INTRODUCTION — Acute procedural anxiety is an excessive fear of medical, dental, or surgical procedures that results in acute distress or interference with completing necessary procedures.
Patients may experience anxiety in anticipation of or during procedures used for screening (eg, mammography), diagnosis (eg, amniocentesis or endoscopy), and treatment (eg, angioplasty or major surgery). Avoidance of clinical procedures due to acute procedural anxiety can have negative health consequences [1-7].
This topic reviews the treatment of acute procedure anxiety other than specific phobias. The epidemiology, clinical manifestations, course, screening, assessment, and differential diagnosis of acute procedure anxiety are reviewed separately. The epidemiology, clinical manifestations, course, screening, assessment, diagnosis, and treatment of specific phobias are also reviewed separately. Specific phobias related to clinical procedures (including dental phobia, blood-injection-injury phobia, and magnetic resonance imaging claustrophobia) are also reviewed separately.
●(See "Acute procedure anxiety in adults: Epidemiology, clinical manifestations, and course".)
●(See "Acute procedure anxiety in adults: Course, screening, assessment, and differential diagnosis".)
●(See "Cognitive-behavioral therapies for specific phobia in adults".)
●(See "Specific phobia in adults: Epidemiology, clinical manifestations, course and diagnosis".)
●(See "Pharmacotherapy for specific phobia in adults".)
●(See "Treatment of specific phobias of clinical procedures in adults".)
APPROACH TO TREATMENT
General principles — Several general principles can be useful in the management of acute procedural anxiety. Unless otherwise specified, these guidelines are based on our clinical experience.
●Establish a trusting clinician-patient relationship – A trusted clinician may be better able to explain to the patient why an indicated procedure is necessary and to reassure them of its safety.
●Educate the patient about their condition, reasons the procedure is recommended, and what they can expect, eg, about the expected amount of pain. This information should be provided face-to-face with sufficient time to allow the patient to ask and receive answers to their questions [8].
●Educate the patient about the procedure – Address any preconceived notions about the procedure and potential outcomes, and allow the patient to ask questions and bring up concerns [9-11].
●Determine what aspect of the procedure is most anxiety provoking for the patient.
•Directly address that underlying focus of fear with the patient through acknowledgment and education.
•Acknowledge the patient’s anxiety [11] and normalize the experience of anxiety if it is common. Avoid telling patients not to worry as this may undermine their concerns and imply that they are able to stop their worries at will.
●Provide patients with as much control as possible during the procedure – This may include assuring the patient that nothing will happen during the procedure that is not agreed upon in advance. Allow the patient to interrupt or end the procedure if anxiety becomes intolerable, as long as it is safe to do so [10,11].
●Make the patient as comfortable as possible during the procedure. As an example, allow family members or friends to be present during the procedure if desired by the patient and not clinically contraindicated [10].
●Acute procedural anxiety is not a DSM-5 diagnosis. “Other specified anxiety disorder,” can be used when a DSM-5 diagnosis is needed for documentation or billing purposes.
Need for treatment — In cases of mild acute procedure anxiety, providing accurate data on procedure outcomes and realistic evaluation of the risks is often sufficient to decrease anxiety [12]. Moderate or severe anxiety may require intervention with medication or psychotherapy to reduce distress and allow completion of a procedure.
Initial treatment
Medication versus CBT — Medication and brief cognitive-behavioral therapy (CBT) are both effective treatments for acute procedural anxiety. (See 'Benzodiazepines' below and 'Brief cognitive-behavioral therapy' below.)
The choice between medication and psychosocial intervention can be made on the basis of patient preference or one of the factors that follow:
●Circumstances favoring medication treatment include:
•Clinical need is an emergency or one time rather than recurring
•Patient's anxiety is too severe to tolerate psychotherapy
•Brief CBT is unavailable or was ineffective
●Circumstances favoring psychosocial intervention:
•Patient is unable to tolerate the medications or has medical contraindications
•The patient requires a procedure on a repeated basis
Medication preferred or indicated — For most patients receiving medication for acute procedural anxiety, we suggest first-line treatment with a benzodiazepine rather than other medications. Benzodiazepines have established efficacy, a broad range of onset, varied duration of action, and can be administered via several different routes. For patients in whom benzodiazepines may be undesirable (eg, those with substance use disorder or cognitive impairments), who are not able to tolerate benzodiazepines, who have medical contraindications to their use, or who have found them ineffective, we suggest treatment of procedural anxiety with melatonin. Doses and administration of benzodiazepines and melatonin are discussed below. (See 'Administration' below and 'Melatonin' below.)
Several benzodiazepines are used for first-line therapy, including midazolam, diazepam, lorazepam, alprazolam, triazolam, and oxazepam. Selection among them is generally based on the efficacy and pharmacokinetics of individual agents, as well as the clinician’s experience. (See 'Benzodiazepines' below.)
When immediate relief of anxiety is desired, benzodiazepines with a rapid onset of action are favored. For outpatient procedures that require a faster recovery time, benzodiazepines with a shorter duration of action after a one-time dose are generally favored.
For surgical or invasive procedures where intravenous access and close monitoring are available, we favor first-line use of intravenous midazolam for acute procedural anxiety over other medications. Midazolam has a rapid onset, short duration of effects, amnestic properties, tolerable side effects, and is acceptable to patients. (See 'Midazolam' below.)
Most clinical trials comparing midazolam with placebo and other benzodiazepines for procedural anxiety found that midazolam had similar or better efficacy compared with other benzodiazepines and was preferred by patients [13-15]. As an example, a clinical trial of 63 patients undergoing bronchoscopy in Czechoslovakia found intravenous midazolam 0.07 mg/kg had stronger sedating and anxiolytic effects than intravenous diazepam 0.14 mg/kg [14]. Midazolam was more likely to cause anterograde amnesia, which is desirable for conscious sedation in bronchoscopy. More patients treated with midazolam reported acceptability of future bronchoscopy. Midazolam is also the most strongly supported benzodiazepine in clinical trials comparing the benzodiazepine with placebo. (See 'Efficacy' below.)
For minor outpatient procedures where intravenous access is not usually indicated or close monitoring is not readily available, we favor first-line treatment with oral diazepam. Diazepam has a rapid onset of action and short duration of effect with one-time dosing. Clinical trials suggest that diazepam is more efficacious in procedural anxiety compared with placebo, but has shown mixed results in comparisons with other benzodiazepines [16-18]. As an example, a clinical trial of 90 women undergoing minor gynecological surgery in England found diazepam 10 mg orally to be more effective than triazolam or placebo in anxiolytic effects [18]. (See 'Diazepam' below.)
Despite clinical trials showing efficacy in procedural anxiety, oral midazolam has led to widely variable clinical results. Oral (tablet and liquid) formulations of the drug have limited availability in some countries.
Oral benzodiazepines given the morning of surgery should be timed 30 to 90 minutes prior to the surgery. Intravenous medication should be reserved as in-hospital premedication for surgical procedures in which there is immediate and adequate airway support. (See 'Administration' below.)
Particular conditions may favor other benzodiazepines. As an example, for procedures or patients who need pretreatment for anxiety more than two hours prior to a procedure (for example, at home prior to the hospital), we would favor a benzodiazepine with a more intermediate onset and intermediate duration of action such as lorazepam. When minimal recall of the details of a procedure is desirable, such as prior to induction of anesthesia, extraction of molars in dental surgery, or bronchoscopy, we favor a benzodiazepine with a stronger amnestic effect such as midazolam.
A table provides information on the pharmacology and dosing of commonly used benzodiazepines in treatment of procedural anxiety (table 1).
For patients with hepatic insufficiency, we favor treatment with oral temazepam or intravenous lorazepam. Oxazepam and lorazepam are reasonable alternatives for oral administration. All three agents are metabolized by glucuronide conjugation and are excreted unchanged by the kidney. Glucuronidation is less affected by hepatic dysfunction [19]. If a faster recovery time is desired, oxazepam or temazepam are a better choice rather than lorazepam. Lorazepam has a longer duration of clinical effects, at least six hours [20], which makes discharge more difficult. The clinical effects of sedation or psychomotor impairment resolve within two hours of administration of oxazepam and temazepam [21].
Women undergoing an abortion procedure or gynecological or breast surgery have responded to oral diazepam or midazolam more variably compared with other benzodiazepines. These patients may require intravenous midazolam, intravenous diazepam, or a higher oral dose of midazolam (at least 10 mg) for treatment of procedural anxiety. This may be due to higher baseline procedural anxiety in women. A clinical trial of 60 patients in Taiwan found that procedural anxiety was higher in women compared with men and younger compared with older patients [22].
A 50 percent dose reduction is suggested in adults [19]:
●Older than 60
●Debilitated
●Premedicated with opioid analgesics
●Hepatic insufficiency (for benzodiazepines other than lorazepam, oxazepam, and temazepam)
No dose adjustment is needed in patients with mild to moderate renal insufficiency.
A substance use disorder is generally not considered a contraindication to one-time use of a benzodiazepine for acute procedure anxiety, as long as the patient is not acutely intoxicated with another sedating substance at the time of the procedure and they are closely monitored for respiratory depression. Patients with regular alcohol or benzodiazepine use leading to tolerance may require a higher-than-usual benzodiazepine dose.
Gabapentin and metoprolol have also shown evidence of efficacy in clinical trials, but have been subject to less study and clinical experience. (See 'Other medications' below.)
Psychotherapy preferred or indicated — For patients receiving psychosocial treatment for acute procedural anxiety, we suggest first line treatment with brief CBT or brief supportive psychotherapy rather than other interventions. Brief CBT is supported by clinical trials and our clinical experience. A limited number of studies support the use of brief supportive psychotherapy. Less robust evidence supports the efficacy of music therapy, and spiritual training. Video observation does not appear to serve any benefits in reducing anxiety for procedures that involve a high level of pain. No trials compare psychosocial interventions. (See 'Brief cognitive-behavioral therapy' below and 'Music therapy' below and 'Video observation' below and 'Spiritual training' below.)
Insufficient response — Some patients may not respond sufficiently to an initial benzodiazepine dose, requiring one or more repeat doses. As an example, about a quarter of the patients receiving sedation prior to a hospital procedure required a second medication dose because of either an inadequate response to the first dose or a prolonged procedure [23]. In cases where multiple doses are needed, patients should be monitored closely for excessive sedation and respiratory depression. Oral dosing may be repeated at one half the initial dose if after 30 minutes to one hour the initial dose has no effect. Peak plasma level following oral administration is reached within 60 minutes for diazepam and within 120 minutes for lorazepam and alprazolam.
Intravenous dosing may be titrated using small increments to desired effect, evaluating its effects two minutes following an increased dose, and not exceeding the maximum recommended total dose (table 1). To maintain the drug’s effects, additional doses of 50 percent of total initial dose may be administered if needed for longer procedures. (See 'Administration' below.)
For patients who do not respond adequately to brief CBT, consider additional sessions to address underlying fear that might not have been evident during brief treatment, or referral to a mental health professional to reevaluate the patient for a co-occurring depression or other anxiety disorder that may contribute to the procedural anxiety. Another option is treatment with a benzodiazepine.
MEDICATIONS — Clinical trials have found most benzodiazepines and melatonin to be efficacious in the treatment of acute procedural anxiety. Initial clinical trials of gabapentin and the beta-blocker metoprolol in procedural anxiety have shown promising results.
Benzodiazepines — In most cases, we favor benzodiazepines over other medications for the treatment of acute procedural anxiety. Benzodiazepines enable patients with acute procedure anxiety to tolerate procedures by reducing anxiety and/or inducing sedation. The use of benzodiazepines for this purpose is common in the United States, though their use may vary nationwide [24,25]. All benzodiazepines have similar mechanism of action and clinical effects including hypnotic, sedation, anxiolytic, and amnestic effects. Pharmacokinetic properties among the agents vary considerably, influencing selection among benzodiazepines, including peak plasma drug levels affecting rate of onset, metabolism, drug distribution and elimination half-life, affecting the duration of effects [26].
Efficacy — Based on a limited number of clinical trials and our clinical experience, most benzodiazepines appear effective in reducing acute procedural anxiety and/or inducing sedation, increasing a patient’s comfort during the procedure, enabling the completion of clinical procedures, and increasing patients’ willingness to repeat the procedure in the future [24,27-31]. Clinical trials comparing the efficacy of individual benzodiazepines with placebo are described below.
Midazolam — Due to its rapid onset of action, short duration of effect, amnestic properties, and evidence for efficacy compared with placebo, midazolam has been most commonly used in the treatment of procedural anxiety. Most clinical trials but not all [15] have supported the efficacy of intravenous [32] or oral [30,33,34] midazolam compared with placebo. Midazolam was ineffective in studies with smaller sample sizes [35] and in patients with low baseline anxiety levels [12]. As examples:
●In a clinical trial of 88 patients undergoing outpatient surgery in the United States, premedication with intravenous midazolam was effective in alleviating anxiety prior to anesthesia [32].
●In two clinical trials comparing 7.5 mg of oral midazolam with placebo, midazolam was more effective compared with placebo in decreasing procedural anxiety in 99 patients undergoing sigmoidoscopy in the United States [33] and 130 patients undergoing upper endoscopy in Hong Kong [30].
Diazepam — Diazepam has a rapid onset of action and short duration of effect with one-time dosing. Trials comparing diazepam with midazolam suggest that diazepam is efficacious for procedural anxiety [36,37]; however, the absence of a placebo treatment group in these trials limits the conclusions that can be drawn. As an example, a clinical trial of 156 patients undergoing first time cataract surgery in the United States found oral diazepam to be as efficacious as intravenous midazolam in reducing procedural anxiety [37]. There was no significant difference in the level of cooperation or pain between the two treatments. Oral diazepam had the added benefit of causing fewer undesired patient movements during surgery. Patients older than 65 were given half doses of the medications.
Alprazolam — Clinical trials of one dose of oral alprazolam prior to clinical procedures have shown mixed effects on procedural anxiety [38,39]. The timing of administration might have accounted for inferior outcomes since alprazolam has a slower onset of action and relatively short duration of effect. Sublingual administration of alprazolam was found to be more effective than placebo or oral alprazolam in treatment of procedural anxiety in a clinical trial of 220 patients undergoing a diagnostic esophagogastroduodenoscopy in Iran [40].
Lorazepam — Clinical trials have found that lorazepam is efficacious for procedural anxiety, has a longer duration of action and longer recovery time compared with diazepam, oxazepam, and triazolam [17,20]. As an example, in a clinical trial of 58 female patients undergoing laparoscopic investigation in Wales, oral triazolam 0.25 mg and lorazepam 2 mg were both effective in reducing procedural anxiety compared with placebo [20]. Triazolam caused more drowsiness at two hours but more rapid recovery by six hours after administration. Patients given lorazepam were still drowsy at six hours after administration. Lorazepam has advantages for patients with hepatic dysfunction. (See 'Medication preferred or indicated' above.)
Temazepam — Temazepam is a benzodiazepine with a relatively rapid onset of action and shorter duration of effect compared with lorazepam, but longer duration of effect compared with midazolam or oxazepam. There are a few clinical trials of temazepam for treatment of procedural anxiety. Clinical trials suggest that temazepam is effective for procedural anxiety, and more effective compared with oxazepam [41]. As an example, a clinical trial of 72 patients undergoing day surgery in England, found temazepam to be more effective than oxazepam and placebo in decreasing procedural anxiety [21]. Effects of temazepam occurred by 60 minutes after administration, whereas oxazepam patients had minimal change. Sedative effects and psychomotor depression resolved two hours after surgery. Temazepam has advantages for patients with hepatic dysfunction. (See 'Medication preferred or indicated' above.)
Oxazepam — Few clinical trials have tested oxazepam for treatment of procedural anxiety, and results have been mixed [42,43]. As an example, a clinical trial of 602 women undergoing gynecological surgery in Norway found no difference between oral oxazepam and placebo in reducing procedural anxiety. Oxazepam has advantages for patients with hepatic dysfunction. (See 'Medication preferred or indicated' above.)
Side effects — Patients should be educated about potential side effects of benzodiazepines, which include sedation, drowsiness, dizziness, lightheadedness, cognitive impairment, motor incoordination, respiratory suppression, amnesia, and (with long-term use) dependence. Side effects are reviewed in more detail separately. (See "Pharmacotherapy for insomnia in adults", section on 'Benzodiazepine hypnotics' and "Safety of infant exposure to antidepressants and benzodiazepines through breastfeeding", section on 'Benzodiazepines'.)
Patients should be evaluated to ensure that they are safe to leave after receiving a benzodiazepine, and should only be discharged if accompanied by a companion [44]. Benzodiazepines can impair performance operating machinery due to sedation and psychomotor impairment. Patients should be warned against driving for a period of time. The duration depends on time for resolution of these effects, which are affected by dosing, route of administration, drug potency, rates of absorption and distribution, and elimination half-life. Examples, based on studies of healthy volunteers, include:
●Diazepam – Avoid driving for at least five hours after oral administration of 10 mg diazepam [45] or intravenous administration of 0.15 mg/kg of diazepam [46]. At higher intravenous doses of diazepam (0.30 mg/kg or 0.45 mg/kg), avoid driving for at least 10 hours [46].
●Midazolam – Patients should not drive for at least five hours after intravenous administration of midazolam at 0.1 mg/kg [47]. At higher doses of midazolam (0.15 mg/kg), residual psychomotor impairment persists at five hours.
●Lorazepam – Avoid driving for up to 24 hours after an oral dose of 2.5 mg lorazepam [45,48]. Although lorazepam has a shorter half-life than diazepam, clinically, the duration of action is longer compared with diazepam, as noted in these and above studies.
Administration — Benzodiazepines are available in different formulations enabling administration by oral, sublingual, intranasal, intramuscular, or intravenous routes, depending on the specific benzodiazepine agent. Intramuscular administration is not as commonly used given pain at injection site. Intramuscular administration may be chosen for patients when oral absorption is compromised or in patients without intravenous access. Lorazepam, midazolam, and diazepam are available for intramuscular use and are well absorbed if given in the deltoid muscle [26].
Intravenous and intranasal benzodiazepines are administered 5 to 15 minutes prior to the procedure; for oral formulations, 30 minutes to 60 minutes before; for sublingual administration, 30 to 90 minutes before.
Oral administration of benzodiazepines is cost-effective and convenient. Most benzodiazepines are well absorbed orally when given on an empty stomach and achieve peak plasma levels within one to three hours [26]. Benzodiazepines should be taken in the absence of antacids, as they disrupt absorption [26]. Oral administration of benzodiazepines has been used to treat anxiety in most types of procedures. The disadvantage is variability in efficacy and difficulty in dose titration compared with intravenous use.
Intravenous administration is the route of choice if there is intravenous access, need for more precise titration of sedation levels and availability of personnel for close monitoring of vital signs. Intravenous use should only be given if personnel are trained and equipped to manage respiratory depression. Intravenous infusions should be given slowly over two to five minutes instead of a rapid push due to risk of respiratory failure. Diazepam, lorazepam, and midazolam are available in intravenous forms. Although commonly used, intravenous medication is costly, labor intensive, and has risk of hemodynamic effects, requiring close monitoring during administration and recovery period to ensure safety. Equipment, medications, and personnel skilled in advanced cardiac life support and with knowledge of the effects of sedatives and reversal agents must be available for intravenous administration.
Sublingual administration confers greater safety and more cost effectiveness compared with intravenous administration and is a good alternative to intravenous benzodiazepines [40]. Sublingual medication has the benefit of more rapid onset of action and better bioavailability compared with oral dosing because of faster absorption and avoidance of first-pass metabolism [40]. Sublingual administration is a good alternative to oral formulations for patients who cannot swallow or who have a full stomach that would delay absorption of medication. Clinical trials suggest that sublingual administration of benzodiazepines are effective [40,49].
If sublingual tablets are not available, solutions intended for intravenous use have been administered sublingually with good effects. A couple of studies administered sublingual midazolam by preparing a solution of midazolam at desired potency in a syringe (without needle), and applying the solution under the tongue [50,51]. Patients are asked to close their mouth and instructed not to swallow for three minutes. Oral tablets of alprazolam have also been applied sublingually with good effects by placing the tablet under the tongue without swallowing [40].
Intranasal midazolam, an effective option available in some countries, has a faster onset of action compared with oral administration because it does not undergo hepatic first-pass metabolism. A clinical trial comparing low-dose intranasal midazolam (1 to 2 mg) with oral midazolam (7.5 mg) in 72 patients with magnetic resonance imaging claustrophobia found intranasal administration effectively reduced anxiety, led to fewer magnetic resonance imaging cancellations, and resulted in better image quality compared with the oral formation [52].
Dosing and pharmacologic information for oral and intravenous administration of commonly used benzodiazepines are provided in a table (table 1). The lowest effective dose that achieves the desired clinical effects should be used. Higher doses may result in greater side effects and sedation [51], longer duration of sedation [53], and longer recovery time [22] without any additional anxiolytic benefits.
Melatonin — Melatonin, a hormone produced by the pineal gland, helps to regulate sleep and wakefulness, and appears to be efficacious for acute procedural anxiety. We suggest melatonin for procedural anxiety in patients who cannot take benzodiazepines. We generally use a 3 mg sublingual dose or a 3 to 10 mg oral dose if sublingual is not available. The dose is given approximately 90 minutes before a procedure, with a repeat dose if there is no effect after 60 minutes. We prefer sublingual over oral administration since the bioavailability of oral melatonin is low at approximately 15 percent [54].
Multiple clinical trials have found that melatonin given sublingually (3 or 5 mg) or orally (3 to 10 mg) reduces preprocedural anxiety with an efficacy similar to that of midazolam [50,55-60]. As an example, in a meta-analysis of 18 trials involving 1264 patients with preoperative anxiety, melatonin reduced anxiety compared with placebo (mean reduction of 11.7 points on a 100 point scale, 95% CI -13.80 to -9.59) [58]. It also was found to have a similar effect on anxiety reduction compared with benzodiazepines. Melatonin produces sedating effects with less psychomotor impairment compared with midazolam [55,58,60]. Melatonin is also less likely to cause amnesia and result in shorter postoperative recovery time compared to midazolam [5,51,57].
Melatonin appears to be more effective in females compared to males [61]. Based on one small, controlled trial, it does not appear to be effective in older adult patients undergoing surgery [62].
Other medications — Other medications that have been used as treatment for acute procedural anxiety include beta-blockers [63,64], gabapentin [65,66], and pregabalin [67]. Preliminary data suggest that the beta blocker metoprolol [64] and gabapentin [65] may be comparable to oral diazepam in efficacy; however, clinical experience with these drugs in procedural anxiety is limited.
LEVELS OF SEDATION — Medications used for treatment of procedural anxiety are generally used to achieve anxiolytic effects with goal of minimal sedation. Sedation is seen as a continuum from minimal sedation to general anesthesia, and the American Society of Anesthesiologists defines the following levels of sedation [68].
●Minimal sedation (anxiolysis) is a drug-induced state during which patients respond normally to verbal commands. Although cognitive function and physical coordination may be impaired, airway reflexes, and ventilator and cardiovascular functions are unaffected. This state may be achieved with low dose benzodiazepines.
●Moderate sedation/analgesia (“conscious sedation”) is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. This state may be achieved with a higher dose of benzodiazepine.
●Deep sedation/analgesia is a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain respiratory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.
●General anesthesia is a drug-induced loss of consciousness during which patients are not able to be aroused, even by painful stimulation. The ability to independently maintain respiratory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired.
If moderate sedation is desired, the American Society of Anesthesiologists recommends new practice guidelines in 2018 addressing the use and management of moderate sedation [69]. In the case of moderate sedation, it is important that the clinician monitors the patient’s level of sedation and be ready to intervene and return the patient to a desired level of sedation if the level of sedation becomes deeper than intended [68].
PSYCHOSOCIAL INTERVENTIONS — Clinical trials suggest that brief cognitive-behavioral therapy (CBT) and brief supportive psychotherapy reduces acute procedural anxiety. Lesser evidence suggests that music therapy, and spiritual training may reduce anxiety associated with clinical procedures.
Brief cognitive-behavioral therapy — Brief CBT incorporates cognitive and behavioral interventions to reduce symptoms of acute procedure anxiety. Components include psychoeducation, cognitive restructuring, exposure therapy, and/or relaxation training. The goal of cognitive restructuring is to gain a more realistic perspective of the procedure by changing maladaptive or irrational thought patterns that are associated with anxious feelings. Behavioral interventions, such as exposure or relaxation training, are used to reduce symptoms or overcome avoidance of a procedure. These interventions may be used together or may be applied selectively based on the patient’s clinical presentation.
Components — Individual components of CBT, described below, have in some cases been tested as monotherapy for acute procedure anxiety but are often combined into multimodal CBT:
●Psychoeducation – The patient receives information on:
•Reasons the procedure was recommended, knowledge about the procedure, what to expect during the procedure and potential outcomes.
•Factors leading to anxiety and avoidance of clinical procedures.
•Physiologic symptoms that may accompany the anxiety.
•Treatment plan and rationale.
●Cognitive restructuring – Cognitive restructuring involves the identification and modification of overly negative cognitions regarding an anxiety-inducing clinical procedure. Cognitive restructuring has not been widely tested as monotherapy in acute procedure anxiety. A single trial of 52 patients did not find the intervention to effectively reduce symptoms of dental phobia [70]. (See "Treatment of specific phobias of clinical procedures in adults", section on 'Cognitive restructuring'.)
●Exposure therapy – In exposure therapy, the patient gradually confronts the anxiety-inducing procedure in a safe and controlled manner [71]. This is preferably done in real-world situations, which is referred to as in vivo exposure, but can also be performed using pictures, narrative, and/or visualization of feared situation in imaginal exposure.
Exposure therapy has not been widely tested as monotherapy for acute procedure anxiety. Trials have found exposure therapy to be efficacious in the treatment of dental phobia [72]. (See "Cognitive-behavioral therapies for specific phobia in adults" and "Treatment of specific phobias of clinical procedures in adults", section on 'In vivo exposure therapy'.)
Although more time consuming to administer than a sedating medication, the benefit of exposure therapy may last for months to years following treatment, while a sedating medication’s clinical effects are limited to the period immediately following their administration. (See "Cognitive-behavioral therapies for specific phobia in adults", section on 'Exposure therapy' and "Treatment of specific phobias of clinical procedures in adults".)
●Relaxation training – Teaching patients relaxation exercises can address the elevated muscle tension and reduced flexibility of autonomic functioning that often accompanies anxiety [73]. In relaxation training, patients are typically trained to systematically relax different muscle groups until proficiency is achieved in relaxation of the whole body on cue [74]. A clinical trial of 159 preoperative patients with planned surgery under general anesthesia found that patients who received relaxation exercises or nature sounds the day prior to surgery had significant decrease in preoperative anxiety compared with a control group who did not receive any intervention [75].
Efficacy — Randomized trials suggest that brief CBT is an effective treatment for acute procedural anxiety, with efficacy in major surgery that was sustained at three- to four-week follow-up.
●A randomized trial of 100 patients awaiting coronary artery bypass graft surgery compared preoperative treatment plus brief CBT with preoperative treatment as usual [76]. Brief CBT consisted of four 60-minute sessions with psychoeducation, cognitive restructuring, and a behavioral intervention. Patients receiving brief CBT experienced reduced symptoms of anxiety and depression after the intervention and at three to four weeks post-discharge compared with the treatment-as-usual group. Patients receiving CBT also experienced more improvement in quality of life and a shorter hospital stay (7.9 days versus 9.2 days).
●As part of a larger trial, 60 patients undergoing thoracoscopic closure of congenital heart defects were randomly assigned to receive standard preoperative care versus standard preoperative care plus CBT [77]. Patients who received CBT had lower anxiety on the fifth day postprocedure compared with patients who received only standard preoperative care. The CBT treatment consisted of daily 40-minute sessions of CBT and relaxation techniques for two days prior to the procedure and four days subsequently.
Administration — Brief CBT has been provided for acute procedural anxiety in four to five daily sessions of 40 to 60 minutes in length. The conceptual foundation and techniques for providing CBT are described in detail separately. (See "Psychotherapy for social anxiety disorder in adults", section on 'Cognitive-behavioral therapy' and "Generalized anxiety disorder in adults: Cognitive-behavioral therapy and other psychotherapies", section on 'Administering CBT'.)
Brief supportive therapy — Supportive therapy is a form of psychotherapy in which the therapeutic alliance is an important component of treatment. The goals of treatment include alleviation of symptoms, regulation of negative emotions, enhancement of self-esteem, and improvement of adaptive skills and functioning [78]. A limited number of trials that utilizes some elements of supportive psychotherapy found that this form of intervention is effective in reducing procedural anxiety. As examples:
●A trial of 253 patients undergoing coronary bypass surgery found that patients who received 30 minutes of individualized information and emotional support by a trained nurse the day before surgery had significantly lower anxiety compared with a control group of patients who did not receive the same supportive psychotherapy [79].
●A trial of 104 patients undergoing general ambulatory surgery reported that patients who received a 15-minute empathic, patient-centered supportive therapy had lower levels of preoperative anxiety, better surgery recovery, better wound healing, and higher levels of daily activity and satisfaction compared with a controlled group who received 15 minutes of standardized information on surgical procedures [80]. Supportive therapy was delivered by a trained nurse who focused on each patient’s needs, emotions, and fears regarding the surgery. The nurse addressed these concerns about the surgery, leading to the patient feeling validated and understood.
Supplemental education — Supplemental education is the provision of information beyond that routinely provided in a procedure’s informed consent process. Clinical trials have found that supplemental education increased patients’ knowledge about a procedure but have been mixed with regard to its effect on patients’ anxiety about the procedure [81-87].
Trials vary in the types of procedures studied, the amount of detail delivered, the content of information provided and the mode of information delivery. These factors, along with methodologic shortcomings of the trials, limit the conclusions that can be drawn. Most trials, for example, do not take into account patient knowledge about the procedure prior to the intervention or their baseline anxiety levels.
●Amount of detail – It is important to inquire as to how much information a patient desires because each patient may require different levels of detail and education can be tailored in a more efficient and effective way. In one study of 3087 surgical patients undergoing any kind of anesthesia and surgeries in Germany, approximately two-thirds of patients believe that obtaining information about the procedure would help them cope with their anxiety, and one-third of patients were information avoiders and prefer to receive as little information as possible [88]. Therefore, education should be tailored to the patient’s individual needs. This is supported by a randomized controlled study that evaluated the effects of a need-based education versus traditional education in 450 day surgery patients in Thailand [89]. In this study, the need-based education group was given the amount of information requested (none, concise, or detailed). Patients in the traditional education group all received detailed information. The need-based education group had greater decrease in anxiety and greater satisfaction compared with the traditional education group. The need-based education group also required significantly less education time from the clinicians since half of the patients preferred concise information.
●Content of information – Information should be specific to the patients’ illness and the procedure they are to receive [84,90]. As an example, a single trial of 90 patients undergoing spinal surgery noted that patients who received a 30- to 40-minute session with a nurse, along with an educational booklet created specifically about the surgery, supplemented with videos and pictures resulted in greater reduction of anxiety compared with a 10- to 15-minute standard education visit by a nurse [90]. A controlled study of 99 patients undergoing percutaneous coronary intervention showed that patients who watched a video specific to their procedure, including benefits and consequences of the procedure, team members, length of the procedure, position and care after the procedure, experienced less anxiety compared with patients who were given just verbal instructions [91].
●Mode of delivery – Obtaining information from a medical staff is considered most helpful to surgical patients in one single trial [88]. A single trial of 132 women undergoing colposcopy found that presenting information about the procedure via a video resulted in lower anxiety levels than presenting similar information in a written format [92]. Another study with 100 patients undergoing anesthesia noted that patients who watched an educational video on anesthesia had less anxiety compared with patients who were given a verbal briefing on anesthesia [93].
Music therapy — Clinical trials have examined the effects of music intervention on procedural anxiety. The studies differ in the types of procedures studies, the types of music played, whether music was chosen by the patient versus standard selection of music or nature sounds, length of the intervention and timing (played before or during the procedure).
Clinical trials have found that exposing patients to music for 15 to 20 minutes prior to and/or during a procedure reduces anxiety levels in samples of patients undergoing various procedures [94-98]: cystoscopy [98] and gastrointestinal [94-97]; port catheter placement [99]; day surgery [100]; flexible cystoscopy [101]; and hysteroscopy [102], ear, nose, and throat surgeries [103]; gynecological surgeries (n = 97) [104,105]; transrectal ultrasound-guided prostate biopsy (n = 40) [106]; awake craniotomy (n = 38) [107]; colonoscopy without sedation (n = 138) [108], and during cast room procedures (n = 199) [109].
An observational trial in patients awaiting surgery found that patients’ subjective reports of decreased anxiety were consistent with heart rate variability, an objective marker of anxiety [110]. These studies did not limit participation to patients with acute procedure anxiety.
Music did not show a benefit during endoscopy in a trial of patients under conscious sedation [111] and did not have effects in a trial of 155 patients undergoing excisional surgery for skin cancer under local anesthesia [112].
The effects of music on procedural anxiety during colposcopy has been mixed, with some studies showing positive effects [97,108] and some showing no effects [113]. Music also had no effect on anxiety of women undergoing large loop excision for cervical dysplasia [114,115].
Music may actually elevate anxiety in women undergoing epidural catheter placement during labor and delivery [116]. The study authors suggest that this unexpected outcome may be related to the high pain level during labor and music seen as an unwelcomed distraction. However, music decreased anxiety and physiological indicators of anxiety (blood pressure, heart rate) in laboring women during cesarean section with anesthesia [117-119]. These studies suggest that effects of music may be limited by the level of pain experienced during a procedure.
Video observation — Video observation allows the patient to view live video images of the procedure on a monitor, providing the same view as that of the physician. In general, video observation does not appear to be helpful in reducing procedural anxiety. A limited number of trials concluded that video observation has no effects on procedural anxiety in patients (n = 155) undergoing an ultrasound-guided local injection [120] or patients (n = 225) undergoing a colposcopy procedure [121]. A trial of 81 women undergoing colposcopy suggest that video observation was only helpful in diagnostic colposcopy but did not reduce anxiety or pain in women undergoing colposcopy with laser treatment where pain is involved [122].
Spiritual training — Connection with spiritual needs may help reduce procedure anxiety in certain highly religious patients undergoing major surgery. In a trial of 70 patients of Muslim religion in Iran, patients who received four to five sessions of spiritual and religious training congruent with Islamic supplication reported lower anxiety compared with those who were given a brief training before undergoing coronary artery bypass graft surgery [123].
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Anxiety and anxiety disorders in adults".)
SUMMARY AND RECOMMENDATIONS
●Acute procedural anxiety – Acute procedural anxiety is an excessive fear of medical, dental, or surgical procedures that results in acute distress or interference with completing necessary procedures. Avoidance of clinical procedures due to acute procedural anxiety can have negative health consequences. (See 'Introduction' above.)
●Need for treatment – In mild cases of acute procedure anxiety, providing accurate data and realistic evaluation of the risks is often sufficient to decrease anxiety. Moderate or severe anxiety may require intervention with medication or psychotherapy to reduce distress or overcome avoidance. (See 'Need for treatment' above.)
●Initial treatment – Medication and brief cognitive-behavioral therapy (CBT) are both effective treatments for acute procedural anxiety and can be used as first line treatment. (See 'Initial treatment' above.)
•Preference for medication – We favor medication as initial therapy under the following circumstances (see 'Medication preferred or indicated' above):
-Patient preference
-Clinical need is emergent or one-time rather than recurring
-Patient’s anxiety is too severe to tolerate psychotherapy
-Brief CBT is unavailable or was ineffective
•Preference for psychosocial intervention (eg, CBT) – We favor psychosocial interventions such as CBT under the following circumstances (see 'Psychotherapy preferred or indicated' above):
-Patient preference
-Patient is unable to tolerate the medications or has medical contraindications
-The patient requires a procedure on a repeated basis
●Benzodiazepine as preferred medication for most – For most patients receiving medication for acute procedural anxiety, we suggest first-line treatment with a benzodiazepine rather than other medications (table 1) (Grade 2C). (See 'Benzodiazepines' above.)
•In outpatients, we favor use of an oral benzodiazepine, such as diazepam, with a rapid onset of action, short duration of clinical effects, and good evidence of efficacy.
•In inpatients with intravenous access, we favor intravenous midazolam.
•For patients with hepatic insufficiency, we favor treatment with oral temazepam or intravenous lorazepam.
●Melatonin as alternative medication – For individuals in whom benzodiazepines may be undesirable (eg, those with substance use disorder or cognitive impairments), who are not able to tolerate benzodiazepines, who have medical contraindications to their use, or who have found them ineffective, we suggest treatment of procedural anxiety with sublingual melatonin rather than other alternatives (Grade 2C). (See 'Melatonin' above.)
Gabapentin and metoprolol have shown initial evidence of efficacy, but have been subject to less testing and clinical experience. (See 'Other medications' above.)
●Sedation – We warn outpatients against driving after procedural use of the medication because of sedating effects and psychomotor impairment. The duration without driving depends on time for resolution of these effects, which is affected by dosing, route of administration, and drug potency. (See 'Side effects' above.)
●Psychosocial intervention – For patients receiving psychosocial treatment for acute procedural anxiety, we suggest first-line treatment with brief CBT or brief supportive psychotherapy rather than other interventions (Grade 2C). Less robust clinical trials also support the efficacy of music therapy, and spiritual training in reducing anxiety prior to clinical procedures. Video observation does not appear to be beneficial for anxiety reduction. (See 'Psychotherapy preferred or indicated' above and 'Psychosocial interventions' above.)
