Resistant, Searing Fear in the ER/ED

“You gain strength, courage and confidence by every experience in which you really stop to look fear in the face. You are able to say to yourself, ‘I have lived through this horror. I can take the next thing that comes along.’ You must do the thing you think you cannot do.”
— Eleanor Roosevelt

Fear is one of our most resistant emotions, and it refuses to be erased quickly, despite Eleanor Roosevelt’s advice. She faced fears which would have traumatized any child, e.g., shipwreck, father’s attempted suicide, and loss of parents to diphtheria.

In addition to her losses, Eleanor was shy due to her mother constantly referring to her as an ugly child she called “Granny.” Unfortunately, her mother was one of the desirable beauties of her age.

Eleanor did manage to conquer her fears, but childhood fears, especially of medical and dental settings, stay with us for too long — into our adult lives. These fears pose threats to our health in their potency to inhibit actions that would save us from illness. How do we tackle this thorny emotion? First, a bit of history on my personal experiences with medical misdiagnosis and fear.

A Child’s Trauma

When I was a young child, a trip to the hospital emergency room felt like I was being led to a torture chamber, which it invariably proved to be. The smell of antiseptic filled the air in the gloom of the old city hospital.

I would be deposited with my mother on a long wooden bench in a hallway waiting to be called in. It always seemed that we were the only ones waiting there. The waiting was as though the torturers were preparing their tools to provide the ultimate in my painful experience.

One experience stands out among all the others. I had a toothache and, since we could not go to a dentist because we had no money, the dental clinic was a trip I was soon to make.

Today, it would be right out of Dustin Hoffman’s “Marathon Man” or “A Clockwork Orange,” maybe even “The Boys From Brazil.” Would the dentist have uttered Robert Duvall’s famous line from “Apocalypse Now” (with a slight change), “I love the smell of antiseptic in the morning.”

After a long wait in the hallway, I was called in, alone, seated in a large chair and surrounded by three nurses and a dentist. The torture was about to begin.

I received a minuscule shot of Novocain, and the dentist proceeded with enthusiasm and a pair of pliers to pull at my tooth. The anesthetic hadn’t yet taken effect, but they weren’t going to wait. As I pleaded, they refused to believe me that it was painful.

Three nurses grabbed me and held me down as the dentist pulled at my tooth until it plopped out. The fear I felt was extraordinary, and they acted as though I were being an unruly child, not one in pain and frightened out of my wits.

The Second Fearful Experience

My next childhood experience in a charity hospital emergency room, as a six-year-old child, was also traumatic and almost catastrophic. I had a leg injury, which was misdiagnosed and, as a result, I was later rushed into surgery.

The surgeon told my parents that they didn’t know if they’d be able to save my leg. They’d waited too long to come in; they hadn’t. The intern they saw earlier in the day sent us home after their first visit to the ER.

As I was wheeled up to surgery, my parents were accused of child abuse by an over-enthusiastic social worker who refused to believe the intern misdiagnosed the injury. I, even as a young child, heard the comments and yelled to support my parents.

I recall blurting out that they did not injure me and that they followed the doctor’s instructions. I have no idea if they believed me or thought I was being a loyal child. We know that abused children generally protect abusers.

I almost lost my leg at the hip because of that misdiagnosis, and my parents were nearly arrested for child abuse. It was all the result of inadequate medical training.

Of course, the fact that we were poor added to the problem. How many poor kids have gone through the same experience and will experience this type of treatment in the future? The thought is more than distressing.

It took a long time, but, as an adult, I overcame my fear and managed to go to the dentist as I would go to any other appointment. I never expected pain, nor did I ever experience it because all the dentists I saw waited for the anesthetic to work.

Stress and Fear Resistance to Extinction

Stress has a critical role in the development and expression of many psychiatric disorders, and is a defining feature of posttraumatic stress disorder (PTSD). Stress also limits the efficacy of behavioral therapies aimed at limiting pathological fear, such as exposure therapy.

Early childhood stress, therefore, plays a central role in the development of stress-related disorders such as dental phobias. But is it solely learning to be fearful in a specific environment, or is there a biological involvement?

Dr. David Barlow theorized three specific types of anxiety-related behavioral outcomes:
1. generalized biological vulnerability, mainly of genetic origin
2. generalized psychological vulnerability, resulting in particular from early life experiences
3. a specific psychological vulnerability focused on particular events or circumstances

Therefore, early childhood experiences, together with a genetic component, are actively responsible for phobic anxiety. While they may be confined to specific places or events, Barlow never delved into the question of biological brain area and structural changes that would embed fear-related memories. The physiological changes in the brain seemed unreasonable. But research provided new clues to early fear imprinting.

The biology of fear and anxiety has now been explored and it has been found that specific areas of the brain are where fear resides.

Vulnerability to psychopathology appears to be a consequence of predisposing factors (or traits), which result from numerous gene-environment interactions during development (particularly during the perinatal period) and experience (life events), (and) the biology of fear and anxiety (is a) systemic brain-behavior relationships, neuronal circuitry, … functional neuroanatomy and cellular/molecular (neurotransmitters, hormones, and other biochemical factors…

Multiple brain structures involved in fear work in an interplay of swift reactions meant to preserve and protect life, usually from saber-tooth tigers, but today real or imagined threats.

The fear response starts in a region of the brain called the amygdala. This almond-shaped set of nuclei in the temporal lobe of the brain is dedicated to detecting the emotional salience of the stimuli — how much something stands out to us.

From the amygdala and other brain structures, e.g., the prefrontal cortex and the hippocampus, the cascade of hormones and neurotransmitters begin to wash the brain in a reaction to danger.

Fear is being laid down in the brain, which will incorporate it into its memory banks in the hippocampus. But the memory of fear is not restricted to the brain alone. All the five senses of sight, olfaction, audition, touch, and taste record their memory in a somewhat dissimilar fashion and save it for later use.

Every physical reaction to fear is mustered during this time as blood pressure rises, the heart beats in an ever-increasing cadence, sweat is produced, and even the intestinal tract works overtime.

Despite all this disturbing activity, abused children, who fear their abusers, protect them. Why? Imaging of these children’s brains shows abnormal portions of their brains, which is believed to be related to the abuse.

The brain, in fact, in fearful children shows areas that are smaller. Fear has hampered and impeded development which then manifests in unexpected, protective behavior of the children toward their abusers.

So, early fearful experiences are not solely learned; they are laid down in neurology in the person in fear. Can this be changed later in life?

Research on brain development and early fear would require something equivalent to the 40-year-study of Donald Super and his colleagues related to school children and career choices. It would be nearly impossible today because of the needed funding and maintaining a dedicated and willing database of participants.

But we march on with various forms of therapy in the belief that we will be able to conquer fear and we do. Does the brain recognize these new and acceptable experiences and respond physically to them? Maybe someday we’ll know the answer to that question.