Address for Correspondence:
Dr. Beena Johnson, MBBS, DCH, MD, PhD, Department of Child
Guidance, Baby Memorial Hospital, Kozhikode, Kerala, India.
Email: jiacam@gmail.com
Abstract
Blood-Injection-Injury phobia is a major health issue
throughout the life span. It usually starts in early
childhood. Avoidance of health care is seen in such
individuals. Children with blood injection injury phobia have
uncontrollable fear of blood, injury, injections and needles.
Because of the intense fear, these children will do everything
possible to avoid it. Various physical symptoms including
increased heart rate, chest discomfort, trembling
movements, feeling of choking and syncope may
occur in these children on mentioning about blood, needles or
any injury. Vasovagal fainting with diphasic response pattern
occurs in about twenty percent of children on exposure to the
phobic stimulus. Other anxiety disorders, depressive disorders
and attention deficit hyperactivity disorder also occur
co-morbidly in children with blood-injection-injury phobia
which makes the prognosis poor. Avoidance of health care
due to phobia causes significant negative impact on health
outcomes. Hence early diagnosis and urgent management of
blood-injection-injury phobia in children is essential.
Key Words:
Blood-Injection-Injury phobia, Specific phobia, Children
Introduction
Epidemiological surveys have proved that one third of the
population is affected by an anxiety disorder during their
lifetime. Anxiety disorders are associated with high health
care costs [1]. Experiencing fear in dangerous situations is
normal and it has a protective purpose. Normal fear activates
the "fight or flight" response and make the individual alert
to respond quickly in dangerous situations. But in phobia,
there is unreasonable fear which leads to intense anxiety and
avoidance. Specific phobia is an anxiety disorder which is
characterized by persistent, irrational fear of
circumscribed objects or situations.
The one year prevalence of specific phobia is 7.9% [2].
Specific phobia has a lifetime prevalence of 12.5% [3].
There are four subtypes of specific phobia which include
animal phobias, natural environment phobias,
blood-injection-injury phobia and situational phobias. Most of
the phobias have onset during childhood.
Blood-Injection-Injury (BII) phobia is a debilitating disorder
of significant importance in paediatric practice. If it is not
managed scientifically during childhood, it can lead to severe
emotional disorders during adulthood.
The lifetime prevalence of BII phobia is 3.5%. The median age
of onset is five and a half years. There is high prevalence in
females. There is significant comorbidity with
obsessive-compulsive disorder, panic disorder and agoraphobia
[4]. BII phobia also shows comorbidity with
attention-deficit/hyperactivity disorder and various emotional
problems in children and adolescents [5]. There is high
comorbidity of depression in individuals with BII phobia
[6]. Hence, blood injection injury phobia should be identified
early and managed effectively during early childhood.
Clinical Features
Children with BII phobia have intense fear of blood, injury,
injection/needles. Symptoms usually start in early childhood.
They experience uncontrollable fear on exposure to the phobic
stimuli. These children will do everything possible to avoid
it. Crying, clinging and tantrums are usually seen in children
with this phobia and they avoid most of the medical
procedures. Tachycardia, hypertension, chest discomfort,
tremors or feeling of choking may occur even on mentioning
about blood, needles or any injury. Vasovagal fainting usually
occurs in children with BII phobias. Diphasic cardiovascular
response is seen in BII phobia [6]. This pattern is seen in up
to 20% of BII phobia patients [7]. Initially, a brief increase
in heart rate occurs. This is followed by bradycardia and
hypotension. This in turn leads to vasovagal syncope [8]. Most
of the patients with BII phobia experience syncope or
presyncope as part of the response to phobia. They have an
underlying autonomic dysregulation. This will predispose to
syncope [9]. Exaggerated inhibition of sympathetic nerve
activity is a predisposing factor for syncope [10]. Reduced
medial prefrontal cortex activity in seen in BII phobia. This
leads to reduction in cognitive control of emotions [11].
Emotional problems mediate fainting responses in BII phobias
[12].
BlI phobia include fear of blood (hemophobia), injury phobia
(traumatophobia) and fear of receiving an injection
(trypanophobia) [13]. The most common painful needle procedure
which a person experiences in life is vaccine injection.
Individuals with high level of fear during vaccination will
have significant distress associated with subsequent needle
procedures [14]. Because of the fear of medical services,
children with this strong phobia will refuse the treatment for
many diseases.
Treatment
The treatment goal is eventual extinction of the phobic
symptoms. In the management of childhood anxiety, coping
skills and self-esteem of the child should be improved.
The therapy should be aimed to make changes in the child's
perception of dangerousness. Cognitive Behaviour Therapy (CBT)
is commonly used in the treatment of specific phobias. A
variant of cognitive-behavioural therapy, which includes in
vivo exposure, psychoeducation, cognitive challenges and
skills training is effective in the management of specific
phobias in children [3]. Coping skills of children should be
increased and self-efficacy should be improved. Exposure
therapy reduces the hyperactivation of amygdala and anterior
cingulate cortex which is found in individuals with specific
phobia.
The recommended treatment for children seven years and older
with injection phobia is in vivo exposure-based therapy [15].
For children above seven years, who are reluctant to undergo
in vivo exposure, non-in vivo exposure is recommended.
Exposure-based interventions are also beneficial for children
less than seven years. Scientific management of needle fear
will lead to improved compliance in health care. Thus health
outcomes in children can definitely be made better.
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