Is Fear of Colonoscopy Pain a Self-fulfilling Prophesy?

Study sheds light on this sometimes traumatic experience

Cleveland Clinic’s James Church, MD, has long devoted himself to making colonoscopy a gentle process, as free as possible from pain, fear and anxiety. Yet when a patient hears “horror stories” from the next-door neighbor or has had their own bad past experience, the odds are weighted against the desirable calm that makes a colonoscopy go most smoothly.

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Patients weigh in

To define and measure levels of fear and anxiety in his patients, Dr. Church designed and disseminated a questionnaire to shed light on what is, for some, a traumatic experience. What he found reinforced some of the expected reasons for patients’ anxiety, but also revealed new insights about their psychological state.

One hundred nineteen patients completed the questionnaire. Only a small number (11) were first-timers to colonoscopy. While the number of patients who experienced either great fear or anxiety was relatively small, those who were fearful reported higher pain levels during the procedure than the average patient (4.7 vs. 2.7 on a 10-point scale). The correlation between anxiety and reports of pain in this study was not significant.

The leading reason for fear and anxiety in the 119 patients surveyed was concern about what would be found during the procedure. Close behind was expectation of pain.

Why pain matters

Beyond the discomfort of these emotions, why does patient fear and anxiety matter? Dr. Church explains that “patients who anticipate a more painful experience actually have more pain and need more sedation to make the procedure comfortable and efficacious.” A relaxed colon is more supple and navigable. Fearful patients tend to brace themselves against the movement of the scope, causing muscle resistance that makes the process longer and more difficult for the colonoscopist and patient alike.

Keeping perspective with reality and humor

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Dr. Church suggests that the physician’s sensitivity to fear and anxiety can guide some simple practices that, in his experience, make a profound difference. “With routine colonoscopies, I spend some time a couple of weeks ahead to point out that it is very, very unlikely we will find a cancer. I tell patients that we do a colonoscopy mostly to find polyps, which we can remove and thereby lower the likelihood of a future cancer.”

He also sends patients home with a “blurb” he wrote about preparations and expectations. It concludes with a promise to “treat your colon the same way I would treat my own.” This paper includes an illustration of the colon as a golf course, complete with doglegs, water hazards, sand traps and trees that mirror anatomical features of the colon. “This field is rife with natural opportunities to share humor. Where appropriate, I capitalize on them to put patients at ease.”

“I also create as calming an atmosphere in the procedure room as possible by playing contemporary soft rock music and working with my staff on how we choose our words. “‘Pain’ is an emotionally charged word. By using it, we can even create pain that wouldn’t be there otherwise. Rather than saying, “Hold on ― the pain will get better soon,” we might say, “turning a corner now” or “just another minute here.”

Dr. Church’s survey results demonstrate that anxiety about the procedure, fortunately, does not affect willingness to have an exam in the future. Following presentation of the study at the American Society of Colon and Rectal Surgeons recent annual meeting, he performed some additional analyses to determine whether high anxiety about colonoscopy correlated strongly with symptoms of general anxiety. As he expected, he found a strong correlation.

“The biggest takeaway from the study, however,” Dr. Church explains, “is that while it is fairly normal for patients, whether typically anxious or not, to feel anxious about colonoscopies, real fear is not normal. Not only do we not want patients to suffer with fear, but it can impact the procedure and the outcomes. Doing what we can ahead of time to allay their fears is well worth the effort.”


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Your patients are never going to enjoy a colonoscopy. But doing what they can to allay their fears is well worth the effort. James Church, MD, explains.


Why managing patients’ fear of colonoscopy is well worth the effort

Study examines whether fear of colonoscopy pain is a self-fulfilling prophesy