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von Mücke-Heim IA, Walter I, Nischwitz S, Erhardt A. Combined Fainting and Psychogenic Non-epileptic Seizures as Significant Therapy Hurdles in Blood-Injury-Injection Phobia: A Mini-Review and Case Report. Front Psychiatry 2022; 13:915058. [PMID: 35903630 PMCID: PMC9314666 DOI: 10.3389/fpsyt.2022.915058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 06/22/2022] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Iven-Alex von Mücke-Heim
- Max Planck Institute of Psychiatry, Outpatient Clinic, Munich, Germany.,International Max Planck Research School for Translational Psychiatry (IMPRS-TP), Munich, Germany
| | - Isabelle Walter
- Max Planck Institute of Psychiatry, Outpatient Clinic, Munich, Germany
| | - Sandra Nischwitz
- Max Planck Institute of Psychiatry, Outpatient Clinic, Munich, Germany
| | - Angelika Erhardt
- Max Planck Institute of Psychiatry, Outpatient Clinic, Munich, Germany.,Department of Psychiatry, Clinical Anxiety Research, University of Würzburg, Würzburg, Germany
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Mason EC, Gaston JE, Pestell CF, Page AC. A comprehensive group-based cognitive behavioural treatment for blood-injection-injury phobia. BRITISH JOURNAL OF CLINICAL PSYCHOLOGY 2021; 61:494-509. [PMID: 34750831 DOI: 10.1111/bjc.12345] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 09/14/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVES A key feature of blood-injection-injury (BII) phobia is activation of disgust responses, in addition to fear. Yet, standard treatments have largely neglected addressing disgust responses. The disorder is further complicated by fainting in 75% of sufferers. Moreover, treatments have been traditionally delivered in an individual format, which may not be as efficient as group treatment. The aim of this study was to develop a group-based programme for BII phobia, with components targeting fear, disgust, and fainting, to determine feasibility and effectiveness of such an intervention. METHODS Participants took part in an 8-session, group-based Cognitive Behavioural Therapy (CBT) programme for BII phobia (N = 40). The key outcome measure was the Multidimensional Blood/Injury Phobia Inventory, which assesses a range of phobic stimuli and responses (including fear, disgust, and fainting). RESULTS There were significant improvements, with large effect sizes, across symptoms over the course of treatment. Participants with higher disgust sensitivity reported higher pre-treatment symptom severity and greater life interference than those with lower disgust scores. Despite this, neither pre-treatment disgust sensitivity nor fainting history impacted on treatment response. For the first time, however, we showed that greater reductions in disgust to BII stimuli were associated with greater overall symptom reductions, highlighting the importance of disgust in the treatment of this disorder, and potentially others. CONCLUSION Despite the heterogeneous nature of BII phobia, this group-based, modified CBT intervention was effective in reducing a variety of phobic responses, including fear, disgust, and fainting. PRACTITIONER POINTS Disgust is a key maintaining factor in blood-injection-injury phobia, which clinicians should consider in their assessment and treatment of this disorder. There is little in the existing literature to guide clinicians in this regard. This study examined a novel group treatment for blood-injection-injury phobia which included strategies to target disgust, in addition to traditional CBT strategies to address fear and fainting. The treatment was feasible and acceptable. Symptoms of fear, disgust, and fainting reduced significantly over treatment. Changes in disgust symptoms were associated with overall symptom changes, however a control group is needed to determine the effects of individual treatment components and to make more robust conclusions about the benefits of this enhanced approach.
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Affiliation(s)
- Elizabeth C Mason
- Clinical Research Unit for Anxiety and Depression, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
| | - Jonathan E Gaston
- Centre for Emotional Health, Department of Psychology, Macquarie University, North Ryde, New South Wales, Australia
| | - Carmela F Pestell
- School of Psychological Science, University of Western Australia, Perth, Western Australia, Australia
| | - Andrew C Page
- School of Psychological Science, University of Western Australia, Perth, Western Australia, Australia
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Abado E, Aue T, Okon-Singer H. Cognitive Biases in Blood-Injection-Injury Phobia: A Review. Front Psychiatry 2021; 12:678891. [PMID: 34326784 PMCID: PMC8313757 DOI: 10.3389/fpsyt.2021.678891] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 06/17/2021] [Indexed: 12/20/2022] Open
Abstract
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.
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Affiliation(s)
- Elinor Abado
- School of Psychological Sciences, University of Haifa, Haifa, Israel.,The Integrated Brain and Behavior Research Center, University of Haifa, Haifa, Israel
| | - Tatjana Aue
- Department of Psychology, University of Bern, Bern, Switzerland
| | - Hadas Okon-Singer
- School of Psychological Sciences, University of Haifa, Haifa, Israel.,The Integrated Brain and Behavior Research Center, University of Haifa, Haifa, Israel
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McMurtry CM, Taddio A, Noel M, Antony MM, Chambers CT, Asmundson GJG, Pillai Riddell R, Shah V, MacDonald NE, Rogers J, Bucci LM, Mousmanis P, Lang E, Halperin S, Bowles S, Halpert C, Ipp M, Rieder MJ, Robson K, Uleryk E, Votta Bleeker E, Dubey V, Hanrahan A, Lockett D, Scott J. 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. Cogn Behav Ther 2016; 45:217-35. [PMID: 27007463 PMCID: PMC4867871 DOI: 10.1080/16506073.2016.1157204] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 02/09/2016] [Indexed: 12/20/2022]
Abstract
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.
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Affiliation(s)
- C. Meghan McMurtry
- Department of Psychology, University of Guelph, Guelph, Canada
- Pediatric Chronic Pain Program, McMaster Children’s Hospital, Hamilton, Canada
- Children’s Health Research Institute, London, Canada
- Department of Paediatrics, Schulich School of Medicine & Dentistry, Western University, London, Canada
| | - Anna Taddio
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
- The Hospital for Sick Children, Toronto, Canada
| | - Melanie Noel
- Department of Psychology, University of Calgary, Calgary, Canada
- Alberta Children’s Hospital Research Institute, Calgary, Canada
| | | | - Christine T. Chambers
- Department of Pediatrics, Department of Psychology and Neuroscience, Dalhousie University, Halifax, Canada
- The Centre for Pediatric Pain Research, IWK Health Centre, Halifax, Canada
| | | | - Rebecca Pillai Riddell
- The Hospital for Sick Children, Toronto, Canada
- Department of Psychology, York University, Toronto, Canada
- Department of Psychiatry, University of Toronto, Toronto, Canada
| | - Vibhuti Shah
- Mount Sinai Hospital, Toronto, Canada
- Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Noni E. MacDonald
- Department of Pediatrics, Dalhousie University, Halifax, Canada
- IWK Health Centre, Halifax, Canada
- Canadian Center for Vaccinology, Halifax, Canada
| | - Jess Rogers
- Centre for Effective Practice, Toronto, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
| | - Lucie M. Bucci
- Immunize Canada, Ottawa, Canada
- Canadian Public Health Association, Ottawa, Canada
| | | | - Eddy Lang
- Alberta Health Services and the Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Scott Halperin
- Department of Pediatrics, Dalhousie University, Halifax, Canada
- IWK Health Centre, Halifax, Canada
- Canadian Center for Vaccinology, Halifax, Canada
- Department of Microbiology & Immunology, Dalhousie University, Halifax, Canada
| | - Susan Bowles
- College of Pharmacy, Dalhousie University, Halifax, Canada
| | - Christine Halpert
- Immunization Programs and Vaccine Preventable Diseases Service, BC Centre for Disease Control, Vancouver, Canada
| | - Moshe Ipp
- The Hospital for Sick Children, Toronto, Canada
- Faculty of Medicine, Department of Paediatrics, University of Toronto, Toronto, Canada
| | - Michael J. Rieder
- Departments of Paediatrics, Physiology & Pharmacology and Medicine, Schulich School of Medicine & Dentistry, Western University, London, Canada
| | - Kate Robson
- Canadian Family Advisory Network, Toronto, Canada
| | | | | | | | - Anita Hanrahan
- Communicable Disease Control, Alberta Health Services, Edmonton, Canada
| | - Donna Lockett
- Bodhi Seed Center for Healing and Conscious Living, Milton, Canada
| | - Jeffrey Scott
- Department of Emergency Medicine, IWK Health Centre, Halifax, Canada
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McMurtry CM, Noel M, Taddio A, Antony MM, Asmundson GJ, Riddell RP, Chambers CT, Shah V. Interventions for Individuals With High Levels of Needle Fear: Systematic Review of Randomized Controlled Trials and Quasi-Randomized Controlled Trials. Clin J Pain 2015; 31:S109-23. [PMID: 26352916 PMCID: PMC4900415 DOI: 10.1097/ajp.0000000000000273] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2015] [Accepted: 06/18/2015] [Indexed: 01/08/2023]
Abstract
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.
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Affiliation(s)
- C. Meghan McMurtry
- Department of Psychology, University of Guelph, Guelph
- Children’s Health Research Institute
- Department of Paediatrics, Western University, London
| | - Melanie Noel
- Department of Psychology, University of Calgary, AB, Canada
| | - Anna Taddio
- Leslie Dan Faculty of Pharmacy
- The Hospital for Sick Children
| | | | | | - Rebecca Pillai Riddell
- Department of Psychiatry
- The Hospital for Sick Children
- Department of Psychology, York University
| | - Christine T. Chambers
- Departments of Pediatrics, Psychology & Neuroscience, Dalhousie University
- Centre for Pediatric Pain Research, IWK Health Centre, Halifax, NS, Canada
| | - Vibhuti Shah
- Health Policy Management and Evaluation, Faculty of Medicine, University of Toronto
- Mount Sinai Hospital, Toronto, ON
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