Managing Self-Injection Difficulties in Patients With Relapsing-Remitting Multiple Sclerosis

Darcy Cox; Jerome Stone


J Neurosci Nurs. 2006;38(3):167-171. 

In This Article

Treatment of Self-Injection Anxiety

Accurate and Timely Patient Education

All pharmaceutical companies that market injectable medications for MS provide injection-training services through home health nurses. The quality of these services varies a great deal, and patients may have received incomplete or inaccurate information during training. We encourage these companies to continue to improve their services but also recognize the difficulties associated with providing services nationwide. We acknowledge that nurses who serve MS patients must also educate patients.

Nurses who work with patients with self-injection anxiety should begin by ensuring that the patient is well-educated about how to prepare the injection and how to inject safely and comfortably. In many cases, ensuring that the patient is well-prepared before self-injection is attempted can prevent the development of self-injection anxiety. It is helpful to gauge patient understanding by asking the patient to repeat what he or she has just learned. The act of teaching through repetition enhances patient retention and can improve patient confidence.

The focus of training at UCSF is on maintaining good hygiene, understanding safe injection techniques, and increasing relaxation and confidence. The authors found that patients develop several different strategies for the injection. Some insert the needle quickly, whereas others insert the needle slowly, perhaps taking 30 seconds or longer to reach the muscle, for an IM injection. Although injecting this slowly is certainly not taught in nursing school and may increase pain in patients who increase muscle tension in response to inserting the needle, there is no hygienic reason to avoid it. One of the authors experimented with this technique on himself and found it to be remarkably comfortable. However, the other author was unable to remain sufficiently relaxed when attempting this technique and found it to be significantly more painful. In short, it is important to focus on hygiene and the individual patient's experience of relaxation and comfort rather than on preconceived notions of the right way to self-inject. We frequently offer multiple strategies and allow patients to experiment to find what works best for them.

In addition to training patients in injection techniques, we directly and repeatedly reassure patients that self-injection is safe. We also proactively work to reassure patients that self-injection is not damaging or potentially fatal.

Allaying Fears

Many patients erroneously believe that injections have the potential to be damaging. Common concerns include fear of injecting an air bubble and causing an embolism, hitting a vein, hitting a bone, or damaging muscle with an IM injection. Many patients focus on the air bubble and mistakenly believe that if they inject any air whatsoever, they will experience an embolism. This belief can lead to increased anxiety, reduced doses, and increased pain, as patients attempt to remove air bubbles that do not need to be removed and adopt other compensatory strategies that may worsen the problem.

In our clinic, we treated a male in his thirties with moderate-to-severe anxiety about self-injection. One of his coping mechanisms was to inject extremely quickly while looking away, pressing the needle hard into a tense muscle, which caused significant pain. On specific questioning about his self-injection beliefs, he revealed his belief that injecting any amount of air could kill him. He therefore injected very quickly with his eyes closed as an attempt to "get it over with." He reported that he almost felt as if he were playing Russian roulette. After receiving education on safe self-injection, including a lengthy question-and-answer session, he relaxed and self-injected with little difficulty.

We often discuss with our patients the difference between hurting and harming. Various aspects of the procedure can lead to hurting (i.e., pain). Medication recently removed from the refrigerator, poor injection technique, poor site selection and rotation, and muscle tension in IM injection can and will increase the subjective experience of pain. However, none of these cause harm (i.e., lasting damage to one's body). If carried out with a reasonable understanding of hygiene, site selection, and technique, injections are not dangerous. For some patients, fear of harm arises from either a lack of information or misinformation. When accurate information is presented, fear subsides. For other patients, including some with medical backgrounds, a fear may be acknowledged as irrational. For example, the patient knows it is not possible to hit the femur while injecting IM into the thigh but, nonetheless, has a persistent image of doing so while injecting. Cognitive reframing may be useful for these patients.

Cognitive Reframing

Cognitive reframing refers to the examination of one's specific thoughts to determine whether the thoughts are accurate or helpful in the given situation and to then modify those thoughts to make them more accurate or useful. This skill can be applied in a number of ways to manage self-injection anxiety. For example, patients can learn to label autonomic reaction as a collection of physical symptoms rather than to assume that the physical reactions are indicative of impending danger. Patients can learn to change their automatic thoughts in response to increased heart rate, respiration, and muscle tension from "something bad is going to happen" to "I am experiencing autonomic reaction symptoms; I need to practice relaxation." Patients also can use cognitive reframing to support accurate beliefs about the safety of self-injecting.

Many patients also find that thoughts about having a chronic illness can pose a barrier to successful self-injection. Such thoughts could be controlled with cognitive reframing. For example, thoughts such as "the injections increase the burden of my disease" might be changed to "injecting helps me maintain my health for the future" with the help of cognitive reframing.

One patient treated at UCSF was a woman in her late twenties who was very successful, both professionally and athletically. She stated that her greatest fear about having MS was "I'm going to end up in a wheelchair." She did not initiate treatment at the time of diagnosis and did so only after having experienced a second exacerbation. She responded quickly to education about self-injection technique but experienced fear, anger, and disgust about self-injecting. When questioned about her beliefs regarding the medication and the disease, she said, "I haven't succeeded in being disease free because I have to start on treatment, and failure means I'm going to end up in a wheelchair."

After further questioning about her beliefs and thought processes, she revealed that when she was initially diagnosed, the neurologist told her she had "benign MS" and gave her the option to either begin treatment or "wait and see." The patient then "tried to forget [she] had MS" and did not educate herself about the disease or examine her thoughts and feelings about her condition. Instead, she fixated on the belief that her disease was benign and that any further disease activity would signify a change in her disease state from benign to malignant. When she experienced a second exacerbation, she interpreted the need for treatment as a sign that her disease was worsening and inevitably would rapidly progress to a high level of physical disability.

Cognitive reframing was used to help shift her focus away from her fear of physical disability and toward the concrete steps she could take to reduce future disability. While acknowledging that no one, including the neurologist, nurse, or herself, could predict what the future might hold and that there was a risk of disability, we discussed both the danger of focusing entirely on the risk and the benefit of taking a broader view of what it means to live with MS. She was encouraged to focus on her strengths and to equip herself with knowledge about the disease and its treatment. Although she was already quite active, with a healthy diet and lifestyle, she committed herself to managing her health, increasing her strength and flexibility, and reducing stress even further. She began to view injections as a proactive step she could take to reduce future disability rather than as a sign that she had "failed at having benign MS and must therefore have really bad MS." After meeting other individuals with MS, she began to understand the range of outcomes in the disease and the ways medications can reduce future disability. As a result, she was able to successfully self-inject and her overall adjustment to her diagnosis improved, as did her mood and quality of life.

Another patient presented to the clinic when she developed self-injection phobia after several months of successful self-injections. She reported that when she had started injectable treatment, her neurologist had told her, "Don't worry, in a year there will be something else." She reported that she gave herself injections without too much difficulty for the first 10 months, but as it became increasingly apparent that there would be no new treatments available, she started to miss injections. By the end of the year, she had stopped treatment entirely. She reported that she thought "I did my 12 months," and said, "I used up my ability to talk myself into it."

The patient had experienced a number of pain-free self-injections and had no problems with technique or fear of harm. Therefore, cognitive reframing needed to focus on the meaning of the illness itself and the treatment. When identifying her thoughts about treatment, she reported that when she was diagnosed, she believed that injections would be a stopgap measure until a new treatment was available, which would not require self-injection and would result in total disease remission. She reported that she needed to accept the thought that "MS is something [she was] going to have for the long term" and that no treatment would "save [her] from MS."

Managing Vasovagal Response

Some patients with self-injection anxiety also report a history of vasovagal response to injection. A vasovagal response involves a brief episode of bradycardia and hypotension, either immediately preceding or concurrent with the injection or injection attempt. It may result in feelings of faintness or dizziness, pallor, queasiness, depersonalization, and ringing in the ears. It is estimated that 25%-37% of people who meet criteria for the diagnosis of blood-injection-injury phobia experience a vasovagal reaction at least once in response to injection (Antony, Brown, & Barlow, 1997; De Jongh et al., 1998; Kleinknecht, Thorndiker, & Walls, 1996). The percentage of patients who need to self-inject and experience such reactions is unknown. However, for those who have had this experience, anticipatory fear of the vasovagal response also can pose a barrier to successful injection.

Relaxation training and graded exposure are useful techniques for patients with self-injection anxiety who have autonomic reaction responses to injections. Patients learn deep muscle relaxation and controlled breathing techniques that prevent hyperventilation and reduce other autonomic reaction symptoms. After patients have mastered these techniques, they are able to move forward with graded exposure to different aspects of the self-injection process. In this way, patients may be able to incrementally increase their comfort and level of self-efficacy (i.e., confidence in themselves) until they are able to attempt self-injection.

For patients who do not benefit from relaxation training, other techniques are available to manage vasovagal responses. The simplest is the maintenance of muscle tension, which prevents hypotension. With SC injection, hypotension can be easily managed by performing jumping jacks or any other brief, vigorous exercise the patient is able to perform. With IM injection, it is best to find an exercise that will not tense the muscle group into which he or she will be injecting. Patients with severe vasovagal responses may benefit from a low-dose beta-blocker before attempting self-injection.

Vasovagal responses are almost always quite brief and benign, although there have been case reports of ventricular fibrillation, myocardial infarction, cerebral infarction, or severe vascular disease following exposure to injection or venipuncture (Hamilton, 1995).

Dealing with Feelings of Disgust

For some people, injections are not simply frightening: They are disgusting. The combination of fear and disgust appears to contribute to worsened phobic symptoms. People who merely fear injections seem to respond better to treatment than those who find injections disgusting as well. Disgust can be managed by normalizing the experience and, in some cases, by applying cognitive reframing techniques to the autonomic experience of disgust.

Managing Pain and Side Effects

Obviously, minimizing injection pain, injection-site pain, and unwanted side effects from medications will make self-injecting easier and less unpleasant. It is essential to titrate interferons, ensure that medications are at room temperature when injected, and select and rotate the injection site appropriately. For IM injections, it is important to be aware of how MS-related spasticity can increase pain and to work with patients to select sites that are not tense. Injection-site reactions are a significant problem for all of the SC-injected MS medications. Educating patients regarding the common occurrence of injection-site reactions with SC injections and teaching them to identify serious reactions and to seek rapid treatment for them can reduce anxiety and help maintain self-injection.

Many people believe that self-injecting will hurt more than receiving the injection from another person. This concern is seen even in individuals who receive injections from others without undue difficulty. Frequently, patients feel that self-injection will be more painful because they are not confident that they have mastered safe self-injection technique. Good education and reassurance can be useful here.

It is important to remember that, for some patients, anxiety can increase the experience of pain and that for others, significant anxiety reduces the experience of pain. For some, the anxiety they experience before self-injecting is so great that they enter a mildly dissociative state and may not experience any pain at all.


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