درمان چند جزئی برای هراس از آسیب تزریق خون در یک مرد جوان با عقب ماندگی ذهنی

Blood-Injury-Injection Phobia (BIIP) is a subtype of specific phobia, characterized by fear and avoidance of seeing blood, an injury, or receiving an injection. In the current case report, we describe the treatment of BIIP in a young man with mental retardation. The multicomponent treatment consisted of fading (graduated exposure), modeling, noncontingent and differential reinforcement, presession anxiolytic medication, and topical analgesic cream.

There is widespread recognition that individuals with developmental disabilities are at increased risk for the development of psychiatric disorders (Borthwick-Duffy, 1994). The presence of anxiety and anxiety disorders in this population has received increased attention in recent years Matson et al 1997 and Ollendick et al 1993. One of the challenges in diagnosing the presence of anxiety disorders in this population is determining whether problem behaviors such as avoidance, ritualistic behaviors, or disruptive outbursts are due to an anxiety disorder or secondary to the developmental disability. In addition, these individuals’ limited abilities to accurately label and verbally express subjective states make it difficult to diagnose an anxiety disorder in some cases (Matson et al., 1997). The majority of published studies on the treatment of anxiety in this population have reported on interventions targeting specific phobias Arntzen and Almas 1997 and Erfanian and Miltenberger 1990. To date, no study has reported on the treatment of blood-injury-injection phobia (BIIP) in individuals with developmental disabilities. In the DSM-IV, BIIP is classified as a subtype of specific phobia characterized by fear/avoidance of seeing blood, an injury, or receiving an injection (DSM-IV; American Psychiatric Association, 1994). In addition, exposure to the stimulus results in an immediate anxiety response; the situation is either avoided or endured with extreme anxiety; the fear and avoidance interferes with the individual’s functioning; the duration is at least 6 months; and is not explained by another anxiety disorder. BIIP is also associated with an unusually high prevalence of fainting (70–80% of cases). Estimates of the prevalence BIIP range from 3 to 4% in the general population; however, there are no data on the prevalence of BIIP among individuals with developmental disabilities (Öst & Hellstrom, 1997). Öst and colleagues have published the majority of treatment studies on BIIP (see Öst & Hellstrom, 1997 for a review). The treatment package developed by Öst involves exposure, modeling, and “applied tension,” a straining procedure used to increase blood pressure to prevent fainting. For cases in which fainting is not part of the anxious response, the applied tension procedure is not used. In the current study, we describe the treatment of BIIP in a young man with moderate mental retardation.

Patrick’s progress with treatment, along with the criteria for reinforcement during each session are depicted in Fig. 1. The level of restraint with which Patrick complied is depicted in the top panel, while the level of invasiveness of medical procedures with which Patrick complied is depicted in the bottom panel. The horizontal lines represent the criteria for reinforcement. Only one pretreatment session was conducted because of Patrick’s intense panic response. Full-size image (13 K) Fig. 1. The top panel depicts the criteria for reinforcement along with the level of restraint. The lower panel represents the criteria for reinforcement and level of invasiveness of the medical procedure. Numbers represent the Step in treatment as described in Table 1. Figure options During the first phase of treatment, Patrick complied with instructions during each session while the level of restraint was gradually increased. During the second phase, Patrick’s compliance remained high as he was exposed to progressively more medical procedures while the level of restraint remained constant. During the third phase, Patrick’s compliance remained high while the level of restraint was increased by tightening the straps on the papoose and increasing the duration of his restraint. In the fourth phase, while the level of restraint remained at its highest, the level of invasiveness of medical procedures was increased to its highest level (having blood drawn). Patrick refused to comply during sessions 16 and 23. In the final phase, Patrick continued to be compliant while the level of restraint was faded out and the level of invasiveness remained high. During the final two sessions, Patrick sat unrestrained in a chair and complied with having blood drawn. By the time of discharge, the number of psychotropic medications targeting his problem behaviors was reduced from five to three (naltrexone and clonodine were discontinued).