Nurse prescriber Claire Newman details how to deal with needle phobic patients in your clinic
It’s very common for aesthetic practitioners to meet patients with a fear of needles. Needle phobias affect between 3.5%-10% of the population.1 These patients will have varying degrees of anxiety relating to the phobia which is distressing for the patient and a challenge for the clinician. Some challenges include managing patient anxiety, minimising agitation to reduce the risk of needle injuries and ensuring a good patient experience and satisfaction. Interventions may not be straightforward such as the use of topical anaesthesia to alleviate the anxiety to aid the fear of needles.2 Treatments need to be individualised with an understanding that the efficacy of these interventions vary from patient to patient and day to day due to fluctuations in their levels of anxiety.
According to First Psychology Scotland, ‘a phobia is a debilitating condition which will cause the person with the phobia to arrange their life so that they can avoid the object of their phobia’.3 The severity and triggers of the phobia will vary between patients and those suffering with severe needle phobia could experience a significant negative impact on their daily lives, specifically when requiring medical interventions.1
Phobias have evolutionary roots; it is a fight or flight response for when we feel threatened or in danger. Ancestors were expected to survive if they came across a situation that evoked fear which in turn causes people to avoid situations that are seen as a threat.4 This can be applied to modern day where people may perceive needles and injections as a threat for instance; varying degrees of pain and discomfort, or fear of side effects/severe side effects due to the treatment.
Needle phobia is often referred to as belonephobia whereas trypanophobia is the fear of injections.5 Within the literature, trypanophobia also appears to be referred to as needle phobia.5 According to Anxiety UK, phobias can arise from traumatic experiences and parental influences instilled in us from an early age.1 Needle phobic patients may result in them avoiding or seeking medical/dental interventions.6 Taking this into account it could be argued that within aesthetic medicine patients are not avoiding the fear and therefore, do not have a phobia. However, patients may present with a degree of anxiety regarding injectable procedures, whether they are new to aesthetic interventions or returning patients.
Symptoms of needle phobia can be divided into behavioural, emotional, and cognitive traits. Characteristics include an inability to relax with feelings of tension, panic, and loss of control of the situation. Patients may present with palpitations, butterflies, excessive sweating, irrational thoughts, nightmares, and avoidance of the situation.1 In extreme cases, some patients may feel like they are going to have a heart attack or may even faint.1 It could be argued that those choosing to undergo aesthetic treatments may have a fear which varies in severity rather than an actual phobia. This is because they are confronting the situation rather than avoiding the situation. Regardless, these patients need support in clinics to manage their physical and psychological symptoms. In theory the more treatments patients have over a period, the more desensitised they will become. Since patients are ‘facing their fears’ rather than avoiding the triggering situation, the assumption is that the level of anxiety will decrease over time. Facing fears is seen to be a very successful intervention when trying to overcome a phobia.7
During the consultation it is important to understand the root cause of a patient’s fears/phobia as well as triggers. To discover if a patient has a fear/phobia, it is ideal to have this mentioned in the consultation form. Questions and further discussions can take place on how to overcome this during the initial consultation. However, for some they may not know the triggers or the root of the phobia. Some fears or phobias can be triggered by a lack of being in control where the patients may feel out of control and that something bad might happen or through a bad experience, such as going to the dentist as a child. This understanding helps clinicians work with patients individually and collaboratively to alleviate their fears and anxieties.
The clinician needs to be realistic in what they can achieve within an aesthetic setting and must also consider no treatment and/or onward referral to a specialist for therapy. Likewise, for some patients’ injectable treatments may not be an option due to their levels of distress. Alternative treatments can be offered to them, with an understanding that it may compromise outcomes. Such alternatives include skin tightening, skin rejuvenation using laser, chemical peels or using devices.
Psychological interventions such as cognitive behavioural therapy (CBT) and graded exposure are effective interventions to help the needle phobic patient.8 Graded exposure is where the patient develops a hierarchy of fears. They begin with what they perceive as being their least feared until they feel that this fear has decreased before moving up to the next situation.9 Not everyone will respond to the same interventions to manage their fears. Therefore, getting to know the patient and building a therapeutic relationship based on trust will help them feel more comfortable with the clinician, allowing them to relax and engage with interventions.
It is important to note that the patient’s level of anxiety may fluctuate depending on the treatment they are receiving. In my experience, it is not uncommon for patients to express higher levels of emotion the closer to the eye.
A helpful tool to use during the consultation is a patient passport which is another layer of communication between clinician and patient. It can help to identify concerns as well as assist to empower patients to choose the best treatment for them. The passport supports the clinician in understanding what a patient likes, and dislikes whilst assisting the practitioner in formulating a collaborative treatment plan and interventions are more likely to succeed.10 This can be reviewed at each appointment in the sense of what interventions went well as well as what did not go so well so that they can be used again in the future. Building a therapeutic relationship with patients based on trust and empathy as well as clear communication is key.
In-clinic treatments will depend on the severity of the patient’s phobia. Distraction techniques are particularly useful such as using squeezy balls, encouraging patients to wriggle their toes, listening to relaxing music or even music of their choice. Some patients do not like to see the needle or know too much detail about the processes as it exacerbates their anxiety, however, some might feel more secure knowing every step of the procedure. Applying a local anaesthesia even when it’s not indicated for treatments such as botulinum toxin or adding ice can help alleviate fears, especially if a patient is concerned about pain. Interventions may be trial and error, and during treatment observing how the patient is responding is imperative, and treatments should be adjusted accordingly.
For those needing some more help alleviating their anxiety, further interventions may be required. An effective coping mechanism is to help patients acquire control over their physiological symptoms. Such mechanisms involve the practitioner assisting patients to relax by using guided imagery which is described as ‘a technique that use visualisations and draws on the participants imagination and mental imagery.’11 Therefore, guided imagery is used as a distraction and encourages patients to let go of the tension they have.8 This is achieved by playing relaxing music so the practitioner can guide the patient to control their breathing slowly and deeply.8 Each time a patient breathes in deeply and out slowly with short pauses, tension is released, allowing the patient to feel more relaxed, calm, and restful each time they breathe out.
If this does not help the patient, further interventions can be added whereby patients are encouraged to relax their arms and legs so they go ‘limp’, which in turn releases any tensions that they may have. Once a patient is in a relaxed state, using guided imagery can encourage patients to focus on the music or think of a serene place such as relaxing on a beach. Giving patients the tools to relax in this way will assist them through the procedure as they will be able to alleviate the anxiety themselves with minimal interventions from the clinician.
It should be noted that this could take a lot of time and potentially have a financial impact to your clinic, so not every clinician will feel confident implementing these techniques.
Mindfulness is a technique that patients can learn at home. The length of time it takes to learn will depend on the individual and the course they have booked on. There are various apps available which teach mindfulness and these techniques can be used by patients during appointments. Mindfulness stems from Buddhist meditation and is the practice of observing what is taking place currently devoid of judgement.12 This includes an awareness of what is going on with how a person is thinking (psychologically), what is going on with their body (physiological) and the environment.12 By becoming more self-aware, patients develop coping mechanisms and can react to their thoughts and emotions to feel less anxious and agitated.12 Patients can use the mechanisms they have learn with the support of the clinician if necessary to relax themselves leading up and during the procedure to alleviate anxieties and agitation.
Throughout our careers we will encounter patients with varying degrees of anxiety/needle phobia. Consulting patients, understanding their fears, and supporting patients by encouraging them to adopt techniques will help to decease patient anxiety and maintain patient satisfaction as well as patient safety. Of course, if the fear is too great, then you should be able to offer alternative treatment modalities to injectables and refer to a specialist for therapy.
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