Treatment of Severe Blood-Injection-Injury Phobia With the Applied-Tension Method

Abstract

Blood-injection-injury phobias can be so severe that they interfere with receiving necessary medical care. Compared with most other phobias that typically increase heart rate, blood-injection-injury phobias are unique in their association with vasovagal responses. Thus, patients with blood-injection-injury phobias are typically less responsive to relaxation techniques, which in fact may be counterproductive. The current case studies describe use and clinical effectiveness of applied tension for treatment of severe blood-injection-injury phobia in two adolescent patients. Treatment included in vivo gradual exposure to feared stimuli combined with mastery of the tension technique to cope with anxiety, reduce vasovagal responses, and ultimately receive recommended medical treatment. Both patients experienced a significant decrease in anxiety and successfully underwent medical intervention without experiencing syncope. Directions for future research are discussed.

Keywords

blood-injection-injury phobia applied-tension technique adolescents

1 Theoretical and Research Basis for Treatment

Blood-injection-injury phobia is characterized by intense fear and avoidance of blood and needles. Epidemiological research suggests that this phobia is prevalent in approximately 3.5% of the general population, with 5.5 years as the median age of onset (Bienvenu & Eaton, 1998). Anxiety involving blood and needles is common in medical settings and may result in significant medical consequences. Specifically, many patients with blood-injection-injury phobias avoid routine medical care and medically necessary interventions that are common in the management of more serious medical conditions (Berlin et al., 1997; Kleinknecht & Lenz, 1989; Marks, 1988). Due to the potentially significant consequences of this phobia, it is essential to develop effective treatments for managing fears associated with blood-injection-injury phobia.

Blood-injection-injury phobia has distinct clinical features that make it less responsive to treatments often used with other phobias (e.g., relaxation training). Whereas most phobic reactions involve an increase in blood pressure and tachycardia (e.g., fast heart rate) when presented with the phobic stimuli, the majority of blood-injection-injury phobic reactions include a unique diphasic physiological response of initial tachycardia and increase in blood pressure, followed by bradycardia (e.g., slow heart rate), decreased blood pressure, vertigo, and potential syncope (e.g., fainting; Marks, 1988). Öst (1992) reported that 56% of patients with blood-injection-injury phobias have fainted when exposed to a needle, whereas 0% of patients with animal phobia, dental phobia, or claustrophobia experienced vasovagal syncope (e.g., type of fainting that occurs when the body overacts to triggers, such as the sight of blood or extreme emotional distress) when presented with their feared stimuli.

Applied tension is a treatment method that is used with patients with blood-injection-injury phobia to alter their physiological response to the feared stimulus. The method includes repeated muscle tensing when in the presence of feared stimuli to counteract the drop in blood pressure and prevent vasovagal syncope. Research has demonstrated that while engaging in applied tension, patients significantly increased their heart rate and cerebral blood flow (Foulds, Wiedmann, Patterson, & Brooks, 1990). Moreover, in a study conducted with patients with recurrent syncope, Krediet, Nynke, Lizner, Van Lieshout, and Wieling (2002) found that muscle tensing at the onset of prodromal symptoms delayed or prevented vasovagal syncope.

There are two components of applied tension in the treatment of blood-injection-injury phobia: (a) practice of the muscle tension technique in which the patient repeatedly tenses the muscles of the thighs, buttocks, stomach, arms, neck, jaw, and fists for 10 to 15 s followed by 20 s of returning to baseline (not overly tense or relaxed) and (b) repeated in vivo exposures to feared stimuli while engaging in the tension technique.

Research has suggested that both treatment components play important roles in the short- and long-term effectiveness of the intervention. In a study comparing applied tension, tension only (engaging in the tension exercise without exposure), and exposure only, Öst, Fellenius, and Sterner (1991) found that the applied-tension and tension-only groups improved significantly more than the exposure-only group (90%, 80%, and 40% respectively). The authors suggest that this improvement indicates that the tension technique is the most important component in applied-tension treatment. Moreover, although graded exposure alone is sufficient for the majority of phobias, with blood-injection-injury phobia, the tendency to experience syncope early in the exposure makes the tension component essential as it allows patients to remain conscious so that they can experience the exposure.

Although a subsequent study completed by the same research group as above (Hellstrom, Fellenius, & Öst, 1996) also found that the tension technique was the most important component of applied tension when first taught the treatment method, these authors conclude that exposures are essential for long-term effectiveness of the treatment. Specifically, results from their study found that individuals who continued with exposures posttreatment were more likely to maintain clinically significant improvement compared with individuals who did not continue to engage in regular exposures. Taken together, it appears that the tension component provides a coping skill that directly counteracts the vasovagal reaction, whereas the exposures provide opportunities to practice the technique and become desensitized to the phobic stimuli.

Efficacy of the applied-tension method in preventing vasovagal reactions in individuals with blood-injection-injury phobia has been demonstrated in a series of studies conducted by Öst and colleagues (Hellstrom et al., 1996; Öst et al., 1991; Öst & Sterner, 1987; Öst, Sterner, & Fellenius, 1989). Their research indicates that applied tension is at least as effective as other methods of treatment (e.g., exposure in vivo) and that patients demonstrate continued positive effects 1 year posttreatment. In a more recent randomized controlled study comparing fainters (individuals who reported vasovagal syncope at the sight of blood or injury) and nonfainters assigned to either applied-tension or a control group, Vogele, Coles, Wardle, and Steptoe (2003) found that applied tension prevented syncope in all fainters in the treatment group, whereas some fainters in the control group experienced syncope.

Although several small studies provide evidence for the effectiveness of applied tension for the prevention of vasovagal reactions in individuals with blood-injection-injury phobia, none of these studies have included children and adolescents. Given that the median age of onset of blood-injection-injury phobia is 5.5 years (Bienvenu & Eaton, 1998), and childhood medical experiences are likely to continue to significantly affect individuals throughout their lives (Pate, Blount, Cohen, & Smith, 1996), examination of the applied-tension method with a pediatric population is essential. As a first step, the following case examples describe use and clinical effectiveness of applied tension for treatment of severe blood-injection-injury phobia in two adolescent patients.

2 Case Introduction

Case 1

P is a 16-year-old Caucasian girl referred for treatment of her blood-injection-injury phobia that had manifested itself as hyperventilation, syncope, and vomiting when anticipating routine phlebotomy.

Case 2

M is a 13-year-old Caucasian girl referred for treatment of her blood-injection-injury phobia that had manifested itself as vertigo and syncope when exposed to needles, pictures of blood or injury, or verbal descriptions of medical events.

3 Presenting Complaints

Case 1

P needed to receive recommended blood work requested by her pediatrician, which she had been refusing for several years. She presented for treatment because her pediatrician was requiring that she finally consent to routine lab work prior to her departure for college the following year.

Case 2

M reported that increased frequency of her fainting episodes was beginning to affect her daily functioning (e.g., avoiding many potentially anxiety-provoking situations). In addition, M’s family was planning to take a trip out of the country that would require M to get a vaccination.

Both adolescents came to treatment to learn coping techniques to meet their respective goals without experiencing extreme distress and syncope.

4 History

Case 1

P had a long history of blood-injection-injury phobia; however, her mother denied any history of medical trauma or precipitating events. P stated that she has always been afraid of needles, “can’t calm down” during medical procedures, usually experiences syncope, and has typically been physically restrained during past medical procedures. P’s mother reported that during a recent endoscopy, her blood work could only be performed under general anesthesia.

P and her mother also reported that P’s history was significant for anxiety within the context of academic and social stressors. In addition, P described a history of headaches and functional abdominal pain, particularly in association with psychosocial stressors.

Finally, P’s history was significant for an episode of suicidal ideation 2 months prior to the onset of treatment during which she impulsively ingested multiple Excedrin after an argument with her mother. She immediately informed her mother who then called the emergency room; however, no additional treatment was pursued prior to the current treatment for blood-injection-injury phobia.

Case 2

M’s history was significant for an initial episode of fainting at age 5 after receiving several injections and a blood draw prior to the start of kindergarten. M recalled this episode in great detail and explained that since that experience, she cannot undergo even minor medical procedures (e.g., splinter removal) without extreme anxiety and syncope. She stated that she has either avoided blood draws and immunizations recommended by her pediatrician, or has endured these procedures with great distress, often requiring restraint and reportedly always resulting in a syncopal event.

M and her mother reported that, historically, M would faint in response to an anxiety-provoking stimuli 1 to 2 times a year; however, over the past 2 years, M’s fainting episodes had increased to 4 to 5 times a year. In addition, both M and her mother reported that M’s fear was so great that she was regularly excused from science class when discussing a potentially anxiety-provoking topic that could lead to syncope. They further explained that M often avoided TV shows and movies that were centered on a medical topic.

5 Assessment

Both adolescents and their mothers participated in an intake interview, which indicated that each patient met criteria for a diagnosis of blood-injection-injury phobia.

Case 1

P and her mother presented for treatment of her blood-injection-injury phobia. At the onset of the current treatment, P denied symptoms of depression, including sad affect, hopelessness, or suicidal ideation. Although her mood was not the presenting complaint or the requested focus of treatment, the treating psychologist (RC) planned to continue to monitor symptoms of depression. In addition, P’s mother reported that although she was seeking treatment at this time to help P learn to manage her blood-injection-injury phobia, she was pleased that P’s mood would be monitored as well.

P was visibly anxious about beginning treatment, and during her initial assessment, she admitted that she had not been able to sleep the previous night because she had been feeling so anxious about this appointment. We agreed during this assessment to meet for weekly treatment sessions until P met her final goal of participating in a blood draw without fainting.

Case 2

During her initial assessment, M and her mother denied that M experienced any other symptoms of anxiety. In fact, M’s mother described M as extremely self-confident and outgoing. They further denied symptoms consistent with any other psychiatric diagnosis. Family history was significant for syncope episodes experienced by M’s maternal grandfather, paternal grandmother, and paternal aunt.

M described feeling ambivalent about learning a technique to manage her phobia, as she had previously participated in relaxation treatment with another provider, and although she was able to relax during sessions, relaxation did not decrease her syncope. The treating psychologist (LM) explained that relaxation training is counterproductive to preventing syncope and that we would use a different technique to manage M’s symptoms. Both M and her mother appeared relieved, and M agreed to participate in weekly treatment sessions.

6 Case Conceptualization

Case 1

P’s case was conceptualized as a long-standing history of blood-injection-injury phobia within the context of an anxious temperament and a past depressive episode. There was no clear identifiable trigger for her development of this phobia, although symptoms had likely been maintained due to her limited coping strategies and general reliance on avoidance of medical procedures. P described a tendency to express emotional distress somatically, as indicated by her prior history of headaches and functional abdominal pain in association with psychosocial stressors and, thus, tended to express her needle phobia in this manner as well, with her anxiety manifesting in syncope, vomiting, and hyperventilation.

Case 2

M’s blood-injection-injury phobia was conceptualized as beginning after her experience of receiving many shots and a blood draw in preparation for the start of kindergarten. However, given her extensive family history for experiencing syncope, it is likely that M had a biological vulnerability that was triggered by this event. Increase in frequency of her syncope episodes coincided with M starting middle school. Thus, it is probable that this increase was the result of being in new environments and situations in which exposure to anxiety-provoking stimuli were more likely to occur. When not in the presence or anticipating exposure to anxiety-provoking stimuli, M appeared to be a well-adjusted, high-functioning adolescent.

7 Course of Treatment and Assessment of Progress

Case 1

Treatment began by teaching P the tension technique using the following script:

Sit in a chair with your feet flat against the floor and your arms on the armrest.

Tense all major muscle groups (thighs, buttocks, stomach, arms, neck, jaw, fists) at the same time for 15 to 20 s and then release to your starting level. Do not try to relax your muscles; just return to your starting level.

Wait 5 s and then repeat.

Do each cycle of tensing and releasing your muscles 5 times.

Your face may feel warm and may turn red; this will help you know that the exercise is working and keeping your blood pressure from dropping.

Practice these exercises at least once every day. This will help your muscles learn to react on your command so that you can use this technique when you need it.

P was instructed to practice daily at home before the next session, which she agreed to do.

During her second treatment session, P created a fear hierarchy in which she ranked components of phlebotomy from least to most anxiety provoking, beginning with the presence of a syringe in the office at the bottom of her fear hierarchy and undergoing a blood draw at the top of her nine-step fear hierarchy. We reviewed that each exposure would be terminated after it was determined that the patient’s anxiety was successfully managed (i.e., P was no longer experiencing vasovagal symptoms) while in the presence of the feared stimuli. P first used applied tension to manage her anxiety and avoid syncope with a syringe behind a closed cabinet in the psychologist’s office. After this exercise, P reported, “it was not as bad as I thought it would be.” She was instructed to continue to practice the tension technique at home between each session, which she reportedly adhered to each week.

For the next four sessions, P successfully managed her anxiety (i.e., did not have a syncopal event) and used applied tension with the following exposures: the syringe on the desk, the syringe at the bottom of her chair, the syringe on her armrest, and finally the syringe on her lap. P experienced increased anxiety at this step (but did not experience syncope), and exposure was terminated prematurely. P’s next three appointments were canceled; she wanted to go to the beach one week, was ill another week, and then her mother had a scheduling conflict. When P returned for treatment, it had been a month since her last appointment. P used the tension technique and tolerated the syringe in her lap without experiencing syncope. The following week, she successfully managed her anxiety and avoided syncope using the tension technique with the syringe resting on her arm over her jacket. At the next appointment, she used applied tension to successfully manage her anxiety and allowed a butterfly needle to be taped to her jacket, followed by a session during which she allowed the butterfly needle to rest on her bare arm.

Two months passed before Ps next appointment at the end of the summer, as P had been traveling and had requested a break from treatment. When she returned, she proudly stated that she had received an immunization at her pediatrician’s office, where she reportedly used the tension technique and “did not freak out” or experience syncope. During this session, P used applied tension to manage her anxiety and avoid syncope with the butterfly needle on her bare arm. Consistent with her good progress, we planned to hold our next session in the hospital blood bank, her chosen blood draw location, to help desensitize P to this environment. Although P was initially receptive to this plan, on the day of her appointment, she began to experience significant anxiety while in the blood bank, and therefore, we explored other possible blood draw locations in the hospital. P ultimately decided that she wanted her blood draw to occur in the hospital outpatient blood drawing area.

Over the next 3 months, P experienced depressive symptoms that were not related to her needle phobia. Because of the pressing nature of her depression, which included passive suicidal ideation, treatment for the blood-injection-injury phobia was suspended, and the focus of treatment shifted to cognitive-behavioral therapy to address her depressed mood. During this time, P had a tuberculosis test at her pediatrician’s office and reported that she did well (no crying or physical restraint) until she saw the “bubble” under her skin and fainted. She explained that she did not use the tension technique during or after this procedure. Cognitive reframing helped P conceptualize this experience positively, emphasizing her ability to successfully tolerate the needle itself. The importance of using applied tension to prevent syncope during and after future procedures was also highlighted.

During her next regular outpatient therapy appointment, P’s session occurred in the outpatient blood drawing area with two phlebotomists. She allowed them to examine her veins and place a tourniquet on her arm. Although visibly anxious, P tolerated the experience well and used the tension technique to avoid syncope. She repeated her next appointment in the same location with the same exposure. The next week, she repeated this procedure a third time, followed by wiping her arm with alcohol and placing the needle against her arm. P canceled her next two appointments, the first for a viral illness, and the second because she felt that she was not yet ready to undergo the blood draw. During her next appointment (her 16th session focused on treating her blood-injection-injury phobia), in the presence of the treating clinician (RC), P used applied tension and successfully underwent a blood draw without experiencing syncope. Immediately following her blood draw, she volunteered to serve as a coach for an adult staff member who also had been reluctant to complete a recommended blood draw. Treatment was terminated soon after this appointment as P had successfully coped with her blood-injection-injury phobia, and her symptoms of depression were well controlled.

Case 2

During M’s first treatment session, she learned the tension technique using the same script detailed above and was instructed to practice daily between her appointments, which she reportedly adhered to each week. She also created a nine-step fear hierarchy, beginning with her least anxiety-provoking scenario (a needle on a table in the room) and terminating with her most anxiety-provoking scenario (receiving a required immunization for a family trip).

All of M’s sessions began with her demonstrating the tension technique. The clinician then presented the feared stimuli. Each exposure was terminated after it was determined that the patient’s anxiety was successfully managed (i.e., the patient was no longer experiencing vasovagal symptoms) while in the presence of the feared stimuli. M’s first two exposure sessions involved using applied tension to manage anxiety and avoid syncope while looking at a syringe on the table and then holding a syringe with a needle. Due to a scheduling conflict, M’s fourth session occurred 2 weeks later. M described an episode in school where she fainted at the sight of a classmate’s pen that looked like a syringe with blood. She explained that she was surprised by the item and did not remember to use the tension technique. We discussed the importance of regular practice and using the tension technique at the first sign of vasovagal symptoms. During this session and the fifth session, M successfully used applied tension to manage her anxiety and avoid syncope with the syringe and needle on her lap.

M’s sixth session involved successfully using applied tension to manage anxiety and avoid syncope while holding the needle to her arm. During this session, she described experiencing frequent symptoms of vertigo when looking at the underside of other people’s arms. Over the next week she successfully completed the assigned task of looking at the underside of someone’s arms once per day and using applied tension to manage any symptoms of anxiety. Her seventh session involved opening an alcohol wipe and rubbing it on her arm prior to touching the needle to her arm again. She successfully completed this step without experiencing syncope and was given several alcohol wipes for daily home practice while using applied tension to manage her anxiety.

During her next 2 sessions, in addition to continued exposure to the syringe and needle, M viewed several graphic pictures and descriptions of medical procedures, and she used applied tension to manage her anxiety and avoid a vasovagal response. M’s 10th session involved a trip to an outpatient clinic where patients receive intravenous medication infusions and blood transfusions. After successfully watching several children receiving treatment and not fainting, M remarked that she now felt ready to receive her immunization. We completed 1 more session in the office in which M held the needle to her arm without experiencing syncope. After this final meeting (Session 11), M and her mother went to her pediatrician’s office and successfully received her immunization while using the tension technique to avoid fainting. M’s mother was present for the injection and reported that this was the first time since her daughter was 5 that she had a medical procedure without experiencing syncope.

8 Complicating Factors

Although M’s case followed a fairly typical treatment protocol for management of a phobia, P’s case included a couple of complicating factors that may have affected her treatment. First, although the focus of her treatment for her blood-injection-injury phobia was behavioral, it is possible that she may have made use of her cognitive modification skills that she learned as part of her treatment for depression to help her cope with her subsequent needle exposures and blood draw. Also, in addition to the interruption in treatment to focus on her depressive symptoms, P had much longer than 1-week time delays between her treatment on two other occasions (1 month and 2 months). These time delays may explain why P’s treatment was several sessions longer than M’s.

9 Follow-up

Treatment effects were monitored long term by the clinicians (informally due to a chance encounter with P and formally with additional sessions several years later for M).

Case 1

One year after treatment was terminated, P approached the treating psychologist (RC) in the hospital hallway. She was dressed in a white lab coat and was carrying a tray of glass vials and syringes. She excitedly reported that she was currently working as a phlebotomist herself.

Case 2

M returned for a “booster” nearly 5 years after initial treatment was terminated. She was planning to go abroad with a friend, which would require her to receive multiple immunizations. She explained that she continued to successfully use the tension technique regularly (i.e., a couple times a week) to avoid syncope in anxiety-provoking situations, but would like to practice again with the clinician in the presence of syringes with needles. At her third booster session, M explained that due to issues with her friend’s passport, they would not be traveling abroad; however, she still wanted to receive the immunizations as she felt prepared and would likely need them in the future. Prior to our next session, M successfully received her immunizations (again in the presence of her mother) while using applied tension to prevent syncope.

10 Treatment Implications of the Case

These case examples illustrate the successful application of the applied-tension method in the treatment of blood-injection-injury phobia in two adolescent patients. It is the first known report of applied tension in pediatric patients with blood-injection-injury phobias. Prior to treatment, both patients had experienced significant anxiety and syncope when presented with routine injections and phlebotomy, and both had been refusing recommended medical care for many years. After learning applied tension, both patients managed their anxiety and physiological responses, and received medical intervention without experiencing syncope. Treatment effects were maintained (i.e., patients were no longer experiencing episodes of syncope when in the presence of needles) for both patients after termination of therapy.

Many pediatric phobias are typically treated with relaxation (e.g., Gosch, Flannery-Schroeder, Mauro, & Compton, 2006) in an effort to reduce patients’ anxiety regarding the feared stimuli. However, because blood-injection-injury phobias are unique in their association with vasovagal syncope, patients with blood-injection-injury phobias are typically less responsive to relaxation. In fact, relaxation training was counterproductive for patient M who continued to experience syncope after using relaxation, thereby increasing her hesitation to engage in subsequent treatment.

Results of the interventions described above indicate that applied tension is a coping skill that can be used to prevent vasovagal symptoms in the presence of needles. Both patients had multiple opportunities to practice applied tension to prevent a vasovagal response in medical settings when presented with feared stimuli. In addition, when combined with exposure opportunities to practice the tension technique, both patients completed treatment in less than 20 sessions and successfully underwent recommended medical procedures without experiencing syncope.

Success of the applied-tension method likely is due in part to its ability to provide a coping skill that targets the physiological response associated with blood-injection-injury phobia. Learning to raise blood pressure and thereby prevent syncope demonstrates to patients with blood-injection-injury phobias that they have tools with which to help them cope with medical intervention and that they can avoid a vasovagal response. Thus, patients may develop increased feelings of self-efficacy as well as an internal locus of control (i.e., “There is something that I can do to cope with a medical intervention”) that may improve their willingness to receive medical treatment.

11 Recommendations to Clinicians and Students

This case series provides preliminary support for the use of applied tension in the treatment of blood-injection-injury phobias in pediatric patients. Results of the interventions described above indicate that the tension technique can be learned easily, applied quickly, and used successfully by patients with blood-injection-injury phobias so that they receive necessary medical care.

However, because these are case examples without collection of formal, empirical data, the success of these two patients must be interpreted with caution. Future research is needed to empirically examine the applied-tension method in a larger sample of pediatric patients with blood-injection-injury phobias. Specifically, studies with formal assessment such as standardized measures of anxiety and distress would help to provide empirical support for the use of applied tension. Also, to provide support for the importance of both aspects of the technique (i.e., exposure and tension), it will be important for randomized controlled trials to be conducted comparing applied tension with tension only and exposure only in large samples of children. It is probable that, unlike the adult trials that suggest that exposures are not an essential part of the initial treatment (Hellstrom et al., 1996; Öst et al., 1991), practice with exposures concurrent with learning the tension component may be particularly important for children and adolescents who likely need more guidance and concrete examples than adults regarding when and how to apply the technique in the future.

The number of treatment sessions in the two cases described in this article represents a further limitation. Although the tension technique itself can be learned quickly, the 16 and 11 sessions conducted with these two patients were significantly more than the 1 or 5 sessions typically reported in the majority of the Öst and colleagues studies (Öst et al., 1989; Öst et al., 1991; Öst & Sterner, 1987; Öst, Svensson, Hellstrom, & Lindwall, 2001). However, this finding is not surprising given that both M and P were significantly younger than the participants in all but one of these studies, had severe cases of blood-injection-injury phobia (e.g., P could only get lab work done under general anesthesia, M experienced syncope with splinter removal), and had previously failed other treatment modalities. It will be important for future research to assess optimal number of treatment sessions necessary to maintain treatment effects. It is quite likely that patients presenting with less extreme phobias may be treated in fewer sessions.

Future research should also include a broad age range to assess the impact of development, as it is not currently known whether younger children can use this technique successfully. However, given that applied tension is simple to learn and can be taught with an age-appropriate script, it seems likely that even young children could benefit from this treatment. Finally, future research that includes parents as coaches (Cohen, Bernard, Greco, & McClellan, 2002; Cohen, Blount, & Papopoulos, 1997) for implementation of applied tension in pediatric medical settings may also be useful.

Footnotes

Acknowledgements

The authors thank the Sara Page Mayo Endowment for Pediatric Pain Research and Treatment for support of this work.

The author(s) declare that they have no potential conflicts of interests with respect to the research, authorship, and/or the publication of this article.

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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