Cover Story

For people fearful of dentists, a routine dental checkup may seem more like a nightmare: A masked dentist towers above them poking sharp objects into their mouth, loudly scraping or drilling their teeth as debris flies left and right. When that fear becomes a phobia, the experience can become even more intense, leading to a rapid heartbeat, heavy breathing, sweating and even fainting.

Such dental phobias and those more generally involving needles or blood--referred to as blood-injection-injury (BII) phobias--may keep some people from seeking medical care and ultimately jeopardize their health, psychologists note.

"People usually feel ashamed of their health-care phobia," says psychologist Elaine Rodino, PhD, who has a private practice in Santa Monica, Calif., and helped organize a dental phobia continuing-education program in 2000 for APA's Div. 42 (Psychologists in Independent Practice). "They might never go to the doctor or dentist or talk about it. But there is an obvious danger to not getting medical treatment. Avoiding medical treatment can be life-threatening."

Meanwhile, another group of health phobic people doesn't so much fear treatment for a disease as the disease itself. And, the public's health anxieties may be getting worse. A recent study shows that the more a society promotes healthy lifestyles, the more people worry about their health and the sicker they feel, according to general practitioner Iona Heath, MD, in the April 23 British Medical Journal (Vol. 330, No. 7,497, pages 954-956). The study found that people living in Bihar, India--the poorest state in India--self-reported less illness than did people in the United States, where greater contemporary health care and preventive care is available.

To help people face their health fears and anxieties about health care and treatment, psychologists have developed a host of interventions incorporating virtual reality (see page 87), hypnosis or cognitive-behavioral techniques that gradually expose health phobic patients to fear-inducing situations.

Dental phobias

In the case of dental phobics, for example, such treatments have shown promise. Among those applying them with patients is Bruce Peltier, PhD--a psychology professor at the University of the Pacific's School of Dentistry in San Francisco--who works with patients to understand the root of their dental fears and anxieties. He uses systematic desensitization, in which clients imagine a trip to the dentist--from entering the front door to the actual dental appointment. Peltier has them continually rehearse the mental images, adding more detail each time, while keeping their muscles relaxed and practicing deep breathing.

"A lot of their fears stem from the perceived lack of control," Peltier says. To help, he advises dentists to slow down dental procedures and give as much control back to the patient as possible, such as by providing patients with the opportunity to call for a break any time they wish. He outlines such treatment options for collaborating dentists and psychologists in the winter 2000 issue of The Independent Practitioner (Vol. 20, No. 1, pages 6-8).

Peltier also works with patients on specific fears like gagging or choking during dental procedures. He normalizes such fears with clients by reassuring them that such feelings are common. Hypnosis also works for some clients, Peltier says. For example, he might advise patients to enter into a trance state during dental appointments so they can focus on something comforting or distracting rather than their fears.

Blood-injection-injury phobias

For some people, medical fears aren't just isolated to the dentist. For instance, BII phobics dread medical visits because they fear the presence of blood, needles or injuries. Of all phobics, BII phobics most often faint when facing a phobic situation--the rate is 70 percent among blood phobics and 56 percent among injection phobics, according to psychologist Lars-Göran Öst, PhD, in the February 1992 issue of the Journal of Abnormal Psychology (Vol. 101, No. 1, pages 68-74). Their blood pressure and heart rate often drop when they encounter blood or needles, which can lead to fainting, according to the study.

Such phobias can be especially problematic for people who must self-inject medication, including people with diabetes or multiple sclerosis (MS). If they are unable to self-inject and rely on others to administer injections, they are more likely to discontinue the medication, according to psychologist David C. Mohr, PhD, an associate professor in the University of California, San Francisco, departments of psychiatry and neurology who studies MS. He found in his research that up to half of people with MS who must take medications that require intramuscular injection are unable to self-inject because of injection anxiety.

"They experience too much arousal and avoidance when they try to inject themselves to carry through with it," says Mohr, noting they often have unwarranted fears such as fear of pain or that the needle will hit a bone or break off. "They often recognize these thoughts aren't valid, but they can't stop themselves from having them," Mohr says.

To help, Mohr and psychologist Darcy Cox, PsyD, have developed an intervention--self-injection anxiety therapy (SIAT)--to help people with MS self-inject. The treatment includes a six-session program, in which psychologists, nurses or other health-care professionals teach patients how to control their anxiety and overcome avoidance when self-injecting. They help patients use relaxation techniques and graded exposure, from first touching the needle to their fingertip to then pressing it against their skin and so forth. A manual and patient workbook is available at www.ucsf.edu/bmrc.

The program has proven effective: After six sessions, about 70 percent of MS patients are able to self-inject, says Mohr, whose studies on SIAT appeared in the March 2002 issue of the Journal of Behavior Therapy and Experimental Psychiatry (Vol. 33, No. 1, pages 39-47) and Multiple Sclerosis (Vol. 11, pages 182-185).

Disease phobias

More so than the fear of health care, some people are consumed by fear for their health. Some may become so frightened of contracting a disease that they are unable to leave their home, says clinical psychologist Steven Taylor, PhD, co-author with psychologist Gordon Asmundson, PhD, of "Treating Health Anxiety: A Cognitive-Behavioral Approach" (Guilford Press, 2004).

Often, disease phobias go hand-in-hand with obsessive-compulsive disorder--in which patients might wash their hands continuously to avoid becoming "contaminated" (see sidebar on Howard Hughes).

Encouragingly, as with other phobias, cognitive-behavioral therapy can help patients overcome such aversions, notes Taylor, a professor of psychiatry at the University of British Columbia in Vancouver. For example, he delves into clients' beliefs about diseases, since some people may hold misperceptions about how diseases are contracted.

A second component of treatment may incorporate behavioral therapy by exposing clients gradually to the fearful situation to help desensitize them to their fears. Taylor might, for example, have a patient sit in a hospital's waiting room.

When treating someone with a disease phobia, however, Taylor says it's important to take into account the person's medical situation.

"They may have a disease phobia but actually can be medically ill, such as with HIV and hepatitis, where their immune system might be severely compromised," he says. In that case, it might not be healthy to expose them to other sick people, so treatment may need to rely more on listening to the patient's concerns.

Regardless, Taylor says it's important to help clients understand why they have a phobia and how it interferes in their life. "It's important to get some insight into the problems and prepare goals to reduce those fears," he says. Likewise, "if you fall off a bike, you might be afraid to get back on it. So you work through all those fears."