Journal of Anxiety Disorders 24 (2010) 941–945

Contents lists available at ScienceDirect

Journal of Anxiety Disorders

Disgust, anxiety, and vasovagal syncope sensations: A comparison of

injection-fearful and nonfearful blood donors
Megan A. Viar ∗ , Erin N. Etzel, Bethany G. Ciesielski, Bunmi O. Olatunji
Department of Psychology, Vanderbilt University, 312 Wilson Hall, 111 21st Avenue South, Nashville, TN 37203, USA

a r t i c l e i n f o a b s t r a c t

Article history: Although research has implicated disgust in the fainting response observed in blood-injection-injury
Received 18 February 2010 (BII) phobia, this finding has not been consistently observed in the literature. The present study further
Received in revised form 19 June 2010 examines the relationship between disgust and fainting symptoms among injection-fearful (n = 108) and
Accepted 21 June 2010
nonfearful (n = 338) blood donors. Volunteers from community blood drives provided pre-donation levels
of anxiety and disgust towards giving blood and completed a standardized measure of vasovagal reactions
Keywords:
(fainting) to blood donation after giving blood. As predicted, injection-fearful participants reported sig-
Blood
nificantly more pre-donation anxiety and disgust compared to nonfearful participants. Injection-fearful
Disgust
Anxiety
donors also reported experiencing more fainting symptoms during blood donation and found the dona-
Fainting tion experience more unpleasant than did nonfearful participants. Although pre-donation disgust and
Donation anxiety levels each uniquely predicted fainting symptoms among nonfearful donors, only pre-donation
Injections anxiety uniquely predicted fainting symptoms among injection-fearful donors. Implications of these
findings for conceptualizing the disgust–faint relationship in BII phobia are discussed.
Published by Elsevier Ltd.

Blood-injection-injury (BII) phobia is characterized by a persis-
tent, excessive, and irrational fear at the sight or anticipation of
blood, wounds, syringes, injuries, mutilation, and similar stimuli
(DSM-IV, American Psychiatric Association, 2000; Marks, 1988).
BII phobia has a lifetime prevalence rate of 3.5% and an early
age of onset at around 5.5 years (DSM-IV, American Psychiatric
Association, 2000). It is also the second most common specific pho-
bia for which people seek treatment (Kleinknecht & Thorndike,
1990). BII phobia may also be chronic in the absence of treatment
(Marks, 1988). In severe cases, phobic individuals may delay or
even avoid seeking necessary medical care despite negative health
consequences (Kleinknecht & Lenz, 1989; Page, 1998).
BII phobia is unique from other phobic disorders in that
approximately 75–80% of those affected have a distinct fainting
response (or vasovagal syncope) during exposure to phobic-
relevant stimuli (Kleinknecht & Lenz, 1989; Meade, France, &
Peterson, 1996; Olatunji, Connolly, & David, 2008; Page, 1994)
which may be partially genetic (Page & Martin, 1998). Several
studies have attempted to delineate the physiological profile of
this unique fainting response in BII phobia. Such research sug-
gests that fainting in BII phobia is marked by a diphasic response
that involves two successive responses with opposing direc-
tions of activity (Graham, Kabler, & Lunsford, 1961). The initial
∗ Corresponding author. Tel.: +1 615 343 5476; fax: +1 615 343 8449.
E-mail address: megan.a.viar@vanderbilt.edu (M.A. Viar).
phase of this diphasic response is characterized by an increase in
sympathetic nervous system activity (i.e., increased heart rate),
which has been attributed to the experience of fear and anxi-
ety (e.g., Curtis & Thyer, 1983). The fainting response is observed
during the second phase where a surge in parasympathetic ner-
vous system activity occurs, leading to a rapid decrease in blood
pressure (Page, 2003).
Additionally, several studies attempting to delineate the emo-
tional correlates of BII phobia are beginning to shed light on
the basic mechanisms behind this unique fainting response.
Kleinknecht, Kleinknecht, and Thorndike (1997) found that highly
fearful individuals report the greatest likelihood of fainting during
exposure to BII-related stimuli. Although BII stimuli produce a reli-
able fear response for phobic individuals (Kleinknecht, 1987, 1988),
they have also been shown to elicit disgust reactions (Olatunji,
Lohr, Sawchuk, & Westendorf, 2005; Page, 2003). For example,
related research has found that while BII phobics respond with
both fear and disgust when exposed to images of threat-relevant
stimuli, disgust is the dominant emotional response (Sawchuk,
Lohr, Westendorf, Menuier, & Tolin, 2002; Tolin, Lohr, Sawchuk,
& Lee, 1997). Furthermore, individuals with BII phobia, compared
to controls, often present with a markedly heightened ‘disgust
sensitivity’, the propensity towards experiencing disgust (Olatunji,
Arrindell, & Lohr, 2005; Olatunji, Lohr, Smits, Sawchuk, & Patten,
2009). Given that the experience of disgust is often character-
ized by parasympathetic activity (Levenson, 1992), one hypothesis
is that the activation of the parasympathetic system that is

0887-6185/$ – see front matter. Published by Elsevier Ltd.

doi:10.1016/j.janxdis.2010.06.021
942 M.A. Viar et al. / Journal of Anxiety Disorders 24 (2010) 941–945

responsible for the unique fainting response in BII phobia may be Table 1
Descriptive statistics for injection-fearful and nonfearful participants.
attributed to disgust (Page, 1994).
Although there are intuitive reasons for implicating disgust Variable Injection-fearful Injection-nonfearful
in the fainting response in BII phobia, empirical evidence sup- (n = 108) (n = 338)
porting this observation has been mixed. For example, Hepburn Demographics
and Page (1999) found that exposure to disgust-evoking images Age* 30.41 (12.25) 37.35 (14.19)
increased symptoms of faintness to BII-related stimuli. Page (2003) Weight (lbs) 166.39 (35.64) 173.94 (39.74)
Ethnicity (% Caucasian) 80.6% 86.9%
has also shown that highly disgust sensitive individuals reported
Gender (% Female) 71.3% 61.5%
more symptoms of faintness during exposure to blood and injec- Pre-screen questions
tion stimuli compared to participants low in disgust sensitivity. Fasting (% Yes) 2.7% 1.5%
However, other research has failed to find evidence for increased Number of times donated* 2.99 (1.28) 3.42 (1.07)
parasympathetic activation among those with BII phobia or even Note. *p < .01.
an association between disgust levels and parasympathetic activa-
tion, suggesting that disgust sensitivity may not directly explain
(range = 18–80; SD = 14.05). Participants endorsing “yes” to the
the fainting response (Gerlach et al., 2006). Furthermore, descrip-
question: “Do you get nervous or afraid when receiving blood draws
tive research has shown that disgust sensitivity does not contribute
or injections?” were classified as injection-fearful and those who
unique variance to the prediction of BII-related fainting symp-
responded “no” were classified as nonfearful.
toms above the variance accounted for by fear and anxiety levels
(Olatunji, Williams, Sawchuk, & Lohr, 2006). These findings suggest
that the disgust-BII-faint relationships may be illusory and perhaps 1.2. Materials
are mediated by the covariation of disgust with fear and anxiety
(Kleinknecht et al., 1997). The Pre Donation Questionnaire (PDQ) was developed to obtain
These conflicting findings about the causal role of disgust in BII- demographic information including age, gender, weight, and eth-
related fainting highlight the need for additional research. To date, nicity. The PDQ also assessed the degree of negative affect (disgust,
this research question has largely been addressed with question- anxiety, fear, pain) expected during the blood donation experience
naire measures completed by undergraduate students (Kleinknecht on a 5-point Likert scale of “None at all” to “Extreme.”
et al., 1997; Olatunji et al., 2006) or in the experimental labo- The Blood Donation Reactions Inventory (BDRI; Meade et al.,
ratory (Exeter-Kent & Page, 2006; Page, 2003). Surprisingly, no 1996; Sauer & France, 1999) assesses subjective physiological
study to date has examined the relationship between disgust reactions to blood donation. The scale requested ratings of 11
and fainting among blood donors, where fainting is often prob- physiological reactions associated with vasovagal syncope, includ-
lematic (France, France, Roussos, & Ditto, 2004; France, Rader, & ing faintness, dizziness, weakness, facial flush, visual disturbance,
Carlson, 2005). Indeed, fainting has been posited as the great- difficulty hearing, lightheadedness, rapid or pounding heart, sweat-
est deterrent of repeat donations for new blood donors (Gorlin & ing, rapid or difficult breathing, and nausea or upset stomach.
Petersen, 2004; Newman, Ahmad, & Newman, 2004; Ownby, Kong, Responses to each item were rated on a 6-point Likert scale of “0”
Watanbe, Tu, & Nass, 1999). Therefore, the present study further (Not at all) to “5” (To an extreme degree). The BDRI had an alpha
examines the relationship between disgust and fainting symptoms coefficient of .93 in the present study.
among injection-fearful and nonfearful blood donors. Consistent Participants also rated how unpleasant the blood donation expe-
with prior research (Olatunji et al., 2006), it was predicted that rience was on a scale of “0” (not at all unpleasant) to “100”
disgust levels would be associated with fainting responses dur- (maximally unpleasant).
ing blood donation among injection-fearful and nonfearful donors.
However, the relationship between disgust levels and fainting 1.3. Procedure
responses during blood donation was predicted to be accounted
for by anxiety levels among injection-fearful, but not nonfearful, Volunteer blood donors were asked to complete the PDQ before
donors. These findings were hypothesized to be specific to fainting donating blood. After successfully giving blood, donors then com-
responses, not simply a generalized unpleasant reaction to blood pleted the BDRI and also indicated how unpleasant the blood
donation. donation experience was.

1. Methods
1.1. Participants
Participants were recruited from community blood drives
between February and July 2008. A total of 446 individuals volun-
teered to participate in the present study. There were 285 females
(63.9%) and 161 males (36.1%) with a joint mean age of 35.67
2. Results
2.1. Participant characteristics
The injection-fearful group consisted of 108 individuals [77
females (71.3%) and 31 males (28.7%) with a joint mean age of
30.41 (SD = 12.25)]. The nonfearful group consisted of 338 individ-
uals [208 females (61.5%) and 130 males (38.5%) with a joint mean
age of 37.35 (SD = 14.19)]. As shown in Table 1, injection-fearful

Table 2
Group means (standard deviations) of study measures among injection-fearful and nonfearful participants and the total sample.

Question/measure All participants Nonfearful Injection-fearful t d

Anxiety .74 (.85) .47 (.64) 1.58 (.89) 14.39* 1.43

Disgust .20 (.54) .10 (.38) .50 (.80) 7.01* .64
Unpleasantness 10.12 (20.48) 7.18 (18.00) 18.69 (24.59) 4.77* .53
BDRI 2.92 (6.55) 2.17 (5.91) 5.08 (7.76) 3.73* .42

Note. BDRI: Blood Donation Reactions Inventory. Cohen’s d was calculated as the difference between the mean scores in each group divided by the pooled standard deviation.
*p < .001.
 M.A. Viar et al. / Journal of Anxiety Disorders 24 (2010) 941–945 943

Table 3 Table 4
Pearson correlations of study measures among injection-fearful and nonfearful Prediction of vasovagal syncope symptoms among injection-fearful and nonfearful
participants. participants.

Question/measure 1 2 3 4 Question/measure B SE B B t

1. Anxiety – .43** .13 .40** Injection-fearful participants

2. Disgust .38** – .16 .25* Step 1
3. Unpleasantness .32** .29** – .55** Age −.09 .06 −.15 −1.51
4. BDRI .39** .35** .53** – Number of times donated −2.25 .64 −.36 −3.52**
Step 2
Note. Correlations above the diagonal are for injection-fearful participants and cor-
Anxiety 2.23 1.00 .24 2.22*
relations below the diagonal are for nonfearful participants. BDRI: Blood Donation
Disgust .85 .95 .09 .89
Reactions Inventory. *p < .05; **p < .001.
Nonfearful participants
Step 1
blood donors were significantly younger and had significantly less Age −.05 .03 −.12 −1.95*
Number of times donated −1.37 .38 −.23 −3.62**
blood donation experience.
Step 2
Anxiety 2.28 .55 .25 4.13**
2.2. Validation of group membership Disgust 3.51 .88 .24 3.98**

Note. *p < .05; **p < .001.

As shown in Table 2, injection-fearful participants expressed
the expectation to experience significantly more anxiety
A second series of hierarchical regression analyses was con-
[t(443) = 14.39, p < .001] and disgust [t(443) = 7.01, p < .001]
ducted to examine whether pre-donation disgust levels uniquely
during blood donation compared to nonfearful participants. Addi-
predicted unpleasantness of the blood donation experience among
tionally, injection-fearful participants reported significantly more
injection-fearful and nonfearful donors. In the first block, age and
fainting symptoms [t(354) = 3.73, p < .001] and found the blood
number of times donated were simultaneously entered as predic-
donation experience significantly more unpleasant [t(355) = 4.77,
tors. In the second block, pre-donation anxiety and disgust ratings
p < .001] compared to nonfearful donors. These findings confirm
were entered as predictors. Table 5 shows that pre-donation anx-
that individuals who endorsed being afraid of injections did indeed
iety and disgust did not contribute significant unique variance
report significantly more anxiety, disgust, and fainting symptoms.
for injection-fearful participants [R2 = .14, F (4, 90) = 3.51 p = .01].
These individuals also found the donation experience to be more
However, both pre-donation anxiety and disgust contributed sig-
unpleasant compared to those who did not indicate a fear of
nificant unique variance in predicting ratings of how unpleasant
injections.
the blood donation experience was for nonfearful donors [R2 = .22,
F (4, 263) = 18.56 p < .001].
2.3. Associations between anxiety, disgust, and fainting
3. Discussion
Pearson correlations revealed that anxiety and disgust rat-
ings were moderately correlated for both injection-fearful (r = .43,
Although disgust has been implicated in the unique faint-
p < .001) and nonfearful participants (r = .38, p < .001). Table 3 also
ing response observed in BII phobia (Page, 1994, 2003), findings
illustrates that, although ratings of unpleasantness regarding blood
inconsistent with this notion have been reported in the literature
donation were moderately correlated with anxiety and disgust
(Gerlach et al., 2006; Olatunji et al., 2006). Thus, the present study
for nonfearful participants (r = .32, p < .001; r = .29, p < .001, respec-
further examined the relationship between disgust and fainting
tively), neither anxiety nor disgust was significantly associated
symptoms among injection-fearful and nonfearful volunteer blood
with ratings of an unpleasant blood donation experience among
donors. As predicted, donors indicating a fear of injections reported
injection-fearful donors. Fainting symptoms experienced during
significantly more anxiety prior to giving blood compared to non-
blood donation were significantly correlated with anxiety, disgust,
fearful donors. Injection-fearful donors also reported significantly
and unpleasantness for both injection-fearful and nonfearful blood
more pre-donation disgust compared to nonfearful participants.
donors.
This finding is consistent with the well-documented notion that
disgust is a key component of the phobic structure for individuals
2.4. Incremental specificity of disgust
Table 5
A series of hierarchical multiple regression analyses was con- Prediction of unpleasantness ratings among injection-fearful and nonfearful
ducted to examine whether pre-donation disgust levels uniquely participants.
predicted fainting symptoms among injection-fearful and nonfear-
Question/measure B SE B B t
ful donors. Predictor variables were entered in two blocks. In the
first block, age and number of times donated were simultaneously Injection-fearful participants
Step 1
entered as predictors1 . In the second block, pre-donation anxi- Age −.28 .21 −.14 −1.33
ety and disgust ratings were entered as predictors. As shown in Number of times donated −5.56 2.11 −.23 −2.64*
Table 4, only pre-donation anxiety significantly explained unique Step 2
variance in predicting fainting symptoms during blood donation Anxiety −1.17 3.51 −.04 −.33
Disgust 3.43 3.26 .12 1.05
for injection-fearful blood donors [R2 = .27, F (4, 91) = 8.09, p < .001].
However, both pre-donation anxiety and disgust uniquely pre- Nonfearful participants
dicted fainting symptoms during blood donation for nonfearful Step 1
Age −.20 .08 −.16 −2.59*
blood donors [R2 = .25, F (4, 266) = 21.38 p < .001].
Number of times donated −4.90 1.13 −.27 −4.35**
Step 2
Anxiety 4.93 1.76 .17 2.80**
1
Disgust 8.89 2.75 .20 3.24**
Age and number of times donated were entered in the first block of regression
analyses due to group differences shown in Table 1. Note. * < .05; ** < .001.
944 M.A. Viar et al. / Journal of Anxiety Disorders 24 (2010) 941–945
prone to the avoidance of BII-relevant stimuli (Olatunji, Arrindell, et
al., 2005; Olatunji et al., 2009). Furthermore, injection-fearful par-
ticipants in the present study reported more fainting symptoms and
found the donation experience to be significantly more unpleasant
compared to nonfearful participants.
The present study also found that self-reported anxiety and
disgust levels prior to giving blood among injection-fearful and
nonfearful donors significantly correlate with self-reported faint-
ing symptoms while giving blood. This finding compliments
prior research showing that highly disgusted individuals report
significantly more fainting symptoms compared to individuals
experiencing no disgust during an injection (Deacon & Abramowitz,
2006). Increased anxiety and disgust prior to giving blood was
also significantly correlated with a more unpleasant donation
experience among nonfearful participants. However, this pattern
of correlations was not found among injection-fearful donors.
Moreover, fainting symptoms while giving blood were positively
correlated with unpleasantness of the donation experience for
both injection-fearful and nonfearful donors. These findings may
indicate that the unpleasantness of the donation experience for
nonfearful individuals is predicted by a variety of factors, both
internal and external (i.e., the temperature of the room, the dis-
position of the phlebotomist, etc.). However, the unpleasantness of
the donation experience for injection-fearful individuals appears
to be specifically tied to the internal sensation of fainting symp-
toms. Although demonstration of an attentional bias among those
fearful of injections has been somewhat elusive (Sawchuk, Lohr,
Lee, & Tolin, 1999), recent research suggests that injection-fearful
individuals are characterized by excessive hypervigilance (Buodo,
Peyk, Junghofer, Palomba, & Rockstroh, 2007). Such vigilance may
be reflected in a heightened awareness of internal sensations asso-
ciated with fainting.
Hierarchical regression analyses showed that while anxiety
and disgust contributed significant variance to the prediction
of vasovagal syncope symptoms for nonfearful donors, only
pre-donation anxiety contributed significant variance for injection-
fearful donors. This finding is consistent with previous research
that has shown that disgust does not contribute unique variance to
the prediction of BII-related fainting symptoms above and beyond
the variance accounted for by anxiety levels (Kleinknecht et al.,
1997; Olatunji et al., 2006). Among fearful or phobic individuals,
the association between disgust and fainting symptoms may man-
ifest as a function of the covariation of disgust with anxiety. Indeed,
Exeter-Kent and Page (2006) found fainting symptoms were expe-
rienced only among individuals sensitive to disgust and high in trait
anxiety when presented with feelings of pain during exposure to
blood. Anxiety and disgust also accounted for significant variance
in the unpleasantness of the donation experience for nonfearful
participants, but did not for injection-fearful donors. This suggests
that, while a variety of factors contribute to an unpleasant donation
experience for nonfearful donors, perhaps only a specific constel-
lation of factors (i.e., pain, fainting symptoms) uniquely predict the
unpleasantness of giving blood among injection-fearful donors.
The present study also highlights the role of age and dona-
tion experience in the prediction of vasovagal syncope sensations
among injection-fearful individuals. However, the observed age
effects may be attributed to differences in age range between
injection-fearful (18–62 years) and nonfearful (18–80 years)
donors. Additionally, regression analyses indicated that for
injection-fearful individuals, more donation experience is associ-
ated with fewer fainting symptoms and a more pleasant donation
experience. This is consistent with previous research demonstrat-
ing that increased donation experience contributes to less adverse
reactions during blood donation (France et al., 2005; Meade et
al., 1996). Moreover, recent research has shown that experienced
donors displaying fewer adverse reactions are more likely to donate
in the future (Olatunji, Etzel, & Ciesielski, 2010). Related research
has also shown that a decrease in fainting symptoms during prior
donations is proportional to an increase in the likelihood of donat-
ing blood in the future (France et al., 2004). These findings offer
some evidence that strategies geared towards encouraging repeat
donation among injection-fearful individuals will ultimately result
in substantial reductions in adverse reactions during blood dona-
tion. Such efforts will also indirectly increase long-term retention
of injection-fearful individuals in the donation pool.
Although the present study highlights important differences
between injection-fearful and nonfearful blood donors in the rela-
tionship between disgust and fainting symptoms, limitations of the
study design must be considered before definitive inferences can be
made. For example, it is important to note that although there were
significant differences between the injection-fearful and nonfear-
ful groups on pre-donation levels of anxiety and disgust towards
giving blood and vasovagal reactions during blood donation; group
means on these variables are relatively low for the injection-fearful
group. This finding may be expected given that individuals with
clinically severe BII phobia would be unlikely to volunteer for blood
donation. Therefore, generalization of the present findings to indi-
viduals with BII phobia is limited. The present study does suggest
that blood donation may represent an ideal naturalistic laboratory
for future research examining predictors of fainting symptoms.
Another important limitation of the current study is exclusive
reliance on self-report. Additionally, although group differences
were observed in ratings of expected anxiety and disgust, these rat-
ings were based on a single item. Future research along these lines
may benefit from a multimodal assessment of vasovagal reactions
during blood donation that includes physiological indices and more
extensive assessment of affective responses. Such methodological
considerations may yield converging data that advance the current
understanding of the underlying affective mechanisms of vasovagal
syncope in BII phobia.
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