Bloodinjury And Injection Phobia

People who require frequent administration of medication by injection, such as diabetics or those with chronic psychosis, are in danger if they are not able to tolerate injections. In a sample of over 1 200 people with insulin-dependent diabetes (Mollema et al., 2001) around

Table 20.1 Outcome studies for treatment of dental phobia



Design (including repeated measures)

Bernstein & Kleinknecht (1982)

Not addressed

Five Groups: graded video-aided exposure, video-presented models, participant modelling (in vivo exposure), attention-placebo, 'positive-dental experience' in vivo

De Jongh etal. (1995)

Not addressed Three Groups: one session of cognitive therapy, or dental information, waiting list

Outcome measures Statistical outcome Clinical significance

Included Fear. Survey Schedule (FSS), Dental Fear Survey (DFS). Health Locus of Control and personality measures; palmar sweat index etc. Records of attendance for dental exam or treatment

State/Trait Anxiety (STAI); Dental Anxiety Scale (DAS), Frequency and credibility of cognitions (Dental Cognitions Q(DCQ))

Only on state anxiety and expected pain was there an improvement. No group better than any other. No difference in dental appointment-making/ attending

Not addressed but attendance for dental care recorded

Negative cognitions decreased in credibility and frequency in all groups. Cognitive therapy showed greatest change but was not superior in frequency of cognitions on follow-up. Dental Anxiety declined most rapidly with cognitive therapy

Not addressed. Not clear if all Ss tolerated the dental inspection. No reports of dental treatment undergone

Design (including Comorbidity repeated measures)

Getka & Glass (1992)

Not addressed Four groups: stress inoculation, six sessions training or semi-automated behaviour therapy (modelling, relaxation, video-exposure); Waiting-list; 'positive dental experience' from dentist

Hammarstrand ef al. Not addressed Two groups: eight

(1995) sessions of hypnotherapy (relaxation reinforced with suggestions) or behaviour therapy (relaxation, exposure to anxiety provoking hierarchy, biofeedback)

Harrison ef al. (1 989) Not addressed Two groups:

systematic desensitisation (SD) (to graded video scenes, relaxation, EMG biofeedback) alone or SD and 'cognitive coping' SDCC, challenging negative self-statements)

Twenty measures: Dental Anxiety Scale (DAS); Dental Fear Survey (DFS); two analogue scales of fear; Dental Self Efficacy Scale (OSES); rating: expectations of pain; Palmar Sweat Index

Anxiety less in stress inoculation and behaviour therapy groups than in others. Not clear if this represents an improvement from pre- to post-therapy

Not addressed but all subjects had a cavity restoration after psychological treatment. No comparison in dentistry acceptance between groups

Dental Anxiety Scale (DAS), Mood Adjective Checklist (MACL); Geer Fear Scale (GFS); Dental Situation Reactions (DSR); dentist rating of co-operation

Hypnotherapy showed no improvement on any measure. Behaviour therapy showed improvement on four of five measures reported by Ss

Not addressed. All but one Ss 'could be referred to dentist to conclude treatment' but no record of such treatment

Dental Anxiety Scale (DAS); Dental Treatment (cavity restoration with local anaesthesia) completed

More patients in SD group than the SDCC Ss completed two assigned dental treatments. Both groups improved on DAS

Fifteen of 16 SD Ss completed dental treatment; 12 of 1 6 SDCC Ss completed No other aspect of clinical significance addressed


Table 20.1 (continued)



Design (including repeated measures)

Jerremalm etal. (1986) Not addressed

Four groups allocated to self-instruction training or applied relaxation; 'cognitive or physiological reactors'

Makkes et al. (1 987) Not addressed Single group, various anxiety management procedures including nitrous oxide sedation

Mathews & Rezin Excluded Five groups: all

(1976) combinations of high/low arousal and coping/no coping instruction cf. relaxation control group

Outcome measures Statistical outcome Clinical significance

Fear Survey Schedule (FSS), Dental Anxiety Scale (DAS), Dental Fear Survey (DFS); Behavioural Test: no of steps tolerated in dental exam; dentist's rating of Ss anxiety, pulse rate Autonomic Perception Q (APQ)

Dental Anxiety Scale (DAS) and other unattributed measures

No change in behavioural measure; pulse rate declined in physiological reactors in both treatments but no change in cognitive reactors. Inconsistent improvement on Dental Fear and Dental Anxiety

Reduction in DAS anxiety but impossible to tell if this was due to anxiety management or because dentistry had been finished

Not addressed but 96 % of Ss had undergone invasive dental treatment -probably a significant improvement

Not addressed

The Dental Anxiety Q; Semantic Differentials; Behavioural Test

Anxiety during behavioural tests improved more for low arousal than for high arousal. No comparisons with control groups

No difference between groups in dental attendance

Design (including

Comorbidity repeated measures) Outcome measures Statistical outcome Clinical significance

Miller, Murphy & Miller

Not addressed. Ss receiving treatment from other health professionals were excluded

Three groups: 10 sessions: EMG feedback, progressive relaxation; control group (seIf-relaxation)

Included EMG, Dental Anxiety Scale (DAS); State-Trait Anxiety Inventory (STAI)

DAS and state anxiety reduced in all groups but more in 2 treatment groups than in the control group

Not addressed

Moore etal. (1991)

Ning & Liddell (1991)

Shaw & Thoresen (1974)

Dental phobic Ss high and low in general anxiety

General anxiety (by Symptom Q): Ss 'not unduly anxious'

Not addressed

Two groups: given imaginal exposure with video stimuli or untreated Ss from waiting-list given 'attention placebo'

Two groups: massed/spaced cognitive therapy and relaxation

Four groups: systematic desensitisation (audio presented hierarchy), video modelling and relaxation and imaginal desensitisation relaxation placebo. Waiting-list

Dental Anxiety Scale (DAS), State-Trait Anxiety Inventory (STAI); Fear Survey Schedule

Ss making dental appointment; attending dentist; Dental Anxiety Scale (DAS). Ss' reports of anxiety, behaviour and physiology ('Discanf')

Visits to dentist and completion of treatment; six ad hoc measures of anxiety and attitudes to dentistry; Fear Survey Schedule (FSS); IPAT Anxiety Scale

Treated group improved on all measures including trait anxiety and non-dental fears and more than the control group

All Ss made appointment and attended. DAS and Discan scores reduced in both groups

Not addressed

Considered together, the two treatment groups had more successful visits to dentist, and showed significant reductions in seven of eight anxiety measures. The comparison groups showed significant irbprovements on three measures only (the placebo group)

Not addressed. No reports of dental treatment completed

Not addressed but dental treatment completion recorded

120 expressed extreme fear of injections. There is a danger, therefore, that they would miss or postpone insulin injections with serious consequences, including death. However, there appear to be no other studies of injection fear in such groups.

Research has shown that many of those who are afraid of injections are prone to fainting during the procedure and during operations, such as blood sampling, a requirement for some of the recent neuroleptic medications. They present a diphasic response in heart rate to the sight of blood - acceleration and then deceleration and bradycardia. Blood pressure changes in a similar fashion, the extreme drop in pressure accompanying fainting (Ost etal., 1984; Page, 1994).

Treatment studies, which have concentrated on subjects who are prone to fainting at the sight of blood, have distinguished the fall in blood pressure and the fear experienced in anticipation of the procedure. Page (1994) has proposed that the experience of the former causes the anticipatory fear. However, studies have depended on the subjects being able to practise the tension exercises that can be used at every blood exposure to control blood pressure. It may not be necessary, therefore, to demonstrate that this has a carry-over effect: that, after practice of the tension exercises, blood pressure is increased without the use of the exercises. The few studies of cognitions in blood-injury and injection phobia have shown that thoughts of disgust are less common than in other phobias, notably of spiders (DeJong & Merckelbach, 1998 ). A clinically significant outcome to treatment could nevertheless include, for some people, the acceptance of injections and a reduction in disgust as well as fear.

Only three studies using groups of subjects have been recorded (Ost, Fellenius & Sterner, 1991; Ost, Hellstrom & Kaver, 1992; Ost, Sterner & Fellenius, 1989), all by the same group. They have addressed both the fear of anticipated procedures and fall in blood pressure on exposure to blood. Applied tension enabled the subjects to raise their blood pressure. That, and in vivo exposure, reduced most measures of fear but was not successful in maintaining blood pressure on testing without applied tension. Subjects with comorbid disorders were excluded in all reports. However, impairment was partially addressed in all studies, most notably by Ost, Hellstrom and Kaver (1992) in whose study eight of 35 women allowed themselves to become pregnant and so endure venupunctures because they had overcome their fear of injections. However, the number of subjects who came to accept injections is not clear. This is disappointing given the need to enable some subjects, such as diabetics, to receive injections repeatedly.

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