Review
Treatments for blood-injury-injection phobia: A critical review of current evidence

https://doi.org/10.1016/j.jpsychires.2009.04.008Get rights and content

Abstract

Blood-injury-injection (BII) phobia presents with a unique anxiety response that often involves blood pressure drops and pronounced bradycardia, which can culminate in fainting. The current recommended treatment for BII phobia is Applied Tension (AT), a tension technique that includes in vivo exposure. However, surprisingly little empirical evidence is available on the additive efficacy of tension beyond exposure alone. Our literature search yielded five controlled treatment studies for BII phobia, all from one research group. Beyond AT, these studies also tested Exposure only (E), Tension only, Applied Relaxation (AR), or a combination of AR and AT. Based on self-reported levels of anxiety, in-session avoidance and fainting, AT was superior over other conditions; however, when considering pre- to post-treatment effect sizes on BII-related questionnaires, E outperformed all other treatments. In addition, AT did not yield better results on physiological measures, and individuals with BII fears improved similarly within studies across treatment groups, regardless of fainting status. Heterogeneity in patient populations (e.g. extent of fainting-proneness), differential targeting of BII phobia manifestations, and small sample sizes may explain some of the variability in findings. Further research is needed to determine the efficacy of treatment techniques for BII phobia patients with and without fainting history.

Introduction

Blood-injury-injection phobia (BII) is a common and unique phobia. Estimates of lifetime prevalence of BII phobia range from 3.5% for men and women (Bienvenu and Eaton, 1998) to as high as 4.9% for women (Costello, 1982), and unlike individuals with other specific phobias, 75% of those with BII phobia report a history of fainting in response to phobic stimuli. The fainting response (sometimes also referred to as emotional fainting) is characterized as a vasovagal syncope and has been described in the literature as a two-phase, or biphasic (also called diphasic) response to BII stimuli (e.g. Engel and Romano, 1947, Graham et al., 1961). The initial phase involves an increase in heart rate and blood pressure as is typical of the fight-flight component of an anxiety response (e.g. Guyton and Hall, 2005), whereas the second phase is characterized by bradycardia (a sharp drop in heart rate) and hypotension (low blood pressure) leading to reduced cerebral blood flow and ultimately fainting (e.g. Graham et al., 1961), although this pattern is not always observed (Öst, 1996).

Fainting in response to BII stimuli is a significant source of concern for many patients suffering from blood phobia and can aggravate avoidance. Phobic avoidance of situations related to blood, injury, and injections poses a particularly serious threat to an individual’s well being as it can lead to the neglect of medical care and life-saving treatments (e.g. de L. Horne and McCormack, 1984, Marks, 1988, Page, 1994).

The treatment technique generally recognized as efficacious for BII phobia is Applied Tension (AT), which combines a muscle tension technique with in vivo exposure (e.g. Choy et al., 2007, Öst, 1996, Peterson and Cigrang, 2003). The tension technique utilizes repeated tense and release sequences of the skeletal muscles to counteract cardiovascular and autonomic changes implicated in BII-related syncope (for a more detailed description of the interventions, please see Section 3). Versions of this technique have been used for some time for combating orthostatic hypotension in patients as well as fainting in various settings such as blood donation (e.g. Ditto et al., 2003a, Ditto et al., 2003b, Krediet et al., 2002, Ten Harkel et al., 1994). Kozak and Montgomery (1981) are generally regarded as the first to have devised AT as a behavioral treatment strategy for BII phobia. Their aim was to target the syncopal episode rather than the initial anxious arousal, which is typically observed as the first stage of the biphasic response. The tensing of skeletal muscles involved in this technique led to increases in blood pressure and heart rate, and was thereby thought to counteract the two major autonomic phenomena involved in the vasovagal syncope: hypotension through peripheral vasodilation and bradycardia by massive vagal excitation. In addition, skeletal muscle tension (particularly in the extremities) promoted increased blood flow to the heart and brain, thereby preventing the fainting response.

Applied Tension is currently widely accepted as a treatment technique for BII phobia (see e.g. Antony and Watling, 2006, Hersen and Rosqvist, 2007), and in some accounts of the literature it is discussed as the preferred or only successful treatment option (Barlow, 2002, Barlow and Durand, 2005, Choy et al., 2007, Peterson and Cigrang, 2003). Recommended treatments such as AT should be able to demonstrate characteristics in accordance with evidence-based criteria for establishing its acceptance as an efficacious treatment, including independent replication (e.g. Chambless and Hollon, 1998). In addition, treatment research should address treatment specificity by investigating mechanisms of change within targeted treatments in order to identify active treatment components versus non-specific treatment effects within the intervention (e.g. Lohr et al., 2005). Because AT is a packaged intervention, which includes two distinct treatment components, one of which is disorder specific (i.e. tension) and one which is a general treatment approach (i.e. exposure), the proposed components of the treatment must be evaluated to determine which are responsible for improvement in symptoms that are maintained over time (e.g. Lohr et al., 2003, Lohr et al., 2005). Thus, the purpose of this review is to examine the evidence from the current state of the BII treatment literature with a particular focus on the efficacy of AT.

Section snippets

Method

To identify potential articles for this review, we performed a systematic search of Medline and PsycINFO using key words related to BII phobia treatment (keywords include—blood phobia, injury phobia, injection phobia, needle phobia, treatment, intervention, cognitive, behavio(u)ral, vasovagal, syncope, vasodepressor syncope, and emotional fainting). Further, we searched through each article’s reference section to identify any additional relevant studies. Only studies from peer-reviewed,

Overview of published controlled trials

To date, five randomized treatment trials for BII-phobia have been published (Hellström et al., 1996, Öst et al., 1984, Öst et al., 1989, Öst et al., 1991, Öst et al., 1992). All studies were conducted by one team (Öst and colleagues), with sample sizes ranging from 16 to 39 patients (total N = 145, 61% female, ages 18–55) (Table 1). Interventions reported in these studies include massed or spaced versions of Exposure only (E), AT, and Tension only (T), as well as Applied Relaxation (AR) and a

Discussion

Our review of controlled treatment trials for blood phobia identified only a small number of studies, all of which had been published exclusively by one research team. To our knowledge, no independent replications are available to confirm the efficacy of the established treatments for BII phobia. Öst et al., 1984, Öst et al., 1989, Öst et al., 1991, Öst et al., 1992, Hellström et al., 1996, Öst, 1996 pointed out this lack of RCT data beyond the five studies published by their own group. Data

Contributors

All authors contributed equally to the literature search, statistical analysis of the data, and the write-up of the manuscript.

Role of funding sources

No funding was provided that played a role in any aspect of this review.

Conflict of interest statement

None declared.

Acknowledgement

We thank David Rosenfield for statistical advice.

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