Needle phobia: a neglected diagnosis

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

Needle Phobia in Family Practice

Those with needle phobia are often terrified of routine needle procedures, and a few are so frightened that they would rather die than have a needle procedure.(4) Even such relatively minor needle procedures as venipuncture(1)(5) or subcutaneous injection(6) can cause a vasovagal shock reflex and evoke patient resistance. When those with needle phobia do agree to needle procedures, they often experience syncope, fall and sustain trauma, have convulsions, lose bowel and bladder control, evoke the calling of cardiac codes, or otherwise cause great concern among staff and family members. Others with needle phobia are simply noncompliant with medical treatment regimens, eg, insulin self-injections.

Victims of needle phobia possess a heightened risk of morbidity and mortality simply because they avoid health care, sometimes for many years,(1)(7) and even when the need for treatment is compelling.(1)(4)(6)(7)(8) Approximately 5% to 15% of the population, for example, decline necessary dental treatment, primarily because they fear oral injections.(8) With an incidence of needle phobia of at least 10%, it is reasonable to hypothesize that a large hidden population goes without regular health care because of this condition. The recognition, acceptance, and communication of this danger by both the medical community and the public, and the development of methods to compensate for needle fear in clinical practice, represent probably the greatest challenges that this condition poses for family medicine.

Needle phobia also can cause major social and legal difficulties in one's life. A fear of blood testing or immunization can interfere with or even destroy plans for marriage, travel, education, immigration, or employment. Students may be discouraged from biological, nursing, or medical careers because of their fear of needles,(4) and women wishing to have children may be thwarted by needle fear.(4)(7) Legal problems can arise when blood tests are ordered by a court in paternity cases, and some victims of needle phobia have even been charged by the police for failure to agree to blood testing.(4) The best-selling book The Blooding detailed the resistance that authorities in England experienced against mass blood testing to eliminate suspects in a murder case.(9) In the United States, involuntary blood testing of accused drunk drivers has led to four cases being appealed to the US Supreme Court.(10)(11)(12)(13)

Occasionally, needle phobia can be fatal. At least 23 reported deaths can reasonably be ascribed solely to needle phobia and its vasovagal reflex during needle procedures such as venipuncture, blood donation, arterial puncture, pleural tap, and intramuscular and subcutaneous injections.(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25) Other reports and indirect evidence further suggest that needle procedures can result in sudden death.(26)(27)(28)(29) A death by needle phobia can be due to either or both of two mechanisms: an abrupt vasovagal drop in blood pressure and perfusion, especially in an arterial tree already compromised by atherosclerosis, could cause myocardial infarction(25)(29) or cerebral infarction; or a vasovagal reflex could impair the sinoatrial or atrioventricular node enough to cause ventricular fibrillation or asystole.(27)(30)