For Some Patients, Fear of Medicine's Most Pointed Treatment Is No Joking Matter
Tuesday, April 13, 2004
The Washington Post
Old Hollywood gag: Doctor approaches patient with big hypodermic needle. Patient sees needle, faints and hits the floor with: a loud crash, taking along everything within reach; a soft whump, landing flat on his back; or, least often, the quiet sighing crumple to the floor.
Woody Allen whumped in "Sleeper." Hugh Grant crumpled in "Nine Months." So did Robin Williams in the same movie, same scene -- except he was the doctor.
It's a big laugh, unless you take this sort of thing seriously, which a good number of us happen to do -- enough that the medical dictionaries have come up with a term for it: aichmophobia. It means, in plain English, fear of needles, pins and other pointed objects doctors might need to stick in patients.
"It is one of the most common medical disorders in the human population" said James Hamilton, a family physician from Durham, N.C., who has made a serious study of aichmophobia (also called belonephobia or tryanophobia). In 1995, the condition was officially recognized in the Diagnostic and Statistical Manual, fourth edition (DSM-IV), the reference book that is a bible to psychiatrists. The diagnosis is characterized by such strong reactions to injections, injuries or blood that patients will either avoid such situations -- and go to extremes to do so -- or tolerate needles only under extreme emotional duress.
Researchers estimate that between 7 and 22 percent of the general population has this degree of needle phobia. Hamilton suspects the percentage is higher: "They tend to select themselves out of the patient population," he said, "so you'll see them only when there's absolutely no choice, when they need to go to the hospital." He bases this finding on his research, but owns up to another source of information: He's a needle-phobe himself.
Not getting your nose or navel pierced because of needle phobia is one thing. Not getting your regular dose of insulin is a whole other matter. Similarly, for people with multiple sclerosis (some of whom need weekly shots of interferon), and those requiring regular injections for any of a host of other medical conditions -- among them migraine, allergy, erectile dysfunction, fertility problems and chronic infections -- this could be a real problem.
Hamilton is a repository of stories of people who have gone to extremes to avoid the doctor's needle: the woman who refused to have a Cesarean section because she didn't want the injected anesthesia; the man who jumped out of a second-story window at a hospital in Knoxville, Tenn., rather than have blood drawn for testing; the patient who tried to punch the nurse who was preparing to give him a shot, ran outside and swung a branch at the pursuing nurse until he passed out. He could remember none of this when he came to a few minutes later.
In general, the medical profession is not terribly sympathetic to aichmophobia.
Said Keith Lamb, a volunteer emergency medical technician in Columbus, Ohio, who is himself needle-phobic, "I find that most medical people don't give a damn. And that is the biggest problem. People just don't recognize it and they don't care."
Look at it from the doctor's point of view. Squeamishness about needles, if taken seriously, can get in the way of a lot of good medicine that depends on a quick jab: immunizations against disease, blood transfusions, anesthesia administration before surgery, insulin delivery (for diabetics), pain-free dental procedures. That simple, short, inexpensive sliver of steel is the linchpin of a lot of commonplace health care. While there is probably a touch of aichmophobia in all humans, most of us tough it out, look the other way or think of something else when we get shots, and we get through it without a lot of fuss.
True aichmophobes, however, don't have that option. Their aversion is entirely involuntary, and there is an actual physiological reaction to the sight or mention of a needle.
The response is called a vasovagal reaction: The blood pressure drops, the heart rate slows, the person feels faint or dizzy and turns pale. Blood pools in his big muscles (in the buttocks, back, legs). As a result, not enough blood reaches the brain, and the person often passes out. Fainting is more common in adults than in children, because they have more muscle mass to pool blood needed by the brain. "The bigger they are, the harder they fall," nurses and phlebotomists often say with a wink -- or maybe a smirk if the patient arrived with a particularly macho attitude.
Winks and smirks aside, the reaction can be complex and serious. In aichmophobic patients undergoing needle procedures, Hamilton says, studies have revealed 11 different types of stress hormones elevating and electrocardiogram patterns going haywire. Additionally, Hamilton and colleagues at Duke University documented 63 related symptoms, including: "transient psychosis, combativeness, random motor movements, rolling eyeballs, involuntary loss of bowel or bladder control, seizures, clenching of the jaw muscles, loss of responsiveness and transient coma."
Lamb, the EMT, does not faint when confronted by needles, though he wishes he could.
He belongs to a small percentage of sufferers who experience extreme anxiety and elevated -- rather than reduced -- blood pressure and heart rate during or seconds before needle penetration .
"I am pain-sensitive," he said. "I don't faint. I just get really scared because I know what's coming. So I just give up and I leave. I refuse. I get anxious, I'm afraid. I get a really intense fear about what's coming at me."
Lamb was so scared that for months he avoided going to the dentist although he had a life-threatening infection that had begun in his teeth and gums.
"I would touch the doorknob at the dental office and I just couldn't get in," he recalled. He said it was "like you're walking into something that's really horrible. My heart rate goes up, my blood pressure goes up, I sweat and I shake. I get really nervous. I am aware of everything. The last thing I'll ever do is faint. If you touch me I would jump."
"I can't imagine anything better than seeing a needle come at me and fainting. It's like self-induced general anesthesia. Wouldn't it be great?" Some researchers say these reactions may be rooted in evolution, that avoiding needles is the remnant of a survival strategy humans learned during tougher times.
"The violent deaths in our species' evolutionary history," writes Hamilton, "have been caused by skin penetration from teeth, claws, fangs and tusks, and from sticks, stone axes, knives, spears, swords and arrows. A reflex that promoted the learning of a strong fear of skin puncture had clear selective value in teaching humans to avoid such injuries."
Other researchers compare the fainting tendency to the tendency of certain animals to play dead in the presence of a predator. The creature's limbs simply go limp; the heart rate goes down. Fainting in the doctor's office is thought to be the modern human equivalent.
Some believe fear of needles runs in families. Hamilton's family is an example. Not only is he needle-phobic himself, so are his brother, an uncle and two first cousins. (They are all also doctors.)
Additionally, Hamilton's father, to whom he dedicated an article on needle phobia in the Journal of Family Practice, died of cardiac arrest after a needle procedure at the age of 63. "My father went in for a routine blood test," he said, "went into a vasovagal shock and had a cardiac arrest and could not be resuscitated. They tried to do CPR, but he was gone."
Lamb, who runs a Web site for people with aichmophobia, disagrees that it is an inherited trait: "Needle-phobes are made, not born," he said. He believes people learn to fear needles based on bad experiences in doctors' or dentists' offices, such as being restrained or mocked, or even upon seeing another patient having a negative reaction.
"The first few encounters that a young patient has with the health care system that involve invasive, unpleasant or painful procedures need to be handled in special ways," Lamb argues. "Needle procedures forced under restraint is one of the most commonly cited initiation factors of needle phobia."
In fact, many needle-phobics trace their distrust of health care workers to being lied to when they were young, Lamb concludes from the many letters he has received from fellow sufferers.
Says Lamb: "There is no room for hiding the truth even if the intent is to be helpful. Painful procedures should not be described with phrases like, 'This won't hurt a bit.' " Lamb, by the way, has no trouble administering needles to patients in his EMT role, and he said that being a needle-phobic gives him an advantage when it comes to his patients.
"My technique is not different, but my attitude is," he said. "I am extremely sensitive to the patient's pain and sympathetic about it."
His own fears, however, almost cost him his career.
During his training, one exercise required trainees to pair up and administer injections to one another. "I freaked out," he recalled.
He went to the instructor and explained the problem, to no avail. "He told me, 'If you can't do this, then you can't finish the class and be certified.' "
But Lamb persisted, arguing, "I don't have a problem doing it, I have a problem receiving it."
The instructor finally yielded. "I guess you are not being certified
to be a patient," he said to Lamb. "Or to be a victim.".
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