Treatment for specific phobias of medical and dental procedures

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Treatment for specific phobias of medical and dental procedures Author Yujuan Choy, MD Disclosures All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Oct 2013. | This topic last updated: Set 30, 2013. INTRODUCTION Acute procedural anxiety is an excessive fear of medical, dental, or surgical procedures that results in acute distress or interference with completing necessary procedures. Patients may experience anxiety in anticipation of or during procedures used for screening (eg, mammography), diagnosis (eg, amniocentesis or endoscopy), and treatment (eg, angioplasty or major surgery). Avoidance of clinical procedures due to acute procedural anxiety can have negative health consequences [1-7]. Specific phobias are a subset of the varied manifestations of acute procedural anxiety, diagnosed under DSM-5 criteria only when the patients fears are specific to the procedure and its immediate effects (eg, fear of suffocation during an MRI) rather than fears not specific to the procedure itself (eg, a fear of the underlying illness that might be diagnosed) [8]. Specific phobias related to clinical procedures include: blood-injection-injury phobia, dental phobia, and MRI claustrophobia. This topic addresses the treatment for specific phobias of clinical procedures. Treatment of acute procedural anxiety in adults that does not constitute a specific phobia is discussed separately. The epidemiology, clinical manifestations, course, screening, assessment, and differential diagnosis of acute procedural anxiety are also discussed separately. The epidemiology, clinical manifestations, course, diagnosis, and treatment of other specific phobias are also discussed separately. (See "Treatment of acute procedure anxiety in adults" and "Acute procedure anxiety in adults: Epidemiology and clinical presentation" and "Acute procedure anxiety in adults: Course, screening, assessment, and differential diagnosis" and "Specific phobia in adults: Epidemiology, clinical manifestations, course and diagnosis" and "Psychotherapy for specific phobia in adults" and "Pharmacotherapy for specific phobia in adults".) SPECIFIC PHOBIAS Presentations of acute procedural anxiety are diagnosed as a specific phobia, under DSM-5 criteria, only when the focus of the patients fears are specific to the procedure or its immediate effects (eg, fear of suffocating during an MRI scan) rather than a focus that is not specific to the procedure itself (eg, a fear of the underlying illness that might be diagnosed) [8]. Interventions for three specific phobias of clinical procedures are discussed below: Blood-injection-injury phobia Dental phobia MRI claustrophobia GENERAL TREATMENT PRINCIPLES Several general principles, used in the management of acute procedural anxiety, can also be helpful in the management of specific phobias related to clinical procedures. (See "Treatment of acute procedure anxiety in adults", section on 'General treatment principles'.) INTERVENTIONS Blood-injection-injury phobia Blood-injection-injury phobia is characterized by the fear of seeing blood, receiving an injection, or of other invasive medical procedures [9]. We suggest applied tension, a combination of muscle tensing and exposure therapy, as first-line treatment for blood-injection-injury phobia. Applied tension Applied tension is used to counteract the vasovagal fainting response associated with blood phobia [10-12]. Applied tension involves repeatedly tensing body muscles to increase blood pressure and Section Editor Murray B Stein, MD, MPH Deputy Editor Richard Hermann, MD

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Treatment for specific phobias of medical and dental procedures

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prevent fainting when in the presence of the phobic stimulus (ie, with in-vivo exposure). In treatment with applied tension, the patient is instructed to tense the muscles in their arms, torso and legs and hold the tension until a warm feeling is experienced in the head, typically 10 to 15 seconds. The patient then releases the tension and waits for 20 to 30 seconds for the body to return to normal. The patient then practices this tension-release cycle repeatedly until he or she becomes skilled in the technique. Once the technique is mastered, the patient is instructed to use the technique in response to the early signs of a drop in blood pressure (eg, lightheadedness) during exposure practice to feared situations. A review of five randomized trials found that applied tension was more effective in blood-injection-injury type phobia than exposure alone or muscle tension alone, leading to reduced anxiety, avoidance, and fainting; however, the trials were limited by small sample sizes and yielded variable results [12,13]. As an example, 30 patients with blood-injection-injury phobia were randomly assigned to five sessions of applied tension, in-vivo exposure alone, or muscle tension alone [14]. Greater rates of response were seen for applied tension and tension alone compared to in-vivo exposure alone (90 and 80 versus 40 percent, respectively). Results were sustained on assessment one year later. Other interventions When there is a known history of fainting and the patient has not learned the applied tension technique, the patient should lie down during a procedure (eg, venipuncture), look away from the site of blood draw, and sit up slowly only after sensations of dizziness and fainting resolve. There are no clinical trials of medication for blood phobia, and in our clinical experience, medication is not useful for the phobia. Commonly used anxiolytics, such as benzodiazepines, have no effect on the vasovagal phenomenon in our clinical experience. Dental phobia We suggest first-line treatment for most cases of dental phobia with in-vivo exposure therapy. However, treatment with nitrous oxide is a reasonable choice in some patients. Clinical trials comparing psychotherapy to medication in dental phobia are described below. Selecting between these modalities in dental phobia follows the principles outlined for other manifestations of acute procedural anxiety. (See "Treatment of acute procedure anxiety in adults", section on 'Treatment selection' and 'Duration of treatment effects' below.) Psychotherapies In the absence of rigorous comparative trials, and based on the trials described below, in-vivo exposure therapy is the psychotherapy of choice in the treatment of dental phobia. Trials of psychotherapy for dental phobia are limited by variations in the definition of dental phobia and in other inclusion criteria, assessment methods, and treatment components. Further information on these psychotherapies for specific phobias is discussed separately. (See "Psychotherapy for specific phobia in adults".) In vivo exposure therapy A single trial of 40 patients with dental phobia found that treatment with in-vivo exposure therapy resulted in decreased anxiety, increased positive thinking and decreased negative thinking about dental treatment, and decreased avoidance of dental treatment compared with a waitlist control [15]. Mean absence of dental care before treatment was 11.4 years. In the year following treatment with exposure therapy, a total of 77 percent of patients sought dental care. Individuals assigned to receive five sessions of exposure therapy experienced greater reduction of dental anxiety compared to patients treated with a single session, but avoidance behavior post-treatment did not differ between the two groups. (See "Treatment of acute procedure anxiety in adults", section on 'Exposure therapy'.) Cognitive restructuring Cognitive restructuring involves the identification and modification of overly negative cognitions regarding the feared stimulus. Evidence from a single clinical trial does not support cognitive restructuring as monotherapy for dental phobia [16]. The trial randomly assigned 52 patients with dental phobia to receive a one-hour session of cognitive restructuring, provision of information about dental health/treatment, or a wait-list control condition. The cognitive intervention was more effective than the control conditions in reducing dental anxiety and decreasing the frequency and believability of negative thoughts about dental treatment. However, patients receiving cognitive therapy still had moderate anxiety post-treatment and only 33 percent were considered to be clinically improved. After one year, there was no difference in dental anxiety between patients who did or did not receive the cognitive intervention. The augmentation of exposure therapy with cognitive treatment, which is an effective strategy for some anxiety disorders, has not been tested in acute procedural anxiety, and has led to mixed results in specific phobias

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unrelated to clinical procedures. (See "Psychotherapy for specific phobia in adults", section on 'Cognitive therapy'.) Systematic desensitization Systematic desensitization involves imaginal exposure to the feared stimulus coupled with muscle relaxation to cope with the anxiety. Clinical trials suggest that systematic desensitization is more efficacious than a control condition, but less efficacious than in-vivo exposure in specific phobia [13,17,18]; the intervention has largely been supplanted by exposure therapy [19,20]. (See "Psychotherapy for specific phobia in adults", section on 'Systematic desensitization'.) Coping strategies Coping strategies used to treat dental anxiety include relaxation and applied relaxation. The most common form of relaxation technique is progressive muscle relaxation in which patients are instructed to practice tensing (5 seconds) and relaxing (10 seconds) different muscle groups starting from top of the head down to the toes [21]. This exercise takes about 15 minutes and is practiced twice a day for 1-2 weeks until proficient. Then the tension part is eliminated and release-only relaxation of different muscle groups is practiced, which takes 5-7 minutes. This is then followed by conditioned relaxation in which the patients learn to relax the whole body at once on cue using the self-instruction relax, which further reduces relaxation to 30 seconds. In applied relaxation, patients are taught to apply the skills of relaxation to anxiety provoking situations as a coping strategy to counteract the physiological arousal experienced when anxious [21]. Patients are instructed first to relax on cue many times a day (15 to 20 times) to daily non-stressful situations. Then, they practice in anxietyprovoking situations. Patients are taught to recognize early signs of anxiety and apply relaxation even before entering an anxious situation. In contrast to in vivo exposure therapy in which patients remain in the anxiety provoking situation for a prolonged period of times (up to one to two hours) with the goal of habituation/extinction of the physiological arousal elicited, exposure in applied relaxation is much briefer (10 to 15 minutes) with the goal of coping with anxiety encountered in natural situations. In a single randomized trial of 112 adults with dental phobia, relaxation therapy (a variation of applied relaxation) was more efficacious in reducing dental and overall anxiety than cognitive therapy [22]. In the relaxation therapy condition, patients were trained in progressive muscle relaxation with the aid of electromyographic (EMG) biofeedback to increase the patients ability to relax. Once proficiency in muscle relaxation was achieved, patients were trained to maintain relaxation during exposure to successively more anxiety provoking dental situations (first video scenes, then progress to handling dental instruments). Although relaxation treatment was more effective, treatment completion rate was higher in the cognitive group compared to the relaxation group (74 percent versus 59 percent). Hypnotherapy Hypnotherapy for dental anxiety includes the following components [23]: Progressive relaxation Suggestions for deepening the hypnotic state, relaxation, and comfort Instructions to the patient to imagine dental scenes and procedures in a successively more anxietyprovoking hierarchy Suggestions to the patient, when in a stage of hypnosis, that he or she would no longer be afraid of the imagined dental situations Clinical trials of hypnotherapy for dental anxiety do not show evidence of efficacy: A clinical trial of 174 patients with dental phobia compared hypnotherapy to systematic desensitization, group therapy, or a waiting list control, finding that all three treatments led to similar reductions of anxiety compared to the control group [24]. Avoidance of dental treatment remained high among patients in all three groups. More than 50 percent of the sample dropped out of the study or did not follow through with dental treatment in the community within one year. A trial randomly assigned 22 female patients with dental phobia to hypnotherapy or to a behavioral intervention involving exposure [23]. Exposure therapy resulted in a reduction in dental anxiety, while hypnotherapy did not. The small sample size and a drop-out rate of 44 percent limit the conclusions that can

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be drawn. Medication For patients with dental phobia in which medication treatment is indicated, we suggest the use of nitrous oxide sedation over general anesthesia or benzodiazepines. (See "Treatment of acute procedure anxiety in adults", section on 'Treatment selection'.) Nitrous oxide Despite the paucity of efficacy data, nitrous oxide/oxygen is the sedation method of choice in dental practice [25]. Administration of nitrous oxide has been associated with reduced anxiety and avoidance in patients with dental phobia in clinical trials, but has not been compared to placebo in this population [26-28]. Other advantages of nitrous oxide sedation include: Pain relief Inhalation method of delivery, eliminating the need for intravenous administration (particularly helpful in patients with injection phobia) Rapid induction of sedation Ability to titrate the level of sedation Rapid elimination from the body such that patients are fully recovered within minutes after discontinuation Relatively safe for use in all ages with minimal side effects. Contraindications of nitrous oxide sedation include early pregnancy, chronic respiratory conditions (eg, chronic pulmonary disease and cystic fibrosis), certain illnesses (eg, upper respiratory tract infections, pneumothorax) and following certain surgical procedures (eg, eye surgeries or tympanic membrane repair with graft). Sedation with nitrous oxide is discussed in more detail separately. (See "Procedural sedation in adults".) Other medications Empirical support for the use of general anesthesia [29] and benzodiazepines in dental phobia [30] is more limited. General anesthesia is usually reserved for the most severe cases of dental fear, and has the advantage of allowing major dental work to be completed in a single treatment. A clinical trial of 99 patients compared general anesthesia to behavioral therapy [29]. After receiving these interventions, followed by dental test treatment, 69 and 92 percent of patients, respectively, completed subsequent dental treatment at a community dental clinic specializing in dental phobia. Although these results lacked a placebo group for comparison, the patients had previously avoided treatment for an average of 15 years. Benzodiazepines are used for sedation and anxiolytic effects during dental treatment, but have disadvantages compared to other treatments. Benzodiazepines cause sedating and psychomotor impairment that can last for hours, in contrast to nitrous oxide, the effects of which wear off in minutes (table 1). The clinical effects of benzodiazepines last only for that treatment episode, while the effects of exposure therapy can last for months or years. Administration of benzodiazepines for acute procedural anxiety is discussed separately. (See "Treatment of acute procedure anxiety in adults", section on 'Benzodiazepines' and 'Nitrous oxide' above and 'Duration of treatment effects' below.) Clinical experience and limited evidence support the effectiveness of benzodiazepines for dental phobia. A clinical trial of 91 patients randomly assigned patients to receive midazolam, psychological treatment (consisting of information, cognitive restructuring, relaxation, and applied relaxation) or no treatment [30]. Fifty patients completed the trial, which found both interventions to decrease dental anxiety compared to no treatment. At two-month and one-year follow up, decreased anxiety was only seen in patients who received psychological treatment, compared to patients who received no treatment. Clinical trials have found benzodiazepines to be effective in other specific phobias. (See "Pharmacotherapy for specific phobia in adults" and "Pharmacotherapy for specific phobia in adults", section on 'Benzodiazepines'.) Duration of treatment effects Limited evidence from clinical trials suggests that the duration of effectiveness may be greater for psychotherapy than for medication in dental anxiety [30,31]: 4 de 8 02/12/2013 05:11

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A trial of pretreatment prior to oral surgery in 91 patients with dental anxiety compared psychotherapy (consisting of information, cognitive restructuring, relaxation, and applied relaxation) to midazolam, or to a control no-treatment condition [30]. Patients receiving either psychotherapy or midazolam experienced reduced anxiety prior to surgery compared to the control group. At follow-up two months after the surgery, patients treated with psychotherapy were more likely to have received continued dental treatment compared to patients treated with midazolam (70 versus 20 percent). On assessment one year after the surgery, only the group that received psychotherapy maintained benefit from treatment. A follow-up study of 29 patients 10 years after treatment for dental anxiety found that patients who received systematic desensitization and biofeedback were more likely to report regular dental care during the follow up period compared to patients who received diazepam or general anesthesia (92 versus 63 or 33 percent) [31]. There was no difference in self-reported anxiety between the psychotherapy and diazepam-treated groups at the 10 year follow-up examination, but anxiety was higher in the group who received general anesthesia. Patients who received general anesthesia had poorer dental health status compared to those in the other two groups. Drop-out rates in clinical trials of psychotherapies and medications in dental phobia are among the highest among the subtypes of specific phobia [13], ranging from 44 to 59 percent [22-24,30]. This finding highlights the severe level of avoidance in dental phobia and the need to develop treatments that are more acceptable and tolerable as well as interventions to enhance patient motivation to seek and stay in treatment. Treatment selection Due to the repeated need for dental care and the evidence of a longer-term benefit from exposure therapy in specific phobias and other anxiety disorders, we suggest first-line treatment for most cases of dental phobia with in-vivo exposure therapy over other treatments. However, treatment with nitrous oxide is a reasonable alternative, particularly when: Nitrous oxide is preferred by the patient Exposure therapy is unavailable Dental treatment is needed on an emergent basis The patients anxiety is too severe to tolerate exposure therapy The patient has previously failed an adequate trial of exposure therapy There are no clinical trials comparing exposure therapy to nitrous oxide in dental phobia. A single trial, described above, comparing midazolam to psychotherapy (consisting of information, cognitive restructuring, relaxation, and applied relaxation) in dental phobia found both interventions to be efficacious in the acute treatment of dental phobia compared to no treatment, but no difference in efficacy between them [30]. Although there is a lack of supporting evidence from clinical trials, in our clinical experience, it may be useful to augment exposure therapy with cognitive restructuring or relaxation training, with their selection, based on the patients clinical presentation. MRI claustrophobia Adjustment of the patients position in the MRI scanner can relieve MRI claustrophobia in some patients. In patients where that approach is not effective, we suggest treatment with benzodiazepines over psychotherapy in most cases. Selection between benzodiazepines and psychotherapy for MRI claustrophobia can be made on the basis of principles described for other manifestations of acute procedural anxiety. (See "Treatment of acute procedure anxiety in adults", section on 'Treatment selection'.) Positional adjustment A simple strategy for managing MRI claustrophobia is to change the patients positioning in the scanner. This approach is feasible only for MRI scans where specific positioning is not critical. The patient should be positioned feet first in the scanner. Feet-first exams are less likely to be associated with a claustrophobic reaction compared to head-first exams [32]. Placing the patient in prone position can also be helpful. Prone positioning compared to supine positioning in the scanner is associated with a lower incidence of premature termination [33] and is less likely to result in a claustrophobic reaction [32]. Based on the clinical experience of 1160 patients undergoing MRI scans, an MRI center reported that 19 patients who were initially unable to complete an MRI scan because of claustrophobia; they reported that all 19 were able to complete the scan when turned prone [34].

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Benzodiazepines If positional adjustment is not possible or ineffective, we suggest treatment of most patients with MRI claustrophobia with a benzodiazepine over other treatments. There are no controlled trials comparing a benzodiazepine to placebo in MRI claustrophobia. In an observational study of 1,133 patients treated with a benzodiazepine prior to an MRI scan, sedation was achieved 89 percent of cases [35]. Sedation for MRI claustrophobia is generally safe. A study of 4,761 patients had a complication rate of 0.4 percent [35]. The most common complication was oxygen desaturation; there were no fatalities. To achieve sedation in a patient with (or likely to experience) MRI claustrophobia, a benzodiazepine is typically administered intravenously 15 minutes prior to the procedure or 30 minutes for oral formulations. Diazepam has a more rapid onset than lorazepam and alprazolam. As an example, 10 mg of oral diazepam is recommended for healthy adults [35]. A table provides dosing of oral and intravenous benzodiazepines commonly used in procedural sedation (table 1). Further details about the use of benzodiazepines for procedural anxiety, including MRI claustrophobia, are discussed separately, including dose adjustments for clinical subgroups, repeat dosing, and patient education about side effects and driving. Adverse effects of benzodiazepines are discussed separately. (See "Treatment of acute procedure anxiety in adults", section on 'Benzodiazepines' and "Treatment of insomnia", section on 'Adverse effects' and "Use of psychotropic medications in breastfeeding women".) Psychotherapies For patients with claustrophobia not limited to MRI, or who require repeated MRIs and prefer psychotherapy, or have medical contraindications to benzodiazepines, we suggest treatment with in-vivo exposure therapy over other treatments. If in-vivo exposure is used for MRI claustrophobia, the therapy should ideally be conducted in an environment similar to that of an MRI suite. Two trials have found cognitive therapy and in-vivo exposure therapy to be equally effective in the treatment of claustrophobia compared to placebo [36,37]. As an example, in a trial of 46 patients with claustrophobia, symptomatic improvement was maintained for one year in 81 to 100 percent of patients receiving exposure therapy, and 93 percent of patients receiving cognitive therapy, but only 17 percent of patients assigned to a waiting list control [37]. In cognitive therapy, distorted and negative beliefs about the MRI scanner, such as fear of suffocation, fear of machine causing harm, and fear of losing control in the scanner, should be identified and challenged [38]. An alternative psychotherapy for claustrophobia is interoceptive exposure in which patients are exposed to the physical sensations of anxiety that are reproduced in a controlled setting. In a trial of 48 patients, interoceptive exposure was shown to have modest effects in decreasing the frequency of negative cognitions and physical sensations of claustrophobia in comparison to modification of negative cognitions, or a control condition [36]. Further study is needed to test whether these findings in claustrophobia can be generalized to MRI claustrophobia. SUMMARY AND RECOMMENDATIONS Presentations of acute procedural anxiety are diagnosed as a specific phobia only when the focus of the patients fear is specific to the procedure or its immediate effects (eg, fears of seeing blood during venipuncture, experiencing pain or being restrained during dental treatment, or suffocating during an MRI scan). (See 'Specific phobias' above.) Acute procedural anxiety that is not specific to the procedure itself (eg, fear that a diagnostic test will reveal a serious illness) is not considered specific phobia and is discussed separately. (See "Treatment of acute procedure anxiety in adults".) For individuals with blood-injection-injury phobia, we suggest treatment with applied tension (muscle tension in combination with exposure treatment) over other treatments (Grade 2B). Commonly used anxiolytics, such as benzodiazepines, have no effect on the vasovagal phenomenon. (See 'Blood-injectioninjury phobia' above.) If a patient has a history of fainting at the sight of blood during an injection, but has not learned the applied tension technique, he or she should lie down during the procedure, look away from the site of the blood draw, and sit up slowly only after sensations of dizziness and fainting resolve. (See 'Other interventions' above.) Due to the usual repeated need for dental care and the evidence of a longer-term benefit from exposure

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therapy, we suggest first-line treatment for most cases of dental phobia with in-vivo exposure therapy over other treatments (Grade 2C). However, treatment of dental phobia with nitrous oxide is a reasonable alternative, particularly when: Nitrous oxide is preferred by the patient Exposure therapy is unavailable Dental treatment is needed on an emergent basis The patients anxiety is too severe to tolerate exposure therapy The patient has previously failed an adequate trial of exposure therapy (See 'Treatment selection' above and 'In vivo exposure therapy' above and 'Nitrous oxide' above.) For MRI claustrophobia, positional adjustment, ie, placing the patient in a prone, feet-first position in the scanner, is sufficient to relieve anxiety in some patients. (See 'Positional adjustment' above.) In most patients where positional readjustment is ineffective or not feasible, we suggest treatment with a benzodiazepine over psychotherapy (table 1) (Grade 2C). As an example, diazepam 10 mg can be given intravenously approximately 15 minutes before the procedure, or orally approximately 25 minutes before the procedure, and repeated if needed after 30 to 60 minutes. (See 'Benzodiazepines' above.) For patients with claustrophobia not limited to MRI, or who require repeated MRIs and prefer psychotherapy, or have medical contraindications to benzodiazepines, we suggest treatment with in-vivo exposure therapy over other treatments (Grade 2B). If in-vivo exposure is used for MRI claustrophobia, the therapy should ideally be conducted in an environment similar to that of an MRI suite. (See 'In vivo exposure therapy' above.) Use of UpToDate is subject to the Subscription and License Agreement. Topic 83458 Version 2.0

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GRAPHICS Common benzodiazepines for treatment of procedural anxiety in adult patients*

Benzodiazepine
Diazepam Alprazolam Lorazepam Midazolam

Oral dose
10 mg 0.5 mg immediate release 2 mg Not recommended

Initial parenteral dose

0.03 to 0.1 mg/kg IV (2.5 to 10 mg per dose) Not available 0.02-0.044 mg/kg IV (2 to 4 mg per dose) 0.02 to 0.03 mg/kg IV (0.5 to 2 mg per dose)

Onset
Rapid Intermediate Intermediate Rapid

* Approximately 50 percent dose reduction is needed for older or debilitated adults, patients with low cardiac output or those premedicated with opioid analgesics. In addition, if dose is administered intravenously, a slower rate of administration and less frequent dosing should be used. Equipment, medications, and personnel skilled in advanced cardiac life support and with knowledge of the effects of sedatives and reversal agents must be available for intravenous administration. See topics on procedural sedation. Repeated dose(s) equal to or one-half of initial dose may be needed 30 to 60 minutes after oral administration or 5 to 30 minutes after intravenous administration, based upon response. For prevention of anxiety associated with non-invasive procedures (eg magnetic resonance imaging), 5 mg/mL midazolam injection solution may be administered intranasally at a dose of 1 to 4 mg[3]. The injection solution is irritating to nasal passages. See text. Data from: 1. Lexicomp Online. Copyright 1978-2013 Lexicomp, Inc. All Rights Reserved. 2. Gan TJ. Pharmacokinetic and pharmacodynamic characteristics of medications used for moderate sedation. Clin Pharmacokinet 2006; 45:855. 3. Hollenhorst J, Munte S, Friedrich L, et al. Using intranasal midazolam spray to prevent claustrophobia induced by MR imaging. AJR 2001; 176:865.

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