Beyond 'White Coat Syndrome'

Fear of doctors and tests can hinder preventive health care.

From the WebMD Archives

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.

Fortunately, there are proven methods for relieving fear of doctors. But dealing with the problem first requires fessing up to it. Many people may hide their fear by saying they don't have time for a doctor's visit, says Jennifer Hay, PhD, a health psychology researcher at Memorial Sloan-Kettering Cancer Center in New York. "The first step to putting [fear] in its place is acknowledging that it's there," says Hay, who also counsels cancer patients. "Some of the most powerful fears are the ones we don't acknowledge."

Fear of a White Coat

Even if setting foot into a doctor's office doesn't feel like walking into a lion's den, your body may be priming for a threat. As much as 20 percent of the population suffers from "white coat syndrome," in which blood pressure surges when measured in the doctor's office. The syndrome produces a challenge for physicians seeking an accurate blood pressure reading. But a fear response in a health care setting is perfectly normal because most people associate hospitals and clinics with sickness and injury, says Nathan Consedine, PhD, a health psychology researcher at Long Island University.

"Fear is a response selected in evolution to promote immediate avoidance of a very salient physical threat," Consedine says. "Doctor's offices and hospitals are places where bad things happen, so it's not surprising that people avoid them." A person with white coat syndrome may not feel anxious even as her body, "at a low level, is ready to run away."

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Our health care anxieties have many sources, Consedine 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.

Fainting Before the Needle

Although some medical procedures may make us nervous, fear of needles can evoke intense reactions. Fear of needles is a recognized phobia, listed in the American Psychiatric Association's DSM-IV manual within the category of blood-injection-injury phobia, according to a 1995 study in the Journal of Family Practice.

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."

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Fear's Silver Lining

Fear can also be your friend when it comes to health care, Consedine says. People who are more afraid of cancer or heart disease are more likely to get screened for those illnesses, studies show. In fact, many people face conflicting emotions about visiting a doctor, Consedine says. For example, a man may fear the discomfort of a colorectal exam, but also fear the consequences of missing a colon cancer diagnosis.

What determines whether we seek proper health care or avoid it? "Fear aroused in the absence of any sense of what to do -- of a coping procedure -- is more likely to lead to delay and avoidance," says Howard Leventhal, PhD, director of the Center for the Study of Health Beliefs and Behavior at Rutgers University. If a person feels that a diagnosis will doom him, or that the health care system is untrustworthy, or that he can't afford treatment, he is more likely to let his fears guide his decisions.

Fear of Doctors: How to Cope

Here are some tips experts suggest to cope with fear of doctors or medical procedures:

1. Identify what worries you. Or as Consedine puts it, deconstruct your anxiety. "Anxiety tends to be diffuse; people are not sure what they're really anxious about. But if you identify what it is, that makes it much easier to manage because you can evaluate your coping potential."

2. Confront anxieties and deal with them rationally. This could be a useful way to overcome fear of screening tests, Consedine says. For example, the digital rectal exam can be important for detecting prostate cancer, and the colorectal exam is important for early detection of colorectal cancers. Studies show that many men avoid these tests because of a perceived threat to their sexuality, Consedine says.

Other screenings such as the mammogram may be uncomfortable, but they are brief and can be life-saving. Surveys show that people anticipate screenings to be more painful than they actually are, Consedine says. And rationally, those brief moments of discomfort are far outweighed by the chance of having your life saved by early detection of a disease.

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3. Ask for sedatives or anesthetics. These can be helpful for people with needle phobia.

4. Ask for a preview of what pain you might feel and how long it will last. Leventhal has found that patients are more relaxed if the doctor or nurse prepares them with a reasonable description of what they are going to feel -- for example, by comparing a needle stick to a mosquito bite -- as well as clear indication of how long the feeling will last. If you're worried about pain from a procedure, you may want to ask for a preview of what you are about to feel, Leventhal suggests.

5. Seek a new doctor. If you're afraid of your doctor, you might want to seek out a new one who evokes a more calming reaction, Lack advises.

6. Try cognitive behavioral therapy. By reframing a patient's state of mind and teaching coping techniques, this form of therapy has been shown to relieve anxiety in as little as two or three sessions, Lack says.

7. Take someone with you. Once you've recognized your fear, talk about it to someone who is unthreatening, Hay says. Many anxious people rely on a spouse, relative, or close friend to get them to an appointment and even sit with them in the examining room. Your greatest resource could prove to be someone who cares deeply enough about your health to help you overcome your fears.

WebMD Feature Reviewed by Louise Chang, MD on July 31, 2008

Sources

SOURCES:

Dorothea Lack, PhD, San Francisco, Calif.

Jennifer Hay, PhD, Memorial Sloan-Kettering Cancer Center, New York.

Nathan S. Consedine, PhD, Long Island University, Brooklyn, N.Y.

Howard Leventhal, PhD, director, Center for the Study of Health Beliefs and Behavior, Rutgers University, New Brunswick, N.J.

Hamilton, J. Journal of Family Practice, August 1995; vol 41: pp. 169-175.

News release, Vyteris, Inc.

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