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Treatment of acute procedural anxiety in adults

Yujuan Choy, MD
Section Editor
Murray B Stein, MD, MPH
Deputy Editor
Richard Hermann, MD


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 and clinical presentation" and "Acute procedure anxiety in adults: Course, screening, assessment, and differential diagnosis" and "Cognitive-behavioral therapies for specific phobia in adults" and "Specific phobia in adults: Epidemiology, clinical manifestations, course and diagnosis" and "Pharmacotherapy for specific phobia in adults" and "Treatment of specific phobias of clinical procedures in adults".)


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 him or her of its safety.

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Literature review current through: Nov 2017. | This topic last updated: Feb 28, 2017.
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  1. Page AC. Blood-injury-injection fears in medical practice. Med J Aust 1996; 164:189.
  2. Lilliecreutz C, Sydsjö G, Josefsson A. Obstetric and perinatal outcomes among women with blood- and injection phobia during pregnancy. J Affect Disord 2011; 129:289.
  3. Doerr PA, Lang WP, Nyquist LV, Ronis DL. Factors associated with dental anxiety. J Am Dent Assoc 1998; 129:1111.
  4. Poulton R, Thomson WM, Brown RH, Silva PA. Dental fear with and without blood-injection fear: implications for dental health and clinical practice. Behav Res Ther 1998; 36:591.
  5. Elter JR, Strauss RP, Beck JD. Assessing dental anxiety, dental care use and oral status in older adults. J Am Dent Assoc 1997; 128:591.
  6. Zambanini A, Newson RB, Maisey M, Feher MD. Injection related anxiety in insulin-treated diabetes. Diabetes Res Clin Pract 1999; 46:239.
  7. Bienvenu OJ, Eaton WW. The epidemiology of blood-injection-injury phobia. Psychol Med 1998; 28:1129.
  8. Lim L, Chow P, Wong CY, et al. Doctor-patient communication, knowledge, and question prompt lists in reducing preoperative anxiety: a randomized control study. Asian J Surg 2011; 34:175.
  9. Betti S, Sironi A, Saino G, et al. Effect of the informed consent process on anxiety and comprehension of patients undergoing esophageal and gastrointestinal surgery. J Gastrointest Surg 2011; 15:922.
  10. Weinreb JC, Maravilla KR, Peshock R, Payne J. Magnetic resonance imaging: improving patient tolerance and safety. AJR Am J Roentgenol 1984; 143:1285.
  11. De Jongh A, Adair P, Meijerink-Anderson M. Clinical management of dental anxiety: what works for whom? Int Dent J 2005; 55:73.
  12. Habib NE, Mandour NM, Balmer HG. Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesia. J Cataract Refract Surg 2004; 30:437.
  13. O'Boyle CA, Harris D, Barry H, et al. Comparison of midazolam by mouth and diazepam i.v. in outpatient oral surgery. Br J Anaesth 1987; 59:746.
  14. Kolek V, Jezdinský J. Comparative study of midazolam and diazepam in premedication of bronchoscopy. Acta Univ Palacki Olomuc Fac Med 1991; 131:233.
  15. Kazemisaeid A, Zeinali AH, Davoodi G, et al. Premedication for coronary angiography: effects on anxiety and hemodynamic status. Indian Heart J 2007; 59:454.
  16. Male CG, Lim YT, Male M, et al. Comparison of three benzodiazepines for oral premedication in minor gynaecological surgery. Br J Anaesth 1980; 52:429.
  17. Male CG, Johnson HD. Oral benzodiazepine premedication in minor gynaecological surgery. Br J Anaesth 1984; 56:499.
  18. Pinnock CA, Fell D, Hunt PC, et al. A comparison of triazolam and diazepam as premedication agents for minor gynaecological surgery. Anaesthesia 1985; 40:324.
  19. Mocromedex Healthcare Series [Internet database]. Greenwood Village, CO: Thomson Healthcare. Updated periodically.
  20. Thomas D, Tipping T, Halifax R, et al. Triazolam premedication. A comparison with lorazepam and placebo in gynaecological patients. Anaesthesia 1986; 41:692.
  21. Greenwood BK, Bradshaw EG. Preoperative medication for day-case surgery. A comparison between oxazepam and temazepam. Br J Anaesth 1983; 55:933.
  22. Sun GC, Hsu MC, Chia YY, et al. Effects of age and gender on intravenous midazolam premedication: a randomized double-blind study. Br J Anaesth 2008; 101:632.
  23. Bluemke DA, Breiter SN. Sedation procedures in MR imaging: safety, effectiveness, and nursing effect on examinations. Radiology 2000; 216:645.
  24. Carroll JK, Cullinan E, Clarke L, Davis NF. The role of anxiolytic premedication in reducing preoperative anxiety. Br J Nurs 2012; 21:479.
  25. Paggi S, Radaelli F, Amato A, et al. Unsedated colonoscopy: an option for some but not for all. Gastrointest Endosc 2012; 75:392.
  26. Arana GW, Rosenbaum JF. Benzodiazepines and other anxiolytic drugs. In: Handbook of Psychiatric Drug Therapy, 4th ed, Lippincott Williams and Wilkins, Philadelphia 2000. p.170.
  27. Baudet JS, Aguirre-Jaime A. The sedation increases the acceptance of repeat colonoscopies. Eur J Gastroenterol Hepatol 2012; 24:775.
  28. Rolo R, Mota PC, Coelho F, et al. Sedation with midazolam in flexible bronchoscopy: a prospective study. Rev Port Pneumol 2012; 18:226.
  29. Conway A, Rolley J, Sutherland JR. Midazolam for sedation before procedures. Cochrane Database Syst Rev 2016; :CD009491.
  30. Mui LM, Teoh AY, Ng EK, et al. Premedication with orally administered midazolam in adults undergoing diagnostic upper endoscopy: a double-blind placebo-controlled randomized trial. Gastrointest Endosc 2005; 61:195.
  31. Hollenhorst J, Münte S, Friedrich L, et al. Using intranasal midazolam spray to prevent claustrophobia induced by MR imaging. AJR Am J Roentgenol 2001; 176:865.
  32. Bauer KP, Dom PM, Ramirez AM, O'Flaherty JE. Preoperative intravenous midazolam: benefits beyond anxiolysis. J Clin Anesth 2004; 16:177.
  33. Kuganeswaran E, Clarkston WK, Cuddy PG, et al. A double-blind placebo controlled trial of oral midazolam as premedication before flexible sigmoidoscopy. Am J Gastroenterol 1999; 94:3215.
  34. Bayer LL, Edelman AB, Fu R, et al. An Evaluation of Oral Midazolam for Anxiety and Pain in First-Trimester Surgical Abortion: A Randomized Controlled Trial. Obstet Gynecol 2015; 126:37.
  35. Abdul-Latif MS, Putland AJ, McCluskey A, et al. Oral midazolam premedication for day case breast surgery, a randomised prospective double-blind placebo-controlled study. Anaesthesia 2001; 56:990.
  36. van Vlymen JM, Sá Rêgo MM, White PF. Benzodiazepine premedication: can it improve outcome in patients undergoing breast biopsy procedures? Anesthesiology 1999; 90:740.
  37. Chen M, Hill GM, Patrianakos TD, et al. Oral diazepam versus intravenous midazolam for conscious sedation during cataract surgery performed using topical anesthesia. J Cataract Refract Surg 2015; 41:415.
  38. De Witte JL, Alegret C, Sessler DI, Cammu G. Preoperative alprazolam reduces anxiety in ambulatory surgery patients: a comparison with oral midazolam. Anesth Analg 2002; 95:1601.
  39. Beydon L, Rouxel A, Camut N, et al. Sedative premedication before surgery--A multicentre randomized study versus placebo. Anaesth Crit Care Pain Med 2015; 34:165.
  40. Shavakhi A, Soleiman S, Gholamrezaei A, et al. Premedication with sublingual or oral alprazolam in adults undergoing diagnostic upper gastrointestinal endoscopy. Endoscopy 2014; 46:633.
  41. O'Boyle CA, Harris D, Barry H. Sedation in outpatient oral surgery. Comparison of temazepam by mouth and diazepam i.v. Br J Anaesth 1986; 58:378.
  42. Barrett RF, James PD, MacLeod KC. Oxazepam premedication in neurosurgical patients. The use of a fast-dissolving oral preparation of oxazepam as a pre-operative anxiolytic drug in neurosurgical patients. Anaesthesia 1984; 39:429.
  43. Hofstad B, Haavik PE, Wickstrøm E, Steen PA. Benzodiazepines as oral premedication. A comparison between oxazepam, flunitrazepam and placebo. Acta Anaesthesiol Scand 1987; 31:295.
  44. Berlin L. Sedation and analgesia in MR imaging. AJR Am J Roentgenol 2001; 177:293.
  45. Seppälä K, Korttila K, Häkkinen S, Linnoila M. Residual effects and skills related to driving after a single oral administration of diazepam, medazepam or lorazepam. Br J Clin Pharmacol 1976; 3:831.
  46. Korttila K, Linnoila M. Recovery and skills related to driving after intravenous sedation: dose-response relationship with diazepam. Br J Anaesth 1975; 47:457.
  47. Nuotto EJ, Korttila KT, Lichtor JL, et al. Sedation and recovery of psychomotor function after intravenous administration of various doses of midazolam and diazepam. Anesth Analg 1992; 74:265.
  48. Greenblatt DJ, Divoll M. Diazepam versus lorazepam: relationship of drug distribution to duration of clinical action. Adv Neurol 1983; 34:487.
  49. Berthold CW, Dionne RA, Corey SE. Comparison of sublingually and orally administered triazolam for premedication before oral surgery. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997; 84:119.
  50. Naguib M, Samarkandi AH. Premedication with melatonin: a double-blind, placebo-controlled comparison with midazolam. Br J Anaesth 1999; 82:875.
  51. Naguib M, Samarkandi AH. The comparative dose-response effects of melatonin and midazolam for premedication of adult patients: a double-blinded, placebo-controlled study. Anesth Analg 2000; 91:473.
  52. Tschirch FT, Göpfert K, Fröhlich JM, et al. Low-dose intranasal versus oral midazolam for routine body MRI of claustrophobic patients. Eur Radiol 2007; 17:1403.
  53. Raybould D, Bradshaw EG. Premedication for day case surgery. A study of oral midazolam. Anaesthesia 1987; 42:591.
  54. Acil M, Basgul E, Celiker V, et al. Perioperative effects of melatonin and midazolam premedication on sedation, orientation, anxiety scores and psychomotor performance. Eur J Anaesthesiol 2004; 21:553.
  55. Khezri MB, Merate H. The effects of melatonin on anxiety and pain scores of patients, intraocular pressure, and operating conditions during cataract surgery under topical anesthesia. Indian J Ophthalmol 2013; 61:319.
  56. Ionescu D, Bãdescu C, Ilie A, et al. Melatonin as premedication for laparoscopic cholecystectomy: a double-blind, placebo-controlled study. South Afr J Anaesth Analg 2008; 14:8.
  57. Ismail SA, Mowafi HA. Melatonin provides anxiolysis, enhances analgesia, decreases intraocular pressure, and promotes better operating conditions during cataract surgery under topical anesthesia. Anesth Analg 2009; 108:1146.
  58. Seet E, Liaw CM, Tay S, Su C. Melatonin premedication versus placebo in wisdom teeth extraction: a randomised controlled trial. Singapore Med J 2015; 56:666.
  59. Capuzzo M, Zanardi B, Schiffino E, et al. Melatonin does not reduce anxiety more than placebo in the elderly undergoing surgery. Anesth Analg 2006; 103:121.
  60. Dyck JB, Chung F. A comparison of propranolol and diazepam for preoperative anxiolysis. Can J Anaesth 1991; 38:704.
  61. Jakobsen CJ, Blom L, Brondbjerg M, Lenler-Petersen P. Effect of metoprolol and diazepam on pre-operative anxiety. Anaesthesia 1990; 45:40.
  62. Kavitha J, Parida S, Kundra P, Srinivasan R. Oral gabapentin premedication for elderly patients undergoing intraocular surgery. Br J Ophthalmol 2013; 97:900.
  63. de Jongh A, Muris P, ter Horst G, et al. One-session cognitive treatment of dental phobia: preparing dental phobics for treatment by restructuring negative cognitions. Behav Res Ther 1995; 33:947.
  64. Moscovitch DA, Antony MM, Swinson RP. Exposure-based treatments for anxiety disorders: Theory and process, Oxford University Press, New York 2009. p.461.
  65. Wolitzky-Taylor KB, Horowitz JD, Powers MB, Telch MJ. Psychological approaches in the treatment of specific phobias: a meta-analysis. Clin Psychol Rev 2008; 28:1021.
  66. Thayer JF, Friedman BH, Borkovec TD. Autonomic characteristics of generalized anxiety disorder and worry. Biol Psychiatry 1996; 39:255.
  67. Ost LG. Applied relaxation: description of a coping technique and review of controlled studies. Behav Res Ther 1987; 25:397.
  68. Shahmansouri N, Janghorbani M, Salehi Omran A, et al. Effects of a psychoeducation intervention on fear and anxiety about surgery: randomized trial in patients undergoing coronary artery bypass grafting. Psychol Health Med 2014; 19:375.
  69. Dao TK, Youssef NA, Armsworth M, et al. Randomized controlled trial of brief cognitive behavioral intervention for depression and anxiety symptoms preoperatively in patients undergoing coronary artery bypass graft surgery. J Thorac Cardiovasc Surg 2011; 142:e109.
  70. Yin QY, Ma ZS, Feng FY, Wang LX. Postoperative anxiety and depression in patients undergoing thoracoscopic closure of congenital heart defects. J Cardiovasc Nurs 2012; 27:547.
  71. Byrom J, Clarke T, Neale J, et al. Can pre-colposcopy sessions reduce anxiety at the time of colposcopy? A prospective randomised study. J Obstet Gynaecol 2002; 22:415.
  72. Chan YM, Lee PW, Ng TY, Ngan HY. Could precolposcopy information and counseling reduce women's anxiety and improve knowledge and compliance to follow-up? Gynecol Oncol 2004; 95:341.
  73. de Bie RP, Massuger LF, Lenselink CH, et al. The role of individually targeted information to reduce anxiety before colposcopy: a randomised controlled trial. BJOG 2011; 118:945.
  74. Marteau TM, Kidd J, Cuddeford L. Reducing anxiety in women referred for colposcopy using an information booklet. Br J Health Psychology 1996; 1:181.
  75. Kutlutürkan S, Görgülü U, Fesci H, Karavelioglu A. The effects of providing pre-gastrointestinal endoscopy written educational material on patients' anxiety: a randomised controlled trial. Int J Nurs Stud 2010; 47:1066.
  76. Ramos ML, de Matos MG, Branquinho C, Pereira LM. Helping patients in cataract peri-and post-surgery: a simple intervention addressing anxiety. Indian J Nurs Midwifery 2011; 3:76.
  77. Eley VA, Searles T, Donovan K, Walters E. Effect of an anaesthesia information video on preoperative maternal anxiety and postoperative satisfaction in elective caesarean section: a prospective randomised trial. Anaesth Intensive Care 2013; 41:774.
  78. Uzbeck M, Quinn C, Saleem I, et al. Randomised controlled trial of the effect of standard and detailed risk disclosure prior to bronchoscopy on peri-procedure anxiety and satisfaction. Thorax 2009; 64:224.
  79. Freeman-Wang T, Walker P, Linehan J, et al. Anxiety levels in women attending colposcopy clinics for treatment for cervical intraepithelial neoplasia: a randomised trial of written and video information. BJOG 2001; 108:482.
  80. El-Hassan H, McKeown K, Muller AF. Clinical trial: music reduces anxiety levels in patients attending for endoscopy. Aliment Pharmacol Ther 2009; 30:718.
  81. Hayes A, Buffum M, Lanier E, et al. A music intervention to reduce anxiety prior to gastrointestinal procedures. Gastroenterol Nurs 2003; 26:145.
  82. López-Cepero Andrada JM, Amaya Vidal A, Castro Aguilar-Tablada T, et al. Anxiety during the performance of colonoscopies: modification using music therapy. Eur J Gastroenterol Hepatol 2004; 16:1381.
  83. Chan YM, Lee PW, Ng TY, et al. The use of music to reduce anxiety for patients undergoing colposcopy: a randomized trial. Gynecol Oncol 2003; 91:213.
  84. Yeo JK, Cho DY, Oh MM, et al. Listening to music during cystoscopy decreases anxiety, pain, and dissatisfaction in patients: a pilot randomized controlled trial. J Endourol 2013; 27:459.
  85. Li Y, Dong Y. Preoperative music intervention for patients undergoing cesarean delivery. Int J Gynaecol Obstet 2012; 119:81.
  86. Binns-Turner PG, Wilson LL, Pryor ER, et al. Perioperative music and its effects on anxiety, hemodynamics, and pain in women undergoing mastectomy. AANA J 2011; 79:S21.
  87. Zengin S, Kabul S, Al B, et al. Effects of music therapy on pain and anxiety in patients undergoing port catheter placement procedure. Complement Ther Med 2013; 21:689.
  88. Ni CH, Tsai WH, Lee LM, et al. Minimising preoperative anxiety with music for day surgery patients - a randomised clinical trial. J Clin Nurs 2012; 21:620.
  89. Zhang ZS, Wang XL, Xu CL, et al. Music reduces panic: an initial study of listening to preferred music improves male patient discomfort and anxiety during flexible cystoscopy. J Endourol 2014; 28:739.
  90. Angioli R, De Cicco Nardone C, Plotti F, et al. Use of music to reduce anxiety during office hysteroscopy: prospective randomized trial. J Minim Invasive Gynecol 2014; 21:454.
  91. Lee KC, Chao YH, Yiin JJ, et al. Evidence that music listening reduces preoperative patients' anxiety. Biol Res Nurs 2012; 14:78.
  92. Stermer E, Levy N, Beny A, et al. Ambience in the endoscopy room has little effect on patients. J Clin Gastroenterol 1998; 26:256.
  93. Walsh JC, Curtis R, Mylotte M. Anxiety levels in women attending a colposcopy clinic: a randomised trial of an educational intervention using video colposcopy. Patient Educ Couns 2004; 55:247.
  94. Hosseini M, Salehi A, Fallahi Khoshknab M, et al. The effect of a preoperative spiritual/religious intervention on anxiety in Shia Muslim patients undergoing coronary artery bypass graft surgery: a randomized controlled trial. J Holist Nurs 2013; 31:164.