Motivation and emotion/Book/2022/Needle fear

Overview




Lisa has a fear of needles which means she can experienced associated physical symptoms such as an increase in heart rate and blood pressure, breathlessness, shaking and blurred vision when needles are presented. She may also experienced a panic attack which link to fainting (see Figure 1).

Needles are a part of life that we all come to face, some of us are more fearful than others. Fear of needles occurs frequently in a wide range of the population, throughout the world and is a common medical phobia with higher prevalence at younger ages. It is more common than most would imagine. You may remember the trembling, shaking and breathlessness feeling while sitting in the waiting room and waiting for injection (see Figure 1). The question is, why are we so afraid of needles and how do we combat our fear? This chapter discusses the concept of fear on needles, the theoretical frames of the causes, and the strategies on the management of needle fears.

Focus questions:
 * What is needle fear?
 * What are the causes?
 * How can it be managed?

What is needle fear?
Fear of needles, known as needle phobia or trypanophobia, is an extreme fear of medical procedures that involves injections or hypodermic needles (see Figure 2). It is closely related to phobias of needles, pins, or sharp objects (Cleveland Clinic, n.d.). And this can lead to avoidance of medical care, including vaccine hesitancy (Martin, 2021). The term ‘needle fear’ and ‘needle phobia’ both describe the emotion situation associate with needles and injections where used (Mclenon & Rogers, 2019).

A meta-analysis evaluating the prevalence of needle fear and the characteristics of individuals who exhibit this fear, found that there are 19% adults avoid medical procedure due to fear of needles and 20% did not obtain a vaccination because they did not like the syringes (Mclenon & Rogers, 2019). This indicates that many people rather put up with the risk of infection than go for a shot.

Needle phobia


Needle phobia has been defined as a type of specific phobia and has been included in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) as part of a group of specific phobias within the diagnostic category of Blood-Injection-Injury type (B-I-I) (Hamilton, 1995). Studies investigated the epidemiology and conditions of this blood-injection-injury phobia found that there are 3% of the population suffers with this phobia at some point in life with a prevalence in females and is associated with several other conditions and psychological ailments such as anxiety and iatrophobia (Bienvenu, 1998; Raghavendra et al., 2010).

Types of needle phobia
Needle phobia can be classified to four types: vasovagal, associate, resistive and hyperalgesic.

Vasovagal
Vasovagal fear is the most common type of needle fear, affecting 50% needle phobias. This type of needle fear is an inherited vasovagal reflex action where people fear the sight and feelings of needles (Raghavendra et al., 2010). Studies have shown that people who experienced a vasovagal response are more likely to have an intense fear response which can result in fainting when they seek treatment (Jenkins, 2014; Wright et al., 2009).



A young woman who was at her 35 weeks pregnant has a vasovagal needle phobia. She has refused blood tests so far by now which has put herself and the baby at risk. She experienced severe fear of fainting and could not bear the sensations associated with the injection (Jenkins, 2014).

Associate
Associate fear of needles is the second common type, affecting 30% needle phobias (Raghavendra et al., 2010). This type of fear is triggered by past traumatic event of a painful injection procedure or witnessing family member undergo such procedure (Zimlich, 2018). Previous study showed that these can negatively impact people’s intention of receiving treatment in healthcare settings (Jenkins, 2014).

Resistive
Resistive trypanophobia is the fear of being controlled or restrained during the procedure (Raghavendra et al., 2010). It has nothing to do with the needle itself but to the feelings and emotions of being forcefully restricted for injections. Such unpleasant experience resulted in a fight or flight response which lead to avoidance of participation. A recent study focusing on providing the insights of needle fear among medical professionals found that 93% of doctors had been asked to reschedule the vaccines due to the unpleasant and traumatised memories on injections (Zimlich, 2018).

Hyperalgesic
This type of fear is associated with the pain of injection. People who are hypersensitivity to pain cannot tolerate the injection procedure which result in the fear of injections. A high level of anxiety and increased heart rate can be experienced at the point of needle penetration (Raghavendra et al., 2010). Additionally, many report such associated pain is the main reason they avoid having needles in the future (Mclenon & Rogers, 2019).

Symptoms
People may experience a range of physical sensations associated with fear response. The sight or thought of the procedure involving needles generate an intense fear and distress (Fristscher, 2021). Sometimes, this stress is so severe that it's debilitating and may lead to a strong physical and hormone changes. In a study of the nature of needle fears in general practice found when asking ‘Are you afraid of needles?’, many recalled the sweaty and breathlessness feelings they experienced in the past when they had injections (Wright et al., 2009).

Other typical physical sensations associated with the fear response include:

(Fritscher, 2021).
 * Fainting (syncope).
 * Racing heart rate.
 * High blood pressure.
 * Panic attacks.
 * Anxiety.
 * Nausea and vomiting.
 * Shortness of breath.
 * feeling emotionally or physically violent.
 * avoiding or running away from medical care.



A 24-year-old young man has been diagnosed with Hodgkin’s lymphoma. He refused to undergo chemotherapy as he is afraid of intravenous cannulation. He has no courage to face his fear even though his wife was four months pregnant at the time. Eventually he agreed to engage in treatment that was not the vasovagal type (Jenkins, 2014).

Quiz
{What is a fear of needles called ? - autophobia + trypanophobia - hydrophobia - ophidiophobia
 * type =""}

What are the causes of needle fear?
There are many reasons that generate the fear to needles and our fear responses. This can be explained through learning perspectives of psychological theory and behavior responses.

Learning theories
From a learning perspective, the acquisition of needle fears can be involved with the following pathways.

Direct conditioning
According to the classic behavioural perspectives, direct conditioning is a conditioned fear response associate with an aversive event or stimulus that is remaining fearful (Rachman, 1997). For example, the pairing of needle (a conditioned stimulus, CS) with pain (unconditioned stimulus, US) is a classic learning response. Individual learned the expected pain through the unpleasant exposure to needle presentation and therefore an aversive feeling of fear is presented through certain avoidance behaviour (Du et al., 2008). In the sample of 7-18 years old, half of the children reported the experience of unpleasant and painful injection, which lead to the fear of needles (Duff & Brownlee, 1999). Therefore, individuals who have experienced the pain would remember the pain as a conditioned reflex when they see the needles again.

Vicarious learning
Another pathway of understanding such fears is through vicarious learning. In opposite to the direct learning conditioning, this response can be learned through an observation of others fear response without experience directly (Du et al., 2008). A recent study investigating children's fear found that at the age of 7 to 9, children who were shown pictures of the scared facial expression on to novel animals learned such expression of fear to specific pictures (Askew & Field, 2017). This indicates that children's reaction of fear can be learned through the acquisition of fear responses.

Negative information transmission
Negative information has an important role in understanding the causes of needle fears. It is about the certain belief individuals possess to stimulus,  fears can be acquired by the transmission of verbal and other types of information (Rachman, 2013). In specific, individuals may increase the threatening and negative belief on injection procedure by a specific stimulus they have experienced. A fear reaction is therefore produced through their own thoughts and imagination. This can link to the avoidance of participation in certain situations. Previous study evaluated the origins of children’s fear found that there is a percentage of 89 children had generated fears to negative information (Ollendick & King, 1991).

Vasovagal syncope reaction
Syncope refers to the loss of consciousness and can occurred in a sudden. Vasovagal syncope (VVS) involves a disruption of the autonomic nervous system and create a reaction chain that resulted in the increase of blood pressure and heart rate (Bédard et al., 2010). According to Engel (1978), this behaviour can be triggered through a feeling of threat which elici emotional responses. People would try to defend themselves when they feel the signs of sensational symptoms and potential outcomes. This automatically triggered through overreaction and can lead to the strong physical reaction of fainting (Orenius et al., 2018).

Quiz
{Every time when Samuel cried for vaccination at the clinic, his mom gives him a lollipop.This is an example of which learning?} - classical conditioning + operant conditioning - negative reinforcement - negative information

Management of needle fear
Being able to control our fear is practicable involves facing the situation we are afraid of. We can use strategies to help us manage the fear and prevent the stressful experience. There is a range of techniques available in the treatment of needle phobia. Previous study investigating the considerations of needle fear among children found that taking the fear seriously can benefit clinicians to find the right strategies with age consideration during intravenous insertion, and consequently can help the patients on overcoming the fear gradually (Carlson et al., 2000).



Cognitive behavioral therapy
The cognitive behavioural therapy (CBT) can be an effective way to help adults and children overcome needle phobia (see Figure 3). It is usually a talk therapy to eliminate the agitation of needles with the help from a qualified specialist (Raghavendra et al. 2010). Through breathing exercises and relaxation, you will alleviate physical responses and thoughts of ‘I cannot take it’ or ‘I’m going to faint’ (Jenkins, 2014).



Thompson (1999) conducted an individual case study where he examined the CBT treatment of blood-injury-injection (BII) phobia of a 14-year-old girl Petra. Petra was referred by her general practitioner for a history of fainting at the sight of blood during injection. She reported a fear of seeing and thinking about blood for shots and has experienced increased heart rate, a difficulty breathing, a feeling of cold prior to the event and would going to faint eventually. To address her issues, thirteen 1-hour sessions of CBT were conducted over 3 months. A 10-item exposure hierarchy was generated with cognitive restructuring on automatic thoughts on a weekly basis. After the sessions, a decrease in anxiety level was found and she noticed her fainting reaction was gone as she is aware now that she is not going to faint because of her fears.

Exposure therapy
Exposure based therapy lies under the behavioural intervention which involves introducing the specific fear into your life and being exposed in a controlled manner (Mcmurtry et al., 2016). This might start by showing pictures of needle, then moving to videos or pictures of someone receiving injection, and gradually to presenting the needle to you and allowing you to handle the needle. A systematic study of the effectiveness of exposure-based interventions among children with high levels of needle fear was conducted through in vivo and non-in vivo method, it found fear hierarchy with books about needles, giving a bear injection could benefit the real needle procedure (Mcmurtry et al., 2016). This indicates that individuals usually work well with graded exposure and is able to manage the fear through systematic desensitization technique (Jenkins, 2014).

Stages of change model management


Prochaska’s stages of change model (the transactional model) is another similar technique that focus on decision-making and intentional change of behaviours (Norcross et al., 2011)(see Figure 4). It is useful in adapting treatment to a specific behaviour. A study investigated the relationship of needle fears and vaccination behaviour, found that the act of getting vaccinated can be improved through programs following the five stages of change model (Martin, 2021). Moving from the first precontemplation stage of ‘I can’t’ to the contemplation stage of ‘I may’, then to the preparation stage of ‘I will’, and eventually the action stage ‘I am’ and continued in the maintenance stage ‘I still am’. These mind changing stages encourage individuals who avoid vaccination from the needle fears to receive shots in a practicable way.

Applied muscle tension
Applied muscle tension is one of the most efficient and easy strategy to reduce physical symptoms relate to needle fears. The rationale for applied tension was explained through various studies. It involves tensing and holding the muscle temporarily for 5 to 10 seconds during injection procedure. If you have a history of faint and feeling anxious, this technique is the best for you prevent fainting from vasovagal reactions (Bédard et al., 2010).

Sit in a comfortable chair and practice several times a week until you are relaxed and ready for real injection. When you relax your muscles, the goal is to let your body return to normal state.

Distraction techniques
Distraction technique is another useful strategy to reduce physical symptoms, especially to children who fear needles due to a traumatised memory. It transfers the attention from self to others and objects which helps reduce behavioural distress (Manne et al., 1990).

This technique is usually associated with the participation of parents and their reassurance (Hamilton, 1995). With the involvement and assistance from their parents, children have a better cooperation in following procedures due to the distraction of attention.



Cavender et al. (2004) conducted a study of the effectiveness of distractors and parental positioning undergoing venipuncture. They wanted to determine the parental positioning-distraction intervention has a potential positive outcome in decreasing needle fears. Distractors were kaleidoscope and items finding books. These were used by parents when children were undergoing treatment. Parents were asked to sit next to the examination table with child on their laps in either a side-sitting, or chest to chest sitting position. Results shown that distraction with parental participation promote a high level of participation in care, where it increases children’s feeling of control and reduces the resistance and fear in relation to injection. This is consistent with the research within the study and indicates a practicable suggestion into the future healthcare strategies.

Medication
Medication can be helpful into the treatment of specific needle fears, especially the hyperalgesia type. One option is the rapid-acting benzodiazepines which can be applied prior to injection (Hamilton, 1995). Another option is the topical anaesthesia at the needle site, this includes choices from ice to ethyl chloride spray (Hamilton, 1995). This is useful in treating the vasovagal reflexes to prevent from fainting as it can temporarily numb the skin. However, medications may have side effects such as hypotension, increased frequency of syncope, and result in depressive symptoms (Bédard et al., 2010). Therefore, it is recommended to seek help from psychotherapies at onset to manage the underlying fears with actual solution and achieve a long-term outcome.

Conclusion
The chapter explains what needle fear is, what causes it and what are the management of such fear. Fear of needles is a common response that occurs when we are in the situation where needles are presented as an evoking threat. It is common in vaccination and immunisation settings and in patients undergoing treatment. Reasons that trigger the fear is related to the past traumatised experience of the painful injection, the observation of others fear response, and the negative information pictured ahead. It is important for fears of needles to be recognised and treated with attention to prevent from worsening physical and psychological conditions, which stopping us from seeking medical treatment. Fear of needles can be managed with finding ways to desensitize the expected pain and associated discomforts. Some of the effective treatments are cognitive behavioural therapy, exposure therapy and distraction techniques. Individuals are encouraged to seek for professional help in the benefit for themselves as they can learn to overcome their fear progressively through changes. Future research should focus on the recommendations for health professionals in the development of needle fears.

Take home message: A fear of needles is a common reaction that everyone may experience at some point and this can be managed through techniques. An avoidance of treatment resulting in needle fears is not the right solution and can cause fatal outcomes. It is encouraged to seek for professional help when you are experiencing associated needle fears.