A commonbut often overlooked and misunderstoodpsychiatric disorder is the phobia of blood and needles. Although generally slight and psychosocially inconsequential, most people become a little uncomfortable when confronted with blood or a needle. However, for some, the reaction can be extreme and go well beyond a touch of nausea and change in heart rate. Fortunately for these individuals, a technique known as applied tension can help them address and deal with the physical and psychological effects of these fears.

Individuals with a phobia of needles or blood often experience lightheadedness, dizziness, andeven fainting. Although passing out at the sight of blood or from an injection is not common, it does happen. And when it does, it can be very distressing for the individual and reinforce avoidance for medically necessary procedures (such as drawing blood to check cholesterol or blood sugar) or job duties (a soldier who needs to learn how to treat an injured comrade on the battlefield, for example).

The symptoms associated with a blood or needle phobia are caused by a rapid drop in one’s blood pressure and heart rate. This may seem a bit confusing and counterintuitive, considering that patients are generally taught that anxiety causes one’s blood pressure and heart rate to rise.

In fact, both are true. In explaining to the patient the mechanisms behind fear reactions to blood and needles, it’s important to communicate that immediately before the trigger (seeing someone bleeding or giving blood), heart rate and blood pressure do increase. However, within seconds, they both drop.

This is called the vasovagal response. This response is named after the tenth cranial nerve (simply referred to as the vagus nerve), which interacts with the parasympathetic control of the heart and leads to the symptoms mentioned above. Although it may sound scary to the patient, serious or permanent injuries associated with a vasovagal episode are rare, and simple reassurance of this fact will ease the concerns of most patients.

When injuries do occur, they tend to be related to falling, either from a standing position when there is nothing to lean or sit on, or upon trying to stand up from sitting. Therefore, its important to instruct patients with blood and needle phobias to be seated or lying down when giving blood or receiving an injection. They should also let their doctor, nurse, or lab technician know that they experience exaggerated vasovagal responses before any procedure takes place.

The good news is that applied tension is a highly effective technique you can use with your patients who suffer from blood or injection phobias. Applied tension is a behavioral technique that intentionally increases one’s blood pressure immediately before and during the feared event (such as giving blood or getting a shot). The increase in blood pressure counters the patient’s natural physiological inclination to experience an acute drop in pressure, which can prevent fainting; or at a minimum, reduce the time it takes to recover from fainting or other troubling symptoms.

Here are instructions for training your patients in applied tension.

  1. Find a quiet and comfortable place you can sit or lie down. Tense the muscles in your arms, legs, and torso for 10 to 15 seconds or until you feel a warm feeling in your face, head, and upper body. Relax for 20 or 30 seconds and repeat the step three or four more times.
  2. Repeat Step 1 four to five times a day for 10 days. When possible, practice the same time every day in the same position. The practice should become automatic at the end of the 10 days. The goal is to prevent your vasovagal symptoms from occurring and to fight them off if they do occur.
  3. The final step is to create a fear ladder (see the example fear hierarchy below). Ranging from 1 (least distress) to 10 (highest distress), develop a stressful blood and/or needle hierarchy of triggering objects, events, or situations. Then gradually expose yourself to these objects, events, or situations.

It’s important to start off with an activity that it is in the medium difficulty range. Engage in the activity until your anxiety disappears or drops to a level you can manage.

Then move up the fear ladder until you reach your number 10. Since this activity can lead to lightheadedness, dizziness, and possible fainting, it’s important to only do the exercise with someone present to support you emotionally and physically.


Getting an injection or giving blood10 (Most Difficult)
Pricking your finger with a sterile needle9
Holding a needle or syringe8
Touching a needle or syringe7
Watching someone getting an injection or giving blood6
Watching a video of someone getting an injection or giving blood5 (Medium Difficulty)
Looking at a picture of a needle or syringe4
Looking at a cartoon picture of a needle or syringe3
Talking with someone about getting an injection or giving blood2
Thinking about getting an injection or giving blood1 (Least Difficult)