Injection and dental phobia (odontophobia) are common disorders. Often these situations aren’t managed completely. It is rare for use of cardio interventions about psychiatric patients with this situation. We intend introduce a case with multiple comorbidity that was candidate for implantation of pace maker for treatment of phobia.

      In an Italian survey on 80 patients, Psychological condition and adjustment were being assessed before and after pace maker insertion. About both sex, anxiety and depression was decreased [1].

      The patient is a 40 years old married man who has been referred with aggressiveness and irritability from a year ago. His symptoms have been aggravated from 6 months ago following his wife’s employment.

      At this time, he has attempted suicide 3 times by Tab Lorazepam 2mg and Tab Olanzapine 5mg. He had pessimistic idea, hyper sexuality, hopelessness, anhedonia, social withdrawal and depressed mood. The patient had no insight. He also had an addiction history of using Opium and Crystal for 20 years and eventually stopped smoking crystal about 10 years ago but still is a heavy smoker by using 1-2 pack/daily of cigarette. He had history of head trauma and had eye deviation after that. An interesting point about this patient is dental phobia. From childhood, he had been afraid of injection, laboratory and dental actions. He had a history of faint experience for 3 times following dental actions in adolescence. After medical commission has been formed and it was decided to set a pace maker up for him. This is a rare case that a pace maker has been set up following dental phobia. The patient didn’t have a faint with dental or laboratory actions following the pace maker's embedding.

Differential diagnosis

Bipolar disorder

      Considering the symptoms of aggression, Irritability, Increased energy, increased libido and being spendthrift that had been exacerbated over the past 3 months, we can consider Bipolar disorder as a differential diagnosis.

Delusional disorder

      According to the delusional beliefs of patient and the belief in his betrayal of his wife and being suspicious and pessimistic to her, we can consider Delusional disorder as a differential diagnosis.

Personality disorders (cluster B)

      According to frequent self-injury with razors on wrist, tattooing on his body, 2 times suicide attempting with taking pills and a long period of using drugs (Opium and Crystal), and according to his aggressiveness and mood changing, Personality disorder can be considered as a differential diagnosis.

General medical condition

      According to his head trauma following a car accident about 10 years ago that after this the patient was in coma state for approximately 1 month and following this state he had cognition and memory disorder that has been diminished after a year but mood changing as aggressiveness and irritability has been started and continued following his head trauma, we can consider brain organic disorders as a differential diagnosis.

      Dental Phobia (odontophobia): According to patient’s childhood history that had been fainted in exposure with blood and regarding to his several faints following dental actions 4 years ago, we can consider dental and blood phobia as differential diagnosis

      Post-traumatic stress disorder: According to irritability and aggression, experience of cardiovascular symptoms when dental actions are attempted

      Other differential diagnosis: Substance related Disorders, Obsessive-Compulsive Disorder and Specific Phobia

      Plan:
-Control Vital Signs
-Electrocardiography
-Routine laboratory tests
-Addiction test
-Control the patient in terms of aggression
-Brain CT scan
-MMPI test
-Consulting the patient in terms of diagnose Depression and Suicide thoughts
-Phobia test in terms of diagnose fear of blood and dental actions

      Medical plan
*Tab Na-valproate 200 mg twice daily
*Tab Risperidone 2 mg every nights
*Tab Lorazepam 1 mg every nights

      As cardiac intervention and pace maker implantation is an invasive and cost operation, it seems that need a psychiatrist or psychologist assess the patient and prepare a psychological and psychopharmacological therapeutic plan. Therefore, it may avoid from an unnecessary intervention. Also, dentists will be success for manage of these patients.

Conclusion

      It is a challenge about cardiac intervention for treatment of dental anxiety before psychological and psychopharmacological therapeutics.

Figure 1: Inserted pace maker under left infraclavicular space