Acute procedure anxiety in adults: Epidemiology and clinical presentation

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Acute procedure anxiety in adults: Epidemiology and clinical presentation Author Yujuan Choy, MD Disclosures All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Oct 2013. | This topic last updated: Jun 11, 2012. INTRODUCTION Acute procedure anxiety is an excessive fear of medical, dental, or surgical procedures that results in acute distress or interference with completing necessary procedures. Patients may experience anxiety in anticipation of and/or during many types of procedures, including for screening (eg, mammography), diagnosis (eg, amniocentesis or endoscopy), and treatment (eg, angioplasty or open heart surgery). Specific phobias are a subset of the varied manifestations of acute procedure anxiety, diagnosed under DSM-IV-TR criteria only when the patients fears are specific to the procedure and its immediate effects (eg, fear of suffocation during an MRI) rather than fears not specific to the procedure itself (eg, a fear of the underlying illness that might be diagnosed). Specific phobias related to clinical procedures include blood-injection-injury phobia, dental phobia, and MRI claustrophobia. This topic addresses the epidemiology and clinical manifestations of acute procedure anxiety in adults, related to common medical and surgical procedures. The topic includes specific phobias where the fear/anxiety is related to clinical care. Specific phobias unrelated to clinical care are discussed separately. The course, screening, assessment, diagnosis, and treatment of acute procedure anxiety are also discussed separately. (See "Acute procedure anxiety in adults: Course, screening, assessment, and differential diagnosis" and "Treatment of acute procedure anxiety in adults" and "Specific phobia in adults: Epidemiology, clinical manifestations, course and diagnosis" and "Psychotherapy for specific phobia in adults" and "Pharmacotherapy for specific phobia in adults".) OVERVIEW Acute procedure anxiety Acute procedure anxiety, which is not a diagnosis found in DSM-IV-TR, is an excessive fear and/or anxiety about a medical procedure that results in acute distress in anticipation of the procedure or during the procedure, or avoidance of the procedure. The fears experienced are often rational (eg, concern that a breast biopsy may find a malignancy), but in some cases can be irrational (eg, fear of suffocation during an MRI). Specific phobias Presentations of acute procedure anxiety are diagnosed as a specific phobia under DSM-IV-TR criteria only when the focus of patients fear is specific to the procedure or its immediate effects (eg, a fear of seeing blood during venipuncture or suffocating during an MRI scan). A specific phobia would not be diagnosed when the patients fear/anxiety is about, for example, the implications or outcomes of the procedure (eg, the fear that a diagnostic procedure may detect an illness with a poor prognosis). Specific phobias related to clinical procedures include Blood-injection-injury phobia Blood-injection-injury phobia is characterized by the fear of seeing blood, receiving an injection, or of other invasive medical procedures [1]. The phobic reaction to seeing blood may be accompanied by a vasovagal response. Individuals with blood-injection-injury phobia often avoid diagnostic and medical procedures, leading to a delay in the diagnosis and treatment of an illness, which may negatively impact health. Dental phobia Dental phobia is the specific fear of going to the dentist and the fear may be triggered by multiple stimuli in the dental office, such as sound of the drill, receiving an intraoral injection or undergoing any dental treatment. Individuals with dental phobia may suffer significant distress, avoid going to the dentist, or require Section Editor Murray B Stein, MD, MPH Deputy Editor Richard Hermann, MD

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Acute procedure anxiety in adults: Epidemiology and clinical presentation

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sedation to have necessary work completed. MRI claustrophobia Claustrophobia is the specific fear of enclosed spaces and is categorized under the situational subtype of specific phobia in DSM-IV-TR [1]. Magnetic resonance imaging (MRI) is the diagnostic procedure most impacted by claustrophobia, as presence of claustrophobia often leads to avoidance or premature termination of the procedure. The MRI scanner poses a phobic situation unlike being in other small spaces, because patients in MRI scanners are required to be in a very tight space without moving, and remain in an uncomfortable position for an extended period of time. There is significant noise interference and the room temperature in an MRI suite is often cold. EPIDEMIOLOGY Given the large number of diagnostic, medical, and surgical procedures in contemporary health care, there is surprisingly scant literature on rates of procedure-related anxiety. Rates of the prevalence of clinically significant anxiety in community based samples are limited to studies of blood-injection-injury phobia and dental phobia. Studies reporting prevalence rates of acute procedure anxiety in patients undergoing specific medical or surgical procedures are described below. Studies reporting mean anxiety levels among such patients are reported more briefly. Many of these studies have methodologic limitations. In studies of acute procedure anxiety unrelated to a diagnosis of specific phobia, data on anxiety levels have been limited to patient completion of self-assessment questionnaires. The instruments used vary widely, from one-item visual analog scales to instruments with established reliability and validity. Specific phobias Community-based studies have estimated that 2 to 5 percent of the general population in the United States (US) has experienced blood-injection-injury phobia, dental phobia, or MRI claustrophobia. Blood-injection-injury phobia Community surveys estimated that 3.1 to 4.5 percent of the general population in the US suffers from blood-injection-injury phobia [2-4]. All of these surveys included dental phobia within the blood-injection-injury phobia subtype. Within this subtype, one study found that 23 percent had a fear of blood, 47 percent a fear of injections, and 78 percent a fear of dentists [4]. There are limited data on the rates of blood-injection-injury phobia in the medical setting: A study of 3315 adults undergoing venipuncture in a US outpatient hospital-based phlebotomy clinic reported that 7.5 percent of the participants reported significant anxiety symptoms during the procedure [5]. Patients experiencing anxiety were more likely to report a history of vasovagal reactions and vasovagal syncope compared to patients who did not, and were also more likely to report significant fears of fainting, disgust, pain, and health concerns during injections. The study had multiple limitations, including the absence of a standardized instrument to assess anxiety. In a study of 1275 patients with insulin-dependent Type I or II diabetes in the Netherlands, 9.3 percent endorsed extreme fear of injecting themselves with insulin and testing their glucose levels [6]. In a study of 115 insulin-treated diabetic patients in the United Kingdom, 14 percent reported that they had avoided insulin injections secondary to anxiety. In a subgroup reporting the highest anxiety levels, 45 percent avoided injections [7]. Among 1529 pregnant women attending an antenatal clinic in Sweden, an estimated 7.2 percent met DSM-IV diagnostic criteria for blood-injection-injury phobia [8]. A community-based study of 1920 individuals found that blood-injection-injury was more common in females, younger adults, and adults with less education compared to individuals in the general population [4]. Dental phobia Based on semi-structured diagnostic interviews, an estimated 2.4 percent of the general adult population in the US meets criteria for DSM-IV-TR dental phobia [3]. The prevalence of anxiety over dental procedures has been estimated at 10 percent, based on studies that have used self-report screening questionnaires [9]. Rates of dental anxiety have been found to vary across population subgroups, with rates of 14 percent in adults over 65 years [10] and as high as 19 percent in university students [11]. A higher prevalence of dental anxiety, compared to dental phobia, is expected as a phobia diagnosis requires

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Acute procedure anxiety in adults: Epidemiology and clinical presentation

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additional functional impairment or distress criteria. In a study of 18-year-olds in New Zealand, only eight of 100 individuals who screened positive for dental anxiety met DSM-III-R criteria for dental phobia [12]. Dental anxiety tends to occur more commonly in females and those with less education [9,10]. Dental anxiety is also more common in patients in the lower income bracket, those without dental insurance, and those without a usual place for dental care [9]. Studies have reported mixed results regarding the influence of age and race [9,10,13]. MRI claustrophobia Based on naturalistic studies from 1984 to 2004 with a total of 17,961 patients, an estimated 2.3 percent of patients undergoing an MRI examination have claustrophobic reactions resulting in premature termination of scanning or medication to complete the scan [14]. Claustrophobic reactions are less likely to occur in newer scanners with a wider magnetic bore compared to convention MRI machines (0.7 versus 2.1 percent) [14]. MRI claustrophobia is more likely to occur in females, those in middle age (40 to 65 years of age), and during head-first examinations [14]. The rate of MRI claustrophobia in the general population may be higher than that estimated in the clinical sample above, as claustrophobia was stringently defined as requiring sedation or premature termination of scanning during an actual MRI examination. Patients who have claustrophobia would not have been included as a case of claustrophobia if they did not take medication but completed the MRI examination despite great distress. Other patients with claustrophobia may simply avoid MRI exams and would not be included in these studies. As an example, in a study of 1215 women with elevated risk of breast cancer who participated in a trial of supplemental MRI screening for the disease, 42.1 percent of participants declined further screening with breast MRI [15]. Of those who declined, 25.4 percent of them refused because of claustrophobia. A high rate of unexpected claustrophobic reactions during MRI scanning [16] suggests the possibility that patients can be anxious in an MRI scanner without having pre-existing claustrophobic reactions to other small spaces. Screening procedures Transvaginal ultrasonography A study of 145 women in the US, who had an elevated risk of ovarian cancer and were screened for the disease with transvaginal ultrasonography, found that 38 percent of premenopausal women and 27 percent of postmenopausal women experienced high levels of cancer risk-related anxiety prior to their first screening test [17]. Colonoscopy A study of 45 patients undergoing a screening colonoscopy because of a strong family history of colorectal cancer found that 65 percent reported moderate anxiety and 19 percent reported severe anxiety prior to the procedure [18]. Other screening procedures Mild to moderate mean levels of anxiety have been found in women awaiting routine mammography screening for breast cancer [19,20]. Moderate mean levels of acute anxiety were found in an observational study of 522 women undergoing gynecological exams in a private office setting in the US [21]. Anxiety levels were comparable to those reported in patients undergoing invasive medical and surgical procedures. Minimally invasive diagnostic procedures These procedures, which involve invasion of a body cavity or access to an internal organ, may include treatment of a positive finding. Prostate biopsy In a study of 1781 men in Sweden undergoing prostate biopsy, 49 percent reported intermediate levels of anxiety and 6 percent reported high levels of anxiety [22]. Two smaller studies, conducted in India and the United Kingdom found similar results [23,24]. Amniocentesis A study of 28 women in England undergoing early prenatal testing with amniocentesis at 13 weeks gestation was associated with clinical levels of anxiety in eight percent of cases [25]. Two case controlled studies in England reported that women of advanced maternal age undergoing amniocentesis had significantly higher average levels of acute anxiety immediately prior to the procedure compared to women in the same gestational age who are undergoing routine ultrasound testing [26], and

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Acute procedure anxiety in adults: Epidemiology and clinical presentation

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compared to women of advanced maternal age who chose not to undergo amniocentesis [27]. Having prenatal testing may ultimately decrease anxiety among pregnant women by providing reassurance of fetal health. A study of 179 women in England found that women who underwent amniocentesis had significantly lower anxiety in the third trimester compared to women who did not undergo amniocentesis [28]. Chorionic villus sampling A study of 23 women in England undergoing prenatal testing with chorionic villus sampling to be associated with clinical levels of anxiety in 24 percent of cases [25]. GI endoscopy A study of 79 outpatients undergoing elective endoscopy without the use of conscious sedation found that 15 percent reported experiencing a panic attack during the procedure [29]. Other diagnostic procedures Elevated levels of anxiety have been reported in samples of patients awaiting or undergoing GI endoscopy, bronchoscopy, breast biopsy, and colposcopy [30-36]. Minimally invasive treatment procedures Coronary procedures Rates of anxiety tend to be higher in patients undergoing coronary angioplasty for the first time (26 percent in first timers versus 42 percent in repeaters) [37] and in women compared to men (24 percent versus 16 percent) [38]. Anxiety levels have been found to be elevated in 16 to 49 percent of patients undergoing coronary angioplasty or stent placement, with some of the variation likely due to differences in anxiety measures and cut-off scores [37-39]. A study of 88 patients in Turkey found that patients have moderate level of anxiety on the day of coronary angiography [40]. Laparoscopic surgery A mean elevated level of anxiety was found in a sample of 57 women in the US undergoing bilateral laparoscopic tubal ligation [41]. Elevated baseline trait anxiety level was associated with increased amount of propofol required to induce and maintain anesthesia. Major surgeries These are typically the most invasive procedures posing the greatest risks to patients. They are usually performed under general anesthesia; thus, anticipatory anxiety is more typically of clinical concern rather than anxiety during the procedure. Open heart surgery A study of 80 patients undergoing open heart surgery found that 32.5 percent reported clinically significant anxiety one day before surgery, 21.5 percent one week after surgery, and 18.7 percent at six months follow-up [42]. Females reported a greater level of anxiety then males at all assessment points. Neurosurgery In a study of 109 patients undergoing brain tumor biopsy or craniotomy with resection of tumor, 30 percent of patients had clinical levels of anxiety prior to the procedure compared to 20 percent in a comparison group of patients undergoing elective spinal surgery [43]. Other major surgeries Other studies have found elevated levels of anxiety in samples of patients awaiting coronary artery bypass graft (CABG) [44] but not among patients undergoing cataract surgery [45,46]. Procedural risk factors For some procedures, characteristics of the procedure, such as the degree of invasiveness, influence the level of acute procedure anxiety. As an example, in a naturalistic study of dental phobia, 987 patients rated invasive procedures as more anxiety provoking than non-invasive procedures [47]. The most anxiety provoking types of invasive dental procedures were: Dental surgery Having some gum burned away Root canal treatment Extraction of a tooth or molar

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Acute procedure anxiety in adults: Epidemiology and clinical presentation

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Cutting or tearing of soft tissue The least anxiety provoking were non-invasive procedures (eg, dental x-ray, dental check-up, getting molds or imprints made, teeth cleaning) and stimuli related to personnel or setting (eg, the dentist as a person, white gown, waiting room). An uncertain diagnostic outcome can be a factor influencing the anxiety engendered by some procedures. Studies suggest that the possibility of a malignant diagnosis may contribute to the anxiety experienced by patients undergoing breast biopsy [36] or prostate biopsy [24]; the possibility of needing CABG can contribute to anxiety experienced by patients undergoing angiography [39]. Pre-procedure anxiety may also be influenced by the presence or absence of sedation during the procedure. As an example, the anticipation of pain and discomfort during a procedure is a common focus of fears, such as among patients undergoing colposcopy [35,48] which is not typically conducted under conscious sedation. Comorbidities Patients with a diagnosis of specific phobia (and possibly acute procedure anxiety) have been found to have a higher rate of comorbid anxiety disorders than patients without specific phobia, including [2]: Agoraphobia Generalized anxiety disorder Panic disorder Social anxiety disorder A community-based study of 1920 individuals found that those with blood-injection-injury phobia were more likely to have had other psychiatric conditions, including marijuana abuse and dependence, major depression, obsessive compulsive disorder, panic disorder, agoraphobia, and other specific phobia [4]. Patients with high dental anxiety have been found to have higher rates of conduct disorder, agoraphobia, social phobia, alcohol dependence, or another specific phobia [49]. (See "Specific phobia in adults: Epidemiology, clinical manifestations, course and diagnosis" and "Agoraphobia in adults: Epidemiology, pathogenesis, clinical manifestations, course, and diagnosis" and "Social anxiety disorder: Epidemiology, clinical manifestations, and diagnosis" and "Overview of fears and specific phobias in children".) CLINICAL MANIFESTATIONS Acute procedure anxiety is the experience of a high level of anticipatory anxiety before a procedure and/or acute anxiety at the time of the procedure. In severe cases, anxiety may be associated with avoidance of the procedure. Anxiety is characterized by the interaction of cognitive, physiological, and behavioral components [50]. At the cognitive level, anxiety is a feeling of apprehension of possible future threat or danger to one's personal safety or security. Physiological manifestations include physical symptoms of arousal, such as elevated heart rate, palpitations, sweating, shortness of breath, or muscle tension. Behavioral features of anxiety may include avoidance or reassurance seeking, which usually has the goal of decreasing the anxiety or escaping from the perceived threatening stimulus. Anxiety exists on a continuum, with normal anxiety when the threat estimate is accurate, to pathological or clinical anxiety when the threat estimate is biased. When anxiety is acute and severe, it may take the form of a panic attack. (See "Panic disorder: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis".) Focus of fear The focus of fear in acute procedure anxiety can vary dependent on procedural type; foci may include: Concerns about the potential risks and complications of the procedure Perceptions of pain and discomfort during the procedure Fears about implications and outcomes of the procedure Uncertainty about illness, disability, and other factors related to the procedure As examples: In patients undergoing oral and maxillary surgery, some of the fearful aspects of treatment included fears of complications (eg, getting an infection), pain during treatment and wait-time before treatment [51].

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Acute procedure anxiety in adults: Epidemiology and clinical presentation

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In pregnant women undergoing invasive prenatal testing, acute procedure anxiety is related to potential complications of the procedure (eg, risk of miscarriage) [25] and concerns about an abnormal result [25,27]. In one study in this population, 48 percent of the women studied reported being worried about having a miscarriage and 42 percent reported anxiety about the results [25]. In women undergoing colposcopy, the three most frequently endorsed concerns are about pain, discomfort, and uncertainty over what would happen during the procedure [35,48]. In patients undergoing angiography, the most fearful aspects of the procedure are (in rank order) [52]: Fears of coronary artery bypass surgery Uncertainty about the illness Death Pain Clinical findings Lying flat in bed In a study of 831 patients in Sweden on a waiting list for angiography, angioplasty, or CABG, six percent of patients reported that the most distressing symptom was fear and 43 percent reported that uncertainty about the future [53]. This uncertainty focused on concerns, eg, whether they would receive treatment in time (as median wait time was five to eight months), their financial situation, and future of their families. In patients undergoing cataract surgery, the most anxiety provoking aspects of the surgery were local anesthesia, the unknown, and possible failure of surgery [46]. Focus with specific phobias When acute procedure anxiety is a manifestation of a specific phobia, the focus of fear is specific to the procedure or its immediate effects. As examples: In patients with claustrophobia, the main focus is fear of suffocation and fear of restriction while in an enclosed space [54]. In the MRI setting, in addition to fear of suffocation and fear of restriction, patients may fear being harmed by the machine (ie, fear of having a stroke in a scanner) or fear of losing control [55]. In patients with blood phobia, the fear at the sight of blood is typically concern about physical sensations, fear of fainting, and feelings of disgust [56]. Blood-injection-injury phobia is distinguished from other subtypes of specific phobia by the presence of a vasovagal fainting response, which occurs in the majority of individuals diagnosed with the subtype [57]. The fainting response in specific phobia appears to be unique to situations associated with blood and medical procedures. Disgust sensitivity may be a possible mediator of the fainting response [58]. Avoidance or delay of procedure Avoidance or delay of a necessary procedure is one of the main negative health consequences in patients with severe acute procedure anxiety. Rates of avoidant behavior have been documented mainly for the specific phobias [15,59], but avoidance occurs in other manifestations of acute procedure anxiety as well. Avoidance of medical procedures can delay diagnosis and treatment, and adversely affect patient outcomes [59], as illustrated in the studies below: Pregnant women with blood-injection-injury phobia have been found to be more fearful of childbirth and have a higher rate of elective cesarean sections, pregnancy complications (eg, preeclampsia and premature contractions), adverse obstetric outcomes (eg, premature delivery and longer hospital stays), and poorer neonatal morbidity (eg, small for gestational age) [60]. A study found that patients with dental anxiety were more likely to avoid dental visits; most had not seen a dentist for at least 18 months [10]. Numerous studies have demonstrated that patients with dental anxiety have significantly worse oral health status compared to non-anxious individuals [9,61]. As examples: A community sample of 455 adults, individuals with dental anxiety were found to have a greater number

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Acute procedure anxiety in adults: Epidemiology and clinical presentation

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of caries but half as many filled surfaces, and higher percentage of teeth with calculi and gingival bleeding, compared to individuals without dental anxiety [9]. In a study of 548 older adults, the presence of dental anxiety was associated with a greater number of missing teeth and root fragments [10]. Studies have reported mixed findings on the health effects of finger-stick and insulin-injection avoidance among patients with insulin-dependent diabetes and a fear of injection. As examples: A study of 115 patients reported that more patients with high injection-related anxiety avoided insulin injection because of anxiety compared to patients with low injection-related anxiety (9 versus 28 percent) [7]. However, there was no correlation between fear of injection and glycemic control. A study of 1275 diabetic patients using retrospective self-report questionnaires found that extreme fear of injections was associated with less frequent self-monitoring of blood glucose, but not associated with the number of insulin injections per day, glycemic control, or diabetes complications [6,7]. A community survey of 1920 adults, eight individuals with diabetes and blood-injection-injury phobia experienced a higher rate of macrovascular complications (peripheral vascular disease and cardiovascular disease), compared to 138 individuals with diabetes alone (76 percent versus 18 percent) [4]. If avoidance is not possible or if a fear reaction was not anticipated prior to the procedure, then the patient may have to endure the procedure with great distress or may require treatment of the anxiety in order for the procedure to be completed [62]. (See "Treatment of acute procedure anxiety in adults".) SUMMARY AND RECOMMENDATIONS Acute procedure anxiety is an excessive fear and/or anxiety about a medical procedure that results in acute distress in anticipation of the procedure or during the procedure, or avoidance of the procedure. The fears experienced are often rational (eg, concern that a breast biopsy may find a malignancy), but in some cases can be irrational (eg, fear of suffocation during an MRI). Studies have found acute procedure anxiety to occur among patients undergoing a wide range of screening, diagnostic, and treatment procedures, including (See 'Epidemiology' above.): Non-invasive diagnostic procedures (See 'Screening procedures' above.) Minimally invasive diagnostic procedures (See 'Minimally invasive diagnostic procedures' above.) Minimally invasive treatment procedures (See 'Minimally invasive treatment procedures' above.) Major surgery (See 'Major surgeries' above.) The focus of fear in acute procedure anxiety varies among individuals and by the type of procedure; foci may include concerns about the procedures potential risks and complications, perceptions of associated pain and discomfort, or fears of the implications and outcomes of a procedure. (See 'Focus of fear' above.) Acute procedure anxiety is diagnosed as a specific phobia using DSM-IV-TR criteria when the focus of the patients fear or anxiety is specific to the procedure or its effects (eg, a fear of seeing blood during venipuncture or suffocating during an MRI scan). A specific phobia would not be diagnosed when the patients fear/anxiety is not specific to the procedure itself, but about, for example, its outcome or implications (eg, a fear that a diagnostic procedure may detect a malignancy). (See 'Specific phobias' above.) Examples of acute procedure anxiety that is diagnosed as a specific phobia include: In patients with blood phobia, the fear at the sight of blood is typically concern about physical sensations, fear of fainting, and feelings of disgust. Dental phobia is the specific fear of going to the dentist and the fear may be triggered by multiple

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Acute procedure anxiety in adults: Epidemiology and clinical presentation

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stimuli in the dental office, such as sound of the drill, receiving an intraoral injection or undergoing any dental treatment. In patients with MRI claustrophobia, the main focus is fear of suffocation and fear of restriction while in an enclosed space, though alternatively, patients may fear being harmed by the machine or losing control. The epidemiology of the specific phobias has been studied with more rigorous methods than other manifestations of acute procedure anxiety. Community-based studies have estimated that 2 to 5 percent of the general population in the US has experienced blood-injection-injury phobia, dental phobia, or MRI claustrophobia. (See 'Epidemiology' above.) The avoidance or delay of clinical procedures resulting from acute procedure anxiety has been associated with poor health outcomes in a variety of patient samples. (See 'Clinical Manifestations' above.) Use of UpToDate is subject to the Subscription and License Agreement. Topic 16618 Version 2.0

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