Acquisition of blood and injection phobia and anxiety response patterns in clinical patients

Interventions to alleviate anxiety and pain during venipuncture in children with chronic gastrointestinal and/or liver disease: A single-center prospective observational study

Objectives

The goal of this longitudinal study was to reduce anxiety and pain in children with chronic conditions from the gastrointestinal tract during venipuncture. These children undergo regular venipuncture as part of their medical management and the procedure is often accompanied with anxiety and pain. In addition, children as well as their parents and health care professionals (HCPs) often suffer "compassionate pain" because of emotional interference.

Method

In a realistic clinical setting, different psychological and medical interventions were examined: (1) Psychoeducational brochures and (2) four different medical-technical interventions during venipuncture. In a large hospital in Germany, 169 children, their parents, and HCPs were asked to rate anxiety and pain during venipuncture before and after the intervention.

Results

Children showed a clear preference for some of the medical-technical interventions. Using Linear Mixed Models anxiety and pain rated by the children themselves showed no significant reduction. However, parents and HCPs reported a significant reduction. Age, gender, and status of liver transplantation were associated with a reduction in anxiety and pain in most of the analyses.

Conclusion

Both psychoeducational brochures and medical-technical interventions had a positive impact on anxiety and pain. However, effectivity for the medical-technical interventions was lower than in previous studies utilizing individual interventions. Reasons for this difference as well as possibilities to improve the intervention are discussed. In addition, this study provides practical day-to-day information about the implementation of interventions for the work in pediatric units such as when and how to provide psychoeducational materials.

Combined Fainting and Psychogenic Non-epileptic Seizures as Significant Therapy Hurdles in Blood-Injury-Injection Phobia: A Mini-Review and Case Report

BACKGROUND

Anxiety disorders are the most frequent mental disorders. Among the different subtypes, specific phobias are the commonest. Due to the ongoing SARS-CoV-19 pandemic, blood-injury-injection phobia (BII) has gained wider attention in the context of large-scale vaccination campaigns and public health. In this BII phobia mini-review and case report, we describe the successful treatment of a severe BII phobia case with combined fainting and psychogenic non-epileptic seizures (PNES) and demonstrate the role of specialized outpatient care.

CASE REPORT

The patient was a 28-year-old woman. She suffered from intense fear and recurrent fainting with regard to needles, injections, injuries, and at the sight of blood since early childhood. Medical history revealed infrequent events suggestive of PNES following panic attacks after sustained exposure to phobic stimuli. Family history was positive for circulation problems and BII fears. Psychopathological evaluation confirmed BII phobia symptoms and diagnosis was made according to the DSM-5. The Multidimensional Blood/Injury Phobia Inventory short version (MBPI-K) revealed severe manifestation of the disease. Neurological examination was ordinary. Repeated electroencephalography detected no epileptic pattern. Cranial magnetic resonance imaging showed normal morphology. Treatment was carried out by a seasoned, multidisciplinary team. Cognitive behavior therapy and exposure were performed. Modification of standard treatment protocol was necessary due to hurdles posed by recurrent fainting and a severe panic-triggered dissociative PNES during in vivo exposure. Modification was implemented by limiting in vivo exposure intensity to moderate anxiety levels. In addition to applied muscle tension and ventilation techniques, increased psychoeducation, cognitive restructuring, and distress tolerance skills (e.g., ice pack, verbal self-instructions) were used to strengthen the patient's situational control during in vivo exposure. A total of 15 sessions were performed. Therapy success was proven by 83% reduction in MBPI-K rating, SARS-CoV-19 vaccination, and a blood draw without psychological assistance, fainting, or seizure.

CONCLUSION

Taken together, this case demonstrates the potential of and need for specialized outpatient care and individualized treatment for severe BII phobia patients in order to provide them the perspective to have necessary medical procedures done and get vaccinated.

A Sorrow Shared Is a Sorrow Halved? Patient and Parental Anxiety Associated with Venipuncture in Children before and after Liver Transplantation

Taking blood via venipuncture is part of the necessary surveillance before and after liver transplantation. The spectrum of response from children and their parents is variable, ranging from a short and limited aversion to paralyzing phobia. The aim of this retrospective, cross-sectional study was to determine the level of anxiety amongst children during venipuncture, to compare the anxiety reported by children and parents, and to identify the factors affecting the children’s and parents’ anxiety in order to develop therapeutic strategies. In total, 147 children (aged 0–17 years, 78 female) and their parents completed questionnaires. Statistical analysis was performed using qualitative and quantitative methods. Results showed that the majority of children reported anxiety and pain during venipuncture. Younger children had more anxiety (self-reported or assessed by parents). Children and parental reports of anxiety were highly correlated. However, the child’s anxiety was often reported as higher by parents than by the children themselves. The child’s general anxiety as well as the parents’ perceived stress from surgical interventions (but not the number of surgical interventions) prompted parental report of child anxiety. For children, the main stressors that correlated with anxiety and pain were factors during the blood collection itself (e.g., feeling the puncture, seeing the syringe). Parental anxiety was mainly related to circumstances before the blood collection (e.g., approaching the clinic, sitting in the waiting room). The main stressors mentioned by parents were the child’s discomfort and their inability to calm the child. Results indicate that the children’s fear of factors during the blood collection, along with the parents’ perceived stress and helplessness as well as their anticipatory anxiety are important starting points for facilitating the drawing of blood from children before and after liver transplantation, thereby supporting a better disease course in the future.

Using Virtual Technology for Fear of Medical Procedures: A Systematic Review of the Effectiveness of Virtual Reality-Based Interventions

Background

Innovations in virtual reality (VR) technologies have improved the adaptability of its use in therapeutic settings, and VR has shown to be a promising treatment for fear of medical procedures, with research increasing in this area in recent years.

Purpose

This review aims to collate evidence for the impact of VR on fear of medical procedures.

Methods

CENTRAL (Cochrane), MEDLINE, EMBASE, and PsychINFO databases were searched up to October 2020. A mix of experimental and case–control studies were included for review, which evaluated the effectiveness of VR for fear, anxiety, and pain of medical procedures for people with needle phobia, dental phobia, claustrophobia of medical scans, and burn wound care anxiety. Risk of bias (RoB) was assessed by Cochrane and ROBINS-I tools.

Results

Twenty-eight studies were selected. Some studies included mixed participant groups of young people adults. The interventions varied, with VR used for distraction, hypnosis, or exposure. These were shown to be effective for reducing fear of medical procedures. However, effectiveness for blood-injection-injury phobias and burn wound care patients was unclear.

Conclusions

Evidence on the effectiveness of VR suggests that it does decrease fear of medical procedures in some situations. However, the RoB assessment illustrated a poor quality of studies across those included in this review, limiting the ability to draw firm general conclusions from the study findings. There is a need for further research exploring the use of VR technologies in the management of anxiety in physical health care settings.

Effects of repeated exposure to fearful and disgusting stimuli on fear renewal in blood-injection-injury phobia

Although exposure is effective for blood-injection-injury (BII) phobia, fear often returns after treatment. While disgust has been implicated in BII phobia, its effects on fear renewal are unclear. To address this knowledge gap, the present study examined the effect of repeated video exposure to fearful and disgusting stimuli in multiple contexts on fear renewal in BII phobia. Individuals with BII phobia (N = 57) were randomized to Disgust-Specific Exposure (DSE) which included exposure to disgusting but threat-irrelevant stimuli (i.e., vomit), Fear-Specific Exposure (FSE) which included exposure to threat-relevant stimuli (i.e., injections), or General Negative Exposure (GNE) which included exposure designed to elicit negative affect (i.e., tornado) without being disgusting or threat-relevant. During session one, participants watched a pre- and post-exposure assessment injection video ("pre/post assessment"), and a novel injection video after exposure to assess renewal effects ("novel 1"). Participants came in one week later to rate the same videos, and a new injection video ("novel 2"). For week one outcomes, comparisons of covariate adjusted means indicated the fear-specific group reported significantly lower levels of anxiety than the general-negative group to the post-exposure and novel 1 stimulus. When presented with the post-exposure stimuli during week two, the disgust-specific and fear-specific groups reported significantly lower levels of anxiety than the general negative group. The fear-specific group also reported significantly lower levels of anxiety than the disgust-specific and general-negative groups when presented with novel 1 and novel 2 stimuli at week two. These findings suggest that repeated exposure to threat-relevant cues in multiple contexts does reduce the return of anxiety. However, repeated exposure to disgusting but threat irrelevant stimuli may also produce some therapeutic effects. The implications of the integration of disgust-relevant processes into exposure-based treatment of BII phobia are discussed.

Managing immunization stress-related response: A contributor to sustaining trust in vaccines

Adverse events following immunizations (AEFI) are important to identify and manage effectively so as to sustain trust in vaccines and optimize health. The AEFI category related to "anxiety about the immunization" was considered problematic as it did not adequately capture the range of stress responses that can occur. The currently used term for this category, immunization stress-related responses (ISRR), is broader, including the full spectrum of signs and symptoms that can arise in response to stress. ISRR can include vasovagal reactions (fainting), hyperventilation and functional neurological symptoms (e.g. weakness, nonepileptic seizures). It is based on a biopsychosocial framework in which biological (e.g. age, sex), psychological (e.g. preparedness, previous experiences, anxiety) and social factors (e.g. response by others, social media) interact to create an individual's stress response to the immunization process. New guidance is available on prevention, early detection and management of ISRRs which is summarized in the article.

Large-Group One-Session Treatment: A Feasibility Study of Exposure Combined With Applied Tension or Diaphragmatic Breathing in Highly Blood-Injury-Injection Fearful Individuals

Objective: Large-group one-session treatments (LG-OSTs) might represent a promising treatment tool as increasing evidence suggests their effectiveness in individuals with different situational fears. In the present study, we explored feasibility and effectiveness of an exposure-based LG-OST protocol applying applied tension and diaphragmatic breathing as coping strategies in a sample of 40 individuals, highly fearful of blood-injury-injection (BII).

Method: We assessed participants’ BII-fear using questionnaires and a behavioral approach test (BAT) before and after treatment, consisting of a blood-drawing procedure. Stability of treatment effects was assessed via online-survey at 7-month follow-up.

Results: The LG-OST procedure evidenced feasible and effective. Pre-post treatment comparisons showed medium to large treatment effects (d = 0.40–0.93) regarding the questionnaire measures. After being treated, 70% of the individuals successfully underwent a blood drawing. Moreover, participants continued to improve in the post follow-up interval leading to large treatment effects (d = 1.19–1.62).

Conclusion: In treating BII-fear, LG-OSTs might not only serve within a framework of a stepped care approach but also could represent a useful single-treatment option. Additionally, due to their high efficiency and standardization of treatment delivery, LG-OST protocols might foster research at the interface of basic and clinical research.

Pharmacists as vaccinators: An analysis of their experiences and perceptions of their new role

OBJECTIVES

In 2012, Ontario pharmacists were granted immunization privileges to administer influenza vaccines to the public. This study explored the experiences and practices of pharmacist vaccinators and the impact of vaccination pain on their practice.

METHODS

Semi-structured interviews were conducted with 12 pharmacists in the Greater Toronto Area. Transcribed interview data were coded and analyzed via thematic analysis.

KEY FINDINGS

Data analysis revealed 4 main themes: 1) expanded scope of practice as an enhancement and challenge to relationships; 2) professional satisfaction and workload demands; 3) knowledge and attitudes regarding pain and fear; 4) practices regarding pain and fear management. Pharmacists reported satisfaction in their new role, despite the associated increased workload. Pharmacists felt that vaccination pain was not a key consideration when administering vaccines and that pain management was generally not necessary. Fear was identified as more important than pain and vaccinating children was challenging and time intensive. Pharmacists' main focus was on injection techniques in managing pain.

CONCLUSION

These findings suggest that pharmacists are accepting of their role as vaccinators but more research is needed to examine impact on workload and pharmacist knowledge and perceptions of injection-related pain and fear.

Minimally-invasive dental anesthesia: Patients' preferences and analysis of the willingness-to-pay index

AIM

The aim of the present prospective study was to evaluate the impact of a computer-controlled anesthesia on patients' comfort and to investigate, through the willingness-to-pay (WTP) index, and patients' acceptance of this new technology.

METHODS

Fifty patients undergoing a class I or II restorative procedure were enrolled. A computer-controlled device for anesthetic delivery was utilized, and a questionnaire on the level of discomfort and WTP was given to all patients.

RESULTS

A total of 86% of participants declared less discomfort than that perceived during their last traditional procedure for pain control; 58% of patients were willing to pay an additional fee for a modern anesthesia technique, with a median WTP value of 20$.

CONCLUSIONS

Computer-controlled systems for local anesthesia represent a relevant tool for reducing patients' discomfort during dental treatment. The WTP index helps to quantify its relevance.

One Session Treatment for Specific Phobias: An Adaptation for Paediatric Blood-Injection-Injury Phobia in Youth

Blood-injection-injury (BII) phobia is a chronic and debilitating disorder, which has largely been neglected in the child literature. The present paper briefly reviews the aetiology of specific phobias with particular attention to BII and provides an integrated developmental model of this disorder in youth. Evidence-based treatments for child-specific phobias are discussed, and the development of a modified one session treatment (OST) approach to enhance treatment outcomes for BII phobia in children and adolescents is described. This approach is illustrated in two children with a primary diagnosis of BII phobia. The cases illustrate the unique challenges associated with treating BII in youth and the need for a modified intervention. Modifications included addressing the role of pain (e.g., psychoeducation, more graduated exposure steps) and disgust (e.g., disgust eliciting exposure tasks) in the expression of the phobia and fainting in the maintenance of this phobia. Moreover, it is recommended that parents be more actively involved throughout treatment (e.g., education session prior to OST, contingency management training, guidance regarding planning exposure tasks following treatment) and for families to participate in a structured e-therapy maintenance programme post-treatment.

Far From "Just a Poke": Common Painful Needle Procedures and the Development of Needle Fear

BACKGROUND

Vaccine injections are the most common painful needle procedure experienced throughout the lifespan. Many strategies are available to mitigate this pain; however, they are uncommonly utilized, leading to unnecessary pain and suffering. Some individuals develop a high level of fear and subsequent needle procedures are associated with significant distress.

OBJECTIVE

The present work is part of an update and expansion of a 2009 knowledge synthesis to include the management of vaccine-related pain across the lifespan and the treatment of individuals with high levels of needle fear. This article will provide a conceptual foundation for understanding: (a) painful procedures and their role in the development and maintenance of high levels of fear; (b) treatment strategies for preventing or reducing the experience of pain and the development of fear; and (c) interventions for mitigating high levels of fear once they are established.

RESULTS

First, the general definitions, lifespan development and functionality, needle procedure-related considerations, and assessment of the following constructs are provided: pain, fear, anxiety, phobia, distress, and vasovagal syncope. Second, the importance of unmitigated pain from needle procedures is highlighted from a developmental perspective. Third, the prevalence, course, etiology, and consequences of high levels of needle fear are described. Finally, the management of needle-related pain and fear are outlined to provide an introduction to the series of systematic reviews in this issue.

DISCUSSION

Through the body of work in this supplement, the authors aim to provide guidance in how to treat vaccination-related pain and its sequelae, including high levels of needle fear.

Interventions for Individuals With High Levels of Needle Fear: Systematic Review of Randomized Controlled Trials and Quasi-Randomized Controlled Trials

BACKGROUND

This systematic review evaluated the effectiveness of exposure-based psychological and physical interventions for the management of high levels of needle fear and/or phobia and fainting in children and adults.

DESIGN/METHODS

A systematic review identified relevant randomized and quasi-randomized controlled trials of children, adults, or both with high levels of needle fear, including phobia (if not available, then populations with other specific phobias were included). Critically important outcomes were self-reported fear specific to the feared situation and stimulus (psychological interventions) or fainting (applied muscle tension). Data were pooled using standardized mean difference (SMD) or relative risk with 95% confidence intervals.

RESULTS

The systematic review included 11 trials. In vivo exposure-based therapy for children 7 years and above showed benefit on specific fear (n=234; SMD: -1.71 [95% CI: -2.72, -0.7]). In vivo exposure-based therapy with adults reduced fear of needles posttreatment (n=20; SMD: -1.09 [-2.04, -0.14]) but not at 1-year follow-up (n=20; SMD: -0.28 [-1.16, 0.6]). Compared with single session, a benefit was observed for multiple sessions of exposure-based therapy posttreatment (n=93; SMD: -0.66 [-1.08, -0.24]) but not after 1 year (n=83; SMD: -0.37 [-0.87, 0.13]). Non in vivo e.g., imaginal exposure-based therapy in children reduced specific fear posttreatment (n=41; SMD: -0.88 [-1.7, -0.05]) and at 3 months (n=24; SMD: -0.89 [-1.73, -0.04]). Non in vivo exposure-based therapy for adults showed benefit on specific fear (n=68; SMD: -0.62 [-1.11, -0.14]) but not procedural fear (n=17; SMD: 0.18 [-0.87, 1.23]). Applied tension showed benefit on fainting posttreatment (n=20; SMD: -1.16 [-2.12, -0.19]) and after 1 year (n=20; SMD: -0.97 [-1.91, -0.03]) compared with exposure alone.

CONCLUSIONS

Exposure-based psychological interventions and applied muscle tension show evidence of benefit in the reduction of fear in pediatric and adult populations.

Does a child's fear of needles decrease through a learning event with needles?

BACKGROUND

Most children have a fear of needles. Suitable preparation can decrease the pain and fear of needles in hospitals; however, few have examined how such preparation affects healthy children. This study examined whether learning with needles decreases fear of needles and changes motivation to get vaccinations in school-age children and the possible association between fear of needles and motivation toward vaccinations.

METHODS

This study included children participating in the "Let's Be Doctors" event, which was held in 4 child centers in Tsukuba city, Ibaraki, Japan. In this event, children learned about injections and how a vaccine works, and injected a vaccine (water) into skin (sponge) using a real syringe and imitation needle. Data were collected just before and after the event by anonymous self-assessment questionnaires that used a 4-point Likert scale to assess fear of needles, motivation to get vaccinations, recommendation of vaccinations, and fear toward doctors among the children. Answers were divided into two categories for statistical analysis.

RESULTS

In total, 194 children participated in the event and 191 children answered the questionnaire (response rate 98.5%). We analyzed 180 subjects, comprising 79 boys (43.9%) and 94 girls (52.2%), mean age of 8.1 ± 1.0 years. The number of children reporting a fear of needles decreased from 69 (38.3%) before the event to 51 (28.3%) after the event, and those unwilling to get vaccinations decreased from 48 (26.7%) to 27 (15.0%). Children who reported fear of needles before the event were more unwilling to get vaccinations than those with no fear of needles (36 [52.2%] vs. 12 [10.8%]), while after the event the number of needle-fearing children unwilling to get vaccinations decreased to 19 (27.5%).

CONCLUSIONS

Children's fear of needles and unwillingness to get vaccinations were decreased after experiencing a learning event with needles. The fear of needles is associated with a negative motivation to get vaccinations in children.

Autobiographical memories of vomiting in people with a specific phobia of vomiting (emetophobia)

BACKGROUND

Vomiting is an almost universal phenomenon, but little is known about the aetiology of a specific phobia of vomiting (SPOV). The associations with vomiting during childhood and autobiographical memories may have relevance for our understanding of the development of SPOV and its treatment.

METHOD

Two groups: (a) a group with SPOV (n = 94) and (b) a control group (n = 90) completed a self-report questionnaire assessing their lifetime memories of both their own vomiting and others vomiting.

RESULTS

People with SPOV recalled the memories of their own and others vomiting experiences from an earlier age and rated them as significantly more distressing than the control group. There was no difference between the groups in the number of memories of their own vomiting recalled before the age at which vomiting became a problem. However, the SPOV group recalled more memories of others vomiting before the onset of the problem. After the age at which the phobia became a problem they recalled less memories of their own vomiting and more memories of others vomiting than the control group. They recalled significantly more memories of vomiting associated with inter-personal events, health or emotional or unrelated life events.

CONCLUSIONS

Avoidance and hyper-vigilance for others vomiting after the onset of the phobia may have slightly reduced the risk of vomiting. There is some evidence for associative learning in SPOV with aversive consequences of vomiting and an unrelated life event. It suggests a model of autobiographical memories of vomiting that have lost a time perspective and context, which are being reactivated with cues for vomiting. The limitations of the study are those of memory biases in both groups.

The role of painful events and pain perception in blood-injection-injury fears

BACKGROUND AND OBJECTIVES

Research suggests that blood, injection, and injury (BII) fears are related to painful experiences; however the role of frequency, intensity, and perceived ability to handle such events remains unknown. The aim of this study was to examine the relationship between BII fears and the frequency and intensity of prior painful experiences with blood, injuries, and injections. The relation of BII fears with self-reported tolerance and avoidance of physical discomfort and pain was also examined.

METHODS

In the context of an undergraduate student survey, 392 participants completed questions about whether they were fearful of blood, injection, and injuries. They also completed questions about experiences with blood and injuries, as well as injections, including pain intensity, frequency of painful experiences, perceived ability to tolerate physical discomfort and pain (pain perception), and avoidance of physical discomfort.

RESULTS

Findings indicated that only pain intensity, but not frequency of painful experiences with blood, injuries, and injections, was related to BII fears. Furthermore, there was a significant association between BII fears and pain perception, such that higher levels of discomfort intolerance were related to greater odds of endorsing BII fears.

CONCLUSIONS

These findings provide preliminary evidence that BII fears are associated with experiences with injections of high pain intensity. Individuals with a lower perceived ability to handle physical pain and discomfort are more likely to endorse BII fears. Clinical considerations and future directions are discussed.

Mental Retrieval of Treatment Context in Dental Phobia

Background: The effect of mental retrieval of an exposure session was investigated during a follow-up examination in dental phobia patients. Method: The exposure session took place at the psychology unit and the follow-up a week later at the dental clinic prior to dental treatment while patients were seated in the dental chair. During exposure, individuals with dental phobia (N = 72) were shown a video of a dental appointment, after which they were instructed to imagine themselves receiving dental treatment. During follow-up half of the participants received instructions to mentally retrieve the exposure session and the other half were asked to recall everyday activities. Before and after exposure treatment, and after mental retrieval, participants were shown three dental instruments while heart rate (HR) and avoidance and subjective units of discomfort (SUD) were recorded. Results: Questionnaires of phobic anxiety administered before and after treatment indicated significant improvement. Mental retrieval of treatment was moderately superior to the control condition with regard to avoidance. Over 80% of patients underwent the subsequent dental treatment session. Those not adhering showed initially more dysfunctional cognitions and more desire for control. Conclusion: There is some evidence that retrieval of treatment context may have a moderately beneficial effect on avoidance.

A pilot study to improve venipuncture compliance in children and adolescents with autism spectrum disorders

OBJECTIVE

Medical procedures, particularly venipuncture (the puncture of a vein especially for the withdrawal of blood), can cause serious distress and behavior disturbance for many children. Noncompliance to blood draws can have significant ramifications in both research and clinical settings. The negative reactions may be exacerbated in individuals with autism spectrum disorders. Even so, there has been little research into the prevalence of the problem or effective intervention procedures. In response to these concerns, we developed and evaluated the Blood Draw Intervention Program. The program was designed to be easy to use, require little provider or family time, effectively reduce negative behaviors, and increase blood draw compliance.

METHOD

In a quasi-randomized trial over the course of ∼ 18 months, 58 of 210 families with children with autism spectrum disorders participating in a larger study of phenotypic and genotypic factors reported significant concerns about blood draws and elected to use the Blood Draw Intervention Program.

RESULTS

Completion of the program increased blood draw compliance rates from 85.4% to 96.6% (odds ratio = 4.80; 95% confidence interval = 1.12, 20.59; p = .03).

CONCLUSION

Results indicate the efficacy of the program in a research setting and suggest a potential clinical application. The current intervention, unlike many others for the same or similar difficulties proposed in the past, was successful without requiring extensive time, training, or effort on the part of providers and parents or their children, nor did it require large-scale institutional changes.

Needle phobia: etiology, adverse consequences, and patient management

Needle phobia has profound health, dental, societal, and legal implications, and severe psychological, social, and physiologic consequences. There is genetic evidence for the physiologic response to needle puncture, and a significant familial psychological component, showing evidence of inheritance. Needle phobia is also a learned behavior. The dental practitioner must recognize patients with needle phobia before the administration of local anesthetics to identify patients who are potentially reactive and to prevent untoward sequelae. Needle phobia is highly associated with avoidance behavior, and the dentist must exhibit compassion and respect. To avoid bradycardia, hypotension, unconsciousness, convulsions, and possibly asystole, oral premedication with benzodiazepines or other antianxiety agents must be considered for patients who are needle phobic. Management of needle phobiaeinduced syncope includes perioperative monitoring, oxygen administration, positioning, atropine, and vasopressors.

The Origins of Specific Phobias: Influential Theories and Current Perspectives

Fears are quick and adaptive responses that permit powerful reply to imminent threats. Less adaptive, phobias are extreme manifestations of fear to objects or situations in the absence of a proportional danger. Although the utility of fear is accepted, the nature of phobias is controversial. Initial theories favored a fear conditioning-based explanation, with vicarious and information learning pathways subsequently included as additional routes to the development of specific phobias. More recently, an important group of investigations strengthened the case for a nonassociative account of fear acquisition proposing that evolutionarily relevant fears can occur without any need of critical learning experiences. In parallel, there is some evidence for a dedicated fear module in the detection of threats, involving the amygdala, which is relatively independent from conscious cognitive control. Nonetheless, cognitive models stress learning and developmental factors and their role in the etiology and maintenance of phobic behavior. This article critically reviews each of these views and theories stressing their recent developments, weaknesses, and controversies with an aim to provide the groundwork for the construction of a more integrated position. Finally, the authors suggest encouraging trends in recent research.

The Use of Emotive Imagery and Behavioral Techniques for a 10-Year-Old Boy's Nocturnal Fear of Ghosts and Zombies

This case describes the use of emotive imagery and behavioral techniques in treating a 10-year-old boy's nocturnal fear of ghosts and zombies. His anxiety had led to nightmares and avoidance of sleeping in his bedroom. To a significant degree, the intervention was led by the child. With the therapist's support, the child developed and deployed a number of imaginary characters during and between sessions to reduce his sense of threat about ghosts and zombies. Relaxation, boundary setting, and an incentive program were also implemented to target residual avoidant behavior. Self-reported anxiety measured by a diary and on the Spence Children's Anxiety Scale reduced during the course of treatment. Furthermore, the frequency of his nightmares decreased and the number of nights that he spent in his bedroom increased. The case highlights the effectiveness of emotive imagery in treating anxiety surrounding imaginary creatures in children. It also suggests that behavioral techniques may also be required to effectively promote behavior change.

The impact of positioning on fear during immunizations: supine versus sitting up

This study explored the impact of a child's position on the level of fear and perception of pain during an immunization injection. One hundred seven children, ages 4-6, participated in a random-assignment, two-group design study to evaluate the effect of positioning on fear and perceived pain. Group 1 was placed in the supine position and Group 2 in the sitting position prior to immunizations. The results substantiated the belief that children are significantly less fearful about receiving an injection when they are sitting up as compared to when they are lying down. There was no difference in perception of pain.

The vicarious learning pathway to fear 40 years on

Forty years on from the initial idea that fears could be learnt vicariously through observing other people's responses to a situation or stimulus, this review looks at the evidence for this theory as an explanatory model of clinical fear. First, we review early experimental evidence that fears can be learnt vicariously before turning to the evidence from both primate and human research that clinical fears can be acquired in this way. Finally, we review recent evidence from research on non-anxious children. Throughout the review we highlight problems and areas for future research. We conclude by exploring the likely underlying mechanisms in the vicarious learning of fear and the resulting clinical implications.

The influence of personality on neural mechanisms of observational fear and reward learning

Fear and reward learning can occur through direct experience or observation. Both channels can enhance survival or create maladaptive behavior. We used fMRI to isolate neural mechanisms of observational fear and reward learning and investigate whether neural response varied according to individual differences in neuroticism and extraversion. Participants learned object-emotion associations by observing a woman respond with fearful (or neutral) and happy (or neutral) facial expressions to novel objects. The amygdala-hippocampal complex was active when learning the object-fear association, and the hippocampus was active when learning the object-happy association. After learning, objects were presented alone; amygdala activity was greater for the fear (vs. neutral) and happy (vs. neutral) associated object. Importantly, greater amygdala-hippocampal activity during fear (vs. neutral) learning predicted better recognition of learned objects on a subsequent memory test. Furthermore, personality modulated neural mechanisms of learning. Neuroticism positively correlated with neural activity in the amygdala and hippocampus during fear (vs. neutral) learning. Low extraversion/high introversion was related to faster behavioral predictions of the fearful and neutral expressions during fear learning. In addition, low extraversion/high introversion was related to greater amygdala activity during happy (vs. neutral) learning, happy (vs. neutral) object recognition, and faster reaction times for predicting happy and neutral expressions during reward learning. These findings suggest that neuroticism is associated with an increased sensitivity in the neural mechanism for fear learning which leads to enhanced encoding of fear associations, and that low extraversion/high introversion is related to enhanced conditionability for both fear and reward learning.

The effect of local cooling on pain perception during infiltration of local anaesthetic agents, a prospective randomised controlled trial

The effect of pre-infiltration local cooling of the site of inguinal herniorrhaphy on pain perception during infiltration of local anaesthetic was studied in a prospective randomised controlled trial. One hundred patients were randomly allocated to receive topical application of either a cooled saline bag (study group) or a saline bag at room temperature (control group) prior to injection of local anaesthetic. Pain scores were recorded using a visual analogue scale following application of the saline bags and again on completion of infiltration with local anaesthetic. There was no significant difference in pain scores following topical saline bag application. However, a highly significant difference (p = 0.0001, Mann-Whitney U) was observed between post-infiltration pain scores of the study group (median = 2) and the control group (median = 6).

Fear of needles and vasovagal reactions among phlebotomy patients

Anxiety associated with blood and injections is a common problem in medical settings and, in severe cases, affects sufferers' ability to receive medically essential treatment. The present study was conducted to examine incidence of adverse reactions to venipunctures among phlebotomy patients, as well as to understand the demographic and psychological characteristics associated with such reactions. A large sample of participants undergoing venipuncture (N=3315) was recruited from hospital-based phlebotomy laboratories. Participants completed a brief questionnaire assessing psychological and physiological reactions to having their blood drawn. Results indicated that a small minority of patients experienced significant anxiety symptoms during venipuncture. Vasovagal reactions and vasovagal syncope were extremely infrequent. A tendency to experience pain, disgust, and fear of fainting during injections was associated with anxious responding to the venipuncture and a probable diagnosis of needle phobia. Theoretical and practical implications are discussed.

The role of imagery in the maintenance and treatment of snake fear

Two studies assessed the role of mental imagery in the maintenance of fear of common phobic stimuli. Study 1 asked participants who were afraid of a wide range of phobic stimuli to report their visual and somatic imagery. Blind ratings of the imagery on horror and vividness were positively correlated with participant's self-reported fear and avoidance. Study 2 tested the efficacy of modifying imagery using cognitive restructuring compared to in vivo exposure and a minimal exposure, relaxation control in snake fearful participants. Both active treatment groups improved significantly more than the control group in self-reported snake fearfulness and behavioral approach. Condition also interacted with initial severity. Highly fearful subjects responded better to the cognitive imagery modification than to the in vivo exposure, and found the cognitive intervention significantly less aversive. These results are seen as supporting a cognitive model of the maintenance of specific phobia.

Treatment of specific phobia in adults

This is a comprehensive review of treatment studies in specific phobia. Acute and long-term efficacy studies of in vivo exposure, virtual reality, cognitive therapy and other treatments from 1960 to 2005 were retrieved from computer search engines. Although specific phobia is a chronic illness and animal extinction studies suggest that relapse is a common phenomenon, little is known about long-term outcome. Treatment gains are generally maintained for one year, but longer follow-up studies are needed to better understand and prevent relapse. Acutely, the treatments are not equally effective among the phobia subtypes. Most phobias respond robustly to in vivo exposure, but it is associated with high dropout rates and low treatment acceptance. Response to systematic desensitization is more moderate. A few studies suggest that virtual reality may be effective in flying and height phobia, but this needs to be substantiated by more controlled trials. Cognitive therapy is most helpful in claustrophobia, and blood-injury phobia is uniquely responsive to applied tension. The limited data on medication have not been promising with the exception of adjunctive D-clycoserine. Despite the acute benefits of in vivo exposure, greater attention should be paid to improve treatment acceptance and retention, and additional controlled studies of more acceptable treatments are needed.

Multimodal classical conditioning of fear: contributions of direct, observational, and verbal experiences to current fears

The authors propose that a multimodal classical conditioning model be considered when clinicians or clinical researchers study the etiology of fears and anxieties learned by human beings. They argue that fears can be built through the combined effects of direct, observed, and verbally presented classical conditioning trials. Multimodal classical conditioning is offered as an alternative to the three pathways to fear argument prominent in the human fear literature. In contrast to the three pathways position, the authors present theoretical arguments for why "learning by observation" and "learning through the receipt of verbal information" should be considered classical conditioning through observational and verbal modes. The paper includes a demonstration of how data, commonly collected in research on the three pathways to fear, would be studied differently using a multimodal classical conditioning perspective. Finally, the authors discuss implications for assessment, treatment, and prevention of learned fears in humans.

Techniques for reducing anesthetic injection pain

BACKGROUND

The authors conducted a study that considered family physicians' and dentists' knowledge and application of techniques to reduce the pain associated with anesthetic injections. They also assessed practitioners' discomfort with patients' injection pain and needle anxiety/phobia.

METHODS

The authors designed a questionnaire about awareness and use of 10 techniques for reducing pain of anesthetic injection and mailed it to 2,000 randomly selected family physicians and general dentists. They analyzed the data to examine differences between disciplines regarding awareness and use of techniques, reasons for not using techniques, number of injections given per week, and predictive value of certain demographic variables on reported use of individual techniques and on practitioner reactions to patients' pain and anxiety.

RESULTS

The response rate was 35 percent. The authors used the chi2 test for differences between disciplines' awareness of and use or nonuse of techniques, Wilcoxon testing to assess differences between disciplines' median values of number of weekly injections and logistic regression to study demographic variables' predictive values (P = .01). General dentists give more injections than do family physicians. Differences existed between disciplines' awareness and use of eight of 10 techniques. Disciplines reported cost and time issues as reasons for not using some techniques. Number of years in practice and age were associated with use of six techniques. Dentists reported feeling greater personal effects of patients' pain and needle anxiety/phobia than did family physicians.

CONCLUSIONS

Those not using pain-lessening techniques inaccurately identified time and cost as problems, suggesting that respondents may be less familiar with these techniques than otherwise reported. Further study is recommended.

CLINICAL IMPLICATIONS

Pain reduction techniques for anesthetic injection cost little to implement, are not time liabilities, and can lessen avoidable pain and reduce the incidence of needle phobia.

Reducing injection pain in children and adolescents with diabetes: a review of indwelling catheters

Most children and adolescents find the pain when injecting insulin quite minimal but still significantly more painful than a placebo injection. However, injection pain and needle phobia are major problems for a small number of patients, even after many years of diabetes. Needle diameter is of less importance for the experienced pain. The use of indwelling catheters (Insuflon, Unomedical, Lynge, Denmark) for introducing insulin injections at the onset of diabetes results in an evident relief of preinjection anxiety, injection problems, and the procedural pain of repeated injections. The average indwelling time is 3-5 d. Fixation problems and local redness at the insertion site are the most frequent side effects. However, the frequency is low and they can be dealt with effectively. Needles of 8-10 mm should be used for injecting to avoid penetration of the tubing of the catheter. Using indwelling catheters for up to 4-5 d does not affect the absorption of insulin, when the catheter is inserted in an area free from lipohypertrophies. The long-term (measured by hemoglobin A1c) and short-term metabolic control (measured by blood glucose profiles and serum-free insulin) is not altered. Using this type of injection aid may decrease the risk of future injection problems, such as needle phobia, in very select patients. In conclusion, indwelling catheters can safely be used from the onset of diabetes to lessen injection pain in children and adolescents, and may facilitate the use of intensive insulin therapy in this age group.

General self-efficacy, dental anxiety and multiple fears among 20-year-olds in Norway

This paper examines the extent to which low general self-efficacy and painful dental and medical experiences are related to dental anxiety, multiple fears and to avoidance of dental care. A total of 754 20-year-olds completed a series of questionnaires, including the General Self-efficacy Scale (GSE), Geer Fear Scale (GFS) and Dental Fear Survey (DFS). Females had lower self-efficacy, higher dental anxiety and higher scores on the GFS than males. Multivariate analyses (linear stepwise regression) indicated that painful dental experiences, a high score on the GFS and negative opinions about own dental health explained 37% of the variance in DFS scores. Self-efficacy had no predictive power for dental anxiety, and only dental anxiety had predictive power for dental avoidance behavior. Thirty-eight percent of the total variance in GFS scores was explained by the following variables: being a female, high dental anxiety (DFS), low general self-efficacy (GSE) and low educational level of the mother.

Psychophysiologic effects of applied tension on the emotional fainting response to blood and injury

OBJECTIVE

The present study was designed to investigate the psychophysiologic effects of "Applied Tension" (AT) on the emotional fainting response to blood and injury in a controlled experiment.

METHOD

Twenty-two persons reporting to generally feel faint or to have fainted at the sight of blood or injury and 22 participants classified as Non-Fainters were randomly allocated to a treatment or control condition. Psychophysiologic responses were continuously monitored while individuals watched a video depicting open-heart surgery and a control film. Prior to the surgery film, participants in the treatment condition were instructed in the use of AT.

RESULTS

All participants classified as Fainters showed a diphasic response pattern while watching the surgery film. This response, however, was significantly attenuated in Fainters in the treatment condition.

CONCLUSIONS

These results suggest that AT provides an effective treatment strategy for the prevention of fainting responses in persons with a fear of blood and injury.

Frequency, comorbidity, and psychosocial impairment of specific phobia in adolescents

Investigated the frequency, comorbidity, and psychosocial impairment of specific phobia and specific fears among 1,035 adolescents 12 to 17 years old. The adolescents were recruited from 36 schools in the province of Bremen, Germany. Specific phobia and other psychiatric disorders were coded based on Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM-IV]; American Psychiatric Association, 1994) criteria using the computerized Munich version of the Composite International Diagnostic Interview (Wittchen & Pfister, 1996). Thirty-six (3.5%) of the adolescents met DSM-IV criteria for specific phobia sometime in their life. Of all the subtypes of specific phobia, animal and natural environment phobia were the most common. More girls than boys received the diagnosis of specific phobia. One third of the adolescents with specific phobia also had depressive and somatoform disorders. Despite the high level of psychosocial impairment experienced by individuals with specific phobia both during the worst episode of their disorder and in the last 4 weeks, only a small portion of them sought professional help.

Injection related anxiety in insulin-treated diabetes

The presence of injection related anxiety and phobia may influence compliance, glycaemic control and quality of life in patients with insulin-treated diabetes. Unselected consecutive, insulin-treated patients attending a diabetes clinic for follow-up, completed a standardised questionnaire providing an injection anxiety score (IAS) and general anxiety score (GAS). A total of 115 insulin-treated (80 Type 1 and 35 Type 2) diabetic patients completed the questionnaire. Injections had been avoided secondary to anxiety in 14% of cases and 42% expressed concern at having to inject more frequently. An IAS > or = 3 was seen in 28% of patients and of these, 66% injected insulin one to two times/day, 45% had avoided injections, and 70% would be bothered by more frequent injections. A significant correlation between IAS and GAS was seen (Kendall's tau-a 0.30, 95% CI 0.19-0.41, P < 0.001). GAS was significantly associated with both previous injection avoidance and expressed concern at increased injection frequency. No significant correlation was seen with HbA1c and injection or general anxiety scores. Symptoms relating to insulin injection anxiety and phobia have a high prevalence in an unselected group of diabetic patients requiring insulin injections and are associated with higher levels of general anxiety.

Reducing children's immunization distress in a primary care setting

The purpose of this study was to compare two brief, inexpensive distraction techniques for children receiving immunizations during a county-sponsored immunization clinic. Preschool children (n = 80) were assigned to a party blower intervention, a pinwheel intervention, or a control group. Nurses were instructed to use "standard instructions" for the control group, and to simply provide the distracter and encourage use, but not to spend time trying to train the child or force them to use it, for the other groups. Results of planned comparisons indicated significant party blower results in the children's ratings of reduced distress (P < .01) and the parents' ratings of having to hold their child less strongly (P = .04), and showed it to be more distracting than the pinwheel (P < .02). The overall pattern of results on all rating scales supports the efficacy of using a party blower for reducing children's immunization distress, with minimal staff training and no procedural delay.

Acquisition and severity of driving-related fears

Rachman's theory of fear acquisition proposes that directly-conditioned fears will differ from indirectly-conditioned fears in magnitude and anxiety response patterns, however the theory has received inconsistent empirical support. The aim of the present study was to describe the fear acquisition pathways for a community sample who reported driving-related fears, and to test Rachman's theory of fear acquisition. One hundred and ninety participants completed a questionnaire which assessed a variety of driving-related situations, reactions to motor vehicle accidents (MVAs), and anxiety response patterns. Professional psychological helpseeking and perceived need for treatment for driving-related fears were also assessed. Results failed to support Rachman's predictions. However, it was confirmed that respondents who had been involved in an MVA were more likely to ascribe their fears to a directly-conditioned pathway. The theoretical and methodological implications of the findings are discussed, along with suggestions for assessment of those with driving-related fears.

Recall and validation of phobia origins as a function of a structured interview versus the Phobia Origins Questionnaire

Memory for fear onset events was examined in 43 dog-fearful and 48 blood/injection-fearful participants. Half of each fear type was administered the Phobia Origins Questionnaire (POQ), and half the Phobia Origins Structured Interview (POSI). Written accounts of recalled onset experiences were sent to participants' parents for verification. More participants assessed by the POQ reported a phobia onset event (93%) than did those assessed by the POSI (54%). A majority in both methods recalled conditioning-like experiences. The POQ resulted in more reports of vicarious and informational onset reports than did the POSI. Parents confirmed more onset event reports obtained by the POSI (81%) than those obtained by the POQ, (50%). In addition, in 21% of cases where a child recalled an event, a parent reported an onset event that predated the one provided by the child. Results are discussed in terms of memory mechanisms operative in autobiographical memories.

Water trauma and swimming experiences up to age 9 and fear of water at age 18: a longitudinal study

A small number of retrospective studies on the etiology of specific fears have obtained findings consistent with a biological (non-associative) explanation of fear acquisition. Unfortunately, reliance on imperfect memory to recall conditioning events which occurred many years earlier limits the conclusions that can be drawn from such data. The present investigation attempts to overcome this methodological shortcoming by examining the relationship between water trauma (i.e. conditioning) and water skills (e.g. swimming) before the age of 9 and the presence of water fear and phobia at age 18 in a longitudinal birth cohort. We found no evidence of a relationship between water confidence and water trauma up to the age of 9 and fear of water at age 18. Similar findings were obtained for water phobia at age 18 with the exception that study members who were less able to immerse themselves in water with confidence at age 9 were more likely to report water phobia at age 18. Associative and non-associative explanations of these findings were discussed.

The convergent validity of the Phobia Origins Questionnaire (POQ): a review of the evidence

The Phobic Origins Questionnaire (POQ) [Ost, L.-G. & Hugdahl, K. (1981). Acquisition of phobias and anxiety response patterns in clinical patients. Behaviour Research and Therapy, 19, 439-447.] is the most commonly cited instrument for determining the origins of phobic anxiety and data obtained using this instrument strongly support the role of conditioning in the acquisition of fear reactions. The construct validity of the POQ in assessing episodes of conditioning has been questioned [e.g. Menzies, R. G. & Clarke, J. C. (1994). Retrospective studies of the origins of phobias: a review. Anxiety, Stress and Coping, 7, 305-318.] This paper examined the convergent validity of the POQ by comparing origins' classifications based on the POQ to classifications based on alternative instruments. The convergent validity of the POQ was found to be extremely poor. The POQ was consistently associated with a much greater likelihood of classifying the origin of fear reactions as due to direct conditioning episodes than was found using alternative instruments. The findings question the usefulness of the POQ in examining the origins of phobic anxiety.

Evidence for a non-associative model of the acquisition of a fear of heights

Theories that fear results from previous traumatic experience (i.e. conditioning theories) have enjoyed widespread support for over half a century. Recent research, however, has cast doubt on the validity of these models in some specific phobias. Two studies on the etiology of height phobia have obtained findings consistent with a non-associative, evolutionary explanation of fear acquisition (Menzies and Clarke, 1993a, Behaviour Research and Therapy, 31, 355-365; Menzies and Clarke, 1995a, Behaviour Research and Therapy, 33, 795-805). Unfortunately, the retrospective nature of these studies limits the conclusions that can be drawn from these data. Like all retrospective research, these studies depend on adult subjects imperfect ability to recall conditioning events that may have occurred many years earlier. The present investigation overcomes these methodological shortcomings by examining the relationship between putative conditioning events before the age of 9 yr and the presence of height fear at ages 11 and 18 yr in a large birth cohort studied longitudinally. To our knowledge this is the first study that has prospectively examined the relationship between relevant traumatic events early in life and the onset of height fear in late adolescence. No positive relationship was found between a history of falls resulting in injury (i.e. fracture, dislocation, intracranial injury or laceration) before the age of 9 and fear of heights at age 11 or 18. Interestingly, falls resulting in injury between the ages of 5 and 9 occurred more frequently in those without a fear of heights at 18 (P < 0.01)--a finding in the opposite direction to that predicted by conditioning theory but consistent with non-associative theories of fear acquisition. In general, the results provide strong support for non-associative models of fear and are difficult to reconcile with conditioning theories.

The etiology of childhood spider phobia

Twenty-six girls with a clinical spider phobia and 26 matched control girls were interviewed about conditioning, modeling, and negative information experiences in connection with spiders. In addition, parents of the phobic girls were independently interviewed about the origins of their child's phobia. Phobic children more often reported aversive conditioning experiences with spiders than did control children. Also, in a number of cases, conditioning events described by the phobic children were confirmed by their parents, a result that replicates the findings of Merckelbach, Muris and Schouten (1996; Behaviour Research and Therapy, 34, 935-938). Taken together, the results contradict a strong version of the non-associative account of phobias and suggest that in at least some cases, conditioning events may contribute to the development of (childhood) spider phobia.

Fear of water in children and adults: etiology and familial effects

Water-fearful children (non-swimmers. 5-8 yrs and adults (non-swimmers or late learners, 23-73 yr) were compared with non-fearful controls of similar swimming ability. Parallel assessments were carried out with children and adults to investigate water-related experiences, water fear and competence in parents and siblings, and the relationship of water fear to other fear dimensions. Children were assessed behaviorally and by self and mother's report, adults by self-report. In neither children nor adults was there clear evidence that fearful and non-fearful groups differed in incidence of aversive water-related experience before fear onset. Parents usually believed that children's fear was present at first contact. In both samples, we found parent-offspring and sibling resemblances in fear. Analysis of details of children's contact with parents suggested that social learning within the family decreased water fear rather than increasing it; when both child and parent showed fear, that was as likely to reflect genetic influences as modeling. Young children's water fear forms part of a generic cluster, fear of the Unknown or Danger, while in adults it becomes independent of generic fears.

Pathways to fear in spider phobic children

Twenty-two children with spider phobia were interviewed about the origins of their fear. More specifically, children were asked about conditioning events, modeling experiences, and negative information transmission. To evaluate the reliability of the information provided by the children, parents were independently interviewed about the origins of their children's phobias. While 46% of the children claimed to have always been afraid, 41% ascribed the onset of their fear to aversive conditioning events. The large majority of these events were confirmed by parents. These findings cast doubts on a strong version of the non-associative account of spider phobia, i.e. the idea that spider phobia is acquired in the complete absence of learning experiences.

Defence style and behaviour therapy outcome in a specific phobia

The Defense Style Questionnaire (DSQ) was administered to patients with a specific phobia (animal type; N = 54) and to control subjects (N = 29). Results indicated that specific phobia patients and non-phobic control subjects exhibit a similar pattern of defences. Also, the study investigated whether specific DSQ defence styles affect behaviour therapy outcome. It was found that an immature defence style, and especially the defence mechanism projection, was related to less favourable treatment results.