User:Emilyc44/sandbox

= Article Draft =

Blood-injection-injury (BII) type phobia is a type of specific phobia characterized by the display of excessive, irrational fear in response to the sight of blood, injury, or injection, or in anticipation of an injection, injury, or exposure to blood. Blood-like stimuli (paint, ketchup) may also cause a reaction.

This is a common phobia with an estimated 3-4% prevalence in the general population, though it has been found to occur more often in younger and less educated groups.

When exposed to phobic triggers, those with the phobia often experience a two-phase response: an initial increase in heart rate and blood pressure, followed quickly by bradycardia (decreased heart rate) and hypotension (decreased blood pressure). This diminishes cerebral blood supply, and will often result in a fainting response. In an individual with BII phobia, expression of these or similar phobic symptoms in response to blood, injection, or injury typically begins before the age of ten.

Many who have the phobia will take steps to actively avoid exposure to triggers. This can lead to health issues in phobic individuals as a result of avoidance of hospitals, doctors’ appointments, blood tests, and vaccinations, or of necessary self-injections in those with diabetes and multiple sclerosis (MS). Due to frequent avoidance of phobic triggers, BII phobics' personal and professional lives may be limited. Some may feel that their phobia precludes them from joining a healthcare profession, or from getting pregnant. The phobia is also able to affect the health of those who don't have it; a BII-phobic, for instance, may have difficulty providing aid to someone else in an emergency situation in which blood is present.

Causes of BII phobia have yet to be fully understood. There is a body of evidence which suggests the phobia has genetic underpinnings, though many phobics also cite a traumatic life event as a cause of their fear. The fainting response accompanying the phobia may have originated as an adaptive evolutionary mechanism.

Applied tension (AT), a method in which individuals alternately tense and relax their muscles while being exposed to a phobic trigger, is widely recognized as an effective form of treatment for BII phobia. While AT is generally the default treatment suggestion, methods of applied relaxation (AR) and exposure-only cognitive-behavioral therapy (CBT) have been found to be effective in diminishing phobic response in some instances. Certain other strategies can be employed to temporarily alleviate symptoms associated with phobic response, such as coughing to increase cranial blood flow. The acute symptoms associated with an episode of triggering are often fully resolved within a few minutes of stimuli removal.

BII phobia does bear some similarity to other phobic disorders: specifically, dental phobia (commonly considered a sub-type of BII phobia) and hemophobia. In each of these phobias, a biphasic fainting response is a common reaction to a trigger.

Epidemiology
BII phobia is one of the more common types of phobia — it is estimated to affect about 3-4% of the general population.

Onset of the phobia generally occurs in middle childhood, before the age of ten years. There are more reports of incidence of the phobia in younger individuals and those with low education levels. Some studies suggest that women also experience the phobia more frequently, however results are mixed concerning relative prevalences of the phobia between the sexes.

Symptoms
In a majority of specific phobias, affected individuals experience heightened anxiety when exposed to a phobic trigger. While BII-phobics experience a similar reaction initially upon exposure, most ultimately respond to a trigger with a biphasic, or two-phase, fainting response. In the first phase, phobics often experience an anxiety reaction characterized by elevated heart rate and heightened blood pressure, as occurs in most other phobias. This is the result of increased activation of the sympathetic nervous system. However, with BII phobia, a second phase usually follows closely, in which the phobic individual experiences a massive dip in heart rate and blood pressure known as vasovagal response. Stimulation of the vagus nerve, a part of the parasympathetic nervous system, is responsible for promoting the lowered heart rate and decreased blood pressure. These physiological changes limit blood flow to the brain and can promote pre-syncope (lightheadedness, feelings of faintness) and syncope (fainting): categorized in this instance as vasovagal fainting. This second, fainting phase is not common to other phobias.

A fainting response pattern is not seen in all individuals with BII phobia, but is found in a majority. Up to 80% of those with BII phobia report either syncope or pre-syncope as a symptom when exposed to a trigger.

Other symptoms that may evolve when exposed to phobic triggers include extreme chest discomfort, tunnel vision, becoming pale, shock, vertigo, diaphoresis (profuse sweating), nausea, and in very rare cases asystole (cardiac arrest) and death. Increase in stress hormone release (particularly of cortisol and corticotrophin) is typical.

Neurological responses to phobic triggers include activation of the bilateral occipito-parietal cortex and the thalamus. It has also been suggested that exposing a BII-phobic individual to a trigger will lead to decreased activity in the brain's medial prefrontal cortex (MPFC). Diminished MPFC activity has been linked with impaired ability to control emotional responses. This lessened emotional control could contribute to a general lack of control over symptoms of anxiety arising when exposed to a phobic trigger.

On the health of those with the phobia
The health of individuals with BII phobia can be jeopardized by the condition as a result of avoidance of phobic triggers. As modern healthcare relies increasingly on injections, it can be difficult for phobics to receive the care they need, since situations involving injections, vaccinations, drawing of blood, etc. are usually avoided. Avoidant behaviors can be especially detrimental to an individual's well-being if they are diabetic and require insulin injections, or experience another pathology or disease which requires treatment via self-injection, such as MS. There may be inappropriate cessation of injection treatment by individuals with the phobia, potentially causing adverse events or reducing treatment efficacy.

Bodily injuries may also be sustained in the course of a fainting response to a phobic trigger.

Comorbidity with other health conditions
Substantial rates of comorbidity with BII phobia have been demonstrated for the following: In individuals with diabetes:
 * other life-long phobias
 * marijuana abuse
 * clinical depression
 * panic disorder
 * obsessive-compulsive disorder (OCD)
 * agoraphobia (AG)
 * social anxiety disorder (SAD)
 * peripheral vascular disease
 * cardiovascular disease

On the health of the broader population
BII phobia is able to affect the health of a broader population than just the community of individuals with the phobia. Someone with the phobia may, for instance, be unable to respond appropriately and/or offer assistance in an emergency event in which another person was injured or cut.

Avoidance of vaccinations due to BII phobia may also prove detrimental to public health at large, as lowered rates of vaccination in a population tend to increase risk of infectious disease outbreak.

Given BII phobics will very often avoid situations involving exposure to blood or needles, these individuals are likely to avoid donating blood. Public health benefit could result from helping them overcome their phobia, such that donation becomes a viable option.

Limitations on personal and professional life
BII phobia may influence the personal and professional decisions of those with the condition. BII-phobic females may, for instance, choose not to get pregnant, as they fear the injections, vaccinations, and labor-induced pain associated with maternity.

Those with the phobia may also be unable to pursue a profession in a health-related field, such as nursing, which would require repeated exposure to feared stimuli. Phobic individuals may find their ability to complete medical school severely impaired.

Causes
The cause of BII phobia is not yet well understood. Various studies indicate an underlying genetic cause, wherein certain genes make an individual more vulnerable to developing specific phobias. The contributing genes have not yet been identified.

BII phobia has markedly strong familial aggregation — if present in a family, multiple members are likely to have the phobia. This aggregation is stronger in BII phobia than in any other known phobic disorder: upwards of 60% of those with the phobia have first-degree relatives who are also BII-phobics. It is believed that this evidences the phobia's genetic underpinnings. One study estimated actual heritability of the phobia at 59%.

Additionally, a majority of phobics attribute their fear to environmental factors. For instance, some sort of traumatic event involving blood, injury, or injection that conditioned them to fear those particular stimuli. Others self-report being conditioned by seeing another person react to the stimuli with a consistent pattern of fear.

It has been theorized that exhibiting vasovagal response when exposed to blood was evolutionarily advantageous, and that this phobia is a vestige of an ancestral evolutionary mechanism. Fainting may have acted as a form of tonic immobility, allowing primitive humans to play dead in a situation where blood was being spilled, perhaps helping them to avoid the attention of enemies. It has also been suggested that the drop in blood pressure associated with seeing blood — as with an individual seeing blood from their own wound — occurs in order to minimize blood loss.

Treatments
Individuals typically seek therapeutic treatment for BII phobia in a bid to alleviate symptoms that arise when exposed to a phobic trigger. Therapists may use a combination of physical and psychological measures, such as cognitive-behavioral-therapy and applied tension (AT), in order to aid in extinguishing the individual's fear response.

Early studies of methods to combat vasovagal fainting found that certain leg exercises and that individuals making themselves angry over imagined scenarios could increase blood pressure, thus elevating cerebral blood flow and preventing fainting upon exposure to a phobic trigger. A later study tested applied muscle tension as a way of preventing fainting when an individual with a fear of injuries was exposed to triggering visual stimuli. Lars-Göran Öst expanded upon this research, having BII-phobic individuals engage in applied muscle tension while shown blood stimuli. Those who were trained in the technique showed notable symptom improvement over the course of five one-hour treatment sessions.

An AT treatment program most often involves an individual being instructed to clench their arm, leg, and chest muscles in 10 to 15 second intervals as they are systematically exposed to triggers of increasing likeness to real blood or needles. This program is designed to increase heart rate and blood pressure, counteracting vasovagal response.

The method of applied tension remains popular — it is the most common BII phobia treatment suggestion, and has been found to be highly effective in a majority of BII-phobics. However, exposure-only cognitive-behavioral therapy (CBT) can also be effective, as can the method of applied relaxation (AR).

CBT is a technique which promotes fear extinguishment by way of gradual, repeated exposure to feared stimuli. BII-phobics may be given pictures of needles or blood, asked to illustrate needles or scenes with blood, or to speak about their phobic triggers. This systematically progresses to the point of the individual directly confronting a phobic stimulus: being given a needle, witnessing blood being drawn, etc. As exposure continues, it is expected that the phobic response will become less pronounced, and symptoms less debilitating.

While AT targets the phobia’s physiological response, aiming to raise blood pressure and directly prevent fainting, AR focuses mainly on helping an individual avoid the phobia’s associated anxiety. A phobic will learn progressive relaxation techniques to help to calm themselves upon exposure to a trigger.

Temporary alleviation of symptoms
Drinking water before a triggering experience such as blood donation has been indicated to aid in prevention of a fainting response. Water will increase sympathetic nervous system activation, raising blood pressure and combating vasovagal response.

Certain physical maneuvers also have the capacity to temporarily boost blood pressure, alleviating symptoms of pre-syncope like lightheadedness by boosting blood flow to the brain. These include the phobic individual crossing their legs, making tight fists with both hands, or engaging muscles of the trunk or arms. Coughing, which can similarly increase cranial blood flow, can also be useful as a coping mechanism to avoid pre-syncope and syncope.

Symptoms of a phobic response are generally able to be fully alleviated within a few minutes simply by removing the phobic trigger.

Dental phobia
Dental phobia is often considered a sub-type of BII phobia, as dental phobics generally fear the aspects of dentistry that are invasive (those commonly involving blood and injections). Some individuals with dental phobia do, however, have fears which center mainly around choking or gagging during a dental procedure.

As with many individuals with BII phobia, many dental phobics will attempt to avoid their triggers. This can lead to refusal to seek dental care, potentially contributing to tooth decay and overall poor oral health. Individuals with dental phobia exhibit symptoms similar to those with BII phobia when exposed to a phobic trigger, including syncope and pre-syncope.

Hemophobia
BII phobia is closely related to hemophobia (fear of blood), though the two are not the same condition. While the anxieties of BII-phobics tend to extend beyond the fear of blood to ideas of pain, needle breakage inside the body, or needle contact with bones, hemophobics tend to be specifically concerned with exposure to blood. However, in both phobias, individuals experience similar symptoms when exposed to phobic triggers.

Initial Article Outline
* bold denotes title of a section

Lead: Symptoms: Effects on Health:
 * definition of BII phobia
 * symptoms expressed when exposed to a phobic trigger
 * prevalence of the phobia
 * treatment availability and efficacy
 * as compared to those more common symptoms associated with exposure to different phobic triggers
 * physiological mechanism(s) responsible for expression of symptoms (decrease in blood pressure via parasympathetic nervous system activation)
 * apparent symptoms (loss of consciousness, tunnel vision, discomfort in chest)
 * fainting
 * disgust reaction

a. On the health of those afflicted (avoidance of doctor’s appointments, vaccinations, necessary blood tests; even of pregnancy due to fear of vaccines, injections, and labor pain; unauthorized discontinuation of treatments which require self-injection)

b. On the health of the broader population (lowered vaccination rates — due to needle/injection avoidance by those with the phobia — proving detrimental to public health writ large)

As a Barrier to Entering a Healthcare Profession:

those with the phobia are often unable to enter healthcare professions dealing with blood and/or injections (incl. being a nurse, doctor, pharmacist)

Causes: Statistics: Treatments: Related Diseases:
 * uncertain
 * possibly linked to genetics
 * evidence to suggest drop in heart rate and blood pressure upon seeing blood is a primitive survival mechanism meant to minimize blood loss when wounded
 * prevalence (in America; in males v. females)
 * as associated with fainting (pre-syncope, syncope)
 * both physical and psychological
 * CBT exposure therapy (fear extinction through desensitization)
 * hypnotherapy
 * applied tension
 * suggested physical maneuvers to combat fainting
 * compared to arachnophobia and dental phobia
 * contrasted with hemophobia

Selected Article and Plans for Improvement
Article: Blood-injection-injury type phobia

What I plan to contribute/notes for improvement:

I’d like to fix or recreate the current lead paragraph, as I don’t think it gives the reader a comprehensive understanding of the topic (for instance, it doesn’t address: what symptoms do those who have the phobia experience when exposed to a phobic trigger? Is treatment available and/or is it successful?) There also aren’t proper citations in the lead, and I find that the “especially children” claim feels a bit misplaced.

Going off of this, I hope to ensure that all statements in the article’s body have proper citation. In addition to cleaning up some minor grammar and wording issues throughout, I’d like to:

- add to the “Symptoms” section to ensure it gives a comprehensive overview of what sufferers report experiencing and of the physiological mechanisms that govern the phobic response

- Edit the “Effects on a person” section, splitting it into two sub-sections:

1. “Effects on Health of Sufferers”: I would be interested in delving further into the issues the phobia presents for pregnant women and those suffering from diabetes who need to self-inject. [I’d also be curious if the phobia has any effect on public health at large: for instance if there are enough people with this phobia who, say, refuse to get vaccinated, that it could prove detrimental to a much wider population than the afflicted].

2. “As a barrier to entering a health profession”

- substantially add to the “Related diseases” section: I’ve seen a great deal of literature relating BII phobia with arachnophobia and/or the disgust response, and think the relationship could be more thoroughly explored in the article. I would also like to add further clarification to the BII v. hemophobia point.

- substantially add to the “Causes” section: I believe it’s been proposed that fainting at the site of blood actually serves as (or is a remnant of) a primitive defense mechanism; supposing I can find reliable sources supporting the claim, I feel this would be valuable to add.

- clean up the “Statistics” section (I don’t think it’s true that “BII phobia is one of the more common psychiatric disorders” — perhaps one of the more common phobias?)

- add to the “Treatments” section: I think it would be appropriate to speak more to efficacy of techniques other than the “Applied Tension”  method.

Gathered Sources:

1. Hermann, A., Schäfer, A., Walter, B., Stark, R., Vaitl, D., & Schienle, A. (2007). Diminished medial prefrontal cortex activity in blood-injection-injury phobia. Biological psychology, 75(2), 124-130.

2. Ritz, T., Meuret, A. E., & Ayala, E. S. (2010). The psychophysiology of blood-injection-injury phobia: looking beyond the diphasic response paradigm. International journal of Psychophysiology, 78(1), 50-67.

3. Ayala, E. S., Meuret, A. E., & Ritz, T. (2009). Treatments for blood-injury-injection phobia: a critical review of current evidence. Journal of psychiatric research, 43(15), 1235-1242.

4. Chapman, L. K., & DeLapp, R. C. (2014). Nine session treatment of a blood–injection–injury phobia with manualized cognitive behavioral therapy: An adult case example. Clinical Case Studies, 13(4), 299-312.

5. de Jong, P. J., & Merckelbach, H. (1998). Blood-injection-injury phobia and fear of spiders: Domain specific individual differences in disgust sensitivity. Personality and Individual Differences, 24(2), 153-158.

6. Tolin, D. F., Lohr, J. M., Sawchuk, C. N., & Lee, T. C. (1997). Disgust and disgust sensitivity in blood-injection-injury and spider phobia. Behaviour research and therapy, 35(10), 949-953.

7. Sawchuk, C. N., Lohr, J. M., Tolin, D. F., Lee, T. C., & Kleinknecht, R. A. (2000). Disgust sensitivity and contamination fears in spider and blood–injection–injury phobias. Behaviour Research and Therapy, 38(8), 753-762.

8. Olatunji, B. O., Smits, J. A., Connolly, K., Willems, J., & Lohr, J. M. (2007). Examination of the decline in fear and disgust during exposure to threat-relevant stimuli in blood–injection–injury phobia. Journal of anxiety disorders, 21(3), 445-455.

9. Olatunji, B. O., Williams, N. L., Sawchuk, C. N., & Lohr, J. M. (2006). Disgust, anxiety and fainting symptoms associated with blood-injection-injury fears: a structural model. Journal of Anxiety Disorders, 20(1), 23-41.

10. McAllister, N., Elshtewi, M., Badr, L., Russell, I. F., & Lindow, S. W. (2012). Pregnancy outcomes in women with severe needle phobia. European Journal of Obstetrics and Gynecology and Reproductive Biology, 162(2), 149-152.

11. Mohr, D. C., Cox, D., & Merluzzi, N. (2005). Self-injection anxiety training: a treatment for patients unable to self-inject injectable medications. Multiple Sclerosis Journal, 11(2), 182-185.

Potential Articles

 * 1) Cognitive behavioral therapy - could create a sub-section under the "'Types" category: 'Combination Therapy', or 'Combined with Pharmacotherapy'. Perhaps even a new section where CBT's efficacy is compared to that of more traditional, pharmacological regimens, and/or to other forms of behavioral therapy. The page is already pretty well-established though, so that may present issues (i.e. it's high-traffic, B-rated, classified as high-importance)
 * 2) Blood-injection-injury type phobia - many claims lack proper citation. Could add a section: 'As a Barrier to Entering a Health Profession'. I would also be interested in elaborating on the health aspect (how the phobia prevents patients from getting necessary blood work or injections done) and on treatment of the condition
 * 3) Combined Psychotherapy and Pharmacotherapy (does not currently exist, at least not under this name - I was unable to find an extant article dedicated just to this topic)

Article Evaluation
Article: Simulated patient

In all, I found this article to be well-written and informative, though lacking in sources. As a result of being under-sourced, many claims the piece makes on the topic of simulated patients are unable to be easily verified.

I feel that (for the most part) the entry has a natural, logical flow to it: at the beginning, a brief and easily digestible definition of “simulated patient” is given, along with a short summary of the role of simulated patients in the health care industry. This is followed by a history of the use of simulated patients, explanations of ways they are currently used, a discussion of the advantages and disadvantages inherent in their use, and an explanation of how individuals are recruited to act as simulated patients. Each of these topics is carefully explored in its own sub-section. My only qualm is with the final sub-section describing “Teaching Associates”; I believe the article is suggesting that teaching associates are simply specially-trained simulated patients who specialize in guiding students through intimate exams, however the exact relationship between the article’s main topic and this sub-section is still unclear to me. A discussion of the difficulty of finding individuals willing to be teaching assistants also didn’t seem to be an appropriate way to conclude the entry, and distracted from other more pertinent information.

This article did take a neutral tone, exploring both the advantages and drawbacks that come with use of simulated patients without over- or under-representing either category. Doubt could be cast on the substance and/or non-biased nature of certain claims, as they’re not attributed to any source, objective and unbiased or otherwise. However, given proper citation with reputable and neutral sources as references, everything in the article would be allowable as neutral, non-biased information.

One link in the references section leads to a page that no longer exists, however the majority of links do seem to work correctly. The sources given corroborate claims made in the article. In general, the references used are also neutral and reliable — some are from U.S. government websites, while others are scholarly analyses of the use of simulated patients seen in medical texts. Unfortunately, however, not all facts stated in the article are appropriately referenced.

A fact that was left out of this article but that I discovered through independent research is that use of simulated patients was ridiculed when first proposed; this information might fit well under the “History” sub-section, as it alerts readers to the fact that this now-widely-used practice was once exceedingly controversial.

The only recent activity on the article’s Talk page is a bot notifying editors that archive links had been added to certain external links. On the same page, it’s seen that the article is part of WikiProject Medicine, and that it bears a “B-Class” rating. The rating indicates that the article is approaching completion, but that it still lacks the requisite characteristics for meeting “good article standards” — likely because of the missing citations. I strongly agree with this characterization of the entry: the piece has a solid foundation, but doesn’t yet meet Wikipedia’s rigorous standards for proper citation.