.23 -.2.94** .10 Blunting -.18 .11 -.11 -.1.59 .11 Monitoring -.13 .09 -.10 -.1.42 .12

Dental anxiety 3.36 1.46 .17 2.30* .10 SCL (preop) -.24 .25 -.06 -.99 .10 Control cognitions -.96 .32 -.20 -2.99** .16 Self-efficacy -.53 .12 -.33 --4.44*** .25 Blunting .49 .58 .05 .84 .25 Monitoring -.38 .50 -.05 -.76 .26

aCoefficients shown are for final equation. Fregression(6,176 ) bCoefficients shown are for final equation. Fregression(6,176) CCoefficients shown are for final equation. Fregression(6,178) *p < .05. **p < .01. ***p < .001.

-- 5.55, p < .001. = 4.05, p < .001. = 10.30, p < .001.

each group is to be compared with the entire set of groups, rather than with a reference group. Because of the additive nature of the groups in this study (and in the interest of simplicity), only the linear effect of groups (i.e., SP > OP > RE > SE > IV) was examined in relation to a possible interaction with coping style. 7 Results of these regression equations yielded no main effect for monitoring behavioral style, and no interaction of moni-

71n this case, the intervention Group variable was coded as follows: SP = -2, OP = -1, RE = 0, SE = 1, and IV = 2. A saturated regression model would include up to three more effects-coded variables, but this linear effects variable was considered to be of greatest interest, as well as the easiest to conceptualize. A significant interaction with coping style would indicate an interaction between number of elements provided by the intervention and degree of monitoring or blunting.


Table VI. Results of Regression Equations with Monitoring and Blunting Behavioral Styles Interacting with Intervention to Predict Coping Outcomes (N = 231)

Cumula- Dependent tive

variable Variable entered b SE of b ~ t R 2

Preoperative distress a Dental anxiety 8.24 1.20 .45 6.84*** .18 Group (linear effect) -2.39 0.96 -0.16 -2.5* .25 Monitoring -1.02 0.46 -0.15 -1.80 27 Group x Monitoring -0.27 0.30 -0.06 -0.88 .29

Behavioral ratings of distress during surgery b Dental anxiety 0.82 0.25 0.24 3.27** .05

Group (linear effect) -0.19 0.20 -0.07 -1.98" .09 Monitoring -0.17 0.09 -0.13 -1.81 .10 Group x Monitoring -0.01 0.06 -0.01 -0.09 .12

Patient-reported distress during surgery c Dental anxiety 6.48 1.38 0.33 4.71"** .11

Group (linear effect) -0.98 1.09 -0.14 -2.05* .18 Monitoring -0.55 0.52 -0.07 -1.06 .20 Group x Monitoring -0.73 0.35 -0.14 -1.81 .22

Preoperative distress d Dental amdety 7.60 1.19 0.42 6.40*** .18 Group (linear effect) -2.57 0.96 -0.17 -2.69** .25 Monitoring 0.80 0.54 0.09 1.46 26 Group x Monitoring 0.75 0.38 0.13 1.99" .29

Behavioral ratings of distress during surgery e

Patient-reported distress during surgery f

Dental anxiety 0.77 0.24 0.22 3.13"* .05 Group .(linear effect) -0.58 0.19 -0.16 -2.12" .09 Monitoring -0.16 0.11 -0.09 -1.37 .06 Group x Monitoring 0.18 0.08 0.17 2.32* .10

Dental anxiety 6.18 1.32 0.31 4.67*** .11 Group (linear effect) -1.37 1.06 -0.10 -2.22* .18 Monitoring 0.43 0.61 0.04 0.71 20 Group x Monitoring 1.65 0.42 0.25 3.86*** .26

Note. All coefficients shown are for final equation. a Fregression(4,182) = 13.99, p < .001. b Fregression(4,180) 3.29, p < .05. c Fregression(4,182) 6.89, p < .001. d Fregression(4,182) 14.04, p < .01. e Fregression(4,180) = 4.28, p < .001. f Fregression(4,182) 9.63, p < .001. *p < .05. **p < .01. ***p < .001.


100

70

~t5

rt ~ 30 13.

2O I I I I I I I I I

0 2 4 6 8 10 12 14 16

O Standard Prep 13 Oral Premed LX Relax Only V Relax + Self-Eft O Self-Eft + IV Desens

28 16~

t - t . .

~.~= 0 : ~

"~ ~ 8

a 4 r i I I I r I I I

0 2 4 6 8 10 12 14 16

100 90

7O

| ~ 50 n f .~ . -

~ o 40 m ~ 30 a. 20

i5 10 0

0 2 4 6 8 10 12 14 16

Blunting Score

Fig. l . Top: Regression lines of self-reported preoperative distress plotted against Miller Behavioral Style blunting score. Middle: Regression lines of behavioral ratings of patient distress during surgery plotted against Miller Behav- ioral Style blunting score. Bottom: Regression lines of patient-reported distress during surgery plotted against Miller Behavioral Style blunting score. Separate regression lines are shown for each preparation condition.

toring with preparation intervention, in predicting any of the outcome measures. Table VI shows the results of these regression equations.


However, when blunting scores were used in the regression equations the interaction of preparation condition with blunting scores was a significant predictor of all the outcome variables. Figure 1 depicts the regression lines plotting blunting score against the three distress measures, preoperative dis t ress ( top) , behaviora l rat ings of distress (middle) , and patient-reported distress during surgery (bottom). Regression lines for each intervention group are plotted separately to illustrate the interaction of blunting with preparation. For all the outcomes shown here those patients who had low blunting scores fared best with progressively more involving preparation interventions. Conversely, those with high blunting scores fared better with less involvement.

DISCUSSION

The present study substantially replicates the findings of our earlier work (Litt et al., 1993). The results indicate that behavioral interventions can be effective in lowering preoperative anxiety and that the addition of more cognitive and behavioral elements makes the intervention more effective. Indeed, the evidence presented here suggests that behavioral interventions are more effective than a commonly prescribed oral premedication in lowering preoperative distress and in improving behavioral coping during surgery.

Regarding the issue of which cognitive or behavioral elements are important, or crucial, to the success of a behavioral intervention for influencing coping with a dental stressor, the present study suggests that each of the elements examined, decreased arousal, enhanced control attributions, and self-efficacy, contributes to coping with an acute stressful procedure. The low correlations among these elements further suggests that they act independently and additively.

The nature of the contrast analyses used made sure that each element was considered sequentially. The first contrast tested the general assump- tion that the more one does for a person, the better he/she will do under stress. But it was also a test of the addition of decreasing autonomic arousal to preparation for surgery. The second contrast was a test of the addition of self-initiated relaxation, as opposed to relaxation produced by medication. The third contrast was used to test for the addition of self-efficacy enhancement to the preparation. Finally, the fourth contrast tested the addition of a specific desensitization component to the intervention.

Had decrease in arousal alone been the key ingredient for improve- ment in coping, only the first of the contrasts would have been significant. If sense of personal control had been crucial, only the second of the con-


trasts would have been significant. If the true key ingredient was self-efficacy enhancement, only the third contrast would have been significant. And if stimulus-specific preparation had been contributory, the fourth contrast would have been significant. The fact that the first three contrasts were significant (at least for two of the three outcome measures) indicates that desensitization, control, and self-efficacy may all contribute to the effectiveness of behavioral interventions. The failure of the fourth contrast to be significant indicates that the level of specificity in the preparation given to the IV group subjects may not have been necessary.

The results also indicate that relevant attributions and appraisals, such as self-efficacy and perceptions of controllability, can be successfully manipulated in the context of a dental stressor. The relaxation interventions appeared to engender significantly greater control perceptions than the standard or oral premedication conditions. Although subjects may have been made more comfortable by the premedication, they did not necessarily feel more control.

Self-efficacy was also changed. Bandura (1977) referred to four sources of self-efficacy: enactive mastery, verbal persuasion, vicarious experience, and physiological state. In previous laboratory and clinical studies by Litt and colleagues (Gattuso et al., 1992; Litt, 1988b; Litt et al., 1993), false feedback was used successfully to enhance coping self-efficacy. By providing false feedback in the present experiment, subjects were given both a sense of enactive mastery (i.e., experience of relaxing successfully) and verbal persuasion to the effect that they should be able to cope successfully with the oral surgery. The results indicate that this was an effective, and potentially clinically useful, means of enhancing self-efficacy appraisals and thereby improving coping.

The fact that self-efficacy ratings also significantly predicted the outcome measures, whereas control cognitions and physiological arousal did not, further supports the utility of the self-efficacy construct and reassures us that the apparent superiority of the SE and IV groups was indeed a result of increases in self-efficacy, and not just a placebo effect or a result of demand characteristics. Regardless of intervention, self-efficacy was predictive of outcome.

It appears, however, that there is a contradiction in the results presented here. Interventions that lowered physiological arousal (at least as measured by SCL) and enhanced control attributions led to better outcomes than those that did not, yet neither arousal nor control cognitions were very strong predictors of outcome, whereas self-efficacy was quite a strong predictor. Self-efficacy alone cannot be predictive of outcome; in that case the Relaxation group, which showed levels of self-efficacy equal to those of the SP and OP groups, would not have yielded better coping

456 Litt, Ny~ and Sha~r

than those groups. One explanation for this may be that individuals simply need to attain a threshoM for decrease in arousal or enhanced control. Once that threshold is reached, further improvements in arousal or control are unnecessary, and not predictive in a linear way. After reaching threshold for arousal and control, perhaps the only predictive variable would be self- efficacy.

Interestingly, this notion takes us away from the idea of degree of control and moves the focus back to the presence vs. absence of control. It also suggests a stepwise approach to coping, such that a minimum level of control must be perceived before self-efficacy can play a role. Ozer and Bandura (1990) allude to a similar process in which cognitive control and coping efficacy give rise to different but complementary paths to coping with physical threats among women. The results also support one of Ban- dura's (1977) main contentions: that other things being equal (in this ease outcome expectancies, arousal, and control attributions), self-efficacy will predict coping outcome.

Adding significantly to our previous work was the finding that blunting behavioral style interacted with preparation intervention to predict outcome. The interaction effect accounted for between 25 and 40% of the explained variance in outcomes, as much as was accounted for by the interventions themselves. Although situation-specific factors such as self-efficacy appear to be playing a major role in the success of behavioral interventions, the interaction of preparation with preferred coping style should be considered as another element in the coping model at least as important as other elements. This suggests that we need to refine our thinking about what makes for more effective interventions. In the present study high "blunters" fared best with standard treatment and reported the most distress with the moreinvolving self-efficacy enhancement interventions. Although subjects overall fared better after having had the serf-efficacy enhancement interventions, the interaction with behavioral style suggests that we can fine-tune our behavioral interventions by matching subjects to interventions that are better suited to their dispositions.

This is the same conclusion reached by Shipley and his colleagues (1978, 1979), who examined the match between intervention and disposition in patients undergoing gastrointestinal endoscopy. Advancing a "congruency hypothesis," Shipley et al. (1979) concluded that information seems to be beneficial to those patients whose coping disposition necessi- tates it but may be disruptive for some patients who prefer not to receive information. Similar results were obtained by Gattuso et al. (1992), also with endoscopy patients. The present results are complementary to those of Logan et al. (1991), who found that dental patients who desired control but perceived little control fared poorly both before and after dental treat-


ment. In the present study it appeared that those who desired no control, but perceived a great deal, fared most poorly. It may be that those who most want to distract themselves (blunters) fare poorly if their preparation interferes with their ability to do so.

In an unusual development, blunting behavioral style was implicated in outcome (in an interaction term), while monitoring behavioral style was not. Past studies, including those done by Miller, have tended to classify individuals as either monitors or blunters. In the present study, monitoring and blunting were treated separately. Clearly these two dimensions are not different ends of the same continuum. In fact, the two dimensions are vir- tually orthogonal to one another. The question then remains, If these dimensions are not on the same dimension, what are they measuring? Blunting is conceptually similar to distracting, an effective short-term coping strategy. The present results support the conclusion that distraction as a preferred strategy may be a cardinal element of coping.

In summary, we conclude that behavioral interventions are effective in helping patients cope with acute stressful experiences such as oral surgery. Furthermore, within the limits of the present study, behavioral interventions were more effective than the single dose of lorazepam administered. Relaxation, provision of control, and enhancement of self-efficacy are all manipulable, and all add to the ability of a behavioral intervention to effect improved coping in a dental context. Although it was believed that the specificity of the IV needle desensitization procedure would add to the effectiveness of the self-efficacy intervention, this was not the case here. We do not know, however, if those patients given desensitization to IV placement at least tolerated the IV placement better than did patients in the other groups. Finally, the belief that enhancement of self-efficacy and feelings of control should contribute to effective coping was generally borne out in this study, but the results suggest that once control and arousal are enhanced only self-efficacy is predictive of outcome. The finding that blunters did poorly with more involving interventions should lead us to look more carefully at matching patients to interventions on the basis of desire for control or distraction, and adds another element to our understanding of behavioral interventions.

ACKNOWLEDGMENTS

Support for this study was provided by National Institutes of Health Grant RO1 DE-09211, awarded to the first author. We would like to thank Drs. Richard Topazian, Leon Assael, and Keith Rogerson for their help in identifying and recruiting patients for this research. Thanks also go to Mar-


garet Chang, the staff, and the residents in oral surgery in the Oral and Maxillofacial Surgery Clinic at the University of Connecticut School of Dental Medicine for their help in data collection. We are also indebted to Howard Tennen for comments on early drafts of the manuscript. Portions of this research were presented at the annual meeting of the Association for Advancement of Behavior Therapy, Boston, MA, November 1992.

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Preparation for oral surgery: Evaluating elements of coping

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