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:

  • heart palpitations
  • feeling sick
  • chest pains
  • difficulty breathing
  • dizziness
  • ‘jelly legs’
  • feeling ‘unreal’
  • intense sweating
  • feeling faint
  • dry throat
  • restricted or ‘fuzzy’ vision or hearing.

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’.

 

 


The basic reference work on which we have drawn is Fears, Phobias and
Rituals by Professor I M Marks, published by Oxford University Press (1987)