Blood-Injection-Injury Phobia and Dog Phobia in Youth: Psychological Characteristics and Associated Features in a Clinical Sample

Specific Phobia, Fear, and the Autism Spectrum in Children and Adolescents: Adapting OST for ASD

Fears and phobias are a common mental health concern for youth, and particularly for autistic youth. The following review briefly summarizes the extant literature on specific phobias and specific phobias in autistic youth. The evidence base is briefly highlighted pointing to the strong base behind behavioral and cognitive-behavioral treatments and techniques. A broad discussion of key evidence-based treatment findings is presented, leading up to the impactful work of Thomas H. Ollendick in researching Öst's One-Session Treatment (OST) with children and adolescents. OST for child specific phobias is discussed, and particular emphasis is given to this treatment's ongoing adaptation for use with youth on the autism spectrum.

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.

Cognitive Biases in Blood-Injection-Injury Phobia: A Review

Blood-injection-injury (BII) phobia can lead to avoidance of crucial medical procedures and to detrimental health consequences, even among health workers. Yet unlike other specific phobias, BII phobia has been understudied. Specifically, while cognitive biases have been extensively investigated in other anxiety disorders, little is known about the same biases in BII phobia. The current article reviews cognitive biases in BII phobia and suggest future directions for further study and treatment. The reviewed biases include attention, expectancy, memory, perception, and interpretation biases. The investigation of these biases is highly relevant, as cognitive biases have been found to interact with anxiety symptoms. Results showed that attention, expectancy, and memory biases are involved in BII phobia, while no studies were found on interpretation nor perception biases. Mixed results were found for attention bias, as different studies found different components of attention bias, while others found no attention bias at all. Similarly, some studies found a-priori/a-posteriori expectancy biases, while other studies found only one type of bias. A better understanding of the cognitive particularities of BII phobia may lead to better treatments and ultimately reduce avoidance of needles and blood-related situations, thereby enabling individuals with BII phobia to undergo potentially life-saving medical procedures.

Profiles of Temperament among Youth with Specific Phobias: Implications for CBT Outcomes

Specific phobias (SPs) are characterized by excessive fear or anxiety regarding an object or situation. SPs often result in a host of negative outcomes in childhood and beyond. Children with SPs are broadly assumed to show dispositional over-regulation and fearfulness relative to children without SPs, but there are few attempts to distinguish dispositional patterns among children with SPs. In the present study, we examined trajectories of differing temperamental profiles for youth receiving a CBT-based treatment for their SP. Participants were 117 treatment seeking youth (M Age = 8.77 years, Age Range = 6-15 years; 54.7% girls) who met criteria for a SP and their mothers. Three temperament profiles emerged and were conceptually similar to previously supported profiles: well-adjusted; inhibited; and under-controlled. While all groups showed similarly robust reductions in SP severity following treatment, differences among the three groups emerged in terms of broader internalizing symptoms, externalizing symptoms, and global outlook. The well-adjusted group was higher in functioning initially than the other two groups. The inhibited group had initial disadvantages in initial internalizing symptoms. The under-controlled group showed greatest comorbidity risks and had initial disadvantages in both internalizing and externalizing symptoms. These distinct clusters represent considerable heterogeneity within a clinical sample of youth with SP who are often assumed to have homogenous behavior tendencies of inhibition and fearfulness. Findings suggest that considering patterns of temperament among children with phobias could assist treatment planning and inform ongoing refinements to improve treatment response.

Brain and Emotion

Progress in understanding the relation between brain profiles and emotions is being slowed by the belief in a collection of basic emotional states, with the names: fear, anger, joy, disgust, and sadness, that do not specify the species or age of the experiencing agent, the origin of the state, or the evidence used to infer it. This article evaluates critically the premise that decontextualized emotional words refer to natural kinds. It also suggests that investigators set aside the currently popular words and search for relations, in humans and animals, between patterns of measures to varied incentives presented in distinctive contexts.

Harm beliefs and coping expectancies in youth with specific phobias

Catastrophic beliefs and lowered coping expectancies are often present in individuals with specific phobias (SPs). The current study examined these beliefs and expectancies in 251 youth who received One Session Treatment for one of the three most common types of SP in youth (animals, natural environment, and situational). We compared the children's subjective beliefs to objective ratings of the likelihood of occurrence and the dangerousness of the feared events. Results revealed pre-treatment differences in the youths' beliefs across phobia types and age. Specifically, children with animal phobias rated their beliefs as more likely to occur than did children with environmental and situational phobias. In addition, older children rated their beliefs as more dangerous than younger children. However, regardless of phobia type or child age, the beliefs improved following treatment. Changes in catastrophic beliefs and coping expectancies were related to changes in clinical severity following treatment but not 6-months following treatment. Moreover, at pre-treatment, children viewed their beliefs as significantly more catastrophic and likely to occur than did independent coders of these beliefs; however, these differences were no longer evident following treatment. Clinical implications are discussed, highlighting how changes in beliefs and expectancies might be associated with treatment outcomes.

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.

Exposure-based Interventions for the management of individuals with high levels of needle fear across the lifespan: a clinical practice guideline and call for further research

Needle fear typically begins in childhood and represents an important health-related issue across the lifespan. Individuals who are highly fearful of needles frequently avoid health care. Although guidance exists for managing needle pain and fear during procedures, the most highly fearful may refuse or abstain from such procedures. The purpose of a clinical practice guideline (CPG) is to provide actionable instruction on the management of a particular health concern; this guidance emerges from a systematic process. Using evidence from a rigorous systematic review interpreted by an expert panel, this CPG provides recommendations on exposure-based interventions for high levels of needle fear in children and adults. The AGREE-II, GRADE, and Cochrane methodologies were used. Exposure-based interventions were included. The included evidence was very low quality on average. Strong recommendations include the following. In vivo (live/in person) exposure-based therapy is recommended (vs. no treatment) for children seven years and older and adults with high levels of needle fear. Non-in vivo (imaginal, computer-based) exposure (vs. no treatment) is recommended for individuals (over seven years of age) who are unwilling to undergo in vivo exposure. Although there were no included trials which examined children < 7 years, exposure-based interventions are discussed as good clinical practice. Implementation considerations are discussed and clinical tools are provided. Utilization of these recommended practices may lead to improved health outcomes due to better health care compliance. Research on the understanding and treatment of high levels of needle fear is urgently needed; specific recommendations are provided.