Psychosomatics 44:253-254, June 2003
© 2003 The Academy of Psychosomatic Medicine
Rapid Desensitization for Needle Phobia
Praveen P. Fernandes, M.D.
Received Aug. 7, 2002; accepted Oct. 24, 2002. From the Department of Mental Health and Behavioral Science, Omaha VA Medical Center; and the Department of Psychiatry, Creighton University School of Medicine, Omaha. Address reprint requests to Dr. Fernandes, Mental Health Clinic, Omaha VA Medical Center—116A1, 4101 Woolworth Ave., Omaha, NE 68105; Praveen.Fernandes{at}med.va.gov (e-mail).
Fear of needles, variously referred to in the literature as "needle phobia" or "blood-injury phobia," is a curious type of specific phobia with distinct clinical features. For most phobias, exposure to phobic cues induces tachycardia. In contrast, patients with needle phobia typically experience a diphasic cardiovascular response of an initial tachycardia, followed by bradycardia, hypotension, shock, vertigo, syncope, diaphoresis, nausea, and, rarely, asystole and death.1,2 The vasovagal response and bradycardia, which may reflect a constitutional autonomic dysregulation,3 make needle phobia less responsive to strategies like relaxation exercises and sedatives, which can actually provoke fainting. While the incidence of needle phobia among the general U.S. population is estimated at around 3%–4%,4,5 most patients do not present themselves to clinics or hospitals as part of the avoidance of the phobic stimulus. As a result, attention to health care is often neglected to a point where they seek treatment at a late stage in their physical illness. By then, management usually becomes urgent and often involves needle insertion for investigations or treatment. Behavioral techniques such as exposure and participant modeling have been successfully used to treat needle phobia.6,7 This report describes the management of severe needle phobia by using rapid desensitization in a patient who urgently needed regular vascular access for dialysis. Practical steps involving prolonged multimodal exposure and counter-response techniques are provided that are simple, easily replicable, and require minimal training.
Case Report
Mr. A, a 64-year-old Caucasian man from a rural background, was diagnosed with chronic renal failure resulting from long-standing hypertension. Regular dialysis was recommended within a month following diagnosis. A major impediment was vascular access because of his needle phobia. The patient reported severe anxiety and fear during needle insertion. During procedures like blood draws, he would become anxious, visibly pale, and diaphoretic; he would report sensations of feeling faint and nauseated. Under general anesthesia, he underwent placement of a catheter in the right internal jugular vein for temporary access while a permanent arteriovenous fistula was created in his left forearm. With passing weeks, the need to discontinue the indwelling catheter and switch to regularly cannulating the fistula became urgent. However, multiple attempts to cannulate the fistula failed. The patient's severe anxiety and reluctance toward needle insertion made the attempts difficult, if not impossible. The dialysis team consulted the psychiatry service for assistance with managing the patient's severe needle phobia.
The behavioral therapy technique of exposure and desensitization was agreed upon, with particular attention to the urgency of the situation, since the dialysis team required access to the fistula within a week. Details of situations that induced fear, nausea, and faintness are listed in Table 1. These symptoms, labeled here as "discomfort," were not directly related to pain associated with needle insertion.
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TABLE 1. Situations Associated With Discomforta in a Patient Undergoing Rapid Desensitization for Treatment of Needle Phobia
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The principle involved in desensitization therapy was explained to the patient. Informed consent was obtained for rapid exposure and desensitization over three sessions. The sessions were held on a monitoring unit; a reclining hospital bed and an automated blood pressure-pulse monitor were used. The patient was initially taught techniques to counter the phobic response of vasovagal syncope and bradycardia,2 namely: 1) adopting a reclining posture, 2) sustained tensing of muscles in the face, trunk, and extremities to prevent peripheral vascular pooling, and 3) thinking of a situation that made him feel angry or insulted. Feedback through the monitor was provided to demonstrate the ability to raise blood pressure and pulse at will, which would prevent fainting.
The patient was systematically exposed by using the hierarchy of increasingly phobic stimuli. As he was unwilling to experience needle insertion in vivo, exposure was attained through imagination. The therapist simulated needle insertion by using alcohol prep pads to clean the skin, poking pointed needle caps on the skin surface, and providing a running commentary on the process. Getting the patient to verbalize back the situation ensured active imagination. The simulated exposure resulted in bradycardia (drop to 60 bpm from baseline of 70) and a fall in blood pressure, along with flushing, sweating, nausea, and feeling faint. The discomfort was greatest when the therapist stroked the pointed needle cap over the skin while verbalizing difficulty in finding a vein, or what the patient referred to as "fishing." The exposure sessions were prolonged, lasting an hour. When the discomfort was unbearable, exposure was interrupted, and the patient practiced techniques to counter the phobic response. These techniques rapidly relieved the discomfort, and exposure was then resumed. The patient underwent three therapist-assisted exposure sessions in a week, along with homework assignments of twice daily self-assisted exposure. By the end of the third session, the bradycardic response was mild, and the patient's subjective level of discomfort significantly decreased. He did not experience any faintness when sitting up from a reclining position. He felt confident enough to request needle cannulation of the fistula. The dialysis team successfully cannulated the fistula, with the patient experiencing minimal discomfort after numbing the skin with lidocaine. He prevented himself from feeling faint and nauseated by practicing techniques as before. The patient currently undergoes needle cannulation of the fistula three times a week for dialysis, which he feels no longer bothers him.
Discussion
This case demonstrates the use of rapid desensitization over three hourly sessions to treat severe needle phobia. The technique described is simple, practical, easily replicable in medical settings, and requires minimal investment. Factors like urgency of the situation and high patient motivation favorably influenced the outcome. No psychotropic medications were used. Minimal training is required to carry out the steps as described.
The key issue is that of prolonged multimodal exposure with a realistic, acceptable stimulus. For example, the patient described did not experience any fear looking at needles or pointed objects, a condition termed as aichmophobia. The major phobic stimulus here was the sensation of a needle on the skin. During therapy, multimodal exposure was used, with the smell of alcohol prep pads, stroking the skin with a pointed needle cap, graphic descriptions of needle insertion verbalized by the therapist, and active imagination of needle insertion by the patient. Sessions lasted an hour, interrupted only to practice counter-responses to vasovagal symptoms. The sessions resulted in rapid remission of his phobic response, facilitating medical procedures that would have been otherwise difficult.
Needle phobia can be a challenging situation in the medical setting, leading to impediments in patient care, especially when vascular access is urgent. The vasovagal response and bradycardia are often underestimated or ignored by medical personnel, which leads to patients perceiving a lack of understanding or empathy toward their illness. Early screening for the condition and using a simple rapid desensitization technique as described can help in patient management.
REFERENCES
- Ellinwood EH, Hamilton JG: Case report of a needle phobia. J Fam Pract 1991; 32:420-422[Medline]
- Marks I: Blood-injury phobia: a review. Am J Psychiatry 1988; 145:1207-1213[Abstract/Free Full Text]
- Accurso V, Winnicki M, Shamsuzzaman AS, Wenzel A, Johnson AK, Somers VK: Predisposition to vasovagal syncope in subjects with blood/injury phobia. Circulation 2001; 104:903-907[Abstract/Free Full Text]
- Bienvenu OJ, Eaton WW: The epidemiology of blood-injection-injury phobia. Psychol Med 1998; 28:1129-1136[CrossRef][Medline]
- Kleinknecht RA: Vasovagal syncope and blood/injury fear. Behav Res Ther 1987; 25:175-178[CrossRef][Medline]
- Trijsburg RW, Jelicic M, van den Broek WW, Plekker AE, Verheij R, Passchier J: Exposure and participant modelling in a case of injection phobia. Psychother Psychosom 1996; 65:57-61[CrossRef][Medline]
- Ko SM: Blood-injury phobia. Singapore Med J 1994; 35:195-197[Medline]
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