Case report of a needle phobia

Journal of Family Practice, April, 1991 by Everett H. Ellinwood, James G. Hamilton

Blood-injury phobia is defined in the psychiatric literature as a fear of exposure to blood, injury, pain, needles, or deformities. [1] In other phobias, exposure to the phobic cue usually causes tachycardia. In contrast, blood-injury phobia victims typically experience a diphasic cardiovascular response of an initial tachycardia, followed by bradycardia, hypotension, shock, vertigo, syncope, diaphoresis, nausea, and occasionally even coma, asystole, and death. [1,2] The concept of needle phobia is important for heath care professionals to understand, since patients fearful of needles often avoid medical and dental treatment. Here a case of severe needle phobia in an otherwise nonphobic physician and his physiological response to having blood drawn is reported.

Case Report

J.G.H. was a 39-year-old, male emergency department and family physician with extensive experience treating surgical wounds, suturing lacerations, and drawing blood. His medical history revealed, however, a lifelong involuntary fear of receiving injections or having blood drawn. He had had a strong sense of dread, with near fainting and diaphoresis, when using needles on others at the start of his medical training. His fear of others having needle procedures had been self-extinguished by first observing and then performing lancet heel sticks on neonates, and later inserting intravenous lines and drawing blood from adults. He remained very fearful of having needle procedures himself. His history revealed multiple episodes over a 19-year period of avoiding or refusing needle procedures such as having blood drawin for routine tests during physical examinations and having a scalp laceration sutured after an automobile accident.

The subject's family history was strong positive for needle phobia. The subject's father had an aversion to any needle procedure. Two of his father's first cousins fainted or almost fainted when they had blood drawn or received injections. The subject's mother experienced near syncope on any needle encounter. She reported an episode of fainting at the sight of an intravenous needle in a relative's foot in the hospital. She also noted that during a minor surgical procedure her pulse rate on a cardiac monitor dropped from 70 beats per minute to about 50 beats per minute on insertion of an intravenous needle. The ubject's brother, an internist and emergency medicine physician, reported great anxiety and near syncope on having his blood drawn. The subject's maternal grandmother refused to have injections and instead always requested oral medication from her family physician. A maternal uncle, a family physician, reported that he experienced near syncope, diaphoresis, palpitations, and tachycardia with any needle procedure, and that his five offspring, two of whom are physicians, are all deathly afraid of having needle procedures. No other blood-injury phobias were discovered during research of the family history.

A treatment program of behavioral desentization using a hierarchy of increasingly phobic stimuli was agreed upon, following standard exposure therapy for phobias as previously described. [1,3-5] Initially, for an hour each day for a month, the subject practiced fantasy rehearsal imaging of sticking a needle into his forearm veins, using a broken cotton swab, an alcohol pad, and a tourniquet. He then progressed to barely breaking the epidermal surface with a 30-gauge needle, and was eventually able to insert the needle into his forearm musculature up to the needle hub. After approximately another month's practice, he was able to self-cannulate a forearm flexor vein with a small butterfly needle long enough to withdraw a 10-mL sample of blood.

After 3 months of treatment, the subject was able to agree to having blood drawn from the antecubital fossa. Before venipuncture, while attached to a cardiac monitor, his heart maintained a rate of 98 beats per minute with a prominent sinus arrhythmia for over 1 hour. His blood pressure remained at his normal 130/90 mm Hg. Immediately upon needle insertion, he experienced severe anxiety, near syncope, pallor, and diaphoresis. His blood pressure plunged to a low of 70/0 mm Hg, and his pulse rate fell to a low of 63 beats per minute. As illustrated in Figure 1, the pulse rate dropeed markedly during each of the three venipunctures in this session. Also computer analysis revealed that each pulse rate drop with venipuncture coincided with a loss of the sinus arrhythmia otherwise present throughout the experiment. A moderate decrease in pulse to approximately 70 beats per minute persisted for over 3 hours after venipuncture. Although the catechol (epinephrine and norepinephrine) levels were well within normal range, the corticosteroid and antidiuretic hormone levels during the needle challenge were clearly elevated (Table 1).

Another blood drawing was performed for a medical examination over 1 1/2 years after this initial experiment. On cannulation of a dorsal hand vein while recumbent,