What Can I Do to Help Patients With Belonephobia (Fear of Needles)?

Mary E. Muscari, PhD, CPNP, APRN-BC


April 28, 2007


I frequently encounter patients with severe belonephobia. Some actually refuse injections of pain medication after major surgery. Others faint just waiting in line for injections. What can I do to help patients with this problem?

Response from Mary E. Muscari, PhD, CPNP, APRN-BC

Many people fear needle-sticks to some extent. However, once that fear becomes persistent, excessive, and unreasonable, the fear becomes a phobia.[1]Belonephobia (blenophobia, needle-phobia, trypanophobia -- all meaning fear of injections) is a common, yet not very well recognized, disorder that affects 3.5% to 10% of the population.[2,3] The median age of onset is 5.5 years,[2] and approximately 80% of affected patients report strong needle fear in a first-degree relative.[4] Belonephobia can result in significant vasovagal responses or avoidance of important healthcare procedures; therefore, it is important that nurse practitioners (NPs) know how to recognize and manage this disorder.

Type of Specific Phobia

Belonephobia is recognized in the Diagnosticand Statistical Manual of Mental Disorders, 4th Edition Text Revision (DSM-IV-TR) as a Specific Phobia(SP), Blood-Injection-Injury Type.[1]The critical feature of an SP is marked and persistent fear of clearly discernible, circumscribed objects or situations, such as needles, animals, heights, elevators, and illness. Exposure to the object or situation usually provokes an immediate anxiety response that may take the form of a panic attack. Adolescents and adults may recognize that their fear is unreasonable, but children may not.[1]

Persons with SP feel anxiety almost immediately upon confronting the phobic stimulus, but the level of anxiety usually varies with both the degree of proximity to the phobic stimulus and the degree to which escape from the stimulus is limited. The intensity of the reaction, however, does not always correlate predictably with the phobic stimulus;[1] a patient can react differently to the same venipuncture procedure on different occasions. Individuals may have more than one SP, as clustering often occurs. Seventy percent of those with blood SP also have injection SP.[5]

The individual's fear may be expressed somatically by rapid heart rate, increased blood pressure, tremor, feeling faint or actually fainting, nausea, diaphoresis, and feelings of panic. A full-blown panic attack can occur if the individual believes that escape is impossible.[5]

Fears of objects or situations are common during childhood, especially during the preschool period, but they do not interfere with the child's daily functioning. Common childhood fears need to be differentiated from SP, as the latter is irrational, interferes with daily routines, and leads to maladaptive behaviors. Children with SP may have symptoms similar to adults', or the child may present with crying, tantrums, clinging, freezing, psychomotor agitation, or immobilization.[1,5,6]

The Blood-Injection-Injury Type of SP is specified if the fear is precipitated by seeing blood or an injury or by receiving an injection or other invasive medical procedure. The anxiety response is often characterized by a strong vasovagal response.

Vasovagal Responses

Belonephobia can cause significant problems. Individuals frequently complain of the full range of emotional and physical problems typical of a SP, as well as a feeling of "impending doom." Persons afflicted with belonephobia may also go to great lengths to avoid needle-sticks, such as delaying or skipping necessary blood tests, immunizations, dental work, and even life-saving minor procedures such as skin biopsies.[6]

Many persons with belonephobia react to phobic stimuli with autonomic vasovagal reflex responses. These responses may include pallor, clammy diaphoresis, nausea, respiratory distress, loss of bladder and bowel control, and various levels of unresponsiveness.[4] The onset of the vasovagal response may be immediate (2 to 3 seconds) following the needle-stick. However, one study of 84 blood donors who fainted found that 16.7% experienced syncope from 5 to 30 minutes after the phlebotomy,[7] and another series of 64 blood donors who fainted found that 14% fainted after leaving the phlebotomy site and returning to work, sometimes several hours later.[8]

Assessment and Diagnosis

One of the key factors in minimizing belonephobic response or noncompliance with treatment regimens is identifying persons at risk for a reaction. Hamilton[6] suggests obtaining the following data during assessment:

Medical history:

  • Self-report of needle fear, dating from childhood, that the patient recognizes as unreasonable

  • Exposure to or anticipation of a needle procedure triggers anxiety response

  • Needle procedures are avoided

  • Needle fear and avoidance interfere with healthcare, occupational, academic, or social activities or cause marked distress

  • Family history of needle phobia in first-degree relative

Clinical assessment (related to needle exposure):

  • Decrease in blood pressure, pulse, or both, with or without an initial rise in blood pressure, pulse, or both

  • Symptoms of syncope, light-headedness, or vertigo, along with other autonomic symptoms

  • Electrocardiogram abnormalities of any type

Rise in any combination of stress hormones, including antidiuretic hormone, human growth hormone, dopamine, catecholamines, and renin.

Diagnosis of SP Blood-Injection-Injury Types (belonephobia) can be made according to DSM-IV-TR criteria: marked, persistent, and excessive fear cued by needles; exposure to needles almost invariably provokes an immediate anxiety response; the person recognizes that the fear is unreasonable (may be absent in children); needle-sticks are avoided or endured with intense anxiety or distress; the avoidance, anxiety, or distress significantly interferes with the person's normal routine, occupational or academic functioning, social activities or relationships, or there is severe distress about having the phobia. If the person is under age 18, the duration of these factors should be at least 6 months.[1]


Individuals with belonephobia require reassurance about the prevalence of needle fear, explanation of the inherited and involuntary nature of belonephobia, and clarification about methods available to counter reactions. The majority of belonephobia victims believe that the problem is "all in their head," thus compounded anxiety can be relieved by giving their problem an illness label and a physiologic explanation.[4]NPs can also communicate empathy and respect for the person's feelings, helping individuals plagued by name-calling to believe they are not "wimps" or "chickens" and to accept their condition without embarrassment.

Avoidance of unnecessary or excessive needle procedures helps to limit the conditioning of the vasovagal-based fear response, which in turn facilitates compliance with healthcare treatment. For situations in which needle-procedures are unavoidable, NPs can use stress-reducing medical devices, which may be as simple as needles and other medical devices decorated with designs and stickers. In a randomized controlled trial of 60 patients (41% pediatric; 59% adult), researchers randomly exposed subjects to 8 different designs of winged needles and 6 different designs of syringes fitted with a needle. The researchers measured the subjects' reactions using validated visual analogue reaction scales and found that, compared with conventional devices, the stress-reducing devices reduced needle phobia aversion by 68%, fear by 53%, and anxiety by 53%.[9]Syringes were decorated so that the marks of the barrel could be seen, and butterfly needles were decorated symmetrically. Favored designs were butterflies, flowers, fish, and smiley faces.[9]

Step-wise intervention may also be helpful. Thurgate and Heppell[10] developed a 3-step strategy for pediatric patients, modified here to include adults:

Step 1: Recognition and relaxation. This step includes identifying those at risk, using an anxiety scale from 0 to 10 (0 being no fear and 10 being severe anxiety), and discussing medical procedures in detail to help alleviate fear of the unknown. These authors recommend cognitive behavioral therapy, counseling, distraction, relaxation, or hypnosis for persons with an anxiety level greater than 3.

Step 2: Control and preparation. The individual is encouraged to participate in decision-making and to optimize ways to relieve tension. The individuals can choose their own environment and have a support person (parent, significant other). They are also encouraged to talk about their worries and ask questions related to the procedure.

Step 3: Graded exposure. Graded exposure is employed once the individual is ready to proceed. Toys, diagrams, and graphics can be used to illustrate the procedural steps while the NP observes the individual's response when exposed to medical equipment: cotton to alcohol wipes to topical anesthetic cream, and finally to unopened syringes and needles.

Medications may be useful for some individuals. Topical anesthetic creams (eg, EMLA cream [lidocaine 2.5% and prilocaine 2.5%]), can numb injection sites if applied as the manufacturer recommends. Rapid-acting benzodiazepines, such as diazepam (Valium) or lorazepam (Ativan), have an onset of action within 5 to 15 minutes and may be useful for some patients with belonephobia. [4]

A counseling referral can be advantageous. Desensitization therapy warrants a motivated patient; however, it may decondition the autonomic symptoms and fear experienced by those with mild needle phobia and may extinguish associated blood-injury fears.[4] Cognitive-behavioral therapy focuses on patterns of maladaptive thinking and the beliefs that underlie such thinking.[11] A person with belonephobia may have the belief of "I am in danger," which triggers the needle-phobic thinking and behavior.

The Bottom Line

Belonephobia can cause distress not only to those who suffer from it, but also to their families and to healthcare workers, especially nurses, phlebotomists, and anesthetists.[6] However, distress can be minimized through careful assessment, diagnosis, and intervention.


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