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Fear of Needles Manual

Manual Index Fear of Needles 

  1. Blood phobia
  2. Virtual environments of Psious for the treatment of blood phobia
  3. Treatment protocol based on Psious
  4. Comments
  5. Recommended bibliography

1. Blood phobia

The fear of blood is a phobia classified on current mental disorders diagnosis systems as aspecific Blood-Injection-Injury type of phobia (BII). Some sort of fear towards blood is common and, in fact, it is considered that the amount of people that experience this fear may exceed 10%. Yet recent studies point out that about 2-3% of the population suffers from BII phobia.

This data is significant; not only because of its prevalence, but also due to the negative consequences that blood phobia can have on the quality of life of those who suffer from it. These people tend to avoid medical interventions that are key to health or pregnancies, as well as quitting on graduate school (e.g. medical school, nursing school), or avoid visiting hospitalized relatives, and so on.

Blood phobia, unlike the rest of phobias, is characterized by a biphasic anxiety response. That is to say, even though during the first seconds of exposure to the feared stimulus an elevated physiological activity takes place (tachycardia, palpitations, sweating, etc.), immediately followed by a rapid drop (blood pressure drops, cardiac rhythm can drop to between 35 to 40 beats per minute, etc). This can lead to dizziness, pallor, and, sometimes, even fainting.

In regard to the treatment of blood phobia, it is not usually recommended to use relaxation techniques during the exposure to the feared situation (though these are useful during the first phase of the biphasic response). On the contrary, it is considered more adequate to use Applied Tension techniques, with the aim of balancing out the physiological drop and so preventing fainting.

In the last few years, Virtual Reality (VR) and Augmented Reality (AR) have shown great clinical efficiency in the treatment of specific phobias. These technologies provide the ideal context to play the situations feared by the patient , in a controlled safe way. In the case of blood phobia, for instance, these technologies allow for blood analysis to be carried out any day of the year, without prior appointment, and offer the chance to set the parameters that are considered suitable and without even leaving the practice.

2. Virtual environments of Psious for the treatment of blood phobia

The Psious platform currently features one Virtual Reality scene (a hospital with its waiting and extraction rooms) and a video (images of a real blood extraction). Furthermore the therapist can combine, in both the video and the scenario, the Virtual Reality with traditional treatments, such as “Relax” 

3. . Treatment protocol based on Psious

The following is an example of a protocol treatment in which Psious is combined with other psychotherapeutic techniques for the treatment of blood phobia. Despite this, it is recommended that each therapist integrate VR technologies into the protocols they usually use in their clinical practice, in addition to adapting the sessions to the rhythm and characteristics of the patient.

The proposed treatment protocol consists of 8 weekly treatment sessions lasting approximately one hour.

SESSION 1: PSYCHOEDUCATION + APPLIED TENSION

  • Information about blood phobia is provided (origin, maintenance and biphasic anxiety response).
  • Treatment techniques that will be used throughout the protocol are presented and justified: exposure to Virtual and Augmented Reality environments, applied tension technique.
  • Introduction and practice of the applied tension technique.

Homework:

Practice of the applied tension technique and filling out the associated self-recording (see Annex 6.1).

SESSION 2-3: PROGRESSIVE MUSCLE RELAXATION

  • The technique of applied tension continues.
  • The use of Jacobson’ s progressive muscle relaxation is introduced.
  • Familiarization accompanied by Psious platform. The patient learns how use the VR headphones and navigate within virtual environments

Homework:

Practice of applied tension and Jacobson progressive muscle relaxation. Applied tension (see Annex 6.1) and relaxation (see Annex 6.2) self-recording.

SESSION 4: RV EXHIBITION TRADITIONAL TECHNIQUES

  • From the fourth session on , the gradual and systematic exposure to virtual environments begins. Throughout the exposure sessions , according to the characteristics of each patient, the VR is combined by the applied tension and progressive muscle relaxation techniques.
  • The patient is exposed to:
  • A Waiting room as a companion.
  • An extraction room as a companion

Homework:

Self-exposure to stimuli related to a feared situation. Applied tension and progressive muscle relaxation practice.

SESSION 5: EXHIBITION RV + TRADITIONAL TECHNIQUES

  • Homework review
  • The patient is exposed to:
  • The waiting room + interoceptive exposure elements.
  • Extraction room + interoceptive exposure elements.

Homework:

Self-exposure to stimuli related to the feared situation. Practice of applied tension and progressive muscular relaxation.

SESSION 6: EXHIBITION RV + TRADITIONAL TECHNIQUES

  • Homework review.
  • The patient is exposed to:
  • Extraction room with a finger prick.
  • Extraction room with easy extraction.

Homework:

Practice of relaxation techniques and self-exposure to needle-related stimuli.

SESSION 7: VR EXPOSURE + TRADITIONAL TECHNIQUES

  • Homework review.
  • The patient is exposed to:
  • Waiting room with interoceptive exposure.
  • Extraction room with hard extraction and/or Injection + a real extraction video.

Homework:

Practice of relaxation techniques and self-exposure to stimuli related to needles.

SESSION 8: RELAPSE PREVENTION

  • The therapeutic process is evaluated and future self-exposure tasks and reinforcement sessions are programmed. 
  • Management and prevention of future relapses 

4. Comments

It is important to complement the exposure with comments, questions or indications, so that the patient can get more in touch with the situation and experience the exposure in a more realistic way.

Some suggestions for blood phobia are:

  • At the waiting room:
  • You are attending a blood extraction on your own. Do you think you would have felt better if someone had come with you?
  • What does the person getting out of the extraction room cause in you? Does he/she make you more nervous? Or does he/she soothe you?
  • Do you think the extraction is going to hurt?
  • How do you think the person sitting next to you feels? Is he/she nervous or calm?
  • How do you feel about that personʼs state?
  • At the extraction room:
  • ­How many years of experience do you think this nurse has?
  • Does this nurse make you feel safe? 
  • When you are ready, look at the needle which the extraction will be performed with.
  • Look at the bloodstained cotton over the small table.

5. Recommended bibliography

Chapman, L. K., & DeLapp, R. C. (2013). Nine session treatment of a blood–injection–injury phobia with manualized cognitive behavioral therapy: An adult case example. Clinical Case Studies. Retrieved October 26, 2014, from http://ccs.sagepub.com/content/ early/2013/10/28/1534650113509304

Wiederhold, B.K., Mendoza, M., Nakatani, T. Bulinger, A.H. & Wiederhold, M.D. (2005). VR for blood-injection-injury phobia. Annual Review of CyberTherapy and Telemedicine, 3, 109-116.

Wolf, J.J. & Symons, F.J. (2013). An evaluation of multi-component exposure treatment of needle phobia in an adult with autism and intellectual disability. Journal of Applied Research in Intellectual Disabilities, 26(4), 344-348.

Ritz, T.M., Meuret, A.E. & ALvord, M.K. (2014). Blood-injection injury-phobia. In Grossman, L. & Walfish, S. (Ed.): Translating psychological research into practice (pp. 295-301). New York, NY, US: Springer Publishing Co, 609. 

Auto-report hierarchy waiting room and extraction room Psious environments

Ítem(Level of discomfort 0-100)
I just had a blood draw and the nurse tells me there’s another one left.
I went into the extraction room and then the nurse pricked my finger to draw a drop of blood.
I am in a hospital waiting room accompanying a friend for a blood test.
I am in the waiting room and I am going to have a blood test soon.
I am standing in an extraction room and my friend is sitting on a stool. The nurse proceeds to give him an injection.
While my friend is sitting in the extraction room, I am standing because I accompany him. The nurse explains that she is going to do a small blood draw and proceeds to do it.
I am home a few hours before I go for a blood test. 
The nurse starts to perform a blood test that lasts a long time, makes a considerable extraction.
I am in the waiting room and they’ re gonna give me an injection shortly.
I entered the extraction room accompanying a friend and then the nurse pricked his finger to draw a drop of blood.
While I am waiting with a friend to be called in for a blood test, the nurse calls someone else into the extraction room. 
I see a video in which they do a blood draw on me. 
am in the extraction room ready for my blood work. The nurse starts and ends right away, because the extraction has been small.
I am driving to the hospital because I’ m getting tested today.
I am in the hospital waiting room with my partner, who’ s coming in for a blood test. We are talking and then the nurse appears and calls him, so we enter the extraction room.
After I went into the extraction room, the nurse gave me an injection. 
I find myself in the waiting room of the hospital, and then the nurse appears, who calls me and makes me go to the extraction room. 
While my partner is in the extraction room, I see how the nurse starts doing a long blood draw, so the procedure takes a while.
I have been waiting a while to get into the extraction room. Then the nurse appears and calls another patient to come in.
I am copilot in a friend’ s car because I am escorting him for a blood test.