Needle phobia: a neglected diagnosis

Journal of Family Practice, August, 1995 by James G. Hamilton

Needle phobia is a recently defined medical condition that affects at least 10% of the population. Because persons with needle phobia typically avoid medical care, this condition is a significant impediment in the health care system. The etiology of needle phobia lies in an inherited vasovagal reflex of shock, triggered by needle puncture. Those who inherit this reflex often learn to fear needles through successive needle exposure. Needle phobia is therefore both inherited and learned.

In a family practice, needle phobia can be managed by reassurance and education, avoidance of needles, postural and muscle tension techniques, benzodiazepines, nitrous oxide gas, and topical anesthesia applied by iontophoresis.

Key words. Needle phobia; phobic disorders; needles; vasovagal reflex; syncope; vasovagal syncope; iontophoresis. (J Fam Pract 1995; 41:169-175)

Needle phobia is a condition that has become an increasingly important issue in medicine because of the modern reliance on injections and blood testing. Contrary to popular belief, needle phobia is not confined to children, is not an emotion-driven or transient phenomenon, and is not a rare condition. Clinicians need to be aware of needle phobia because it is a common condition and because needle-phobic persons tend to avoid medical treatment, which can lead to serious health problems as well as social and legal problems.

Needle phobia has been defined as a formal medical condition(1)(2) and has recently been included in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) within the diagnostic category of Blood-Injection-Injury Phobia.(3) A review of the background medical literature and suggestions for management of needle phobia are presented here.

The etiology of needle phobia is rooted in an inherited vasovagal reflex that causes shock with needle puncture. With repeated needle exposure, those with an inherited vasovagal shock reflex tend to develop a fear of needles. Unlike most other phobias, in which exposure to the feared object excites tachycardia, victims of needle phobia typically experience a temporary anticipatory tachycardia and hypertension, which on needle insertion turns into bradycardia and hypotension (Figure), accompanied by pallor, diaphoresis, tinnitus, syncope or near-syncope, and sometimes asystole or death.(1)

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According to the DSM-IV, a phobia is defined by the presence of fear and by avoidance behavior.(3) The symptom of avoidance of needles, doctors, dentists, etc, is central to the definition of needle phobia, since avoidance of health care is surely a health care problem. However, because needle phobia is also accompanied by numerous physiological changes in blood pressure, pulse, electrocardiogram (ECG) waveforms, and stress hormone levels,(1)(2) these measurements can also be used to define this condition (Table 1). While a dislike or mild fear of needles is very common, needle phobia can be more rigorously defined by objective clinical findings in addition to subjective symptoms.

Table 1. The Primary Factors Underlying the Recognition and Diagnosis of

Needle Phobia

Past medical history(*)

(1) Self-report by the patient of a long-term needle fear, usually from childhood, that the patient recognizes as unreasonable.

(2) Exposure to or anticipation of a needle procedure invariably triggers immediate anxiety, sometimes in the form of a panic attack. In children, the anxiety may be expressed by crying, psychomotor agitation, freezing, or clinging.

(3) Needle procedures, often along with associated medical objects or situations, are avoided either some or all of the time.

(4) The needle avoidance and fear interfere significantly with health care or with normal occupational, academic, or social activities, or the patient is markedly distressed about having the fear.

Family medical history

Approximately 80% of patients with needle phobia report strong needle fear in a first-degree relative, ie, parent, child, or sibling.

Clinical findings

(1) Physical symptoms of syncope, near-syncope, light-headedness, or vertigo upon needle exposure, along with other autonomic symptoms, eg, pallor, diaphoresis, nausea.

(2) Cardiovascular depression with a drop in blood pressure or pulse or both; with or without an initial rise in blood pressure or pulse or both.

(3) Electrocardiogram anomalies of virtually any type.

(4) Rises in any combination of several stress hormones: antidiuretic hormone, human growth hormone, dopamine, catecholamines, corticosteroids, renin, endothelin, and [beta]-endorphin.

(*)Modified from Diagnostic criteria for specific phobia. In: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC: American Psychiatric Association, 1994:410.

NOTE: A diagnosis of needle phobia can be made by past medical history alone. In addition, however, victims of needle phobia typically have symptoms of decreased cerebral perfusion, cardiovascular changes, electrocardiogram changes, and hormonal rises.