Trypanophobia

Background
Trypanophobia is the extreme and irrational fear of medical procedures involving injections or hypodermic needles. It is occasionally referred to as aichmophobia, belonephobia, or enetophobia, names that are technically incorrect because they simply denote a “fear of pins/needles” and do not refer to the medical aspect of trypanophobia. The term aprilophobia may also be used to refer to the specific fear of hypodermic needles, though this term also does not refer to the medical aspect. The name that is in common usage is simply needle phobia.

Overview and Incidence
The condition was officially recognized in 1994 in the DSM-IV (Diagnostic and Statistical Manual, 4th edition) as a specific phobia of blood/injection/injury type. Phobic level responses to injections cause sufferers to avoid inoculations, blood tests and in the more severe cases, all medical care.

It is estimated that at least 10% of American adults are trypanophobic, and it is likely that the actual number is larger, as the most severe cases are never documented due to the tendency of the sufferer to simply avoid all medical treatment.

Evolutionary Basis of Trypanophobia
According to Dr. James Hamilton, author of the pioneering paper on needle phobia, it is likely that the form of needle phobia that is genetic has some basis in evolution, given that thousands of years ago humans who meticulously avoided stab wounds and other incidences of pierced flesh would have a greater chance of survival.

Types of Trypanophobia
Although trypanophobia is defined simply as an extreme fear of medically related shots/injections, it appears in several varieties.

Vaso-Vagal Trypanophobia
Although most specific phobias stem from the individual themselves, the most common type of trypanophobia, affecting 50% of trypanophobes, is an inherited reflex. Approximately 80% of trypanophobes report that a relative within the first degree exhibits the same disorder.

People who suffer from vaso-vagal trypanophobia fear the sight, thought or feeling of needles or needle-like objects. The primary symptom of vaso-vagal trypanophobia is vasovagal syncope, or fainting due to a decrease of blood pressure.

The physiological changes associated with this type of trypanophobia also include feeling faint, sweating, nausea, pallor, tinnitus, panic attacks and initially high blood pressure and heart rate followed by a plunge in both at the moment of injection.

Although most phobias are dangerous to some degree, trypanophobia is one of the few that actually kills. In cases of severe trypanophobia, the drop in blood pressure caused by the vaso-vagal shock reflex may cause death.

The best treatment strategy for this type of trypanophobia is desensitization or the progressive exposure of the patient to gradually more frightening stimuli, allowing them to become desensitized to the stimulus that triggers the phobic response.

Associative Trypanophobia
Associative Trypanophobia is the second most common type of trypanophobia, affecting 30% of needle phobes. This type of trypanophobia is the classic specific phobia in which a traumatic event such as an extremely painful medical procedure or witnessing a family member or friend undergo such, causes the patient to associate all procedures involving needles with the original negative experience.

This form of trypanophobia causes symptoms that are primarily psychological in nature, such as extreme unexplained anxiety, insomnia, preoccupation with the coming procedure and panic attacks.

Treatments that are effective for this form of trypanophobia include cognitive therapy, hypnosis, and/or the administration of anti-anxiety medications.

Resistive Trypanophobia
Resistive Trypanophobia occurs when the underlying fear involves not simply needles or injections but also being controlled or restrained. It typically stems from repressive upbringing or poor handling of prior needle procedures i.e with forced physical or emotional restraint.

This form of trypanophobia affects around 20% of needle phobes. Symptoms of this form of trypanophobia include combativeness, high heart rate coupled with extremely high blood pressure, violent resistance, avoidance and flight.

The suggested treatment for this form of trypanophobia is psychotherapy, teaching the patient self-injection techniques or finding a trusted healthcare provider.

Hyperalgesic Trypanophobia
Hyperalgesic Trypanophobia is another form of trypanophobia that does not have as much to do with fear of the actual needle. Patients with this form of trypanophobi have an inherited hypersensitivity to pain, or hyperalgesia. To them, the pain of an injection is unbearably great and many cannot understand how anyone can tolerate such procedures.

This form of trypanophobia affects around 10% of needle phobes. The symptoms of this form of trypanophobia include extreme explained anxiety, and elevated blood pressure and heart rate at the immediate point of needle penetration or seconds before.

The recommended forms of treatment for this type of trypanophobia include some form of anesthesia, either topical or general.

Vicarious Needle Phobia
Whilst witnessing procedures involving needles it is possible for the phobic present to suffer the symptoms of a needle phobic attack without actually being injected. Prompted by the sight of the injection the phobic may exhibit the normal symptoms of vascal vagal syncope and fainting or collapse is common. While the cause of this is not known, it may be due to the phobic imagining the procedure being performed on themselves. Recent neuroscience research shows that feeling a pin prick sensation and watching someone else's hand get pricked by a pin activate the same part of the brain (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?holding=npg&cmd=Retrieve&db=PubMed&list_uids=15460933&dopt=Abstract)

Comorbidity and Triggers
Trypanophobia, especially in its more severe forms, is often comorbid with other phobias and psychological ailments, for example, iatrophobia, or an irrational fear of doctors, is often seen in needle phobic patients.

A needle phobic patient does not need to physically be in a doctor's office to experience panic attacks or anxiety brought on by trypanophobia. There are many triggers in the outside world that can bring on an attack through association. Some of these are blood, injuries, the sight of the needle physical or on a screen, examination rooms, hospitals, white lab coats, hospital gowns, doctors, dentists, nurses, the antiseptic smell associated with offices and hospitals, even the sight of a person who physically resembles the patient's regular healthcare provider, or even reading this article.

Treatment of Trypanophobia
As well as the specific methods recommended for a case of trypanophobia that is clearly of one of the four types, there are other treatments available, some more effective than others. As not every trypanophobic patient falls clearly into one of the four categories and there are both hybrid phobias and phobias of other, as yet unnamed classifications, it is best to research all available treatment options before coming to a decision as to which one will be effective in a particular case.


 * Local anesthetic injections - This form of treatment is readily available and economically sensible. However, it provides only superficial pain control and it is completely impractical to treat needle phobia with an injection.


 * Ethyl Chloride Spray (and other freezing agents) - Easily administered, but provides only superficial pain control.


 * Topical Anesthetic Creams - This form of treatment is painless and portable but takes a long time to become effective and is messy.


 * Jet Injectors - Jet Injectors work by introducing substances into the body through a jet of high pressure gas as opposed to by a needle. Though these eliminate the needle, some people report that they cause more pain.  Also, they are only helpful in a very limited number of situations involving needles i.e insulin and some inoculations.


 * Iontophoresis - Iontophoresis drives anesthetic through the skin by using an electric current. It provides effective anesthesia, but is generally unavailable on the commercial market and is also inconvenient to use.


 * Behavioral Therapy - Effectiveness of this varies greatly depending on the person and the severity of the condition. Generally, it has limited efficacy in treating needle phobic patients and tends to be expensive. Any therapy that endorses relaxation methods is usually ineffective against trypanophobia as this encourages a drop in blood pressure that only enhances the vasovagal reflex.


 * Laughing Gas - This will provide sedation and reduce anxiety for the patient, along with some mild analgesic effects.


 * Inhalation General Anesthesia - This will eliminate all pain and also all memory of any needle procedure. On the other hand, it is a very extreme solution, as it is not covered by insurance in most cases and most physicians will not order it. It can be risky, cost a great deal of money and require a hospital stay.

Trypanophobia in popular culture
Like other phobias, Trypanophobia has also played a part of popular culture in either TV Shows, Films, and even some celebrities have admitted to having this phobia. Here is some clear examples:


 * Late Night host, Conan O'Brien has self-declared a fear of needles (Cited from Late Night on October 11, 2005 when offered a flu shot).
 * Trypanophobia was the main theme in the Ed, Edd n Eddy episode, This won't hurt an Ed, where Eddy learns that Kevin has trypanophobia, not knowing everyone else also has a fear of needles. Edd, Jonny, and Plank are the only ones who don't have trypanophobia.
 * Monk (TV series),
 * Adrian Monk, the title character, has this problem among his list of phobias
 * Gerard Way, lead singer and frontman of the platinum album band My Chemical Romance, said in an interview that he is deathly afraid of needles.
 * In The Suite Life of Zack and Cody, it was revealed that Moseby is afraid of needles when the staff gets a blood test.
 * In the film SLC Punk!, Heroin Bob has a very prominent case of trypanophobia. This led to a cut on his hand getting infected to the point where he had to be quarantined.