Introduction: Blood- and injection phobia is an anxiety disorder with a prevalence of approximately 3-5% in the general population. The etiology is often a combination of genetic factors and a conditioning experience. The symptoms of blood- and injection phobia are dizziness, confusion, nausea, epigastria discomfort, anxiety and sometimes panic attacks when receiving injections, seeing blood or having a blood sample taken. Unique for this specific phobia is the high probability of fainting when the phobic situation is encountered if there is no possibility to escape or to avoid the stimuli. During pregnancy and labor, women with blood- and injection phobia are exposed to most of their fears and they therefore find themselves in anxiety-ridden situations. Stress and anxiety during pregnancy is known to be risk factors for adverse obstetric and neonatal outcomes. Studies have shown an altered hypothalamic-adrenal-pituitary axis in women with stress or/and anxiety during pregnancy and increased cortisol concentrations can imply negative consequences for the unborn child. Cognitive behavioral therapy (CBT) is known to be effective in treating specific phobias such as blood- and injection phobia. Aim: The prevalence, obstetric and neonatal consequences, impact on the hypothalamic adrenal-pituitary axis and treatment aspects of blood- and injection phobia in a pregnant population have not been investigated before. The aims of this thesis were to study each of these phenomena. Material and methods: During 2005 a total of 1606 pregnant women were approached at their first visit in an antenatal care clinic in the southeast region in Sweden. They were asked to complete the “Injection Phobia Scale-Anxiety” questionnaire. All women who scored ≥ 20 on the “Injection Phobia Scale-Anxiety” questionnaire (N=347), were interviewed and either diagnosed for blood- and injection phobia or dismissed. In total, 110 women were diagnosed as having blood- and injection phobia. Among the women who scored <20 on the “Injection Phobia Scale-Anxiety” questionnaire, 220 women were randomly stratified for age and parity as a control group. The women in the study population answered questionnaires in gestational week 25, 36 and postpartum concerning symptoms of blood- and injection phobia, depression and anxiety. Samples of cortisol in the saliva were collected in the morning and evening in gestational week 25 and 36 in both groups of pregnant women. The medical records from the antenatal care visits, the delivery and postpartum check-up was used to collect data of importance. A treatment study was conducted using a two session cognitive behavioral therapy in a group of pregnant woman with blood- and injection phobia. Results: The prevalence of blood- and injection phobia is 7 % in a pregnant population. Pregnant women with blood- and injection phobia stated more often a fear of childbirth (p<0.001) and were more frequently delivered by elective cesarean section (p=0.032). The incidence of having a baby diagnosed with a complication (p=0.001) was also higher among these women. The women with blood- and injection phobia had increased cortisol concentrations in the saliva compared to the healthy controls (p=0.014). A two-session CBT in group for pregnant women with blood- and injection phobia reduced phobic (p<0.001) anxiety (p<0.001) and depressive (p<0.001) symptoms during pregnancy. Conclusions: Blood- and injection phobia during pregnancy is rather common. Pregnant women with blood- and injection phobia are more likely to be delivered by elective cesarean section and having a baby born with a complication compared to women not suffering from this specific phobia. Untreated blood- and injection phobia during pregnancy increases salivary cortisol concentrations indicating an altered hypothalamic-adrenal-pituitary axis during these weeks of pregnancy. To enhance psychological well being in pregnant women with blood- and injection phobia a two-session program providing CBT for groups of pregnant women is valuable and produces stable results for at least 3 months after delivery.

Injection phobia is a prevalent anxiety disorder that puts youth at risk for adverse health outcomes. There is a need to develop accessible, timely, and effective treatments for injection phobia. Combining telehealth and intensive treatment approaches is a promising new direction for the treatment of youth injection phobia as it could address common accessibility barriers and help youth return to healthier functioning more quickly. In addition to testing a telehealth-delivered, intensive treatment for youth injection phobia, this dissertation project includes a critical review of measures of cognitive biases, which have been proposed to contribute to and maintain anxiety disorders. Chapter 1 presents the results of a novel telehealth-delivered, intensive treatment for youth injection phobia. The study used a multiple baseline design to investigate the acceptability, feasibility, and preliminary efficacy of this intervention in 11 youth with injection phobia (Mage=12.5). I hypothesized that the intervention would be rated as feasible and acceptable, and that youth participants would show significant reductions in injection fear and avoidance following treatment. These hypotheses were supported by the study’s results. Chapter 2 is a case series report that describes how the novel telehealth-delivered, intensive treatment for youth injection phobia was tailored to address factors (i.e., attentional difficulties low motivation, and high clinical acuity) that can interfere with the appropriateness and efficacy of telehealth treatment. Clinical implications are then discussed. Chapter 3 provides a comprehensive review of measures commonly utilized to quantify attentional, interpretation, and memory biases in anxious samples. In this review, I highlight how the psychometric and theoretical shortcomings of current measures limit the field’s ability to accurately capture cognitive biases, and in turn, the nuanced relationship between cognitive biases and anxiety symptoms. I also detail specific measurement considerations that can help guide future research focused on anxiety-linked cognitive biases. Overall, this project 1) demonstrates that a combined telehealth-delivered and intensive treatment approach appears to be a viable and effective delivery format for treating youth injection phobia and 2) provides recommendations for how to improve the measurement of cognitive biases so as to enhance our understanding of the etiology of youth anxiety disorders. / 2026-10-02