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Dealing with Fear of Needles

I work in a single chair draw station. I have placed old calendar pictures on the walls around the chair and usually have 2 or 3 people comment each day on the pretty pictures. I found that having something for the patient to look at, such as a green restful picture with a running stream helps with the needle phobia.

Susan Roberts 
 
More Tips From The Pros  

Watch this short phlebotomy video clip! A nervous patient anticipates the needle stick:

Click here! >  
attention ATTENTION: Please realize that this video (published from YouTube) is NOT HERE TO TEACH you phlebotomy techniques, but merely to show you different scenarios of the phlebotomist's daily routine. The video may contain techniques, or procedures that do not conform to proper, and safe venipuncture protocol. Viewer discretion is strongly advised.

 

Welcome to the Needle Phobia Page
A starting point for overcoming an important, but often-ignored condition of fear of needles
© 1997-2003 Jerry Emanuelson
 

This is an exact reprint from: http://www.webcom.com/cfsc/needles.html 

Needle phobia is a defined* medical condition that affects more than 10 percent of the population to an extent that it causes them to avoid needed medical care. The medical profession pays inadequate attention to needle phobia, in part, because those with needle phobia tend to avoid contact with the medical profession.

A 1997 Medline search of the medical literature since 1985 turned up only 16 articles in response to a keyword search for needle phobia. One would expect that any disorder affecting more than 10 percent of the population would generate thousands of medical journal articles. For example, a keyword search in the same database at that time on diabetes listed 66,190 articles.

There is only one comprehensive review of needle phobia in the medical literature. That review is an excellent and comprehensive article: Needle Phobia: A Neglected Diagnosis by James G. Hamilton, M.D. in the August, 1995 issue of The Journal of Family Practice. [Vol. 41, No.2, pp. 169-175]

Dr. Hamiliton's review does have 56 references, dating back as far as 1939, to other medical journal articles -- although many of the references are to single case histories, or to topics only secondarily related to needle phobia. There are large differences among individuals with needle phobia, but needle phobia can be put into four broad categories:

(1) The type of needle phobia described in Dr. Hamilton's article is characterized by the vasovagal reflex reaction, a frightening reaction which includes plunging blood pressure and (often) loss of consciousness. This reaction generally occurs only after puberty, and is more common in men than women.

(2) It is very common for young children to be afraid of needles. Most children will simply "outgrow" their fear. Others will become adult needle phobics. Children who are needle phobic can be administered topical EMLA cream or iontophoresis (see below). Forcing needle phobic children to undergo needle procedures without the treatments described below will only increase the chances that they will become severe needle phobics and avoid medical care as adults.

(3) Some needle phobics have an acute sensitivity to pain. Needle procedures that are painless to most people cause considerable physical pain to these needle phobics. The purchase of one of the iontophoresis units described below will greatly improve the lives of these individuals.

(4) The rarest type of needle phobia (but the type that most people think that they have) is a classic phobia that results from an early traumatic experience. Many people with needle phobia remember an early experience which they believe triggered their needle phobia. Most of the time, though, these people are simply remembering their first needle phobia reaction. The traumatic experience that is described is usually a routine needle procedure that occurred without any significant problem other than the needle phobia reaction itself.

Many needle phobics fit into more than one of these categories, and there may be other categories that are not listed here. Needle phobia is a subject that has received very little formal study. Whatever form your needle phobia takes, some of the treatments listed below are likely to be useful.

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About 80 percent of needle phobics have a first-degree relative (parent, child or sibling) with needle phobia. This is evidence that needle phobia has a genetic component. It is a genetic trait that had survival value for humans prior to the 20th century. Before modern medicine, an individual with an inordinate fear of being stuck with a fang, a thorn or a knife was less likely to die in accidents or in encounters with hostile animals or men. Prior to the 20th century, even an otherwise non-fatal puncture wound had a reasonable chance of causing a fatal infection. This trait that had positive survival value prior to the 20th century now has a negative survival value as it shuts its victims off from many of the benefits of 21st-century medicine.

An episode of needle phobia can be frightening not only for the needle phobic, but for others present as well. When needle phobia results in loss of consciousness, it is not uncommon for it to be accompanied by convulsions or respiratory distress. There are, in fact, at least 23 documented cases of death due to needle phobia. One of those deaths was the father of Dr. Hamilton, who wrote the review article mentioned above.

Of much greater concern than the rare cases of death directly due to needle phobia are the countless thousands of premature deaths caused by the avoidance of medical care due to needle phobia. The avoidance of medical care due to needle phobia causes an amount of human suffering that is on a scale with many major well-known diseases.

Needle phobia can be overcome, though. In fact, even though I am a lifelong needle phobic, I am writing the first draft for this page as I am sitting here with a needle in my left arm, undergoing an elective 3-hour intravenous therapy as part of a my personal program of preventive medicine. I'm doing fine now, in the 2nd of 10 such sessions. I decided to set up this web page after suffering a vasovagal reflex reaction and losing consciousness shortly after beginning the first of these 3-hour I.V. treatments a week earlier. That was my first needle phobia reaction in many years, even though it had been a constant problem for me up through my early twenties.

Overcoming needle phobia does present special difficulties, and it does not usually respond well to traditional techniques for overcoming phobias. It is usually a distinct physiological reaction that is, to some extent, hard-wired into the human brain.

Quite often, even after a person has lost his conscious fear of needles, he may retain anxiety about the physiological needle-phobia reaction. For many needle phobics, the physiological needle-phobia reaction is much more unpleasant and anxiety-provoking than the needle stick itself. (I have pretty much lost all conscious fear of needles myself, and I can even give myself injections; but I still have a vasovagal reflex reaction occasionally if I'm not careful, and I find the vasovagal reflex reaction to be a truly terrifying experience.)

The differences between needle phobia and other common phobias cannot be over-emphasized. Psychologists and counselors should be warned against attempting to treat needle phobics in a non-medical environment. (Conventional treatments for phobias have a very poor track record against needle phobia, even in cases where the phobia is acquired from a traumatic event.) Conjuring up images of needle procedures can evoke a full needle-phobic reaction, including vasovagal shock and possible cardiovascular problems. Although permanent injury is very rare, no one should risk evoking the physiological needle-phobic reaction without emergency oxygen and the presence of medical personnel skilled in cardiovascular resuscitation.

The rare fatal reactions to needle phobia should not deter anyone from getting needed medical attention, or even preventive medical procedures. Even a needle phobic with a weak heart is more likely to die in a traffic accident on the way to the doctor's office than of a needle phobia reaction. Every needle phobic is far more likely to die from avoiding medical care than from a needle phobia reaction. Even though there is no solid data on the subject, nearly everyone who looks seriously at the needle phobia problem will conclude that needle phobics suffer premature deaths in large numbers as a result of avoiding medical care.

A modern physician's office is well-equipped to deal with a typical needle phobia reaction and has several people present who are well-trained in cardiovascular resuscitation in the rare event that it should become necessary.

Many needle phobics who were born prior to the mid-1960's had their needle phobia reinforced in childhood by poor quality control in needle manufacture which resulted in occasional dull or poorly-beveled needles. Also, many medicines, such as penicillin, that were given in earlier days were highly-viscous liquids that required large gauge needles. Most substances given by injection today use very thin and very sharp needles that can hardly be felt by most people. Quality control in needle manufacture is far superior to what it was thirty or more years ago.




This page was started on February 14, 1997. It will have frequent additions and modifications as I acquire new information (and as I have time).

This page originated because of my strong personal interest in preventive medicine. Preventive medicine may have remarkably beneficial effects that are indicated clearly on blood tests, but those benefits may remain invisible for years without the necessary lab tests. Since effective preventive medicine can be expensive and time-consuming, if the benefits are invisible in the short-term, motivation may be lost; and the unfortunate result may be that a very effective program of preventive medicine is discontinued.




Treatments

There are a number of methods that can be used to "unlearn" the needle phobia reaction:

One of the most effective steps in overcoming severe needle phobia is to anesthetize the site of the needle stick. Since modern sharp needles produce a needle stick that is usually painless, topical anesthetics are rarely used. But this misses the point of using anesthesia in needle phobics. (Part of the needle phobia reaction is often a great amplification of any pain that does occur.) The reason for topical anesthesia is to totally eliminate the sensation of being stuck by a needle.

Topical lidocaine may be useful for this, but topical lidocaine alone will anesthetize skin only to a depth of 2 or 3 mm. Iontophoresis is a process which uses a mild electrical current to drive lidocaine into the skin so the injection or venipuncture site can be quickly anesthetized to a depth of 1 or 2 centimeters. An FDA-approved medical device made by Life-Tech called the NeedleBuster has been designed for this purpose and is now available to health care professionals. A similar competing iontophoresis product is Numby Stuff from Iomed Clinical Systems. Iontophoresis units cost a few hundred dollars. Most can be purchased by individuals if they have a doctor's prescription for the device.

EMLA(Eutectic Mixture of Local Anesthetics) is a unique topical anesthetic cream that is available by prescription in the U.S., and over-the-counter in much of Canada. One of its uses listed on the FDA-approved labeling is for "intravenous cannulation and venipuncture." EMLA is a mixture of lidocaine and prilocaine that is a liquid at room temperature, even though both lidocaine and prilocaine are room-temperature solids. (This is what is meant by eutectic. Another common eutectic mixture is solder, which has a lower melting point that its constituent metals.)

The liquid penetrates much more deeply than ordinary anesthetic solutions. The anesthetic doesn't penetrate as deeply as it does with the NeedleBuster or Numby Stuff, nor does it act nearly as fast; but EMLA has the advantage of being much more readily available for most people. EMLA must be applied at least one hour before the needle procedure. Any pharmacy either has it or can get it easily. U.S. residents can purchase EMLA without a prescription from canadapharmacy.com. EMLA cream should be applied one hour before the needle procedure. (Some individuals may require more time.)

The effectiveness of EMLA cream varies greatly from individual to individual. EMLA works quite well for most people whose needle phobia reaction is triggered by the sensation of the needle going in. EMLA does not work well for most people whose primary problem is an acute sensitivity to pain. EMLA is made by Astra-Zeneca Pharmaceuticals. An EMLA patch is also available. For more information, visit the EMLA web site.

If neither EMLA nor an iontophoresis device is available, ice can often be used to carefully numb the injection site. Like EMLA, this works for some people whose reaction is triggered by the sensation of the needle going in, but it does little for acute sensitivity to pain. Ice does not work as well as EMLA or iontophoresis, but it works well enough for some people.

Another effective technique for overcoming needle phobia is to for the patient to be given a fast-acting anti-anxiety agent such as diazepam (Valium) prior to the needle stick. A relatively large dose may be needed, depending on the severity of the needle phobia, but eventually the anti-anxiety agent may become unnecessary as the needle-phobia reaction is "unlearned." Do not drive while under the influence of a large dose of an anti-anxiety agent. These anti-anxiety medicines must be used as directed by a physician, but they can be very effective, especially for those whose main problem the fainting (the vasovagal reflex reaction).

Elevation of the legs, or even lying down, during the needle procedure can reduce the vasovagal reflex and help to prevent loss of consciousness and other physical symptoms. Some patients must lie with legs elevated and their head lowered. The patient must be encouraged to remain lying or sitting until he feels quite comfortable slowly standing up.

If vasovagal reflex (fainting) is your main problem, then the class of medicines called beta blockers may be useful. There have been a number of scientific tests of beta blockers for vasovagal reflex, but the results have been very inconsistent. Beta blockers do seem to be very useful for some people, though. The older beta blockers, such as propranolol (Inderal) and atenolol (Tenormin) are very inexpensive and very safe. When used only intermittently in healthy people, they are almost completely free of side effects. Beta blockers are most commonly used as blood pressure medications, but they have many other uses. One big advantage of beta blockers over other medications is that they rarely have any significant effect on thinking and reaction time. So, unlike large doses of tranquilizers or anti-anxiety medications, beta blockers usually don't affect your ability to do things like driving.

Dr. Hamilton reports that nitrous oxide can be quiet useful, either alone or combined with an oral anti-anxiety agent. Nitrous oxide is probably the safest and most convenient anti-anxiety agent, especially for milder cases of needle phobia.

Needle phobics should be treated only by medical personnel who are experienced and skilled at injections or venipuncture. Relatively inexperienced nurses should gain their experience on non-needle-phobic patients. Also, be aware that problems with any of the apparatus during venipuncture are likely to unduly panic a needle-phobic patient. Such problems may even cause a relapse among patients who have overcome their needle phobia. Consider temporarily aborting the procedure if problems are encountered with any of the equipment during procedures performed on a needle phobic patient.

Shallow and/or rapid breathing can be a symptom of needle phobia, but it can also hasten further physiological needle phobia reactions. Needle phobics need to make a conscious attempt to breath deeply and slowly. This cannot be emphasized enough.

Needle phobics who know details of their own particular needle phobic reactions should not hesitate to communicate that information to medical personnel. Many needle phobics have preferred locations for a needle insertion. During I.V. procedures, certain needle puncture locations make the presence of a needle much less obvious than other locations.

Needle phobics who have avoided medical care and have not received an injection in a long time should consider taking a first step in overcoming this condition by getting a routine vaccination (such as a flu shot at the appropriate time of the year). Get the injection at a doctor's office. Let the nurse know that you are needle phobic, and get the injection while your are sitting or lying down. Don't get up too quickly. Stay in the doctor's office for fifteen minutes or so after the injection. The physiological needle phobia reaction sometimes doesn't occur until a few minutes after the injection.
 

In spite of the fact that the physiological vasovagal reflex reaction is very consistent, there are individual differences in the subjective perceptions of needle phobics. The best techniques to use vary greatly from individual to individual. These individual differences must be taken into account when choosing a solution.

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According to Dr. Hamilton's article, the clinical findings associated with the vasovagal reflex reaction include:

  • Physical symptoms of syncope (fainting), near-syncope, light-headedness, or vertigo upon needle exposure, along with other autonomic symptoms, e.g., pallor, profuse sweating, nausea.
  • Cardiovascular depression with a drop in blood pressure and/or pulse; with or without an initial rise in blood pressure and/or pulse prior to the needle stick.
  • Electrocardiogram anomalies of virtually any type.
  • Rises in any combination of several stress hormones: antidiuretic hormone (vasopressin), human growth hormone, dopamine, catecholamines, corticosteroids, renin, endothelin, and beta-endorphin.

Those who wish to learn more about needle phobia are encouraged to read the article by Dr. Hamilton mentioned above. The Journal of Family Practice is available in any medical library. Most cities have at least one hospital with a medical library that is available to the public. Many people have recently been having a very difficult time finding this article since many smaller libraries are no longer keeping issues from 1995 or earlier on the shelves.

I have arranged to make copies of the article available. The only practical way for me to do this is to buy expensive custom bulk reprints from publisher of The Journal of Family Practice,. Reprints of the article are available for sale (from Colorado Futurescience, the science education company that hosts this web site) for $10 each, including postage. (Additional copies beyond the first reprint are $8.00 each.) I don't like the fact that a 7-page article costs this much, but the only reprints that the publisher makes available are expensive reprints on heavy glossy stock. After you purchase one copy, you can make your own copies for personal use.

Please address all order inquiries to Jerry Emanuelson.
 

phlebotomy web site break 

Important: Showing a copy of the article from the Journal of Family Practice to your physician may encourage him to take your needle phobia more seriously. I can't emphasize the importance of this enough. Often, the only way to convey new medical information to a physician is to show the physician a copy of an article from a respected medical journal. You may be surprised how often this can make a real difference in your treatment. Every time that you successfully educate a medical professional about needle phobia, you will be making life better for yourself and for other needle phobics, as well.
 

Needle phobia is a medical condition that deserves treatment just as much as any other medical condition. You shouldn't be ashamed of having needle phobia any more than you should be ashamed of having a headache. Doctors and other medical professionals need to be educated about the nature of needle phobia and its treatments. Unfortunately, it is up to patients with needle phobia to educate themselves about this condition, and then to convey that information to their physicians.




Also see Keith Lamb's Needle Phobia Page for more valuable information about needle phobia and an excellent review of some of the treatments to relieve needle phobia. Keith has made an excellent and very informative site, which he has recently greatly expanded.




*Needle Phobia is a defined medical condition according to the standard reference work on the subject, the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV).




This page contains a considerable amount of information in a small amount of space. If you are suffering from needle phobia, it is a good idea to re-read this information carefully. Also read the information carefully on Keith Lamb's site mentioned above. (Keith and I suffer from different types of needle phobia, and we have somewhat different perspectives on the problem.)

Unfortunately, I do not know of any physicians offering help or treatment for this condition. I would very much like to develop a list of physicians who treat needle phobia, but that list does not yet exist. Physicians who make special provisions for needle phobic patients are desperately needed. I am asking doctors who are interested to contact me.
 

Dr. Hamilton is not in private practice, but he can be contacted by writing to him at:

Dr. James Hamilton
1821 Hillandale Road Suite 1B-159
Durham, NC 22705

Dr. Hamilton is seriously considering writing a book on needle phobia. He is currently sending his book proposal to publishers. I have been contacted by one dentist who specializes in needle phobia and other dental phobias. You can contact him at the Dental Phobia Page.

I received an interesting email from a Ph.D. candidate in clinical psychology who was doing research into a needle phobia treatment. He has now received his Ph.D and is in private practice in Colorado Springs. For information about receiving treatment using the methods in his research project, see the additional information here. I have no personal knowledge about this treatment, but it is the only such treatment available anywhere of which I am aware.




Copies of this page may be made for any non-commercial use as long as the copyright notice is included. It may be especially useful for patients to take a copy of this page to their physicians. In fact, I strongly encourage patients to inform their physicians about this subject. The only way that needle phobia is ever going to be taken seriously by the medical profession is if needle phobics take charge of the situation and insist that provisions are made for their needle phobia. 

This page is for informational purposes only. It is not intended to provide any medical advice. This Needle Phobia Page is maintained by Jerry Emanuelson.   

Jerry Emanuelson's email address is:
jerry@futurescience.com 

 

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