It always amazes me how some days are better than others. Last week I was feeling pretty good. I was confident that I could get my tetanus shot, quit smoking and finish up getting my teeth fixed. I viewed it as not so bad and that I would get through it. Now confident is the last thing I feel.
The past few days have not been so easy on me. My mind is back in some form of chaos. I have no idea what causes my down fall. Maybe it is the little things that add up or at least little things that I let get to me. Things I rather not discuss with people or sometimes when I do open up about them the lack of concern I get about an issue.
I have not drank alcohol in almost a year. But something else started a year ago after I stopped. Something that has worried me a lot. It is not the most pleasant topic. But my bowel color is way off a lot of the time. It was always normal before, I never had a problem with it. Now I get all shades. The worst being gray and sometimes almost white.
This of course last year concerned me a great deal. I looked up that it could mean liver problems and with the way I use to drink it would not have surprised me. I also read it meant that it could mean gallbladder problems. So last year despite my immense fear (to put it mildly) I had my blood taken to check my liver enzymes and I also had an ultrasound of my gallbladder, gallbladder duct, liver and pancreas. That was all ordered of course after I told my nurse of the color change and how light it was.
All the tests came back perfect. I started to think it was the xanax I was taking. So I tapered off the xanax and everything went back to normal. So I was happy. I thought problem solved. Then a few weeks later the light pale color returned. I looked at what I was eating, anything that could be causing this problem. Back when I first had the tests run I was so sick feel. Sicker than I have ever felt in my life. I can't even put into words how I felt. There was no pain just this feeling of death growing inside me, sucking every last bit of energy out of my body.
Most of the time when it happens now I don't feel sick, but sometimes I still do. I have told the nurse I see that it still occurs on and off but I get that "silly look"..the kind of look you get when you are an "anxious person". I have told my mom about it, but she not knowing hardly anything medical is no help. She usually says things like "well you can't be the only one with it." and I am sure I am not the "only one" but I would like to know what the hell is going on with my body.
It is not like I have not have had things go wrong before. Major things, like having part of my right lung removed a few months before it would have killed me. Part of this is my problem. I could push more. Demand more tests, but the truth is, I am too scared. I think the next test would be a colon scope and I know to many people it would not be that big of a deal, to me it is. Between the tetanus shot and up coming dental work as silly as it may sound I just can't add anything else to my plate.
Since this problem happens with or without taking xanax I finally went back on xanax a little over a month ago, maybe longer. I am allowed to take 3 pills a day but because of my history with substance abuse I take one pill a day. I break it in half and take half in the morning and the other half twelve hours later. On really bad days I might take three halves.
This morning in the shower I just started crying. I only allowed myself to do it for a minute or so. What I was really crying over I don't even know. I think I just feel overwhelmed. I don't feel like I am able to take care of myself. Many times I feel like my words are empty. It's funny the only people that actually listen to me are strangers. Strangers that have gone through some of my hardships or even have had more. At least they understand where I am coming from.
I am not one to live in guilt, but sometimes I can't help but feel guilty about how I complain about things when I know others are way worse off. All I have to do is get a tetanus shot (that I assume will kill me or disable me) and get a few teeth fixed. Assuming the pale bowel color really is nothing..then there is nothing wrong with me. Some people are actually dying or suffering thousands of times more than me right now. Yet here I sit, complaining and deeply upset. I don't even know sometimes why I am so upset.
Oh just so people know if you have been following my blog, I did end up taking an HIV test and it came back negative. So I don't have HIV which is a large weight off my shoulders. I also took a genetic test for Hemochromatosis (Iron Overload) and I had none of the genes for that disorder. I checked because I am of Irish descent which accounts for a large portion of people with Hemochromatosis. Not having the genes does not make it impossible not to develop it but it makes it a lot less likely.
Awhile back I wrote about a person in Cambodia that I mailed money too. We had become online friends and I just wanted to help him out. He never asked me for money, but I just felt the need to do something for someone else. He did end up getting the money and was thankful. Every so often I mail more to him. We keep in touch through e-mail.
Keith and I went to Walmart over a month ago and he bought me a pair of new sneakers. For some reason even though they were my size they really did not end up fitting. So I ended up getting a new pair. We never got around to bringing them back so I asked Keith if he would mind if I just gave them away for free. He said he didn't mind. I asked him to pick a state for me to send them too. I figured since he bought them he should pick the state. He choose New Orleans, Louisiana. So at some point this week I am going to place ad on craigslist on the New Orleans board. The first person to send me their mailing address will get them.
Maybe I am crazy. I don't know why I choose to mail things all over the country or world for that matter. Sometimes I feel I should do things for others. Other times maybe it is a selfish move on my part. Giving to burn off some Karmic debt I owe. But then if I am helping to improve my own Karma or improve my standing with God in general it is a lost cause. You have to actually give without expecting anything in return. And sometimes I am expecting less suffering and less fear.
Though I know I am not going to drink alcohol, esp. while taking xanax, sometimes I just want to be drunk or drugged out of my mind. I just want to escape myself even if it is for a little while. Other times I just want to wrap myself up in a cocoon and never come out, but that is not how life works. Tomorrow I will wake up, get out of bed and push through another day.
Sunday, October 5, 2008
Thursday, October 2, 2008
The Medicine Buddha
The Medicine Buddha. I listen to this to try to quiet my mind. Maybe it will work for someone else out there.
(If this youtube video ever goes down for more than a few days please email me so I can replace it)
(If this youtube video ever goes down for more than a few days please email me so I can replace it)
Back Seeing A Therapist.
I am back to seeing a therapist.
I go to this program every year now. This being my third year. Since I don't have health insurance all I can afford is to see students in training. Each year I get someone new and each year I have to reexplain my situation. Usually I have new concerns I need addressed as I quickly fill the new person in within a few 50 min sessions with 32 years of my life story.
This year I am taking a more direct route. I have printed off about 30 pages from this blog and just handed it over. It is easier than explaining everything again. Truth is I am tired of explaining myself.
The person I am seeing would like to try CBT (Cognitive Behavioral Therapy MAP-3). Which for me is nothing new. CBT is the first thing I did when I first saw someone in 1996. It seems to have come full circle. The Chapter 1 she photo copied out of the CBT Book states that people with panic disorder or anxiety in general do not have a chemical imbalance in their brain. Isn't that what I have been defending over the past decade to doctors and therapists? And more recently on this blog and youtube.
I never bought into the "imbalance" but I have lived through the SSRI era of paxil and zoloft. The quick fix for all problems. I am not saying that these drugs don't work in some people. I am saying their is always a price to be paid and risks. You just have to measure the risks you are willing to take. Like right now I take Xanax. Not that it helps much.
Now for me CBT does not work at least in the past. CBT is sort of how I cope in general anyway on my own. But sure why not do it again? What else is there?
Truth be told I almost want to just stop going to therapy altogether. Sometimes I have just stopped caring. I can only do so much on my own but without support and understanding from most medical professionals, family, or the public in general how can I do it all alone?
So anyway to speed up the process with the new person I am seeing I have yet another letter I will hand her next Tuesday. In some parts it might sound harsh but I rather not have to deal with the crap I normally do.
Here is the letter it is mostly worked out but still in draft form. Oh and when it says "(packet included)" it is the print out of what I have listed in my last post about blood/needle phobia and the things in quotes is just in reference to what the CBT MAP-3 program states:
""Clients learn specific intervention skills, including how to slow down physiological reactivity through breathing retraining and muscle relaxation training"
This I already do and 90% of the time this is how I cope (this eases it but does not stop it). The other 10% of the time breaks down to the following.
1) I am not in the mood to cope that day so I just deal with the situation or to tired to deal with it so I just don't bother.
2) Other people around me cause distractions or help make the situation worse. Example when I told the dentist "I know my gums bleed but lets not talk about that" stated before hand it is brought up anyway. Or "you don't look so good" when I am already trying to focus and not pass out during a blood draw.
3) The anxiety is so intense that I have not mastered easing it at that level (happens rarely)
"how to decatastrophise through actual prediction testing:"
1) I do this as well. Example when I get my hair cut nothing overwhelming has ever happened and even if something did I would have to deal with the situation at hand and just get through it. Yet knowing this does not seem to make a difference. In fact most situations that I know are not dangerous and nothing ever has happened before, or even something I enjoy doing still sets the process in motion automatically. This can and has happened even when I am fed up with the anxiety and could careless about myself or anyone else for that matter (meaning I care zero what people think about me at that time). Basicly I question my disastrous thoughts and paint them in a different more positive way, know that I can not predict the future and it is never as bad as I imagine anyway (so far).
"how to lessen fearfulness through exposure to feared sensations in safe settings."
1) Exposure no matter how often or far apart seems to have no effect. Going to the same job everyday does not ease it. Getting my hair cut in the past once a month for 17 years.. sometimes even at places that were quiet and the people who worked there were enjoyable did not change the out come much. Also somedays at work were better than others anxiety wise. There is nothing different between the days other than the fact my body is not acting up on some. Somedays at work everything was fine other days I was throwing up.
"sensations in safe settings"
1) I can not get these sensations in a safe setting. Most I can't even bring on if I wanted to at will. Hyperventilation is not something I do during a panic attack or anxiety in general. I was able to eliminate that years ago and am not willing to do that just to get dizzy and bring that feeling back into the forefront of my mind. I also don't get dizzy during panic attacks anymore. Unless it was a long lasting dizzy spell I am not bothered by feeling temporarily dizzy as I experience that at random times be it from being tired or having a cold.
---------
I am not willing to work on blood phobia in this setting because I do not feel this is the proper clinical setting to address that phobia (infomation packet included).
----------
What I am willing to work on:
1) How to cope when my mind becomes so filled with chaos that I cannot stop the racing thoughts, worries and dreams even with deep breathing and decatastrophizing / or positive thoughts. Uncontrolled this can lead me into a depression.
2) I am not scared of when I throw up, not scared of the panic attack or anxiety in itself. I am just tired of feeling so uncomfortable all the time. Years ago I was scared and worried it would kill me on the spot. It hasn't and I have had no choice but to endure it. A lot of therapy depending on the treatment plan can include exposure, breathing techniques, distraction, self-hypnosis, religion (in a church setting treatment plan), medication etc etc.
What it does not address and what I would like and I don't even know if it is possible is deep down I do not want to be focusing on my breathing while shopping, getting my hair cut, seeing a doctor etc etc. I just want to be normal and have my body just behave itself. After all these are not dangerous situations and I know it. I would like to enjoy them without my body fighting me.
A lot of times therapy goes back and forth with "are you worried you are going to throw up?" "so what if you do throw up?" "why do you mind what people think if you throw up?" "sometimes people have a virus and throw up so it's normal" (which I am aware of but this is not a virus or a one time flu). "have you tried not to throw up? and what happens when you do try not to?" "do you worry about throwing up therefore causing a self fulfilling prophecy?" .....For me the real answer is when I am nervous I throw up it is just what happens. It is a pain to deal with and most likely damaging to my health. I do not want to throw up when nervous so how do I stop that? How do I stop my body from shaking even when I am not scared of the situation or even if I am?
How do I deal with people who are demeaning, rude, unsympathetic, uneducated or just plain jerks about my situation? How do I claim my place of power when I am not in a place of power in some situations? How do I do this without a proper support structure in place?
How do I deal with a situation that makes me nervous that I do deem as a possible dangerous situation? How do I sleep when my body refuses to?
How do I know when something real is happening such as a heart attack and not just blow it off as anxiety?
------------------------------------
Word games:
If I say I "can't" I do not mean there is some invisable wall or force stopping me. In general I just mean I "can't" do something at that moment in time for whatever the reason or situation at hand. I do not think I always "can't" I am using the word "can't" as anyone would in everyday common language. "can't" does not mean I am unwilling.
"is just what happens" does not mean there is a law in my head that states that there is a rule, a conclusion of absolutes. I just mean in this time and space, it is what it is, and has been occuring in the now and/or past. There is no future prediction of forever happening. Most the time I am not thinking in terms of "forever" or "always" (in future tense).
"always" I am using in common terms meaning most of the time (and sometimes "always" does mean something "always" happens in the present and past)
"normal" means in general what most the population does not "do, have or think"
Word games do nothing for me other than frustrate me since I then have to define every meaning of common words I may use in a sentence to convey a thought or explain to someone who is not me how something "is" or "feels".
------------------------------------
Praise:
I am not receptive to praise in most cases. It depends on the delivery. In a normal adult voice and only when it's for something big. Some how being praised for going to the supermarket, mailbox, or any other simple everyday tasks makes me feel ill. To me it's corny and the "woooooow thaaaats Greeattt" is not needed. For some reason praise in general does not motivate me.
--------------------------------------
I am an extremely open person (maybe to open with people). You can ask me any question you want. If it is something I rather not answer at that time I will just say "I do not want to answer that". I am hard to offend so don't be concerned with that. (and no I am not worried that you are concerned).
I do not think I am always right. New information can and does change my mind about issues or changes it over time. When it comes to people in general we all in some way have a belief system. So at times I just agree to disagree.
Basicly I am flexable."
So that is it. That is my letter. Any of you who have been in therapy for any amount of time might be able to relate to what I am talking about.
You know reading over my posts sometimes I hope some of you are getting something out of this because I find it very difficult to express what I am feeling into words. That mixed with my grammar being awful....well I just hope someone gets it. :-)
I go to this program every year now. This being my third year. Since I don't have health insurance all I can afford is to see students in training. Each year I get someone new and each year I have to reexplain my situation. Usually I have new concerns I need addressed as I quickly fill the new person in within a few 50 min sessions with 32 years of my life story.
This year I am taking a more direct route. I have printed off about 30 pages from this blog and just handed it over. It is easier than explaining everything again. Truth is I am tired of explaining myself.
The person I am seeing would like to try CBT (Cognitive Behavioral Therapy MAP-3). Which for me is nothing new. CBT is the first thing I did when I first saw someone in 1996. It seems to have come full circle. The Chapter 1 she photo copied out of the CBT Book states that people with panic disorder or anxiety in general do not have a chemical imbalance in their brain. Isn't that what I have been defending over the past decade to doctors and therapists? And more recently on this blog and youtube.
I never bought into the "imbalance" but I have lived through the SSRI era of paxil and zoloft. The quick fix for all problems. I am not saying that these drugs don't work in some people. I am saying their is always a price to be paid and risks. You just have to measure the risks you are willing to take. Like right now I take Xanax. Not that it helps much.
Now for me CBT does not work at least in the past. CBT is sort of how I cope in general anyway on my own. But sure why not do it again? What else is there?
Truth be told I almost want to just stop going to therapy altogether. Sometimes I have just stopped caring. I can only do so much on my own but without support and understanding from most medical professionals, family, or the public in general how can I do it all alone?
So anyway to speed up the process with the new person I am seeing I have yet another letter I will hand her next Tuesday. In some parts it might sound harsh but I rather not have to deal with the crap I normally do.
Here is the letter it is mostly worked out but still in draft form. Oh and when it says "(packet included)" it is the print out of what I have listed in my last post about blood/needle phobia and the things in quotes is just in reference to what the CBT MAP-3 program states:
""Clients learn specific intervention skills, including how to slow down physiological reactivity through breathing retraining and muscle relaxation training"
This I already do and 90% of the time this is how I cope (this eases it but does not stop it). The other 10% of the time breaks down to the following.
1) I am not in the mood to cope that day so I just deal with the situation or to tired to deal with it so I just don't bother.
2) Other people around me cause distractions or help make the situation worse. Example when I told the dentist "I know my gums bleed but lets not talk about that" stated before hand it is brought up anyway. Or "you don't look so good" when I am already trying to focus and not pass out during a blood draw.
3) The anxiety is so intense that I have not mastered easing it at that level (happens rarely)
"how to decatastrophise through actual prediction testing:"
1) I do this as well. Example when I get my hair cut nothing overwhelming has ever happened and even if something did I would have to deal with the situation at hand and just get through it. Yet knowing this does not seem to make a difference. In fact most situations that I know are not dangerous and nothing ever has happened before, or even something I enjoy doing still sets the process in motion automatically. This can and has happened even when I am fed up with the anxiety and could careless about myself or anyone else for that matter (meaning I care zero what people think about me at that time). Basicly I question my disastrous thoughts and paint them in a different more positive way, know that I can not predict the future and it is never as bad as I imagine anyway (so far).
"how to lessen fearfulness through exposure to feared sensations in safe settings."
1) Exposure no matter how often or far apart seems to have no effect. Going to the same job everyday does not ease it. Getting my hair cut in the past once a month for 17 years.. sometimes even at places that were quiet and the people who worked there were enjoyable did not change the out come much. Also somedays at work were better than others anxiety wise. There is nothing different between the days other than the fact my body is not acting up on some. Somedays at work everything was fine other days I was throwing up.
"sensations in safe settings"
1) I can not get these sensations in a safe setting. Most I can't even bring on if I wanted to at will. Hyperventilation is not something I do during a panic attack or anxiety in general. I was able to eliminate that years ago and am not willing to do that just to get dizzy and bring that feeling back into the forefront of my mind. I also don't get dizzy during panic attacks anymore. Unless it was a long lasting dizzy spell I am not bothered by feeling temporarily dizzy as I experience that at random times be it from being tired or having a cold.
---------
I am not willing to work on blood phobia in this setting because I do not feel this is the proper clinical setting to address that phobia (infomation packet included).
----------
What I am willing to work on:
1) How to cope when my mind becomes so filled with chaos that I cannot stop the racing thoughts, worries and dreams even with deep breathing and decatastrophizing / or positive thoughts. Uncontrolled this can lead me into a depression.
2) I am not scared of when I throw up, not scared of the panic attack or anxiety in itself. I am just tired of feeling so uncomfortable all the time. Years ago I was scared and worried it would kill me on the spot. It hasn't and I have had no choice but to endure it. A lot of therapy depending on the treatment plan can include exposure, breathing techniques, distraction, self-hypnosis, religion (in a church setting treatment plan), medication etc etc.
What it does not address and what I would like and I don't even know if it is possible is deep down I do not want to be focusing on my breathing while shopping, getting my hair cut, seeing a doctor etc etc. I just want to be normal and have my body just behave itself. After all these are not dangerous situations and I know it. I would like to enjoy them without my body fighting me.
A lot of times therapy goes back and forth with "are you worried you are going to throw up?" "so what if you do throw up?" "why do you mind what people think if you throw up?" "sometimes people have a virus and throw up so it's normal" (which I am aware of but this is not a virus or a one time flu). "have you tried not to throw up? and what happens when you do try not to?" "do you worry about throwing up therefore causing a self fulfilling prophecy?" .....For me the real answer is when I am nervous I throw up it is just what happens. It is a pain to deal with and most likely damaging to my health. I do not want to throw up when nervous so how do I stop that? How do I stop my body from shaking even when I am not scared of the situation or even if I am?
How do I deal with people who are demeaning, rude, unsympathetic, uneducated or just plain jerks about my situation? How do I claim my place of power when I am not in a place of power in some situations? How do I do this without a proper support structure in place?
How do I deal with a situation that makes me nervous that I do deem as a possible dangerous situation? How do I sleep when my body refuses to?
How do I know when something real is happening such as a heart attack and not just blow it off as anxiety?
------------------------------------
Word games:
If I say I "can't" I do not mean there is some invisable wall or force stopping me. In general I just mean I "can't" do something at that moment in time for whatever the reason or situation at hand. I do not think I always "can't" I am using the word "can't" as anyone would in everyday common language. "can't" does not mean I am unwilling.
"is just what happens" does not mean there is a law in my head that states that there is a rule, a conclusion of absolutes. I just mean in this time and space, it is what it is, and has been occuring in the now and/or past. There is no future prediction of forever happening. Most the time I am not thinking in terms of "forever" or "always" (in future tense).
"always" I am using in common terms meaning most of the time (and sometimes "always" does mean something "always" happens in the present and past)
"normal" means in general what most the population does not "do, have or think"
Word games do nothing for me other than frustrate me since I then have to define every meaning of common words I may use in a sentence to convey a thought or explain to someone who is not me how something "is" or "feels".
------------------------------------
Praise:
I am not receptive to praise in most cases. It depends on the delivery. In a normal adult voice and only when it's for something big. Some how being praised for going to the supermarket, mailbox, or any other simple everyday tasks makes me feel ill. To me it's corny and the "woooooow thaaaats Greeattt" is not needed. For some reason praise in general does not motivate me.
--------------------------------------
I am an extremely open person (maybe to open with people). You can ask me any question you want. If it is something I rather not answer at that time I will just say "I do not want to answer that". I am hard to offend so don't be concerned with that. (and no I am not worried that you are concerned).
I do not think I am always right. New information can and does change my mind about issues or changes it over time. When it comes to people in general we all in some way have a belief system. So at times I just agree to disagree.
Basicly I am flexable."
So that is it. That is my letter. Any of you who have been in therapy for any amount of time might be able to relate to what I am talking about.
You know reading over my posts sometimes I hope some of you are getting something out of this because I find it very difficult to express what I am feeling into words. That mixed with my grammar being awful....well I just hope someone gets it. :-)
Blood/Needle Phobia UPDATE
To copy and paste the information on the seriousness of blood and needle phobia go to a page I setup http://www.silentjealousy.org
From there you can copy and paste the information to your friends and/or print it out to bring to your doctors.
Thank You.
From there you can copy and paste the information to your friends and/or print it out to bring to your doctors.
Thank You.
Blood/Needle Phobia and Death
Many people do not know that blood/needle phobia is the only phobia that can lead to death in rare cases. I have this phobia and working with the medical community on this issue has been a nightmare. I have found them to me ill informed on the subject and how to handle the situation.
So below I have a report wrote by a Doctor (Hamilton, James G. MD.,Source: Journal of Family Practice)
I am going to have to start taking responsibility for educating my surrounding area on this topic by making copies with what little money I have and sending this report or dropping this report off in person to nursing organizations, hospitals, dentists and blood labs. I assume in some cases I will have to bring 100 copies to places like Emergency Rooms since they are heavily staffed.
You can help in the following way. Copy the report below and mail it or drop it off to your doctor and local dentist offices etc. Look up random addresses to doctors in the phone book if you have to and mail copies when you can.
The people who have anxiety and depression (including myself) have to start fighting back against the biases we face from having this illness or illnesses. I am not concerned with the cause or treatment when it comes to doctors and the lay public. We have all heard "Well just take a pill", "Just relax". You each have heard your own condescending remakes I am sure. And as we all know their treatments do not work for everyone.
If you do not have blood/needle phobia please still take time to print out the report below and mail it to some places in your area. The more we take a stand the more things will change for us and others in the future with an issue.
Also by all means if you have a great doctor or dentist email me their name and address and contact info so I can post it. Also if you have had a negative experience with a medical professional of any kind email me with their info and your experience with them so they can be exposed and people with these conditions can avoid the hardships you have endured. My email is silentjealousy77@yahoo.com. You can also write to me:
Brian
PO BOX 8533
Albany, NY. 12208
The report below is the part you would print and send to the medical professionals in your area.
--------------------------------------------------------------------------
The following is by James G. Hamilton, M.D. in the August, 1995 issue of The Journal of Family Practice. [Vol. 41, No.2, pp. 169-175]
"Needle Phobia: A Neglected Diagnosis
Source: Journal of Family Practice
Date: 08/1995
Citation (v41 n2) Start Page: p169(7) ISSN: 0094-3509
Author(s): Hamilton, James G.
Needle phobia is a recently defined medical condition that affects at least 10% of the population. Because persons with needle phobia typically avoid medical care, this condition is a significant impediment in the health care system. The etiology of needle phobia lies in an inherited vasovagal reflex of shock, triggered by needle puncture. Those who inherit this reflex often learn to fear needles through successive needle exposure. Needle phobia is therefore both inherited and learned.
In a family practice, needle phobia can be managed by reassurance and education, avoidance of needles, postural and muscle tension techniques, benzodiazepines, nitrous oxide gas, and topical anesthesia applied by iontophoresis.
Key words. Needle phobia; phobic disorders; needles; vasovagal reflex; syncope; vasovagal syncope; iontophoresis. (J Fam Pract 1995; 41:169-175)
Needle phobia is a condition that has become an increasingly important issue in medicine because of the modern reliance on injections and blood testing. Contrary to popular belief, needle phobia is not confined to children, is not an emotion-driven or transient phenomenon, and is not a rare condition. Clinicians need to be aware of needle phobia because it is a common condition and because needle-phobic persons tend to avoid medical treatment, which can lead to serious health problems as well as social and legal problems.
Needle phobia has been defined as a formal medical condition(1)(2) and has recently been included in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) within the diagnostic category of Blood-Injection-Injury Phobia.(3) A review of the background medical literature and suggestions for management of needle phobia are presented here.
The etiology of needle phobia is rooted in an inherited vasovagal reflex that causes shock with needle puncture. With repeated needle exposure, those with an inherited vasovagal shock reflex tend to develop a fear of needles. Unlike most other phobias, in which exposure to the feared object excites tachycardia, victims of needle phobia typically experience a temporary anticipatory tachycardia and hypertension, which on needle insertion turns into bradycardia and hypotension (Figure), accompanied by pallor, diaphoresis, tinnitus, syncope or near-syncope, and sometimes asystole or death.(1)
[ILLUSTRATION OMITTED]
According to the DSM-IV, a phobia is defined by the presence of fear and by avoidance behavior.(3) The symptom of avoidance of needles, doctors, dentists, etc, is central to the definition of needle phobia, since avoidance of health care is surely a health care problem. However, because needle phobia is also accompanied by numerous physiological changes in blood pressure, pulse, electrocardiogram (ECG) waveforms, and stress hormone levels,(1)(2) these measurements can also be used to define this condition (Table 1). While a dislike or mild fear of needles is very common, needle phobia can be more rigorously defined by objective clinical findings in addition to subjective symptoms.
Table 1. The Primary Factors Underlying the Recognition and Diagnosis of
Needle Phobia
Past medical history(*)
(1) Self-report by the patient of a long-term needle fear, usually from childhood, that the patient recognizes as unreasonable.
(2) Exposure to or anticipation of a needle procedure invariably triggers immediate anxiety, sometimes in the form of a panic attack. In children, the anxiety may be expressed by crying, psychomotor agitation, freezing, or clinging.
(3) Needle procedures, often along with associated medical objects or situations, are avoided either some or all of the time.
(4) The needle avoidance and fear interfere significantly with health care or with normal occupational, academic, or social activities, or the patient is markedly distressed about having the fear.
Family medical history
Approximately 80% of patients with needle phobia report strong needle fear in a first-degree relative, ie, parent, child, or sibling.
Clinical findings
(1) Physical symptoms of syncope, near-syncope, light-headedness, or vertigo upon needle exposure, along with other autonomic symptoms, eg, pallor, diaphoresis, nausea.
(2) Cardiovascular depression with a drop in blood pressure or pulse or both; with or without an initial rise in blood pressure or pulse or both.
(3) Electrocardiogram anomalies of virtually any type.
(4) Rises in any combination of several stress hormones: antidiuretic hormone, human growth hormone, dopamine, catecholamines, corticosteroids, renin, endothelin, and [beta]-endorphin.
(*)Modified from Diagnostic criteria for specific phobia. In: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC: American Psychiatric Association, 1994:410.
NOTE: A diagnosis of needle phobia can be made by past medical history alone. In addition, however, victims of needle phobia typically have symptoms of decreased cerebral perfusion, cardiovascular changes, electrocardiogram changes, and hormonal rises.
Needle Phobia in Family Practice
Those with needle phobia are often terrified of routine needle procedures, and a few are so frightened that they would rather die than have a needle procedure.(4) Even such relatively minor needle procedures as venipuncture(1)(5) or subcutaneous injection(6) can cause a vasovagal shock reflex and evoke patient resistance. When those with needle phobia do agree to needle procedures, they often experience syncope, fall and sustain trauma, have convulsions, lose bowel and bladder control, evoke the calling of cardiac codes, or otherwise cause great concern among staff and family members. Others with needle phobia are simply noncompliant with medical treatment regimens, eg, insulin self-injections.
Victims of needle phobia possess a heightened risk of morbidity and mortality simply because they avoid health care, sometimes for many years,(1)(7) and even when the need for treatment is compelling.(1)(4)(6)(7)(8) Approximately 5% to 15% of the population, for example, decline necessary dental treatment, primarily because they fear oral injections.(8) With an incidence of needle phobia of at least 10%, it is reasonable to hypothesize that a large hidden population goes without regular health care because of this condition. The recognition, acceptance, and communication of this danger by both the medical community and the public, and the development of methods to compensate for needle fear in clinical practice, represent probably the greatest challenges that this condition poses for family medicine.
Needle phobia also can cause major social and legal difficulties in one's life. A fear of blood testing or immunization can interfere with or even destroy plans for marriage, travel, education, immigration, or employment. Students may be discouraged from biological, nursing, or medical careers because of their fear of needles,(4) and women wishing to have children may be thwarted by needle fear.(4)(7) Legal problems can arise when blood tests are ordered by a court in paternity cases, and some victims of needle phobia have even been charged by the police for failure to agree to blood testing.(4) The best-selling book The Blooding detailed the resistance that authorities in England experienced against mass blood testing to eliminate suspects in a murder case.(9) In the United States, involuntary blood testing of accused drunk drivers has led to four cases being appealed to the US Supreme Court.(10)(11)(12)(13)
Occasionally, needle phobia can be fatal. At least 23 reported deaths can reasonably be ascribed solely to needle phobia and its vasovagal reflex during needle procedures such as venipuncture, blood donation, arterial puncture, pleural tap, and intramuscular and subcutaneous injections.(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25) Other reports and indirect evidence further suggest that needle procedures can result in sudden death.(26)(27)(28)(29) A death by needle phobia can be due to either or both of two mechanisms: an abrupt vasovagal drop in blood pressure and perfusion, especially in an arterial tree already compromised by atherosclerosis, could cause myocardial infarction(25)(29) or cerebral infarction; or a vasovagal reflex could impair the sinoatrial or atrioventricular node enough to cause ventricular fibrillation or asystole.(27)(30)
Prevalence of Needle Phobia
Because needle phobia has only recently been defined, only indirect estimates of its prevalence can be inferred from the literature. One study of 449 Canadian women found that 21.2% experienced mild to intense fear, and 4.9% had a phobic level of fear of injections, blood, injury, doctors, dentists, and hospitals.(31) Another study estimated that 9% of the US population in the age bracket of 10 to 50 years old have an injection phobia, and 5.7% have seen a physician about this phobia.(32) Dread of a painful injection was present in 11% of 100 English office patients.(33) Through in-hospital interviews, 22% of 184 teenaged maternity patients in Nashville, Tennessee, were found to have a fear of blood drawing strong enough to make it hard for them to come to a public clinic for prenatal care.(34) In random surveys, 23% of 200 Swedes(35) and 27% of 177 US college students(36) reported needle fear as the main reason for not donating blood.
The prevalence of needle phobia is probably lower in population samples from clinics or hospitals since those with needle phobia tend to select themselves out of such populations. Even in a general population sample, many people express denial of their needle fear. Therefore, most of the studies done so far probably underestimate the true prevalence of needle phobia. Although the percentage is currently unknown, an estimate of at least 10% is credible.
Etiology of Needle Phobia
In the author's experience with over 50 patients with needle phobia, and in all similar cases reported in the medical literature, those afflicted inevitably display symptoms of an autonomic vasovagal reflex whenever they undergo a needle procedure. The neurophysiology of the vasovagal reflex is grounded in both a vagal bradycardia and a vasodilatation from withdrawal of [alpha]-sympathetic arteriolar tone, which together cause hypotension.(2)(30) In addition, associated neurological circuits cause ECG anomalies and stress hormone release.(30) Because most victims of the vasovagal reflex do not actually lose consciousness, the term "vasovagal reflex" is more accurate than "vasovagal syncope," the term most often used in the older literature. Although the vasovagal reflex has classically been described as being biphasic, with an anticipatory rise in blood pressure and pulse before needle puncture and a sudden plunge in both after puncture(1)(4)(27)(37) (Figure), the author has observed that some patients with needle phobia do not have this initial cardiovascular rise.
Physical Symptoms of the Vasovagal Reflex
The vasovagal reflex in needle phobia may include virtually any type and combination of autonomic symptoms, eg, a clammy diaphoresis, pallor, nausea, respiratory disturbances, and various levels of unresponsiveness.(1)(4)(30)(37)(38)(39)(40) Although the onset of the vasovagal reflex from the start of a needlestick is often immediate, ie, within 2 to 3 seconds, a prospective study of 84 blood donors who fainted found that 16.7% experienced syncope from 5 to 30 minutes after phlebotomy.(38) Another series of 64 blood donors who fainted found that 14% fainted after leaving the phlebotomy site and returning to work, sometimes several hours later.(39)
Although most victims of needle phobia who faint are unconscious for only a few seconds, a survey of 298 vasovagal fainters found that several had a loss of consciousness for 10 to 30 minutes, and a few lost consciousness for 1 to 2 hours.(40) Although blood pressure usually returns to normal within 2 hours, and most vasovagal victims feel well enough to resume normal activity within several hours, others have anxiety, malaise, and weakness for 1 to 2 days after a vasovagal attack.(38)(40)
Convulsions during vasovagal fainting, which are much more frequent than commonly realized, are a general response of the central nervous system (CNS) to the cerebral hypoxia of vasovagal shock. Of 84 blood donors who fainted, 14.3% had prominent tonic--clonic episodes, and another 27% had tonic muscular rigidity.(38) Furthermore, even having a finger pricked for blood typing can cause syncope with convulsive seizures.(38)
Electrocardiogram Changes
In several case reports, ECG changes during the vasovagal reflex among patients with needle phobia have included sinus arrhythmia, premature atrial contractions, premature junctional contractions, unifocal and multifocal premature ventricular contractions, bigeminy, first- and second-degree block, changes in P waves, ST waves, and T waves, sinus bradycardia, sinus tachycardia, ventricular tachycardia, ventricular fibrillation, and asystole.(1)(2)(5)(26)(27)(28)(37) Presumably, these ECG changes are secondary to vagal influence on the sinoatrial and atrioventricular nodes, and perhaps also to the antagonism between the activated sympathetic and parasympathetic systems on the heart.(27)
Stress Hormone Changes
At least 11 stress hormones have been reported to elevate during needle stimulation. Increased cortisol and corticotropin (ACTH) levels secondary to venipuncture and needle phobia have been documented.(1)(2)(41)(42) In one study, cortisol levels rose above average in 7 of 15 subjects, with a positive correlation between cortisol level and the number of vasovagal symptoms.(42) In my experience, corticotropin-releasing factor also can elevate during needle procedures, as can dopamine. In 25% of 28 subjects in 112 trials, human growth hormone levels rose in response to venous catheterization.(42) In three needle-induced vasovagal subjects, [beta]-endorphin levels were observed to rise,(42) but sometimes they do not rise.(1)
Similarly, epinephrine and norepinephrine levels do not always become elevated during episodes of needle phobia.(1) They have been observed to decrease in eight subjects who fainted after venipuncture, presumably related to the withdrawal of sympathetic vascular tone.(43) In another study, however, 21 young women dental patients had increased levels of epinephrine, but not norepinephrine, with a decrease in epinephrine after the procedure.(44) The findings of both of these studies are compatible with a biphasic cardiovascular response.
Probably because the pituitary perceives a reduced intravascular volume during vasovagal shock, vasopressin or antidiuretic hormone (ADH) rises in the vasovagal reflex with venipuncture,(1)(2)(45) as does endothelin.(45) Renin also increased by 200% in one patient with needle phobia,(46) but aldosterone and angiotensin levels have not yet been tested in needle phobic patients. The ADH rise causes pallor during the vasovagal reflext by sharply decreasing cutaneous blood flow, and may also contribute to nausea.(1) This ADH rise is often dramatic, reaching as high as 46 times normal values,(45) and may be responsible, along with the catecholamine elevation, for the intense fear that victims of needle phobia learn in response to their vasovagal reflexes.(1)
Needle Phobia: Inherited or Learned?
Clear evidence exists to support the hypothesis of a hereditary component to needle phobia. Both the vasovagal reflex and needle phobia strongly tend to run in families.(1)(2)(7)(47)(48)(49) The heritability of blood-injury phobia in twin studies, including fear of injections, wounds, blood, and pain, has been estimated to be 48%.(50) Variations in PR, QRS, and QT intervals and heart rate have heritabilities of 30% to 60%,(51) and the autonomic control of the cardiovascular system in general, based on twin comparisons, is probably genetically influenced.(52) Therefore, the plunges in blood pressure and pulse and the ECG anomalies during a needle-phobic response are surely also genetically influenced. The release of stress hormones likewise can reasonably be assumed to be genetically influenced.
In addition to genetic factors, however, a learned component to needle fear also can be identified among those with needle phobia. Needle fear often first comes into awareness after a negative experience at the doctor's or dentist's office.(6)(7)(8) One patient, for example, developed needle phobia in childhood when he was verbally abused and restrained by health care personnel during several painful medical procedures.(6) In one study of 56 persons with injection phobia, 52% traced their fear to such negative conditioning, with a mean age at onset of 8.06 years, and another 24% dated their fear to an episode of vicarious conditioning at seeing another child, often a sibling, have a negative reaction to needles.(47) Over time, with more needle exposures, this fear tends to organize and solidify into a conscious phobia, with an anticipatory anxiety before needle encounters. The learning of fear often becomes generalized in that those who are initially fearful only of needles may develop fear of objects or situations associated with needles, such as blood, injuries, syringes, doctors, dentists, nurses, white laboratory coats, examination rooms, hospitals, and even the antiseptic smell of offices or hospitals.(4)(31)(50)
Based on these studies, one can hypothesize that the trait of needle phobia is both inherited and learned. A vasovagal reflex has been found in all patients with needle phobia tested so far, and the medical histories of most of them include an adverse learning experience that triggered the needle fear.(47) Therefore, a reasonable theoretical model might propose that needle phobia depends both on an inherited reflex that is hard-wired in neurocardiovascular and neuroendocrine pathways and on the learning of a conscious fear.
Blood-injury phobia, which is often linked with needle phobia,(3) probably often arises when a patient with a strong vasovagal reflex undergoes a needle procedure or has an accident that results in a vasovagal response. The victim may focus on the sight of blood or injury to the extent that the blood-injury cue serves as a conditioned stimulus to trigger a vasovagal response thereafter. Although many needle-phobic persons also have blood-injury fears, further consideration should be given to whether these two phobias should be combined into a single diagnostic category, as is now the case in DSM-IV.
Evolution of the Needle Phobia Trait
The presence of a genetic trait among a species automatically indicates that the trait must have been selected for during the evolution of that species. The needle phobia trait probably evolved among the human species in response to piercing, stabbing, and cutting injuries.(1) The vast majority of violent deaths in our species' evolutionary history have been caused by skin penetration from teeth, claws, fangs and tusks, and from sticks, stone axes, knives, spears, swords, and arrows. Besides death resulting from direct trauma or hemorrhage, many of these deaths were due to infections secondary to skin penetration. A reflex that promoted the learning of a strong fear of skin puncture had clear selective value in teaching humans to avoid such injuries. Over the 4+ million years of human evolution, surely many genes controlling blood pressure, pulse, cardiac rhythm, and stress hormone release were selected for to create the vasovagal reflex.
The wide variation in the subjective symptoms and physiological responses of persons with needle phobia means that this trait, like most other human traits, is not an all-or-none phenomenon. The genes that promote needle phobia, as with other polygenic traits such as height, weight, or intelligence, are probably distributed among the human population in a continuous bell-shaped curve. Thus, both strong- and weak-trait individuals interact with the medical environment in a lifelong process of learning through varying needle exposure to create a wide expression of the needle phobia trait.
Management of Patients with Needle Phobia
It is essential that family physicians be knowledgeable about how to manage needle fear if they are to adequately treat these patients (Table 2). Communicating empathy and respect for patients with needle phobia by assuring them that they are not "wimps" or "oddballs" helps them accept their condition without embarrassment. Most victims of needle phobia sincerely believe that their problem is all in their mind and that they would not be fearful if they were stronger or more mature. Many simply do not realize that there are many others with similar fears. Giving patients a name for this condition legitimatizes it to them and gives them a tool they can use to buffer their interaction with the health care system. Reassurance and education, mainstays within the family doctor's armamentarium, almost always help.
Table 2. Techniques of Managing Patients with Needle Phobia
* Reassurance: discussion about the normality and prevalence of needle fear.
* Education: explanation of the inherited, involuntary nature of needle phobia and the various methods available to counter this condition.
* Avoidance of unnecessary or excessive needle procedures limits the conditioning of a vasovagal-based fear response and facilitates patient compliance with medical treatment.
* Desensitization therapy requires a motivated patient, yet may decondition the autonomic symptoms and fear experienced by patients with mild needle phobia and can extinguish associated blood-injury fears.
* Nerve-gate blocking distracts the patient by stimulating the area of needle use.
* Elevation of lower extremities in recumbent position with applied muscle tension augments the central venous reservoir, increases stroke volume, and helps maintain cerebral perfusion.
* Rapid-acting benzodiazepines, eg, diazepam or lorazepam, have an onset of action within 5 to 15 minutes from ingestion. A relatively large dose (eg, 10 to 20 mg po of diazepam) may be necessary and can be combined with nitrous oxide.
* Topical anesthesia at the needle site, eg, ice, ethyl chloride spray, or topical anesthetics. Topical anesthetics penetrate the skin much faster and deeper when driven by iontophoresis.
Alternative methods of drug delivery can sidestep the issue of needle fear by avoiding needles altogether. Nasal sprays that deliver vasopressin, calcitonin and insulin, sprays that immunize against influenza and dust-mite allergens, and an oral form of insulin are all now in investigative trials in the United States. Topical analgesic patches and opiate suppositories can be used in cases of severe pain, eg, metastatic cancer, which might otherwise be managed with intravenous drips. Many other medicines could obviously be administered without needles.
When needle use is necessary, any one of several methods or a combination of methods may be useful. Desensitization therapy by a psychiatrist or clinical psychologist is usually lengthy, expensive, and of variable efficacy.(1)(6)(7)(8) Nerve gate-blocking methods, eg, pinching or rubbing the area to distract the patient during a needle-stick, can be helpful. Shock and syncope are reduced among phobic patients by having them lie supine with legs elevated and tense their muscles during needle procedures to increase cerebral blood flow.(53) Needle-phobic patients should also be routinely premedicated with oral, sublingual, or intranasal benzodiazepines,(2) with N[O.sub.2],(8) or both. Sublingual atropine to block bradycardia also may be beneficial.(2) Since a vasovagal reaction can injure or even kill a patient, having on hand an oxygen source and a "crash cart" for cardiac resuscitation is mandatory with any needle-phobic patient undergoing a needle procedure.
Topical anesthesia of the autonomic sensory neural net at the needle site can be used to interrupt the vasovagal reflex at its origin so that the reflex is not triggered. Ethyl chloride spray can temporarily anesthetize the skin, but this affects only the superficial skin layers and lasts for only a few seconds. The skin can also be anesthetized by an ice pack, although freezing is unpleasant and can damage tissue. In placebo-controlled studies, topical anesthetics containing a mixture of lidocaine and prilocaine have been shown to work well in pediatric patients,(54) and topical mixtures of tetracaine, adrenalin, and cocaine (TAC ointment) or tetracaine, adrenalin, and lidocaine have been long used in emergency departments for surface anesthesia.(55) To work on intact skin, however, all these mixtures must be applied for 1 to 2 hours and have a depth of anesthesia of only 2 to 3 mm.
The depth and effectiveness of topical anesthesia is greatly enhanced by the technique of iontophoresis (or ionphoresis). Iontophoresis involves soaking an absorbent pad with lidocaine and driving it through the skin with a tiny electrical current from a battery-powered unit.(35)(56) Because lidocaine is a positively charged molecule, the electrode pad's positive charge repels the lidocaine, propelling it through the skin by way of the sweat ducts. Using iontophoresis, an injection or venipuncture site can be completely anesthetized to a depth of 1 to 2 cm in less than 10 minutes.(56)
The procedure of iontophoresis has been assigned insurance reimbursement codes, and an iontophoresis unit(*) for use with needle phobic persons has been cleared by the Food and Drug Administration. This instrument has been demonstrated to be effective for venipuncture and joint injections(56) and has applications, for example, in blood donor drives(35) and pediatric immunization programs. The ease of use of iontophoresis raises the intriguing possibility of creating in the near future medical environments that are completely free of needle phobia.
Acknowledgments
The author wishes to thank Nancy R. Hamilton, RN, for her most gracious patience and support during the preparation of this paper, and also Gary Hadden, Department of Psychiatry, Duke University, for his expert assistance.
References
(1.)Ellinwood EH, Hamilton JG. Case report of a needle phobia. J Fam Pract 1991; 32:420-3.
(2.)Hamilton J, Ellinwood E. Needle phobia [abstract]. South Med J 1991; 84(Suppl):2S-27.
(3.)Diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC: American Psychiatric Association, 1994:405-11.
(4.)Marks I. Blood-injury phobia: a review. Am J Psychiatry 1988; 145:1207-13.
(5.)Galena HJ. Complications occurring from diagnostic venipuncture. J Fam Pract 1992; 34:582-4.
(6.)Jacobsen PB. Treating a man with needle phobia who requires daily injections of medication. Hosp Community Psychiatry 1991; 42:877-8.
(7.)Hsu LKG. Novel symptom emergence after behavior therapy in a case of hypodermic injection phobia. Am J Psychiatry 1978; 135:238-9.
(8.)Lemasney NJ, Holland T, O'Mullane D, O'Sullivan VR. The aetiology and treatment of needle phobia in the young patient--a review. J Ir Dent Assoc 1989; 35:20-3.
(9.)Wambaugh J. The blooding. New York, NY: William Morrow, 1989:210-4, 217.
(10.)Schmerber v California, 384 US 757, 86 SCt 1826 (1966).
(11.)Breithaupt v Abram, 352 US 432, 77 SCt 408 (1957).
(12.)South Dakota v Neville, 459 US 553, 103 SCt 916 (1983).
(13.)Hammer v Gross, 932 F2d 842 (USCA, 9th Cir, 1991). cert denied, 112 SCt 582 (1991).
(14.)Boas EP. Some immediate causes of cardiac infarction. Am Heart J 1942; 23:1-15.
(15.)Cass N [letter]. Anaesth Intensive Care 1978; 6:169-70.
(16.)Dale WA. Cardiac arrest: review and report of 12 cases. Ann Surg 1952; 135:376-93.
(17.)Kulvin MM. Scared to death [letter]. JAMA 1966; 198:90.
(18.)Lockey RF, Benedict LM, Turkeltaub PC, Bukantz SC. Fatalities from immunotherapy (IT) and skin testing (ST). J Allergy Clin Immunol 1987; 79:660-7.
(19.)Lockhart RJ. Toxic erythema; T.A.B. (intravenously); coronary thrombosis; sudden death. Br J Dermatol Syphilis 1939; 51:318-21.
(20.)Morland A. Pleural shock. Lancet 1949; 2:1021-3.
(21.)Rutsky EA. Bradycardic rhythms during peritoneal dialysis. Arch Intern Med 1971; 128:445-7.
(22.)Sauls LJ. Sudden death at impasse. Psychoanal Forum 1966; 1:88-93.
(23.)Turk LN, Glenn WWL. Cardiac arrest. N Engl J Med 1954; 251: 795-803.
(24.)Turkeltaub PC, Gergen PJ. The risk of adverse reactions from percutaneous prick-puncture allergen skin testing, venipuncture, and body measurements. J Allergy Clin Immunol 1989; 84:886-90.
(25.)Zukerman CM. Fatality in a blood donor; a case report, with a review of the literature. Ann Intern Med 1947; 26:603-8.
(26.)Caplan RA, Ward RJ, Posner K, Cheney FW. Unexpected cardiac arrest during spinal anesthesia. Anesthesiology 1988; 68:5-11.
(27.)Engel GL. Psychologic stress, vasodepressor (vasovagal) syncope, and sudden death. Ann Intern Med 1978; 89:403-12.
(28.)Schlesinger Z, Barzilay J, Stryjer D, Almog CH. Life-threatening "vagal reaction" to emotional stimuli. Isr J Med Sci 1977; 13:59-61.
(29.)Spiess BD, Sassetti R, McCarthy RJ, Narbone RF, Tuman KJ, Ivankovich AD. Autologous blood donation: hemodynamics in a high-risk patient population. Transfusion 1992; 32:17-22.
(30.)van Lieshout JJ, Wieling W, Karemaker JM, Eckberg DL. The vasovagal response. Clin Sci 1991; 81:575-86.
(31.)Costello CG. Fears and phobias in women. J Abnorm Psychol 1982; 91:280-6.
(32.)Agras S, Sylvester D, Oliveau D. The epidemiology of common fears and phobias. Compr Psychiatry 1969; 10:1511-56.
(33.)Keep PJ, Jenkins JR. From the other end of the needle. The patient's experience of routine anesthesia. Anaesthesia 1978; 33:830-2.
(34.)Cartwright PS, McLaughlin FJ, Martinez AM, Caul DE, Hogan IG, Reed GW, Swafford MS. Teenagers' perceptions of barriers to prenatal care. South Med J 1993; 86:737-41.
(35.)Arvidsson SB, Ekroth RH, Hansby AMC, Lindholm AH, William-Olsson G. Painless venipuncture. A clinical trial of iontophoresis of lidocaine for venipuncture in blood donors. Acta Anaesthesiol Scand 1984; 28:209-10.
(36.)Oswalt RM, Napoliello M. Motivations of blood donors and nondonors. J Appl Psychol 1974; 59:122-4.
(37.)Greenfield ADM. An emotional faint. Lancet 1951; 1:1302-3.
(38.)Lin JT-Y, Ziegler DK, Lai C-W, Bayer W. Convulsive syncope in blood donors. Ann Neurol 1982; 11:525-8.
(39.)Poles FC, Boycott M. Syncope in blood donors. Lancet 1942; 2:531-5.
(40.)Wayne HH. Syncope. Am J Med 1961; 30:418-38.
(41.)Kraemer RR, Blair S, Kraemer GR, Castracane VD. Effects of treadmill running on plasma beta-endorphin, corticotropin, and cortisol levels in male and female 10K runners. Eur J Appl Physiol Occup Physiol 1989; 58:845-51.
(42.)Rose RM, Hurst MW. Plasma cortisol and growth hormone responses to intravenous catheterization. J Hum Stress 1975; 1:22-36.
(43.)Ziegler MG, Echon C, Wilner KD, Specho P, Lake CR, McCutchen JA. Sympathetic nervous withdrawal in the vasodepressor (vasovagal) reaction. J Auton Nerv Syst 1986; 17:273-8.
(44.)Taggart P, Hedworth-Whitty R, Carruthers M, Gordon PD. Observations on electrocardiogram and plasma catecholamines during dental procedures: the forgotten vagus. BMJ 1976; 2:787-9.
(45.)Kaufmann H, Oribe E, Oliver JA. Plasma endothelin during up-right tilt: relevance for orthostatic hypotension? Lancet 1991; 338:1542-5.
(46.)Goldstein DS, Spanarkel M, Pitterman A, Toltzis R, Gratz E, Epstein S, Keiser HR. Circulatory control mechanisms in vasodepressor syncope. Am Heart J 1982; 104:1071-5.
(47.)Ost L-G. Acquisition of blood and injection phobia and anxiety response patterns in clinical patients. Behav Res Ther 1991; 29:323-32.
(48.)Kleinknecht RA, Lenz J. Blood/injury fear, fainting and avoidance of medically-related situations: a family correspondence study. Behav Res Ther 1989; 27:537-47.
(49.)Camfield PR, Camfield CS. Syncope in childhood: a case control clinical study of the familial tendency to faint. Can J Neurol Sci 1990; 17:306-8.
(50.)Torgersen S. The nature and origin of common phobic fears. Br J Psychiatry 1979; 134:343-51.
(51.)Hanson B, Tuna N, Bouchard T, Heston L, Eckert E, Lykken D, et al. Genetic factors in the electrocardiogram and heart rate of twins reared apart and together. Am J Cardiol 1989; 63:606-9.
(52.)Losse H, Kretschmer M, Kuban G, Bottger K. Die vegetative struktur des individuums I and II. Acta Neuroveg 1956; 13:337-99.
(53.)Ost L-G, Fellenius J, Sterner U. Applied tension, exposure in vivo, and tension-only in the treatment of blood phobia. Behav Res Ther 1991; 29:561-74.
(54.)Joyce TH III. Topical anesthesia and pain management before venipuncture. J Pediatr 1993; S24-9.
(55.)Ernst AA, Marvez E, Nick TG, Chin E, Wood E, Gonzaba WT. Lidocaine adrenalin tetracaine gel versus tetracaine adrenaline cocaine gel for topical anesthesia in linear scalp and facial lacerations in children aged 5 to 17 years. Pediatrics 1995; 95:255-8.
(56.)Hamilton JG, Wrenn R, Garcia-Caro M, Hamilton N. Office management of needle fear and needle phobia by lidocaine iontophoresis. Presented at 87th Scientific Assembly, Southern Medical Association, New Orleans, La, Oct 31, 1993.
(*)This unit, the NeedleBuster, is now available commercially from Life-Tech, Inc, Houston, Texas; (800) 231-9841.
COPYRIGHT 1995 Dowden Health Media, Inc.
COPYRIGHT 2004 Gale Group"
So below I have a report wrote by a Doctor (Hamilton, James G. MD.,Source: Journal of Family Practice)
I am going to have to start taking responsibility for educating my surrounding area on this topic by making copies with what little money I have and sending this report or dropping this report off in person to nursing organizations, hospitals, dentists and blood labs. I assume in some cases I will have to bring 100 copies to places like Emergency Rooms since they are heavily staffed.
You can help in the following way. Copy the report below and mail it or drop it off to your doctor and local dentist offices etc. Look up random addresses to doctors in the phone book if you have to and mail copies when you can.
The people who have anxiety and depression (including myself) have to start fighting back against the biases we face from having this illness or illnesses. I am not concerned with the cause or treatment when it comes to doctors and the lay public. We have all heard "Well just take a pill", "Just relax". You each have heard your own condescending remakes I am sure. And as we all know their treatments do not work for everyone.
If you do not have blood/needle phobia please still take time to print out the report below and mail it to some places in your area. The more we take a stand the more things will change for us and others in the future with an issue.
Also by all means if you have a great doctor or dentist email me their name and address and contact info so I can post it. Also if you have had a negative experience with a medical professional of any kind email me with their info and your experience with them so they can be exposed and people with these conditions can avoid the hardships you have endured. My email is silentjealousy77@yahoo.com. You can also write to me:
Brian
PO BOX 8533
Albany, NY. 12208
The report below is the part you would print and send to the medical professionals in your area.
--------------------------------------------------------------------------
The following is by James G. Hamilton, M.D. in the August, 1995 issue of The Journal of Family Practice. [Vol. 41, No.2, pp. 169-175]
"Needle Phobia: A Neglected Diagnosis
Source: Journal of Family Practice
Date: 08/1995
Citation (v41 n2) Start Page: p169(7) ISSN: 0094-3509
Author(s): Hamilton, James G.
Needle phobia is a recently defined medical condition that affects at least 10% of the population. Because persons with needle phobia typically avoid medical care, this condition is a significant impediment in the health care system. The etiology of needle phobia lies in an inherited vasovagal reflex of shock, triggered by needle puncture. Those who inherit this reflex often learn to fear needles through successive needle exposure. Needle phobia is therefore both inherited and learned.
In a family practice, needle phobia can be managed by reassurance and education, avoidance of needles, postural and muscle tension techniques, benzodiazepines, nitrous oxide gas, and topical anesthesia applied by iontophoresis.
Key words. Needle phobia; phobic disorders; needles; vasovagal reflex; syncope; vasovagal syncope; iontophoresis. (J Fam Pract 1995; 41:169-175)
Needle phobia is a condition that has become an increasingly important issue in medicine because of the modern reliance on injections and blood testing. Contrary to popular belief, needle phobia is not confined to children, is not an emotion-driven or transient phenomenon, and is not a rare condition. Clinicians need to be aware of needle phobia because it is a common condition and because needle-phobic persons tend to avoid medical treatment, which can lead to serious health problems as well as social and legal problems.
Needle phobia has been defined as a formal medical condition(1)(2) and has recently been included in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) within the diagnostic category of Blood-Injection-Injury Phobia.(3) A review of the background medical literature and suggestions for management of needle phobia are presented here.
The etiology of needle phobia is rooted in an inherited vasovagal reflex that causes shock with needle puncture. With repeated needle exposure, those with an inherited vasovagal shock reflex tend to develop a fear of needles. Unlike most other phobias, in which exposure to the feared object excites tachycardia, victims of needle phobia typically experience a temporary anticipatory tachycardia and hypertension, which on needle insertion turns into bradycardia and hypotension (Figure), accompanied by pallor, diaphoresis, tinnitus, syncope or near-syncope, and sometimes asystole or death.(1)
[ILLUSTRATION OMITTED]
According to the DSM-IV, a phobia is defined by the presence of fear and by avoidance behavior.(3) The symptom of avoidance of needles, doctors, dentists, etc, is central to the definition of needle phobia, since avoidance of health care is surely a health care problem. However, because needle phobia is also accompanied by numerous physiological changes in blood pressure, pulse, electrocardiogram (ECG) waveforms, and stress hormone levels,(1)(2) these measurements can also be used to define this condition (Table 1). While a dislike or mild fear of needles is very common, needle phobia can be more rigorously defined by objective clinical findings in addition to subjective symptoms.
Table 1. The Primary Factors Underlying the Recognition and Diagnosis of
Needle Phobia
Past medical history(*)
(1) Self-report by the patient of a long-term needle fear, usually from childhood, that the patient recognizes as unreasonable.
(2) Exposure to or anticipation of a needle procedure invariably triggers immediate anxiety, sometimes in the form of a panic attack. In children, the anxiety may be expressed by crying, psychomotor agitation, freezing, or clinging.
(3) Needle procedures, often along with associated medical objects or situations, are avoided either some or all of the time.
(4) The needle avoidance and fear interfere significantly with health care or with normal occupational, academic, or social activities, or the patient is markedly distressed about having the fear.
Family medical history
Approximately 80% of patients with needle phobia report strong needle fear in a first-degree relative, ie, parent, child, or sibling.
Clinical findings
(1) Physical symptoms of syncope, near-syncope, light-headedness, or vertigo upon needle exposure, along with other autonomic symptoms, eg, pallor, diaphoresis, nausea.
(2) Cardiovascular depression with a drop in blood pressure or pulse or both; with or without an initial rise in blood pressure or pulse or both.
(3) Electrocardiogram anomalies of virtually any type.
(4) Rises in any combination of several stress hormones: antidiuretic hormone, human growth hormone, dopamine, catecholamines, corticosteroids, renin, endothelin, and [beta]-endorphin.
(*)Modified from Diagnostic criteria for specific phobia. In: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC: American Psychiatric Association, 1994:410.
NOTE: A diagnosis of needle phobia can be made by past medical history alone. In addition, however, victims of needle phobia typically have symptoms of decreased cerebral perfusion, cardiovascular changes, electrocardiogram changes, and hormonal rises.
Needle Phobia in Family Practice
Those with needle phobia are often terrified of routine needle procedures, and a few are so frightened that they would rather die than have a needle procedure.(4) Even such relatively minor needle procedures as venipuncture(1)(5) or subcutaneous injection(6) can cause a vasovagal shock reflex and evoke patient resistance. When those with needle phobia do agree to needle procedures, they often experience syncope, fall and sustain trauma, have convulsions, lose bowel and bladder control, evoke the calling of cardiac codes, or otherwise cause great concern among staff and family members. Others with needle phobia are simply noncompliant with medical treatment regimens, eg, insulin self-injections.
Victims of needle phobia possess a heightened risk of morbidity and mortality simply because they avoid health care, sometimes for many years,(1)(7) and even when the need for treatment is compelling.(1)(4)(6)(7)(8) Approximately 5% to 15% of the population, for example, decline necessary dental treatment, primarily because they fear oral injections.(8) With an incidence of needle phobia of at least 10%, it is reasonable to hypothesize that a large hidden population goes without regular health care because of this condition. The recognition, acceptance, and communication of this danger by both the medical community and the public, and the development of methods to compensate for needle fear in clinical practice, represent probably the greatest challenges that this condition poses for family medicine.
Needle phobia also can cause major social and legal difficulties in one's life. A fear of blood testing or immunization can interfere with or even destroy plans for marriage, travel, education, immigration, or employment. Students may be discouraged from biological, nursing, or medical careers because of their fear of needles,(4) and women wishing to have children may be thwarted by needle fear.(4)(7) Legal problems can arise when blood tests are ordered by a court in paternity cases, and some victims of needle phobia have even been charged by the police for failure to agree to blood testing.(4) The best-selling book The Blooding detailed the resistance that authorities in England experienced against mass blood testing to eliminate suspects in a murder case.(9) In the United States, involuntary blood testing of accused drunk drivers has led to four cases being appealed to the US Supreme Court.(10)(11)(12)(13)
Occasionally, needle phobia can be fatal. At least 23 reported deaths can reasonably be ascribed solely to needle phobia and its vasovagal reflex during needle procedures such as venipuncture, blood donation, arterial puncture, pleural tap, and intramuscular and subcutaneous injections.(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25) Other reports and indirect evidence further suggest that needle procedures can result in sudden death.(26)(27)(28)(29) A death by needle phobia can be due to either or both of two mechanisms: an abrupt vasovagal drop in blood pressure and perfusion, especially in an arterial tree already compromised by atherosclerosis, could cause myocardial infarction(25)(29) or cerebral infarction; or a vasovagal reflex could impair the sinoatrial or atrioventricular node enough to cause ventricular fibrillation or asystole.(27)(30)
Prevalence of Needle Phobia
Because needle phobia has only recently been defined, only indirect estimates of its prevalence can be inferred from the literature. One study of 449 Canadian women found that 21.2% experienced mild to intense fear, and 4.9% had a phobic level of fear of injections, blood, injury, doctors, dentists, and hospitals.(31) Another study estimated that 9% of the US population in the age bracket of 10 to 50 years old have an injection phobia, and 5.7% have seen a physician about this phobia.(32) Dread of a painful injection was present in 11% of 100 English office patients.(33) Through in-hospital interviews, 22% of 184 teenaged maternity patients in Nashville, Tennessee, were found to have a fear of blood drawing strong enough to make it hard for them to come to a public clinic for prenatal care.(34) In random surveys, 23% of 200 Swedes(35) and 27% of 177 US college students(36) reported needle fear as the main reason for not donating blood.
The prevalence of needle phobia is probably lower in population samples from clinics or hospitals since those with needle phobia tend to select themselves out of such populations. Even in a general population sample, many people express denial of their needle fear. Therefore, most of the studies done so far probably underestimate the true prevalence of needle phobia. Although the percentage is currently unknown, an estimate of at least 10% is credible.
Etiology of Needle Phobia
In the author's experience with over 50 patients with needle phobia, and in all similar cases reported in the medical literature, those afflicted inevitably display symptoms of an autonomic vasovagal reflex whenever they undergo a needle procedure. The neurophysiology of the vasovagal reflex is grounded in both a vagal bradycardia and a vasodilatation from withdrawal of [alpha]-sympathetic arteriolar tone, which together cause hypotension.(2)(30) In addition, associated neurological circuits cause ECG anomalies and stress hormone release.(30) Because most victims of the vasovagal reflex do not actually lose consciousness, the term "vasovagal reflex" is more accurate than "vasovagal syncope," the term most often used in the older literature. Although the vasovagal reflex has classically been described as being biphasic, with an anticipatory rise in blood pressure and pulse before needle puncture and a sudden plunge in both after puncture(1)(4)(27)(37) (Figure), the author has observed that some patients with needle phobia do not have this initial cardiovascular rise.
Physical Symptoms of the Vasovagal Reflex
The vasovagal reflex in needle phobia may include virtually any type and combination of autonomic symptoms, eg, a clammy diaphoresis, pallor, nausea, respiratory disturbances, and various levels of unresponsiveness.(1)(4)(30)(37)(38)(39)(40) Although the onset of the vasovagal reflex from the start of a needlestick is often immediate, ie, within 2 to 3 seconds, a prospective study of 84 blood donors who fainted found that 16.7% experienced syncope from 5 to 30 minutes after phlebotomy.(38) Another series of 64 blood donors who fainted found that 14% fainted after leaving the phlebotomy site and returning to work, sometimes several hours later.(39)
Although most victims of needle phobia who faint are unconscious for only a few seconds, a survey of 298 vasovagal fainters found that several had a loss of consciousness for 10 to 30 minutes, and a few lost consciousness for 1 to 2 hours.(40) Although blood pressure usually returns to normal within 2 hours, and most vasovagal victims feel well enough to resume normal activity within several hours, others have anxiety, malaise, and weakness for 1 to 2 days after a vasovagal attack.(38)(40)
Convulsions during vasovagal fainting, which are much more frequent than commonly realized, are a general response of the central nervous system (CNS) to the cerebral hypoxia of vasovagal shock. Of 84 blood donors who fainted, 14.3% had prominent tonic--clonic episodes, and another 27% had tonic muscular rigidity.(38) Furthermore, even having a finger pricked for blood typing can cause syncope with convulsive seizures.(38)
Electrocardiogram Changes
In several case reports, ECG changes during the vasovagal reflex among patients with needle phobia have included sinus arrhythmia, premature atrial contractions, premature junctional contractions, unifocal and multifocal premature ventricular contractions, bigeminy, first- and second-degree block, changes in P waves, ST waves, and T waves, sinus bradycardia, sinus tachycardia, ventricular tachycardia, ventricular fibrillation, and asystole.(1)(2)(5)(26)(27)(28)(37) Presumably, these ECG changes are secondary to vagal influence on the sinoatrial and atrioventricular nodes, and perhaps also to the antagonism between the activated sympathetic and parasympathetic systems on the heart.(27)
Stress Hormone Changes
At least 11 stress hormones have been reported to elevate during needle stimulation. Increased cortisol and corticotropin (ACTH) levels secondary to venipuncture and needle phobia have been documented.(1)(2)(41)(42) In one study, cortisol levels rose above average in 7 of 15 subjects, with a positive correlation between cortisol level and the number of vasovagal symptoms.(42) In my experience, corticotropin-releasing factor also can elevate during needle procedures, as can dopamine. In 25% of 28 subjects in 112 trials, human growth hormone levels rose in response to venous catheterization.(42) In three needle-induced vasovagal subjects, [beta]-endorphin levels were observed to rise,(42) but sometimes they do not rise.(1)
Similarly, epinephrine and norepinephrine levels do not always become elevated during episodes of needle phobia.(1) They have been observed to decrease in eight subjects who fainted after venipuncture, presumably related to the withdrawal of sympathetic vascular tone.(43) In another study, however, 21 young women dental patients had increased levels of epinephrine, but not norepinephrine, with a decrease in epinephrine after the procedure.(44) The findings of both of these studies are compatible with a biphasic cardiovascular response.
Probably because the pituitary perceives a reduced intravascular volume during vasovagal shock, vasopressin or antidiuretic hormone (ADH) rises in the vasovagal reflex with venipuncture,(1)(2)(45) as does endothelin.(45) Renin also increased by 200% in one patient with needle phobia,(46) but aldosterone and angiotensin levels have not yet been tested in needle phobic patients. The ADH rise causes pallor during the vasovagal reflext by sharply decreasing cutaneous blood flow, and may also contribute to nausea.(1) This ADH rise is often dramatic, reaching as high as 46 times normal values,(45) and may be responsible, along with the catecholamine elevation, for the intense fear that victims of needle phobia learn in response to their vasovagal reflexes.(1)
Needle Phobia: Inherited or Learned?
Clear evidence exists to support the hypothesis of a hereditary component to needle phobia. Both the vasovagal reflex and needle phobia strongly tend to run in families.(1)(2)(7)(47)(48)(49) The heritability of blood-injury phobia in twin studies, including fear of injections, wounds, blood, and pain, has been estimated to be 48%.(50) Variations in PR, QRS, and QT intervals and heart rate have heritabilities of 30% to 60%,(51) and the autonomic control of the cardiovascular system in general, based on twin comparisons, is probably genetically influenced.(52) Therefore, the plunges in blood pressure and pulse and the ECG anomalies during a needle-phobic response are surely also genetically influenced. The release of stress hormones likewise can reasonably be assumed to be genetically influenced.
In addition to genetic factors, however, a learned component to needle fear also can be identified among those with needle phobia. Needle fear often first comes into awareness after a negative experience at the doctor's or dentist's office.(6)(7)(8) One patient, for example, developed needle phobia in childhood when he was verbally abused and restrained by health care personnel during several painful medical procedures.(6) In one study of 56 persons with injection phobia, 52% traced their fear to such negative conditioning, with a mean age at onset of 8.06 years, and another 24% dated their fear to an episode of vicarious conditioning at seeing another child, often a sibling, have a negative reaction to needles.(47) Over time, with more needle exposures, this fear tends to organize and solidify into a conscious phobia, with an anticipatory anxiety before needle encounters. The learning of fear often becomes generalized in that those who are initially fearful only of needles may develop fear of objects or situations associated with needles, such as blood, injuries, syringes, doctors, dentists, nurses, white laboratory coats, examination rooms, hospitals, and even the antiseptic smell of offices or hospitals.(4)(31)(50)
Based on these studies, one can hypothesize that the trait of needle phobia is both inherited and learned. A vasovagal reflex has been found in all patients with needle phobia tested so far, and the medical histories of most of them include an adverse learning experience that triggered the needle fear.(47) Therefore, a reasonable theoretical model might propose that needle phobia depends both on an inherited reflex that is hard-wired in neurocardiovascular and neuroendocrine pathways and on the learning of a conscious fear.
Blood-injury phobia, which is often linked with needle phobia,(3) probably often arises when a patient with a strong vasovagal reflex undergoes a needle procedure or has an accident that results in a vasovagal response. The victim may focus on the sight of blood or injury to the extent that the blood-injury cue serves as a conditioned stimulus to trigger a vasovagal response thereafter. Although many needle-phobic persons also have blood-injury fears, further consideration should be given to whether these two phobias should be combined into a single diagnostic category, as is now the case in DSM-IV.
Evolution of the Needle Phobia Trait
The presence of a genetic trait among a species automatically indicates that the trait must have been selected for during the evolution of that species. The needle phobia trait probably evolved among the human species in response to piercing, stabbing, and cutting injuries.(1) The vast majority of violent deaths in our species' evolutionary history have been caused by skin penetration from teeth, claws, fangs and tusks, and from sticks, stone axes, knives, spears, swords, and arrows. Besides death resulting from direct trauma or hemorrhage, many of these deaths were due to infections secondary to skin penetration. A reflex that promoted the learning of a strong fear of skin puncture had clear selective value in teaching humans to avoid such injuries. Over the 4+ million years of human evolution, surely many genes controlling blood pressure, pulse, cardiac rhythm, and stress hormone release were selected for to create the vasovagal reflex.
The wide variation in the subjective symptoms and physiological responses of persons with needle phobia means that this trait, like most other human traits, is not an all-or-none phenomenon. The genes that promote needle phobia, as with other polygenic traits such as height, weight, or intelligence, are probably distributed among the human population in a continuous bell-shaped curve. Thus, both strong- and weak-trait individuals interact with the medical environment in a lifelong process of learning through varying needle exposure to create a wide expression of the needle phobia trait.
Management of Patients with Needle Phobia
It is essential that family physicians be knowledgeable about how to manage needle fear if they are to adequately treat these patients (Table 2). Communicating empathy and respect for patients with needle phobia by assuring them that they are not "wimps" or "oddballs" helps them accept their condition without embarrassment. Most victims of needle phobia sincerely believe that their problem is all in their mind and that they would not be fearful if they were stronger or more mature. Many simply do not realize that there are many others with similar fears. Giving patients a name for this condition legitimatizes it to them and gives them a tool they can use to buffer their interaction with the health care system. Reassurance and education, mainstays within the family doctor's armamentarium, almost always help.
Table 2. Techniques of Managing Patients with Needle Phobia
* Reassurance: discussion about the normality and prevalence of needle fear.
* Education: explanation of the inherited, involuntary nature of needle phobia and the various methods available to counter this condition.
* Avoidance of unnecessary or excessive needle procedures limits the conditioning of a vasovagal-based fear response and facilitates patient compliance with medical treatment.
* Desensitization therapy requires a motivated patient, yet may decondition the autonomic symptoms and fear experienced by patients with mild needle phobia and can extinguish associated blood-injury fears.
* Nerve-gate blocking distracts the patient by stimulating the area of needle use.
* Elevation of lower extremities in recumbent position with applied muscle tension augments the central venous reservoir, increases stroke volume, and helps maintain cerebral perfusion.
* Rapid-acting benzodiazepines, eg, diazepam or lorazepam, have an onset of action within 5 to 15 minutes from ingestion. A relatively large dose (eg, 10 to 20 mg po of diazepam) may be necessary and can be combined with nitrous oxide.
* Topical anesthesia at the needle site, eg, ice, ethyl chloride spray, or topical anesthetics. Topical anesthetics penetrate the skin much faster and deeper when driven by iontophoresis.
Alternative methods of drug delivery can sidestep the issue of needle fear by avoiding needles altogether. Nasal sprays that deliver vasopressin, calcitonin and insulin, sprays that immunize against influenza and dust-mite allergens, and an oral form of insulin are all now in investigative trials in the United States. Topical analgesic patches and opiate suppositories can be used in cases of severe pain, eg, metastatic cancer, which might otherwise be managed with intravenous drips. Many other medicines could obviously be administered without needles.
When needle use is necessary, any one of several methods or a combination of methods may be useful. Desensitization therapy by a psychiatrist or clinical psychologist is usually lengthy, expensive, and of variable efficacy.(1)(6)(7)(8) Nerve gate-blocking methods, eg, pinching or rubbing the area to distract the patient during a needle-stick, can be helpful. Shock and syncope are reduced among phobic patients by having them lie supine with legs elevated and tense their muscles during needle procedures to increase cerebral blood flow.(53) Needle-phobic patients should also be routinely premedicated with oral, sublingual, or intranasal benzodiazepines,(2) with N[O.sub.2],(8) or both. Sublingual atropine to block bradycardia also may be beneficial.(2) Since a vasovagal reaction can injure or even kill a patient, having on hand an oxygen source and a "crash cart" for cardiac resuscitation is mandatory with any needle-phobic patient undergoing a needle procedure.
Topical anesthesia of the autonomic sensory neural net at the needle site can be used to interrupt the vasovagal reflex at its origin so that the reflex is not triggered. Ethyl chloride spray can temporarily anesthetize the skin, but this affects only the superficial skin layers and lasts for only a few seconds. The skin can also be anesthetized by an ice pack, although freezing is unpleasant and can damage tissue. In placebo-controlled studies, topical anesthetics containing a mixture of lidocaine and prilocaine have been shown to work well in pediatric patients,(54) and topical mixtures of tetracaine, adrenalin, and cocaine (TAC ointment) or tetracaine, adrenalin, and lidocaine have been long used in emergency departments for surface anesthesia.(55) To work on intact skin, however, all these mixtures must be applied for 1 to 2 hours and have a depth of anesthesia of only 2 to 3 mm.
The depth and effectiveness of topical anesthesia is greatly enhanced by the technique of iontophoresis (or ionphoresis). Iontophoresis involves soaking an absorbent pad with lidocaine and driving it through the skin with a tiny electrical current from a battery-powered unit.(35)(56) Because lidocaine is a positively charged molecule, the electrode pad's positive charge repels the lidocaine, propelling it through the skin by way of the sweat ducts. Using iontophoresis, an injection or venipuncture site can be completely anesthetized to a depth of 1 to 2 cm in less than 10 minutes.(56)
The procedure of iontophoresis has been assigned insurance reimbursement codes, and an iontophoresis unit(*) for use with needle phobic persons has been cleared by the Food and Drug Administration. This instrument has been demonstrated to be effective for venipuncture and joint injections(56) and has applications, for example, in blood donor drives(35) and pediatric immunization programs. The ease of use of iontophoresis raises the intriguing possibility of creating in the near future medical environments that are completely free of needle phobia.
Acknowledgments
The author wishes to thank Nancy R. Hamilton, RN, for her most gracious patience and support during the preparation of this paper, and also Gary Hadden, Department of Psychiatry, Duke University, for his expert assistance.
References
(1.)Ellinwood EH, Hamilton JG. Case report of a needle phobia. J Fam Pract 1991; 32:420-3.
(2.)Hamilton J, Ellinwood E. Needle phobia [abstract]. South Med J 1991; 84(Suppl):2S-27.
(3.)Diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC: American Psychiatric Association, 1994:405-11.
(4.)Marks I. Blood-injury phobia: a review. Am J Psychiatry 1988; 145:1207-13.
(5.)Galena HJ. Complications occurring from diagnostic venipuncture. J Fam Pract 1992; 34:582-4.
(6.)Jacobsen PB. Treating a man with needle phobia who requires daily injections of medication. Hosp Community Psychiatry 1991; 42:877-8.
(7.)Hsu LKG. Novel symptom emergence after behavior therapy in a case of hypodermic injection phobia. Am J Psychiatry 1978; 135:238-9.
(8.)Lemasney NJ, Holland T, O'Mullane D, O'Sullivan VR. The aetiology and treatment of needle phobia in the young patient--a review. J Ir Dent Assoc 1989; 35:20-3.
(9.)Wambaugh J. The blooding. New York, NY: William Morrow, 1989:210-4, 217.
(10.)Schmerber v California, 384 US 757, 86 SCt 1826 (1966).
(11.)Breithaupt v Abram, 352 US 432, 77 SCt 408 (1957).
(12.)South Dakota v Neville, 459 US 553, 103 SCt 916 (1983).
(13.)Hammer v Gross, 932 F2d 842 (USCA, 9th Cir, 1991). cert denied, 112 SCt 582 (1991).
(14.)Boas EP. Some immediate causes of cardiac infarction. Am Heart J 1942; 23:1-15.
(15.)Cass N [letter]. Anaesth Intensive Care 1978; 6:169-70.
(16.)Dale WA. Cardiac arrest: review and report of 12 cases. Ann Surg 1952; 135:376-93.
(17.)Kulvin MM. Scared to death [letter]. JAMA 1966; 198:90.
(18.)Lockey RF, Benedict LM, Turkeltaub PC, Bukantz SC. Fatalities from immunotherapy (IT) and skin testing (ST). J Allergy Clin Immunol 1987; 79:660-7.
(19.)Lockhart RJ. Toxic erythema; T.A.B. (intravenously); coronary thrombosis; sudden death. Br J Dermatol Syphilis 1939; 51:318-21.
(20.)Morland A. Pleural shock. Lancet 1949; 2:1021-3.
(21.)Rutsky EA. Bradycardic rhythms during peritoneal dialysis. Arch Intern Med 1971; 128:445-7.
(22.)Sauls LJ. Sudden death at impasse. Psychoanal Forum 1966; 1:88-93.
(23.)Turk LN, Glenn WWL. Cardiac arrest. N Engl J Med 1954; 251: 795-803.
(24.)Turkeltaub PC, Gergen PJ. The risk of adverse reactions from percutaneous prick-puncture allergen skin testing, venipuncture, and body measurements. J Allergy Clin Immunol 1989; 84:886-90.
(25.)Zukerman CM. Fatality in a blood donor; a case report, with a review of the literature. Ann Intern Med 1947; 26:603-8.
(26.)Caplan RA, Ward RJ, Posner K, Cheney FW. Unexpected cardiac arrest during spinal anesthesia. Anesthesiology 1988; 68:5-11.
(27.)Engel GL. Psychologic stress, vasodepressor (vasovagal) syncope, and sudden death. Ann Intern Med 1978; 89:403-12.
(28.)Schlesinger Z, Barzilay J, Stryjer D, Almog CH. Life-threatening "vagal reaction" to emotional stimuli. Isr J Med Sci 1977; 13:59-61.
(29.)Spiess BD, Sassetti R, McCarthy RJ, Narbone RF, Tuman KJ, Ivankovich AD. Autologous blood donation: hemodynamics in a high-risk patient population. Transfusion 1992; 32:17-22.
(30.)van Lieshout JJ, Wieling W, Karemaker JM, Eckberg DL. The vasovagal response. Clin Sci 1991; 81:575-86.
(31.)Costello CG. Fears and phobias in women. J Abnorm Psychol 1982; 91:280-6.
(32.)Agras S, Sylvester D, Oliveau D. The epidemiology of common fears and phobias. Compr Psychiatry 1969; 10:1511-56.
(33.)Keep PJ, Jenkins JR. From the other end of the needle. The patient's experience of routine anesthesia. Anaesthesia 1978; 33:830-2.
(34.)Cartwright PS, McLaughlin FJ, Martinez AM, Caul DE, Hogan IG, Reed GW, Swafford MS. Teenagers' perceptions of barriers to prenatal care. South Med J 1993; 86:737-41.
(35.)Arvidsson SB, Ekroth RH, Hansby AMC, Lindholm AH, William-Olsson G. Painless venipuncture. A clinical trial of iontophoresis of lidocaine for venipuncture in blood donors. Acta Anaesthesiol Scand 1984; 28:209-10.
(36.)Oswalt RM, Napoliello M. Motivations of blood donors and nondonors. J Appl Psychol 1974; 59:122-4.
(37.)Greenfield ADM. An emotional faint. Lancet 1951; 1:1302-3.
(38.)Lin JT-Y, Ziegler DK, Lai C-W, Bayer W. Convulsive syncope in blood donors. Ann Neurol 1982; 11:525-8.
(39.)Poles FC, Boycott M. Syncope in blood donors. Lancet 1942; 2:531-5.
(40.)Wayne HH. Syncope. Am J Med 1961; 30:418-38.
(41.)Kraemer RR, Blair S, Kraemer GR, Castracane VD. Effects of treadmill running on plasma beta-endorphin, corticotropin, and cortisol levels in male and female 10K runners. Eur J Appl Physiol Occup Physiol 1989; 58:845-51.
(42.)Rose RM, Hurst MW. Plasma cortisol and growth hormone responses to intravenous catheterization. J Hum Stress 1975; 1:22-36.
(43.)Ziegler MG, Echon C, Wilner KD, Specho P, Lake CR, McCutchen JA. Sympathetic nervous withdrawal in the vasodepressor (vasovagal) reaction. J Auton Nerv Syst 1986; 17:273-8.
(44.)Taggart P, Hedworth-Whitty R, Carruthers M, Gordon PD. Observations on electrocardiogram and plasma catecholamines during dental procedures: the forgotten vagus. BMJ 1976; 2:787-9.
(45.)Kaufmann H, Oribe E, Oliver JA. Plasma endothelin during up-right tilt: relevance for orthostatic hypotension? Lancet 1991; 338:1542-5.
(46.)Goldstein DS, Spanarkel M, Pitterman A, Toltzis R, Gratz E, Epstein S, Keiser HR. Circulatory control mechanisms in vasodepressor syncope. Am Heart J 1982; 104:1071-5.
(47.)Ost L-G. Acquisition of blood and injection phobia and anxiety response patterns in clinical patients. Behav Res Ther 1991; 29:323-32.
(48.)Kleinknecht RA, Lenz J. Blood/injury fear, fainting and avoidance of medically-related situations: a family correspondence study. Behav Res Ther 1989; 27:537-47.
(49.)Camfield PR, Camfield CS. Syncope in childhood: a case control clinical study of the familial tendency to faint. Can J Neurol Sci 1990; 17:306-8.
(50.)Torgersen S. The nature and origin of common phobic fears. Br J Psychiatry 1979; 134:343-51.
(51.)Hanson B, Tuna N, Bouchard T, Heston L, Eckert E, Lykken D, et al. Genetic factors in the electrocardiogram and heart rate of twins reared apart and together. Am J Cardiol 1989; 63:606-9.
(52.)Losse H, Kretschmer M, Kuban G, Bottger K. Die vegetative struktur des individuums I and II. Acta Neuroveg 1956; 13:337-99.
(53.)Ost L-G, Fellenius J, Sterner U. Applied tension, exposure in vivo, and tension-only in the treatment of blood phobia. Behav Res Ther 1991; 29:561-74.
(54.)Joyce TH III. Topical anesthesia and pain management before venipuncture. J Pediatr 1993; S24-9.
(55.)Ernst AA, Marvez E, Nick TG, Chin E, Wood E, Gonzaba WT. Lidocaine adrenalin tetracaine gel versus tetracaine adrenaline cocaine gel for topical anesthesia in linear scalp and facial lacerations in children aged 5 to 17 years. Pediatrics 1995; 95:255-8.
(56.)Hamilton JG, Wrenn R, Garcia-Caro M, Hamilton N. Office management of needle fear and needle phobia by lidocaine iontophoresis. Presented at 87th Scientific Assembly, Southern Medical Association, New Orleans, La, Oct 31, 1993.
(*)This unit, the NeedleBuster, is now available commercially from Life-Tech, Inc, Houston, Texas; (800) 231-9841.
COPYRIGHT 1995 Dowden Health Media, Inc.
COPYRIGHT 2004 Gale Group"
Subscribe to:
Posts (Atom)