Course content © Copyright 2011 - 2026 by David C. Mohr, Ph.D.. All rights reserved.

COURSE OUTLINE

Introduction

Learning Objectives

Basic Information about Injections and Injection Anxiety

The Collaborative Relationship with your Patient

The Clinician’s Manual

Session I

Establish Rapport

Review the Anxiety Response

Introduce Subjective Units of Distress (SUDS) Rating

Establish SUDS Hierarchy

Introduce Cognitive Behavioral Treatment and Relaxation Training

Session II

Establish SUDS Rating

Finalize Hierarchy

Practice Items from the Hierarchy

Session III

Get SUDS Rating and Review Homework

Introduce Unhelpful Thought Record and Complete

Set Date for Self-Injecting (if not done)

Session IV

Review SUDS Rating and Homework

Review Unhelpful Thought Record

Attempt Self-Injection (if not done)

Session V

Review SUDS Rating and Homework

Review Thoughts Record

Self-Injection and Transfer of Learning to Patient’s Home

Session VI

Relapse Prevention

The Patient Workbook

The topics in the patient workbook follow the interventions outlined in the Clinician’s Manual.

Self-Injection Assessment Questionnaire (SIAQ) Development Article

Assessment of self-injection experience in patients with rheumatoid arthritis

Background: Problems with self-injection in Rheumatoid Arthritis

Purpose and Need for the Assessment Instrument

Questionnaire Development and Methods

Discussion

Overview of Study Results

Key Strengths of the SIAQ

Limitations of the Study

Suggestions for Further Research

INTRODUCTION

This course includes this brief introduction and a review of the following three public domain publications: 

The Self-Injection Anxiety Counseling (SIAC): Manual for Counselors

The Learning to Self-Inject Patient Workbook

The article: Assessment of self-injection experience in patients with rheumatoid arthritis: psychometric validation of the Self-Injection Assessment Questionnaire (SIAQ).  

The Patient Workbook is designed to be used in conjunction with the 6-week intervention outlined in the Clinician’s Manual.  The research article provided is a discussion of the development of an assessment tool to be used with patients who show self-injection anxiety. This can be used to help evaluate patients with self-injection anxiety and to help guide treatment (including response to intervention).

This treatment is designed for patients who have needle anxiety and who rely on self-injection for the management of their illness. Many of these patients are not phobic enough to prevent them from receiving medications when someone else injects them, but anxiety interferes with their ability to self-inject. There are several reasons why it is useful for patients to learn to self-inject:

In the experience of the authors, the vast majority of patients who initially cannot self-inject due to psychological reasons cannot self-inject, are able learn to do so within 6 weeks, some in only one or two weeks (D. C. Mohr, Cox, Epstein, & Boudewyn, 2002).

The treatment manual included in this course was designed to assist the person providing SIAC.  SIAC was developed by psychologists working in a multiple sclerosis center (D. C. Mohr et al., 2002). However, they have successfully trained nurses to administer this treatment.  The treatment is straightforward; the counselor is candid with the patient about the rationale behind the treatment, the reasons behind the exercises, and answers questions in a direct manner. As such, this manual is designed simply to augment the information provided in the patient workbook.  Most of the required information is in the patient workbook.  The manual provides some additional direction to the counselor as to the goals of each session, and some tips on how to present the material, and what types of problems the counselor might encounter. While the manual offers suggestions for each session, the counselor and patient together will need to individualize the treatment to best meet the patient’s needs.  For example, a patient who quickly masters relaxation and managing unhelpful thoughts does not need to wait until the 4th or 5th session to begin attempting to self-inject.  Or, a patient who reports primarily difficulties with unhelpful intrusive thoughts may get more benefit from addressing those thoughts immediately. All of the techniques in this manual have been helpful for patients, but the patient and counselor together need to select the tools that will be most helpful for each individual patient.

This treatment is designed to be conducted in 6 weekly 50-minute sessions. While some patients may have success earlier, many patients require this amount of time to both learn to self-inject and to learn skills to maintain their abilities in the face of any potential future reemergence of anxiety. Thus, the intervention is highly focused on the goal of helping the patient self-inject, rather than any other psychological issues that may arise for the patient in the course of treatment.

While it is important to address these other psychological issues, such as depression, in the context of learning to self-inject, the counselor should remain focused on the goal.  The counselor should be aware of the resources available for the patient, should the patient need a referral to receive treatment for depression, other anxiety disorders, substance abuse, or other psychological issues that may interfere with treatment or successful self-injection.

Diagnosis

The Diagnostic and Statistics Manual-IV (DSM-IV; American Psychiatric Association, 1994), the primary diagnostic system used in American psychiatry, diagnoses a specific phobia when symptoms of intense fear and avoidance of a non-dangerous stimulus are present, and when this fear and/or avoidance interferes significantly with the patient’s normal routine, relationships, or causes marked distress. Specific phobia – blood, injection, and injury (BII) is a diagnosis that is characterized by phobic reactions to exposure to injections, injury, or blood, leading to avoidance of such situations or tolerating these situations only under extreme emotional duress.  Patients may experience unreasonable anxiety when presented with any of these stimuli or only when receiving an injection.

However, many patients who can receive injections without difficulty may experience phobic reactions when faced with the need to self-inject. In the text, we will refer to anxiety that prevents self-injection as “self-injection anxiety.”  Self-injection anxiety is not currently part of the DSM or ICD diagnostic system. However, inability to self-inject is clearly prevalent, distressing, and can have a significant impact on patients’ healthcare, as discussed below.   Research from the two populations where this issue has been most frequently studied, diabetes and multiple sclerosis (MS), suggest that this issue needs to be addressed when treating patients with these conditions.

Consequences of Self-Injection Anxiety

The use of regular self-injection for the treatment of chronic conditions is increasing. While self-injected insulin has long been used to treat diabetes (Glasgow, McCaul, & Schafer, 1986; S. B. Johnson, 1992), more recently self-injected medications have become available for a variety of conditions, including migraine headache (Schulman et al., 2000), allergy (Hurst, Gordon, Fornadley, & Hunsaker, 1999), multiple sclerosis (MS; Jacobs et al., 1996; K. P. Johnson et al., 1995; The IFNB Multiple Sclerosis Study Group, 1993), erectile dysfunction, impaired female fertility (Gocial, Keye, Fein, & Nardi, 2000), arthritis, and chronic infection (Esposito, 2000). In addition, cancer treatment often requires the need for self-injection.  As you can imagine, and is supported by the research, these disorders combined impact a significant percentage of the population representing millions of individuals.  Although MS is discussed in an Appendix in the Patient Workbook, more up to date information can be found in the BehavioralHealthCE course, The Mysteries of Multiple Sclerosis: Psychological Changes, Stress, and the Immune System, by Dr. Farrell. 

The relationship between self-injection anxiety and compliance has been directly examined in two diseases: MS and diabetes.  The researchers and authors of the Manual and Patient Workbook comprising this course, followed a group of MS patients initiating treatment with interferon beta-1a (IFN β-1a), which requires weekly IM injections (D. C. Mohr et al., 2001). Inability to self-inject at treatment initiation was significantly related to discontinuation of medication during the first 6 months of treatment. Similar findings have been observed in type I and type II diabetes patients prescribed subcutaneous insulin injection up to 4 times per day.  In these patients greater injection anxiety was associated with increased avoidance of injections and increased avoidance of blood glucose testing (Mollema, Snoek, Ader, Heine, & van der Ploeg, 2001; Zambanini, Newson, Maisey, & Feher, 1999). Injection anxiety and phobia have been shown to correlate with increased glycohemoglobin (GHb), as a result of poor blood glucose test compliance (Berlin et al., 1997). Many other studies also find lower compliance with blood glucose testing (Bienvenu & Eaton, 1998; Mollema et al., 2001; Zambanini et al., 1999).

As such, BII and self-injection anxiety appear to impact adherence to treatment recommendations, although the impact of self-injection anxiety and BII on long-term health outcomes has not been well examined.

Prevalence and Demographics

The prevalence of injection phobia, generally defined in terms of ability to receive an injection, has been estimated to be between 7% and 22% in the general population (Agras, Sylvester, & Oliveau, 1969; Bienvenu & Eaton, 1998). Good epidemiological data on self-injection anxiety is lacking but is likely quite variable depending on the medical condition, age at diagnosis, type of injection, and consequences of the injection. For example, self-injection phobia was seen in half of all MS prescribed IFN β-1a, which requires weekly intramuscular injections (D. C. Mohr, Boudewyn, A.C., Likosky, W., Levine, E., Goodkin, D.E., 2001). In a sample of 115 insulin dependent diabetics, 14% were reported to have avoided injections due to anxiety, and 42% reported concern about the need to inject more frequently in the future (Zambanini et al., 1999). However, other authors, using a questionnaire to assess level of self-injection anxiety in diabetics postulate a very low (.2-1.3% of the population) prevalence of anxiety severe enough that injections are missed due to anxiety (Mollema et al., 2001). There may be several potential moderators of self-injection anxiety, including type of injection, frequency of injection, and consequences of injection. Two types of self-injections are commonly performed at home: subcutaneous (SC) injections and intramuscular (IM) injections. IM injections may prove more daunting for patients due to the length and gauge of the needle.

In addition to the type of injection, the frequency and duration of the injection schedule may contribute to or help reduce phobic symptoms. Repeated exposure to a feared stimulus can reduce phobic symptoms.  As such, frequent self-injection may facilitate habituation to self-injection, while longer intervals between injections may strengthen anxiety and phobic reactions, particularly following unpleasant injection experiences such as pain, bleeding, injection site reactions, or medication side effects. In other words, more frequent self-injections may allow patients to “get used to it.”  The consequences of self-injection may also serve to increase or decrease anxiety and phobic reactions. In the case of self-injection for migraine or sexual dysfunction, the resulting relief from migraine pain or the pleasure associated with improved sexual functioning may reinforce self-injection. For patients who use medications that are primarily preventative or medications with severe side effects, the unpleasant injection experiences and aftermath may be the primary experience. These patients may be more vulnerable to anxiety and phobic reactions, particularly following an unpleasant injection experience.

Psychiatric Co-morbidities

The limited literature on the relationship between psychiatric disturbance and self-injection anxiety suggests that people with self-injection anxiety are at greater risk for depression and other types of phobias (Mollema et al., 2001). Thus, practitioners working with injection phobic patients should be alert to such co-morbidities.  The presence of other depressive or anxiety disorders may complicate the treatment by reducing adherence to treatment procedures (DiMatteo, Lepper, & Croghan, 2000; D. C. Mohr et al., 1997; D. C. Mohr et al., 1996). For example, depressed individuals may lack the motivation to carry through on homework, while patients with other anxiety disorders may be too overwhelmed to participate constructively. If other psychiatric problems are interfering, the injection counselor should refer the person for treatment of these disorders before proceeding with injection training.

The Patient Workbook is designed to be used in conjunction with the 6-week intervention outlined in the Clinician’s Manual.  The research article provided is a discussion of the development of an assessment tool to be used with patients who show self-injection anxiety. This can be used for identification of patients with this issue and to guide treatment (including response to intervention).

Procedure for Taking the Course

This course is based upon 3 documents which can either be reviewed online or downloaded and printed (they are pdf files).  This makes the review for the course very convenient.  It should be noted that since this course is based primarily on pdf documents, the Help-Feature for the test questions is not available.  The test questions are presented in an order that follows reading the Manual first, the Patient Workbook second, and the research article last.

To take the course, simply read the following publications.  These are classics in the area and are all in the public domain and access. Therefore you are also free to use the Manual and Patient Workbook in your practice. Once you have reviewed the materials, you can take the test at any time.  We hope you find this valuable information interesting and useful to your patients. 

You can view and/or download the Self-Injection Anxiety Counseling (SIAC): Manual for Counselors by clicking here.

You can view and/or download the Learning to Self-Inject Patient Workbook by clicking here.

You can view and/or download “Assessment of self-injection experience in patients with rheumatoid arthritis: psychometric validation of the Self-Injection Assessment Questionnaire (SIAQ) by clicking here.