Blood Phobics Research Articles

Is this blood? An ERP study on the visual identification of red fluids in patients with blood phobia

Blood can be easily recognized in situations involving injury. However, very little is known about the ability of humans to identify blood without such context information. We investigated the blood detection capacity and associated electrocortical correlates (event-related potentials) in 20 women with blood phobia and 20 non-phobic females. The participants viewed images depicting droplets of pig blood, and water with pink or red food coloring. They were asked to decide, whether the pictures showed real blood or not. Blood provoked enhanced P100 amplitudes (90–140 ms) in blood phobics. Late positivity (P300: 340–500 ms) as well as classification accuracy did not differ between the groups. However, blood elicited a general P300 enhancement (relative to red and pink fluids) possibly reflecting elevated visual attention to blood as a general characteristic in humans. The P100 augmentation in blood phobics very likely reflects enhanced early selective attention. Patients with BII phobia showed prioritized visual processing of blood without having to rely on contextual information.

Emotional sensitization highlights the attentional bias in blood–injection–injury phobics: An ERP study

The presence of an attentional bias towards disorder-related stimuli has not been consistently demonstrated in blood phobics. The present study was aimed at investigating whether or not an attentional bias, as measured by event-related potentials (ERPs), could be highlighted in blood phobics by inducing cognitive–emotional sensitization through the repetitive presentation of different disorder-related pictures. The mean amplitudes of the N100, P200, P300 and late positive potentials to picture onset were assessed along with subjective ratings of valence and arousal in 13 blood phobics and 12 healthy controls. Blood phobics, but not controls, showed a linear increase of subjective arousal over time, suggesting that cognitive–emotional sensitization did occur. The analysis of cortical responses showed larger N100 and smaller late positive potentials in phobics than in controls in response to mutilations. These findings suggest that cognitive–emotional sensitization induced an attentional bias in blood phobics during picture viewing, involving early selective encoding and late cognitive avoidance of disorder-related stimuli depicting mutilations.

Lack of startle blink potentiation to mutilation pictures irrespective of fearfulness

Previous research has shown that in healthy individuals blood-related stimuli elicit a distinctive autonomic response pattern and heightened processing as compared with other unpleasant and arousing visual stimuli. In addition, growing evidence suggests that information processing of disorder-related stimuli is also different in blood phobia as compared with other specific phobias. In the present study, the magnitude of the startle eyeblink reflex elicited during the viewing of mutilation, human attack, erotica and neutral pictures was recorded in 22 blood phobics and 25 healthy controls. Startle eyeblink responses were measured at 300, 1500, 3500 and 4500-ms time intervals after picture onset in order to assess the attentional/affective modulation and its temporal course. Reliable startle inhibition to erotic pictures and startle potentiation to human attack scenes were found relative to neutral pictures. However, while both groups rated mutilations as the most unpleasant and arousing content, no blink facilitation relative to neutral contents was found at either early or late probe times. Crucially, such effect occurred independently of fear levels, as no difference between phobics and controls was found in the size of the startle blinks elicited throughout the viewing of blood pictures.

The neural correlates of attentional bias in blood phobia as revealed by the N2pc.

In the literature, a lack of attentional bias in blood phobia has been reported, using both behavioral and ERP measures. However, in the tasks employed so far, attentional resources to single stimuli, rather than attentional selection, were evaluated. The present study investigated whether in blood phobics disorder-relevant pictures can capture visuo-spatial attention when paired with neutral or non-specific unpleasant pictures (attack), and participants have to focus on a visual detection task. The N2pc component of the ERPs was measured as an index of spatial attentional selection. Results showed that in blood phobics, but not in controls, injuries elicited a larger early N2pc than attack pictures when paired with neutral material. Moreover, only in blood phobics a reliable N2pc to injury-attack pairs was found. The late N2pc reversal to injury pictures suggests that early orienting to phobic cues was followed by cognitive avoidance.

Cardiovascular dynamics in blood phobia: Evidence for a key role of sympathetic activity in vulnerability to syncope

This study was aimed at clarifying the mechanism predisposing people with blood phobia to syncope by investigating the complete hemodynamic response pattern and the underlying autonomic control. Blood phobics and controls were shown 3 film-clips: phobia-related, phobia-unrelated, and neutral. Hemodynamic responses were recorded using impedance cardiography and Finapres. Preejection period and respiratory sinus arrhythmia were employed as indices of cardiac sympathetic and parasympathetic activity. Self-ratings of emotion were also collected. Blood phobics displayed global heart rate and cardiac output increases to the phobic film, mediated by augmented cardiac sympathetic activity. Systolic blood pressure and total peripheral resistance markedly declined, with no evidence of diphasic reaction or parasympathetic activation. An impaired vasomotor response under sympathetic control might be the key mechanism underlying the phobic dysfunctional response.

Event-related potentials and visual avoidance in blood phobics: is there any attentional bias?

The possible presence of processing biases for threat-relevant information in blood-injection-injury phobia has been largely neglected in the literature. This issue was addressed by recording the late components (P300 and slow waves) of event-related potentials (ERPs) in the context of affective picture perception, as indicators of processing resources allocation. Blood phobics and healthy controls were shown threat-relevant, emotional threat-irrelevant, and neutral pictures. Free viewing time (VT) was measured as an index of voluntary visual avoidance, along with self-reports of pleasantness and arousal. No group differences as a function of picture content emerged for ERPs. Blood phobics spent less time viewing mutilations than did controls, but they did not show a clear-cut visual avoidance. As expected, individuals with phobias rated blood-related pictures as more unpleasant and arousing relative to controls. ERP results are in line with the limited behavioral data in the literature in demonstrating that blood phobics do not show an attentional bias toward threat-relevant stimuli.

End-Tidal pCO2 in Blood Phobics During Viewing of Emotion- and Disease-Related Films

Many patients with blood, injection, and injury (BII) phobia respond to specific stimuli with vasovagal dysregulation and fainting. However, little is known about the role of hyperventilation in the distress of these patients. Hyperventilation, defined by subnormal arterial pCO2 levels, induces anxiety and may promote the development of fainting. We studied end-tidal pCO2 in 12 patients with BII phobia and 14 nonanxious controls during presentation of emotional films. Ten film clips were shown, two in each of 5 categories: pleasant, unpleasant, neutral, BII-related (surgery), and asthma-related (portraying labored breathing). For each subject, two subsets were created, each containing one clip from each category. For one subset, the instruction was simply to view the film, and for the other subset, to view the film while tensing the leg muscles. PCO2, heart rate, blood pressure, and leg electromyogram were recorded continuously during viewing, and self-report of symptoms and emotion was collected after each film. Patients reported the greatest anxiety and disgust during surgery films. PCO2 was relatively stable throughout all categories except surgery films, during which minima were below 30 mm Hg, indicating significant hypocapnia. Cardiovascular variables suggested biphasic patterns in two patients with BII phobia. These patients, together with one additional patient and one control who were close to fainting after or during one surgery film, also showed a marked fall in pCO2) Leg muscle tension raised heart rate and systolic blood pressure for all films, but was not related to near-fainting or endurance in surgery film viewing. Hyperventilation is part of the fear response of patients with BII phobia, but was transitory in experimental fear induction using surgery films. Its role in real-life exposure and fainting deserves further study.

Blood phobia and spider phobia: two specific phobias with different autonomic cardiac modulations

Cardiac reactions to two fear-related and one control film were compared in individuals high in spider or blood/injury fear. Twelve subjects in each phobic group were selected on the basis of their scores in the Spider or Mutilation Questionnaires and a semi-structured interview. Cardiac responses and self-reported affective ratings to the films were investigated. Sympathetic and parasympathetic cardiac influences were indexed by T-wave amplitude and respiratory sinus arrhythmia measured during film viewing. Basal parasympathetic cardiac control was also assessed during a paced breathing task. Results indicate differential autonomic modulation of cardiac responses for blood and spider phobics. Although each group reacted with marked cardiac activation to its feared stimulus, a sympathetic increase followed by withdrawal over time was found in blood phobics. Greater vagal tone at rest was present in blood phobics compared with spider phobics.

The Diphasic Reaction in Blood Phobic Situations: Individually or Stimulus Bound?

When a person suffering from blood phobia is confronted with blood-injury stimuli there is a unique, so-called diphasic reaction. First, there is an increase in heart rate and blood pressure, followed by a rapid decrease, often leading to the person fainting. The purpose of the present study was to determine whether this reaction is situationally or individually bound. The study included 16 blood phobics and 16 control subjects (blood donors). The two groups of subjects were exposed to a film about thoracic operations, and two different stress tests, during which heart rate and blood pressure were measured. The results showed that only the blood phobics had a diphasic reaction and only when exposed to the blood-injury stimuli. In the stress tests both groups reacted with increases in both heart rate and blood pressure during the stress phases, returning to baseline during the rest phases. The conclusion that can be drawn is that the diphasic reaction is determined both situationally and individually since it only occurs in blood phobics, and only when confronted with blood-injury stimuli.

Anxiety and autonomic flexibility: a cardiovascular approach

Autonomic characteristics of panickers, blood phobics, and nonanxious controls were compared with a variety of cardiovascular measures, including spectral analysis of the cardiac inter-beat interval time series (derived from the electrocardiogram). Responses to laboratory stressors (shock avoidance and cold face stress) of 16 participants who reported recent occurrences of frequent severe panic attacks, 15 participants who reported strong somatic reactions and fainting to the sight of blood, and 15 controls, were recorded. Results suggested distinct autonomic patterns among the three groups. Across conditions, panickers displayed the highest heart rates (HR) coupled with the least HR variability, which indicates low levels of cardiac vagal tone. Blood phobics showed more vagally mediated HR variability than panickers, with a significant association between cardiac rate and mean arterial pressure. Controls generally showed the most HR variability and `spectral reserve' (a quality that indicates flexible responsivity). Results are discussed in the context of traditional models of anxiety and autonomic activity in contrast to contemporary notions of stability and change in biological systems.

The Council on National Affairs

Back to table of contents Previous article Next article ArticleNo AccessThe Council on National AffairsTerry S. SteinTerry S. SteinSearch for more papers by this authorPublished Online:1 Apr 2006https://doi.org/10.1176/ajp.152.2.317AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail PDFThis content is only available as a PDF. Access content To read the fulltext, please use one of the options below to sign in or purchase access. Personal login Institutional Login Sign in via OpenAthens Purchase Save for later Item saved, go to cart PPV Articles - American Journal of Psychiatry $35.00 Add to cart PPV Articles - American Journal of Psychiatry Checkout Please login/register if you wish to pair your device and check access availability. Not a subscriber? Subscribe Now / Learn More PsychiatryOnline subscription options offer access to the DSM-5 library, books, journals, CME, and patient resources. This all-in-one virtual library provides psychiatrists and mental health professionals with key resources for diagnosis, treatment, research, and professional development. Need more help? PsychiatryOnline Customer Service may be reached by emailing [email protected] or by calling 800-368-5777 (in the U.S.) or 703-907-7322 (outside the U.S.). FiguresReferencesCited byDetailsCited bySleep disturbance in PTSD and other anxiety-related disorders: an updated review of clinical features, physiological characteristics, and psychological and neurobiological mechanisms23 August 2019 | Neuropsychopharmacology, Vol. 45, No. 1Sleep in Psychiatric Disorders3 May 2017Current Psychiatry Reports, Vol. 14, No. 5, Vol. 2Expert Review of Neurotherapeutics, Vol. 9, No. 2Psychosomatic Medicine, Vol. 68, No. 4End-Tidal pCO2 in Blood Phobics During Viewing of Emotion- and Disease-Related FilmsPsychosomatic Medicine, Vol. 67, No. 4International Review of Psychiatry, Vol. 17, No. 4Neurotic, stress-related and somatoform disorders11 September 2013Depression and Anxiety, Vol. 18, No. 4Depression and Anxiety, Vol. 16, No. 2The Journal of Nervous and Mental Disease, Vol. 190, No. 9Depression and Anxiety, Vol. 14, No. 4Psychosomatic Medicine, Vol. 63, No. 4Depression and Anxiety, Vol. 11, No. 1Depression and Anxiety, Vol. 12, No. 2Depression and Anxiety, Vol. 12, No. 2Panic Disorder Subtypes: Differential Responses to CO2 ChallengeBengi Biber, M.D., and Tunç Alkln, M.D.1 May 1999 | American Journal of Psychiatry, Vol. 156, No. 5Depression and Anxiety, Vol. 9, No. 3Respiratory Psychophysiology of Panic Disorder: Three Respiratory Challenges in 98 SubjectsLaszlo A. Papp, M.D., Jose M. Martinez, M.A., Donald F. Klein, M.D., Jeremy D. Coplan, M.D., Robert G. Norman, M.S., Randolph Cole, M.D., Marybeth J. de Jesus, B.A., Donald Ross, Ph.D., Raymond Goetz, Ph.D., and Jack M. Gorman, M.D.15 January 2015 | American Journal of Psychiatry, Vol. 154, No. 11Hyperventilation and panic attacks1 April 2006 | American Journal of Psychiatry, Vol. 153, No. 4Current Opinion in Psychiatry, Vol. 9, No. 2Psychosomatic Medicine, Vol. 58, No. 4 Volume 152Issue 2 February 1995Pages 317-321 Metrics PDF download History Published online 1 April 2006 Published in print 1 February 1995

Autonomic characteristics of nonclinical panic and blood phobia

Autonomic characteristics of nonclinical panic and blood phobia were compared using spectral analysis of the electrocardiogram (EKG), as well as more conventional cardiovascular measures. The cardiovascular responses of 11 subjects who reported recent occureence of frequent severe panic attacks, and 10 subjects who reported intense somatic reactions to the sight of blood (including episodes of syncope) were recorded during a variety of laboratory tasks (quiet rest, reaction time/shock avoidance, face immersion, and combined reaction time/face immersion). Results suggest distinct autonomic patterns in the groups. Panickers showed (a) higher heart rate and reduced heart-rate variability (b) aberrant associations among cardiovascular measures, and (c) dominant sympathetic control of heart rate coupled with diminished vagal tone. Blood phobics generally displayed an opposite pattern. The relevance of these findings to the etiology of panic and blood phobia, as well as to biological models of anxiety disorders in general, is discussed.

Blood phobics and nonphobics: Psychological differences and affect during exposure

This study compared psychological dimensions of blood phobics and nonphobic controls, examined affect in response to phobic and neutral stimuli, and investigated the relationship between reported feelings of faintness and blood pressure. Blood phobics (24 adults with extreme Mutilation Questionnaire scores) and 24 nonphobics completed several psychological measures and viewed one of two 60 sec surgery scenes and a 60 sec neutral scene in counterbalanced order. Subjective, psychophysiologic, and motoric measures of affect were assessed. On questionnaires, phobics reported greater anxiety sensitivity, empathic distress, fear and insecurity, and nightmares, but no difference in autonomic arousal, muscle tension, motion sickness, or other empathy domains. During surgery scenes, phobics had more negative affect than controls; however, phobics were more anxious during only one of the two surgeries, and often only when the surgery was presented prior to the neutral scene. Fainting did not occur, and self-reported feelings of faintness were unrelated to blood pressure changes. The findings highlight the lack of information on blood phobic stimulus properties, fainting's relationship to self-reports and blood pressure, and the specific emotion experienced in blood phobia.

Acquisition of blood and injection phobia and anxiety response patterns in clinical patients

The ways in which blood phobics (N = 81) and injection phobics (N = 56) had acquired their phobias were retrospectively investigated. The patients were required to answer a questionnaire concerning: (a) the origin of the phobia, with items relevant for conditioning experiences, vicarious experiences and experiences of negative information/instruction; (b) physiological reactions; (c) anticipatory anxiety; and (d) negative thoughts while in the phobic situation. In addition background data on marital and occupational status, family history of phobia, fainting history, and severity of the phobia were obtained. Furthermore, the patients' behavioral, physiological, and cognitive-subjective reactions during the behavioral test were assessed. The results showed that a majority (52%) of the patients attributed the onset of their phobias to conditioning experiences, while 24% recalled vicarious experiences, 7% instruction/ information and 17% could not remember any specific onset circumstances. There was no significant relationship between ways of acquisition and anxiety components, nor did conditioning and indirectly acquired phobias differ in severity.

Ways of acquiring phobias and outcome of behavioral treatments

The way of acquisition of phobias was studied in relation to different behavioral treatments for phobias. Ss ( N = 183) were clinical patients belonging to six different phobic groups (agoraphobics, claustrophobics, social phobics, animal phobics, blood phobics and dental phobics), and the treatments were categorized as behaviorally focused (exposure in vivo and social-skills training), physiologically focused (systematic desensitization and applied relaxation) and cognitively focused (self-instruction training and fading). Results showed that both for patients with direct conditioning experiences and indirect acquisition those treated with behavioral and physiological methods improved more than those receiving cognitive methods when looking at the change-score data. Regarding the proportion of clinically improved patients there was no difference between treatments among the Ss with a background of conditioning experiences. In the group with indirect acquisition, on the other hand, the cognitive methods were more effective.

Acquisition of blood and dental phobia and anxiety response patterns in clinical patients

The ways in which blood phobics and dental phobics ( N = 73) had acquired their phobias were retrospectively investigated in the present study. The patients were requested to answer a questionnaire concerning: (a) the origin of the phobia, with items relevant for conditioning experiences, vicarious experiences and experiences of negative information/instruction; (b) physiological reactions; (c) anticipatory anxiety; and (d) negative thoughts while in the phobic situation. In addition background data on marital and occupational status, family history of phobia, medication, generalized anxiety and severity of the phobia were obtained. Furthermore the patients' behavioral, physiological and cognitive-subjective reactions during a behavioral test were assessed. The results showed that a large majority (61%) of the patients attributed the onset of their phobias to conditioning experiences, while 18% recalled vicarious experiences. 7% instruction/information and 14% could not remember any specific onset circumstances, there was no significant relationship between ways of acquisition and anxiety components, nor did conditioning and indirectly acquired phobias differ in severity.

Physiological responses in blood phobics

Eighteen patients with blood phobia were shown a film of thoracic operations containing large amounts of blood. Their heart rate (HR) and blood pressure (BP) were measured continuously before, during and after the watching of the film. The group data showed a diphasic response; an increase in HR and BP from baseline to the beginning of the film, and then a sharp drop in these parameters with the lowest values 4 min after the film was turned off. Individual data from 5 patients who fainted or were on the edge of doing so, showed massive bradycardia or drop in BP or both. In all of these patients at least one (range 1–33) 5-sec period of asystole was recorded. Possible theoretical explanations for this characteristic response pattern are discussed.