The psychophysiology of blood-injection-injury phobia: looking beyond the diphasic response paradigm

Abstract

Blood-injection-injury (BII) phobia is an anxiety disorder that may be accompanied by vasovagal fainting during confrontation with the feared stimuli. The underlying pattern of autonomic regulation has been characterized as a diphasic response, with initial increases in heart rate and blood pressure that are typical of a fight-flight response, and subsequent drops in blood pressure and/or heart rate that may precipitate vasovagal fainting. Tensing skeletal muscles of the arms, legs, and trunk (applied tension) has been proposed as a technique to cope with this dysregulation. This review critically examines the empirical basis for the diphasic response and its treatment by applied tension in BII phobia. An alternative perspective on the psychophysiology of BII phobia and vasovagal fainting is offered by focusing on hypocapnia that leads to cerebral blood flow reductions, a perspective supported by research on neurocardiogenic and orthostatically-induced syncope. The evidence may indicate a role for respiration-focused coping techniques in BII phobia.

Figure 1.

Heart rate and blood pressure of one BII-phobia patient during exposure to a neutral (upper panel), anger (center panel), and surgery (lower panel) film; the patient showed presyncopal symptoms and terminated the surgery film prematurely after 219 s, but remained in the sitting position during the subsequent 5-min recovery period.

Figure 2.

Heart rate and blood pressure of one BII-phobia patient during exposure to a neutral (upper panel), anger (center panel), and surgery (lower panel) film; the patient showed presyncopal symptoms, but viewed the complete film and remained in the sitting position during the subsequent 5-min recovery period.

Figure 3.

Heart rate and blood pressure of one BII-phobia patient during exposure to a neutral (upper panel), anger (center panel), and surgery (lower panel) film; the patient showed presyncopal symptoms and terminated the surgery film prematurely after 258 s; the ensuing posture change to the lying position rendered the Finapres blood pressure recordings uninterpretable during recovery from the surgery film.