Behal. Rex. Thu. Vol. 25, No. 1. pp. 25-29. 1987 0005-7967/87 53.00 + 0.

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Printed in Great Britain. All rights reserved Copyright 0 1987 Pergamon Journals Ltd

APPLIED TENSION

A SPECIFIC BEHAVIORAL METHOD FOR TREATMENT

OF BLOOD PHOBIA

LARS-G~RAN&T and ULF STERNER

Psychiatric Research Center, University of Uppsala, Ulleraker Hospital, 750 17 Uppsala, Sweden

(Received I4 April 1986; accepted 12 May 1986)

Summary-The rationale and practice of applied tension are described. The purpose of this treatment
method, specially developed for blood phobia, is to teach the patient a coping skill which will enable
him/her to reverse the fall in blood pressure, and thus prevent fainting. Treatment is short, only 5 sessions,
and the preliminary outcome data are very promising. A 6-month follow-up showed that the results were
maintained.

INTRODUCTION

Phobia of blood, wounds and injuries is one of the most common phobias in the general
population. Agras, Sylvester and Oliveau (1969) found a prevalence of 31/1000, while Costello
(1982) reported what was termed intense fear with avoidance at a frequency of 45jlOOOin a female
population. Despite this fact there is a paucity of behavioral research on this specific phobia. In
the only controlled study published, by bst, Lindahl, Sterner and Jerremalm (1984b), exposure in
oivo was compared with applied relaxation, and showed equally good results. About 15 uncon-
trolled case studies using different behavioral methods have been published (see bst et al., 1984b).
The most outstanding characteristic of blood phobics is their unique physiological pattern when
confronted with the phobic stimuli. As a group they display what Graham, Kabler and Lunsford
(1961) called a diphasic response, i.e. an initial increase in blood pressure (BP) and heart rate (HR)
followed by a rapid drop in these parameters, which eventually leads to fainting if the patient
remains in the situation (&t, Sterner and Lindahl, 1984~). This pattern is displayed by blood
phobics only in relation to blood stimuli (bst, 1986). When studied in ordinary stress situations
(mental arithmetic and the Stroop color-word test) they reacted as normal controls, i.e. with
increases in BP and HR.
The treatment methods used in the published studies follow the common behavioral methods.
With one exception, the physiological response pattern described above has not been taken into
consideration when designing the treatments. The only exception is a case study by Kozak and
Montgomery (1981) in which they described a tension technique with the specific purpose of
increasing the cerebral blood flow. This was used in the outcome study of &t er al. (1984b) as
part (one session) of the applied relaxation treatment. This study did not, however, allow any
conclusion regarding the effectiveness of the tension technique as it was incorporated in an applied
relaxation treatment. Our clinical impressions were so positive however, that development of
applied tension into a treatment method seemed warranted.
The primary purpose of the present paper is to give a detailed description and rationale of applied
tension, as it has been used in a clinical outcome study at our clinic and in private practice. The
second purpose is to present some preliminary data concerning the effectiveness of this method.

APPLIED TENSION
Rationale
The rationale for applied tension is very simple, and after describing the diphasic pattern the
patient is given the following explanation. As the second phase of the diphasic response consists
of a rapid drop in BP the cerebral blood flow is also reduced and the patient feels dizzy, and

25
26 LARS-G~~RAN
6s~ and ULF STERNER

eventually faints. In order to reverse this development the patient needs to learn a coping skill that
can be applied quickly and easily in almost any situation. One coping skill that produces an increase
in BP and cerebral blood flow is applied tension. This consists of two parts; first learning to tense
the gross body muscles, and second learning to identify the earliest signs of the drop in BP, and
using these as a cue to apply the tension technique. By being exposed to different blood-injury
stimuli under the therapists supervision, the patient will gradually gro)v more and more efficient
in identifying these early signs and applying the tension.
After having described the technique in general terms the therapist should answer any questions
that the patient might have concerning it. For example; what happens if I am not quick enough:
will I faint? Is is dangerous to faint? etc. It is not dangerous to faint in the treatment situation,
providing you do not fall and hurt yourself. On the contrary, it is positive that you have a fainting
reaction, on which you can practice the tension technique. It is also important to show the patient
that the recovery time after a fainting reaction can be reduced considerably from 3~4 hr to
5-lOmin, by using the technique. Furthermore, the patients performance anxiety should be
reduced by telling him/her that the technique is easy to learn but it takes practice to master it, like
any other skill. One can not expect to be perfect at once.

Outline of the treatment program

Session 1. Providing that a thorough behavior analysis has been done the first session starts with
describing the rationale and answering questions concerning the treatment. As in every behavioral
treatment it is important that the patient understands and encompasses the rationale, and what
will happen during the treatment.
Then the therapist proceeds with modeling of the tension technique. The patient is sitting in an
armchair and instructed to tense the muscles of the arms, the torso and legs, and keep the tension
for 10-15 set; long enough to feel the warmth rising in the face. Then he/she releases the tension,
but not to a relaxed state, just back to normal. After 20-30 set the patient does the tension again,
and then releases it. This procedure is repeated 5 times, and as a homework assignment the patient
is instructed to perform 5 tension-release cycles 5 times a day.
One problem that a few of the patients have encountered during the performance of homework
assignments is headache. This is due to a tension that is too intensive and probably too frequent,
and can easily be solved by instructing the patient to reduce both intensity and frequency. Another
problem that some patients have described is difficulties finding the right muscles to tense. One
solution to this has been instructing the patient to imagine him-/herself being a bodybuilder.
Another way is to use the BP apparatus to show the patient directly that the BP is rising and that
he/she is using the correct muscles.
~e~~io~~ 2 and 3. During the second and third session the patient is shown a series of slides
(n = 32) depicting wounded and mutilated people. The purpose of showing these slides is two-fold.
First to teach the patient to recognize the earliest signs of a drop in BP. These can be individual,
e.g. dizziness, cold sweat in the forehead, a queasy feeling in the stomach, or even nausea, to name
the most common. The second purpose is, of course, to provide ample opportunities for application
training of the skill that later is to be used in natural situations. Thus, most of the interaction
between therapist and patient during these sessions concerns the producing of BP drops, teaching
of introspection and verbalization of early signs, and coaching the patient to apply the technique
quickly enough and long enough to reverse the response. If the patient were to faint while watching
the slides it is important to encourage him/her to appiy the tension technique. This will shorten
the time during which the patient feels badly.
Session 4. This session the patient is accompanied to the Blood Donor Center at the university
hospital. The primary purpose of the session is to provide a natural situation in which the patient
can practice applying the tension technique. First the patient is shown around by a nurse and
informed how the donated blood is taken care of. Then he/she watches other blood donors, and
finally has a blood sample of their own withdrawn. The secondary purpose is to find out whether
the patient is suitable as a blood donor. If this is the case, donating blood regularly is one of the
ways in which the patient can maintain the coping skill learnt during therapy.
One problem that might arise during this session is that the patients tensing of the arms can
interfere with the venipuncture. This can be solved by spending a few minutes teaching the patient
 Applied tension 27

how to relax the non-dominant arm while at the same time tensing the dominant arm. the torso
and the leg muscles.
Session 5. In the final session the patient is brought to the Department of Thoracic Surgery at
the university hospital in order to observe a thoracic operation. e.g. open-heart or lung surgery,
from the observation room. During this session the patient is sitting one floor above and about
5 m from the operating table. During this session the patient has ample opportunities to practice
application of the tension technique, and the therapists primary task is to encourage the patient
to do so. If the patient faints, which rarely happens, the therapist has to help him/her regain
consciousness and then continue the exposure to the surgical situation as soon as possible. This
can be accomplished by first letting the patient tense for a couple of minutes. first lying on the floor,
then sitting turned away from the operating table, and then gradually turning towards it while
tensing continuously if necessary.
This session, being the last of the program, ends with a review of the progress accomplished by
the patient so far. There is also a description of the maintenance program that the patient is
expected to follow for the next 6 months, up to the follow-up assessment. This program consists
of a contract between the therapist and patient of his/her continuing exposure to blood-injury
situations. For each individual patient a number of possible situations is described, e.g. looking
at pictures of wounded persons, watching TV programs of surgical procedures, talking about such
things, visiting the Blood Donor Center and watching others donating blood and donating blood
oneself. The patient notes on a specific form which situations he/she has been exposed to as well
as the reactions experienced and mails this to the therapist each fortnight for the first 3 months
and once a month thereafter. Upon receiving the form the therapist phones the patient for a short
conversation (10-I 5 min).

Patients
All Ss (n = 10) fulfilled the DSM-III (APA, 1980) criteria for simple phobia and were treated
as outpatients at Ulleraker mental hospital. They were all handicapped by their blood phobia to
a large extent, and the majority had chosen their occupation, or changed it, because of their phobia.
There were 7 females and 3 males, with a mean age of 29.2 yr (range 17-44). The mean age at onset
was 8.9 yr (range 5-14) and mean duration 20.3 yr (range 7-36). Eight of the patients reported
having fainted in the phobic situation, and the mean number of faintings was 8.1 (range l-30).
Eight were married and 2 single; 6 worked full-time, 2 part-time and 2 were full-time students.

Assessment
The patients went through a series of assessment instruments, only some of which will be
described here. Before coming to the screening interview the patient completed the Mutilation
Questionnaire (Klorman et al., 1974) which is a 30-item true-false scale. At the end of the screening
interview the patients were given a behavioral test, consisting of watching a 30-min color videofilm
on thoracic operations. During the test the patients rated, every 2 min, the degree of anxiety
experienced on a O-10 scale, and the experimenter rated degree of fainting behavior on a O-4
scale. Finally, immediately after the test the patient rated (t&-4) the frequency with which he/she
had had 10 different thoughts, 5 positive and 5 negative. The score on this measure had a range
from -20 to +20. Follow-up assessment was done 6 months after the end of treatment.

RESULTS
Direct eflects
In order to study if the tension technique really does what it is supposed to do, i.e. increases
the BP, the following assessment was done. During Sessions 2 and 3, while watching the slides,
the patients BP and HR were assessed with an automatic BP apparatus (Ueda UD-8 10). This was
done at the beginning of each session, every 5 min during the session and immediately after each
tensing period. The results of this are shown in Table 1. The mean increase in systolic BP is
substantial, 13.6 mmHg [t(9) = 4.56, P < 0.011, with a range of 3-34. The mean changes in diastolic
BP, 1.8 mmHg (range -9 to 11.5), and HR, -0.8 (range -40 to 1l), were much lower and
non-significant.
28 LARS-G&AN &r and ULF STERNER

Table 1. Direct effects of applied tenston on systolic (SBP) and diastohc (DBP)
blood pressure and heart rate (HR) during appiication training sessions and the
uost-treatment behavior test
Mean pre-tension ievei Mean change of
Patient -i%P
SBP HR -SBP DBP HR
A. During applicolion mining sessions (e.xposure to sbdes)
I 121.8 94.8 88.8 6.8 -1.5 6.3
2 121.0 81.0 67.0 22.0 4.0 11.0
3 122.5 86.0 72.3 Il.3 3.8 5.5
4 108.7 79.0 74.3 12.9 4.0 1.3
5 113.3 68.0 58.9 2.7 -5.6 4.4
6 III.8 15.5 68.1 12.1 3.8 2.4
1 100.0 53.0 53.0 19.5 11.5 2.5
8 128.3 77.1 91.3 3.1 I.7 - 6.6
9 83.0 71.0 121.0 34.0 -9.0 - 40.0
10 150.6 12.3 62.0 11.0 Il.3 5.6
Mean 116.1 75.8 75.7 13.6 1.8 -0.8
SD 17.9 11.2 20.0 9.4 7.1 14.5
B. Derring the posr-trmztmeni beh&orai fen
fn =4j 96.3 71.0 82.8 16.5 1.3 4.0
.

When looking at the data from the post-treatment behavioral test (Table 1) there was also a
significant change [r(9) = 4.09, P -=z0.051 in systolic BP, mean 16.5 mmHg (range 10-28). This was,
however, not the case for diastolic BP, 1.3 mmHg, and HR, 4.0.

Therapeutic efects
Table 2 shows the outcome on the most important clinical measures for the patients treated with
applied tension. As can be seen from this table the patients displayed significant improvements on
all measures. Especially noteworthy are the changes on the behavioral measures, time watching the
film and observer rating of fainting behavior. After the treatment all patients could watch the entire
film (30 min) without any fainting behavior whatsoever. Furthermore, as can be seen in Table 1,
only 4 of the patients needed to use the tension technique at the post-treatment assessment. When
asked about this the others explained that they felt secure now, knowing that they had an effective
skill to use if the fainting reaction should start. This cognitive change is also evident on the
Thought Index.
The treatment effects were largely maintained at the &month follow-up assessment. Mean time
watching the film was reduced by 1 min, which was due to I patient only, who watched the film
for 20 min. However, rating of fainting behavior was unchanged and self-rating of anxiety further
improved. There was also a small deterioration on the Thought Index, and a significant one
[r(9) = 2.34, P < 0.051 on the Mutilation Questionnaire. The latter was, however, only 1.2 points,
which is not ~Iini~a~iy signi~cant.

DISCUSSION

Applied tension has proved to be an effective. as well as efficient treatment method for blood
phobia. All patients reached the maximum score on both behavior measures after treatment, i.e.
could watch the entire film about thoracic operations with no fainting reactions whatsoever.
Furthermore, they did so in a rather short treatment period, only 5 sessions of 1 hr duration.
Applied tension is, to the best of our knowledge, the first behavioral technique specifically
tailored to the physiological reactions of blood phobics. The method contains two components;

Table 2. Means (SDS) on behavioral and self-reoork measures

M~FMlrC Prr Post Follow-up fpte-port fpo,tA.llow.p
Time watching the film 7.46(8.1) 30.0 (0.0) 29.0 (3.2) 8.81 1.0
Rating of fainting behavior l.Y(l.5) 0.0 (0.0) 0.0 (0.0) 4.15 0
Self-rating of anxiety 7.73(1.9) 3.3 (1.8) 2.7 (2.3) 7.27*** 0.93
Thought Index - 1.5(10.0) 13.5 (3.4) 10.9 (7.4) 5.81*** 1.16
Mutilation Qu~tionnai~ 20.6(5.33 IO.5 (4.7) 11.7(4.7) 7.12** 2.34
*P < 0.05; *+P < 0.01; +**p < 0.001; ****fJ < 09301
 Applied tension 29

the coping-skill of tensing ones muscles to increase the blood pressure and cerebral blood flow,
and exposure to different phobic situations. It is impossible, at our current state of knowledge
about this method, to say which of these components is the most important. From a clinical point
of view it is quite natural to use a series of exposure situations for application training in order
for the patient to acquire the coping skill properly. In this respect applied tension resembles
another coping technique, applied relaxation, which the author has found effective for agoraphobia
(&t, Jerremalm and Jansson, 1984a), social phobia (&t, Jerremalm and Johansson, 1981) and
claustrophobia (&t, Johansson and Jerremalm, 1982). One difference between these methods is
that while applied tension uses 80% (4/5) of the sessions for application training, the reverse is true
for applied relaxation, 20% (2/10).
Our clinical impression from working with applied tension is that the application training
sessions are needed to make the method credible, at least for those with strong fainting behavior.
For those with little or no fainting behavior, teaching the patient how to increase tension, i.e. the
first session of our treatment program, might be enough. We plan to investigate this possibility.
Thus far we have touched on the physiological component, the tension skill, and the behavioral
component, exposure in uivo. However, the reason why applied tension works might be related to
the cognitive component. The fact that only 4 of the patients actually found a need to use the skill
at the post-treatment assessment, and the others expressed an increased confidence in their ability
to manage and cope with tendencies to fainting behavior, indicates a cognitive change. This is also
corroborated by the significant change on the cognitive measure, Thought Index. This idea also
needs to be tested.

Acknowledgemenf-This research was supported by Grant 05452 from the Swedish Medical Research Council. Reprint
requests should be addressed to L.-G. t)st.

REFERENCES
Agras S., Sylvester D. and Oliveau D. (1969) The epidemiology of common fears and phobia. Compreh. Psychiat. 10,
151-156.
APA; American Psychiatric Association (1980) DSM-III. Diagnostic and Statisrical Manual of Mental Disorder, 3rd edn.
APA, Washington, D.C.
Costello C. G. (1982) Fears and phobias in women: a community study. J. abnorm. Psychol. 91, 280-286.
Graham D. T., Kabler J. D. and Lbnsford L. (1961) Vasovagal fainting: a diphasic response. Psychosom. Med. 23,493-507.
Klorman R.. Weerts T. C.. Hastinns J. E.. Melamed B. G. and Lang P. J. (1974) Psychometric description of some
specific-fear questionnaires. Beh& Ther: 5, 401-409.
Kozak M. J. and Montgomery G. K. (1981) Multimodal behavioral treatment of recurrent injury-scene-elicited fainting
(vasodepressor syncope). Behav. Psychother. 9, 3 16-32 1.
&t L.-G. (1986) Physiological reactions in blood phobic and non-phobic subjects in phobic and ordinary stress situations.
Manuscript in preparation.
t%t L.-G., Jerremalm A. and Johansson J. (1981) Individual response patterns and the effects of different behavioral
methods in the treatment of social phobia. Behao. Res. Ther. 19, 1-16.
C)st L.-G., Johansson J. and Jerremalm A. (1982) Individual response patterns and the effects of different behavioral
methods in the treatment of claustrophobia. Behav. Res. Ther. 20, 44460.
bst L.-G., Jerremalm A. and Jansson L. (1984a) Individual response patterns and the effects of different behavioral methods
in the treatment of agoraphobia. Behav. Res. Ther. 22, 697-707.
&t L.-G., Lindahl I.-L., Sterner U. and Jerremalm A. (1984b) Exposure in uivo vs applied relaxation in the treatment of
blood phobia. Behav. Res. Ther. 22, 205-216.
&t L.-G., Sterner U. and Lindahl I.-L. (1984~) Physiological responses in blood phobics. Behav. Res. Ther. 22, 109-177.