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Blood-injection-injury phobia: preventative intervention for syncope.


Few, if any, medical laboratory personnel working for any length of measurable time can claim they have not encountered needle phobic patients. Whether the fear is exclaimed overtly or quietly concealed in anxious silence, these patients present a particularly difficult challenge for the lab technician. The DSM IV TR (DSM = Diagnostic and Statistical Manual of Mental Disorders) diagnosis of Blood-Injection-Injury Type Specific Phobia (BII) encompasses various fears of seeing blood, receiving injections, or injury in a medical setting (APA, 2000). The specific related phobias include trypanophobia, fear of medical procedures involving the use of needles; belonephobia, fear of sharp objects or instruments; and hemophobia, fear of the sight of blood. A prominent complication with these phobias is the vasovagal response leading to syncope, during phlebotomy procedures. Detrimental consequences of BII phobia are related to the patient resisting routine medical checkups and blood work, putting their general health at risk (APA, 2000). This article will explore the physiological and psychological mechanisms which trigger the vasovagal response, techniques for minimizing patient fear and syncope risk during blood draws, and behavioral treatments mitigating the anxiety and fear associated with BII phobia.

The Vasovagal Response

With an estimated prevalence of 3% to 4%, BII phobia is a common psychiatric disorder (Agras, Sylvestor, & Oliveau, 1969). In 75% of those presenting with BII phobia, a history of syncope when confronted with the feared situation is reported (APA, 2000). In contrast to other specific phobias such as fear of animals or heights, which elevate blood pressure and heart rate, BII phobia is associated with the vasovagal response which causes vasodilation, hypotension, and slowing of the heart (bradycardia) (Mednick & Claar, 2012). Basically, the vasovagal response is a homeostatic dysfunction of the autonomic nervous system. It is sometimes referred to as emotional fainting, and is typically characterized by a two-phase or di-phasic response (Graham, Kabler, & Lunsford, 1961). The initial phase involves an increase in blood pressure and heart rate, similar to other common phobic responses. However, this initial stage of flight and fright, typical of anxiety responses (Guyton & Hall, 2005) is short lived and quickly replaced by the second phase of hypotension and bradycardia (Graham, Kabler, & Lunsford, 1961).

During the vasovagal response, emotional reactions are translated via the hypothalamic mechanisms into autonomic impulses (Wallin, 1993). Whether the emotional response is triggered by fear of needles, disgust prompted by the sight of their own blood, entry of the needle, or the pain associated with the venipuncture, one fact is salient--the emotional unpleasantness of the blood draw is overwhelming to the BII phobic. In a study conducted by Deacon and Abramowitz (2006) of 3,315 patients undergoing phlebotomy procedures, they found 14.8% (n = 490) of the participants experienced anxiety prior to blood draws. The study also found that 4.3% (n = 141) of the participants had lost consciousness in the past while having blood drawn, and 2.2% (n = 72) of the participants qualified for a DSM diagnosis of BII phobia. When comparing those qualifying for a diagnosis of BII phobia with those experiencing no needle fear, the effect size differences related to fear of fainting (d = 3.51) and disgust (d = 3.26) were the most significant, while pain (d = 2.13) and health concerns (d = 1.09) contributed less to the psychological variance between the two groups. Deacon and Abramowitz also noted those with higher ratings on needle disgust tended to psychologically exacerbate pain and vasovagal reactions during needle injection.

Most people having a vasovagal response leading to syncope experience a combination of hypotension and reduced cardiac output. According to Rea and Thames (1993), the hypotension is often the result of a vasodepressor reaction, precipitated by the Bezold-Jarisch reflex. This reflex, triggered by numerous psychological stressors (Sledge, 1978), originates in the heart, where sensory receptors respond to mechanical and chemical stimuli by increasing the C-fiber vagal afferent signaling to the brain. This increases parasympathetic outflow, while inhibiting vasoconstriction efferent sympathetic outflow, resulting in vasodilation and hypotension (Rea & Thames, 1993). Stimulation of the vagal nerve also causes parasympathetic efferent pathways to release acetylcholine, causing negative inotropic and chronotropic effects (Levy, 1971). The inhibitory action of the acetylcholine essentially causes a slowing of the contraction and conduction rates of the heart, resulting in bradycardia.

Data obtained in a study by Accurso et al. (2001) suggests that blood phobic persons may be predisposed to vasovagal syncope in other non-phobic situations. The study was conducted on 22 participants, with 11 meeting the diagnostic criteria of BII phobia, and 11 control participants with no prior diagnosis of BII phobia. All participants were subjected to a 45 minute tilt table test. During the procedure, 9 of the 11 BII phobic participants experienced syncope or pre-syncope, while only 1 participant in the control group experienced pre-syncope. The study suggests as a hypothesis that BII phobic individuals could be predisposed to syncope, and might develop their phobia not exclusively due to a fear of needles and blood, but rather as a consequence of fearing syncope (Marks, 1988).

Preventing Syncope During Phlebotomy Procedures

During the course of a phlebotomist or lab technician's career, they may become desensitized to the expression of patient fear elicited by the procedures of blood sample collection. In fact, as the skill and confidence of the technician increases, the signs of patient fear may fade from awareness. However, it is imperative the technician not become too cavalier in their assessment of patient anxiety. This becomes a particularly salient point if the patient happens to be a new patient, child, adolescent, or young adult.

While making positive patient identification prior to the blood draw, the patient should be asked if they are fearful of the procedure, or if they have ever become lightheaded or faint during a past blood draw. If the patient indicates he or she has a history of fainting, the technician should insist the patient lie down for the procedure or sit in a reclining chair (McCall & Tankersley, 2008). Placing the patient in a supine position has three advantages. First, with the patient lying horizontally, it reduces the effect of gravity, and provides less resistance for blood flowing from the lower extremities to the brain. Secondly, if the patient was to become lightheaded or lose consciousness during the procedure, the danger of them becoming injured due to a fall is abated. Finally, depending on the build and position of the patient, some technicians may find it easier keeping needles, blood, and the procedure out of patient view.

In a perfect world, patients would always identify themselves as someone with BII phobia, and every lab would have a bed, reclining chair, or table for such patients to lie on for blood draws. However, the world is not perfect, and the medical lab is no exception. Eventually, it is almost certain that every lab technician will discover a BII phobic patient in the chair during the course of a blood draw procedure. If the technician is faced with this scenario, it is crucial the patient is carefully observed during the procedure for the prodromal signs of syncope. These early signs include a general uncomfortable feeling, sensations of warmth, abdominal cramping, and mild nausea (Wieling et al., 2009).

If the technician finds himself/herself with a seated patient in the prodromal stage of syncope, there is a simple counter maneuver with empirical support which could avert patient fainting. Studies have indicated the applied tension technique, a term first derived by Kozak and Montgomery (1981), and later detailed by Ost and Sterner (1987), has been shown to raise blood pressure, reduce anxiety, and reduce syncope risk by having the patient tighten skeletal muscles during the blood draw (Holly, Balegh, & Ditto, 2011). One such study by Krediet et al. (2002) tested this procedure by recruiting 21 participants predisposed to vasovagal syncope, and subjecting them to a tilt table test while they performed the applied tension maneuver.

The researchers first taught the applied tension technique to the participants by having them cross their legs, and then repeatedly tense the leg, abdominal, and buttock muscles for 10 to 15 seconds, followed by a 20 to 30 second release without relaxing. Once the tilting experiment began, and participants were in the prodromal stage of syncope, they were instructed to begin the maneuver. In 20 of the 21 participants, syncope was avoided while they performed the maneuver (some repeating it 4-5 times). After participants ceased the maneuver, 5 of the participants continued to avoid syncope in the tilted position, while 15 of them eventually fainted. However, after the maneuver was halted, the average time syncope was delayed for fainting participants was 2.5 minutes. During the maneuver, mean blood pressure was elevated in the group, with systolic increasing from (M = 65, SD = 13) to (M = 106, SD = 16, p < .001), and diastolic pressure increasing from (M = 43, SD = 9) to (M = 65, SD = 10, p < .001). Mean heart rate for the group also increased significantly during the maneuver, going from (M = 73, SD = 22) to (M = 82, SD = 15, p < .01) (Krediet et al., 2002).

By crossing the legs and contracting muscles in the legs, buttocks, and abdomen, the pooled venous blood in the lower extremities is given assistance moving back to the heart, blood pressure is increased, and circulation to the brain is improved. Although the Krediet et al. (2002) study was conducted using a tilt table, the study simulates the position of a patient leaning or reclining back in the drawing chair with the legs extended outward, and is a technique worth considering as a counter measure to vasovagal syncope. Furthermore, given the efficacy of tightening the skeletal muscles to avoid syncope, the empirical research indicates the technician should avoid telling patients to relax when pre-syncope symptoms are detected.

Psychological Treatments for Vasovagal Syncope

Human fear of blood and injection injury is not itself psychopathological unless it causes marked distress, and difficulty in the person's everyday life. If the individual's fear becomes so pronounced that it interferes with lifesaving procedures or treatments such as dialysis or insulin injection, treatment becomes mandatory (Marks, 1988). Treatment for BII phobia often involves typical behavioral exposure techniques used to treat anxiety disorders, which gradually expose the client to more intense fear stimuli (Barlow, 2002). The exposure therapy can be implemented as a stand-alone treatment, or it can be coupled with coping techniques such as applied tension (Ayala, Meuret, & Ritz, 2009).

To implement a behavioral exposure treatment, the clinician must first ascertain from the patient what provokes the most anxiety and fear in him or her. The clinician can then formulate a plan of prolonged exposure to these fear-inducing stimuli. The most effective habituation or decreased psychological response to the stimulus is accomplished with prolonged exposures to the feared stimulus for at least an hour. In addition, exposure therapy is most effective when in-vivo exposure is utilized, using either real or filmed representations rather than imagined themes. Therapists will often create homework assignments for patients, which they can do on their own, while keeping diaries of their progress (Marks, 1988).

The applied tension technique discussed earlier can also be performed during exposure at the first sign of blood pressure decrease. Educating patients on how to recognize the signs of blood pressure drop is essential when implementing this technique (Ayala, Meuret, & Ritz, 2009). The exposure, applied tension, and tension only technique (tension without exposure) were compared by Ost, Fellenius, and Sterner (1991) for short and long term effectiveness. They found the applied tension and tension only groups showed significantly more improvement at 90% and 80% respectively, while the exposure only group showed a 40% improvement after treatment. The authors indicated the tension aspect of the treatment may be the most important component. Other available studies reveal clinically significant improvements in 70% to 80% of patients in tension and exposure only therapies. Treatments emphasizing exposure tended to reduce injection and other related BII phobic fears, while the tension techniques emphasized coping skills, which gave the patient a sense of control over fainting, but did little to address the patient's BII phobia specific fears (Ayala, Meuret, & Ritz, 2009).


BII is a common phobia, and one that can potentially threaten an individual's health by causing avoidance of medical tests and procedures. Unlike other phobias, BII phobia is unique in that it causes blood pressure and heart rate to decrease by means of the vasovagal response, which can potentially lead to syncope. If BII phobic patients are identified prior to blood draws, preventative measures can be taken such as having the patient lie down, which can lessen the chance of syncope. If prodromal symptoms of syncope occur while the patient is seated, the applied tension technique can help elevate blood pressure and heart rate sufficiently to avoid syncope in some cases. When BII phobia is interfering with the patient receiving vital medical care, treatment is mandatory. This treatment is generally linked to exposure therapy, where the patient is exposed to the feared stimulus for extended periods of time. Research has shown that exposure therapy coupled with the applied tension technique may be the most effective treatment plan for reducing patient fear, and mitigating syncope risk.

Editor's Note: This article was originally published as Article 407 in the January 2014 issue of Journal of Continuing Education Topics & Issues, but incorrect references were inadvertently attributed to the article. The following is a reprint of that article with the correct references. We apologize for this printing error.


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Steven L. Powden, RPT(AMT), Doctoral Student at the Forest Institute of Professional Psychology, Springfield, Missouri
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Author:Powden, Steven L.
Publication:Journal of Continuing Education Topics & Issues
Article Type:Report
Date:Apr 1, 2014
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