Applied Tension Treatment of Vasovagal Syncope during Pregnancy

Military Medicine, Sep 2004 by Peterson, Alan L, Isler, William C III

Vasovagal syncope is a common clinical problem that is often difficult and expensive to diagnose and treat. Applied tension is a behavioral treatment approach that has been demonstrated to be efficacious for the treatment of vasovagal syncope associated with injection phobia. The present case study evaluated the treatment of vasovagal syncope in a 41-year-old pregnant patient with injection phobia. The treatment included the use of applied muscle tension to increase blood pressure and prevent syncope during graduated exposure to increasingly greater anxiety-provoking stimuli. After completion of the treatment, the patient was able to undergo a blood draw and other medical procedures involving exposure to needles, with significantly reduced anxiety and no episodes of syncope. Applied tension is an effective and relatively inexpensive treatment for patients with vasovagal syncope related to injection phobia and may hold promise as a treatment for other types of syncope.

Introduction

Vasovagal syncope is a common clinical problem that is often difficult to evaluate and treat.12 The pathophysiological features of vasovagal syncope (know alternatively as neurocardiogenic, vasodepressor, or neurally mediated syncope) are complicated and not fully understood.3 Vasovagal syncope has been described as a biphasic response consisting of an initial increase in blood pressure followed by a sudden decrease in blood pressure, often resulting in fainting.4 Treatment approaches for syncope often include the use of medications and cardiac pacemakers.5-8

Vasovagal syncope is also associated with injection, blood, or injury phobia.9 Injection phobia is the specific fear and avoidance of needles, receiving injections, or having blood drawn via venipuncture.10 A hallmark of injection phobia is the high probability of fainting or vasovagal syncope during an injection or blood drawing or with the anxious anticipation of such medical procedures.11

The prevalence of injection phobia in the general population has not been established. Studies of blood/injury phobia have reported prevalences of 3.1 to 4.5%.13 The lifetime prevalence of simple phobia was reported to be 11.3% in the National Comorbidity Survey.14 However, simple phobia includes a number of specific phobias, such as those involving snakes, spiders, and dogs.15

A common suggestion by health care providers to a patient with a history of injection phobia and syncope is for the patient to "just relax." However, relaxation in this situation often has the antithetical effect of further decreasing blood pressure and increasing the likelihood of vasovagal syncope. Applied tension is a behavioral treatment that has been demonstrated to be effective for the treatment of injection and blood phobia.10,16-18 The goal of this treatment is to apply muscle tension to temporarily increase blood pressure, to prevent vasovagal syncope, during graduated exposure to increasingly greater anxiety-provoking stimuli. This approach uses applied isometric tensing of muscles, similar to the "anti-G maneuver" used by fighter pilots to avoid syncope when flying high-performance aircraft. The combination of applied tension and repeated graduated exposure usually results in the eventual extinction of the vasovagal syncope reaction, often with only one extended treatment session. In most cases, patients no longer need to use the applied tension technique, because future exposure to the stressful stimuli (e.g., needles or injections) no longer triggers the vasovagal syncope response. However, once patients have learned the applied tension technique, they are usually confident that they can avoid any future syncopal episodes by using the applied tension technique if necessary. A randomized trial of applied tension for injection phobia, with stringent criteria for clinically significant improvement (finger prick, subcutaneous injection, and venipuncture), demonstrated that 80% of patients exhibited clinical improvement after just one treatment session and 90% continued to exhibit improvement at the 1-year follow-up evaluation.10

This case study outlines the use of applied tension for the treatment of a pregnant patient with needle phobia and vasovagal syncope. The use of behavioral treatment was requested by the patient's referring provider, because the patient required medical assessment and treatment procedures involving the use of needles. There was also concern regarding potential injury to the patient and/or fetus related to falling during a syncopal episode. In addition, there was concern regarding the potential negative consequences of medications or other more invasive medical interventions with a pregnant patient. Written informed consent was obtained from the patient before submission of the case study for publication.

Case Report

The patient was a 41-year-old female subject who was 17 weeks pregnant. She had a 16-year history of fainting and had previously been diagnosed with vasovagal syncope and convulsive syncope related to injections and blood draws. She was referred to the clinical health psychology service at Wilford Hall Medical Center for behavioral treatment after she experienced a syncopal episode while undergoing amniocentesis. A 1-hour clinical interview was conducted, for completion of a full assessment and discussion of treatment planning. Voluntary informed consent was obtained from the patient before initiation of the behavioral treatment.