Clinical Review
`
`Needle Phobia: A Neglected Diagnosis
`
`James G. H am ilto n , M D
`A lexandria, L o u is ia n a
`
`Needle phobia is a recently defined medical condition
`that affects at least 10% o f the population. Because per­
`sons with needle phobia typically avoid medical care,
`this condition is a significant impediment in the health
`care system. The etiology o f needle phobia lies in an in­
`herited vasovagal reflex of shock, triggered by needle
`puncture. Those who inherit this reflex often learn to
`fear needles through successive needle exposure. Needle
`phobia is therefore both inherited and learned.
`
`In a family practice, needle phobia can be managed
`by reassurance and education, avoidance of needles,
`postural and muscle tension techniques, benzodiaz­
`epines, nitrous oxide gas, and topical anesthesia applied
`by iontophoresis.
`
`Key words. Needle phobia; phobic disorders; needles;
`vasovagal reflex; syncope; vasovagal syncope; ionto­
`phoresis. ( / Fam Pract 1995; 41:169-175)
`
`Needle phobia is a condition that has become an increas­
`ingly important issue in medicine because of the modern
`reliance on injections and blood testing. Contrary to pop­
`ular belief, needle phobia is not confined to children, is
`not an emotion-driven or transient phenomenon, and is
`not a rare condition. Clinicians need to be aware of needle
`phobia because it is a common condition and because
`needle-phobic persons tend to avoid medical treatment,
`which can lead to serious health problems as well as social
`and legal problems.
`Needle phobia has been defined as a formal medical
`condition1-2 and has recently been included in the Amer­
`ican Psychiatric Association’s Diagnostic and Statistical
`Manual of Mental Disorders, Fourth Edition (DSM-IV)
`within the diagnostic category o f Blood-Injection-Injury
`Phobia.3 A review o f the background medical literature
`and suggestions for management of needle phobia are
`presented here.
`The etiology o f needle phobia is rooted in an inher­
`ited vasovagal reflex that causes shock with needle punc­
`ture. With repeated needle exposure, those with an inher­
`ited vasovagal shock reflex tend to develop a fear of
`
`Submitted, revised, Ju n e 16, 1995.
`
`This paper is dedicated to the memory of the author’s father, M r Edward Winslow
`Hamilton, Sr, who died in 1977 o f cardiac arrest after a venipuncture.
`
`From Rapides Parish, Louisiana. Requests fo r reprints should be addressed to Jam es
`'' Hamilton, MD, 1252 Canterbury Drive, Alexandria, LA 71303.
`
`ISSN 0094-3509
`© 1995 Appleton & Lange
`The Journal of Family Practice, Vol. 41, No. 2(Aug), 1995
`
`needles. Unlike most other phobias, in which exposure to
`the feared object excites tachycardia, victims of needle
`phobia typically experience a temporary anticipatory
`tachycardia and hypertension, which on needle insertion
`turns into bradycardia and hypotension (Figure), accom­
`panied by pallor, diaphoresis, tinnitus, syncope or near­
`syncope, and sometimes asystole or death.1
`According to the DSM-IV, a phobia is defined by the
`presence of fear and by avoidance behavior.3 The symp­
`tom of avoidance o f needles, doctors, dentists, etc, is
`central to the definition of needle phobia, since avoidance
`of health care is surely a health care problem. However,
`because needle phobia is also accompanied by numerous
`physiological changes in blood pressure, pulse, electrocar­
`diogram (ECG) waveforms, and stress hormone levels,1-2
`these measurements can also be used to define this con­
`dition (Table 1). While a dislike or mild fear o f needles is
`very common, needle phobia can be more rigorously de­
`fined by objective clinical findings in addition to subjec­
`tive symptoms.
`
`Needle Phobia in Family Practice
`Those with needle phobia are often terrified o f routine
`needle procedures, and a few are so frightened that they
`would rather die than have a needle procedure.4 Even
`such relatively minor needle procedures as venipunc­
`ture1-5 or subcutaneous injection6 can cause a vasovagal
`
`169
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`SPRUCE - EXHIBIT 2002
`Neurocrine Biosciences, Inc. v. Spruce Biosciences, Inc. - PGR2022-00025
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`

`Needle Phobia
`
`and the public, and the development of methods to coir,
`pensate for needle fear in clinical practice, representprob
`ably the greatest challenges that this condition poses f(
`family medicine.
`Needle phobia also can cause major social and |P
`difficulties in one’s life. A fear o f blood testing or immu I
`nization can interfere with or even destroy plans for mar-'
`riage, travel, education, immigration, or employment
`Students may be discouraged from biological, nursing,#
`medical careers because o f their fear of needles,4 and
`women wishing to have children may be thwarted k
`needle fear.4'7 Legal problems can arise when blood test
`are ordered by a court in paternity cases, and some victims
`o f needle phobia have even been charged by the police for
`failure to agree to blood testing.4 The best-selling bool;
`The Blooding detailed the resistance that authorities in
`England experienced against mass blood testing to elim­
`inate suspects in a murder case.9 In the United States,
`involuntary blood testing o f accused drunk drivers has led
`to four cases being appealed to the US Supreme
`Court.10-13
`Occasionally, needle phobia can be fatal. At least 23
`reported deaths can reasonably be ascribed solely to nee­
`dle phobia and its vasovagal reflex during needle proce­
`dures such as venipuncture, blood donation, arterial i
`puncture, pleural tap, and intramuscular and subcutane­
`ous injections.14-25 Other reports and indirect evidence
`further suggest that needle procedures can result in sud­
`den death.26-29 A death by needle phobia can be due to
`either or both o f two mechanisms: an abrupt vasovagal
`drop in blood pressure and perfusion, especially in an j
`arterial tree already compromised by atherosclerosis.
`
`HYPOTENSION
`
`BRADYCARDIA
`
`TIME >
`Figure. Theoretical biphasic expression o f the vasovagal reflex in
`needle phobia.
`
`shock reflex and evoke patient resistance. When those
`with needle phobia do agree to needle procedures, they
`often experience syncope, fall and sustain trauma, have
`convulsions, lose bowel and bladder control, evoke the
`calling o f cardiac codes, or otherwise cause great concern
`among staff and family members. Others with needle pho­
`bia are simply noncompliant with medical treatment reg­
`imens, eg, insulin self-injections.
`Victims o f needle phobia possess a heightened risk of
`morbidity and mortality simply because they avoid health
`care, sometimes for many years,1'7 and even when the
`need for treatment is compelling.T4-6-8 Approximately
`5% to 15% o f the population, for example, decline neces­
`sary dental treatment, primarily because they fear oral
`injections.8 With an incidence o f needle phobia o f at least
`10%, it is reasonable to hypothesize that a large hidden
`population goes without regular health care because of
`this condition. The recognition, acceptance, and commu­
`nication o f this danger by both the medical community
`
`Table 1. The Primary Factors Underlying the Recognition and Diagnosis o f Needle Phobia
`
`P ast m edical history*
`(1) Self-report by the patient o f a long-term needle fear, usually from childhood, that the patient recognizes as unreasonable.
`(2) Exposure to or anticipation o f a needle procedure invariably triggers immediate anxiety, sometimes in the form o f a panic attack. In
`children, the anxiety may be expressed by crying, psychomotor agitation, freezing, or clinging.
`(3) Needle procedures, often along with associated medical objects or situations, are avoided either some or all o f the time.
`(4) The needle avoidance and fear interfere significantly with health care or with normal occupational, academic, or social activities, or the
`patient is markedly distressed about having the fear.
`
`Fam ily medical history
`Approximately 80% o f patients with needle phobia report strong needle fear in a first-degree relative, ie, parent, child, or sibling.
`
`Clinical findings
`(1) Physical symptoms o f syncope, near-syncope, light-headedness, or vertigo upon needle exposure, along with other autonomic symptoms,
`eg, pallor, diaphoresis, nausea.
`(2) Cardiovascular depression with a drop in blood pressure or pulse or both; with or without an initial rise in blood pressure or pulse or both
`(3) Electrocardiogram anomalies o f virtually any type.
`(4) Rises in any combination o f several stress hormones: antidiuretic hormone, human growth hormone, dopamine, catecholamines,
`corticosteroids, renin, endothelin, and /3-endorphin.
`* Modified from Diagnostic criteria fo r specific phobia. In: Diagnostic and Statistical Manual o f Mental Disorders, Fourth Edition. Washington, D C : American PsvcIm:
`Association, 1994: 410.
`Note: A diagnosis o f needle phobia can be made by past medical history alone. In addition, however, victims o f needle phobia typically have symptoms o f decreased cerebral pap®
`cardiovascular changes, electrocardiogram changes, an d hormonal rises.
`
`170
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`

`Needle Phobia
`
`Hamilton
`
`could cause myocardial infarction25-29 or cerebral infarc­
`tion; or a vasovagal reflex could impair the sinoatrial or
`atrioventricular node enough to cause ventricular fibrilla­
`tion or asystole.27-30
`
`puncture and a sudden plunge in both after punc­
`ture1-4’27’37 (Figure), the author has observed that some
`patients with needle phobia do not have this initial car­
`diovascular rise.
`
`Prevalence of Needle Phobia
`Because needle phobia has only recently been defined,
`only indirect estimates o f its prevalence can be inferred
`front the literature. One study o f 449 Canadian women
`found that 21.2% experienced mild to intense fear, and
`4.9% had a phobic level o f fear of injections, blood, injury,
`doctors, dentists, and hospitals.31 Another study esti­
`mated that 9% of the US population in the age bracket of
`10 to 50 years old have an injection phobia, and 5.7% have
`seen a physician about this phobia.32 Dread of a painful
`injection was present in 11% o f 100 English office pa­
`tients.33 Through in-hospital interviews, 22% o f 184 teen-
`aged maternity patients in Nashville, Tennessee, were
`found to have a fear o f blood drawing strong enough to
`make it hard for them to come to a public clinic for
`prenatal care.34 In random surveys, 23% o f 200 Swedes35
`and 27% of 177 US college students36 reported needle
`fear as the main reason for not donating blood.
`The prevalence o f needle phobia is probably lower in
`population samples from clinics or hospitals since those
`with needle phobia tend to select themselves out o f such
`populations. Even in a general population sample, many
`people express denial o f their needle fear. Therefore, most
`of the studies done so far probably underestimate the true
`prevalence of needle phobia. Although the percentage is
`currently unknown, an estimate of at least 10% is credible.
`
`Etiology of Needle Phobia
`In the author’s experience with over 50 patients with
`needle phobia, and in all similar cases reported in the
`medical literature, those afflicted inevitably display symp­
`toms of an autonomic vasovagal reflex whenever they
`undergo a needle procedure. The neurophysiology of the
`vasovagal reflex is grounded in both a vagal bradycardia
`and a vasodilatation from withdrawal of a-sympathetic
`arteriolar tone, which together cause hypotension.2’30 In
`addition, associated neurological circuits cause ECG
`anomalies and stress hormone release.30 Because most
`victims of the vasovagal reflex do not actually lose con­
`sciousness, the term “ vasovagal reflex” is more accurate
`than “vasovagal syncope,” the term most often used in
`the older literature. Although the vasovagal reflex has
`classically been described as being biphasic, with an antic­
`ipatory rise in blood pressure and pulse before needle
`
`Physical Symptoms o f the Vasovagal Reflex
`The vasovagal reflex in needle phobia may include virtu­
`ally any type and combination of autonomic symptoms,
`eg, a clammy diaphoresis, pallor, nausea, respiratory dis­
`turbances,
`and various
`levels
`o f unresponsive­
`ness.1’4’30’37"40 Although the onset of the vasovagal reflex
`from the start o f a needlestick is often immediate, ie,
`within 2 to 3 seconds, a prospective study of 84 blood
`donors who fainted found that 16.7% experienced syn­
`cope from 5 to 30 minutes after phlebotomy.38 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.39
`Although most victims o f needle phobia who faint
`are unconscious for only a few seconds, a survey of 298
`vasovagal fainters found that several had a loss of con­
`sciousness for 10 to 30 minutes, and a few lost conscious­
`ness for 1 to 2 hours.40 Although blood pressure usually
`returns to normal within 2 hours, and most vasovagal
`victims feel well enough to resume normal activity within
`several hours, others have anxiety, malaise, and weakness
`for 1 to 2 days after a vasovagal attack.38-40
`Convulsions during vasovagal fainting, which are
`much more frequent than commonly realized, are a gen­
`eral response of the central nervous system (CNS) to the
`cerebral hypoxia of vasovagal shock. O f 84 blood donors
`who fainted, 14.3% had prominent tonic-clonic episodes,
`and another 27% had tonic muscular rigidity.38 Further­
`more, even having a finger pricked for blood typing can
`cause syncope with convulsive seizures.38
`
`Electrocardiogram Changes
`In several case reports, ECG changes during the vasovagal
`reflex among patients with needle phobia have included
`sinus arrhythmia, premature atrial contractions, prema­
`ture junctional contractions, unifocal and multifocal pre­
`mature ventricular contractions, bigeminy, first- and
`second-degree block, changes in P waves, ST waves,
`and T waves, sinus bradycardia, sinus tachycardia,
`ventricular
`tachycardia, ventricular
`fibrillation, and
`asystole.1’2-5’26-28’37 Presumably, these ECG changes are
`secondary to vagal influence on the sinoatrial and atrio­
`ventricular nodes, and perhaps also to the antagonism
`between the activated sympathetic and parasympathetic
`systems on the heart.27
`
`The Journal of Family Practice, Vol. 41, No. 2(Aug), 1995
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`Needle Phobia
`
`______________________________ _____________ Hamikoi
`
`Stress Hormone Changes
`
`At least 11 stress hormones have been reported to elevate
`during needle stimulation. Increased cortisol and cortico­
`tropin (ACTH ) levels secondary to venipuncture and nee­
`dle phobia have been documented.T2-41-42 In one study,
`cortisol levels rose above average in 7 o f 15 subjects, with
`a positive correlation between cortisol level and the num­
`ber o f vasovagal symptoms.42 In my experience, cortico­
`tropin-releasing factor also can elevate during needle pro­
`cedures, as can dopamine. In 25% o f 28 subjects in 112
`trials, human growth hormone levels rose in response to
`venous catheterization.42 In three needle-induced vaso­
`vagal subjects, j3-endorphin levels were observed to rise,42
`but sometimes they do not rise.1
`Similarly, epinephrine and norepinephrine levels do
`not always become elevated during episodes o f needle
`phobia.1 They have been observed to decrease in eight
`subjects who fainted after venipuncture, presumably re­
`lated to the withdrawal o f sympathetic vascular tone.43 In
`another study, however, 21 young women dental patients
`had increased levels o f epinephrine, but not norepineph­
`rine, with a decrease in epinephrine after the procedure.44
`The findings o f both o f these studies are compatible with
`a biphasic cardiovascular response.
`Probably because the pituitary perceives a reduced
`intravascular volume during vasovagal shock, vasopressin
`or anti diuretic hormone (ADH) rises in the vasovagal
`reflex with venipuncture,1-2-45 as does endothelin.45 Re­
`nin also increased by 200% in one patient with needle
`phobia,46 but aldosterone and angiotensin levels have not
`yet been tested in needle phobic patients. The ADH rise
`causes pallor during the vasovagal reflex by sharply de­
`creasing cutaneous blood flow, and may also contribute
`to nausea.1 This ADH rise is often dramatic, reaching as
`high as 46 times normal values,45 and may be responsible,
`along with the catecholamine elevation, for the intense
`fear that victims o f needle phobia learn in response to
`their vasovagal reflexes.1
`
`Needle Phobia: Inherited or Learned?
`Clear evidence exists to support the hypothesis o f a he­
`reditary component to needle phobia. Both the vasovagal
`reflex and needle phobia strongly tend to run in fami­
`lies. 1,2,7,47-49 The heritability o f blood-injury phobia in
`twin studies, including fear o f injections, wounds, blood,
`and pain, has been estimated to be 48%.50 Variations in
`PR, QRS, and QT intervals and heart rate have heritabil-
`ities o f 30% to 60%,51 and the autonomic control o f the
`cardiovascular system in general, based on twin compari­
`sons, is probably genetically influenced.52 Therefore, the
`plunges in blood pressure and pulse and the ECG anom-
`
`alies during a needle-phobic response are surely also gf (
`netically influenced. The release o f stress hormones like
`wise can reasonably be assumed to be geneticalli
`influenced.
`In addition to genetic factors, however, a learned
`component to needle fear also can be identified amor*
`those with needle phobia. Needle fear often first con» |
`into awareness after a negative experience at the doctor:
`or dentist’s office.6" 8 One patient, for example, developer
`needle phobia in childhood when he was verbally abused
`and restrained by health care personnel during several
`painful medical procedures.6 In one study of 56 persons
`with injection phobia, 52% traced their fear to such ne» I
`ative conditioning, with a mean age at onset of 8.06years,
`and another 24% dated their fear to an episode of vicari
`ous conditioning at seeing another child, often a sibling,
`have a negative reaction to needles.47 Over time, with
`more needle exposures, this fear tends to organize and j
`solidify into a conscious phobia, with an anticipator)' anx I
`iety before needle encounters. The learning of fear often
`becomes generalized in that those who are initially fearfui
`only o f needles may develop fear o f objects or situations
`associated with needles, such as blood, injuries, syringes,
`doctors, dentists, nurses, white laboratory coats, exami­
`nation rooms, hospitals, and even the antiseptic smell of
`offices or hospitals.4’31-50
`Based on these studies, one can hypothesize that the
`trait o f needle phobia is both inherited and learned. A
`vasovagal reflex has been found in all patients with needle
`phobia tested so far, and the medical histories of most of
`them include an adverse learning experience that trig­
`gered the needle fear.47 Therefore, a reasonable theoret-1
`ical model might propose that needle phobia depends
`both on an inherited reflex that is hard-wired in neuro-
`cardiovascular and neuroendocrine pathways and on the
`learning o f a conscious fear.
`Blood-injury phobia, which is often linked with nee
`die phobia,3 probably often arises when a patient with 1 1
`strong vasovagal reflex undergoes a needle procedure or
`has an accident that results in a vasovagal response. The
`victim may focus on the sight o f blood or injury to the
`extent that the blood-injury cue serves as a conditioned
`stimulus to trigger a vasovagal response thereafter. Al­
`though many needle-phobic persons also have blood-in
`jury' fears, further consideration should be given to
`whether these two phobias should be combined into a
`single diagnostic category, as is now the case in DSM-K
`
`Evolution of the Needle Phobia Trait
`The presence of a genetic trait among a species automat
`ically indicates that the trait must have been selected for
`
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`

`Needle Phobia
`
`Hamilton
`
`Table 2. Techniques o f Managing Patients with Needle Phobia
`
`• Reassurance: discussion about the normality and prevalence of needle fear.
`
`• Education: explanation of the inherited, involuntary nature of needle phobia and the various methods available to counter this condition.
`
`• Avoidance o f unnecessary or excessive needle procedures limits the conditioning o f a vasovagal-based fear response and facilitates patient
`compliance with medical treatment.
`
`• Desensitization therapy requires a motivated patient, yet may decondition the autonomic symptoms and fear experienced by patients with mild
`needle phobia and can extinguish associated blood-injury fears.
`
`• Nerve-gate blocking distracts the patient by stimulating the area o f needle use.
`
`• Elevation of lower extremities in recumbent position with applied muscle tension augments the central venous reservoir, increases stroke volume,
`and helps maintain cerebral perfusion.
`
`• Rapid-acting benzodiazepines, eg, diazepam or lorazepam, have an onset o f action within 5 to 15 minutes from ingestion. A relatively large dose
`(eg, 10 to 20 mg po o f diazepam) may be necessary and can be combined with nitrous oxide.
`
`• Topical anesthesia at the needle site, eg, ice, ethyl chloride spray, or topical anesthetics. Topical anesthetics penetrate the skin much taster and
`deeper when driven by iontophoresis.
`
`during the evolution o f that species. The needle phobia
`trait probably evolved among the human species in re­
`sponse to piercing, stabbing, and cutting injuries.1 The
`vast majority o f violent deaths in our species’ evolutionary
`history have been caused by skin penetration from teeth,
`claws, fangs and tusks, and from sticks, stone axes, knives,
`spears, swords, and arrows. Besides death resulting from
`direct trauma or hemorrhage, many of these deaths were
`due to infections secondary to skin penetration. A reflex
`that promoted the learning o f a strong fear o f skin punc­
`ture had clear selective value in teaching humans to avoid
`such injuries. Over the 4 + million years o f human evolu­
`tion, surely many genes controlling blood pressure, pulse,
`cardiac rhythm, and stress hormone release were selected
`for to create the vasovagal reflex.
`The wide variation in the subjective symptoms and
`physiological responses o f persons with needle phobia
`means that this trait, like most other human traits, is not
`an all-or-none phenomenon. The genes that promote
`needle phobia, as with other polygenic traits such as
`height, weight, or intelligence, are probably distributed
`among the human population in a continuous bell­
`shaped curve. Thus, both strong- and weak-trait individ­
`uals interact with the medical environment in a lifelong
`process of learning through varying needle exposure to
`create a wide expression o f the needle phobia trait.
`
`Management of Patients with
`Needle Phobia
`It is essential that family physicians be knowledgeable
`about how to manage needle fear if they are to adequately
`treat these patients (Table 2). Communicating empathy
`
`and respect for patients with needle phobia by assuring
`them that they are not “ wimps” or “ oddballs” helps
`them accept their condition without embarrassment.
`Most victims of needle phobia sincerely believe that their
`problem is all in their mind and that they would not be
`fearful if they were stronger or more mature. Many simply
`do not realize that there are many others with similar
`fears. Giving patients a name for this condition legitima­
`tizes it to them and gives them a tool they can use to buffer
`their interaction with the health care system. Reassurance
`and education, mainstays within the family doctor’s arma­
`mentarium, almost always help.
`Alternative methods of drug delivery can sidestep the
`issue of needle fear by avoiding needles altogether. Nasal
`sprays that deliver vasopressin, calcitonin and insulin,
`sprays that immunize against influenza and dust-mite al­
`lergens, and an oral form of insulin are all now in investi­
`gative trials in the United States. Topical analgesic
`patches and opiate suppositories can be used in cases of
`severe pain, eg, metastatic cancer, which might otherwise
`be managed with intravenous drips. Many other medi­
`cines could obviously be administered without needles.
`When needle use is necessary, any one o f several
`methods or a combination of methods may be useful.
`Desensitization therapy by a psychiatrist or clinical psy­
`chologist is usually lengthy, expensive, and o f variable
`efficacy.1-6-8 Nerve gate-blocking methods, eg, pinching
`or rubbing the area to distract the patient during a needle-
`stick, can be helpful. Shock and syncope are reduced
`among phobic patients by having them lie supine with
`legs elevated and tense their muscles during needle pro­
`cedures to increase cerebral blood flow.53 Needle-phobic
`patients should also be routinely premedicated with oral,
`sublingual, or intranasal benzodiazepines,2 with N 0 2,8 or
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`The Journal of Family Practice, Vol. 41, No. 2(Aug), 1995
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`

`Needle Phobia
`
`both. Sublingual atropine to block bradycardia also may
`be beneficial.2 Since a vasovagal reaction can injure or
`even kill a patient, having on hand an oxygen source and
`a “ crash cart” for cardiac resuscitation is mandatory with
`any needle-phobic patient undergoing a needle proce­
`dure.
`Topical anesthesia o f the autonomic sensory neural
`net at the needle site can be used to interrupt the vasova­
`gal reflex at its origin so that the reflex is not triggered.
`Ethyl chloride spray can temporarily anesthetize the skin,
`but this affects only the superficial skin layers and lasts for
`only a few seconds. The skin can also be anesthetized by
`an ice pack, although freezing is unpleasant and can dam­
`age tissue. In placebo-controlled studies, topical anes­
`thetics containing a mixture o f lidocaine and prilocaine
`have been shown to work well in pediatric patients,54 and
`topical mixtures o f tetracaine, adrenalin, and cocaine
`(TAC ointment) or tetracaine, adrenalin, and lidocaine
`have been long used in emergency departments for sur­
`face anesthesia.55 To work on intact skin, however, all
`these mixtures must be applied for 1 to 2 hours and have
`a depth o f anesthesia o f only 2 to 3 mm.
`The depth and effectiveness o f topical anesthesia is
`greatly enhanced by the technique o f iontophoresis (or
`ionphoresis). Iontophoresis involves soaking an absor­
`bent pad with lidocaine and driving it through the skin
`with a tiny electrical current from a battery-powered
`unit.35'56 Because lidocaine is a positively charged mole­
`cule, the electrode pad’s positive charge repels the lido­
`caine, propelling it through the skin by way o f the sweat
`ducts. Using iontophoresis, an injection or venipuncture
`site can be completely anesthetized to a depth o f 1 to 2 cm
`in less than 10 minutes.56
`The procedure o f iontophoresis has been assigned
`insurance reimbursement codes, and an iontophoresis
`unit* for use with needle phobic persons has been cleared
`by the Food and Drug Administration. This instrument
`has been demonstrated to be effective for venipuncture
`and joint injections56 and has applications, for example, in
`blood donor drives35 and pediatric immunization pro­
`grams. The ease o f use o f iontophoresis raises the intrigu­
`ing possibility o f creating in the near future medical envi­
`ronments that are completely free o f needle phobia.
`
`Acknowledgments
`The author wishes to thank Nancy R. Hamilton, R N , for her most
`gracious patience and support during the preparation o f this paper,
`and also Gary Hadden, Department o f Psychiatry, Duke University,
`for his expert assistance.
`
`*This unit, the NeedleBuster, is now available commercially from Life-Tech, Inc,
`Houston, Texas; (800) 231-9841.
`
`Hamilton
`
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`
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`2. Hamilton J, Ellinwood E. Needle phobia [abstract] South Mm'
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`3. Diagnostic and statistical manual o f mental disorders. 4th ed Wash
`ington, D C : American Psychiatric Association, 1994:405-11
`4. Marks I . Blood-injury phobia: a review. Am J Psychiatry 198S I
`145:1207-13.
`5. Galena H J. Complications occurring from diagnostic venipuncture I
`J Fam Pract 1992; 3 4:582-4.
`6. Jacobsen PB. Treating a man with needle phobia who requiresdail I
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