Overcoming Medical Phobias

Including fear of blood, injections, dentists & hospitals

Phobias are very common - experts believe that one person in ten is affected by a phobia at some time in their life - and ‘medical’ phobias, concerning hospitals, dentists, injections and blood, are among the most common.

Because there is an obvious common link between these conditions, we have dealt with blood, dental, hospital and injection phobias together, adding some comments on the somewhat different condition of ‘illness phobia’. However, because the specific conditions can occur in isolation, we have also gone into these separately.

WHAT EXACTLY IS A PHOBIA?

Phobias are fears. Fear is a normal part of life, and there are many things in life which can be dangerous or painful - including wasps, muggers, car crashes and having operations.

Most people have experienced a certain level of ‘sensible’ anxiety when faced with the prospect of medical or dental treatment, especially when it is ‘invasive’. We humans have a tendency to be squeamish at the sight of blood or injury. This reaction may well be instinctive, since many other species also show acute alarm at the sight of one of their fellows injured. We are programmed to avoid our soft and vulnerable bodies being punctured, and suffering injury and losing blood as a result. Thus our reaction to being ‘threatened’ with sharp objects such as a hypodermic needle or dentist’s drill is also to some degree natural. The reasons for being apprehensive about pain are obvious.

Sensible people take precautions to avoid pain, injury and situations that are genuinely dangerous. It is natural to feel anxious when such situations arise. In this sense, anxiety is very useful. It warns you when danger is threatening. Fear (which we can think of as severe anxiety) can also be useful. When we find ourselves in a situation of real danger - such as being faced by a robber in a dark alley - the fear reaction is just what we need.

It releases adrenaline and other chemicals into our blood, and these speed up our heart-beat, sharpen our senses and heighten our physical powers. These changes prepare us for what is called ‘flight or fight’ - either to fight for our lives, or to run for them.

A phobia is a disorder in which the body reacts in exactly the same way, and we experience exactly the same feelings of fear - but in situations where ‘flight or fight’ is quite inappropriate. For example, although we may be anxious about going to the dentist, we know that it is actually for our own good. Fear of dentists at the phobic level is a very different matter. It is as if we have lost all sense of proportion, and internally sets up an uncontrollable scream of `Danger! Danger! Don’t do it!’

When the fear reaction is as strong as this, even an entirely harmless checkup can feel like a serious and imminent threat to life and limb. People with phobias usually realise all too well that their reaction is irrational, but this makes no difference to its effect. Of course, ‘normal’ people find this very difficult to understand.

But phobias aren’t just severe anxiety: the anxiety is turned into a phobia by avoidance. In the early stages of a phobia, people affected sometimes try to tackle their fears head on by forcing themselves to go into the feared situation. If they succeed in staying there, the phobia can be overcome quite quickly. Unfortunately, these brief ventures usually end in a hasty retreat when the anxiety starts to rise. Because this avoidance brings a reduction of the tension, it rapidly becomes a habit. The next attempt then becomes more difficult, and so on until the attempts to face the problem stop altogether. Avoiding the situations that make us feel frightened makes us more sensitive to those situations, and ‘conditions’ us to fear them even more.

Avoidance is like retreating from an enemy. We may feel safer to begin with, but we’re letting the enemy get us on the run. This is why phobias can be such a big problem. Because we tend to avoid the things we fear, the fear can worsen very rapidly. And we have to retreat further and further, until we find that our ability to live a normal life has been drastically reduced. In the case of medical phobias, avoiding treatment may put our health, and even our lives, at risk.

To recover, we need to put that process into reverse.

WHAT ARE THE SYMPTOMS OF PHOBIA?

The medical phobias dealt with in this leaflet can produce all the unpleasant physical symptom of ‘normal’ fear:

In severe cases, people may feel certain that they are about to die, go mad, or lose control of themselves and injure someone, or do something disgusting and humiliating. Most of all they feel an overpowering urge to ‘escape’ from the situation they are in. They also develop an acute fear of repeating these very unpleasant experiences, and this is what really creates the phobia.

The level of symptoms that people with medical phobias experience varies a great deal, from gnawing anxiety to very severe panic and terror.

Of course, these are only feelings. Even the worst panic attacks do not cause any long-term ill-effects; people who panic simply do not die, go mad, or cause mayhem as a result. In fact these frightening symptoms are exactly the same thing that ‘normal’ people feel in situations that really are dangerous. Soldiers in a battle feel exactly that way. The only thing different about a phobia, is that the fear is wildly out of proportion to the ‘danger’.

IT CAN’T JUST BE ANXIETY, CAN IT?

Someone with severe phobic symptoms has a ‘severe anxiety condition’, which is much worse than just being nervous or ‘a bit of a worrier’. Anxiety at this level can be as disabling as many physical diseases, and phobic people are often convinced that there must be a more ‘logical’ explanation.

Sometimes they convince themselves that their symptoms are due to a serious mental or physical illness, and since they fear seeking treatment, this may make the anxiety even worse.

The facts are that the bodily changes caused by severe anxiety do indeed cause nasty symptoms which can seem like a serious disease, but that a phobia is definitely not a mental illness either. (However, this does not rule out the possibility that a person with a medical phobic condition also has a separate medical problem.)

ABOUT BLOOD PHOBIA

People have a tendency to be squeamish at the sight of blood, injury or deformity. It is probably born in us as many species show acute alarm at the sight of one of their fellows injured. Mild fear of blood is common in children and in adults. (44% of 6-8 year olds and 27% of 9-12 year olds experience it). Intense fear, to a phobic level is less common, affecting 2-3% of children and adults. Onset is usually at a younger age than most phobias. Well over half the documented cases of blood phobia have a family member with a similar problem. This is between three and six times higher than for the incidence of phobia in the families of agoraphobics, social phobics and animal phobics. The most probable reason for this is that blood phobics have a genetically inherited physiological response to the sight of blood or injury, which involves a drop in heart beat rate (most phobics experience an increase in heart beat when faced with the phobic stimuli). This leads to sweating, nausea, pallor and, often, fainting

Lower heart beat rate is a good protective device when faced with injury as it reduces the chance of bleeding to death. However, with some people, this seems to have got out of hand with the reaction spreading to include the sight of any blood, and even reading about, or discussion about, blood. Blood phobics are the only phobics who actually faint at the sight of their stimuli (blood). Other phobics may believe they will, or they may faint in response to heat or over crowding rather than the actual dreaded situation. Blood phobics may also be able to defer the faint slightly in order to find a safer place to fall, a facility they share with some epileptics, which can lead to outsiders viewing the faint as an over reaction or even as a fake.

Typically, a blood phobic will experience more nausea and faintness that fear and anxiety, although anxiety at the possibility of fainting is obviously present, and the nausea may be experienced as different to that associated with vomiting.

ABOUT FEAR OF INJECTIONS

This common phobia combines several ‘sensible’ fears, such as those of blood, injury and being ‘threatened’ by a sharp object, and a certain level of anxiety about these things can be expected. However, when fear of injections puts a person’s safety at risk - as in refusing to consult a doctor for fear of being given a blood test - then the problem has to be dealt with.

While some people simply become upset or slightly panicky if they are faced with an injection, others find it impossible to enter any situation that might have an injection at the end of it.

DENTAL PHOBIA

Most people are mildly anxious about having dental treatment, but the problem reaches the level of a phobia in about five percent of the population. It is more common in women, starts in childhood or adolescence and can be associated with similar fears in parents and some increase in other emotional problems. This phobia often occurs on its own, but may also be associated with fear of blood, of injury and of hospitals.

Dental phobics particularly fear injections and the drill. They react by tensing their muscles, and usually expect more pain than they actually feel during treatment. Research shows, however, that they have the same level of pain tolerance during treatment as non-phobics, but that they may have a lower pain threshold, or the same threshold but feel more pain.

Obviously people are at many different points on the phobic scale. While some dental phobics experience - but cope with - unpleasant physical symptoms when faced with the prospect of dentistry, others would rather pull out their own teeth than visit a dentist (and have on occasion done so). These are different ends of the same line, but can both be labelled ‘phobic reactions’.

Some dental phobics also have a problem with an increased sensitivity to gagging (the reflex which occurs in the throat when a finger is placed in the mouth near the soft palate). Gagging protects us from swallowing objects or substances that may be dangerous, but the response becomes a problem when it spreads to include all sorts of other ‘foreign objects’ in the mouth. This may lead to a person being unable to brush their teeth or even allow their neck to be touched, (much less suffer the attentions of dental equipment,) for fear of choking.

FEAR OF HOSPITALS

This is also a fairly common fear. As with dental treatment and injections, most people would probably feel somewhat anxious about going into hospital - focusing on pain, blood, ‘injury’, and being separated from the family and under the control of strangers etc. However, when the fear becomes irrational to the point where necessary medical treatment might be avoided, then the problem must be dealt with.

The level of fears experienced varies a great deal. Some hospital phobics simply become upset or slightly panicky when they are faced with a hospital visit, while others may find it completely impossible to enter into any situation that might involve a trip to hospital.

WHAT CAUSES MEDICAL PHOBIAS?

It’s hard to be precise, though sometimes an unpleasant experience may be the trigger. Some children experience great distress when hospitalised at a very young age, and can lock away these fears and terrors so that they remain just raw fear, never moderated by an adult’s wider understanding. Looking at them years later can sometimes uncover a basic child’s misconception that is relatively easy to work through.

Apart from this example, while it may be useful to know the ‘cause’ of a phobia, it isn’t vital. The phobia is just one possible form that underlying anxiety can take. The reasons why it has become focused on dentists, injections, blood or hospitals may be quite accidental. In reality, a run of unpleasant ‘life events’ such as illness, death of a close relative, marriage break-up, losing a job or bad depression may be the real culprit.

For this reason, it is not generally worth spending a lot of time and energy on ‘rooting out the cause’. The point is to learn to control the phobia.

HOW CAN I OVERCOME MY PHOBIA?

People with phobias have become ‘conditioned’ to produce the fear reaction in situations which aren’t really dangerous at all. The best way to counter this is by ‘de-conditioning’: training themselves to react correctly.

This is done by gradually exposing themselves to the things they fear, and experiencing the fears without running away, and so becoming less sensitive to them.

The idea is simple, but it calls for a fair amount of courage and determination. The help of family and friends can make self-treatment much easier to manage, and this is also why many people prefer to join a self-help group where they can get support from people in a similar situation. Desensitisation in medical phobias is bound to depend on the co-operation of caring dentists, doctors and nurses, and help from a psychiatrist or clinical psychiatrist may also be needed.

Anyone who decides to try desensitisation needs to draw up a personal ‘training programme’. This means working out what they can do now, deciding what they want to be able to do at the end, and fitting as many gradual ‘exposure’ steps in between as they need. The first step can be as simple as staying in a situation that can just be managed now, but for a little longer than before.

Obviously these phobias take many different forms, and different people’s phobias are at many different levels and may focus on many different fears. However, here are some suggestions for how desensitisation could be handled.

1. Blood phobia

Treatment for blood phobia involves gradually increasing the tolerance for blood by exposing the sufferer to situations involving it. This is done via a series of steps starting with what is just possible and working through until a normal level of response is reached. (According to research, this often includes becoming a blood donor once the problem has been overcome!) However, because of the problems of fainting and lowered heart rate with some blood phobics, the exposure work is best done under the guidance of a clinical psychologist or psychiatrist. At the very least, it should be closely monitored by a health professional.

2. Injection phobia

The levels of anxiety in different individuals are so different that it is not possible to offer a single series of exposure steps applicable to all cases, but there are some suggestions that would be worth considering for anyone starting desensitisation.

Work out if the environment makes a difference. Do doctors’ surgeries and hospitals bring on the anxiety regardless of whether an injection is a possibility? If so, work out a programme of steps that will reduce this, such as sitting in the waiting room with things to do such as reading, listening to a personal stereo, etc. Keep a written record of anxiety feelings and levels as the situation changes (people looking afraid, unwell, holding swabs to arms etc.). Most clinics and hospitals will be aware of the problem and will not object to such activity. Build up to actually watching somebody being injected if this is possible. If this is not a reasonable step (some people feel worse in such situations), get help from a professional or a friend, using relaxation techniques or ways of distracting your thoughts if you cannot avoid having to wait with others facing injections.

3. Dental phobia

It is not possible to suggest a list of exposure steps that will apply to everyone, and in any event, the steps will require the assistance of a caring dentist. Some aren’t particularly caring, and may view helping a dental phobic as an extension of the time needed to treat and so a reduction in income, rather than as part of the treatment that a responsible professional should be giving. If this is a problem, look in the Yellow Pages under ‘Health Authority’ and then for ‘District Medical Officer’. He or she should be able to direct you to a reasonably local dentist who is experienced in helping dental phobics.

Successful desensitisation programmes have included:

• watching videos of dental treatment and working up to watching it live

• getting used to sitting in the waiting room and then in the chair

• befriending the dentist

• having a signal system arranged whereby the dentist promises to stop at the signal (some dentists even have a cut-off switch on the equipment to allow the patient to stop all work instantly).

Although a dental phobic with no experience of dentistry can be helped by watching somebody in their peer group undergo treatment, live or on film, children (and possibly some acutely phobic adults) may actually be made worse by simply watching someone else being injected or examined. They may need to become used to the dentist and his or her surgery first. Children might accomplish this by playing, talking and relaxing in the venue with parents and friends. They might also need to practise some coping techniques, like controlled breathing and using distracting thoughts, before undergoing treatment.

If the problem includes gagging, this too can be reduced by a desensitisation programme. Here, ordinary clothing buttons may be used. First the person learns to tolerate one in his or her mouth, then two etc. If the gagging is made worse by a tendency to swallow tensely with pursed lips, clenched teeth and the tongue thrust forward against them, they can be taught to swallow with the teeth slightly apart and the tongue relaxed on the floor of mouth. A therapist (or a friend) could help by gently stroking the front of the person’s tongue until they get used to it, which might take half an hour or so; then work further back on the tongue, etc. As people begin to understand what triggers the gagging, this can also help to decrease the problem to normal proportions.

If you can find a sympathetic dentist, you must be ready to do enough at each step to increase your anxiety. You are trying to become used to experiencing the physical symptoms at a manageable level, where you are in control. If it is possible to find a friend willing to work with you, who can talk positively and calmly while the steps are done (not over-sympathising or constantly asking how bad you feel) this can be a help.

4. Fear of hospitals

Although it is impossible to provide a single set of steps that will suit every case, here are some suggestions that should be helpful for someone considering starting a desensitisation programme.

First, work out what the main fear involves. People tend to think they know exactly what they are afraid of, but a surprising number do not. Is it one of the fears we have already mentioned - such as injection, injury, blood, or separation from the family? Or has it focused on something specific such as white coats, or hospital smells? If so, these can be integrated into the programme.

Early steps might involve walking past a hospital, or through it, working up to having tea in the canteen and sitting in the waiting room. Anxiety while sitting in a hospital might be eased by arming yourself with things to do, such as reading, or listening to a personal stereo. It is also useful to keep a written record of anxiety feelings as the situation changes.

ABOUT ILLNESS PHOBIA

Illness phobias are quite common, and usually involve endless ruminations about disease (including death from disease); avoiding any kind of media coverage on the subject (or more rarely, obsessively collecting such information); repeatedly examining ones body own bodies, and also requesting frequent examinations from any medical practitioner willing to provide them; constantly demanding reassurance that disease is not present from family, friends and doctors.

Illness phobias in some ways resemble Obsessive/Compulsive Disorder, as the accompanying rituals can be as troublesome as those found in OCD, and the ruminations about illness are very like obsessions. For this reason we have not described Illness Phobia in detail in this leaflet: there is a separate leaflet on the subject.

SOME HINTS FOR SELF-EXPOSURE WORK

• The first step in the programme can be very simple - perhaps staying in a situation that can just be managed now, but for a little longer than before.

• The steps can be as large or as small as necessary, and big steps can be broken down into smaller ones. However, it is important to make sure that each step challenges the anxiety a little more than the last.

• Don’t be overwhelmed by the size of the task. As a rule, the steps become steadily easier as you work through them.

• Don’t expect to be completely free from anxiety before you leave each step and go onto the next - it will go completely in its own time as you progress.

• Do the exercises as often as you can. You are trying to build up positive memories to replace all the bad ones of being beaten by the phobia, and too long a gap between efforts makes this more difficult.

• ‘Fantasy exposure’ can also be useful. This is working through the dreaded situation in the mind, and accepting the anxiety this causes until the person can think through the whole process without trying to avoid anxiety symptoms. Handling a syringe and talking to those responsible for injecting can also be linked into the steps at some point.

• An hour or so of self-exposure work at a time and repeating this every day is best. Waiting until you feel ‘strong’ or until you cannot avoid it any longer is not a positive approach.

• Do enough at each step to increase your anxiety. You are trying to raise the level of physical symptoms that you can manage, and where you are in control.

• If it is possible to find someone to work with, who can talk to you calmly and positively while you are doing the steps (not over-sympathising or endlessly asking how bad you are feeling) this can help.

• When the work becomes hard, remind yourself that running away from the phobic situation keeps you phobic, while holding on through the anxiety that it brings helps to break the phobia down. However, don’t torture yourself with this. If the problem simply doesn’t respond to self-help, ask your GP to refer you to a clinical psychologist. Alternatively, contact your local department of psychology yourself and ask what professional help is available in your region. (Some departments take direct referral.)

• Relaxation techniques can be helpful in tackling the next step, and it is easy to practice relaxation in the privacy of your own home.

• If the steps you have chosen prove impossible, of if you are depressed or have other severe anxiety problems, then professional help from a clinical psychologist or psychiatrist may be needed. You can reach such professionals through your GP; and in any case we recommend that you contact your GP and talk to him or her about your disorder.

PANIC ATTACKS

For many people affected by phobic conditions, the thing they dread most is the possibility of having a panic attack in some public place. Panic is a very unpleasant experience, and while it is happening it is very hard to think rationally. Typically, people who are having a panic attack feel that they are about to have a heart attack, or go mad, or lose control of their bowels, or run amok and injure themselves and others. The urge to prevent this happening produces a powerful desire to escape from the situation immediately.

In reality, the imagined horrors do not occur. Anxiety Care has never come across a single instance of someone having a heart attack, stroke, or brain haemorrhage, or going mad as a result of a panic attack. People don’t collapse or have ‘fits’ during panic either. The worst that can happen is that they feel faint or dizzy and have to sit down.

‘Losing control’ is very rare. People do not shout and scream, or foam at the mouth, murder children or mow down passers-by during a panic. Even in the few cases where someone has claimed to have lost control, the reality is a little different. One person described to Anxiety Care how she ‘rushed screaming out of the house’ - but it turned out that she had taken the time to close the doors and windows first. Another ‘kicked insanely at the car window to get out’, but thoughtfully removed her shoes first to avoid doing any damage!

Panic is basically an internal event. It may feel as though the mind and body are breaking up, but the truth is that other people seldom even notice when someone is having an attack, especially in a busy place. They are too busy thinking about their own affairs, and even if they see someone get up and run out they are likely to assume there is a ‘sensible’ reason - like being late for a bus. In any event, they will have forgotten all about it in a moment or two.

The boring truth about panic is that although it feels dreadful at the time, and although the overdose of adrenaline and other chemicals can leave a person feeling drained and shaken:

• panic does not cause any permanent harm

• it does not drive people insane

• panic attacks only last a short time, and then they subside

• they subside irrespective of whether you stay in the ‘panic situation’ or ‘escape’.