Monday, August 4, 2014

Patient Dignity 11: Fear of Doctors

 While it is normal for anyone to have a certain level of discomfort or fear related to medical exams or  procedures, some people fear them so much that they will avoid medical treatment altogether, or exhibit other forms of avoidant or anxious behavior.

Tomophobia: refers to a severe and irrational fear of surgery or surgical operations. While it is natural for anyone to be nervous when they know they have an impending surgery, surgery represents a situation far too dangerous and life threatening to undergo for the tomophobic.Nosocomephobia: is overwhelmingly afraid of hospitals. Nosophobia: is an uncontrollable fear of a specific disease, versus other phobias that are fears of all diseases.Pharmacophobia: is a fear of medication, usually pills or injections.Trypanophobia: is the extreme fear of hypodermic needles or injections in medical procedures.

Fear vs Phobia

Fear has been described as a normal response to threatening stimuli, and involves three response systems:
  • physiological arousal
  • covert feelings and thoughts and
  • overt behavioural reactions.
Often this arousal is disproportional to the actual stimuli or even completely misapprehended in the actual situation.
Think of  FEAR as an acronym for: "False Expectations Appearing Real".
Phobias, however, can be described as unreasonable responses to a benign stimulus which results in one of the three elements of fear being excessively and persistently activated.
(Source: The Nurse Path)
When we are ill or just to try and stay in good health, visiting a physician or doctor seems to be the obvious choice. During these examinations, professionals are able to recommend proper treatments. If we make the personal choice to avoid medical exams and treatments, our health will obviously suffer.

However, avoiding medical treatment is much more of a choice for some than it is for others. For some, receiving medical treatment can be absolutely terrifying and a catalyst for anxiety attacks. Medical experiences can cause a person severe panic attacks and usually leads to an avoidance of healthcare, even when it is needed.

Recognizing Phobias in the Healthcare Setting

A 2009 study, "Tomophobia, the phobic fear caused by an invasive medical procedure - an emerging  anxiety disorder: a case report physiological arousal covert feelings and thoughts and overt behavioral reactions,"came to the following conclusion:
Due to the rising number of surgical interventions in modern medicine, as well as the high number of  unrecognized cases of tomophobia, this common but underdiagnosed anxiety disorder should be  highlighted.

Here are excerpts from the case:
The patient was a 69-year-old Caucasian man without a history of mental illness or any previous psychiatric treatment. He was initially transferred to a medical emergency department with marked dyspnoeic symptoms and tachycardia, where an acute coronary syndrome was diagnosed. After laboratory testing and an electrocardiogram a non-ST elevation myocardial infarction (NSTEMI) was diagnosed. The following coronary angiography (an intervention that was endured by the patient with enormous dread), revealed severe three-vessel disease. 
The patient was informed of the urgent indication of a bypass operation, which was planned as an emergency intervention on the same day. At the end of the angiographic intervention, this information caused a severe panic reaction with hyperventilation, tachycardia and the feeling of loss of control, which was successfully treated with benzodiazepines. He described an intensely irrational and unavoidable fear of putting himself in the hands of others -surgeons and anesthetists in this case. Moreover, the fear of losing control of his body through loss of consciousness or compromise of physical integrity during an operation or surgical intervention was reported. The patient was not able to give his agreement for the operative intervention because of overwhelming panic and anxiety. Due to his intense fear he eventually refused the bypass operation...
...The psychopathological findings at the time of psychiatric exploration were limited to intense fear in relation to the forthcoming surgical procedures and interventions. During the psychiatric exploration, the patient was polite, friendly, and honest. Compulsive symptoms were limited to the repeated checking of electric appliances. As a consequence of his lifelong avoidance strategies he seemed not to feel oppressive limitations in everyday life. Until then, he had never consulted a psychiatrist or a psychotherapist regarding his phobic symptoms. He described being ashamed of his unreasonable fear symptoms. Panic disorder symptoms were not observed at any time during the psychiatric exploration. No history of syncope was found. Family history revealed a suspected anxiety disorder in the patient's father, although he reportedly never consulted any physician or other healthcare professional. Further examinations of the patient such as laboratory tests, duplex sonography, an electroencephalogram and a cranial magnetic resonance imaging were entirely normal. A Specific Phobia was diagnosed according to DSM-IV criteria... 
...Our patient neither experienced syncope nor symptoms of massive disgust while being confronted with the phobic stimuli, but he complained of intense fears related to the impending operation. Considering the absence of disgust response and fainting, the assignment to the situational subtype or a combined form of phobia could be the more appropriate diagnostic category for the reported case of tomophobia. 
Bienvenu et al. reported a study of 1920 subjects, which showed a prevalence of the "blood-injection-injury" phobia of 3.5%. None of these patients was receiving mental health treatment specifically for phobia [6]. With regard to tomophobia, the number of undiagnosed cases might be much higher than the number of cases that are actually diagnosed, possibly because repression and avoidance of feared situations are the leading behaviour of these phobic patients. The majority of patients suffering from specific phobia do not seek professional psychiatric or psychotherapeutic help (only 12-30% do) unless they have a comorbid disorder [1]. In addition, the presence of "blood-injection-injury" related symptoms worsen the prognosis of panic disorder and agoraphobia [7]. 
Due to progress in the development of invasive treatment and an increased number of established intervention procedures in modern medicine, cases of diagnosed tomophobia might increase in the near future. Above all, surgeons and general physicians may be increasingly confronted with patients who refuse medically urgent procedures due to tomophobic fears. Our patient became symptomatic when he was informed about the indication of the necessary operation. The patient's refusal of the surgical intervention can be comprehended as typical avoidance behaviour as a result of his permanent phobic disorder. The patient was always cognitively capable of understanding the consequences of his unreasonable decision, but the fear of impairment of physical integrity and of losing control while accepting the bypass operation was greater than the fear of dying as a consequence of the detected heart disease... 
...Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Another Article

There is an article on WebMD, "Beyond 'White Coat Syndrome.'"I realize the amount of skepticism providers put in WebMD, but it was reviewed by an MD. Here are some excerpts from that article:
When Dorothea Lack was a little girl, she hid under a doctor's desk to avoid a vaccination. Undaunted, the doctor crawled under the desk and vaccinated her then and there. Lack said the incident provoked a fear of doctors that followed her into adulthood. "I didn't feel I could trust them," says Lack, PhD, now a psychologist who performs research on doctor-patient relations. 
It's a rare soul who truly enjoys visiting the doctor. But for a significant minority of the population, fear and anxiety prevents them from getting vital care. The problem has grown in importance with medicine's increasing emphasis on preventive care. Screenings such as mammograms, colorectal exams, cholesterol checks, and digital rectal exams can save lives, but only if people are willing to submit to uncomfortable procedures well before symptoms have emerged... 
...Our health care anxieties have many sources, Consedine (Nathan Consedine, PhD, a health psychology researcher at Long Island University) says. We fear the prospect of a painful procedure; we're embarrassed about being naked or being touched; or we fear being criticized for unhealthy behavior. The most common fear is of a bad diagnosis, which helps to explain why as many as 40% of women who receive abnormal mammogram results do not submit to a follow-up test as recommended by a physician, Consedine says. "People just want to stick their heads in the sand." 
Lack believes the American health care system tends to exacerbate these anxieties. Doctors are busier and less likely to build long-term relationships with their patients, and news stories about medical errors abound. The result is a reduction in trust in doctors and hospitals that can frighten people away from care. One of Lack's patients who suffered a bone fracture avoided a hospital because of news about the prevalence of hospital-based infections. As a result, the bone healed improperly, Lack says... 
Needle-phobes experience panic attacks, lightheadedness, or fainting when exposed to a needle, according to the author, James G. Hamilton, MD. (Hamilton says that 80% of patients with needle phobia also report the fear in a close relative, suggesting the phobia has a genetic component.) 
A 2006 study showed that 15 million adults and 5 million children reported high discomfort or phobic behavior when faced with a needle. Nearly a quarter of those 15 million adults said they refused a blood draw or recommended injection because of fear. (The study, which extrapolated from a survey of 11,460 people, was commissioned by Vyteris, Inc., a company that makes a patch, called LidoSite, designed to relieve needle pain.) Hamilton estimates that needle phobia "affects at least 10% of the population." 
"Blood tests are one of the most important diagnostic tools modern medicine has at its disposal," Mark Dursztman, MD, a physician at New York Presbyterian Hospital, said in a news release announcing the study findings. Fear of needles, therefore, is "an important public health issue." 
Hamilton says needle-phobic patients deserve to be recognized as suffering from an involuntary condition rather than being made to feel like "wimps" or "oddballs."

I like how the subject of the WebMD article (Dorothea Lack, PhD, psychologist) acknowledges that it was her experience being vaccinated as a child that lead to her fear of doctors. Nathan Consedine, PhD, a health psychology researcher at Long Island University acknowledges the fear some people have of being naked or being touched.

Some of these experiences may be traumatic, especially for children. Many people who suffer from fears, phobias, or PTSD from healthcare trace their roots to childhood experiences. What may not seem scary to an adult (like a vaccination or being exposed for a physical exam) may be terrifying to a child. The event becomes when the child is forced to endure it. Being exposed for a physical exam further traumatizes the patient when there are additional people in the room (students, chaperones, nurses).

How Trauma Disorders Form And What Causes Them

Trauma disorders form after major events that are deemed traumatic to a patient; while many trauma survivors don’t form disorders, those who do can display many different symptoms. “Trauma” is arguably subjective.

The Symptoms Of Post-Traumatic Conditions

People with trauma disorders may display a wide range of symptoms. The type and extent of symptoms may help to diagnose the disorder. Some symptoms include feelings of disassociation and depersonalization or forming a new identity. These occur after major trauma, but other coping mechanisms may be less severe or noticeable. 

The Conflict

The major issue that people suffering from fears, phobias, or PTSD are labelled as "mentally ill." While the  DSM-IV listing legitimizes these fears, healthcare BLAMES the patient, especially when it is healthcare that caused the problem.

We'll create the cure; we made the disease,  (song: Misery, by artist: Soul Asylum, 1995)

Most doctors are good doctors in the eyes of most patients. Patients want to trust their doctors. A article in the British Journal of Medicine, titled "Patients' views of the good doctor," states:
Patients increasingly expect to participate in decisions about their care, but these aspirations are rarely met...
...Themes that were most commonly mentioned included honesty, openness, responsiveness, having one's best interests at heart, and willingness to be vulnerable without fear of being harmed.

If a good provider does everything correctly (by that I mean meeting the patient's needs, and not traumatizing the patient, that only affects the next (single) encounter, traumatize the patient, and that affects ALL the subsequent  encounters with ALL providers.

Why is this so hard to grasp for most providers?


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