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Procedure-related anxiety and needle phobia: rapid techniques to calm

- Identify causes and presentation of anxiety and phobias linked to medical procedures

 - Prioritise steps to sensitively help patients who are phobic, fearful or anxious

- Learn two teachable rapid techniques to quickly ease anxiety and distress for future procedures

Cannulations, wound dressings, catheterisations, and scans are common scenarios for procedural anxiety. Fear and anxiety are normal reactions to perceived extreme threat. However, if unpleasant physical and/or psychological responses to any procedure are sufficiently reinforced then a patient can develop a specific phobia. This is defined by Choy et al.1 as “an excessive, irrational fear of a specific object or situation” to be avoided at all cost or endured with extreme distress. Additional 'red flags' indicating a correlated risk of anxiety and phobic reactions have been identified; these include smoking which can heighten anxiety and narrow blood vessels (see Box 1). 
Blood-injection-injury (BII) phobia is the fear and avoidance of receiving injections, giving a blood sample and being cannulated. Such procedures can cause severe distress for both patients and are typically viewed as disgusting.2 Prevalence estimates vary considerably but Deacon & Abramowitz's3 study of 3,315 venepuncture participants identified 2.17% as being needle phobic. These were more likely to be women (68%) and of a younger age (mean 43 years). BII phobia is unique in that patients who are affected may also experience a vasovagal reflex in response to fear. The vagus nerve is triggered which widens blood vessels, slows the heart rate and drops blood pressure leading to dizziness, syncope (fainting) and shock. Research suggests a correlation between vasovagal syncope, over breathing (hyperventilation) and disgust sensitivity.2 Many more patients will report some form of acute anxiety, fear and distress related to medical procedures, which may not (yet) proceed to a full phobic response. Typically, they will present with the 'fight and flight' responses, including muscle tension, reduction in peripheral circulation and a hyperactive response to additional stressors.4,5 All of these responses may converge to hinder venous access, success in completing scans, and the ability to tolerate repeated dressings. It is important to explore sensitive approaches to reducing anxiety and rapid techniques to utilise prior to or at the time of a procedure and for future use.
Developing partnership conversations about medical procedures
It is pivotal to planned procedures to develop a partnership approach aimed at managing anxiety and preventing phobia. The patient's story can inform nurses of patients' overwhelming fears such as the needle breaking, being totally out of control or even dying. Importantly, the story may elicit the cause of the initial trauma and give insight into the patient's understanding of their fear and specific needs. Our study of radiotherapy patients (n=112), indicated that 43 reported flashbacks of a past traumatic event during mask making procedures, which in turn triggered the panic episode. Examples given by patients included being held down for an injection as a child or being physically/emotionally bullied.6 Our suggestions to establishing a partnership approach are to:
 1. Acknowledge the patient has arrived for the procedure despite being fearful.
2. Ask the patient to identify and rate their most distressing thought, physical sensations and feeling. They can continue to feed back their subjective ratings (and possible improvement) as the procedure continues. 
Observe and sensitively reframe the anxiety response
Anxiety is often physically and emotionally observable in a patient, and these signs can identify interventions that will be most appropriate. Cues can include over-breathing, dry mouth/lips, difficulty swallowing, agitation, sweating, nausea, heightened sensitivity to pain, inability to take in what is happening, cold hands and feet, and increased respiratory and pulse rates. Patients need to know and be reassured that these are normal protective 'flight and fight' responses. Regularly checking for and affirming changes in cues, confirms the patient's mastery of anxiety and also the efficacy of the intervention(s). 
Create a trusting dialogue
Our purpose is to model and uphold the patient's right to say “stop”, “I wish to take a break” and then, when ready (for example after practicing a rapid technique) “go ahead”. The ideal signal would be a simple gesture or word practiced ahead of an agreed procedure. Knowing that there is a bilateral commitment:
 - Fosters trust in the working alliance.
 - Promotes patient self-efficacy (ability).
 - Can reduce anxiety.
 - Can be soothing in the moment. 
Additionally, it is helpful to engage with a patient at the start about their involvement or role during the procedure, for example, do they wish to look away or observe, and be actively informed of each step or not.
Be mindful of nocebo language 
We associate placebo effects with positive expectations of treatment. Conversely, nocebo, the 'evil twin' of placebo, is ascribed to the magnification of side effects or negative consequences of treatment. Nocebo communication includes “sharp scratch coming” and frowning or shaking your head when assessing veins. Language and behaviours which may escalate anxiety causing the patient to tense with fear and their veins to shrink. 
Two teachable rapid techniques 
The two techniques are short so they can be 'stacked' to amplify the calming and soothing responses. They are also discrete and effective methods that the patient can practice as 'self-soothers' at home for future use.
Mindful moist mouth (MMM) 
This helps to reverse the unpleasant symptoms of a dry mouth/difficulty swallowing. Guiding a patient to move the tongue around the gums and gently squeeze the tip against the roof of the mouth stimulates the buccal response and flow of saliva.7 Inviting a patient to sip and hold a little water on their tongue can discretely prevent/reverse over-breathing (hyperventilation) as well as intercept anxiety. When the MMM technique is modelled alongside the patient, it becomes a 'teachable' moment and a shared calming experience. MMM combined with a suggestion to breathe out for slightly longer on the outbreath mitigates against over- breathing. The patient can be encouraged to future plan for successful procedures by carrying water and practicing MMM.
Modified progressive muscle relaxation training/applied tension technique
Progressive muscle relaxation (PMR) training can be shortened to focus on three areas, eg. feet, knees, and one/both hands. Each areas worked is repeated four times. Starting with the feet directs attention away from the area to be cannulated and helps prevent a vasovagal reaction by promoting venous return.8 Modelling this alongside the patient assists with understanding instructions and is mutually calming. 
Ask the patient to tighten the feet and calves, holding for a count of three, and then letting the feet flop back. Then invite the patient to move on and squeeze the knees together with the in breath, hold, and then release tension on the out breath and let the knees flop apart. Reassure the patient that in between any slow guided movements they can breathe at their own rate and depth. Finish with the hand or hands (if one is to be cannulated). A squeezy ball or suitable shape can also be used to aid focus (see Figure 1). 
The purpose of any chosen intervention or strategy is to enable the patient to stay 'exposed' and present to the cause of fear in a controlled situation. It is important to recognise together that anxiety can ease, 'catastrophic thinking' does pass, and skills can be learnt to achieve more positive experience of procedures. Enabling a patient to move from being frozen with fear to a state of calmness can prevent phobic responses. Key practice points are listed in Box 2. 
1. Choy Y, Fyer A, Lipsitz J. Treatment of specific phobia in adults. Clinical Psychology Review 2007;27:266-86. 
2. Olatunji B, Connolly K, David B, Behavioral avoidance and self-reported fainting symptoms in blood/injury fearful individuals: an experimental test of disgust domain specificity. Journal of Anxiety Disorders 2008;22:837-48.
3. Deacon B, Abramowitz J. Fear of needles and vasovagal reactions among phebotomy patients. Anxiety Disorders 2006;20:946-60.
4. Parrish C, Radomsky A, Dugas M. Anxiety-control strategies: is there room for neutralization in successful exposure treatment? Clinical Psychology Review 2008;28(8):1400-12. 
5. Bamgbade O. Severe needle phobia in the perianaesthesia setting. Journal of Peri-Anaesthesia Nursing 2007;22(5):322-9. 
6. Mackereth P, Tomlinson L, Maycock P, Donald G, Carter A, Mehrez A, Lawrence P, Stanton T. Calming panic states in the Mould Room and beyond: a pilot complementary therapy head and neck cancer service. Journal of Radiotherapy in Practice 2012;11(2):83-91. 
7. Ono K, Inoue H, Masuda W, Morimoto Y, Tanaka T, Yokota M, Inega K. Relationship of chewing-stimulated whole saliva flow rate and salivary gland size. Arch Oral Bio 2007;2(5):427-31.
8. Mackereth P, Tomlinson L. Progressive muscle relaxation: a remarkable tool for therapist and patients. In: Cawthorn A, Mackereth P. eds. Integrative Hypnotherapy: complementary approaches in clinical care. London: Elsevier Science; 2010.
9. Wolitzky-Taylor K, Horowitz J, Powers M, Telch M. Psychological approaches in the treatment of specific phobias: a meta-analysis. Clinical Psychology Revie. 2008;28:1021-37.