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Blood phobia

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Title:
Blood phobia a comparison of phobics and nonphobics and an examination of affect during visual and auditory exposure
Alternate title:
Comparison of phobics and nonphobics and an examination of affect during visual and auditory exposure
Creator:
Lumley, Mark Allan, 1962-
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Language:
English
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viii, 146 leaves : ill. ; 29 cm.

Subjects

Subjects / Keywords:
Anxiety ( jstor )
Blood ( jstor )
Disgust ( jstor )
Experimentation ( jstor )
Headphones ( jstor )
Magnetic storage ( jstor )
Mental stimulation ( jstor )
Phobias ( jstor )
Questionnaires ( jstor )
Syncope ( jstor )
Adaptation, Psychological ( mesh )
Affect ( mesh )
Blood ( mesh )
Department of Clinical and Health Psychology thesis Ph.D ( mesh )
Dissertations, Academic -- College of Health Related Professions -- Department of Clinical and Health Psychology -- UF ( mesh )
Personality ( mesh )
Phobic Disorders ( mesh )
Psychological Tests ( mesh )
Research ( mesh )
Genre:
bibliography ( marcgt )
non-fiction ( marcgt )

Notes

Thesis:
Thesis (Ph.D.)--University of Florida, 1990.
Bibliography:
Bibliography: leaves 137-144.
General Note:
Typescript.
General Note:
Vita.
Statement of Responsibility:
by Mark Allan Lumley.

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University of Florida
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University of Florida
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Copyright [name of dissertation author]. Permission granted to the University of Florida to digitize, archive and distribute this item for non-profit research and educational purposes. Any reuse of this item in excess of fair use or other copyright exemptions requires permission of the copyright holder.
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ALW2213 ( NOTIS )

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BLOOD PHOBIA: A COMPARISON OF PHOBICS AND NONPHOBICS AND AN
EXAMINATION OF AFFECT DURING VISUAL AND AUDITORY EXPOSURE












By

MARK ALLAN LUMLEY


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA


1990














ACKNOWLEDGEMENTS

The doctoral dissertation documents the independent,

scholarly ability of the candidate, but it is never a

solitary effort. My efforts have been buttressed by many

others in various capacities. Foremost, I wish to note the

contributions my committee, starting with my chairperson,

Dr. Barbara Melamed, whose mentorship, support, and

friendship have made graduate school and this dissertation

pleasantly memorable. I also thank Dr. Peter Lang, whose

thoughtful critique of my research content and encouragement

to conduct a programmatic study of answerable questions have

been most helpful. My appreciation also goes to Dr. Wilse

Webb, who has gently modeled for me the role of psychologist

as discoverer and disseminator of knowledge. Dr. Sandra

Seymour is thanked for helping me keep the task in

perspective. Finally, Drs. Nancy Norvell and Anthony Greene

are acknowledged for their participation. I greatly

appreciate this committee's joy of research, desire for me

to learn, and consideration of my needs and interests.

Others have contributed in various ways. Dr.

Christopher Patrick instructed me in the conduct of

physiological assessment and the use of the data collection

software. Randle Blanco assisted in writing software

programs to convert data to analyzable format. Dr. Lars-









Goran Ost provided the surgical operations video stimulus.

Dr. Debbie Ader and Angel Siebring created the audiotapes.

Undergraduates Terry Keenan, Rick McCali, and Donna Livesey

assisted in data collection and coding. The Psychology

Department at the University of Florida provided access to

their undergraduate subject pool. The American

Psychological Association awarded a dissertation grant to

help defray costs. Finally, the National Institute of

Dental Research Training Program and the University of

Florida Presidential Graduate Research Fellowship funded my

graduate training. I am thankful for all of this aide.

Finally, to one whose sustenance I cherish, whose

caring ameliorated the tensions induced by hours in the

laboratory or at the computer, whose hope for the future

makes the trials worthwhile, I thank my wife Sherry.


iii















TABLE OF CONTENTS
page

ACKNOWLEDGEMENTS ....................................... ii

ABSTRACTo .................... ............. ....... vii

GENERAL INTRODUCTION................................ 1

Classification and Epidemiology.................... 1
Affective Responding in Blood Phobia................. 2
Purpose of these Studies ............................. 3

STUDY ONE ........ ... ..... ....... ..... ..... ........ 5

Introduction.... ...... ...................... ....... 5
Phobic Subjects and Controls... .............. 5
Stimulus Characteristics and Presentation Methods.. 6
Personality Dimensions............................. 8
Summary and Purpose of the Study.................. 11

Method. ....... .... . 11
Method i... ....... . ........ 11
OverviewS.... .. ... .......... 11
Subjects ......h.s.... ............................. 12
Procedure ....... .. ...................... ........ 13
Stimuli...... ........................ ...... ... ... .. 17
Experimental Environment and Apparatus............. 18
Questionnaires............................ ....... 19
Dependent Measures................................. 22

Results.. .... ................................... 26
Personality Measures........................... .... 26
Videotape Stimuli................................. 27
Audiotape Stimuli .................................. .. 36

Discussion................ ....... ... .. .. .. .. 39
Psychometric Assessment............................ 39
Affect During Videotaped Stimuli.................... 41
Affect During Audiotaped Stimuli................... 47
Methodological Issues.............................. 47

Notes................ .. ....... .................... 49

STUDY TWO ........ .... ........ ...... ........ ........ .... 50

Introduction.. ..... ............. ........ ....... .. 50
Exposure and Affect Change......................... 50
Preparatory Information.............................. 51









pace


Summary and Purpose of the Study...................

Method. ..................... ........................
Overview ................... ........................
Subjects...........................................
Procedure ................. ............... ..........
Experimental Groups...............................
Stimuli ......................................... ...
Questionnaires ....................................
Dependent Measures.................................

Results ............................. ****************
Effects of Repeated Visual Exposure ................
Effects of Auditory Preparation....................
Effects of Personality Variables...................

Discussion ........... .......... ..... ** ** *
Affect Change to Repeated Surgery Exposures........
Generalization of Affect Reduction to Novel
Phobic Stimuli ...................................
Effects of Preparation ............................
Individual Differences Variables...................
Methodological Issues.............................

Notes .............. .................................

GENERAL DISCUSSION..................... ........ .......

A Comparison of Blood Phobia and Other Phobias........
Unanswered Questions...............................


APPENDIX A


APPENDIX B

APPENDIX C

APPENDIX D

APPENDIX E


APPENDIX F


APPENDIX G


APPENDIX H


INFORMED CONSENT TO PARTICIPATE
IN RESEARCH (STUDY 1).................... 98

SUBJECT INSTRUCTIONS (STUDY 1)............. 100

SELF-ASSESSMENT MANIKIN (SAM) INSTRUCTIONS. 102

DEBRIEFING FORM (STUDY 1).................. 105


PHOBIC AND NEUTRAL AUDIOTAPE
TRANSCRIPTS (STUDIES 1 AND 2)............

VPM CONTROL PROGRAM FOR DATA ACQUISITION
AND STIMULUS PRESENTATION (STUDY 1)......

INFORMED CONSENT TO PARTICIPATE
IN RESEARCH (STUDY 2)....................


106


111


115


SUBJECT INSTRUCTIONS (STUDY 2)............. 118












APPENDIX I

APPENDIX J


DEBRIEFING FORM (STUDY 2)..................

VPM CONTROL PROGRAM FOR DATA ACQUISITION


120
120


AND STIMULUS PRESENTATION (STUDY 2)...... 121

APPENDIX K ORDER EFFECTS (STUDY 1) .................... 126

APPENDIX L ANOVA TABLES (STUDIES 1 AND 2)............. 127

REFERENCES... ...... .................... .......... 137

BIOGRAPHICAL SKETCH...................................... 145















Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy

BLOOD PHOBIA: A COMPARISON OF PHOBICS AND NONPHOBICS AND AN
EXAMINATION OF AFFECT DURING VISUAL AND AUDITORY EXPOSURE

By

MARK ALLAN LUMLEY

December, 1990

Chairman: Barbara G. Melamed, Ph.D.
Major Department: Clinical and Health Psychology

Two studies examined subjective, psychophysiologic

(heart rate, skin conductance level, blood pressure), and

motoric (stimulus avoidance and facial disgust expressions)

responses of blood phobics and nonphobics (defined by

elevated or below median Mutilation Questionnaire scores)

when viewing or listening to 60 s surgical and neutral

videotapes and audiotapes. Study 1 assessed several

personality domains and found that phobics (n = 24) were

more sensitive to their own anxiety, experienced greater

distress with others' negative affect, and were generally

less secure than nonphobics (n = 24). Affect was assessed

during exposure to surgical and neutral videotapes followed

by an audiotaped surgical or neutral description. Blood

phobics had more negative affect than nonphobic controls

during a surgery videotape, and phobics had greater negative

affect during a surgery than during a neutral videotape.


vii









These differences were most prominent during only one of two

surgery scenes and when the surgery was presented prior to

rather than following the neutral videotape. Phobics and

nonphobics did not differ in affect during the neutral

scene. An audiotape describing the prior surgery elicited

slightly more arousal than a neutral description audiotape,

but phobics and controls did not differ in affect to the

description. Study 2 examined affect change to repeated

presentations of a surgery videotape, and the role of

preparatory descriptions in reducing negative affect. Sixty

blood phobics were randomly assigned to three experimental

groups. One group viewed a surgery seven times and then saw

a novel surgery; these subjects habituated during

repetitions and dishabituated to the novel surgery. Two

other groups differed in the preparation they received prior

to each of four surgery videotape repetitions. One group

heard a description of the upcoming surgery, and the second

group heard a neutral, control description. The prepared

group had moderately less negative affect during the surgery

videotapes than the control group. Individual differences

in coping style influenced responding to repeated surgery

scenes; among the prepared phobics, blunters increased

negative affect over two presentations, and monitors reduced

affect. The findings indicate the need for continued basic

research of blood phobia, especially its relationship to

fainting (which did not occur in either study) and its

current classification as a simple phobia.


viii














GENERAL INTRODUCTION

Classification and Epidemiology

For some individuals, exposure to blood, bodily injury,

mutilation, disease, and related stimuli evokes a subjective

experience of fear, disgust, or aversion; autonomic arousal;

and commonly, escape from and avoidance of future encounters

with the stimulus (Marks, 1988). When this stimulus-

response pattern is sufficiently intense, it is termed

"blood phobia" (Thyer, Himle, & Curtis, 1985), and is

classified as a simple phobia in the revised third edition

of the Diagnostic and Statistical Manual of Mental Disorders

(DSM-IIIR; American Psychiatric Association, 1987).

This composite of negative subjective experience,

physiologic arousal, and escape from or avoidance of

exposure to blood and related stimuli emerges consistently

as a unitary factor in specific fear surveys (e.g., Agras,

Sylvester, & Oliveau, 1969). Additionally, fainting or

syncope during exposure to blood-related stimuli is

prevalent. Kleinknecht (1987, 1988a) found that 14.5% to

19.3% of college students reported a history of nearly or

completely fainting. About 15% of blood donors approach

syncope during or after venipuncture (Graham, 1961).

Blood phobia has been associated with reduced

motivation to donate blood, avoidance of medical or dental









visits, interference with routine tests such as

venipuncture, decreased desire for the care of one's own or

another's injuries, and the redirection of potential health

professionals from their field of interest (Lloyd & Deakin,

1975; Oswalt, 1977). Avoidance of blood-related stimuli

typically is easy for most phobics; therefore, few seek

treatment of their phobia. Nonetheless, this condition

hinders many people from full participation in activities

where blood-related stimuli occur.

Affective Responding in Blood Phobia

Emotions are best quantified by three response systems:

subjective or verbal report, physiologic activation, and

overt motor behavior (Lang, 1968). Subjectively, blood

phobics report an uncomfortable or disagreeable affect

during exposure to blood-related stimuli. Most researchers

label the emotion "fear," although no studies have

documented the occurrence of fear as opposed to a different

emotion such as disgust. Thus, this dissertation will

employ a general term such as "negative affect" to describe

the subjective component of the blood phobic's experience.

Second, some blood phobics experience a physiological

reaction, unique among the phobias, termed the "biphasic

response," in which initial sympathetic arousal is replaced

by or alternates with parasympathetic activity (Engel, 1978;

Graham, Kabler, & Lunsford, 1961). Like other simple

phobias, sympathetic activity includes tachycardia,

hypertension, striate muscle tension, perspiration, and









increased respiration, which occur during the anticipation

of or initial exposure to a blood-related stimulus. Unlike

other simple phobias, however, continued exposure may yield

parasympathetic symptoms of bradycardia, hypotension,

yawning, nausea, lightheadedness, narrowing of vision, and

ultimately fainting, if escape is precluded (Ost, Sterner, &

Lindahl, 1984). Unfortunately, many studies of blood phobia

have included only subjects who report faintness,

potentially misleading investigators to conclude that

fainting is a common, perhaps necessary concomitant of blood

phobia. Indeed, the actual prevalence of parasympathetic

symptoms and fainting per se among those who report negative

affect to and avoidance of blood-related stimuli is unknown.

Overt motor behavior is the third emotional response

domain. Like other simple phobias, blood phobics usually

physically escape from the bothersome stimulus, thus ending

the negative experience. Additionally, blood phobics appear

to successfully escape by simply turning their heads or

closing their eyes (Beck & Emery, 1985).
Purpose of these Studies

Most of our knowledge of blood phobia stems from the

treatment literature, which contains many case studies and

several controlled investigations. For example, systematic

desensitization (Babcock & Powell, 1982; Cohn, Kron, &

Brady, 1976; Elmore, Wildman, & Westefeld, 1980; Kozak &

Montgomery, 1981; McGrady & Bernal, 1986; Ost, Lindahl,

Sterner, & Jerremalm, 1984; Yule & Fernando, 1980),









implosion (McCutcheon & Adams, 1975; Ollendick & Gruen,

1972) and in vivo exposure treatments with modifications to

prevent fainting (Curtis & Thyer, 1983; Ost, Lindahl,

Sterner, & Jerremalm, 1984; Ost & Sterner, 1987; Ost,

Sterner, & Fellenius, 1989) appear efficacious in treating

blood phobia.

Although effective treatments are available, there

exists little descriptive information about the basic

psychophysiology, psychopathology, and phenomenology of

blood phobia. The process of affect change, which is

typically complicated in treatment studies, also has

received little empirical attention. This dissertation

presents two studies which attempt to increase our basic

knowledge of blood phobia. Study 1 examined differences

between blood phobics and nonphobics in their subjective,

physiological, and motoric responses to phobic and neutral

material and in several personality characteristics. Study

1 also explored differences in affect to two different

blood-related stimuli and examined the effects of stimulus

presentation order. Study 2 examined first the change in

affect during exposure to phobic material using a

habituation-dishabituation paradigm to repeated

presentations of a phobic stimulus. Study 2 also

investigated the effects of preparing subjects for exposure

to the phobic stimulus with audiotaped descriptions, and it

examined the influence of imagery ability and coping style

on affect across multiple stimulus presentations.














STUDY 1

Introduction

Phobic Subjects and Controls

Researchers typically have recruited blood phobics for

study from three sources: patients presenting for treatment

of their phobia (e.g., Ost et al., 1989), blood donaters who

faint (Graham et al., 1961), and respondents (usually

college students) with deviant scores on blood phobia

questionnaires (Beiman et al., 1978; Kleinknecht, 1988a,

1988b).

Regardless of recruitment method, only a few studies

have compared blood phobics with nonphobic controls.

Klorman and colleagues (Klorman et al., 1975, 1977) found

that blood phobics (more explicitly, students with elevated

scores on the Mutilation Question [MQ], an instrument

designed to assess blood-related concerns) responded with

cardiac acceleration during 10-second exposures to

mutilation slides, whereas normals (low scoring subjects)

showed cardiac deceleration. Steptoe and Wardle (1988),

used a simple screening questionnaire (not the MQ) and found

that blood phobics reported greater anxiety and

lightheadedness and had higher heart rates and systolic

blood pressures during a surgery film than did nonphobics.

The current study also compared blood phobics (those with









elevated MQ scores) with nonphobic controls (low MQ scorers)

during exposure to phobic and neutral stimuli and on several

personality dimensions in order to enlighten fundamental

aspects of blood phobia.

Stimulus Characteristics and Presentation Methods

Research on blood phobics have employed several

different stimulus modalities. Some investigators have

assessed responding during an in vivo procedure such as

venipuncture (Engel & Romano, 1947; Graham, 1961; Kaloupek,

Scott, & Khatami, 1985), cardiac catheterization (Glick &

Yu, 1963), and pneumoencephalography (Graham, Kabler, &

Lunsford, 1961). Unfortunately, this methodology usually

lacks rigorous experimental control, exact replications are

difficult, and multiple noxious stimuli (e.g., the sight of

blood, blood loss, needles, and pain) are present. Other

investigators have used movies or films depicting surgical

procedures (Steptoe & Wardle, 1988). For example, Ost and

colleagues (Ost et al., 1989; Ost, Sterner, & Lindahl, 1984)

used a 30-minute continuous, silent videotape showing a

series of thoracic surgeries. Slides of mutilations or

homicides are the third major stimulus type employed in

blood phobia research (Hare, Wood, Britain, & Shadman, 1971;

Klorman, Weisberg, & Wiesenfeld, 1977; Klorman, Wiesenfeld,

& Austin, 1975). This methodology affords the greatest

degree of interpretive clarity, especially because the

stimulus remains static. Although a comparison has not been

done, films are expected to elicit more powerful exposure









effects than slides because of their increased similarity to

in vivo stimuli. Unfortunately, lengthy films such as that

of Ost and colleagues lead to differential viewing durations

across subjects because of fainting in some subjects.

Therefore, the current study used 60 s surgery scenes from

Ost's film. These were brief enough that all subjects were

expected to be able to watch for the full duration.

The surgical depictions in Ost's film may vary in

aversiveness for blood phobics. It is of interest to

determine the comparative aversiveness of several different

surgical scenes. Therefore, this study compared empirically

two of these surgery scenes, to determine if they elicit

different degrees of negative affect.

In addition to the above noted utility of studying

nonphobic control subjects, it is also important to compare

affect to a phobic stimulus with affect to a neutral,

nonarousing stimulus. This comparison permits conclusions

about the blood-related content of the stimulus as the

elicitor of negative affect independent of aspects of the

experimental setting involved in simply viewing a stimulus.

Steptoe and Wardle (1988) conducted such a comparison and

confirmed that blood phobics responded with less negative

affect to a neutral film than to a surgery film. This is

the only study using films for stimuli that has conducted

such a comparison, although several studies using slides

have found similar results (Hare et al., 1971; Klorman et

al., 1977, Klorman et al., 1975).









Steptoe and Wardle (1988), however, did not

counterbalance the order of surgery and neutral film

presentation, but always presented the surgery film first.

They assumed that phobics would show undesired anticipatory

anxiety to the neutral film if it were presented prior to

the surgery film. Their failure to counterbalance order

opens their findings to the alternative hypothesis that

habituation or another learning process resulted in less

negative affect during the neutral film. Study 1 corrected

for this lapse by counterbalancing stimulus order and

evaluating the effects of the two orders to determine the

validity of Steptoe and Wardle's findings.

Finally, auditory stimulus presentation is another

modality which has been employed in studies of emotion and

other anxiety disorders but not in the study of blood

phobia. Thus, Study 1 presented to both blood phobics and

controls either surgical or neutral audiotaped descriptions

of the stimulus film that they had seen earlier. Thus, the

group and stimulus content comparisons which were made for

the visual material were repeated for auditory material.

Personality Dimensions

In addition to affective differences between blood

phobics and nonphobics during surgical and neutral stimuli,

it is also of interest to study personality characteristics

of blood phobics. Study 1 examined four personality

dimensions, derived from anecdotal observations and theories

of blood phobia.









Blood phobia's etiology has received some theoretical

and empirical attention. Retrospective interviews conducted

by behavioral researchers have suggested classical and/or

vicarious conditioning etiologies similar to those found for

other simple phobias (Ost & Hugdahl, 1985), perhaps

facilitated by a genetically-based "preparedness" (Marks,

1969; Seligman, 1971). Several other hypotheses have

focused on blood phobia's uniqueness. Engel (1978)

attempted to explain both the initial anxiety and subsequent

syncope. He suggested that blood phobics, like most people,

are simultaneously sympathetically and parasympathetically

aroused by an unnatural sight such as a wound. Sympathetic

sensations consistent with the "fight or flight" response

fluctuate in dominance with feelings of queasiness and

hypotension of the parasympathetic branch. The blood phobic

is highly sensitive to his/her arousal, discomfort, and

lightheadedness, but strongly wishes to appear in control

and attempts to remain socially stoic. Thus, the phobic

feels helpless, unable either to fight or flee. The stifled

sympathetic branch is deactivated, leaving the remaining

parasympathetic activity unfettered, and syncope results.

One testable hypothesis from this theory is that blood

phobics are more sensitive to their own physical arousal

than are nonphobics. Kleinknecht (1988a) found that

subjects who reported a history of having nearly or

completely fainted had higher "anxiety sensitivity" (Reiss,

Peterson, Gursky, & McNally, 1986) than nonfainters; that









is, they were inordinately aware of, focused on, and

concerned about their physical reactions when aroused.

Study 1 attempted to replicate this finding and extend it to

blood phobics defined somewhat differently than those

studied by Kleinknecht.

Anecdotal observations suggest that blood phobics have

highly vivid visual images in response to verbal

descriptions of blood stimuli. Furthermore, blood phobics

frequently report that they "feel" in their own bodies the

injury or invasive procedure observed on another. Beck and

Emery (1985) noted that such identification with the pain or

distress of the victim induces great anxiety in blood

phobics, who experience the injury as their own. These

observations suggest that blood phobics may have greater

visual imagery abilities and a greater capacity for empathy.

Imagery ability of blood phobics has not been studied yet,

but Kleinknecht (1988a) administered a multidimensional

scale of empathy, and found that self-reported fainters had

greater feelings of personal discomfort in emotional

interpersonal situations than nonfainters. No differences

were found on other empathy dimensions such as fantasy,

perspective-taking, and general concern. Both imagery

ability and empathy were examined in this study.

Finally, a broader question is how similar blood phobia

is to other anxiety disorders or to what degree blood

phobics experience various dimensions of anxiety in their

daily life. For example, are blood phobics' muscle tension,









autonomic arousal, and feelings of fear and insecurity

greater than those of nonphobics? Or are these dimensions

no different from controls, suggesting dissimilarity to

other anxiety and stress-related disorders?

Summary of the Purpose of the Study

Study 1 attempted to increase the rigor of blood phobia

studies by including nonphobics controls and a neutral

stimulus and by counterbalancing the order of stimulus

presentation. Thus, affective differences of blood phobics

and nonphobics to surgical and neutral stimuli were

examined. Within this paradigm, the effects of stimulus

order were evaluated, as were the differences between two

surgery scenes. Additionally, audiotaped descriptions of

the surgeries were presented to determine whether the

auditory modality reliably induces affect differences across

experimental groups and stimuli. This study also examined

differences between blood phobics and nonphobic controls on

several personality dimensions of theoretical importance:

anxiety sensitivity, manifest anxiety, mental imagery, and

empathy.
Method

Overview

Forty-eight (48) volunteer undergraduate students, half

of whom were blood phobic and half of whom were nonphobic,

completed questionnaires on mental imagery, empathy, anxiety

sensitivity, and manifest anxiety. Subjects then viewed two

60-second video stimuli in counterbalanced order, including









one of two bloody surgeries and a neutral scene. Subjective

ratings, physiological responses, and facial expressions of

disgust and eye avoidance served as dependent measures.

Subsequently, half of the phobics and half of the nonphobics

heard an audiotaped description of the surgery, whereas the

remaining subjects heard a description of the neutral

videotape. Physiological and subjective measures were

assessed during the audiotapes.

Subjects

Subjects were 48, 17 to 25-year-old (M = 18.9)

volunteer University of Florida undergraduates currently

enrolled in General Psychology. The final sample was

secured after screening 450 potential subjects with the

Mutilation Questionnaire (MQ) at the beginning of the

semester. Scores from the MQ were arranged in ascending

order separately for each gender. Blood phobics (n = 24)

were defined as the highest scoring 12 males and 12 females

(maximum MQ score = 30), which represented the top 6% of

each gender distribution. Scores ranged from 15 to 23 (M =

18.2) for phobic males and from 23 to 28 (M = 25.3) for

phobic females. Nonphobics (n = 24) were defined as

subjects scoring below the median of each gender

distribution. The lower half of the distribution was

divided equally into twelfths (in order to sample the full

range of nonphobics scoring below the median), and one

subject was selected from each twelfth, yielding 12

nonphobic males and 12 nonphobic females. Mutilation









Questionnaire scores ranged from 0 to 7 (M = 4.1) for

nonphobic males and from 1 to 10 (M = 5.6) for nonphobic

females. Selected subjects were contacted via telephone and

asked to participate if they were fluent in English and not

pregnant. They were told that the study involved "watching

several short television presentations and hearing several

headphone descriptions while your physical responses are

recorded." Four subjects (including one blood phobic)

declined to participate due to lack of interest and were

replaced. Subjects were paid five dollars for

participating.

Procedure

The study took place during a 1 h session; subjects

were studied individually.

Psychometric assessment. After subjects read and

signed the informed consent form (see Appendix A), they

completed two randomly selected questionnaires from the pool

of four questionnaires completed during the session (see

below). Subjects then were seated in the experimental room

for physiological attachments and instructions.

Instructions. Upon entering the experimental room, the

experimenter attached to the subject an automated blood

pressure (BP) cuff and electrodes to assess heart rate (HR)

and skin conductance level (SCL). Attachments were modified

until acceptable signal quality was achieved. The BP cuff

was inflated several times prior to data collection to

accommodate the subject to its functioning. The









experimenter then read to the subject the instructions and

protocol which are presented in full in Appendix B.

Briefly, subjects were informed that they would be presented

a few short videotapes which would depict surgical and/or

neutral scenes. Following each presentation, they would

rate their emotions experienced during the presentation and

then complete a questionnaire. After several video

presentations, audiotape presentations would occur according

to the same format.

Next, the experimenter taught subjects in the use of

the Self Assessment Manikin (SAM), the computerized affect

self-report system (Appendix C). After answering subjects'

questions, the experimenter exited to the adjacent control

room, where he ascertained subjects' group status (phobic or

nonphobic), and then randomly determined the order of

stimulus presentation and which of the two surgical stimuli

were to be used.

Experimental paradigm. Table 1 presents the

experimental design and trial sequence of the study, and

Table 2 presents the timing durations and measurements for

each trial. Baseline subjective ratings were obtained prior

to the presentation of the first stimulus; subjects rated

their emotions experienced while waiting for the first

videotape presentation. After this baseline rating, the

paradigm of three trials began.

Each of the three trials followed the same data

collection format. The trial began with a baseline BP









assessment. After the cuff deflated, baseline HR and SCL

were recorded for the next 30 s, immediately prior to

stimulus onset. Contiguous with the end of this 30 s

period, the experimenter presented the stimulus to the

subject, and HR and SCL continued to be recorded during the

60 s presentation. Immediately at stimulus offset, BP was

sampled again, and the affective ratings screen illuminated

for subjects to rate the affect they experienced during the

videotape. They then waited for the next trial.

For Trials 1 and 2, one of the two surgical videotapes

(randomly selected) and the neutral videotape were

presented, counterbalancing the order of presentation both

for group and gender. For these two trials, the

experimenter presented the visual stimulus on the subject's

television, and the subject's face was videotaped during the

presentation for later analysis of avoidance behavior and

facial expression. Following the subjective ratings for

Trials 1 and 2, the experimenter reentered the experimental

chamber and gave subjects the third (after Trial 2) and the

fourth (after Trial 3) personality questionnaires;

completion time of each averaged about five minutes.

Following Trial 2 and the fourth questionnaire completion,

the experimenter placed headphones on the subject for Trial

3 (the final trial), which was a single audiotape

presentation. The experimenter randomly selected either the

surgical audiotape (describing the surgical videotape the

subject had viewed) or the neutral audiotape (describing the









Table 1. Experimental Procedure and Trial Sequence for
Study 1


TRIAL 1 _I TRIAL 2 1 I TRIAL 3

QUESTION Surgery QUESTION Neutral QUESTION Surgery
NAIRES or NAIRE or NAIRE or
# 1 & 2 Neutral # 3 Surgery # 4 Neutral
VIDEOTAPE VIDEOTAPE AUDIOTAPE
I I I I I


Table 2. Timing Durations and Measures for Each Trial


0 0
N F
S F
E S
T Stimulus presented E
T
BP base IHR, SCL base HR, SCL, (Face:Trials 1,2) BP, SAM
I I I
about 30 si 30 s 60 s I about
30 s









neutral videotape the subject had viewed). The selection of

the surgical or neutral audiotape was balanced across phobia

group, gender, and the order of videotape stimulus

presentation (surgical stimulus first or neutral stimulus

first) during Trials 1 and 2. Trial 3 followed the timing

and data recording paradigm of the first two trials, except

that subjects' faces were not videotaped. After Trial 3,

the experimenter disconnected the recording devices,

debriefed subjects in accordance with APA guidelines

(Appendix D), and dismissed them.

Stimuli

Both phobic (surgical) and neutral videotape and

audiotape stimuli were used in this study; all stimuli were

60 s in duration. Three different videotapes were used,

including two surgical tapes and one neutral tape; all

videotapes were silent. The two surgical videotapes were

taken from the 30-minute film of thoracic operations used by

Ost and colleagues in their studies of blood phobia (e.g.,

Ost & Sterner, 1987). The two 60 s segments used in this

study depicted particularly aversive procedures in which

some cutting or piercing with a sharp instrument occurs.

"Incision" showed a scalpel incising the abdomen several

times, and other sharp instruments cutting muscle tissue.

The second surgical stimulus, "Tubes," showed a sharp tool

puncturing two holes in the abdomen and then plastic

drainage tubes being pulled through the holes. Neither

surgical scene revealed the patient's head or genitalia.









The single neutral videotape showed a wooden toy truck being

pushed over several white ramps and a person's hand picking

up and later putting down yellow blocks.

Three audiotape stimuli (two surgical and one neutral)

were employed, one corresponding to each of the three video

stimuli noted above. Each audiotape presented the voice of

a female who narrated the events in the respective videotape

in an informative, effectively neutral manner. Each

description was 60 s and 160 words long. (See Appendix E

for the transcripts of these descriptions and others used in

Study 2.)

Experimental Environment and Apparatus

Subjects were seated in a recliner with their legs

parallel to the floor, and torso reclined at approximately

30 degrees from vertical, in a 4 m X 4 m experimental

chamber. The chamber's overhead lights were off, but the

room was dimly lit by a floor lamp. A 66 cm (26 in) RCA

Lyceum color television was positioned 2 m in front of the

subject's face. This television presented the videotape

stimuli which were recorded on half-inch VHS videotapes and

played from a Panasonic videorecorder in the adjacent

control room. A 25.4 cm (10 in) Apple computer video

monitor positioned immediately to the right of the subjects'

television presented the self-report ratings display.

Subjects controlled the display by manipulating a

potentiometer knob on a control box attached to the right

arm of their chair. A black and white Panasonic videocamera









with a zoom lens was mounted on the wall in the experimental

chamber near the ceiling slightly to the left of the

television. The camera was focused on the subject's face,

permitting accurate assessment of the direction of gaze, eye

closings, and tensing of facial muscles. Videorecordings of

the subject were made on half-inch VHS videotapes in a

second Panasonic videorecorder in the control room. During

Trial 3, subjects wore comfortable Realistic NOVA 40 stereo

headphones, through which they heard the audio stimuli,

which were recorded on audiocassette tapes and played to

subjects from a General Electric stereo cassette player.

The control room was further equipped with an IBM-PC AT

which ran VPM software (Cook, Atkinson, & Lang, 1987) to

control physiological data collection and the presentation

of the affect ratings display. (See Appendix F for the VPM

control program for this study.) VPM also controlled

physiological data sampling, recording, and analysis using a

Scientific Solutions Labmaster board, an Axon Instruments

TL-1 interface panel, and Coulbourne modules. The control

room also housed a Roche Ultrasonic Blood Pressure Monitor,

Arteriosonde 1225.

Questionnaires

Five questionnaires were used in this study.

1) Mutilation Questionnaire (MQ; Klorman, Weerts, Hastings,

Melamed, & Lang, 1974). The MQ is a 30-item, true-false

questionnaire designed to assess an individual's fear of,

discomfort with, or aversion to blood, injury, mutilation,









and related stimuli. The questionnaire's authors provided

normative data for male and female college students.

Several studies have shown the validity of the MQ relative

to psychophysiological and behavioral indices of blood-

injury concerns (Beiman et al., 1978; Green, Webster,

Beiman, Rosmarin, & Holliday, 1981; Klorman et al., 1977;

Ost, Lindahl, Sterner, & Jerremalm, 1984; Ost & Sterner,

1987).

2) Questionnaire Upon Mental Imagery (QMI; Sheehan 1967).

This questionnaire is the shortened version of Betts' (1909)

original instrument. The QMI contains 35 stimulus items

categorized in seven major sensory modalities. Subjects are

asked to rate the vividness of the images that come to mind

for each item using a seven point scale ranging from 1

("Perfectly clear and vivid") to 7 ("No image at all"). The

sum of all ratings is the total score, which ranges from 35

- 245, with low scores indicating better imagery ability.

This questionnaire has been normed (White, Ashton, & Brown,

1977) and has demonstrated reliability (Evans & Kamemoto,

1973; Hiscock, 1978) and validity (Cook, Melamed, Cuthbert,

McNeil, & Lang, 1988; Miller et al., 1987; Hiscock, 1978).

3) Interpersonal Reactivity Index (IRI; Davis, 1980). The

IRI is a 28-item, self-report questionnaire consisting of

four, factor-derived, 7-item subscales, each of which

assesses a specific aspect of empathy. The Perspective-

Taking scale measures the tendency to adopt the point of

view of other people in everyday life. The Fantasy scale









measures the tendency to transpose oneself into the feelings

and actions of fictitious characters in books, movies, and

plays. The Empathic Concern scale measures the tendency to

experience feelings of warmth, compassion, and concern for

other people. The Personal Distress scale taps one's own

emotional feelings of personal unease and discomfort in

reaction to the emotions of others. Subjects responded to

each item on a 5-point scale ranging from 0 ("does not

describe me well") to 4 ("describes me very well"). Ratings

are summed for the items in each scale, yielding four

scores. Davis (1980) reported that the four scales have

adequate internal consistency and test-retest reliability,

although females score higher than males on all scales.

Convergent and discriminant validity have been reported with

other self-report dimensions (Davis, 1983) and affective

reactions to video stimuli (Davis, Hull, Young, & Warren,

1987).

4) Anxiety Sensitivity Index (ASI, Reiss et al., 1986). The

ASI is a 12-item questionnaire that measures individual

differences in hypersensitivity to one's own anxiety

responses and behavior. Respondents endorse each item using

a 5-point scale ranging from "Very little" (0) to "Very

much" (4). A person's score on the ASI is the sum of the

scores on the 16 items. Reiss et al. (1986) provided

reliability data showing that the ASI has adequate internal

consistency and test-retest reliability. They also found

that anxiety disorder patients scored higher than non-









disordered subjects, and the questionnaire accounted for

Fear Survey Schedule variance which remained unaccounted for

by specific fear endorsement.

5) Fenz and Epstein Anxiety Questionnaire (FEQ; Fenz &

Epstein, 1965; Fenz, 1967). The FEQ is a 53-item

questionnaire listing symptoms of anxiety which are rated by

the respondent on a 5-point scale ranging from 1 ("never

applies to you") to 5 ("experience it almost all of the

time"). The scale was developed and factor analyzed to

divide manifest anxiety into its component dimensions.

Three factors are separately scored by totaling the ratings

for the items in each scale: striated muscle tension,

autonomic arousal, and feelings of fear and insecurity.

Fenz (1967) provided reliability coefficients for each scale

and found that "neurotics" scored higher than normals on all

three scales.

Dependent Measures

Dependent measures are categorized according to Lang's

(1968) three systems model of emotion: self-report indices

(i.e., verbal behavior or subjective responses),

physiological reactions, and overt motor behavior.

Self-report.1 The Self Assessment Manikin (SAM; Hodes,

Cook, & Lang, 1985; Lang, 1980) is a graphic video display

instrument for obtaining subjective ratings on three

independent affective dimensions: pleasure--displeasure,

arousal-calmness, and control--lack of control. SAM is

presented as a manikin whose features are dynamically









modifiable by subjects to represent their affect using a

potentiometer on the arm of their chair. The VPM software

program presents the three graphic displays in random order

to the subject on a video monitor. The pictorial display is

converted by the computer to a 21-point scale. In the

pleasure display, SAM's facial expression changes from a

smile to a frown; in the arousal display, SAM's "abdomen" (a

random and changing patters of dots) increases or decreases

in size and rate of change, and SAM's eyes open and close;

in the control display, SAM changes in size from very small

to very large. The validity of the three SAM ratings of

affect has been demonstrated in several studies (Cook et

al., 1988; Greenwald, Cook, & Lang, in press; Hodes et al.,

1985). For these three self-report measures, difference

scores were calculated by subtracting the baseline affect

rating (taken before Trial 1) from the affect rating for

each trial. These studies used labels for the negative

poles of each affective dimension ("displeasure," "arousal,"

"lack of control") to achieve consistency in presentation.
Physiological indices. Three different physiological

indices of affect were assessed.

1) Skin conductance level (SCL). SCL was recorded from two

Beckman Ag-AgC1 miniature electrodes placed on the thenar

and hypothenar eminence of the left hand after moistening

the palm with distilled water. A neutral paste (petroleum

jelly) was used in the electrode. Analog SCL was sampled at
10 hertz using a .5 volt constant voltage Coulbourne Skin









Conductance Coupler (S71-22), which output a digital signal

to the computer. VPM software reconverted the digital value

to micromhos, and calculated mean SCL for the 10 s baseline

immediately prior to stimulus onset and for the entire 60 s

stimulus presentation period. SCL difference scores were

calculated by subtracting the 10 s baseline SCL from the

stimulus SCL.

2) Heart rate (HR). The electrocardiogram (ECG) was

recorded from two Beckman Ag-AgC1 miniature electrodes

placed on the left and right forearms after preparing the

subject's skin with alcohol and electrode paste (Hewlett-

Packard Redux). The ECG waveform was sampled at 10 hertz

and fed from a Coulbourne bioamplifier (S75-01) into a

Coulbourne Bipolar Comparator (S21-06), which detected the

"R" wave at suprathreshold levels, and output the signal

into a Coulbourne Retriggerable One Shot (S52-12), which

then output a digital signal to the computer. VPM software

calculated R-R interbeat intervals to the nearest

millisecond and converted heart period to heart rate. Mean

HR was calculated for 10 s baseline immediately prior to

stimulus onset and for the 60 s stimulus presentation

period. HR difference scores were calculated by subtracting

the baseline HR from the stimulus HR.

3) Blood pressure. Both systolic blood pressure (SBP) and

diastolic blood pressure (DBP) were monitored using an

automated sphymomanometer with the cuff attached to

subjects' left upper arm. The experimenter manually









initiated cuff inflation from the control room and then

recorded the LED digital output by hand. Cuff inflation

required about 5 s, and deflation required about 25 s.

Difference scores were calculated by subtracting the SBP and

DBP values taken before each trial from the values obtained

at stimulus offset.

Motor behavior. Two variables were assessed from the

videotaped recordings of subjects' faces while they watched

the surgery and neutral videotapes. Two independent raters,

blind to the study hypotheses and to the videotape type

(surgery versus neutral) for each subject were trained to

code these variables.

1) Avoidance of eye contact with stimulus. This measure was

recorded as the number of seconds out of 60 that a subject's

eyes were closed or were not directed at the television

screen during the stimulus. Because the resulting

distribution was highly skewed and, therefore, not amenable

to parametric statistics, subjects were dichotomously

classified for each videotape. Avoidance was coded

positively if subjects showed at least one second of

avoidance during the videotape, and negatively if there was

less than one second of avoidance. Interrater reliability

was calculated as the percentage agreement between the two

coders. They agreed on the presence or absence of avoidance

for 47 of 48 subjects (98%) during the surgery videotape,

and they agreed on all 48 subjects (100%) for the neutral

videotape.









2) Facial expressions of disgust. An evaluation of all

videotapes indicated that when subjects made a facial

expression during viewing, they routinely tensed either or

both of two muscle groups, resulting in furrowing of the

eyebrows and raising of the upper lip. According to Ekman,

Friesen, and Ellsworth (1972), this facial pattern signifies

the emotion of disgust. Thus, coders rated the maximum

degree that these muscle groups were tensed during each 60 s

videorecording using a 5-point scale (0 = "no tensing

evident," 1 "minimal tensing," 2 "mild tensing," 3 -

"moderate tensing," 4 = "severe tensing"). Since the

distribution of ratings for the nonphobics was restricted

greatly, and the vast majority of ratings for both groups

was zero during the neutral videotape, the data were treated

as frequency data and collapsed into three categories to

increase the n per cell. Original values of 0 were

classified as "none," values of 1 and 2 were classified as

"low," and values of 3 and 4 were classified as "high." The

two raters agreed on the scoring for the three levels of

facial disgust for 46 of 48 subjects (96%) during the

surgery stimulus, and 45 of 48 subjects (94%) during the

neutral stimulus.
Results

Personality Measures

The means and standard deviations for each of the four

personality questionnaires and their subscales for the

phobics and nonphobics are presented in Table 3. Phobics









were compared with nonphobics using independent groups t-

tests. As Table 3 indicates, phobics had greater anxiety

sensitivity (ASI), feelings of personal distress (IRI-

Personal Distress), and general fear and insecurity (FEQ)

than did the controls. The groups did not differ on the IRI

subscales of Fantasy, Empathic Concern, or Perspective

Taking Ability, nor on the FEQ subscales of Muscular Tension

or Autonomic Arousal. Unexpectedly, the nonphobics reported

better mental imagery ability (QMI) than did the phobics.

Videotape Stimuli

Data analysis. A general data analytic strategy

examined affect during the two videotape stimuli (Trials 1

and 2) for displeasure, arousal, lack of control, HR, SCL,

SBP, and DBP. First, each dependent measure was analyzed in

a mixed-model repeated-measures analysis of variance (ANOVA)

in which Video (surgery and neutral videotape) was the

within-subject effect, and Group, Order (surgery videotape

presented first or neutral videotape presented first), and

Surgery ("Incision" or "Tubes" videotape) were between-

subjects variables. Significant interactions from this

model were examined via simple effects analyses using

appropriate error terms for repeated-measures models

(Howell, 1982) and corrected error degrees of freedom when

heterogeneous sources of error variance were pooled

(Satterthwaite, 1946). Typically, these simple effects

analyses examined differences between phobics and controls

for each videotape separately, and each Group was examined










Table 3. Questionnaires Scores for Phobics and Nonphobics


Phobics
M (SD)

24.1 (8.2)


Nonphobics
M (SD) t(46)


15.9 (10.4)


3.04 .004


IRI
Personal Distress
Fantasy
Empathic Concern
Perspective taking

FEQ
Fear/Insecurity
Muscular Tension
Autonomic Arousal


QMI


14.9
17.6
21.0
16.0


49.8
31.0
30.8


(5.0)
(5.2)
(3.3)
(5.9)


(10.9)
(7.9)
(7.6)


92.0 (24.1)


8.8
18.7
20.4
18.5


40.3
30.9
28.4


(3.4)
(5.6)
(4.9)
(4.9)


(11.6)
(10.8)
(10.0)


74.3 (14.3)


a p-values were determined


Measure


ASI


4.87
0.70
0.52
1.63


2.91
0.04
0.93

3.12


.0001
n.s.
n.s.
.11


.006
n.s.
n.s.


.003


using two-tailed tests









separately across the two videotapes. Simple effects

analyses were considered significant at the .01 probability

level. Appendix L presents the complete ANOVA tables.

Self-report measures. Displeasure, arousal, and lack

of control change scores from baseline for the phobics and

nonphobics for both surgery and neutral videotapes are

presented in Table 4. Similar results were found for all

three measures. During the surgery videotape, phobics

reported more arousal, displeasure, and lack of control than

did the nonphobics, whereas during the neutral videotape,

the two groups did not differ in any measure. Across

videotapes, the phobics reported greater negative affect on

all three measures to the surgery than to the neutral

videotape. The nonphobics reported greater arousal to the

surgery than to the neutral videotape, but no difference in

control to the two videotapes, (Video X Group interactions

for displeasure, E(1, 40) = 34.91, R < .0001; arousal, F(1,

40) = 14.76, R < .0004; and lack of control, F(l, 40) =

24.33, p < .0001). For displeasure, however, there was an

influence of videotape order (see Appendix K for these

data). Phobics reported more displeasure to the surgery

videotape when it was presented before, but not after, the

neutral videotape. Nonphobics reported more displeasure to

the surgery videotape than to the neutral videotape only

when the surgery was presented after, but not before, the

neutral videotape, (displeasure Video X Group X Order

interaction, f(l, 40) = 8.73, R < .006). Videotape order









Table 4. Self-Reported Changes in Displeasure, Arousal,
and Lack of Control During the Surgery and
Neutral Videotapes for Phobics and Nonphobics


Videotape Stimulus

Surgery Neutral
M (SD) M (SD)
Phobics
Displeasure 9.7 (4.6) -0.7 (2.6)
Arousal 8.1 (6.9) -4.0 (6.7)
Lack of Control 4.7 (6.3) -5.4 (4.4)

Nonphobics
Displeasure 2.8 (3.8) -0.3 (3.2)
Arousal 2.8 (5.7) -3.6 (4.2)
Lack of Control -1.9 (5.0) -4.1 (4.5)









did not affect arousal or control, and surgery type ("Tubes"

or "Incision") was unrelated to any self-report variable.

Physiological measures. Figure 1 presents mean SCL and

HR change scores during the "Incision" and "Tubes" surgery

videotapes and the neutral videotape for phobics and

nonphobics. As the figure reveals, the SCL and HR of the

phobics who viewed "Incision" was greater than the SCL and

HR of a) nonphobics who viewed "Incision," and b) phobics

who viewed "Tubes." Phobics and nonphobics did not differ

in SCL or HR during "Tubes," nor did the nonphobics' SCL or

HR differ to the two surgeries. Across videotapes, both

phobics and nonphobics had a greater SCL during the surgery

than the neutral videotape, regardless of Surgery type.

However, HR change was greater during the surgery than the

neutral videotape only for phobics who viewed "Incision,"

but not for phobics who viewed "Tubes" or for the

nonphobics. Phobics and nonphobics did not differ in SCL or

HR during the neutral videotape, (for SCL: Group X Surgery,

f(1, 40) = 4.30, E = .044, and Video X Group X Surgery, E(l,

40) = 3.74, R = .06; for HR: Video X Group X Surgery, F(l,

40) = 12.07, R = .001).

Although videotape Order failed to significantly affect

SCL, it did influence HR (see Appendix K). Phobics who

viewed a surgery before viewing the neutral videotape had a

greater HR increase than a) nonphobics who saw a surgery

first, and b) phobics who saw a surgery second. Across

videotapes, only those phobics who saw a surgery before the










PI.....PI Phobics, Incision
PT---PT Phobics, Tubes
NI- -NI Nonphobics, Incision
NT._._.NT Nonphobics, Tubes


2.0 +


6 +


PI
4

e

*

*


*


*
*
*,
*
*
*

.
*
*
*
*
*
*
*


S
S


4 +


NT
\
PT \




NI






\ .\ .*
\ \ .


*.

NT


0 +


C
0
N
D
U
C
T
A
N
C
E

C
H
A
N
G
E



M
I
C
R
0
M
H
0
S


-2 H


NPI
'NT


NI
/


INI
-4 +
--------------+--


Videotape


Figure 1.


Skin Conductance Level Change and Heart Rate
Change Across Surgery and Neutral Videotapes for
Phobics and Nonphobics by Type of Surgery Viewed


1.5 +


B
P
M
"""'


1.0









0.5









0.0


-0.5


----------------
--+--------+--


Surgery


Neutral


Surgery


Neutral









neutral videotape had a greater HR during the surgery than

during the neutral, (Video X Order, F(1, 40) = 12.79, R =

.0009; Group X Order, f(1, 40) = 4.16, R = .048).

Analyses of changes in SBP and DBP failed to reveal any

significant effects or even nonsignificant trends within or

across videotapes or as a function of Group, Order, or

Surgery for either dependent measure.

Motor behavior measures. Avoidance and the maximum

facial expression of disgust during the videotapes were

analyzed as frequency data using chi-square analyses.

Tables 5 and 6 present these data for both phobics and

nonphobics for both videotapes by type of surgery and order

of presentation. Phobics more frequently avoided and showed

"high" disgust2 than did the nonphobics during the surgery

"Incision" but not during "Tubes," (avoidance, X2(1) = 8.71,

R < .005; disgust, X2(1) = 9.88, R < .005). Among the
phobics, avoidance was significantly more frequent, and

"high" disgust tended to be more frequent during "Incision"

than during "Tubes," (avoidance, X2(1) = 6.171, R < .013;

and disgust, X2(1) = 2.74, R < .10). Avoidance and disgust

of the nonphobics was not influenced by the type of surgery.

With respect to stimulus order, phobics avoided the surgery

videotape more than the nonphobics only when the surgery was

shown first, X2(1) = 5.04, R < .025; but the groups did not

differ in avoidance of the surgery when it was presented

after the neutral videotape. Stimulus order did not affect

the phobics or nonphobics' avoidance of the surgery when









Table 5. Number of Phobics and Nonphobics Displaying
Avoidance Behavior During the Surgery and Neutral
Videotapes by Type of Surgery Viewed and Order of
Videotape Presentation



Videotape Stimulus
Surgery Neutral

Avoidance
Yes No Yes No

Phobics (n=24) 10 14 4 20

Type of Surgery
"Incision" (n=12) 8 4 4 8
"Tubes" (n=12) 2 10 0 12

Order of Presentation
Surgery first (n=12) 6 6 3 9
Neutral first (n=12) 4 8 1 11

Nonphobics (n=24) 2 22 2 22

Type of Surgery
"Incision" (n=12) 1 11 0 12
"Tubes" (n=12) 1 11 2 10

Order of Presentation
Surgery first (n=12) 1 11 1 11
Neutral first (n=12) 1 11 1 11










Table 6. Number of Phobics and Nonphobics Displaying Facial
Expressions of Disgust During the Surgery and
Neutral Videotapes by Type of Surgery Viewed and
Order of Videotape Presentation


Videotape
Surgery


none low


Phobics (n=24)

Type of Surgery
"Incision"
"Tubes"


Stimulus
Neutral


Disgust Level
high none low


5 9 10


2 0


(n=12)
(n=12)


Order of Presentation
Surgery first (n=12)
Neutral first (n=12)

Nonphobics (n=24)


8 16 0


3 0


Type of Surgery
"Incision"
"Tubes"


(n=12)
(n=12)


Order of Presentation
Surgery first (n=12) 5 7 0 10 2 0
Neutral first (n=12) 3 9 0 11 1 0


high









each group was examined alone. The disgust of both groups

was not affected by the order of presentation. Finally,

during the neutral videotape, phobics did not differ from

nonphobics in avoidance or disgust.

Next, the frequency of avoidance and disgust across the

two videotapes was examined.3 Significantly more phobics (7

of 8) differentially avoided the surgery rather than the

neutral videotape, X2(1) = 4.50, E < .035; and more phobics

(19 of 19) showed higher levels of disgust during the

surgery videotape than during the neutral videotape, X2(1) =

19.0, R < .0001. The nonphobics did not differentially

avoid the two stimuli, but all 13 of the nonphobics who

differentially showed disgust to the two videotapes showed

higher disgust levels during the surgery videotape, X2(1) =

13.0, E < .001. Surgery type and presentation order did not

influence disgust across videotapes.

Audiotape Stimuli

Data analyses. Dependent measures assessed during the

audiotape presentation (Trial 3) included displeasure,

arousal, lack of control, HR, SCL, SBP, and DBP. Motor

behavior was not assessed during the audiotape trial. Data

analyses for these dependent measures used univariate ANOVAs

which included the following between-subjects effects and

their interactions: Audio (whether the subject heard the

surgery or the neutral audiotape), Group, Order (of the

preceding surgery and neutral videotapes), and Surgery.









Self-report measures. Data for the three self-report

measures for phobics and nonphobics by type of audiotape

presentation (surgery or neutral) are presented in Table 7.

The results for displeasure and control lack are identical.

Phobics who heard a surgery audiotape reported more

displeasure and lack of control than nonphobics who heard a

surgery audiotape, and more displeasure and lack of control

than phobics who heard the neutral audiotape. These two

variables did not differ for the nonphobics during the two

audiotapes. The two groups did not differ in displeasure or

lack of control during the neutral audiotape, (Group X Audio

interactions for displeasure, F(l, 32) = 7.95, R < .009; and

lack of control, F(l, 32) = 10.57, R < .003). For arousal,

whether subjects were phobic or not, greater arousal was

reported to the surgery audiotape than to the neutral

audiotape, (Audio main effect, F(1, 32) = 27.03, E < .0001).

For all three self-report measures, there was no difference

in response to "Incision" or "Tubes" or to the order in

which the subjects had viewed the preceding videotapes.

Physiological measures. Subjects who heard the surgery

audiotape had a higher SCL (M = -0.21, SD = 0.56) than

subjects who heard the neutral audiotape (M = -0.51, SD =

0.36), Audio main effect, F(l, 32) = 5.08, R < .032. There

were no differences between phobics and nonphobics, nor were

there differences as a function of Surgery or Order. For

HR, SBP, and DBP, the ANOVAs revealed no significant effects

of Audiotape, Group, or the other independent variables.









Table 7. Self-reported Change in Displeasure, Arousal,
and Lack of Control During the Audiotape
Presentation for Phobics and Nonphobics by Type of
Audiotape (Surgery or Neutral)


Audiotape Stimulus

Surgery Neutral
Phobics M (SD) M (SD)

Displeasure 7.7 (4.7) 0.3 (3.6)
Arousal 4.8 (4.6) -2.6 (7.3)
Lack of Control 3.1 (4.9) -6.3 (3.5)

Nonphobics

Displeasure 2.7 (2.5) 1.9 (2.8)
Arousal 3.2 (4.9) -5.4 (5.2)
Lack of Control -1.7 (3.8) -3.1 (4.3)









Discussion

This study accomplished several goals. First, it

compared blood phobics with nonphobic controls on specific

personality dimensions and found differences of theoretical

importance. Second, affect (subjective, psychophysiologic,

and motor) of phobics and nonphobics was examined during

surgical and neutral videotapes. Phobics displayed more

negative affect to the surgical presentation than did the

nonphobics, but the groups did not differ during the neutral

stimulus. Both groups had greater negative affect to the

surgical than to the neutral stimulus. Third, two different

surgery videotapes were compared, and one was more aversive

than the other. Fourth, the order of surgical and neutral

stimulus presentations was evaluated and found to have some

effect on responding. Finally, phobics and nonphobics heard

surgical or neutral audiotape presentations, and the

observed differences were fairly limited.

Psychometric Assessment

Theory and anecdotal observations specific to blood

phobia guided the assessment of four personality dimensions.

Consistent with the findings of Kleinknecht (1988a), blood

phobics reported greater "anxiety sensitivity," suggesting

they are more attuned to and concerned about physiological

indices of their own arousal than are nonphobics.

Unfortunately, the questionnaire assessed sympathetic

aspects of anxiety and not the parasympathetic activity

which blood phobics may experience. Nonetheless, if one can









extrapolate from the current assessment of anxiety to

parasympathetic symptoms, then this finding supports Engel's

(1978) hypothesis that blood phobics are hypervigilant about

and overly fearful of their own negative physical and

emotional responses to blood-related stimuli. Future

research should assess parasympathetic symptoms to test this

extrapolation.

The Fenz-Epstein Anxiety Questionnaire assessed the

degree to which blood phobics differ from normals and are

like other anxiety and psychosomatic disordered patients

("neurotics"). Blood phobics did not have elevated general
levels of autonomic arousal or muscular tension, suggesting

that they differ from the classic neurotic pattern of

anxious tension and autonomic liability. However, like other

"neurotic" patients, blood phobics reported greater general

fear and insecurity than controls. This finding is

consistent with Engel's (1978) model in that blood phobics

may overly seek to appear socially adequate and in control,

especially when experiencing discomforting physical and

emotional sensations.

The suggestion that blood phobics strongly identify

with the victim (Beck & Emery, 1986)--that they are able to

"feel" what the other person is feeling or to "get under the

skin" of the other--was assessed via questionnaires of

empathy and mental imagery. On the empathy scale, blood

phobics and controls did not differ in their ability to

fantasize, to take another's perspective, or in their









concern and caring about others. Yet blood phobics rated

themselves as more likely to feel personal distress or

unease in reaction to other's negative emotions. This

finding replicates that of Kleinknecht (1988a) and helps to

operationalize the notion of identifying with a victim.

Thus, an injury or pain in another person precipitates quite

readily negative affect in the blood phobic.

Mental imagery ability was assessed also to examine

identification with the victim. Unexpectedly, nonphobic

controls reported more vivid mental imagery than phobics.

This may be due not to poor imagery of phobics, but rather

to a nonphobic sample with unusually good imagery scores.

Replication with another sample is needed to confirm the

group difference.

It is tempting to speculate that the increased anxiety

sensitivity, general fear and insecurity, and personalized

empathic distress predated and abetted the full-blown

phobia; however, it is quite possible that these

characteristics resulted from one or more negative reactions

to blood-relevant stimuli. Longitudinal research is needed

to clarify this interpretive bind.

Affect During Videotaped Stimuli

This study used neutral stimulus material to control

for the effects of the experimental setting and stimulus

viewing and to permit definitive conclusions regarding the

affective responding of phobics and nonphobics to phobic

material. Thus, all subjects viewed a 60 s neutral









videotape in addition to a 60 s surgical videotape.

Equivalent levels of negative affect were displayed by both

groups during the neutral videotape, suggesting that any

observed differences during the surgical scene were not

attributable to extraneous factors of the experimental

setting.

Given the affective equivalence of phobics and

nonphobics to the neutral stimulus, it was expected that

phobics would report greater negative affect, be more

physiologically aroused, and show more avoidance and facial

expressions of disgust during a surgical videotape than

would nonphobics. Indeed, for most dependent measures, the

average scores of the blood phobics as a group indicated

that they had greater negative affect. Yet, the observed

differences for several dependent measures were limited by

the particular surgery scene viewed and/or the order of

videotape presentation.

For HR, SCL, facial disgust, and avoidance, differences

between phobics and controls were limited to the surgery

videotape, "Incision," which depicted a scalpel cutting a

person's abdomen and sharp tools opening the wound. Phobics

who viewed this surgery responded more negatively than did

nonphobics who viewed "Incision." No differences were found

between phobics and nonphobics during the surgery videotape

"Tubes," which showed a pliers-type tool puncturing a

person's abdomen and pulling plastic drainage tubes through

the holes. The nonphobics responded with a fairly low level









of negative affect to both surgeries; however, among the

phobics, "Incision" was more aversive than "Tubes." The

observed differences between the two surgical scenes is

interesting, in that both scenes show blood and the

"mutilation" of a portion of one's abdomen.

There are several possible explanations for the

observed differences. First, although the two videotapes

were similar in gross aspects, "Incision" simply may be a

more powerful aversive stimulus than "Tubes," in that a

scalpel cutting may be more aversive than a pair of pliers

puncturing and pulling. A second, perhaps related

hypothesis pertains to the observers' comprehension of the

events depicted. In this study, subjects had been informed

previously only that the videotapes showed portions of a

surgery on a living human being. The insertion of the tubes

might have not been recognized readily as a surgical

procedure, in contrast to the clearly recognized scalpel

incision. Thus, "Tubes" might have evoked increased

curiosity, and hence, less aversion than "Incision." This

hypothesis might be empirically examined by providing

subjects a description of the "Tubes" surgery before or

during viewing, thus eliminating uncertainty about content.

Affective group differences to the surgery videotapes

were limited also by the order of videotape presentation.

During the surgery presentation, phobics had higher HRs and

showed more avoidance than controls only when the surgical

stimulus was presented first rather than second; when the









surgery was presented after the neutral, the groups did not

differ. Among phobics, a surgical scene viewed first

elicited more displeasure as well as tachycardia and

avoidance than did a surgical presentation after the neutral

videotape.

A parsimonious explanation for the observed effects is

that habituation occurred, and subjects felt generally less

aroused to a later presentation of a surgery than to an

earlier presentation due to the passage of time and

accommodation to the experimental setting. An alternative

explanation is that subjects acquired information during the

earlier presentation of the neutral stimulus which resulted

in lower anxiety on a subsequent presentation. Information

potentially acquired during the initial neutral exposure

included the duration of the stimulus, the functioning of

the television, and a reduction in ambiguity regarding which

stimulus (surgery or neutral) they were most likely to see

next. A test of these two hypotheses might be achieved by

comparing two groups of phobics, one which views a neutral

followed by a surgery film, whereas the other waits an equal

length of time before viewing a surgery film.

Alternatively, order effects might be controlled by

providing a practice videotape trial before presenting the

two stimuli of interest and informing subjects of the order

of scenes.

Thus, several variables other than the presence or

absence of blood phobia influenced responding to surgical









stimuli. It should be remembered, however, that the

observed effects of surgery type and/or order may be due to

bias in random assignment; for example, the 12 phobics

assigned to view "Incision" or to view a surgery before the

neutral videotape may have differed in some important, yet

unassessed way from other phobics. The need for replication

on a different and larger sample of phobics is clear.

In addition to comparisons between phobics and

nonphobics, this study examined each group's affect to both

surgical and neutral stimuli. As expected, phobics reported

greater displeasure, lack of control, and arousal during the

surgery videotape than during the neutral videotape.

Nonphobics also reported greater arousal to the surgery

stimulus, but limited or absent differences in displeasure

and control. On physiological measures, the differences

between videotapes were less robust. Both phobics and

nonphobics had a higher SCL during the surgery videotape in

comparison to the neutral videotape. For HR, only those

phobics who viewed "Incision" or who viewed a surgery first

were more tachycardic during the surgery than during the

neutral videotape. The HR of other phobic subgroups and of

the nonphobics did not differ during the two stimuli. Blood

pressure measures did not differentiate the two videotapes

for either group. Finally, both phobics and nonphobics more

frequently displayed facial expressions of disgust to the

surgery than to the neutral videotape; however, only the

phobics more frequently avoided the surgery than the neutral









videotape. In summary, phobics clearly showed more negative

affect during the surgery videotape than during the neutral

videotape, especially for the surgery "Incision," whereas

nonphobics showed similar but less pronounced and less

consistent affective differences to the two stimuli. The

observation of some increase in negative affect to the

surgery scene for the nonphobics is consistent with the view

that aversiveness to blood-related stimuli exists on a

continuum. Whereas extreme cases may be considered phobic,

cases selected from other portions of the distribution (such

as below the median) have relatively less aversion, but

still more than to a neutral stimulus.

Steptoe and Wardle (1988) suspected that when both

blood-related and neutral material were presented to blood

phobics, the order of presentation would be important. In

their study, they eschewed stimulus counterbalancing and

presented to all subjects the bloody stimulus first followed

by the neutral stimulus. They presumed that the

presentation of the neutral stimulus first to half of the

phobics would have yielded a biased sample of "neutral"

responding, with elevated fear due to anticipatory anxiety

over the upcoming phobic stimulus. The current study tested

their assumption and found, contrary to their hypothesis, no

evidence that responses during a first presentation of the

neutral videotape differed from responses during the second

neutral stimulus presentation. Furthermore, the order

effects found in this study suggest that Steptoe and









Wardle's presentation of the blood stimulus first probably

resulted in greater negative affect to it, and greater

differences between the blood and subsequent neutral

stimulus.

Affect During Audiotaped Stimuli

This study also assessed affective responding during

verbal descriptions of phobic and neutral stimuli in order

to understand how various stimulus presentation modalities

influence the affect of blood phobics. All subjects heard

an audiotaped description of either the surgery or the

neutral scene that they had just seen.

Phobics who listened to a surgical description reported

more displeasure and control lack than phobics who heard the

neutral description or nonphobics who heard a surgical

description; however, only these two variables discriminated

conditions. Self-reported arousal and SCL were increased

during the surgery audiotape regardless of whether a person

was phobic or not, and neither HR nor BP measures differed

as a function of stimulus content or group. In summary, the

effects of group and stimulus type during audiotape

presentations were less robust than during videotape

presentations. Potential reasons are discussed later.

Methodological Issues

It must be acknowledged that the observed differences

between phobics and nonphobics and also between surgical and

neutral stimuli were of limited magnitude. First, the

subject selection procedure probably reduced group









differences. Phobics and nonphobics were selected from

different points of a nearly normal distribution of MQ

scores using rather arbitrary cut-scores. Restriction of

those ranges by studying only the few highest scoring

phobics or lowest scoring nonphobics might have increased

the observed effect size. Alternatively, studying phobics

presenting for treatment (although such people are rare)

likely would have yielded more clear differences.

Limited differences also were found between surgical

and neutral stimuli. In addition to the effects of stimulus

presentation order and surgery type described above, the

type of phobic stimulus undoubtedly had an impact. First,

it is possible that a videotaped portion of a surgery is

less aversive than, for example, mutilation scenes such as

injuries, accidents, etc. Additionally, although the two

surgery scenes were taken from an apparently powerful phobic

stimulus of thoracic operations (Ost, Sterner, & Lindahl,

1984), the presentation methods differed markedly. Ost and

colleagues showed a continuous 30 minute videotape that

included scenes of the full human patient during surgery.

In the current study, the elimination of scenes showing the

patient's face or full body might have reduced the negative

impact of the stimulus. Indeed, during debriefing, many

phobics noted that the operation seemed somewhat unreal,

partly because they did not know for sure that a human was

undergoing surgery. Finally, unlike the methodology of Ost

and colleagues in which the 30 minute stimulus was not









stopped until fainting or continuous avoidance occurred,

this study's use of a 60 s stimulus permitted the collection

of uniform data for all subjects but probably also decreased

exposure intensity. In summary, a more intense phobic

stimulus probably would have increased group differences.
Notes

1 An attempt was made to assess feelings of faintness and of
nausea independent from the three SAM scores by presenting
two VPM-generated visual analog scales to subjects following
each of the SAM ratings. Scores from these faintness and
nausea scales were found to be highly correlated with the
self-reported displeasure (r = .66 and .70, respectively),
to be much more highly endorsed by females (unlike the three
SAM measures), and to be highly skewed with most scores
being zero. Additionally, given the experimental nature of
these scales and the lack of prior psychometric data, these
scales are not presented in this manuscript.
2 When examining the effects of Surgery and Order on facial
disgust, three levels of disgust would have resulted in
unacceptably low sample sizes for chi-square analyses. Thus,
for these analyses, a single "low" category was created by
collapsing the "none" and "low" categories.

3 Chi-square analyses across stimuli (within-subjects) must
not violate the assumption of independent observations;
therefore, these analyses for avoidance and facial disgust
utilized McNemar's (1969) suggestion to determine if the
number of subjects who, for example, showed avoidance
differentially during the two videotapes varied
significantly from expected. The null hypothesis in this
case is that the number of subjects who avoided the surgical
videotape but not the neutral videotape equals the number of
subjects who avoided the neutral videotape but not the
surgery. Chi-square goodness of fit tests evaluated this
hypothesis.

4 The small number of subjects who showed differential
avoidance to the two videotapes precluded an analysis of the
effects of surgery type and presentation order.















STUDY 2

Introduction

The goals of Study 2 were to a) evaluate the presence

and extent of habituation to repeated exposures to a

surgical visual stimulus and dishabituation to a novel

surgical stimulus; b) assess the effect on habituation and

dishabituation of preparing blood phobics by providing

either a relevant description of the upcoming surgery or a

neutral control description; and c) examine how imagery

ability and coping style moderate the effects of preparation

and repeated exposures.

Exposure and Affect Change

A wealth of clinical data strongly supports the

proposal that exposure--by various means--changes affect

(Barlow, 1988; Foa & Kozak, 1985; Marks, 1978). In

particular, these researchers agree that exposure to

anxiety-evoking stimuli produces the changes noted during

treatment of anxiety disorders and phobias. It is

noteworthy that each of the therapeutic interventions for

blood phobia noted in the General Introduction incorporates

some form of exposure to blood-relevant material.

Yet few studies have examined the process of emotional

change during exposure to aversive stimuli in blood phobia.

Hare et al. (1971) studied normal adults and found that









repeated presentations of the same mutilation slide resulted

in rapid physiological habituation, whereas different

mutilation slides interfered with habituation. Similar

studies have presented mutilation slides with the purpose of

studying orienting and defense reactions in blood phobics

(Klorman et al., 1975, 1977). The use of repeated exposure

to videotapes or films is rare (see Klorman, 1974 for an

exception) and has not been conducted with blood phobics.

It is difficult to achieve prolonged exposure in blood

phobia without incorporating syncope-preventing strategies

or suffering missing data. Therefore, the current paradigm

used brief, repeated exposures to surgical stimuli to

produce habituation in blood phobics.

Studies of repeated exposures to aversive stimuli

typically have not examined the generalization of reduced

affect to related stimuli once extinction or habituation to

one stimulus has occurred. Yet repeated visual exposures to

a blood-related stimulus may result in reduced negative

affect to a novel blood-related stimulus secondary to

modifications in the "blood-related" emotional network.

Preparatory Information

Exposing subjects to films was the paradigmatic

approach of Lazarus and colleagues, who explored the

efficacy of verbal "defensive sets" to modify stress

responses during mutilation and other stressful films

(Lazarus & Alfert, 1964; Lazarus, Speisman, Mordkoff, &

Davison, 1962; Speisman, Lazarus, Mordkoff, & Davison,









1964). In these studies, introductory statements or film

soundtracks were modified to induce "intellectualization" or

"denial" sets. The finding of group differences on some

physiological measures prompted the authors' claim that

defensive sets effectively "short-circuited" stress.

Alternatively, the presentation of accurate preparatory

information may have led to decreased physiological arousal.

A large literature indicates the need to consider the

affect-modifying role of preparatory information. Many

studies have demonstrated that preparing medical and dental

patients with information about upcoming aversive procedures

reduces physiological arousal, behavioral escape or

avoidance, and subjective distress at various points before,

during, and after the procedure (Anderson & Masur, 1983;

MacDonald & Kuiper, 1983; Rogers & Reich, 1986; Silver &

Wortman, 1980). These preparation researchers have not

discussed the affect-modifying effects of information in an

emotional imagery framework (Hebb, 1968; Lang, 1979, 1985).

In this view, a perceptual-motor memory is activated,

observable visceral and motor responses occur, and

modification of the memory's stimulus, meaning, and response

propositions is facilitated. Thus, preparatory information

may reduce fear of an event by activating the relevant

emotional network and permitting fear modification.

Several individual difference variables may influence

the effect of preparatory information and/or the change in

affect across exposure repetitions. First, individuals









differ in their ability to create vivid images from verbal

prompts, with resulting differences in visceral activity,

and these imagery ability differences can be reliably

assessed via questionnaire (Miller et al., 1987). Good

imagers processing fear-relevant verbal descriptions

demonstrate more arousal than do poor imagers (Cook et al.,

1988).

Second, a person's coping style may influence

preparation effects and emotion during single or repeated

presentations of an aversive stimulus. Briefly, the coping

style literature claims that people consistently differ in

their preferred manner of dealing with aversive stimuli.

Some people preferentially gather information about and

directly engage the stimulus in order to decrease negative

affect. Others tend to avoid information about the stimulus

and negate its relevance and impact. These two coping

styles variously have been termed sensitization and

repression (Byrne, 1961), confrontation and avoidance (Suls

& Fletcher, 1986), and monitoring and blunting (Miller,

1980), and can be assessed reliably via questionnaires such

as Miller's (1980) instrument. Prior research on preparing

medical patients for noxious procedures found that

continuous presentations of information decreased anxiety of

monitors but increased anxiety of blunters (Shipley, Butt, &

Horwitz, 1979; Shipley, Butt, Horwitz, & Farby, 1978). Of

importance to the current study, information and stimulus

repetition may interact with subjects' coping style,









yielding different patterns of affect change across

repetitions.

Summary and Purpose of the Study

This study addressed several questions about exposure

and affect change in blood phobia. First, does repeated

exposure to a phobic stimulus (surgery videotape) result in

decreased negative affect over repetitions? If such

habituation occurs, to what degree does it generalize to a

novel blood-related stimulus? These questions were

addressed by exposing one group of blood phobics (Video Only

Group) to seven repetitions of a surgical videotape followed

by one novel surgery presentation.

Second, this study examined the effects on habituation

and dishabituation of providing blood phobics with

preparatory verbal descriptions before each surgery

videotape exposure. Two types of verbal descriptions were

used. One group of phobics (Surgery Audiotape Group) heard

a factual description of the upcoming surgery before each

repetition. They were compared with a control group of

phobics (Neutral Audiotape Group) who heard an irrelevant

preparatory description before each surgery videotape

repetition. It was expected that the prepared phobics would

have less negative affect than the controls during each

surgery videotape. Finally, this study examined the effects

of imagery ability on the affect of both groups during the

preparatory descriptions, and it examined the effects of

coping style on affect during surgery videotape exposures.









Method
Overview

Sixty volunteer adult blood phobics were interviewed,

completed questionnaires of imagery ability and coping

style, and were randomly assigned to one of three groups:

Video Only, Surgery Audiotape, or Neutral Audiotape. Video

Only subjects were exposed seven times to a surgical

videotape, followed by a single exposure to a novel surgery.

Subjects in the Surgery Audiotape and Neutral Audiotape

Preparation Groups experienced a different exposure

paradigm. Four presentations of a preparatory audiotape

alternated with four presentations ("test trials") of a

surgery videotape. Subsequently, these subjects viewed a

novel surgery videotape. These two groups differed only in

the type of preparatory audiotape they heard prior to each

of the four surgery test trials: Surgery Audiotape subjects

heard a factual description of the upcoming surgery, and

Neutral Audiotape subjects heard a neutral irrelevant

description. Subjective affect, physiological responses,

and facial expressions of disgust and avoidance served as

dependent measures for all three groups.

Subjects

Subjects were 60, 18 to 25-year-old (M = 19.7)

volunteer University of Florida undergraduates currently

enrolled in General Psychology. The final sample was

secured after screening approximately 500 potential subjects

with the Mutilation Questionnaire (MQ) at the beginning of









the semester. The highest scoring males and females were

telephoned and invited to participate in a study if they

spoke English and were not pregnant. One male declined to

participate fearing his anticipated reaction to the stimuli,

and one female with panic disorder was excluded. Mutilation

Questionnaire scores of blood phobic males (n = 30) ranged

from 14 to 24 (M = 17.4), and scores of blood phobic females

(n = 30) ranged from 21 to 29 (M = 23.6). Approximately the

upper 15th percentile of each gender distribution was used

from this sample. All subjects received course credit for

participating in the experiment.

Procedure

Each subject was studied individually during a 2 h

experimental session.

Interview and psychometric assessment. After subjects

read and signed the informed consent form (Appendix G), they

completed severally randomly ordered questionnaires,

including the Questionnaire Upon Mental Imagery and the

Miller Behavioral Style Survey.

Experimental session. Following questionnaire

completion, subjects entered the experimental room,

instructions were presented (Appendix H), and the electrodes

for HR and SCL and the BP cuff were attached. The cuff was

inflated several times to accommodate the subject to its

function. Next, all subjects had one practice videotape

trial using a neutral video stimulus in order to accommodate

them to the videotape presentation. The protocol for this









practice trial was the same as for all other trials

described below, except that no data were collected during

this practice trial. Following the practice, the

experimenter reentered the room, answered the subject's

questions, placed the audio headphones on the subject, and

departed. In order to accommodate subjects to the

headphones and the speaker's voice, subjects heard over the

headphones a brief reminder about the instructions of the

study (Appendix H). Following these headphone reminders,

subjects rated the affect they experienced during the

headphone instructions. These ratings served as the study

baseline subjective ratings. Subjects then waited several

minutes for the first presentation, during which the BP cuff

was inflated twice, one minute apart, and the average of

these two BP assessments served as the study baseline BP.

Group and stimulus assignment. Prior to the start of

the study, a research assistant randomly assigned subjects

to one of the three experimental groups (in blocks of three

or six subjects) and matched the groups for gender,

resulting in 20 blood phobic subjects--10 males and 10

females--per experimental group. The group assignment for

each subject was placed in an envelope and opened by the

experimenter after his last interaction with the subject

prior to the start of the trials, thus keeping the

experimenter blind to group assignment during his

interactions with the subject. The assignment of the

particular stimulus (or stimulus pair for the Neutral









Audiotape group) for each subject also was determined

randomly prior to the study using Latin squares. Stimulus

assignment was conducted to assure that each surgical

videotape and each novel videotape were seen an equal number

of times per group and per gender within each group.

Experimental paradigm. Table 8 presents the trial

sequence for the study, which is detailed below for each

experimental group. After the baseline recordings, the

sequence of trials began. All stimulus presentations were

separated by a variable length interval which averaged 1.5

minutes (range of 1 to 2 min) during which the subject

remained quietly seated, waiting for the next stimulus

presentation. The experimenter did not reenter the

experimental room until after the final (novel surgery)

trial, when he disconnected electrodes, debriefed (Appendix

I), and dismissed the subject.

The structure of all of the stimulus presentations

trials--both videotape and audiotape--was similar to that in

Study 1.1 Baseline HR and SCL were assessed during the 10 s

immediately prior to the onset of the stimulus, which was

presented for 60 s during which HR and SCL continued to be

recorded. For the four "test trials" (Exposures 1, 3, 5,

and 7 for the Video Only Group) and the Novel trial, the

subject's face was videotaped as he/she watched the surgery

videotape being presented. Faces were not videotaped during

audiotape presentations. Immediately upon stimulus offset,

BP was assessed, the affective ratings screen illuminated,









Table 8. Experimental Design for Study 2


Surgery Videotape Exposure

Video I 1 I I I I Novel
Only I la 2 1 3a 4 5a 6 I 7a ISurger
Group I I I I I I I Video

a Subjects' faces were videotaped for analysis of avoidance
and disgust.



Trial

IPrep ITest Prep ITest Prep ITest Prep ITest Novel
Group 1 1 2 2 3 3 4 4
I I VI I VI I I I V I V
V V| V VI V
SURG IS IISURG S IISURG IS I SURG IS I S I
Surgery UI D IU DI IU D U DINUD
Audiotape AUDIO R EIAUDIOIR EIAUDIOIR E AUDIO R EIO R E
G 0 __G 01 G 01 G OIV GO
I E TI IE TI IE TI E TEET
Neutral INEUT IR AINEUT IR AINEUT IR A NEUT R A L R A
Audiotapel IY P1 IY PI IY P IY PI Y P
AUDIO E AUDIO EIAUDIOI E AUDIO El E
I I I I I I I I I









and subjects rated the affect they experienced during the

stimulus.

Experimental Groups

Subjects were randomly assigned to one of three

experimental groups which varied in the type of

presentations they received prior to the Novel trial. For

the Novel trial, all subjects were presented a novel

surgical videotape, which was chosen randomly from among the

surgical videotapes not used for that subject; assignment of

novel stimulus was conducted to assure that all surgeries

were presented equally often within and between experimental

groups and for each gender. The details of stimulus

presentation for each of the three experimental groups were

as follows:

Video Only Group. The function of this group was to

evaluate the affect change during multiple repetitions of a

single surgery videotape followed by a novel surgery. Thus,

these 20 blood phobics were presented one particular surgery

scene seven times (listed in Table 8 by Exposure number),

followed by a single presentation of a novel surgery.2

Although these subjects wore the headphones just like other

subjects, they heard no audiotaped stimulus descriptions

during the study.

Two other groups were studied to compare the effects of

relevant and control preparatory verbal descriptions. For

these two groups, there were four preparation trials during

which an audiotaped description was presented repeatedly,









four test trials during which a particular surgery videotape

was presented repeatedly, followed by one presentation of a

novel surgery videotape.

Surgery Audiotape Group. During the four preparation

presentations, each subject in this group heard a relevant

and factual description of the upcoming surgery that was

presented during each of the four test trials. For each

subject, the audiotape was repeated four times, because the

same surgery videotape was repeated on the four test trials.

Neutral Audiotape Group. This group served as a

control for the Surgery Audiotape group. Each subject heard

a neutral audiotape description as "preparation" prior to

each test trial. Like the Surgery Audiotape subjects, these

subjects heard the same neutral audiotape for the four

preparations. On the four test trials they repeatedly

viewed one of the surgery videotapes, prior to viewing the

novel surgery videotape for the final trial. The inclusion

of this group permitted a controlled evaluation of the

effects of listening to a scene that lacked phobic content.

Stimuli

Three types of stimuli were used in this study, each of

which had five exemplars. First, in addition to the two

surgical videotapes employed in Study 1 ("Incision" and

"Tubes"), three additional 60 s surgical videotapes were

taken from Ost's film of thoracic operations. The three

additional video stimuli were the following: "Rib," which

showed a tool cleaning and removing a rib; "Heart," which









showed a beating heart being punctured with an instrument

and then sutured to stop bleeding; and "Sutures," which

showed the chest incision being sutured with needles and

thread. Blood and bodily deformation are depicted in all

five scenes. For each subject, one of these five surgery

videotapes was repeatedly presented, and one of the

remaining four was presented during the novel trial.

Sixty second audiotaped descriptions of each surgery

videotape were employed. In addition to the two audio

descriptions of "Incision" and "Tubes," three additional

audiotapes of 160 words narrated the three additional

surgery videotapes used in this study. The same female

voice recorded all audio stimuli in an effectively neutral

manner. These audiotapes were presented only to the Surgery

Audiotape subjects, and the surgery audiotape selected for

that subject was one that described the surgery videotape

that had been assigned to the subject.

The third category of stimuli were audiotaped verbal

descriptions of neutral, everyday activities. Five

audiotaped narratives, 60 s in duration, and 160 words long,

were recorded by the same female assistant who recorded the

surgical audiotape descriptions. The five neutral

descriptions included a person baking a cake, planting in

the garden, typing on a typewriter, paddling a canoe, and

flying a kite. These scenes were expected to be neutral in

affective content, yet all described human hand movement,

which was similar to the descriptions in the surgical









audiotapes. Only subjects in the Neutral Audiotape Group

heard these descriptions. Each neutral description was

presented an equal number of times with ordering of

presentation determined via a Latin square. (See Appendix E

for the transcripts of the five verbal and five neutral

descriptions.) In summary, since there were five surgery

and audiotape exemplars, four subjects of the 20 in each

experimental group received the same stimulus or stimulus

pair.

The practice neutral videotape stimulus which preceded

the experimental trials was a silent, 60 s videotape of a

scene from Jonathon Livingston Seagull which shows a seagull

in flight over mountains and the ocean.

Questionnaires

The Mutilation Questionnaire and the Questionnaire Upon

Mental Imagery were already described in Study 1. The

additional questionnaire of interest in this study was the

Miller Behavioral Style Scale (MBSS). Miller (1980)

developed this instrument to assess a subject's preferred

coping style under stressful circumstances. The scale asks

the subject to imagine being in four stress-evoking

situations. Each scene is followed by eight statements

representing different ways of coping with the situation.

Four of the statements relate to confronting and seeking

information (a "monitoring" style), and the other four

statements indicate distracting and avoiding information

("blunting"). Separate monitoring and blunting scores are









obtained by summing the number of statements endorsed for

each coping style. The scale has good discriminant validity

(Miller, 1987a; Miller, Brody, & Summerton, 1988) and

predictive validity (Gard & Edwards, 1986; Miller, 1987a,

Phipps & Zinn, 1986, Watkins, Weaver, & Odegaard, 1986).

Dependent Measures

Three classes of dependent measures were assessed in

this study. Subjective measures included self-reported

displeasure, arousal, and lack of control, for which change

scores were calculated by subtracting the study baseline

value from the value obtain for each stimulus presentation.

Physiological measures of HR and SCL change scores were

calculated by subtracting the trial baseline mean (the 10 s

prior to stimulus onset) from the mean value obtained during

the stimulus. The two BP measures were derived by

subtracting the study baseline from the values obtain after

each stimulus.

Motor behavior measures of avoidance and maximum facial

disgust were coded by two independent raters from the

videotape of the subject. Avoidance was coded dichotomously

based on at least 1 s of avoidance. The 5-point rating of

maximum facial disgust was reduced to a dichotomous code to

provide a sufficient number of subjects for frequency

analyses; original scores of 0 or 1 were classified as "low"

disgust, and scores of 2, 3, or 4 were classified as "high"

disgust. Percent agreement for these two measures was

calculated between the two independent raters' dichotomous









classifications. For avoidance, percent agreement ranged

from 92% to 97% for the five trials. For maximum facial

disgust, percent agreement ranged from 93% to 98%. Thus,

acceptable interrater reliability was achieved.

This study used the same environment and apparatus as

in Study 1. A separate VPM control program was written to

assess physiology and present stimuli (Appendix J).

Results
Three major issues were addressed in this study. In

the first section below, changes in affect to repeated

surgical exposures and to a novel surgery were evaluated

using data from the Video Only Group. In the second

section, the Surgery Audiotape and Neutral Audiotape groups

were compared to evaluate the effect of auditory preparation

on affect during repeated surgery presentations. In the

third section, the influence of imagery ability and coping

style on affect for those two groups of subjects who

received auditory preparations was examined.

Effects of Repeated Visual Exposure

The 20 subjects of the Video Only Group viewed one

surgery videotape seven times prior to viewing a novel

surgery. The dependent measures of displeasure, arousal,

lack of control, SCL, HR, SBP, and DBP were assessed during

each of these eight exposures. These measures were analyzed

with a repeated-measures ANOVA in which Trial (eight levels)

was the within-subject effect. The use of Greenhouse-

Geisser corrections resulted in fractional degrees of









freedom. Planned contrasts between exposures were conducted

to more thoroughly evaluate affect change.

Self-report measures. Table 9 presents displeasure,

arousal, and lack of control change scores from baseline

over the seven exposure trials and the Novel Exposure for

Video Only subjects. As indicated by significant Trial

effects and planned contrasts between exposures, all three

variables showed a significant reduction in negative affect

from Exposure 1 to Exposure 7, and a significant and

immediate return of negative affect to the Novel Exposure to

levels not significantly different from those reported

during Exposure 1 (all R > .42). At Exposure 7, arousal and

lack of control did not differ from their study baselines (R

> .65), although displeasure remained above its baseline

value, (Trial effect: displeasure, E(3.2, 60.3) = 8.61, R <

.0001; arousal, (2.8, 52.6) = 10.34, R < .0001; lack of

control, E(3.0, 56.7) = 7.76, E < .0002.

Physiological measures. Figure 2 presents the SCL and

HR change data for the Video Only subjects on the same graph

for easy comparison. The trend in SCL and HR parallels that

of the self-report data, although only for SCL was there a

significant Trial effect, (2.6, 49.1) = 4.28, R = .012.

The SCL habituated rapidly after an initial elevation during

Exposure 1, dropped significantly to its lowest value during

Exposure 5 (which was not significantly different from

baseline, R > .44), and then increased somewhat (although

nonsignificantly) during the Novel surgery. The SCL during









Table 9. Changes in Self-Report and Motor Measures Across
Repeated Surgery Videotape Exposures and a Novel
Surgery for the Video Only Group


Exposure


Measure


1 2 3 4 5 6 7 Novel


Displeasure 6.5 5.9
(4.0) (3.6)


Arousal


5.9 4.4
(8.2) (8.3)


Control Lack 5.3 4.7
(5.8) (6.1)


Avoidance
(Yes/No) 8/12
Disgust
(High/Low) 10/10


4.9 4.6
(3.6) (3.7)

3.5 2.2
(8.2) (8.0)

3.4 1.9
(6.3) (6.6)


9/11

6/14


3.8
(4.0)

1.2
(7.9)

1.3
(7.2)


5/15

6/14


3.4
(4.7)

0.8
(7.8)


3.7 7.2
(4.5) (8.2)

0.4 6.4
(7.9) (7.5)


1.2 0.7 5.7
(6.7) (6.9) (7.1)


10/10 9/11

5/15 9/11


a Means (and standard deviations) are presented for the
self-report measures; frequency data are presented for the
motor measures.











5 +
H

SN

+




4 +




+




3 +




+




2 +




+




1 +


H
E
A
R
T

R
A
T
E

C
H
A
N
G
E


B
P
%


S


+ 0.6




+ 0.4




+ 0.2




+ 0.0




+-0.2


+ 1.4

S.....S Skin Conductance
Level

H--- H Heart Rate + 1.2




+ 1.0



H
1 + 0.8


-------+----------+-----+-----+-----+------
1 2 3 4 5 6 7 Novel


EXPOSURE


Figure 2. Changes in Heart Rate and Skin Conductance Level
Across Seven Surgery Videotape Exposures and the
Novel Surgery Exposure for the Video Only Group


S


S
K
I
N

C
O
N
D
U
C
T
A
N
C
E

C
H
A
N
G
E


M
I
C
R
0
M
H
0
S









the novel surgery did not differ from that during Exposure 1

(p > .12). Neither SBP nor DBP change scores showed a
statistically reliable trend across exposures.

Motor behavior measures. The motor measures of

avoidance and facial disgust were assessed during only

Exposures 1, 3, 5, 7, and the Novel Exposure and are

presented in Table 9. These dichotomous measures were

analyzed via chi-squares using McNemar's (1969)

recommendation for within-subject analyses. As can be seen,

avoidance behavior remained at a relatively constant level

across the four exposures and the novel surgery, except for

a nonsignificant drop in avoidance during the Exposure 5.

For facial disgust, half of the Video Only subjects showed

"high" disgust during Exposure 1; this frequency decreased

in subsequent exposures and the difference reached

statistical significance at Exposure 7, X2(1) = 5.0, R <

.05. Additionally, significantly more subjects increased

than decreased disgust from Exposure 7 to the Novel Surgery,

X2(1) = 4.00, R < .05. Disgust during the novel surgery and
Exposure 1 did not differ.

Effects of Auditory Preparation

The effects of auditory preparation were examined by

comparing the affect of the relevantly-prepared Surgery

Audiotape Group with the control Neutral Audiotape Group at

the four videotape "test trials" and the novel surgery.3

Data analyses used mixed-model repeated measures ANOVAs in

which Group (Surgery Audiotape or Neutral Audiotape) was the









between-subjects effect and Trial (five levels) was the

within-subject effect. Greenhouse-Geisser corrections were

applied.4

Self-report measures. Figure 3 shows the displeasure

change during each of the four test trials and the novel

trial for Surgery Audiotape and Neutral Audiotape subjects.

For all three self-report measures, negative affect

decreased significantly between Test Trials 1 and 4 and

increased significantly from Test Trial 4 to the Novel

Surgery (all R < .007). Group differences were of greater

interest, however. As Figure 3 suggests, Surgery Audiotape

subjects reported less displeasure than the Neutral

Audiotape subjects across trials, Group main effect, F(1,

38) = 4.40, R = .042. The Trial X Group interaction was not

significant, indicating that the group difference in

displeasure did not change across trials. Lack of control

followed a similar trend across trials in that the sample

mean of the Surgery Audiotape Group suggested they had less

lack of control than the Neutral Audiotape Group; however,

this Group main effect failed to reach significance, R =

.16. Self-reported arousal was similar for the two groups

across all trials.

Physiological measures. Figure 4 shows the change in

SCL across the four test trials and novel trial for the two

groups. There was a significant decrease in SCL over the

four test trials and increase during the Novel Trial, (R <

.001). More importantly, Figure 4 suggests that the SCL of













10 +





9+





8+
D
I
S
P
L
E 7+
A
S
U
R
E
6+





5+


SA.....SA Surgery Audiotape

NA---- NA Neutral Audiotape


NA NA


SA.. .SA
SA "SA
*


SA.

*SA
4+

---+----------+----------+------------ ---- -


Test 1


Test 2


Test 3

TRIAL


Test 4


Figure 3.


Self-Reported Displeasure Change Across Four
Surgery Videotape Test Trials and the Novel
Surgery Trial for the Surgery and Neutral
Audiotape Groups


Novel






72






S 1.2 + NA
K
I SA.....SA Surgery Audiotape
N
NA---NA Neutral Audiotape
C 1.0 +
0
N
D
U
C 0.8 +
T
A NA
N
C
E 0.6 +

C
H SA NA SA
A
N 0.4 +
G
E


0.2 + .NA
I
C "
R .
0
M 0.0+ .
H SA NA .
0
O
N, *SA .. ..... SA
-0.2 +

---- ---------+---------+--------------------
Test 1 Test 2 Test 3 Test 4 Novel

TRIAL


Figure 4. Skin Conductance Level (60 s Mean) Change Across
Four Surgery Videotape Test Trials and the Novel
Surgery Trial for the Surgery and Neutral
Audiotape Groups









the Surgery Audiotape Group was less than that of the

Neutral Audiotape Group; however, the Group main effect only

neared significance, F(1, 38) = 2.73, R = .10. Nonetheless,

simple effects analysis revealed that at Test Trial 1, the

SCL of the prepared subjects was less than that of the

control subjects, R < .03. There was no Trial X Group

interaction. The HR, SBP, and DBP changes did not differ

significantly across trials or between groups.

Motor behavior measures. Table 10 presents avoidance

and facial disgust frequency data for the Surgery Audiotape

and Neutral Audiotape Groups. Consistent with the findings

for displeasure and SCL, these motor measures indicated that

the prepared subjects had less negative affect during the

surgery videotapes than the control subjects.

Avoidance did not change significantly for either group

across the five trials. "High" disgust for the Neutral

Audiotape subjects steadily declined from Test Trial 1 to

Test Trial 4, X2(1) = 7.0, R < .01; the fairly low disgust

displayed by the Surgery Audiotape subjects did not decrease

across test trials. Both groups had significantly more

subjects increase than decrease disgust from Test Trial 4 to

the Novel Trial, (Surgery Audiotape, X2(1) = 4.00, R < .05;

Neutral Audiotape, X2(1) = 7.00, R < .01).

Next, differences at each trial were examined. The

Surgery Audiotape Group tended to avoid less frequently than

the Neutral Audiotape Group at Test Trials 1 and 4, (X2(1) =

2.50 and 7.06, R = .114 and .058, respectively), and they










Table 10.


Frequency of Avoidance and Facial Disgust Across
Four Test Trials and the Novel Surgery for
Surgery Audiotape and Neutral Audiotape Groups


Behavioral Measure

Avoidance (Yes/No)

Surgery Audiotape
Neutral Audiotape


Disgust


Trial


Test 1 Test 2 Test 3 Test 4


2/18
6/14


2/18
10/10


4/16
7/13


2/18
7/13


(High/Low)


Surgery Audiotape
Neutral Audiotape


4/16
11/9


1/19
9/11


1/19
6/14


1/19
4/16


Novel

0/20
6/14


5/15
11/9









avoided significantly less often than the control subjects

during Test Trial 2 and the Novel Trial, (X2(1) = 7.62 and

7.06, R = .006 and .008, respectively). The Surgery

Audiotape Group had significantly fewer "high" disgust

subjects than the Neutral Audiotape Group during Test Trials

1, 2, 3, and the Novel Trial, (X2(1) = 5.23, 8.53, 4.33, and

3.75; R = .022, .003, .037, and .053, respectively).

Effects of Personality Variables

Two personality variables, imagery ability and coping

style, were examined for their influence on affect of

subjects receiving preparation--the Surgery Audiotape and

Neutral Audiotape Groups. Analyses used repeated-measures

ANOVAs with Group and the personality measure as between-

subjects effects; personality measures were left continuous

for the ANOVA, but were dichotomized via a median split for

chi-square analyses of their relationship with avoidance and

disgust and for graphic presentation.

Mental imagery ability (QMI). Imagery ability was

hypothesized to influence affect during the auditory

preparation trials; thus, affect during Preparations 1 and 2

was analyzed. Only self-reported lack of control was

related significantly to imagery ability. Examination of

the plotted data revealed an effect of little interest: the

lack of control of good imaging Neutral Audiotape subjects,

(but not Surgery Audiotape subjects) was lower during both

of the neutral audiotape descriptions, (QMI X Group, F(1,

36), E = .033).









Coping style (MBSS). The MBSS yielded both Monitoring

and Blunting scores which were not correlated in this sample

of 40 subjects, (r(38) = -.16, 2 = .31); therefore, each

variable was examined separately. Coping style was expected

to relate to emotional responding during the actual

presentation of the surgery stimuli. Thus, repeated-

measures ANOVAs and chi-squares examined each variable

during Test Trials 1 and 2 and again during Test Trial 4 and

the Novel Surgery.

The Monitor variable was related to only one dependent

measure; all five of the Surgery Audiotape subjects who

showed "high" disgust to the Novel Surgery were low in

Monitoring, X2(l) = 6.67, E = .01.

The Blunting variable, however, showed several

interesting relationships with various dependent measures.

The self-report measures were related to Blunting during

Test Trials 1 and 2, whereas several of the physiological

measures were related to Blunting during Test Trial 4 and

the Novel Surgery. Across Test Trials 1 and 2, high

blunting subjects reported a rise in displeasure, whereas

low blunting subjects reported an decrease in displeasure,

regardless of Group, (Trial X Blunting interaction, f(1, 36)

= 5.10, R = .03). The analyses of arousal and lack of

control across Test Trials 1 and 2 were consistent with

displeasure and even more revealing in that the groups

differed. The interactions for both dependent measures were

interpreted similarly; therefore, only arousal change scores









for the two groups as a function of blunting are presented

in Figure 5. As the figure reveals, Surgery Audiotape high

blunters reported increased arousal and lack of control

across the two surgery presentations, whereas low blunting

Surgery Audiotape subjects reported a reduction in arousal

and lack of control. Neutral Audiotape subjects, however,

showed little change in arousal or control across these

surgeries as a function of blunting; indeed, Neutral

Audiotape high blunters reported somewhat greater arousal

and lack of control during these presentations than low

blunters (Trial X Group X Blunting interactions for arousal,

F(l, 36) = 8.78, p = .005; and lack of control, F(1, 36) =

13.44, R = .0008).

Blunting was related also to affect during Test Trial 4

and the Novel Surgery. For SCL, collapsing across both

trials, the Surgery Audiotape high blunters tended to have a

higher SCL than Surgery Audiotape low blunters, whereas

Neutral Audiotape high blunters had a lower SCL than Neutral

Audiotape low blunters, (Group X Blunting, F(1, 36) = 3.75,

R = .06). The two BP measures specified these effects for

each trial, and since the interpretation of the interactions

is similar, only SBP data for both groups over both surgery

presentations as a function of Blunting is presented in

Figure 6. Consistent with SCL, SBP and DBP increased from

Test Trial 4 to the Novel Trial for high blunting Surgery

Audiotape and low blunting Neutral Audiotape subjects,

whereas SBP and DBP showed little change across surgery












Surgery Audiotape
Group
13 +
L



12 +




11 +




10 +


L

9+


H

8+




7+




6+
H


---I+-----------+---


TEST TRIAL


Figure 5.


Neutral Audiotape
Group


L.....L

H-----H


Low Blunting

High Blunting


HL


















L. ..........L


TEST TRIAL


Arousal Change Across Test Trials 1 and 2 for the
Surgery Audiotape and the Neutral Audiotape
Groups as a Function of Blunting















S
Y
S
T
O
L
I
C

B
L
O
0
O
D

P
R
E
S
S
U
R
E

C
H
A
N
G
E


M
M

H
G


Test 4


Novel


Neutral Audiotape
Group


Surgery Audiotape
Group
8 +





6 + H





4 +





2 +



L

0 +



*


-2 + L





-4 + H


----+------------+---


Test 4


Novel


TRIAL


Figure 6. Systolic Blood Pressure Change Across Test Trial
4 and the Novel Trial for the Surgery Audiotape
and the Neutral Audiotape Groups as a Function of
Blunting


L.....L Low Blunting

H----H High Blunting









presentations for low blunting Surgery Audiotape and high

blunting Neutral Audiotape subjects, (Trial X Group X

Blunting interactions for SBP, F(1, 36) = 8.35, R = .0065;

and DBP, F(1, 36) = 5.12, p = .030). Finally, findings for

self-reported arousal were not completely consistent with

the physiological data. Both Neutral Audiotape and Surgery

Audiotape low blunters reported a greater increase in

arousal from the Test Trial 4 to the Novel Trial than did

the high blunters, (Trial X Group X Blunter interaction,

F(l, 36) = 4.86, p = .034).
Discussion

Affect Change to Repeated Surgery Exposures

A fundamental question regarding emotional change is

whether blood phobics become less uncomfortable or anxious

as a phobic stimulus is presented repeatedly. This study

indicated that such change does occur. Indeed, in a sample

of 20 phobics who viewed one surgery stimulus repeatedly for

seven trials, there was a significant decline on most

measures of negative affect across repetitions. This

finding supports a basic premise of emotional functioning--

exposure leads to reductions in negative affect (Foa &

Kozak, 1986).
Similar findings were reported by Hare et al. (1971)

who demonstrated habituation of arousal with multiple

repetitions of mutilation scenes. Hare and colleagues

studied normals using slides; the current study extends

their findings to blood phobics viewing videotapes.









Generalization of Affect Reduction to Novel Phobic Stimuli

A second question of fundamental importance concerns

the extent to which the attenuation of emotion which

occurred during repeated presentations generalized to new

blood-related stimuli. The results of the current study

indicated that, although the aversive qualities of a

particular blood-related stimulus attenuated fairly quickly

to repetition, very little or no generalization occurred.

Indeed, when a novel surgery scene was presented, there was

a substantial return of negative affect to levels not

different from those observed during the first presentation

of the surgery scene. Using a different paradigm, Hare et

al. (1971) found that presenting different mutilation slides

interfered with habituation. Limited generalization to a

novel stimulus might be viewed as secondary to affective

network changes in only those specific stimulus properties

shown in the repeated surgery scene, rather than to a

elaborated network of "blood-related stimuli." A further

test of generalization might be to repeatedly present the

"novel" stimulus. If the rate of habituation to it is

faster than to the original stimulus, evidence for some

generalization of affect reduction would be adduced.

Effects of Preparation

A second portion of this study examined the effects of

two types of preparation for upcoming surgery videotape

exposures. The prepared group of blood phobics heard an

accurate, effectively neutral description of the surgery









prior to each of four viewings. Their affect during the

four repeated exposures and during a novel stimulus was

compared to that of a control group of subjects who heard a

neutral, unrelated audiotaped description before each

exposure.

Generally, the relevant preparation produced only

modest reductions in negative affect during exposure,

compared with the control preparation. The relevantly

prepared group reported significantly less displeasure and

showed less facial disgust and avoidance than did control

subjects. The lack of control and SCL change showed similar

although less reliable trends. Preparation effects tended

to be somewhat more evident during the first surgery

exposure than later exposures. Thus, although the effect

does not appear robust, there is tentative support for the

hypothesis that preparing blood phobics to view a surgery by

providing them a description modestly reduces negative

affect in comparison to an irrelevant preparation.

Admittedly, however, group differences were limited

with respect to the number of variables differentiating

conditions and the magnitude of the effects. One important

potential reason for the limited effects is that the current

paradigm simply did not permit large effects. In this

study, the experimental manipulation was a variation in

preparation for blood phobics viewing surgeries; one might

expect rather small or even absent effects from this

manipulation, especially in light of the limited effects









found in Study 1, where powerful experimental conditions

were created phobicss versus nonphobics, aversive versus

neutral material).

The content of the preparatory audiotapes may further

account for limited effects. The affect of the Surgery

Audiotape group during the first audiotape presentation was

minimally negative; only two subjective measures indicated

increased arousal. The narrative of each audiotape was

effectively neutral and purely descriptive of the surgery;

it contained no references to the observed patient's

experience of the surgery nor to the subject's possible

reaction during viewing. The empirical literature on

preparation for stressful procedures has demonstrated that

verbal preparations which include not only descriptions of

upcoming procedures but also of the sensations that the

patient or listener might experience, (i.e., sensory

information) often result in less anxiety during and after

the stressful event (Anderson, & Masur, 1983). A different

domain of empirical inquiry--affective imagery--suggests

that verbal scripts for emotional imagery evoke increased

affect when they include response propositions, or

descriptions of the imaging person's affective reactions in

the imaged scene (Lang, Kozak, Miller, Levin, & McLean,

1980; Lang, Levin, Miller, & Kozak, 1983). Additionally,

the current subjects were instructed only to listen to the

description, whereas other research has demonstrated that

instructions to vividly imagine oneself in the scene elicits









greater affect during imagery (Lang, 1979). Thus, the

preparatory capacity of the audiotaped descriptions might

have been enhanced by modifying the instructions and

incorporating response propositions.

Individual Difference Variables

Finally, another reason for limited group preparation

effects is the variability in affect accounted for by

individual differences, especially in coping style. Imagery

ability was assessed also, but it was found to have little

relation to affect during the verbally presented preparation

descriptions, where imagery effects might have been expected

to occur.

The effects of coping style appear to be more robust,

however. The monitoring style was limited in its relation

to affect during the surgery videotapes. Its one

relationship was consistent with the effects of the blunting

style and is described below. The blunting coping style was

related to increases or decreases in self-reported affect

and physiology from the first to the second surgery

videotape presentation and the fourth surgery to the novel

presentation. Moreover, blunting coping style interacted

with the type of preparation given to subjects, yielding

different relationships for the two preparation groups.

Among the relevantly prepared subjects, blunters

reported lower levels of negative affect to the first

surgery presentation, but their negative affect increased

during the second surgery presentation. Subjects who









typically avoid blunting reported greater negative affect on

the first presentation, but their anxiety decreased to the

second surgery. The unprepared subjects did not show this

effect, but tended to display the opposite relation.

Similar effects occurred during the presentation of a

novel surgery as indexed by physiological measures.

Prepared subjects who blunt showed an increase in

physiological arousal to the novel surgery compared with

prepared subjects who do not blunt. Also, prepared subjects

who were low on monitoring (typically considered as similar

to blunting) had the greatest facial disgust to the novel

surgery. Again, unprepared subjects did not show this

pattern of results. In the transition from the repeated

surgery to the novel surgery, unprepared control subjects

who do not blunt had increased physiological arousal.

The findings with the prepared subjects are consistent

with those of Shipley and colleagues (1978, 1979) who found

that repressors (like blunters in the current study) became

more anxious (indexed by tachycardia) during a second

presentation of a surgery preparation videotape, whereas

sensitizers were more anxious during the first presentation

and became less so during a second viewing. This study

extends their findings by suggesting that when a novel

surgery is shown later in the repetition sequence, low

blunters (like sensitizers) continue to show reduced affect,

but blunters (like repressors) are increasingly disturbed









and unable to blunt as successfully as they did during the

initial presentation.

The different relationship of blunting with affect for

the preparation and control groups is interesting. It is

possible that the surgical descriptions for the prepared

subjects permitted almost continuous activation of their

affective networks, with the result that the subjects'

preferred manner of coping with aversive stimuli had

predictable effects over exposures. However, providing

other phobics irrelevant, potentially distracting

descriptions prior to each viewing might have precluded

continuous activation of the emotion, with the result that

low blunters were unable to decrease their arousal over

presentations, and high blunters successfully maintained

affective distance. Naturally, these explanations are

speculative, and since the construct of coping style is

itself poorly understood, it is quite difficult to enlighten

the complicated interaction of coping style with variations

in exposure. Further theory and research which addresses

the mechanism by which coping style influences emotional

network activation is needed.

Methodological Issues

Study 2's methodology had several problems which

hindered clear interpretations of the results and probably

reduced the size of observed effects. First, the study used

five different surgery scenes rather than a single scene or

two, as in Study 1. It was hoped that multiple surgeries









would increase the generalizability of the findings to a

larger population of blood-related stimuli. Although no

experimental confound occurred (each surgery was used

equally often), the increase in response variation

attributable to the use of multiple surgeries probably

resulted in increased between-subjects variance and a

concomitant decrease in statistical power. Additionally,

too many surgeries were employed to permit adequate

statistical comparisons of their affect-eliciting power.

Ideally, the same two surgeries used in Study 1 should have

been employed in Study 2 to more clearly replicate and

extend the findings of Study 1.

Second, avoidance and facial disgust should have been

recorded during verbally presented descriptions in both

studies. Bioinformational theory predicts that various

stimulus modalities reliably activate affective networks,

resulting in measurable efferent outflow (Lang, 1979).

Thus, future research should include facial affect

assessments during verbal stimulus trials. A more important

experimental concern is that no baseline avoidance or facial

affect measures were recorded; thus, it is possible that the

observed differences between groups were attributable to

preexisting differential tendencies to avoid or show

disgust. An acceptable baseline might be obtained by

presenting a stimulus that lacks the phobic content under

study, but is hypothesized to be equally bothersome to all









experimental conditions, such as a snake or height stimulus

in studies of blood phobics and controls.
Notes

1 For the first 30 subjects only, BP was assessed during the
20 s prior to each stimulus onset, with the hope of using
this measure as a baseline. This procedure was discontinued
when it was discovered that the frequent cuff inflation was
excessively uncomfortable for subjects and may have cued
them as to the timing of stimulus onset. Discontinuation of
this assessment occurred after an equal number of subjects
(balanced for gender) from each group had completed
participation and after each surgical stimulus had been
presented an equal number of times. Therefore, no
experimental confound occurred. The prestimulus BP data
collected on the 30 subjects were not analyzed.
2 Prior to Exposure 1, Video Only subjects were not
presented any stimulus while the other groups were hearing
their first preparation audiotape. It was originally
intended that the lack of this stimulus presentation would
permit the Video Only subjects to serve as a "waiting, no
intervention control" for the auditory preparations
presented to the other two groups.

3 Since the Video Only Group received no preparation for the
first exposure, their affect during Exposure 1 was compared
with that of the other two groups during Test Trial 1. The
Video Only Group did not differ from the Neutral Audiotape
Group on any measures, and only differed from the Surgery
Audiotape Group in having more frequent avoidance and "high"
disgust.

4 Affect differences between the Surgery and Neutral
Audiotape Groups during the initial audiotape preparation
per se were examined to determine whether hearing the
surgery description led to greater negative affect than
hearing the neutral, control description. As expected,
Surgery Audiotape subjects reported more displeasure and
arousal than Neutral Audiotape subjects (both E < .0002).
Lack of control and SCL followed this same pattern, but
neither reached statistical significance. Neither HR nor
the two BP measures differed between groups during this
preparation audiotape.















GENERAL DISCUSSION

An aversive negative reaction to blood, injury, or

bodily deformation is a fairly common phenomenon

traditionally termed "blood phobia" and classified as a

simple phobia. Research has enlightened possible etiologies

(Kleinknecht, 1987; Ost & Hugdahl, 1985), examined subjects'

cognitions during exposure to blood-related stimuli

(Kaloupek & Stoupakis, 1985; Kaloupek, Scott, & Khatami,

1985), and developed exposure-based techniques with

modifications to prevent fainting (Ost & Sterner, 1987).

Generally, however, it has been less researched than other

simple phobias, perhaps because most authors view it as

simply another phobia (Marks, 1988). Yet its unique

features hinder straightforward extrapolation from the

extensive theory and empirical literature on simple phobias.

A Comparison of Blood Phobia and Other Phobias

The literature on blood phobia has consistently used

the term "fear" to describe the affect of phobics vis-a-vis

blood-related stimuli. For example, the Mutilation

Questionnaire is considered to measure respondent's "fear"

of mutilation stimuli (Klorman et al., 1974). One wonders,

however, what is it specifically that is feared? It is

unlikely that the external blood-related stimulus itself is

feared, for what damage or harm can it accomplish? Beck and









Emery (1985) noted that blood phobics do not report fear

during actual confrontation with the stimulus, rather, they

feel queazy, disgusted, or squeamish. Additionally, the

facial expression exhibited by the blood phobics in the

current study was routinely one of disgust rather than fear.

Thus, it appears that the subjective experience of blood

phobics is complicated, possibly encompassing fear prior to

or early during exposure, but that another affect such as

disgust is dominant during exposure. More detailed study of
the subjective emotional experience of blood phobics both

before and during exposure is worthwhile.

The psychophysiology of blood phobia is thought to be

unique among phobias. In other simple phobias, exposure to

the phobic stimulus results in a prolonged sympathetic

response with classic markers of fear and anxiety such as

tachycardia, hypertension, and increased sweating and

respiration rate. Yet blood phobia is considered to have a

biphasic response pattern of sympathetic activation followed

by parasympathetic activity which, if exposure is continued,

leads to fainting. Research indicates that fainting is

uniquely associated with blood phobia and not with other

phobias (Connolly, Hallam, & Marks, 1976), and many

researchers suggest that most blood phobics faint (Marks,

1988). Yet of the 84 blood phobics participating in both

studies, none fainted nor appeared to near faint during

exposure to the surgeries.









There are several potential reasons for the

discrepancies between the current studies and past research.

It is possible that these subjects were not sufficiently

phobic, and that more severe blood phobics would have

fainted. Several clinical studies have found about a 70%

prevalence of fainting in the histories of blood phobics

presenting for treatment (Ost, Sterner, & Lindahl, 1984;

Connolly et al., 1976; Thyer et al., 1985). However,

generalizations from clinic patients to all blood phobics

may not be appropriate. It is also possible that the

stimuli used in the current studies were insufficiently

aversive either due to the content or duration. In vivo

exposure to an operation or undergoing venipuncture and

blood donation probably are more aversive and likely to

elicit fainting (Graham et al., 1961). Regarding stimulus

duration, brief exposures to mutilation stimuli resulted in

tachycardia but not significant bradycardia in Study 1 and

in studies by Klorman et al. (1975, 1977). Longer duration

presentations (Ost et al., 1984; Steptoe & Wardle, 1988)

more frequently find parasympathetic activity and fainting.

Thus, longer stimulus presentations may permit the

occurrence of the parasympathetic portion of the biphasic

reaction, whereas shorter presentations permit only

sympathetic activity.

It is possible, however, that fainters constitute a

distinct group, only partially overlapping with blood

phobics. Kleinknecht and Lenz (1989) recently found that









the population of people who report fear to blood stimuli

can be subdivided into fainters and nonfainters, and that

some fainters report little or no fear of blood stimuli.

This apparently accounts for Kleinknecht's (1988a) earlier

finding of only a modest correlation (r = .30) between MQ

scores and a history of fainting to blood-injury stimuli.

Thus, aversion or fear of blood-related stimuli appears to

be less tightly associated with fainting than an examination

of clinic blood phobics and blood donation fainters would

lead one to believe. Alternatively, Kleinknecht's blood

phobics and those in the current studies were college

students and younger than patients in the above clinical

studies. It is possible that these subjects were unsure

whether or not they would faint, because they too rarely

have encountered blood-related stimuli or because they

reliably escape or avoid. Future research might find that

if such people were to continue exposure to a sufficiently

intense blood-related stimulus, perhaps most or all would

faint. Thus, an important area of research is an evaluation

of the extent of fainting among blood phobics, those

situations in which fainting occurs, and the differences

between fainters and nonfainters.

Behavioral avoidance testing to assess the motoric fear

response is commonplace in studies of simple phobias. With

blood phobia, however, only Ost's research team has used a

behavioral measure: duration of viewing a prolonged surgery

film. Blood phobia may differ from other phobias in that




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BLOOD PHOBIA: A COMPARISON OF PHOBICS AND NONPHOBICS AND AN
EXAMINATION OF AFFECT DURING VISUAL AND AUDITORY EXPOSURE
By
MARK ALLAN LUMLEY
A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY
UNIVERSITY OF FLORIDA
1990

ACKNOWLEDGEMENTS
The doctoral dissertation documents the independent,
scholarly ability of the candidate, but it is never a
solitary effort. My efforts have been buttressed by many
others in various capacities. Foremost, I wish to note the
contributions my committee, starting with my chairperson,
Dr. Barbara Melamed, whose mentorship, support, and
friendship have made graduate school and this dissertation
pleasantly memorable. I also thank Dr. Peter Lang, whose
thoughtful critique of my research content and encouragement
to conduct a programmatic study of answerable questions have
been most helpful. My appreciation also goes to Dr. Wilse
Webb, who has gently modeled for me the role of psychologist
as discoverer and disseminator of knowledge. Dr. Sandra
Seymour is thanked for helping me keep the task in
perspective. Finally, Drs. Nancy Norvell and Anthony Greene
are acknowledged for their participation. I greatly
appreciate this committee's joy of research, desire for me
to learn, and consideration of my needs and interests.
Others have contributed in various ways. Dr.
Christopher Patrick instructed me in the conduct of
physiological assessment and the use of the data collection
software. Randle Blanco assisted in writing software
programs to convert data to analyzable format. Dr. Lars-
ii

Goran Ost provided the surgical operations video stimulus.
Dr. Debbie Ader and Angel Siebring created the audiotapes.
Undergraduates Terry Keenan, Rick McCali, and Donna Livesey
assisted in data collection and coding. The Psychology
Department at the University of Florida provided access to
their undergraduate subject pool. The American
Psychological Association awarded a dissertation grant to
help defray costs. Finally, the National Institute of
Dental Research Training Program and the University of
Florida Presidential Graduate Research Fellowship funded my
graduate training. I am thankful for all of this aide.
Finally, to one whose sustenance I cherish, whose
caring ameliorated the tensions induced by hours in the
laboratory or at the computer, whose hope for the future
makes the trials worthwhile, I thank my wife Sherry.
iii

TABLE OF CONTENTS
Page
ACKNOWLEDGEMENTS Ü
ABSTRACT vii
GENERAL INTRODUCTION 1
Classification and Epidemiology 1
Affective Responding in Blood Phobia 2
Purpose of these Studies 3
STUDY ONE 5
Introduction 5
Phobic Subjects and Controls 5
Stimulus Characteristics and Presentation Methods.. 6
Personality Dimensions 8
Summary and Purpose of the Study 11
Method 11
Overview 11
Subjects 12
Procedure 13
Stimuli 17
Experimental Environment and Apparatus 18
Questionnaires 19
Dependent Measures 22
Results 26
Personality Measures 2 6
Videotape Stimuli 27
Audiotape Stimuli 36
Discussion 39
Psychometric Assessment 39
Affect During Videotaped Stimuli 41
Affect During Audiotaped Stimuli 47
Methodological Issues 47
Notes 49
STUDY TWO 50
Introduction 50
Exposure and Affect Change 50
Preparatory Information 51
iv

page
Summary and Purpose of the Study 54
Method 55
Overview 55
Subjects 55
Procedure 56
Experimental Groups 60
Stimuli 61
Questionnaires 63
Dependent Measures 64
Results 65
Effects of Repeated Visual Exposure 65
Effects of Auditory Preparation 69
Effects of Personality Variables 75
Discussion 80
Affect Change to Repeated Surgery Exposures 80
Generalization of Affect Reduction to Novel
Phobic Stimuli 81
Effects of Preparation 81
Individual Differences Variables 84
Methodological Issues 86
Notes 88
GENERAL DISCUSSION 89
A Comparison of Blood Phobia and Other Phobias 89
Unanswered Questions 95
APPENDIX A INFORMED CONSENT TO PARTICIPATE
IN RESEARCH (STUDY 1) 98
APPENDIX B SUBJECT INSTRUCTIONS (STUDY 1) 100
APPENDIX C SELF-ASSESSMENT MANIKIN (SAM) INSTRUCTIONS. 102
APPENDIX D DEBRIEFING FORM (STUDY 1) 105
APPENDIX E PHOBIC AND NEUTRAL AUDIOTAPE
TRANSCRIPTS (STUDIES 1 AND 2) 106
APPENDIX F VPM CONTROL PROGRAM FOR DATA ACQUISITION
AND STIMULUS PRESENTATION (STUDY 1) Ill
APPENDIX G INFORMED CONSENT TO PARTICIPATE
IN RESEARCH (STUDY 2) 115
APPENDIX H SUBJECT INSTRUCTIONS (STUDY 2) 118
v

gage
APPENDIX I DEBRIEFING FORM (STUDY 2) 120
APPENDIX J VPM CONTROL PROGRAM FOR DATA ACQUISITION
AND STIMULUS PRESENTATION (STUDY 2) 121
APPENDIX K ORDER EFFECTS (STUDY 1) 12 6
APPENDIX L ANOVA TABLES (STUDIES 1 AND 2) 127
REFERENCES 137
BIOGRAPHICAL SKETCH 145
VÍ

Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy
BLOOD PHOBIA: A COMPARISON OF PHOBICS AND NONPHOBICS AND AN
EXAMINATION OF AFFECT DURING VISUAL AND AUDITORY EXPOSURE
By
MARK ALLAN LUMLEY
December, 1990
Chairman: Barbara G. Melamed, Ph.D.
Major Department: Clinical and Health Psychology
Two studies examined subjective, psychophysiologic
(heart rate, skin conductance level, blood pressure), and
motoric (stimulus avoidance and facial disgust expressions)
responses of blood phobics and nonphobics (defined by
elevated or below median Mutilation Questionnaire scores)
when viewing or listening to 60 s surgical and neutral
videotapes and audiotapes. Study 1 assessed several
personality domains and found that phobics (n = 24) were
more sensitive to their own anxiety, experienced greater
distress with others' negative affect, and were generally
less secure than nonphobics (n = 24). Affect was assessed
during exposure to surgical and neutral videotapes followed
by an audiotaped surgical or neutral description. Blood
phobics had more negative affect than nonphobic controls
during a surgery videotape, and phobics had greater negative
affect during a surgery than during a neutral videotape.
vii

These differences were most prominent during only one of two
surgery scenes and when the surgery was presented prior to
rather than following the neutral videotape. Phobics and
nonphobics did not differ in affect during the neutral
scene. An audiotape describing the prior surgery elicited
slightly more arousal than a neutral description audiotape,
but phobics and controls did not differ in affect to the
description. Study 2 examined affect change to repeated
presentations of a surgery videotape, and the role of
preparatory descriptions in reducing negative affect. Sixty
blood phobics were randomly assigned to three experimental
groups. One group viewed a surgery seven times and then saw
a novel surgery; these subjects habituated during
repetitions and dishabituated to the novel surgery. Two
other groups differed in the preparation they received prior
to each of four surgery videotape repetitions. One group
heard a description of the upcoming surgery, and the second
group heard a neutral, control description. The prepared
group had moderately less negative affect during the surgery
videotapes than the control group. Individual differences
in coping style influenced responding to repeated surgery
scenes; among the prepared phobics, blunters increased
negative affect over two presentations, and monitors reduced
affect. The findings indicate the need for continued basic
research of blood phobia, especially its relationship to
fainting (which did not occur in either study) and its
current classification as a simple phobia.
viii

GENERAL INTRODUCTION
Classification and Epidemiology
For some individuals, exposure to blood, bodily injury,
mutilation, disease, and related stimuli evokes a subjective
experience of fear, disgust, or aversion; autonomic arousal;
and commonly, escape from and avoidance of future encounters
with the stimulus (Marks, 1988). When this stimulus-
response pattern is sufficiently intense, it is termed
•'blood phobia" (Thyer, Himle, & Curtis, 1985) , and is
classified as a simple phobia in the revised third edition
of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-IIIR; American Psychiatric Association, 1987).
This composite of negative subjective experience,
physiologic arousal, and escape from or avoidance of
exposure to blood and related stimuli emerges consistently
as a unitary factor in specific fear surveys (e.g., Agras,
Sylvester, & Oliveau, 1969). Additionally, fainting or
syncope during exposure to blood-related stimuli is
prevalent. Kleinknecht (1987, 1988a) found that 14.5% to
19.3% of college students reported a history of nearly or
completely fainting. About 15% of blood donors approach
syncope during or after venipuncture (Graham, 1961).
Blood phobia has been associated with reduced
motivation to donate blood, avoidance of medical or dental
1

2
visits, interference with routine tests such as
venipuncture, decreased desire for the care of one's own or
another's injuries, and the redirection of potential health
professionals from their field of interest (Lloyd & Deakin,
1975; Oswalt, 1977). Avoidance of blood-related stimuli
typically is easy for most phobics; therefore, few seek
treatment of their phobia. Nonetheless, this condition
hinders many people from full participation in activities
where blood-related stimuli occur.
Affective Responding in Blood Phobia
Emotions are best quantified by three response systems:
subjective or verbal report, physiologic activation, and
overt motor behavior (Lang, 1968). Subjectively, blood
phobics report an uncomfortable or disagreeable affect
during exposure to blood-related stimuli. Most researchers
label the emotion "fear," although no studies have
documented the occurrence of fear as opposed to a different
emotion such as disgust. Thus, this dissertation will
employ a general term such as "negative affect" to describe
the subjective component of the blood phobic's experience.
Second, some blood phobics experience a physiological
reaction, unique among the phobias, termed the "biphasic
response," in which initial sympathetic arousal is replaced
by or alternates with parasympathetic activity (Engel, 1978;
Graham, Kabler, & Lunsford, 1961). Like other simple
phobias, sympathetic activity includes tachycardia,
hypertension, striate muscle tension, perspiration, and

3
increased respiration, which occur during the anticipation
of or initial exposure to a blood-related stimulus. Unlike
other simple phobias, however, continued exposure may yield
parasympathetic symptoms of bradycardia, hypotension,
yawning, nausea, lightheadedness, narrowing of vision, and
ultimately fainting, if escape is precluded (Ost, Sterner, &
Lindahl, 1984). Unfortunately, many studies of blood phobia
have included only subjects who report faintness,
potentially misleading investigators to conclude that
fainting is a common, perhaps necessary concomitant of blood
phobia. Indeed, the actual prevalence of parasympathetic
symptoms and fainting per se among those who report negative
affect to and avoidance of blood-related stimuli is unknown.
Overt motor behavior is the third emotional response
domain. Like other simple phobias, blood phobics usually
physically escape from the bothersome stimulus, thus ending
the negative experience. Additionally, blood phobics appear
to successfully escape by simply turning their heads or
closing their eyes (Beck & Emery, 1985).
Purpose of these Studies
Most of our knowledge of blood phobia stems from the
treatment literature, which contains many case studies and
several controlled investigations. For example, systematic
desensitization (Babcock & Powell, 1982; Cohn, Kron, &
Brady, 1976; Elmore, Wildman, & Westefeld, 1980; Kozak &
Montgomery, 1981; McGrady & Bernal, 1986; Ost, Lindahl,
Sterner, & Jerremalm, 1984; Yule & Fernando, 1980),

4
implosion (McCutcheon & Adams, 1975; Ollendick & Gruen,
1972) and in vivo exposure treatments with modifications to
prevent fainting (Curtis & Thyer, 1983; Ost, Lindahl,
Sterner, & Jerremalm, 1984; Ost & Sterner, 1987; Ost,
Sterner, & Fellenius, 1989) appear efficacious in treating
blood phobia.
Although effective treatments are available, there
exists little descriptive information about the basic
psychophysiology, psychopathology, and phenomenology of
blood phobia. The process of affect change, which is
typically complicated in treatment studies, also has
received little empirical attention. This dissertation
presents two studies which attempt to increase our basic
knowledge of blood phobia. Study 1 examined differences
between blood phobics and nonphobics in their subjective,
physiological, and motoric responses to phobic and neutral
material and in several personality characteristics. Study
1 also explored differences in affect to two different
blood-related stimuli and examined the effects of stimulus
presentation order. Study 2 examined first the change in
affect during exposure to phobic material using a
habituation-dishabituation paradigm to repeated
presentations of a phobic stimulus. Study 2 also
investigated the effects of preparing subjects for exposure
to the phobic stimulus with audiotaped descriptions, and it
examined the influence of imagery ability and coping style
on affect across multiple stimulus presentations.

STUDY 1
Introduction
Phobic Subjects and Controls
Researchers typically have recruited blood phobics for
study from three sources: patients presenting for treatment
of their phobia (e.g., Ost et al., 1989), blood donaters who
faint (Graham et al., 1961), and respondents (usually
college students) with deviant scores on blood phobia
questionnaires (Beiman et al., 1978; Kleinknecht, 1988a,
1988b).
Regardless of recruitment method, only a few studies
have compared blood phobics with nonphobic controls.
Klorman and colleagues (Klorman et al., 1975, 1977) found
that blood phobics (more explicitly, students with elevated
scores on the Mutilation Question [MQ], an instrument
designed to assess blood-related concerns) responded with
cardiac acceleration during 10-second exposures to
mutilation slides, whereas normals (low scoring subjects)
showed cardiac deceleration. Steptoe and Wardle (1988),
used a simple screening questionnaire (not the MQ) and found
that blood phobics reported greater anxiety and
lightheadedness and had higher heart rates and systolic
blood pressures during a surgery film than did nonphobics.
The current study also compared blood phobics (those with
5

6
elevated MQ scores) with nonphobic controls (low MQ scorers)
during exposure to phobic and neutral stimuli and on several
personality dimensions in order to enlighten fundamental
aspects of blood phobia.
Stimulus Characteristics and Presentation Methods
Research on blood phobics have employed several
different stimulus modalities. Some investigators have
assessed responding during an in vivo procedure such as
venipuncture (Engel & Romano, 1947; Graham, 1961; Kaloupek,
Scott, & Khatami, 1985), cardiac catheterization (Glick &
Yu, 1963), and pneumoencephalography (Graham, Kabler, &
Lunsford, 1961). Unfortunately, this methodology usually
lacks rigorous experimental control, exact replications are
difficult, and multiple noxious stimuli (e.g., the sight of
blood, blood loss, needles, and pain) are present. Other
investigators have used movies or films depicting surgical
procedures (Steptoe & Wardle, 1988). For example, Ost and
colleagues (Ost et al., 1989; Ost, Sterner, & Lindahl, 1984)
used a 30-minute continuous, silent videotape showing a
series of thoracic surgeries. Slides of mutilations or
homicides are the third major stimulus type employed in
blood phobia research (Hare, Wood, Britain, & Shadman, 1971;
Klorman, Weisberg, & Wiesenfeld, 1977; Klorman, Wiesenfeld,
& Austin, 1975). This methodology affords the greatest
degree of interpretive clarity, especially because the
stimulus remains static. Although a comparison has not been
done, films are expected to elicit more powerful exposure

7
effects than slides because of their increased similarity to
in vivo stimuli. Unfortunately, lengthy films such as that
of Ost and colleagues lead to differential viewing durations
across subjects because of fainting in some subjects.
Therefore, the current study used 60 s surgery scenes from
Ost*s film. These were brief enough that all subjects were
expected to be able to watch for the full duration.
The surgical depictions in Ost's film may vary in
aversiveness for blood phobics. It is of interest to
determine the comparative aversiveness of several different
surgical scenes. Therefore, this study compared empirically
two of these surgery scenes, to determine if they elicit
different degrees of negative affect.
In addition to the above noted utility of studying
nonphobic control subjects, it is also important to compare
affect to a phobic stimulus with affect to a neutral,
nonarousing stimulus. This comparison permits conclusions
about the blood-related content of the stimulus as the
elicitor of negative affect independent of aspects of the
experimental setting involved in simply viewing a stimulus.
Steptoe and Wardle (1988) conducted such a comparison and
confirmed that blood phobics responded with less negative
affect to a neutral film than to a surgery film. This is
the only study using films for stimuli that has conducted
such a comparison, although several studies using slides
have found similar results (Hare et al., 1971; Klorman et
al., 1977, Klorman et al., 1975).

Steptoe and Wardle (1988), however, did not
counterbalance the order of surgery and neutral film
8
presentation, but always presented the surgery film first.
They assumed that phobics would show undesired anticipatory
anxiety to the neutral film if it were presented prior to
the surgery film. Their failure to counterbalance order
opens their findings to the alternative hypothesis that
habituation or another learning process resulted in less
negative affect during the neutral film. Study 1 corrected
for this lapse by counterbalancing stimulus order and
evaluating the effects of the two orders to determine the
validity of Steptoe and Wardle's findings.
Finally, auditory stimulus presentation is another
modality which has been employed in studies of emotion and
other anxiety disorders but not in the study of blood
phobia. Thus, Study 1 presented to both blood phobics and
controls either surgical or neutral audiotaped descriptions
of the stimulus film that they had seen earlier. Thus, the
group and stimulus content comparisons which were made for
the visual material were repeated for auditory material.
Personality Dimensions
In addition to affective differences between blood
phobics and nonphobics during surgical and neutral stimuli,
it is also of interest to study personality characteristics
of blood phobics. Study 1 examined four personality
dimensions, derived from anecdotal observations and theories
of blood phobia.

9
Blood phobia's etiology has received some theoretical
and empirical attention. Retrospective interviews conducted
by behavioral researchers have suggested classical and/or
vicarious conditioning etiologies similar to those found for
other simple phobias (Ost & Hugdahl, 1985), perhaps
facilitated by a genetically-based "preparedness" (Marks,
1969; Seligman, 1971). Several other hypotheses have
focussed on blood phobia's uniqueness. Engel (1978)
attempted to explain both the initial anxiety and subsequent
syncope. He suggested that blood phobics, like most people,
are simultaneously sympathetically and parasympathetically
aroused by an unnatural sight such as a wound. Sympathetic
sensations consistent with the "fight or flight" response
fluctuate in dominance with feelings of queasiness and
hypotension of the parasympathetic branch. The blood phobic
is highly sensitive to his/her arousal, discomfort, and
lightheadedness, but strongly wishes to appear in control
and attempts to remain socially stoic. Thus, the phobic
feels helpless, unable either to fight or flee. The stifled
sympathetic branch is deactivated, leaving the remaining
parasympathetic activity unfettered, and syncope results.
One testable hypothesis from this theory is that blood
phobics are more sensitive to their own physical arousal
than are nonphobics. Kleinknecht (1988a) found that
subjects who reported a history of having nearly or
completely fainted had higher "anxiety sensitivity" (Reiss,
Peterson, Gursky, & McNally, 1986) than nonfainters; that

10
is, they were inordinately aware of, focussed on, and
concerned about their physical reactions when aroused.
Study 1 attempted to replicate this finding and extend it to
blood phobics defined somewhat differently than those
studied by Kleinknecht.
Anecdotal observations suggest that blood phobics have
highly vivid visual images in response to verbal
descriptions of blood stimuli. Furthermore, blood phobics
frequently report that they "feel" in their own bodies the
injury or invasive procedure observed on another. Beck and
Emery (1985) noted that such identification with the pain or
distress of the victim induces great anxiety in blood
phobics, who experience the injury as their own. These
observations suggest that blood phobics may have greater
visual imagery abilities and a greater capacity for empathy.
Imagery ability of blood phobics has not been studied yet,
but Kleinknecht (1988a) administered a multidimensional
scale of empathy, and found that self-reported fainters had
greater feelings of personal discomfort in emotional
interpersonal situations than nonfainters. No differences
were found on other empathy dimensions such as fantasy,
perspective-taking, and general concern. Both imagery
ability and empathy were examined in this study.
Finally, a broader question is how similar blood phobia
is to other anxiety disorders or to what degree blood
phobics experience various dimensions of anxiety in their
daily life. For example, are blood phobics' muscle tension,

11
autonomic arousal, and feelings of fear and insecurity
greater than those of nonphobics? Or are these dimensions
no different from controls, suggesting dissimilarity to
other anxiety and stress-related disorders?
Summary of the Purpose of the Study
Study 1 attempted to increase the rigor of blood phobia
studies by including nonphobics controls and a neutral
stimulus and by counterbalancing the order of stimulus
presentation. Thus, affective differences of blood phobics
and nonphobics to surgical and neutral stimuli were
examined. Within this paradigm, the effects of stimulus
order were evaluated, as were the differences between two
surgery scenes. Additionally, audiotaped descriptions of
the surgeries were presented to determine whether the
auditory modality reliably induces affect differences across
experimental groups and stimuli. This study also examined
differences between blood phobics and nonphobic controls on
several personality dimensions of theoretical importance:
anxiety sensitivity, manifest anxiety, mental imagery, and
empathy.
Method
Overview
Forty-eight (48) volunteer undergraduate students, half
of whom were blood phobic and half of whom were nonphobic,
completed questionnaires on mental imagery, empathy, anxiety
sensitivity, and manifest anxiety. Subjects then viewed two
60-second video stimuli in counterbalanced order, including

12
one of two bloody surgeries and a neutral scene. Subjective
ratings, physiological responses, and facial expressions of
disgust and eye avoidance served as dependent measures.
Subsequently, half of the phobics and half of the nonphobics
heard an audiotaped description of the surgery, whereas the
remaining subjects heard a description of the neutral
videotape. Physiological and subjective measures were
assessed during the audiotapes.
Subjects
Subjects were 48, 17 to 25-year-old (M = 18.9)
volunteer University of Florida undergraduates currently
enrolled in General Psychology. The final sample was
secured after screening 450 potential subjects with the
Mutilation Questionnaire (MQ) at the beginning of the
semester. Scores from the MQ were arranged in ascending
order separately for each gender. Blood phobics (n = 24)
were defined as the highest scoring 12 males and 12 females
(maximum MQ score = 30), which represented the top 6% of
each gender distribution. Scores ranged from 15 to 23 (M =
18.2) for phobic males and from 23 to 28 (M = 25.3) for
phobic females. Nonphobics (n = 24) were defined as
subjects scoring below the median of each gender
distribution. The lower half of the distribution was
divided equally into twelfths (in order to sample the full
range of nonphobics scoring below the median), and one
subject was selected from each twelfth, yielding 12
nonphobic males and 12 nonphobic females. Mutilation

13
Questionnaire scores ranged from 0 to 7 (M = 4.1) for
nonphobic males and from 1 to 10 (M = 5.6) for nonphobic
females. Selected subjects were contacted via telephone and
asked to participate if they were fluent in English and not
pregnant. They were told that the study involved "watching
several short television presentations and hearing several
headphone descriptions while your physical responses are
recorded." Four subjects (including one blood phobic)
declined to participate due to lack of interest and were
replaced. Subjects were paid five dollars for
participating.
Procedure
The study took place during a 1 h session; subjects
were studied individually.
Psychometric assessment. After subjects read and
signed the informed consent form (see Appendix A), they
completed two randomly selected questionnaires from the pool
of four questionnaires completed during the session (see
below). Subjects then were seated in the experimental room
for physiological attachments and instructions.
Instructions. Upon entering the experimental room, the
experimenter attached to the subject an automated blood
pressure (BP) cuff and electrodes to assess heart rate (HR)
and skin conductance level (SCL). Attachments were modified
until acceptable signal quality was achieved. The BP cuff
was inflated several times prior to data collection to
accommodate the subject to its functioning. The

14
experimenter then read to the subject the instructions and
protocol which are presented in full in Appendix B.
Briefly, subjects were informed that they would be presented
a few short videotapes which would depict surgical and/or
neutral scenes. Following each presentation, they would
rate their emotions experienced during the presentation and
then complete a questionnaire. After several video
presentations, audiotape presentations would occur according
to the same format.
Next, the experimenter taught subjects in the use of
the Self Assessment Manikin (SAM), the computerized affect
self-report system (Appendix C). After answering subjects'
questions, the experimenter exited to the adjacent control
room, where he ascertained subjects' group status (phobic or
nonphobic), and then randomly determined the order of
stimulus presentation and which of the two surgical stimuli
were to be used.
Experimental paradigm. Table 1 presents the
experimental design and trial sequence of the study, and
Table 2 presents the timing durations and measurements for
each trial. Baseline subjective ratings were obtained prior
to the presentation of the first stimulus; subjects rated
their emotions experienced while waiting for the first
videotape presentation. After this baseline rating, the
paradigm of three trials began.
Each of the three trials followed the same data
collection format. The trial began with a baseline BP

15
assessment. After the cuff deflated, baseline HR and SCL
were recorded for the next 30 s, immediately prior to
stimulus onset. Contiguous with the end of this 30 s
period, the experimenter presented the stimulus to the
subject, and HR and SCL continued to be recorded during the
60 s presentation. Immediately at stimulus offset, BP was
sampled again, and the affective ratings screen illuminated
for subjects to rate the affect they experienced during the
videotape. They then waited for the next trial.
For Trials 1 and 2, one of the two surgical videotapes
(randomly selected) and the neutral videotape were
presented, counterbalancing the order of presentation both
for group and gender. For these two trials, the
experimenter presented the visual stimulus on the subject's
television, and the subject's face was videotaped during the
presentation for later analysis of avoidance behavior and
facial expression. Following the subjective ratings for
Trials 1 and 2, the experimenter reentered the experimental
chamber and gave subjects the third (after Trial 2) and the
fourth (after Trial 3) personality questionnaires;
completion time of each averaged about five minutes.
Following Trial 2 and the fourth questionnaire completion,
the experimenter placed headphones on the subject for Trial
3 (the final trial), which was a single audiotape
presentation. The experimenter randomly selected either the
surgical audiotape (describing the surgical videotape the
subject had viewed) or the neutral audiotape (describing the

16
Table 1. Experimental Procedure and Trial Sequence for
Study 1
1 TRIAL 1
1 1
TRIAL 2
1
1 TRIAL 3
QUESTION
1
| Surgery
1 1
|QUESTION|
Neutral
1
|QUESTION
1
| Surgery
NAIRES
or
| NAIRE |
or
| NAIRE
or
# 1 & 2
Neutral
| # 3 |
Surgery
| # 4
j Neutral
|VIDEOTAPE
1
1 1
1 1
VIDEOTAPE
1
1
|AUDIOTAPE
1
Table 2. Timing Durations and Measures for Each Trial
0
0
N
F
S
F
E
S
T
Stimulus presented E
T
BP base |HR,
1
SCL base|HR,
1
SCL, (Face:Trials 1,2)|
1
BP, SAM
about 30 s|
30 S |
u
o
VO
about
30 s

17
neutral videotape the subject had viewed). The selection of
the surgical or neutral audiotape was balanced across phobia
group, gender, and the order of videotape stimulus
presentation (surgical stimulus first or neutral stimulus
first) during Trials 1 and 2. Trial 3 followed the timing
and data recording paradigm of the first two trials, except
that subjects' faces were not videotaped. After Trial 3,
the experimenter disconnected the recording devices,
debriefed subjects in accordance with APA guidelines
(Appendix D), and dismissed them.
Stimuli
Both phobic (surgical) and neutral videotape and
audiotape stimuli were used in this study; all stimuli were
60 s in duration. Three different videotapes were used,
including two surgical tapes and one neutral tape; all
videotapes were silent. The two surgical videotapes were
taken from the 30-minute film of thoracic operations used by
Ost and colleagues in their studies of blood phobia (e.g.,
Ost & Sterner, 1987). The two 60 s segments used in this
study depicted particularly aversive procedures in which
some cutting or piercing with a sharp instrument occurs.
"Incision" showed a scalpel incising the abdomen several
times, and other sharp instruments cutting muscle tissue.
The second surgical stimulus, "Tubes," showed a sharp tool
puncturing two holes in the abdomen and then plastic
drainage tubes being pulled through the holes. Neither
surgical scene revealed the patient's head or genitalia.

18
The single neutral videotape showed a wooden toy truck being
pushed over several white ramps and a person's hand picking
up and later putting down yellow blocks.
Three audiotape stimuli (two surgical and one neutral)
were employed, one corresponding to each of the three video
stimuli noted above. Each audiotape presented the voice of
a female who narrated the events in the respective videotape
in an informative, affectively neutral manner. Each
description was 60 s and 160 words long. (See Appendix E
for the transcripts of these descriptions and others used in
Study 2.)
Experimental Environment and Apparatus
Subjects were seated in a recliner with their legs
parallel to the floor, and torso reclined at approximately
30 degrees from vertical, in a 4 m X 4 m experimental
chamber. The chamber's overhead lights were off, but the
room was dimly lit by a floor lamp. A 66 cm (26 in) RCA
Lyceum color television was positioned 2 m in front of the
subject's face. This television presented the videotape
stimuli which were recorded on half-inch VHS videotapes and
played from a Panasonic videorecorder in the adjacent
control room. A 25.4 cm (10 in) Apple computer video
monitor positioned immediately to the right of the subjects'
television presented the self-report ratings display.
Subjects controlled the display by manipulating a
potentiometer knob on a control box attached to the right
arm of their chair. A black and white Panasonic videocamera

19
with a zoom lens was mounted on the wall in the experimental
chamber near the ceiling slightly to the left of the
television. The camera was focussed on the subject's face,
permitting accurate assessment of the direction of gaze, eye
closings, and tensing of facial muscles. Videorecordings of
the subject were made on half-inch VHS videotapes in a
second Panasonic videorecorder in the control room. During
Trial 3, subjects wore comfortable Realistic NOVA 40 stereo
headphones, through which they heard the audio stimuli,
which were recorded on audiocassette tapes and played to
subjects from a General Electric stereo cassette player.
The control room was further equipped with an IBM-PC AT
which ran VPM software (Cook, Atkinson, & Lang, 1987) to
control physiological data collection and the presentation
of the affect ratings display. (See Appendix F for the VPM
control program for this study.) VPM also controlled
physiological data sampling, recording, and analysis using a
Scientific Solutions Labmaster board, an Axon Instruments
TL-1 interface panel, and Coulbourne modules. The control
room also housed a Roche Ultrasonic Blood Pressure Monitor,
Arteriosonde 1225.
Questionnaires
Five questionnaires were used in this study.
1) Mutilation Questionnaire (MQ; Klorman, Weerts, Hastings,
Melamed, & Lang, 1974). The MQ is a 30-item, true-false
questionnaire designed to assess an individual's fear of,
discomfort with, or aversion to blood, injury, mutilation,

20
and related stimuli. The questionnaire's authors provided
normative data for male and female college students.
Several studies have shown the validity of the MQ relative
to psychophysiological and behavioral indices of blood-
injury concerns (Beiman et al., 1978; Green, Webster,
Beiman, Rosmarin, & Holliday, 1981; Klorman et al., 1977;
Ost, Lindahl, Sterner, & Jerremalm, 1984; Ost & Sterner,
1987) .
2) Questionnaire Upon Mental Imagery (QMI; Sheehan 1967).
This questionnaire is the shortened version of Betts' (1909)
original instrument. The QMI contains 35 stimulus items
categorized in seven major sensory modalities. Subjects are
asked to rate the vividness of the images that come to mind
for each item using a seven point scale ranging from 1
("Perfectly clear and vivid") to 7 ("No image at all"). The
sum of all ratings is the total score, which ranges from 35
- 245, with low scores indicating better imagery ability.
This questionnaire has been normed (White, Ashton, & Brown,
1977) and has demonstrated reliability (Evans & Kamemoto,
1973; Hiscock, 1978) and validity (Cook, Melamed, Cuthbert,
McNeil, & Lang, 1988; Miller et al., 1987; Hiscock, 1978).
3) Interpersonal Reactivity Index (IRI; Davis, 1980). The
IRI is a 28-item, self-report questionnaire consisting of
four, factor-derived, 7-item subscales, each of which
assesses a specific aspect of empathy. The Perspective-
Taking scale measures the tendency to adopt the point of
view of other people in everyday life. The Fantasy scale

21
measures the tendency to transpose oneself into the feelings
and actions of fictitious characters in books, movies, and
plays. The Empathic Concern scale measures the tendency to
experience feelings of warmth, compassion, and concern for
other people. The Personal Distress scale taps one's own
emotional feelings of personal unease and discomfort in
reaction to the emotions of others. Subjects responded to
each item on a 5-point scale ranging from 0 ("does not
describe me well") to 4 ("describes me very well"). Ratings
are summed for the items in each scale, yielding four
scores. Davis (1980) reported that the four scales have
adequate internal consistency and test-retest reliability,
although females score higher than males on all scales.
Convergent and discriminant validity have been reported with
other self-report dimensions (Davis, 1983) and affective
reactions to video stimuli (Davis, Hull, Young, & Warren,
1987) .
4) Anxiety Sensitivity Index (ASI, Reiss et al., 1986). The
ASI is a 12-item questionnaire that measures individual
differences in hypersensitivity to one's own anxiety
responses and behavior. Respondents endorse each item using
a 5-point scale ranging from "Very little" (0) to "Very
much" (4). A person's score on the ASI is the sum of the
scores on the 16 items. Reiss et al. (1986) provided
reliability data showing that the ASI has adequate internal
consistency and test-retest reliability. They also found
that anxiety disorder patients scored higher than non-

22
disordered subjects, and the questionnaire accounted for
Fear Survey Schedule variance which remained unaccounted for
by specific fear endorsement.
5) Fenz and Epstein Anxiety Questionnaire (FEQ; Fenz &
Epstein, 1965; Fenz, 1967). The FEQ is a 53-item
questionnaire listing symptoms of anxiety which are rated by
the respondent on a 5-point scale ranging from 1 ("never
applies to you") to 5 ("experience it almost all of the
time"). The scale was developed and factor analyzed to
divide manifest anxiety into its component dimensions.
Three factors are separately scored by totaling the ratings
for the items in each scale: striated muscle tension,
autonomic arousal, and feelings of fear and insecurity.
Fenz (1967) provided reliability coefficients for each scale
and found that "neurotics" scored higher than normals on all
three scales.
Dependent Measures
Dependent measures are categorized according to Lang's
(1968) three systems model of emotion: self-report indices
(i.e., verbal behavior or subjective responses),
physiological reactions, and overt motor behavior.
Self-report.1 The Self Assessment Manikin (SAM; Hodes,
Cook, & Lang, 1985; Lang, 1980) is a graphic video display
instrument for obtaining subjective ratings on three
independent affective dimensions: pleasure—displeasure,
arousal-calmness, and control—lack of control. SAM is
presented as a manikin whose features are dynamically

23
modifiable by subjects to represent their affect using a
potentiometer on the arm of their chair. The VPM software
program presents the three graphic displays in random order
to the subject on a video monitor. The pictorial display is
converted by the computer to a 21-point scale. In the
pleasure display, SAM's facial expression changes from a
smile to a frown; in the arousal display, SAM's "abdomen" (a
random and changing patters of dots) increases or decreases
in size and rate of change, and SAM's eyes open and close;
in the control display, SAM changes in size from very small
to very large. The validity of the three SAM ratings of
affect has been demonstrated in several studies (Cook et
al., 1988; Greenwald, Cook, & Lang, in press; Hodes et al.,
1985). For these three self-report measures, difference
scores were calculated by subtracting the baseline affect
rating (taken before Trial 1) from the affect rating for
each trial. These studies used labels for the negative
poles of each affective dimension ("displeasure," "arousal,"
"lack of control") to achieve consistency in presentation.
Physiological indices. Three different physiological
indices of affect were assessed.
1) Skin conductance level (SCL). SCL was recorded from two
Beckman Ag-AgCl miniature electrodes placed on the thenar
and hypothenar eminence of the left hand after moistening
the palm with distilled water. A neutral paste (petroleum
jelly) was used in the electrode. Analog SCL was sampled at
10 hertz using a .5 volt constant voltage Coulbourne Skin

24
Conductance Coupler (S71-22), which output a digital signal
to the computer. VPM software reconverted the digital value
to micromhos, and calculated mean SCL for the 10 s baseline
immediately prior to stimulus onset and for the entire 60 s
stimulus presentation period. SCL difference scores were
calculated by subtracting the 10 s baseline SCL from the
stimulus SCL.
2) Heart rate (HR). The electrocardiogram (ECG) was
recorded from two Beckman Ag-AgCl miniature electrodes
placed on the left and right forearms after preparing the
subject's skin with alcohol and electrode paste (Hewlett-
Packard Redux). The ECG waveform was sampled at 10 hertz
and fed from a Coulbourne bioamplifier (S75-01) into a
Coulbourne Bipolar Comparator (S21-06), which detected the
"R" wave at suprathreshold levels, and output the signal
into a Coulbourne Retriggerable One Shot (S52-12), which
then output a digital signal to the computer. VPM software
calculated R-R interbeat intervals to the nearest
millisecond and converted heart period to heart rate. Mean
HR was calculated for 10 s baseline immediately prior to
stimulus onset and for the 60 s stimulus presentation
period. HR difference scores were calculated by subtracting
the baseline HR from the stimulus HR.
3) Blood pressure. Both systolic blood pressure (SBP) and
diastolic blood pressure (DBP) were monitored using an
automated sphymomanometer with the cuff attached to
subjects' left upper arm. The experimenter manually

25
initiated cuff inflation from the control room and then
recorded the LED digital output by hand. Cuff inflation
required about 5 s, and deflation required about 25 s.
Difference scores were calculated by subtracting the SBP and
DBP values taken before each trial from the values obtained
at stimulus offset.
Motor behavior. Two variables were assessed from the
videotaped recordings of subjects' faces while they watched
the surgery and neutral videotapes. Two independent raters,
blind to the study hypotheses and to the videotape type
(surgery versus neutral) for each subject were trained to
code these variables.
1) Avoidance of eye contact with stimulus. This measure was
recorded as the number of seconds out of 60 that a subject's
eyes were closed or were not directed at the television
screen during the stimulus. Because the resulting
distribution was highly skewed and, therefore, not amenable
to parametric statistics, subjects were dichotomously
classified for each videotape. Avoidance was coded
positively if subjects showed at least one second of
avoidance during the videotape, and negatively if there was
less than one second of avoidance. Interrater reliability
was calculated as the percentage agreement between the two
coders. They agreed on the presence or absence of avoidance
for 47 of 48 subjects (98%) during the surgery videotape,
and they agreed on all 48 subjects (100%) for the neutral
videotape.

26
2) Facial expressions of disgust. An evaluation of all
videotapes indicated that when subjects made a facial
expression during viewing, they routinely tensed either or
both of two muscle groups, resulting in furrowing of the
eyebrows and raising of the upper lip. According to Ekman,
Friesen, and Ellsworth (1972), this facial pattern signifies
the emotion of disgust. Thus, coders rated the maximum
degree that these muscle groups were tensed during each 60 s
videorecording using a 5-point scale (0 = "no tensing
evident," 1 = "minimal tensing," 2 = "mild tensing," 3 =
"moderate tensing," 4 = "severe tensing"). Since the
distribution of ratings for the nonphobics was restricted
greatly, and the vast majority of ratings for both groups
was zero during the neutral videotape, the data were treated
as frequency data and collapsed into three categories to
increase the n per cell. Original values of 0 were
classified as "none," values of 1 and 2 were classified as
"low," and values of 3 and 4 were classified as "high." The
two raters agreed on the scoring for the three levels of
facial disgust for 46 of 48 subjects (96%) during the
surgery stimulus, and 45 of 48 subjects (94%) during the
neutral stimulus.
Results
Personality Measures
The means and standard deviations for each of the four
personality questionnaires and their subscales for the
phobics and nonphobics are presented in Table 3. Phobics

27
were compared with nonphobics using independent groups t-
tests. As Table 3 indicates, phobics had greater anxiety
sensitivity (ASI), feelings of personal distress (IRI-
Personal Distress), and general fear and insecurity (FEQ)
than did the controls. The groups did not differ on the IRI
subscales of Fantasy, Empathic Concern, or Perspective
Taking Ability, nor on the FEQ subscales of Muscular Tension
or Autonomic Arousal. Unexpectedly, the nonphobics reported
better mental imagery ability (QMI) than did the phobics.
Videotape Stimuli
Data analysis. A general data analytic strategy
examined affect during the two videotape stimuli (Trials 1
and 2) for displeasure, arousal, lack of control, HR, SCL,
SBP, and DBP. First, each dependent measure was analyzed in
a mixed-model repeated-measures analysis of variance (ANOVA)
in which Video (surgery and neutral videotape) was the
within-subject effect, and Group, Order (surgery videotape
presented first or neutral videotape presented first), and
Surgery ("Incision" or "Tubes" videotape) were between-
subjects variables. Significant interactions from this
model were examined via simple effects analyses using
appropriate error terms for repeated-measures models
(Howell, 1982) and corrected error degrees of freedom when
heterogeneous sources of error variance were pooled
(Satterthwaite, 1946). Typically, these simple effects
analyses examined differences between phobics and controls
for each videotape separately, and each Group was examined

28
Table 3. Questionnaires Scores for Phobics and Nonphobics
Measure
Phobics
M (SD)
Nonphobics
M (SD)
t(46)
E
ASI
24.1
(8.2)
15.9
(10.4)
3.04
.004
IRI
Personal Distress
14.9
(5.0)
8.8
(3.4)
4.87
. 0001
Fantasy
17.6
(5.2)
18.7
(5.6)
0.70
n. S.
Empathic Concern
21.0
(3.3)
20.4
(4.9)
0.52
n. s.
Perspective taking
16.0
(5.9)
18.5
(4.9)
1.63
.11
FEQ
Fear/Insecurity
49.8
(10.9)
40.3
(11.6)
2.91
.006
Muscular Tension
31.0
(7.9)
30.9
(10.8)
0.04
n. s.
Autonomic Arousal
30.8
(7.6)
28.4
(10.0)
0.93
n. s.
QMI
92.0
(24.1)
74.3
(14.3)
3.12
.003
a p-values were determined using two-tailed tests

separately across the two videotapes. Simple effects
analyses were considered significant at the .01 probability
level. Appendix L presents the complete ANOVA tables.
29
Self-report measures. Displeasure, arousal, and lack
of control change scores from baseline for the phobics and
nonphobics for both surgery and neutral videotapes are
presented in Table 4. Similar results were found for all
three measures. During the surgery videotape, phobics
reported more arousal, displeasure, and lack of control than
did the nonphobics, whereas during the neutral videotape,
the two groups did not differ in any measure. Across
videotapes, the phobics reported greater negative affect on
all three measures to the surgery than to the neutral
videotape. The nonphobics reported greater arousal to the
surgery than to the neutral videotape, but no difference in
control to the two videotapes, (Video X Group interactions
for displeasure, F(l, 40) = 34.91, p < .0001; arousal, F(l,
40) = 14.76, p < .0004; and lack of control, F(l, 40) =
24.33, e < .0001). For displeasure, however, there was an
influence of videotape order (see Appendix K for these
data). Phobics reported more displeasure to the surgery
videotape when it was presented before, but not after, the
neutral videotape. Nonphobics reported more displeasure to
the surgery videotape than to the neutral videotape only
when the surgery was presented after, but not before, the
neutral videotape, (displeasure Video X Group X Order
interaction, F(l, 40) = 8.73, e < .006). Videotape order

30
Table 4. Self-Reported Changes in Displeasure, Arousal,
and Lack of Control During the Surgery and
Neutral Videotapes for Phobics and Nonphobics
Videotape Stimulus
Surgery Neutral
M
(SD)
M
(SD)
Phobics
Displeasure
9.7
(4.6)
-0.7
(2.6)
Arousal
8.1
(6.9)
-4.0
(6.7)
Lack of Control
4.7
(6.3)
-5.4
(4.4)
Nonphobics
Displeasure
2.8
(3.8)
-0.3
(3.2)
Arousal
2.8
(5.7)
-3.6
(4.2)
Lack of Control
-1.9
(5.0)
-4.1
(4.5)

31
did not affect arousal or control, and surgery type ("Tubes"
or "Incision") was unrelated to any self-report variable.
Physiological measures. Figure 1 presents mean SCL and
HR change scores during the "Incision" and "Tubes" surgery
videotapes and the neutral videotape for phobics and
nonphobics. As the figure reveals, the SCL and HR of the
phobics who viewed "Incision" was greater than the SCL and
HR of a) nonphobics who viewed "Incision," and b) phobics
who viewed "Tubes." Phobics and nonphobics did not differ
in SCL or HR during "Tubes," nor did the nonphobics' SCL or
HR differ to the two surgeries. Across videotapes, both
phobics and nonphobics had a greater SCL during the surgery
than the neutral videotape, regardless of Surgery type.
However, HR change was greater during the surgery than the
neutral videotape only for phobics who viewed "Incision,"
but not for phobics who viewed "Tubes" or for the
nonphobics. Phobics and nonphobics did not differ in SCL or
HR during the neutral videotape, (for SCL: Group X Surgery,
F(1, 40) = 4.30, p = .044, and Video X Group X Surgery, F(l,
40) = 3.74, e = -06; for HR: Video X Group X Surgery, F(l,
40) = 12.07, E = .001).
Although videotape Order failed to significantly affect
SCL, it did influence HR (see Appendix K). Phobics who
viewed a surgery before viewing the neutral videotape had a
greater HR increase than a) nonphobics who saw a surgery
first, and b) phobics who saw a surgery second. Across
videotapes, only those phobics who saw a surgery before the

32
PI PI Phobics, Incision
PT PT Phobics, Tubes
NI- - -NI Nonphobics, Incision
NT._._.NT Nonphobics, Tubes
2.0 +
S
K
I
N
C
O
N
D
U
c
T
A
N
C
E
C
H
A
N
G
E
PI
1.5 +
1.0 +
-0.5 +
Surgery Neutral
PI
6 +
H
E
A
R 4 +
T
R
A
E
2 + PT
Surgery Neutral
Videotape
Figure 1. Skin Conductance Level Change and Heart Rate
Change Across Surgery and Neutral Videotapes for
Phobics and Nonphobics by Type of Surgery Viewed

33
neutral videotape had a greater HR during the surgery than
during the neutral, (Video X Order, F(l, 40) = 12.79, p =
.0009; Group X Order, F(l, 40) = 4.16, p = .048).
Analyses of changes in SBP and DBP failed to reveal any
significant effects or even nonsignificant trends within or
across videotapes or as a function of Group, Order, or
Surgery for either dependent measure.
Motor behavior measures. Avoidance and the maximum
facial expression of disgust during the videotapes were
analyzed as frequency data using chi-square analyses.
Tables 5 and 6 present these data for both phobics and
nonphobics for both videotapes by type of surgery and order
of presentation. Phobics more frequently avoided and showed
"high" disgust2 than did the nonphobics during the surgery
"Incision" but not during "Tubes," (avoidance, X2(l) = 8.71,
p < .005; disgust, X2(l) =9.88, p < .005). Among the
phobics, avoidance was significantly more frequent, and
"high" disgust tended to be more frequent during "Incision"
than during "Tubes," (avoidance, X2(l) = 6.171, p < .013;
and disgust, X2(l) = 2.74, p < .10). Avoidance and disgust
of the nonphobics was not influenced by the type of surgery.
With respect to stimulus order, phobics avoided the surgery
videotape more than the nonphobics only when the surgery was
shown first, X2(l) = 5.04, p < .025; but the groups did not
differ in avoidance of the surgery when it was presented
after the neutral videotape. Stimulus order did not affect
the phobics or nonphobics' avoidance of the surgery when

34
Table 5. Number of Phobics and Nonphobics Displaying
Avoidance Behavior During the Surgery and Neutral
Videotapes by Type of Surgery Viewed and Order of
Videotape Presentation
Videotape Stimulus
Surgery Neutral
Phobics (n=24)
Type of Surgery
"Incision" (n=12)
"Tubes" (n=12)
Order of Presentation
Surgery first (n=12)
Neutral first (n=12)
Nonphobics (n=24)
Type of Surgery
"Incision" (n=12)
"Tubes" (n=12)
Order of Presentation
Surgery first (n=12)
Neutral first (n=12)
Avoidance
Yes
No
Yes
No
10
14
4
20
8
4
4
8
2
10
0
12
6
6
3
9
4
8
1
11
2
22
2
22
1
11
0
12
1
11
2
10
1
11
1
11
1
11
1
11

35
Table 6. Number of Phobics and Nonphobics Displaying Facial
Expressions of Disgust During the Surgery and
Neutral Videotapes by Type of Surgery Viewed and
Order of Videotape Presentation
Videotape Stimulus
Surgery Neutral
Phobics (n=24)
none
5
low
9
Disgust
hicrh
10
Level
none
22
low
2
hicrh
0
Type of Surgery
•’Incision"
(31=12)
1
4
7
10
2
0
"Tubes"
(11=12)
4
5
3
12
0
0
Order of Presentation
Surgery first (n=12)
2
4
6
12
0
0
Neutral first
(n=12)
3
5
4
10
2
0
Nonphobics (n=24)
8
16
0
21
3
0
Type of Surgery
"Incision"
03=12)
4
8
0
10
2
0
"Tubes"
01=12)
4
8
0
11
1
0
Order of Presentation
Surgery first (n=12)
5
7
0
10
2
0
Neutral first
(11=12)
3
9
0
11
1
0

36
each group was examined alone. The disgust of both groups
was not affected by the order of presentation. Finally,
during the neutral videotape, phobics did not differ from
nonphobics in avoidance or disgust.
Next, the frequency of avoidance and disgust across the
two videotapes was examined.3 Significantly more phobics (7
of 8) differentially avoided the surgery rather than the
neutral videotape, X2(l) = 4.50, p < .035; and more phobics
(19 of 19) showed higher levels of disgust during the
surgery videotape than during the neutral videotape, X2(l) =
19.0, p < .0001. The nonphobics did not differentially
avoid the two stimuli, but all 13 of the nonphobics who
differentially showed disgust to the two videotapes showed
higher disgust levels during the surgery videotape, X*(l) =
13.0, p < .001. Surgery type and presentation order did not
influence disgust across videotapes.4
Audiotape Stimuli
Data analyses. Dependent measures assessed during the
audiotape presentation (Trial 3) included displeasure,
arousal, lack of control, HR, SCL, SBP, and DBP. Motor
behavior was not assessed during the audiotape trial. Data
analyses for these dependent measures used univariate ANOVAs
which included the following between-subjects effects and
their interactions: Audio (whether the subject heard the
surgery or the neutral audiotape), Group, Order (of the
preceding surgery and neutral videotapes), and Surgery.

37
Self-report measures. Data for the three self-report
measures for phobics and nonphobics by type of audiotape
presentation (surgery or neutral) are presented in Table 7.
The results for displeasure and control lack are identical.
Phobics who heard a surgery audiotape reported more
displeasure and lack of control than nonphobics who heard a
surgery audiotape, and more displeasure and lack of control
than phobics who heard the neutral audiotape. These two
variables did not differ for the nonphobics during the two
audiotapes. The two groups did not differ in displeasure or
lack of control during the neutral audiotape, (Group X Audio
interactions for displeasure, F(l, 32) = 7.95, p < .009; and
lack of control, F(l, 32) = 10.57, p < .003). For arousal,
whether subjects were phobic or not, greater arousal was
reported to the surgery audiotape than to the neutral
audiotape, (Audio main effect, F(l, 32) = 27.03, p < .0001).
For all three self-report measures, there was no difference
in response to •'Incision” or "Tubes” or to the order in
which the subjects had viewed the preceding videotapes.
Physiological measures. Subjects who heard the surgery
audiotape had a higher SCL (M = -0.21, SD = 0.56) than
subjects who heard the neutral audiotape (M = -0.51, SD =
0.36), Audio main effect, F(l, 32) = 5.08, p < .032. There
were no differences between phobics and nonphobics, nor were
there differences as a function of Surgery or Order. For
HR, SBP, and DBP, the ANOVAs revealed no significant effects
of Audiotape, Group, or the other independent variables.

38
Table 7. Self-reported Change in Displeasure, Arousal,
and Lack of Control During the Audiotape
Presentation for Phobics and Nonphobics by Type of
Audiotape (Surgery or Neutral)
Audiotape Stimulus
Surgery Neutral
Phobics
M
(SD)
M
(SD)
Displeasure
7.7
(4.7)
0.3
(3.6)
Arousal
4.8
(4.6)
-2.6
(7.3)
Lack of Control
3.1
(4.9)
-6.3
(3.5)
Nonphobics
Displeasure
2.7
(2.5)
1.9
(2.8)
Arousal
3.2
(4.9)
-5.4
(5.2)
Lack of Control
-1.7
(3.8)
-3.1
(4.3)

39
Discussion
This study accomplished several goals. First, it
compared blood phobics with nonphobic controls on specific
personality dimensions and found differences of theoretical
importance. Second, affect (subjective, psychophysiologic,
and motor) of phobics and nonphobics was examined during
surgical and neutral videotapes. Phobics displayed more
negative affect to the surgical presentation than did the
nonphobics, but the groups did not differ during the neutral
stimulus. Both groups had greater negative affect to the
surgical than to the neutral stimulus. Third, two different
surgery videotapes were compared, and one was more aversive
than the other. Fourth, the order of surgical and neutral
stimulus presentations was evaluated and found to have some
effect on responding. Finally, phobics and nonphobics heard
surgical or neutral audiotape presentations, and the
observed differences were fairly limited.
Psychometric Assessment
Theory and anecdotal observations specific to blood
phobia guided the assessment of four personality dimensions.
Consistent with the findings of Kleinknecht (1988a), blood
phobics reported greater "anxiety sensitivity," suggesting
they are more attuned to and concerned about physiological
indices of their own arousal than are nonphobics.
Unfortunately, the questionnaire assessed sympathetic
aspects of anxiety and not the parasympathetic activity
which blood phobics may experience. Nonetheless, if one can

40
extrapolate from the current assessment of anxiety to
parasympathetic symptoms, then this finding supports Engel's
(1978) hypothesis that blood phobics are hypervigilant about
and overly fearful of their own negative physical and
emotional responses to blood-related stimuli. Future
research should assess parasympathetic symptoms to test this
extrapolation.
The Fenz-Epstein Anxiety Questionnaire assessed the
degree to which blood phobics differ from normals and are
like other anxiety and psychosomatic disordered patients
("neurotics"). Blood phobics did not have elevated general
levels of autonomic arousal or muscular tension, suggesting
that they differ from the classic neurotic pattern of
anxious tension and autonomic lability. However, like other
"neurotic" patients, blood phobics reported greater general
fear and insecurity than controls. This finding is
consistent with Engel's (1978) model in that blood phobics
may overly seek to appear socially adequate and in control,
especially when experiencing discomforting physical and
emotional sensations.
The suggestion that blood phobics strongly identify
with the victim (Beck & Emery, 1986)—that they are able to
"feel" what the other person is feeling or to "get under the
skin" of the other—was assessed via questionnaires of
empathy and mental imagery. On the empathy scale, blood
phobics and controls did not differ in their ability to
fantasize, to take another's perspective, or in their

41
concern and caring about others. Yet blood phobics rated
themselves as more likely to feel personal distress or
unease in reaction to other's negative emotions. This
finding replicates that of Kleinknecht (1988a) and helps to
operationalize the notion of identifying with a victim.
Thus, an injury or pain in another person precipitates quite
readily negative affect in the blood phobic.
Mental imagery ability was assessed also to examine
identification with the victim. Unexpectedly, nonphobic
controls reported more vivid mental imagery than phobics.
This may be due not to poor imagery of phobics, but rather
to a nonphobic sample with unusually good imagery scores.
Replication with another sample is needed to confirm the
group difference.
It is tempting to speculate that the increased anxiety
sensitivity, general fear and insecurity, and personalized
empathic distress predated and abetted the full-blown
phobia; however, it is quite possible that these
characteristics resulted from one or more negative reactions
to blood-relevant stimuli. Longitudinal research is needed
to clarify this interpretive bind.
Affect During Videotaped Stimuli
This study used neutral stimulus material to control
for the effects of the experimental setting and stimulus
viewing and to permit definitive conclusions regarding the
affective responding of phobics and nonphobics to phobic
material. Thus, all subjects viewed a 60 s neutral

42
videotape in addition to a 60 s surgical videotape.
Equivalent levels of negative affect were displayed by both
groups during the neutral videotape, suggesting that any
observed differences during the surgical scene were not
attributable to extraneous factors of the experimental
setting.
Given the affective equivalence of phobics and
nonphobics to the neutral stimulus, it was expected that
phobics would report greater negative affect, be more
physiologically aroused, and show more avoidance and facial
expressions of disgust during a surgical videotape than
would nonphobics. Indeed, for most dependent measures, the
average scores of the blood phobics as a group indicated
that they had greater negative affect. Yet, the observed
differences for several dependent measures were limited by
the particular surgery scene viewed and/or the order of
videotape presentation.
For HR, SCL, facial disgust, and avoidance, differences
between phobics and controls were limited to the surgery
videotape, "Incision," which depicted a scalpel cutting a
person's abdomen and sharp tools opening the wound. Phobics
who viewed this surgery responded more negatively than did
nonphobics who viewed "Incision." No differences were found
between phobics and nonphobics during the surgery videotape
"Tubes," which showed a pliers-type tool puncturing a
person's abdomen and pulling plastic drainage tubes through
the holes. The nonphobics responded with a fairly low level

43
of negative affect to both surgeries; however, among the
phobics, "Incision” was more aversive than "Tubes." The
observed differences between the two surgical scenes is
interesting, in that both scenes show blood and the
"mutilation" of a portion of one's abdomen.
There are several possible explanations for the
observed differences. First, although the two videotapes
were similar in gross aspects, "Incision" simply may be a
more powerful aversive stimulus than "Tubes," in that a
scalpel cutting may be more aversive than a pair of pliers
puncturing and pulling. A second, perhaps related
hypothesis pertains to the observers' comprehension of the
events depicted. In this study, subjects had been informed
previously only that the videotapes showed portions of a
surgery on a living human being. The insertion of the tubes
might have not been recognized readily as a surgical
procedure, in contrast to the clearly recognized scalpel
incision. Thus, "Tubes" might have evoked increased
curiosity, and hence, less aversion than "Incision." This
hypothesis might be empirically examined by providing
subjects a description of the "Tubes" surgery before or
during viewing, thus eliminating uncertainty about content.
Affective group differences to the surgery videotapes
were limited also by the order of videotape presentation.
During the surgery presentation, phobics had higher HRs and
showed more avoidance than controls only when the surgical
stimulus was presented first rather than second; when the

44
surgery was presented after the neutral, the groups did not
differ. Among phobics, a surgical scene viewed first
elicited more displeasure as well as tachycardia and
avoidance than did a surgical presentation after the neutral
videotape.
A parsimonious explanation for the observed effects is
that habituation occurred, and subjects felt generally less
aroused to a later presentation of a surgery than to an
earlier presentation due to the passage of time and
accommodation to the experimental setting. An alternative
explanation is that subjects acquired information during the
earlier presentation of the neutral stimulus which resulted
in lower anxiety on a subsequent presentation. Information
potentially acquired during the initial neutral exposure
included the duration of the stimulus, the functioning of
the television, and a reduction in ambiguity regarding which
stimulus (surgery or neutral) they were most likely to see
next. A test of these two hypotheses might be achieved by
comparing two groups of phobics, one which views a neutral
followed by a surgery film, whereas the other waits an equal
length of time before viewing a surgery film.
Alternatively, order effects might be controlled by
providing a practice videotape trial before presenting the
two stimuli of interest and informing subjects of the order
of scenes.
Thus, several variables other than the presence or
absence of blood phobia influenced responding to surgical

45
stimuli. It should be remembered, however, that the
observed effects of surgery type and/or order may be due to
bias in random assignment; for example, the 12 phobics
assigned to view "Incision" or to view a surgery before the
neutral videotape may have differed in some important, yet
unassessed way from other phobics. The need for replication
on a different and larger sample of phobics is clear.
In addition to comparisons between phobics and
nonphobics, this study examined each group's affect to both
surgical and neutral stimuli. As expected, phobics reported
greater displeasure, lack of control, and arousal during the
surgery videotape than during the neutral videotape.
Nonphobics also reported greater arousal to the surgery
stimulus, but limited or absent differences in displeasure
and control. On physiological measures, the differences
between videotapes were less robust. Both phobics and
nonphobics had a higher SCL during the surgery videotape in
comparison to the neutral videotape. For HR, only those
phobics who viewed "Incision" or who viewed a surgery first
were more tachycardic during the surgery than during the
neutral videotape. The HR of other phobic subgroups and of
the nonphobics did not differ during the two stimuli. Blood
pressure measures did not differentiate the two videotapes
for either group. Finally, both phobics and nonphobics more
frequently displayed facial expressions of disgust to the
surgery than to the neutral videotape; however, only the
phobics more frequently avoided the surgery than the neutral

46
videotape. In summary, phobics clearly showed more negative
affect during the surgery videotape than during the neutral
videotape, especially for the surgery "Incision," whereas
nonphobics showed similar but less pronounced and less
consistent affective differences to the two stimuli. The
observation of some increase in negative affect to the
surgery scene for the nonphobics is consistent with the view
that aversiveness to blood-related stimuli exists on a
continuum. Whereas extreme cases may be considered phobic,
cases selected from other portions of the distribution (such
as below the median) have relatively less aversion, but
still more than to a neutral stimulus.
Steptoe and Wardle (1988) suspected that when both
blood-related and neutral material were presented to blood
phobics, the order of presentation would be important. In
their study, they eschewed stimulus counterbalancing and
presented to all subjects the bloody stimulus first followed
by the neutral stimulus. They presumed that the
presentation of the neutral stimulus first to half of the
phobics would have yielded a biased sample of "neutral"
responding, with elevated fear due to anticipatory anxiety
over the upcoming phobic stimulus. The current study tested
their assumption and found, contrary to their hypothesis, no
evidence that responses during a first presentation of the
neutral videotape differed from responses during the second
neutral stimulus presentation. Furthermore, the order
effects found in this study suggest that Steptoe and

47
Wardle's presentation of the blood stimulus first probably
resulted in greater negative affect to it, and greater
differences between the blood and subsequent neutral
stimulus.
Affect During Audiotaped Stimuli
This study also assessed affective responding during
verbal descriptions of phobic and neutral stimuli in order
to understand how various stimulus presentation modalities
influence the affect of blood phobics. All subjects heard
an audiotaped description of either the surgery or the
neutral scene that they had just seen.
Phobics who listened to a surgical description reported
more displeasure and control lack than phobics who heard the
neutral description or nonphobics who heard a surgical
description; however, only these two variables discriminated
conditions. Self-reported arousal and SCL were increased
during the surgery audiotape regardless of whether a person
was phobic or not, and neither HR nor BP measures differed
as a function of stimulus content or group. In summary, the
effects of group and stimulus type during audiotape
presentations were less robust than during videotape
presentations. Potential reasons are discussed later.
Methodological Issues
It must be acknowledged that the observed differences
between phobics and nonphobics and also between surgical and
neutral stimuli were of limited magnitude. First, the
subject selection procedure probably reduced group

48
differences. Phobics and nonphobics were selected from
different points of a nearly normal distribution of MQ
scores using rather arbitrary cut-scores. Restriction of
those ranges by studying only the few highest scoring
phobics or lowest scoring nonphobics might have increased
the observed effect size. Alternatively, studying phobics
presenting for treatment (although such people are rare)
likely would have yielded more clear differences.
Limited differences also were found between surgical
and neutral stimuli. In addition to the effects of stimulus
presentation order and surgery type described above, the
type of phobic stimulus undoubtedly had an impact. First,
it is possible that a videotaped portion of a surgery is
less aversive than, for example, mutilation scenes such as
injuries, accidents, etc. Additionally, although the two
surgery scenes were taken from an apparently powerful phobic
stimulus of thoracic operations (Ost, Sterner, & Lindahl,
1984), the presentation methods differed markedly. Ost and
colleagues showed a continuous 30 minute videotape that
included scenes of the full human patient during surgery.
In the current study, the elimination of scenes showing the
patient's face or full body might have reduced the negative
impact of the stimulus. Indeed, during debriefing, many
phobics noted that the operation seemed somewhat unreal,
partly because they did not know for sure that a human was
undergoing surgery. Finally, unlike the methodology of Ost
and colleagues in which the 30 minute stimulus was not

49
stopped until fainting or continuous avoidance occurred,
this study's use of a 60 s stimulus permitted the collection
of uniform data for all subjects but probably also decreased
exposure intensity. In summary, a more intense phobic
stimulus probably would have increased group differences.
Notes
1 An attempt was made to assess feelings of faintness and of
nausea independent from the three SAM scores by presenting
two VPM-generated visual analog scales to subjects following
each of the SAM ratings. Scores from these faintness and
nausea scales were found to be highly correlated with the
self-reported displeasure (r = .66 and .70, respectively),
to be much more highly endorsed by females (unlike the three
SAM measures), and to be highly skewed with most scores
being zero. Additionally, given the experimental nature of
these scales and the lack of prior psychometric data, these
scales are not presented in this manuscript.
2 When examining the effects of Surgery and Order on facial
disgust, three levels of disgust would have resulted in
unacceptably low sample sizes for chi-square analyses. Thus,
for these analyses, a single "low” category was created by
collapsing the "none" and "low" categories.
3 Chi-square analyses across stimuli (within-subjects) must
not violate the assumption of independent observations;
therefore, these analyses for avoidance and facial disgust
utilized McNemar's (1969) suggestion to determine if the
number of subjects who, for example, showed avoidance
differentially during the two videotapes varied
significantly from expected. The null hypothesis in this
case is that the number of subjects who avoided the surgical
videotape but not the neutral videotape equals the number of
subjects who avoided the neutral videotape but not the
surgery. Chi-square goodness of fit tests evaluated this
hypothesis.
4 The small number of subjects who showed differential
avoidance to the two videotapes precluded an analysis of the
effects of surgery type and presentation order.

STUDY 2
Introduction
The goals of Study 2 were to a) evaluate the presence
and extent of habituation to repeated exposures to a
surgical visual stimulus and dishabituation to a novel
surgical stimulus; b) assess the effect on habituation and
dishabituation of preparing blood phobics by providing
either a relevant description of the upcoming surgery or a
neutral control description; and c) examine how imagery
ability and coping style moderate the effects of preparation
and repeated exposures.
Exposure and Affect Change
A wealth of clinical data strongly supports the
proposal that exposure—by various means—changes affect
(Barlow, 1988; Foa & Kozak, 1985; Marks, 1978). In
particular, these researchers agree that exposure to
anxiety-evoking stimuli produces the changes noted during
treatment of anxiety disorders and phobias. It is
noteworthy that each of the therapeutic interventions for
blood phobia noted in the General Introduction incorporates
some form of exposure to blood-relevant material.
Yet few studies have examined the process of emotional
change during exposure to aversive stimuli in blood phobia.
Hare et al. (1971) studied normal adults and found that
50

51
repeated presentations of the same mutilation slide resulted
in rapid physiological habituation, whereas different
mutilation slides interfered with habituation. Similar
studies have presented mutilation slides with the purpose of
studying orienting and defense reactions in blood phobics
(Klorman et al., 1975, 1977). The use of repeated exposure
to videotapes or films is rare (see Klorman, 1974 for an
exception) and has not been conducted with blood phobics.
It is difficult to achieve prolonged exposure in blood
phobia without incorporating syncope-preventing strategies
or suffering missing data. Therefore, the current paradigm
used brief, repeated exposures to surgical stimuli to
produce habituation in blood phobics.
Studies of repeated exposures to aversive stimuli
typically have not examined the generalization of reduced
affect to related stimuli once extinction or habituation to
one stimulus has occurred. Yet repeated visual exposures to
a blood-related stimulus may result in reduced negative
affect to a novel blood-related stimulus secondary to
modifications in the "blood-related" emotional network.
Preparatory Information
Exposing subjects to films was the paradigmatic
approach of Lazarus and colleagues, who explored the
efficacy of verbal "defensive sets" to modify stress
responses during mutilation and other stressful films
(Lazarus & Alfert, 1964; Lazarus, Speisman, Mordkoff, &
Davison, 1962; Speisman, Lazarus, Mordkoff, & Davison,

52
1964). In these studies, introductory statements or film
soundtracks were modified to induce "intellectualization" or
"denial" sets. The finding of group differences on some
physiological measures prompted the authors' claim that
defensive sets effectively "short-circuited" stress.
Alternatively, the presentation of accurate preparatory
information may have led to decreased physiological arousal.
A large literature indicates the need to consider the
affect-modifying role of preparatory information. Many
studies have demonstrated that preparing medical and dental
patients with information about upcoming aversive procedures
reduces physiological arousal, behavioral escape or
avoidance, and subjective distress at various points before,
during, and after the procedure (Anderson & Masur, 1983;
MacDonald & Kuiper, 1983; Rogers & Reich, 1986; Silver &
Wortman, 1980). These preparation researchers have not
discussed the affect-modifying effects of information in an
emotional imagery framework (Hebb, 1968; Lang, 1979, 1985).
In this view, a perceptual-motor memory is activated,
observable visceral and motor responses occur, and
modification of the memory's stimulus, meaning, and response
propositions is facilitated. Thus, preparatory information
may reduce fear of an event by activating the relevant
emotional network and permitting fear modification.
Several individual difference variables may influence
the effect of preparatory information and/or the change in
affect across exposure repetitions. First, individuals

53
differ in their ability to create vivid images from verbal
prompts, with resulting differences in visceral activity,
and these imagery ability differences can be reliably
assessed via questionnaire (Miller et al., 1987). Good
imagers processing fear-relevant verbal descriptions
demonstrate more arousal than do poor imagers (Cook et al.,
1988) .
Second, a person's coping style may influence
preparation effects and emotion during single or repeated
presentations of an aversive stimulus. Briefly, the coping
style literature claims that people consistently differ in
their preferred manner of dealing with aversive stimuli.
Some people preferentially gather information about and
directly engage the stimulus in order to decrease negative
affect. Others tend to avoid information about the stimulus
and negate its relevance and impact. These two coping
styles variously have been termed sensitization and
repression (Byrne, 1961), confrontation and avoidance (Suls
& Fletcher, 1986), and monitoring and blunting (Miller,
1980), and can be assessed reliably via questionnaires such
as Miller's (1980) instrument. Prior research on preparing
medical patients for noxious procedures found that
continuous presentations of information decreased anxiety of
monitors but increased anxiety of blunters (Shipley, Butt, &
Horwitz, 1979; Shipley, Butt, Horwitz, & Farby, 1978). Of
importance to the current study, information and stimulus
repetition may interact with subjects' coping style,

yielding different patterns of affect change across
repetitions.
Summary and Purpose of the Study
54
This study addressed several questions about exposure
and affect change in blood phobia. First, does repeated
exposure to a phobic stimulus (surgery videotape) result in
decreased negative affect over repetitions? If such
habituation occurs, to what degree does it generalize to a
novel blood-related stimulus? These questions were
addressed by exposing one group of blood phobics (Video Only
Group) to seven repetitions of a surgical videotape followed
by one novel surgery presentation.
Second, this study examined the effects on habituation
and dishabituation of providing blood phobics with
preparatory verbal descriptions before each surgery
videotape exposure. Two types of verbal descriptions were
used. One group of phobics (Surgery Audiotape Group) heard
a factual description of the upcoming surgery before each
repetition. They were compared with a control group of
phobics (Neutral Audiotape Group) who heard an irrelevant
preparatory description before each surgery videotape
repetition. It was expected that the prepared phobics would
have less negative affect than the controls during each
surgery videotape. Finally, this study examined the effects
of imagery ability on the affect of both groups during the
preparatory descriptions, and it examined the effects of
coping style on affect during surgery videotape exposures.

55
Method
Overview
Sixty volunteer adult blood phobics were interviewed,
completed questionnaires of imagery ability and coping
style, and were randomly assigned to one of three groups:
Video Only, Surgery Audiotape, or Neutral Audiotape. Video
Only subjects were exposed seven times to a surgical
videotape, followed by a single exposure to a novel surgery.
Subjects in the Surgery Audiotape and Neutral Audiotape
Preparation Groups experienced a different exposure
paradigm. Four presentations of a preparatory audiotape
alternated with four presentations ("test trials") of a
surgery videotape. Subsequently, these subjects viewed a
novel surgery videotape. These two groups differed only in
the type of preparatory audiotape they heard prior to each
of the four surgery test trials: Surgery Audiotape subjects
heard a factual description of the upcoming surgery, and
Neutral Audiotape subjects heard a neutral irrelevant
description. Subjective affect, physiological responses,
and facial expressions of disgust and avoidance served as
dependent measures for all three groups.
Subjects
Subjects were 60, 18 to 25-year-old (M = 19.7)
volunteer University of Florida undergraduates currently
enrolled in General Psychology. The final sample was
secured after screening approximately 500 potential subjects
with the Mutilation Questionnaire (MQ) at the beginning of

56
the semester. The highest scoring males and females were
telephoned and invited to participate in a study if they
spoke English and were not pregnant. One male declined to
participate fearing his anticipated reaction to the stimuli,
and one female with panic disorder was excluded. Mutilation
Questionnaire scores of blood phobic males (n = 30) ranged
from 14 to 24 (M = 17.4), and scores of blood phobic females
(n = 30) ranged from 21 to 29 (M = 23.6). Approximately the
upper 15th percentile of each gender distribution was used
from this sample. All subjects received course credit for
participating in the experiment.
Procedure
Each subject was studied individually during a 2 h
experimental session.
Interview and psychometric assessment. After subjects
read and signed the informed consent form (Appendix G), they
completed severally randomly ordered questionnaires,
including the Questionnaire Upon Mental Imagery and the
Miller Behavioral Style Survey.
Experimental session. Following questionnaire
completion, subjects entered the experimental room,
instructions were presented (Appendix H), and the electrodes
for HR and SCL and the BP cuff were attached. The cuff was
inflated several times to accommodate the subject to its
function. Next, all subjects had one practice videotape
trial using a neutral video stimulus in order to accommodate
them to the videotape presentation. The protocol for this

57
practice trial was the same as for all other trials
described below, except that no data were collected during
this practice trial. Following the practice, the
experimenter reentered the room, answered the subject's
questions, placed the audio headphones on the subject, and
departed. In order to accommodate subjects to the
headphones and the speaker's voice, subjects heard over the
headphones a brief reminder about the instructions of the
study (Appendix H). Following these headphone reminders,
subjects rated the affect they experienced during the
headphone instructions. These ratings served as the study
baseline subjective ratings. Subjects then waited several
minutes for the first presentation, during which the BP cuff
was inflated twice, one minute apart, and the average of
these two BP assessments served as the study baseline BP.
Group and stimulus assignment. Prior to the start of
the study, a research assistant randomly assigned subjects
to one of the three experimental groups (in blocks of three
or six subjects) and matched the groups for gender,
resulting in 20 blood phobic subjects—10 males and 10
females—per experimental group. The group assignment for
each subject was placed in an envelope and opened by the
experimenter after his last interaction with the subject
prior to the start of the trials, thus keeping the
experimenter blind to group assignment during his
interactions with the subject. The assignment of the
particular stimulus (or stimulus pair for the Neutral

58
Audiotape group) for each subject also was determined
randomly prior to the study using Latin squares. Stimulus
assignment was conducted to assure that each surgical
videotape and each novel videotape were seen an equal number
of times per group and per gender within each group.
Experimental paradigm. Table 8 presents the trial
sequence for the study, which is detailed below for each
experimental group. After the baseline recordings, the
sequence of trials began. All stimulus presentations were
separated by a variable length interval which averaged 1.5
minutes (range of 1 to 2 min) during which the subject
remained quietly seated, waiting for the next stimulus
presentation. The experimenter did not reenter the
experimental room until after the final (novel surgery)
trial, when he disconnected electrodes, debriefed (Appendix
I), and dismissed the subject.
The structure of all of the stimulus presentations
trials—both videotape and audiotape—was similar to that in
Study l.1 Baseline HR and SCL were assessed during the 10 s
immediately prior to the onset of the stimulus, which was
presented for 60 s during which HR and SCL continued to be
recorded. For the four "test trials" (Exposures 1, 3, 5,
and 7 for the Video Only Group) and the Novel trial, the
subject's face was videotaped as he/she watched the surgery
videotape being presented. Faces were not videotaped during
audiotape presentations. Immediately upon stimulus offset,
BP was assessed, the affective ratings screen illuminated,

59
Table 8. Experimental Design for Study 2
Surcrerv Videotape Exposure
Video |
Only
Group j
Ia
1
1 „ 1 1*1 1
2 | 3a | 4 | 5a | 6 |
1 1 1 1 1
| Novel
7a |Surgery
| Videoa
a Subjects' faces were videotaped for analysis of avoidance
and disgust.
Trial
Group
| Prep
| 1
1
|Test|Prep
j 1 | 2
1 1
|Test|Prep
| 2 | 3
1 1
|Test|Prep
| 3 | 4
1 1
|Test|
1 4 |
1 1
Novel
1
1
V|
1
V|
1
V|
1
V|
V
| SURG
1 s
11SURG
1 S
I|SURG
1 s
11SURG
1 s
I|
S
I
Surgery
1
|U
D |
|U
D |
|U
D j
|U
D
N
U
D
Audiotape
|AUDIO
|R
E|AUDIO
|R
E|AUDIO
| R
E|AUDIO
|R
E |
0
R
E
1
| G
0|_
| G
0[_
| G
o
IG
o
V
G
0
1
| E
T |
1 E
T |
| E
T |
| E
T
E
E
T
Neutral
|NEUT
|R
A|NEUT
| R
A|NEUT
|R
A NEUT
R
A |
L
R
A
Audiotape
1
1 Y
P|
| Y
P|
j Y
P|
| Y
P|
Y
P
|AUDIO
1
EI AUDIO
1
EI AUDIO
1
EI AUDIO
1
El
E

and subjects rated the affect they experienced during the
stimulus.
60
Experimental Groups
Subjects were randomly assigned to one of three
experimental groups which varied in the type of
presentations they received prior to the Novel trial. For
the Novel trial, all subjects were presented a novel
surgical videotape, which was chosen randomly from among the
surgical videotapes not used for that subject; assignment of
novel stimulus was conducted to assure that all surgeries
were presented equally often within and between experimental
groups and for each gender. The details of stimulus
presentation for each of the three experimental groups were
as follows:
Video Only Group. The function of this group was to
evaluate the affect change during multiple repetitions of a
single surgery videotape followed by a novel surgery. Thus,
these 20 blood phobics were presented one particular surgery
scene seven times (listed in Table 8 by Exposure number),
followed by a single presentation of a novel surgery.2
Although these subjects wore the headphones just like other
subjects, they heard no audiotaped stimulus descriptions
during the study.
Two other groups were studied to compare the effects of
relevant and control preparatory verbal descriptions. For
these two groups, there were four preparation trials during
which an audiotaped description was presented repeatedly,

61
four test trials during which a particular surgery videotape
was presented repeatedly, followed by one presentation of a
novel surgery videotape.
Surgery Audiotape Group. During the four preparation
presentations, each subject in this group heard a relevant
and factual description of the upcoming surgery that was
presented during each of the four test trials. For each
subject, the audiotape was repeated four times, because the
same surgery videotape was repeated on the four test trials.
Neutral Audiotape Group. This group served as a
control for the Surgery Audiotape group. Each subject heard
a neutral audiotape description as "preparation" prior to
each test trial. Like the Surgery Audiotape subjects, these
subjects heard the same neutral audiotape for the four
preparations. On the four test trials they repeatedly
viewed one of the surgery videotapes, prior to viewing the
novel surgery videotape for the final trial. The inclusion
of this group permitted a controlled evaluation of the
effects of listening to a scene that lacked phobic content.
Stimuli
Three types of stimuli were used in this study, each of
which had five exemplars. First, in addition to the two
surgical videotapes employed in Study 1 ("Incision" and
"Tubes"), three additional 60 s surgical videotapes were
taken from Ost's film of thoracic operations. The three
additional video stimuli were the following: "Rib," which
showed a tool cleaning and removing a rib; "Heart," which

62
showed a beating heart being punctured with an instrument
and then sutured to stop bleeding; and "Sutures," which
showed the chest incision being sutured with needles and
thread. Blood and bodily deformation are depicted in all
five scenes. For each subject, one of these five surgery
videotapes was repeatedly presented, and one of the
remaining four was presented during the novel trial.
Sixty second audiotaped descriptions of each surgery
videotape were employed. In addition to the two audio
descriptions of "Incision" and "Tubes," three additional
audiotapes of 160 words narrated the three additional
surgery videotapes used in this study. The same female
voice recorded all audio stimuli in an affectively neutral
manner. These audiotapes were presented only to the Surgery
Audiotape subjects, and the surgery audiotape selected for
that subject was one that described the surgery videotape
that had been assigned to the subject.
The third category of stimuli were audiotaped verbal
descriptions of neutral, everyday activities. Five
audiotaped narratives, 60 s in duration, and 160 words long,
were recorded by the same female assistant who recorded the
surgical audiotape descriptions. The five neutral
descriptions included a person baking a cake, planting in
the garden, typing on a typewriter, paddling a canoe, and
flying a kite. These scenes were expected to be neutral in
affective content, yet all described human hand movement,
which was similar to the descriptions in the surgical

63
audiotapes. Only subjects in the Neutral Audiotape Group
heard these descriptions. Each neutral description was
presented an equal number of times with ordering of
presentation determined via a Latin square. (See Appendix E
for the transcripts of the five verbal and five neutral
descriptions.) In summary, since there were five surgery
and audiotape exemplars, four subjects of the 20 in each
experimental group received the same stimulus or stimulus
pair.
The practice neutral videotape stimulus which preceded
the experimental trials was a silent, 60 s videotape of a
scene from Jonathon Livingston Seagull which shows a seagull
in flight over mountains and the ocean.
Questionnaires
The Mutilation Questionnaire and the Questionnaire Upon
Mental Imagery were already described in Study 1. The
additional questionnaire of interest in this study was the
Miller Behavioral Style Scale (MBSS). Miller (1980)
developed this instrument to assess a subject's preferred
coping style under stressful circumstances. The scale asks
the subject to imagine being in four stress-evoking
situations. Each scene is followed by eight statements
representing different ways of coping with the situation.
Four of the statements relate to confronting and seeking
information (a "monitoring" style), and the other four
statements indicate distracting and avoiding information
("blunting"). Separate monitoring and blunting scores are

64
obtained by summing the number of statements endorsed for
each coping style. The scale has good discriminant validity
(Miller, 1987a; Miller, Brody, & Summerton, 1988) and
predictive validity (Gard & Edwards, 1986; Miller, 1987a,
Phipps & Zinn, 1986, Watkins, Weaver, & Odegaard, 1986).
Dependent Measures
Three classes of dependent measures were assessed in
this study. Subjective measures included self-reported
displeasure, arousal, and lack of control, for which change
scores were calculated by subtracting the study baseline
value from the value obtain for each stimulus presentation.
Physiological measures of HR and SCL change scores were
calculated by subtracting the trial baseline mean (the 10 s
prior to stimulus onset) from the mean value obtained during
the stimulus. The two BP measures were derived by
subtracting the study baseline from the values obtain after
each stimulus.
Motor behavior measures of avoidance and maximum facial
disgust were coded by two independent raters from the
videotape of the subject. Avoidance was coded dichotomously
based on at least 1 s of avoidance. The 5-point rating of
maximum facial disgust was reduced to a dichotomous code to
provide a sufficient number of subjects for frequency
analyses; original scores of 0 or 1 were classified as "low"
disgust, and scores of 2, 3, or 4 were classified as "high"
disgust. Percent agreement for these two measures was
calculated between the two independent raters' dichotomous

classifications. For avoidance, percent agreement ranged
from 92% to 97% for the five trials. For maximum facial
65
disgust, percent agreement ranged from 93% to 98%. Thus,
acceptable interrater reliability was achieved.
This study used the same environment and apparatus as
in Study 1. A separate VPM control program was written to
assess physiology and present stimuli (Appendix J).
Results
Three major issues were addressed in this study. In
the first section below, changes in affect to repeated
surgical exposures and to a novel surgery were evaluated
using data from the Video Only Group. In the second
section, the Surgery Audiotape and Neutral Audiotape groups
were compared to evaluate the effect of auditory preparation
on affect during repeated surgery presentations. In the
third section, the influence of imagery ability and coping
style on affect for those two groups of subjects who
received auditory preparations was examined.
Effects of Repeated Visual Exposure
The 20 subjects of the Video Only Group viewed one
surgery videotape seven times prior to viewing a novel
surgery. The dependent measures of displeasure, arousal,
lack of control, SCL, HR, SBP, and DBP were assessed during
each of these eight exposures. These measures were analyzed
with a repeated-measures ANOVA in which Trial (eight levels)
was the within-subject effect. The use of Greenhouse-
Geisser corrections resulted in fractional degrees of

66
freedom. Planned contrasts between exposures were conducted
to more thoroughly evaluate affect change.
Self-report measures. Table 9 presents displeasure,
arousal, and lack of control change scores from baseline
over the seven exposure trials and the Novel Exposure for
Video Only subjects. As indicated by significant Trial
effects and planned contrasts between exposures, all three
variables showed a significant reduction in negative affect
from Exposure 1 to Exposure 7, and a significant and
immediate return of negative affect to the Novel Exposure to
levels not significantly different from those reported
during Exposure 1 (all p > .42). At Exposure 7, arousal and
lack of control did not differ from their study baselines (p
> .65), although displeasure remained above its baseline
value, (Trial effect: displeasure, F(3.2, 60.3) = 8.61, p <
.0001; arousal, F(2.8, 52.6) = 10.34, p < .0001; lack of
control, F(3.0, 56.7) = 7.76, p < .0002.
Physiological measures. Figure 2 presents the SCL and
HR change data for the Video Only subjects on the same graph
for easy comparison. The trend in SCL and HR parallels that
of the self-report data, although only for SCL was there a
significant Trial effect, F(2.6, 49.1) = 4.28, p = .012.
The SCL habituated rapidly after an initial elevation during
Exposure 1, dropped significantly to its lowest value during
Exposure 5 (which was not significantly different from
baseline, p > .44), and then increased somewhat (although
nonsignificantly) during the Novel surgery. The SCL during

67
Table 9. Changes in Self-Report and Motor Measures Across
Repeated Surgery Videotape Exposures and a Novel
Surgery for the Video Only Group
Measure3
1
2
3
Displeasure
6.5
5.9
4.9
(4.0)
(3.6)
(3.6)
Arousal
5.9
4.4
3.5
(8.2)
(8.3)
(8.2)
Control Lack
5.3
4.7
3.4
(5.8)
(6.1)
(6.3)
Avoidance
(Yes/No)
Disgust
8/12
9/11
(High/Low)
10/10
6/14
Exposure
4
5
6
7
Novel
4.6
3.8
3.4
3.7
7.2
(3.7)
(4.0)
(4.7)
(4.5)
(8.2)
2.2
1.2
0.8
0.4
6.4
(8.0)
(7.9)
(7.8)
(7.9)
(7.5)
1.9
1.3
1.2
0.7
5.7
(6.6)
(7.2)
(6.7)
(6.9)
(7.1)
5/15
10/10
9/11
6/14
5/15
9/11
a Means (and standard deviations) are presented for the
self-report measures; frequency data are presented for the
motor measures.

2 ^ W J M O 2¡ > K O M H > W
63
5 +
+ 1.4
S Skin Conductance
Level
EXPOSURE
Changes in Heart Rate and Skin Conductance Level
Across Seven Surgery Videotape Exposures and the
Novel Surgery Exposure for the Video Only Group
Figure 2
2 h « w

69
the novel surgery did not differ from that during Exposure 1
(E > .12). Neither SBP nor DBP change scores showed a
statistically reliable trend across exposures.
Motor behavior measures. The motor measures of
avoidance and facial disgust were assessed during only
Exposures 1, 3, 5, 7, and the Novel Exposure and are
presented in Table 9. These dichotomous measures were
analyzed via chi-squares using McNemar's (1969)
recommendation for within-subject analyses. As can be seen,
avoidance behavior remained at a relatively constant level
across the four exposures and the novel surgery, except for
a nonsignificant drop in avoidance during the Exposure 5.
For facial disgust, half of the Video Only subjects showed
"high" disgust during Exposure 1; this frequency decreased
in subsequent exposures and the difference reached
statistical significance at Exposure 7, X (1) =5.0, p <
.05. Additionally, significantly more subjects increased
than decreased disgust from Exposure 7 to the Novel Surgery,
X2(l) = 4.00, p < .05. Disgust during the novel surgery and
Exposure 1 did not differ.
Effects of Auditory Preparation
The effects of auditory preparation were examined by
comparing the affect of the relevantly-prepared Surgery
Audiotape Group with the control Neutral Audiotape Group at
the four videotape "test trials" and the novel surgery.3
Data analyses used mixed-model repeated measures ANOVAs in
which Group (Surgery Audiotape or Neutral Audiotape) was the

70
between-subjects effect and Trial (five levels) was the
within-subject effect. Greenhouse-Geisser corrections were
applied.4
Self-report measures. Figure 3 shows the displeasure
change during each of the four test trials and the novel
trial for Surgery Audiotape and Neutral Audiotape subjects.
For all three self-report measures, negative affect
decreased significantly between Test Trials 1 and 4 and
increased significantly from Test Trial 4 to the Novel
Surgery (all p < .007). Group differences were of greater
interest, however. As Figure 3 suggests, Surgery Audiotape
subjects reported less displeasure than the Neutral
Audiotape subjects across trials, Group main effect, F(l,
38) = 4.40, p = .042. The Trial X Group interaction was not
significant, indicating that the group difference in
displeasure did not change across trials. Lack of control
followed a similar trend across trials in that the sample
mean of the Surgery Audiotape Group suggested they had less
lack of control than the Neutral Audiotape Group; however,
this Group main effect failed to reach significance, p =
.16. Self-reported arousal was similar for the two groups
across all trials.
Physiological measures. Figure 4 shows the change in
SCL across the four test trials and novel trial for the two
groups. There was a significant decrease in SCL over the
four test trials and increase during the Novel Trial, (p <
.001). More importantly, Figure 4 suggests that the SCL of

71
4 +
—+ + + + +-
Test 1 Test 2 Test 3 Test 4 Novel
TRIAL
Figure 3. Self-Reported Displeasure Change Across Four
Surgery Videotape Test Trials and the Novel
Surgery Trial for the Surgery and Neutral
Audiotape Groups

72
S
K
I
N
C
O
N
D
U
C
T
A
N
C
E
C
H
A
N
G
E
M'
I
C
R
0
M
H
O
S,
1.2 + NA
1.0
0.8
0.6
0.4
0.2
0.0
* SA«
SA
-0.2 +
Test 1
Test 2
Test 3
Test 4
Novel
TRIAL
Skin Conductance Level (60 s Mean) Change Across
Four Surgery Videotape Test Trials and the Novel
Surgery Trial for the Surgery and Neutral
Audiotape Groups
Figure 4.

73
the Surgery Audiotape Group was less than that of the
Neutral Audiotape Group; however, the Group main effect only
neared significance, F(l, 38) = 2.73, p = .10. Nonetheless,
simple effects analysis revealed that at Test Trial 1, the
SCL of the prepared subjects was less than that of the
control subjects, p < .03. There was no Trial X Group
interaction. The HR, SBP, and DBP changes did not differ
significantly across trials or between groups.
Motor behavior measures. Table 10 presents avoidance
and facial disgust frequency data for the Surgery Audiotape
and Neutral Audiotape Groups. Consistent with the findings
for displeasure and SCL, these motor measures indicated that
the prepared subjects had less negative affect during the
surgery videotapes than the control subjects.
Avoidance did not change significantly for either group
across the five trials. "High" disgust for the Neutral
Audiotape subjects steadily declined from Test Trial 1 to
Test Trial 4, X2(l) =7.0, p < .01; the fairly low disgust
displayed by the Surgery Audiotape subjects did not decrease
across test trials. Both groups had significantly more
subjects increase than decrease disgust from Test Trial 4 to
the Novel Trial, (Surgery Audiotape, X2(l) = 4.00, p < .05;
Neutral Audiotape, X2(l) =7.00, p < .01).
Next, differences at each trial were examined. The
Surgery Audiotape Group tended to avoid less frequently than
the Neutral Audiotape Group at Test Trials 1 and 4, (X2(l) =
2.50 and 7.06, p = .114 and .058, respectively), and they

74
Table 10. Frequency of Avoidance and Facial Disgust Across
Four Test Trials and the Novel Surgery for
Surgery Audiotape and Neutral Audiotape Groups
Behavioral Measure Trial
Avoidance (Yes/No)
Test 1
Test 2
Test 3
Test 4
Novel
Surgery Audiotape
2/18
2/18
4/16
2/18
0/20
Neutral Audiotape
6/14
10/10
7/13
7/13
6/14
Disgust (High/Low)
Surgery Audiotape
4/16
1/19
1/19
1/19
5/15
Neutral Audiotape
11/9
9/11
6/14
4/16
11/9

75
avoided significantly less often than the control subjects
during Test Trial 2 and the Novel Trial, (X2(l) = 7.62 and
7.06, p = -006 and .008, respectively). The Surgery
Audiotape Group had significantly fewer "high" disgust
subjects than the Neutral Audiotape Group during Test Trials
1, 2, 3, and the Novel Trial, (X2(l) =5.23, 8.53, 4.33, and
3.75; P = .022, .003, .037, and .053, respectively).
Effects of Personality Variables
Two personality variables, imagery ability and coping
style, were examined for their influence on affect of
subjects receiving preparation—the Surgery Audiotape and
Neutral Audiotape Groups. Analyses used repeated-measures
ANOVAs with Group and the personality measure as between-
subjects effects; personality measures were left continuous
for the ANOVA, but were dichotomized via a median split for
chi-square analyses of their relationship with avoidance and
disgust and for graphic presentation.
Mental imagery ability (OMI). Imagery ability was
hypothesized to influence affect during the auditory
preparation trials; thus, affect during Preparations 1 and 2
was analyzed. Only self-reported lack of control was
related significantly to imagery ability. Examination of
the plotted data revealed an effect of little interest; the
lack of control of good imaging Neutral Audiotape subjects,
(but not Surgery Audiotape subjects) was lower during both
of the neutral audiotape descriptions, (QMI X Group, F(l,
36), p = .033).

76
Coping style (MBSS). The MBSS yielded both Monitoring
and Blunting scores which were not correlated in this sample
of 40 subjects, (r(38) = -.16, p = .31); therefore, each
variable was examined separately. Coping style was expected
to relate to emotional responding during the actual
presentation of the surgery stimuli. Thus, repeated-
measures ANOVAs and chi-squares examined each variable
during Test Trials 1 and 2 and again during Test Trial 4 and
the Novel Surgery.
The Monitor variable was related to only one dependent
measure; all five of the Surgery Audiotape subjects who
showed "high” disgust to the Novel Surgery were low in
Monitoring, X2(l) = 6.67, p = .01.
The Blunting variable, however, showed several
interesting relationships with various dependent measures.
The self-report measures were related to Blunting during
Test Trials 1 and 2, whereas several of the physiological
measures were related to Blunting during Test Trial 4 and
the Novel Surgery. Across Test Trials 1 and 2, high
blunting subjects reported a rise in displeasure, whereas
low blunting subjects reported an decrease in displeasure,
regardless of Group, (Trial X Blunting interaction, F(l, 36)
= 5.10, p = .03). The analyses of arousal and lack of
control across Test Trials 1 and 2 were consistent with
displeasure and even more revealing in that the groups
differed. The interactions for both dependent measures were
interpreted similarly; therefore, only arousal change scores

77
for the two groups as a function of blunting are presented
in Figure 5. As the figure reveals, Surgery Audiotape high
blunters reported increased arousal and lack of control
across the two surgery presentations, whereas low blunting
Surgery Audiotape subjects reported a reduction in arousal
and lack of control. Neutral Audiotape subjects, however,
showed little change in arousal or control across these
surgeries as a function of blunting; indeed, Neutral
Audiotape high blunters reported somewhat greater arousal
and lack of control during these presentations than low
blunters (Trial X Group X Blunting interactions for arousal,
F(1, 36) = 8.78, p = .005; and lack of control, F(l, 36) =
13.44, p = .0008).
Blunting was related also to affect during Test Trial 4
and the Novel Surgery. For SCL, collapsing across both
trials, the Surgery Audiotape high blunters tended to have a
higher SCL than Surgery Audiotape low blunters, whereas
Neutral Audiotape high blunters had a lower SCL than Neutral
Audiotape low blunters, (Group X Blunting, F(l, 36) = 3.75,
E = .06). The two BP measures specified these effects for
each trial, and since the interpretation of the interactions
is similar, only SBP data for both groups over both surgery
presentations as a function of Blunting is presented in
Figure 6. Consistent with SCL, SBP and DBP increased from
Test Trial 4 to the Novel Trial for high blunting Surgery
Audiotape and low blunting Neutral Audiotape subjects,
whereas SBP and DBP showed little change across surgery

78
13
Surgery Audiotape
Group
+
L
Neutral Audiotape
Group
12 +
L L Low Blunting
H H High Blunting
11 +
A
R
0
U
s
A
L
C
H
A
N
G
E
10 +
L
•L
TEST TRIAL
TEST TRIAL
Figure 5. Arousal Change Across Test Trials 1 and 2 for the
Surgery Audiotape and the Neutral Audiotape
Groups as a Function of Blunting

OK 3 3
79
S
Y
S
T
0
L
I
C
B
L
0
0
D
P
R
E
S
S
u
R
E
C
H
A
N
G
E
8
Surgery Audiotape
Group
+
6 +
4 +
2 +
0 +
-2 +
-4 +
H
Neutral Audiotape
Group
L
L L Low Blunting
H H High Blunting
+—
Test 4
—+—
Novel
Test 4 Novel
TRIAL
Figure 6. Systolic Blood Pressure Change Across Test Trial
4 and the Novel Trial for the Surgery Audiotape
and the Neutral Audiotape Groups as a Function of
Blunting

80
presentations for low blunting Surgery Audiotape and high
blunting Neutral Audiotape subjects, (Trial X Group X
Blunting interactions for SBP, F(l, 36) = 8.35, p = .0065;
and DBP, F(l, 36) = 5.12, p = .030). Finally, findings for
self-reported arousal were not completely consistent with
the physiological data. Both Neutral Audiotape and Surgery
Audiotape low blunters reported a greater increase in
arousal from the Test Trial 4 to the Novel Trial than did
the high blunters, (Trial X Group X Blunter interaction,
F(1, 36) = 4.86, p = .034) .
Discussion
Affect Change to Repeated Surgery Exposures
A fundamental question regarding emotional change is
whether blood phobics become less uncomfortable or anxious
as a phobic stimulus is presented repeatedly. This study
indicated that such change does occur. Indeed, in a sample
of 20 phobics who viewed one surgery stimulus repeatedly for
seven trials, there was a significant decline on most
measures of negative affect across repetitions. This
finding supports a basic premise of emotional functioning—
exposure leads to reductions in negative affect (Foa &
Kozak, 1986).
Similar findings were reported by Hare et al. (1971)
who demonstrated habituation of arousal with multiple
repetitions of mutilation scenes. Hare and colleagues
studied normals using slides; the current study extends
their findings to blood phobics viewing videotapes.

81
Generalization of Affect Reduction to Novel Phobic Stimuli
A second question of fundamental importance concerns
the extent to which the attenuation of emotion which
occurred during repeated presentations generalized to new
blood-related stimuli. The results of the current study-
indicated that, although the aversive qualities of a
particular blood-related stimulus attenuated fairly quickly
to repetition, very little or no generalization occurred.
Indeed, when a novel surgery scene was presented, there was
a substantial return of negative affect to levels not
different from those observed during the first presentation
of the surgery scene. Using a different paradigm, Hare et
al. (1971) found that presenting different mutilation slides
interfered with habituation. Limited generalization to a
novel stimulus might be viewed as secondary to affective
network changes in only those specific stimulus properties
shown in the repeated surgery scene, rather than to a
elaborated network of "blood-related stimuli." A further
test of generalization might be to repeatedly present the
"novel" stimulus. If the rate of habituation to it is
faster than to the original stimulus, evidence for some
generalization of affect reduction would be adduced.
Effects of Preparation
A second portion of this study examined the effects of
two types of preparation for upcoming surgery videotape
exposures. The prepared group of blood phobics heard an
accurate, affectively neutral description of the surgery

82
prior to each of four viewings. Their affect during the
four repeated exposures and during a novel stimulus was
compared to that of a control group of subjects who heard a
neutral, unrelated audiotaped description before each
exposure.
Generally, the relevant preparation produced only
modest reductions in negative affect during exposure,
compared with the control preparation. The relevantly
prepared group reported significantly less displeasure and
showed less facial disgust and avoidance than did control
subjects. The lack of control and SCL change showed similar
although less reliable trends. Preparation effects tended
to be somewhat more evident during the first surgery
exposure than later exposures. Thus, although the effect
does not appear robust, there is tentative support for the
hypothesis that preparing blood phobics to view a surgery by
providing them a description modestly reduces negative
affect in comparison to an irrelevant preparation.
Admittedly, however, group differences were limited
with respect to the number of variables differentiating
conditions and the magnitude of the effects. One important
potential reason for the limited effects is that the current
paradigm simply did not permit large effects. In this
study, the experimental manipulation was a variation in
preparation for blood phobics viewing surgeries; one might
expect rather small or even absent effects from this
manipulation, especially in light of the limited effects

83
found in Study 1, where powerful experimental conditions
were created (phobics versus nonphobics, aversive versus
neutral material).
The content of the preparatory audiotapes may further
account for limited effects. The affect of the Surgery
Audiotape group during the first audiotape presentation was
minimally negative; only two subjective measures indicated
increased arousal. The narrative of each audiotape was
affectively neutral and purely descriptive of the surgery;
it contained no references to the observed patient's
experience of the surgery nor to the subject's possible
reaction during viewing. The empirical literature on
preparation for stressful procedures has demonstrated that
verbal preparations which include not only descriptions of
upcoming procedures but also of the sensations that the
patient or listener might experience, (i.e., sensory
information) often result in less anxiety during and after
the stressful event (Anderson, & Masur, 1983). A different
domain of empirical inquiry—affective imagery—suggests
that verbal scripts for emotional imagery evoke increased
affect when they include response propositions, or
descriptions of the imaging person's affective reactions in
the imaged scene (Lang, Kozak, Miller, Levin, & McLean,
1980; Lang, Levin, Miller, & Kozak, 1983). Additionally,
the current subjects were instructed only to listen to the
description, whereas other research has demonstrated that
instructions to vividly imagine oneself in the scene elicits

84
greater affect during imagery (Lang, 1979). Thus, the
preparatory capacity of the audiotaped descriptions might
have been enhanced by modifying the instructions and
incorporating response propositions.
Individual Difference Variables
Finally, another reason for limited group preparation
effects is the variability in affect accounted for by
individual differences, especially in coping style. Imagery
ability was assessed also, but it was found to have little
relation to affect during the verbally presented preparation
descriptions, where imagery effects might have been expected
to occur.
The effects of coping style appear to be more robust,
however. The monitoring style was limited in its relation
to affect during the surgery videotapes. Its one
relationship was consistent with the effects of the blunting
style and is described below. The blunting coping style was
related to increases or decreases in self-reported affect
and physiology from the first to the second surgery
videotape presentation and the fourth surgery to the novel
presentation. Moreover, blunting coping style interacted
with the type of preparation given to subjects, yielding
different relationships for the two preparation groups.
Among the relevantly prepared subjects, blunters
reported lower levels of negative affect to the first
surgery presentation, but their negative affect increased
during the second surgery presentation. Subjects who

85
typically avoid blunting reported greater negative affect on
the first presentation, but their anxiety decreased to the
second surgery. The unprepared subjects did not show this
effect, but tended to display the opposite relation.
Similar effects occurred during the presentation of a
novel surgery as indexed by physiological measures.
Prepared subjects who blunt showed an increase in
physiological arousal to the novel surgery compared with
prepared subjects who do not blunt. Also, prepared subjects
who were low on monitoring (typically considered as similar
to blunting) had the greatest facial disgust to the novel
surgery. Again, unprepared subjects did not show this
pattern of results. In the transition from the repeated
surgery to the novel surgery, unprepared control subjects
who do not blunt had increased physiological arousal.
The findings with the prepared subjects are consistent
with those of Shipley and colleagues (1978, 1979) who found
that repressors (like blunters in the current study) became
more anxious (indexed by tachycardia) during a second
presentation of a surgery preparation videotape, whereas
sensitizers were more anxious during the first presentation
and became less so during a second viewing. This study
extends their findings by suggesting that when a novel
surgery is shown later in the repetition sequence, low
blunters (like sensitizers) continue to show reduced affect,
but blunters (like repressors) are increasingly disturbed

and unable to blunt as successfully as they did during the
initial presentation.
86
The different relationship of blunting with affect for
the preparation and control groups is interesting. It is
possible that the surgical descriptions for the prepared
subjects permitted almost continuous activation of their
affective networks, with the result that the subjects'
preferred manner of coping with aversive stimuli had
predictable effects over exposures. However, providing
other phobics irrelevant, potentially distracting
descriptions prior to each viewing might have precluded
continuous activation of the emotion, with the result that
low blunters were unable to decrease their arousal over
presentations, and high blunters successfully maintained
affective distance. Naturally, these explanations are
speculative, and since the construct of coping style is
itself poorly understood, it is quite difficult to enlighten
the complicated interaction of coping style with variations
in exposure. Further theory and research which addresses
the mechanism by which coping style influences emotional
network activation is needed.
Methodological Issues
Study 2's methodology had several problems which
hindered clear interpretations of the results and probably
reduced the size of observed effects. First, the study used
five different surgery scenes rather than a single scene or
two, as in Study 1. It was hoped that multiple surgeries

87
would increase the generalizability of the findings to a
larger population of blood-related stimuli. Although no
experimental confound occurred (each surgery was used
equally often), the increase in response variation
attributable to the use of multiple surgeries probably
resulted in increased between-subjects variance and a
concomitant decrease in statistical power. Additionally,
too many surgeries were employed to permit adequate
statistical comparisons of their affect-eliciting power.
Ideally, the same two surgeries used in Study 1 should have
been employed in Study 2 to more clearly replicate and
extend the findings of Study 1.
Second, avoidance and facial disgust should have been
recorded during verbally presented descriptions in both
studies. Bioinformational theory predicts that various
stimulus modalities reliably activate affective networks,
resulting in measurable efferent outflow (Lang, 1979).
Thus, future research should include facial affect
assessments during verbal stimulus trials. A more important
experimental concern is that no baseline avoidance or facial
affect measures were recorded; thus, it is possible that the
observed differences between groups were attributable to
preexisting differential tendencies to avoid or show
disgust. An acceptable baseline might be obtained by
presenting a stimulus that lacks the phobic content under
study, but is hypothesized to be equally bothersome to all

88
experimental conditions, such as a snake or height stimulus
in studies of blood phobics and controls.
Notes
1 For the first 30 subjects only, BP was assessed during the
20 s prior to each stimulus onset, with the hope of using
this measure as a baseline. This procedure was discontinued
when it was discovered that the frequent cuff inflation was
excessively uncomfortable for subjects and may have cued
them as to the timing of stimulus onset. Discontinuation of
this assessment occurred after an equal number of subjects
(balanced for gender) from each group had completed
participation and after each surgical stimulus had been
presented an equal number of times. Therefore, no
experimental confound occurred. The prestimulus BP data
collected on the 30 subjects were not analyzed.
2 Prior to Exposure 1, Video Only subjects were not
presented any stimulus while the other groups were hearing
their first preparation audiotape. It was originally
intended that the lack of this stimulus presentation would
permit the Video Only subjects to serve as a "waiting, no
intervention control" for the auditory preparations
presented to the other two groups.
3 Since the Video Only Group received no preparation for the
first exposure, their affect during Exposure 1 was compared
with that of the other two groups during Test Trial 1. The
Video Only Group did not differ from the Neutral Audiotape
Group on any measures, and only differed from the Surgery
Audiotape Group in having more frequent avoidance and "high"
disgust.
4 Affect differences between the Surgery and Neutral
Audiotape Groups during the initial audiotape preparation
per se were examined to determine whether hearing the
surgery description led to greater negative affect than
hearing the neutral, control description. As expected,
Surgery Audiotape subjects reported more displeasure and
arousal than Neutral Audiotape subjects (both p < .0002).
Lack of control and SCL followed this same pattern, but
neither reached statistical significance. Neither HR nor
the two BP measures differed between groups during this
preparation audiotape.

GENERAL DISCUSSION
An aversive negative reaction to blood, injury, or
bodily deformation is a fairly common phenomenon
traditionally termed "blood phobia" and classified as a
simple phobia. Research has enlightened possible etiologies
(Kleinknecht, 1987; Ost & Hugdahl, 1985), examined subjects'
cognitions during exposure to blood-related stimuli
(Kaloupek & Stoupakis, 1985; Kaloupek, Scott, & Khatami,
1985), and developed exposure-based techniques with
modifications to prevent fainting (Ost & Sterner, 1987).
Generally, however, it has been less researched than other
simple phobias, perhaps because most authors view it as
simply another phobia (Marks, 1988). Yet its unique
features hinder straightforward extrapolation from the
extensive theory and empirical literature on simple phobias.
A Comparison of Blood Phobia and Other Phobias
The literature on blood phobia has consistently used
the term "fear" to describe the affect of phobics vis-a-vis
blood-related stimuli. For example, the Mutilation
Questionnaire is considered to measure respondent's "fear"
of mutilation stimuli (Klorman et al., 1974). One wonders,
however, what is it specifically that is feared? It is
unlikely that the external blood-related stimulus itself is
feared, for what damage or harm can it accomplish? Beck and
89

90
Emery (1985) noted that blood phobics do not report fear
during actual confrontation with the stimulus, rather, they
feel queazy, disgusted, or squeamish. Additionally, the
facial expression exhibited by the blood phobics in the
current study was routinely one of disgust rather than fear.
Thus, it appears that the subjective experience of blood
phobics is complicated, possibly encompassing fear prior to
or early during exposure, but that another affect such as
disgust is dominant during exposure. More detailed study of
the subjective emotional experience of blood phobics both
before and during exposure is worthwhile.
The psychophysiology of blood phobia is thought to be
unique among phobias. In other simple phobias, exposure to
the phobic stimulus results in a prolonged sympathetic
response with classic markers of fear and anxiety such as
tachycardia, hypertension, and increased sweating and
respiration rate. Yet blood phobia is considered to have a
biphasic response pattern of sympathetic activation followed
by parasympathetic activity which, if exposure is continued,
leads to fainting. Research indicates that fainting is
uniquely associated with blood phobia and not with other
phobias (Connolly, Hallam, & Marks, 1976), and many
researchers suggest that most blood phobics faint (Marks,
1988). Yet of the 84 blood phobics participating in both
studies, none fainted nor appeared to near faint during
exposure to the surgeries.

91
There are several potential reasons for the
discrepancies between the current studies and past research.
It is possible that these subjects were not sufficiently
phobic, and that more severe blood phobics would have
fainted. Several clinical studies have found about a 70%
prevalence of fainting in the histories of blood phobics
presenting for treatment (Ost, Sterner, & Lindahl, 1984;
Connolly et al., 1976; Thyer et al., 1985). However,
generalizations from clinic patients to all blood phobics
may not be appropriate. It is also possible that the
stimuli used in the current studies were insufficiently
aversive either due to the content or duration. In vivo
exposure to an operation or undergoing venipuncture and
blood donation probably are more aversive and likely to
elicit fainting (Graham et al., 1961). Regarding stimulus
duration, brief exposures to mutilation stimuli resulted in
tachycardia but not significant bradycardia in Study 1 and
in studies by Klorman et al. (1975, 1977). Longer duration
presentations (Ost et al., 1984; Steptoe & Wardle, 1988)
more frequently find parasympathetic activity and fainting.
Thus, longer stimulus presentations may permit the
occurrence of the parasympathetic portion of the biphasic
reaction, whereas shorter presentations permit only
sympathetic activity.
It is possible, however, that fainters constitute a
distinct group, only partially overlapping with blood
phobics. Kleinknecht and Lenz (1989) recently found that

92
the population of people who report fear to blood stimuli
can be subdivided into fainters and nonfainters, and that
some fainters report little or no fear of blood stimuli.
This apparently accounts for Kleinknecht's (1988a) earlier
finding of only a modest correlation (r = .30) between MQ
scores and a history of fainting to blood-injury stimuli.
Thus, aversion or fear of blood-related stimuli appears to
be less tightly associated with fainting than an examination
of clinic blood phobics and blood donation fainters would
lead one to believe. Alternatively, Kleinknecht's blood
phobics and those in the current studies were college
students and younger than patients in the above clinical
studies. It is possible that these subjects were unsure
whether or not they would faint, because they too rarely
have encountered blood-related stimuli or because they
reliably escape or avoid. Future research might find that
if such people were to continue exposure to a sufficiently
intense blood-related stimulus, perhaps most or all would
faint. Thus, an important area of research is an evaluation
of the extent of fainting among blood phobics, those
situations in which fainting occurs, and the differences
between fainters and nonfainters.
Behavioral avoidance testing to assess the motoric fear
response is commonplace in studies of simple phobias. With
blood phobia, however, only Ost's research team has used a
behavioral measure: duration of viewing a prolonged surgery
film. Blood phobia may differ from other phobias in that

93
the physical distance from the stimulus appears to be less
important than duration of eye contact with the stimulus
(Beck & Emery, 1985). Closing one's eyes and looking away
appear to be effective escape and avoidance behaviors, but
it is the rare study that has assessed these affect indices
(Hare et al. 1971) , although some have monitored eye contact
via the electrooculogram for the purpose of ascertaining
compliance with viewing (Klorman et al., 1975, 1977). In
the current studies, videotaping the subject's observing
behavior and coding eye contact were fairly simple
procedures which provided data not only on viewing
compliance but also on behavioral avoidance; this measure
showed some discriminatory power as a dependent measure.
Thus, it is recommended that future studies which present
visual stimuli monitor observing behavior, both to verify
stimulus observation and to more fully assess emotion.
A second motor system dependent measure in these
studies was the facial expression of affect. This dependent
measure has rarely been assessed in studies of phobia,
although there exists an impressive literature on facial
expressions and emotions (Adelmann & Zajonc, 1989; Ekman &
Oster, 1979). In the current studies, subjects either
remained expressionless, or they displayed a characteristic
expression of disgust which varied in intensity. The
presence and intensity of this expression also proved quite
useful as a dependent measure.

In summary, several differences between blood phobia
and other simple phobias have been noted in the literature
94
and found in the current studies. First, the dominant
emotion during exposure to blood-related stimuli may not be
fear, as it apparently is in other simple phobias, but
probably disgust, at least as assessed thus far via facial
expressions and verbal reports. Second, at least some blood
phobics display the unigue biphasic psychophysiologic
reaction of sympathetic followed by parasympathetic activity
and associated fainting. It is unclear what factors
predispose to this physiological reaction, but it is not
found in other simple phobias. Third, effective avoidance
and escape behaviors include not only increasing the
physical distance from the stimulus, but averting eye
contact with the stimulus, a behavior with questionable
efficacy in other phobias. Finally, although not addressed
in these studies, blood phobics appear to have a much higher
percentage of biological relatives with the same condition
than is found for the other simple phobias (Marks, 1987).
Despite these differences, researchers continue to
consider blood phobia as another simple phobia (e.g, Marks,
1988). This may occur because of key similarities between
blood phobia and other phobias. In both cases, a physical
stimulus elicits a temporary aversive reaction which gives
rise to escape and future avoidance behavior. Yet this
pattern is seen also in other conditions not considered
phobias such as learned taste aversions in which contact

95
with the aversive substance elicits disgust and avoidance
behavior consisting predominantly of preventing sensory
contact with the offensive agent rather than maximizing
physical distance (De Silva & Rachman, 1987; Garcia,
Kimmeldorf, & Koelling, 1955).
Although blood phobia is similar to other simple
phobias in the eliciting stimuli and superficial overt motor
responses, differences appear to exist in subjective
experience, psychophysiology, facial expression, successful
escape and avoidance behaviors, and family patterns. Thus,
blood phobia may be fundamentally different from other
simple phobias (Thyer et al., 1985) and may be more akin to
an aversion. An interesting study that might elucidate the
relationship between these blood and simple phobias would be
to study multiphobic subjects—those who manifest both blood
phobia and another common simple phobia, such as snake
phobia. Presenting such subjects both phobic stimuli while
assessing multiple response systems would help to determine
how blood phobia differs, while controlling for all
individual differences. Another interesting research venue
is to clarify similarities and differences between aversions
and blood phobia.
Unanswered Questions
The studies in this dissertation shed some light on
blood phobia but also served to illuminate its vast darkness
of unanswered questions. First, little is known about how
blood phobics differ from nonphobics. It is inadequate

96
simply to state that they have learned to fear a certain
stimulus. Rather, an understanding of that learning process
and of the many environmental and individual differences
that influence and maintain the phobia is needed. For
example, the current studies suggest that blood phobics are
more sensitive to their own bodily reactions, they more
easily experience distress at the emotional pain of others,
and they have greater generalized fear and insecurity than
nonphobics. Yet there are no differences in certain aspects
of empathy and classical neurotic features such as increased
muscle tension and autonomic arousal. Most prior studies
that have examined the differences between blood phobics and
nonphobics have not been guided by theory (see Kleinknecht &
Lenz, 1989, for an exception). Future studies should seek
to provide a comprehensive description of blood phobics by
testing predictions of theoretical models such as Engel's
(1978) via guestionnaires and/or behavioral assessments of
relevant personality attributes.
Although a host of stimuli including injury, bodily
deformation, illness, pain, and needles in addition to blood
appear to elicit the blood phobic reaction, little or no
research has examined the effects of different stimuli or
individual differences in what is considered aversive. The
following is hypothesized. The ultimate stimulus which
elicits the reaction is the personalized image that one's
own body is unnaturally and dangerously injured. The
greater the imagined injury and danger, the more distressed

97
the subject will be. External stimuli will correlate along
a continuum with this personalized image and will evoke
corresponding degrees of anxiety. For example, the sight of
blood pouring from a wound might be more highly correlated
with this "dangerous injury" affective network than the
sight of an amputated leg. The latter stimulus might elicit
greater anxiety than a healing scar. Such a priori
predictions based on injury severity and imminent danger
will permit testing of the hypothesis.
Other stimulus and personality dimensions call for
study. One interesting observation is that some blood
phobics have greater aversion to their own injury or blood,
while other phobics are more distressed by that of another
person. The processes involved in such differences need
exploration. Manipulation of the similarity of the "victim"
to the subject (e.g, human vs. animal, gender, race) might
reveal insights. Additionally, some aspect of the
naturalness or unnaturalness of the blood-related stimulus
might influence responding; one wonders whether blood
associated with childbirth or menstruation elicit the same
reaction as blood from an unnatural source (e.g., wound).
Clearly, these many research domains can be fruitful to
furthering our understanding not only about blood phobia,
but also about important psychological processes such as
empathy, fantasy, imagery, and emotion.

APPENDIX A
INFORMED CONSENT TO PARTICIPATE IN RESEARCH (STUDY 1)
J. HILLIS MILLER HEALTH CENTER
UNIVERSITY OF FLORIDA
GAINESVILLE, FLORIDA 32610
You are being asked to volunteer as a participant in a
research study. This form is designed to provide you with
information about this study and to answer any of your
questions.
1.TITLE OF RESEARCH STUDY
Exposure to Visual and Verbal Stimuli
2. PROJECT DIRECTORS
Name: Barbara G. Melamed, Ph.D.
Mark A. Lumley, M.S.
Telephone Number: 392-0295
or 392-4551
3. THE PURPOSE OF THE RESEARCH
The purpose of this study is to learn how people react
to seeing and hearing different sorts of scenes presented by
videotape and audiotape. A second goal is to see how
personality differences relate to how people react to these
videotapes and audiotapes.
4.PROCEDURES FOR THIS RESEARCH
The study will take place during one 1 hour session.
When you arrive at the Behavioral Medicine Laboratory, you
will complete several questionnaires about different aspects
of your personality. Next, heart rate and skin conductance
sensors will be connected to your hand and arms to produce a
record of physiological activity. There is no pain or
discomfort in applying or recording with these sensors. A
blood pressure cuff will be connected to your upper arm, and
it will inflate and deflate automatically every few minutes.
You will then be asked to watch several short videotapes on
a television. Some of the videotapes may include scenes
such as everyday activities, whereas other videotapes may
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99
show part of a surgery on a person. After viewing the
videotapes, you will wear headphones through which you will
hear short descriptions. The audiotapes may describe scenes
such as an operation or some everyday activity. Exactly
what sorts of videotapes and audiotapes you are presented
will depend on the experimental group to which you will be
randomly assigned. After each presentation, you will rate
how you felt using a computer rating system, and you will
complete a questionnaire. During the videotape and
audiotape presentations, your body's reactions will be
recorded and your behavior will be videotaped. After the
presentations, you will be interviewed briefly about your
feelings about the presentations, and then you will be
dismissed.
Feel free to ask questions about the study. You may
withdraw from the study at any time for any reason without a
penalty. All questionnaires, videotapes, and other
materials will remain confidential, and you will be
identified only by number and not by your name. All
information will be destroyed after the data have been
analyzed.
5.POTENTIAL RISKS OR DISCOMFORTS
We expect there to be little risk from participating in
this study. However, some people might feel some discomfort
or lightheadedness from watching or listening to some of the
video or audiotapes. However, these symptoms are known to
be short-lived. If you wish to discuss these or any other
discomforts you may experience, you may call the Project
Director listed in #2 of this form.
6.POTENTIAL BENEFITS TO YOU OR TO OTHERS
You will be paid for participation when you complete
the study. Additionally, as a student in the psychology
subject pool, you have the opportunity to learn about how
psychology research is conducted. Society and science also
may benefit from your participation. This research will
help us better understand why people react differently when
they see and hear a variety of types of material.
7.ALTERNATIVE TREATMENT OR PROCEDURES. IF APPLICABLE
Not applicable

APPENDIX B
SUBJECT INSTRUCTIONS (STUDY 1)
The purpose of this study is to learn how people react
when they see and hear different types of scenes presented
by videotape and audiotape. In addition, I want to see how
people's personalities as reported by questionnaires relate
to how they react to these videotapes and audiotapes. In a
few moments, this television in front of you will present
several short videotapes. Some videotapes may show
everyday, commonplace scenes, whereas others may show scenes
such as a surgical operation on a person's chest. For all
presentations, there is a picture on the television but
there is no sound. Whenever the television turns on, you
should watch the presentation until it is over. Please try
your best not to look away or close your eyes. It is very
important that you watch the entire presentation.
Immediately after each presentation ends, your blood
pressure will be taken, and this computer screen will turn
on so that you can rate how you felt during the
presentation. I will explain how to use the computer in a
few moments. After you have finished rating the feelings
you had during the presentation, I will step back in the
room and have you fill out a short questionnaire before the
next presentation. After several television presentations,
I will have you wear a pair of headphones, and you will hear
some descriptions over the headphones. After each headphone
description, you will rate how you felt during the
description. When the headphone presentations are over, I
will talk with you briefly about how you felt about the
presentations, and then you can leave. I'll pay you as you
leave.
To determine how you react to the television
presentations and the headphone presentations, I am going to
record your body's responses. Let me attach the recording
sensors right now.
(ATTACH HR AND SCL LEADS, BP CUFF)
The blood pressure cuff will inflate before and after
each television and or headphone presentation.
(PRESENT SAM INSTRUCTIONS: APPENDIX C)
Let me tell you the order of things that will happen.
In a few moments, I am going to go into the other room. The
first thing that will happen is that the computer screen
will turn on. Please watch for the computer to turn on.
When it does, I would like you to rate how you are feeling
right then; that is rate your feelings as you sit there
waiting for the television presentations to start.
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101
Remember, you will rate how happy vs. unhappy, calm vs.
aroused, in control vs. controlled, and how faint and how
sick or nauseas you are feeling right then. After you are
done rating, please be still and wait patiently for about a
minute. Please watch for the television to turn on. After
the first television presentation, the computer screen will
turn on and you should rate how you felt while you watched
the presentation. After you have made your ratings, I will
come back into the room to have you complete another
questionnaire. Then we will repeat the same procedure for
another television presentation, and so on. Do you have any
questions?
(CONDUCT FIRST TWO TRIALS USING VIDEOTAPE STIMULI:
AFTER TRIAL 2, CONTINUE WITH INSTRUCTIONS:)
In a moment I'll have you put these headphones on.
This part of the study will proceed just like the first
part, except that you will hear descriptions over the
headphones rather than see anything on the television. The
descriptions may be about things such as a surgery on a
person's chest or about everyday activities. When the
headphones turn on, I want you to listen very carefully to
what the person is describing, and think about it. After
the headphone presentation ends, your blood pressure will be
taken, and you should use the computer screen to rate how
you felt during that headphone presentation. I'll come back
in after the first headphone presentation. Do you have any
questions?

APPENDIX C
SELF-ASSESSMENT MANIKIN (SAM) INSTRUCTIONS
In addition to your physiological responses, I'm
interested in your emotional feelings that you experienced
while you watched the television or listened to the
headphones. Right now I'll show you how to use the computer
to rate your feelings. To rate your emotions, a stick
figure called SAM will be presented on this computer screen
(POINT). SAM's features can be adjusted using this black
knob (POINT) to represent your feelings on three dimensions:
happy vs. unhappy, calm vs. aroused, and in control vs.
controlled. Right now, I'll turn on the screen and go into
the other room to start the demonstration. Watch the screen
turn on and I'll be right back to show you how to use the
control box and the screen. I'm also going to take your
blood pressure again.
(TURN ON SAM BOX, MONITOR, GO TO OTHER ROOM, ASSESS BP,
HIT SHIFT, RETURN TO SUBJECT ROOM)
When the screen first turns on, you'll see this
message, "Please center the ratings knob." First, let me
explain how to do this. To center the knob, turn the knob
first one way and then the other and watch the screen as you
do. You can turn it quickly, but don't force it too hard
because it could break. You will know when the knob is
centered because this message will disappear and the screen
will list the emotion which you are going to rate. The
first emotion that you will practice rating this time is
happy vs. unhappy. Go ahead and center the knob by turning
it one way or the other, and notice the happy vs. unhappy
label on the screen. (PAUSE)
This is SAM. Let me tell you about the happy vs.
unhappy scale. First, turn the knob all the way to the
right. At this end of the scale, you felt completely HAPPY,
PLEASED, SATISFIED, CONTENTED, HOPEFUL. This is the way SAM
should look if you felt completely contented or happy during
the presentation. Now let's look at the opposite feeling
from pleasure-at the other end of the scale. Turn the knob
to the left. This is the way SAM should look if you felt
completely UNHAPPY, ANNOYED, UNSATISFIED, DEPRESSED,
DESPAIRING. Now slowly turn the knob back all the way to
the other end. Notice that SAM's expression changes
gradually, allowing you to show exactly how happy vs.
unhappy you felt, not just only one extreme or the other.
OK, let's practice. Have SAM show me that you felt
completely DISSATISFIED and DEPRESSED during a presentation.
(PAUSE) Good! Show me that you felt completely HAPPY AND
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103
HOPEFUL. (PAUSE) Let's try some less extreme feelings.
How would SAM look if you felt somewhat UNHAPPY or ANNOYED?
(PAUSE) How about if you felt mostly CONTENTED AND PLEASED.
(PAUSE) Good, notice that SAM can show extreme feelings and
all the small differences in between.
When you have positioned the knob so that SAM exactly
represents how happy vs. unhappy you felt during the
preceding presentation, you should push the red button on
the control box so that the computer records your rating.
This also advances the screen. Go ahead and push the red
button. (PAUSE)
Again, you see the message to center the knob. This
time when you do it, you will see the second type of feeling
that SAM can represent, "calm vs. aroused." Watch the
screen as you center the knob. (PAUSE) Turn the knob all
the way to the right. At this end of the calm vs. aroused
scale you had feelings such as: STIMULATED, EXCITED,
FRENZIED, JITTERY, WIDE-AWAKE, AROUSED. If you felt most
jittery and wide awake, SAM should look like this. Now
let's look at the opposite feeling from arousal—at the
other end of the scale. Turn the knob all the way to the
left. This is the way SAM should look if you felt
completely: RELAXED, CALM, SLUGGISH, DULL, SLEEPY,
UNAROUSED. Now, slowly turn the knob all the way to the
other end, and notice the changes in SAM'S stomach and eyes.
Now have SAM show that you felt completely RELAXED AND
UNAROUSED. (PAUSE) Now have SAM show that you felt
completely WIDE-AWAKE AND AROUSED. (PAUSE) Let's try some
moderate feelings. If you felt somewhat JITTERY; (PAUSE)
if you felt moderately CALM. (PAUSE) Once again you should
try to rate exactly how you felt using any part of the
scale. When SAM represents exactly how calm vs. aroused you
felt during a presentation, push the red button to record
your feeling. Go ahead and push it.
The next emotion that you will rate is "in control vs.
controlled." First, center the knob. Now turn it all the
way to the right. At this extreme of the scale you have
feelings characterized as controlling, INFLUENTIAL, IN
CONTROL, IMPORTANT, DOMINANT, AUTONOMOUS. If you felt most
influential and in complete control, SAM should look like
this. Now let's look at the opposite feeling from being in
control. This is the way SAM should look if you felt
completely: CONTROLLED, INFLUENCED, CARED-FOR, SUBMISSIVE,
GUIDED, UNIMPORTANT. Notice that SAM is large when you felt
important and influential, and that SAM is very small when
you felt submissive and guided. Make SAM show that you felt
completely CONTROLLING and DOMINANT. (PAUSE) Now make SAM
show that you felt completely SUBMISSIVE and CONTROLLED.
(PAUSE) Again, try rating some of your moderate feelings of
control: if you felt only moderately SUBMISSIVE OR
INFLUENCED, (PAUSE) or just slightly DOMINANT AND
INFLUENTIAL. (PAUSE) Once again press the red button after
you have made SAM represent exactly how in control vs.
controlled you felt.

104
The last two ratings you will make do not involve SAM,
but are ratings of how faint and how nauseous or sick to
your stomach you might have felt during the television or
headphone presentation. The first rating scale is the
faintness rating. First center the knob. Use the knob to
position the arrow at the appropriate point on the scale of
faintness. You can place the arrow at either end or any
point in between to rate your feelings of faintness during
the presentation. After positioning the arrow, press the
red button. Now center the knob. Next comes the rating of
nauseous feelings. Position the arrow to rate how nauseous
or sick to your stomach you felt during the presentation.
Again, use any part of the scale. When you have positioned
the arrow to represent how nauseous you felt, then press the
red button. The computer will turn off, and then I'll come
back into the room.
In summary, the computer will turn on after each
television and headphone presentation. The 3 SAM ratings
will be first, although the computer will present them in
different orders each time. First center the knob, and then
use the knob to make SAM represent how you felt during the
preceding presentation. Press the red button to record your
feeling. After the three SAM ratings, you should then rate
the faintness and nauseous feelings experienced during the
presentation.
Do you have any questions about the computer?

APPENDIX D
DEBRIEFING FORM (STUDY 1)
This study is now over, and I thank you very much for
your participation. This form is intended to explain
further the purpose of the study.
My research team is interested in better understanding
the reaction that some people have when they see something
bothersome, such as blood or injuries, and in what ways
these people differ from others who are not particularly
bothered by these sights. Furthermore, we are trying to
understand how people's negative feelings can be reduced so
that they are not bothered by seeing blood and injuries.
This study involved showing you both a surgery videotape and
a neutral videotape in order to compare your reactions to
these two types of material. If you find blood-related
things to be bothersome, we hypothesized that your reaction
would be stronger to the surgery videotape than to the
neutral videotape, and that it would be stronger when
viewing the surgery videotape in comparison to people who
report less of a problem with seeing blood-related things.
If you are not particularly bothered by blood-related
sights, we hypothesized that your reaction would not differ
between the two tapes. In addition, we are interested in
seeing if the same pattern of responding occurs when you
hear rather than see the presentations. Thus, half of the
research participants heard a tape describing an operation,
and the other half heard a neutral description. Finally the
questionnaires will be used to determine what personality
attributes are related to how people react when they see and
hear surgery and neutral scenes.
Because of the nature of the experiment, please DO NOT
DISCUSS this study with any of your classmates. They may be
participating later, and their knowledge about the study
might invalidate the results. I appreciate your
participation. Please ask any questions and tell me your
thoughts before you leave.
Signature of Subject Date
Signature of Experimenter Date
105

APPENDIX E
PHOBIC AND NEUTRAL AUDIOTAPE TRANSCRIPTS (STUDIES 1 AND 2)
Fear Scene 1 (Studies 1 and 2): "Incision"
The surgeon holds a scalpel which is pulled slowly
across the patient's chest leaving a thin red mark where the
skin is cut. Blood drips from the cut. Again, the scalpel
is pulled slowly to make the incision wider and longer
across the chest. The inside of the wound reveals yellow
tissue. The scalpel is drawn a third time across the
incision, which is pulled open several inches wide. Next,
large metal cutters are placed in the incision. A small
retractor holds the wall of the incision open. The surgeon
forcefully squeezes the cutters to snip the tough muscle or
bone which covers the chest cavity. Again, the surgeon
squeezes the cutters several times to make more cuts through
the muscle. Next, the surgeon holds the incision open with
a finger, and sharp scissors are used to snip the remaining
muscle tissue. The wound now reveals the interior of the
chest cavity where moist, pink-colored lungs slowly inflate
and deflate.
Fear Scene 2 (Study 2): "Rib"
Red muscle surrounds the patient's rib. The surgeon's
hands use a sharp needle to clean tissue from the rib. The
rib is cleaned and small blood drops are wiped with a cloth.
Next, the surgeon forcefully pushes a flat metal tool down
the length of the rib to remove muscle from the rib. The
tool is pushed up the rib to remove more tissue and then is
pushed down again. Next, the tool is slid underneath the
rib from top to bottom to clean off muscle from below.
Finally, only the ends of the rib remain connected to the
patient's body. Next, cutters are squeezed around the rib's
upper end, and the rib is cut and twisted off. The cleaning
tool is slid down underneath the rib. The cutters snip the
rib at the lower end and twist it free from the body. Blood
oozes from the wound, and a cloth is placed in the wound to
stop the bleeding.
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107
Fear Scene 3 (Study 2): "Heart"
The patient's heart, covered with yellow fat, beats
rapidly within the red, muscular chest walls. The surgeon
pokes a thin, sharp needle into the beating heart. Forceps
are pushed deep into this hole, and blood flows from the
wound. The surgeon's finger is placed over the hole in the
heart. Sharp scissors snip an artery, and blood squirts
from the cut. While the heart beats, a tube is pushed into
the hole. Blood leaks from the hole. The surgeon squeezes
pliers attached to the tube, and then removes the tube from
the heart. The surgeon's apron has red stains on it. The
surgeon's finger is removed from the heart, and streams of
blood squirt with each heartbeat. The surgeon's replaces
the finger over the hole to stop the bleeding. Forceps
insert a needle and thread around the hole as blood
continues to squirt. The surgeon ties the thread around the
hole. The heart is cleaned with cloth and continues
beating.
Fear Scene 4 (Studies 1 and 2): "Tubes"
The patient's chest is open, revealing internal organs.
The surgeon grips the side of the wound, stretching the
skin, and uses a scalpel to make two small incisions in the
patient's abdomen. The scalpel makes the incisions deeper
and wider. The surgeon then forces long, sharp scissors
down into one incision. The scissors are turned and pushed
until forced into the chest cavity. A white tube is
attached to the scissors and pulled back through the
incision. Several feet of tube are pulled from the chest
out through the abdomen. The surgeon then forces the
scissors through the other incision into the chest cavity.
A second white tube is attached and pulled back through the
abdomen. The abdomen skin is forcefully pulled away from
the underlying muscle. Pliers push a metal needle and
thread through the chest wall. The needle is pushed into
the opposing muscle wall and pulled through. The lungs
slowly inflate and deflate within the chest cavity.
Fear Scene 5 (Study 2): "Sutures"
The surgeon uses forceps, a needle, and thread to
stitch the patient's chest incision, which is several inches
wide. The surgeon pushes the needle through a muscle and
pulls it through the other side. The needle is pushed
through another muscle. This is repeated several times
while the surgeon holds the bloody muscle tissue. Next, the
stitches are all in place, but are not tightly pulled
together. The lungs continue to inflate and deflate. The
surgeon squeezes the pliers to pull the walls of the
incision together. Two red muscles are brought together
over the surface of the incision. Forceps push a needle and
thread through each muscle and pull the thread to bring the

108
muscles together. Next, all the muscles in the incision are
joined together. The surgeon ties the thread several times
and pulls other threads to further close the skin. Several
more knots are made before the thread are cut. A cloth is
placed in the wound.
Neutral Scene (Study 1): "Truck"
The toy blue truck is made of wood. A trailer
connected to it is also constructed of wood and painted
blue. The trailer carries several yellow blocks. The truck
is slowly pushed up the long white ramp until it reaches the
top, where it is pushed straight ahead. The toy truck is
stopped, and one yellow block is moved from the front to the
back of the trailer. All six blocks are then straightened
out. The truck is gradually pushed up another ramp as the
blue wheels rotate slowly. The truck is stopped and three
more yellow blocks are gently placed on the trailer, one at
a time. The truck is pushed again, this time, down the
ramp. As it reaches the bottom, it turns slightly before
stopping. One block is removed and is placed on the floor.
A second block is also removed and placed on top of the
first. Finally, two more blocks are picked up and removed
from the truck.
Neutral Scene 1 (Study 2): "Cake"
The baker slowly tips the box, and yellow cake mix
pours into the large bowl. The baker taps the bottom of the
box and more yellow mix falls into the bowl. Next, the
baker takes a large egg from an egg carton. The egg is
gently tapped against the bowl until a crack appears in the
shell. The baker gently pulls the egg apart, and the egg
white and yolk drop into the bowl. The baker takes a
spatula and pokes the egg yolk causing the yellow liquid to
flow from it. The baker then stirs the mix by quickly
rotating the spatula. The spatula turns in one direction
and then in the other. Next, the baker holds a measuring
cup in one hand and, with the other hand, pours some clear
oil from a plastic bottle. The baker tips the measuring cup
to pour the oil into the mixing bowl. The spatula is used
to stir the mix again.
Neutral Scene 2 (Study 2): "Typewriter"
The secretary sits in front of an electric typewriter.
A blank sheet of white paper is lifted up to the typewriter
roller and gently placed down against the left edge marker.
The secretary's hand slowly twists the knob at the end of
the roller until the paper is securely locked and reappears
in front of the typewriter keys. The secretary's fingers
rest briefly on the keys and then begin to move, first
hitting this key, then that one, and many in succession.
Occasionally, the space bar is pressed. Gradually the

109
typing approaches the right side of the paper. The
secretary's hand presses the return key, and the typing head
automatically moves back to the other side. The secretary's
hand returns to the original position and begins typing
again. The fingers continue pressing and moving for several
minutes. Next, the secretary slowly rotates the knob and
removes the paper from the typewriter. The secretary places
the paper down on the desk.
Neutral Scene 3 (Study 2): "Garden”
The gardener is kneeling in the garden between two rows
of brown dirt. Nearby is a yellow plastic cup which holds
several short, green plants. The gardener's hand digs a
small hole, several inches deep, in one of the rows of dirt.
One plant is taken from the plastic cup, and the roots are
shaken gently. The plant is dropped to the bottom of the
hole, and using the other hand, the gardener pushes the dirt
back into the hole to cover the roots. Next, the gardener
reaches for a metal watering can, and tips the spout of the
can toward the plant. Clear water pours quickly onto the
dirt all around the plant. The gardener gently sets the
watering can down and pushes more dirt around the plant's
base. The gardener moves several inches to the left and
proceeds to make another small hole in the brown dirt. The
next plant is taken from its cup for this spot.
Neutral Scene 4 (Study 2): "Canoe"
The shiny silver canoe floats gently down the river.
The canoeist sits quietly in the back of the canoe. The old
wooden paddle is held firmly in the canoeist's hands.
First, the paddle is moved to the right side of the canoe
and placed in the water to the top of the blade. It is
slowly pulled back, forcing the water before it and
gradually pushing the canoe forward. When the paddle has
travelled several feet, the canoeist leaves it there for
several seconds. Next, the canoeist picks up the paddle and
brings it forward. Drops of water fall from the blade. The
paddle is moved across the canoe to the other side, and the
canoeist's hands switch position on the paddle. Now, the
right hand holds the top and the left hand the bottom. The
canoeist reaches the paddle forward and places it into the
water for another stroke. The canoeist pulls the paddle and
the canoe moves forward.
Neutral Scene 5 (Study 2): "Kite"
A warm breeze blows across the park. A person quickly
walks toward the center of the park, gradually unrolling a
ball of string. At the other end of the string is a big
blue and red kite, lying on the ground. The person
continues to unroll several more feet of string and then
stops walking and firmly grasps the ball of string. After

110
several seconds, the person's hands and arms pull the
string, and the person moves several feet further away from
the kite. The kite rises in the air. The person stops
moving and slowly unrolls the ball of string, watching the
kite rise above the trees. After several minutes, the
breeze begins to fade, and the person stops releasing
string. As the kite begins to fall, the person's right hand
quickly begins to twirl the string around the ball,
retrieving the slack in the string. After several moments,
the person stops twirling the string and watches the kite.

APPENDIX F
VPM CONTROL PROGRAM FOR DATA ACQUISITION AND STIMULUS
PRESENTATION (STUDY 1)
title vpm control file for Lumley's dissertation study 1
include macros.vpm
include constnts.vpm
•
9
; one millisec time base
/
BEGINDCA 1000,0,30000,CGA,CGA,ANALOG,2047,LABMASTER
9
comment %
Control file to run exposure paradigm for Lumley's
dissertation study 1 using the VPM and the IBM PC-AT
%
•
9
jump start
9999999999999999
timing durations
fiftyeightsec:
dw
thirtysec:
dw
twentysixsec:
dw
twentysec:
dw
tenhalfsec:
dw
fourhalfsec:
dw
twohalfsec:
dw
tenth:
dw
shifts:
dw
temp:
dw
vidbit:
dw
zero:
dw
three:
•
dw
58000
30000
26000
20000
10500
4500
2500
100
3
•
2; video is bit
0
3
1 of Digital Output
sampling table
channel 1: Skin Conductance
scltable:
storagetable 1 /sample 1 channels
storagerow 1, 100 ;skin conductance, channel 1 at 10 HZ
111

112
M M í n M / / M í M / > M M ; M / M M M ; M M M M
fainting/nausea rating definitions
99999999999999999999999999999999999999999
faintleft:
dw
2;# lines in left message
defmsg
"Not at all"
defmsg
"faint"
faintright:
dw
2 ;# lines in right message
defmsg
"Extremely"
defmsg
"faint"
faintcntr:
dw
2 ;# lines in center message
defmsg
"How faint did you feel during"
defmsg
"the last presentation?"
nauseleft:
dw
2;# lines in left message
defmsg
"Not at all"
defmsg
"nauseous"
nauseright:
dw
2 ;# lines in right message
defmsg
"Extremely"
defmsg
"nauseous"
nausecntr:
dw
2 ;# lines in center message
defmsg
"How nauseous did you feel during
defmsg
"the last presentation?"
99999999999999999999999999999
messages to the experimenter
/ I I f f M í / M / M f M f / í M M / f / M
•
9
mwait:
defmsg
massessbp:
defmsg
mbaseSAM:
defmsg
mstartaudio:
defmsg
mstartvideovcr:
defmsg
mstimpres:
defmsg
mexpdone:
defmsg
9 9 9 9 9 9 9 9 9
"hit SHIFT twice to start a trial"
"assess blood pressure"
"hit SHIFT to start baseline SAM"
"start AUDIOtape presentation"
"start VIDEOtape;RECORD small VCR"
"stimulus being presented"
"experiment completed"
This is a macro which runs the trial structure
runloop macro
collect:
upcount
clockreset
9999999999999999999999999999999999999999999999999
strike SHIFT key twice to start the next trial
9999999999999999999999999999999999999999999999999
waitloop:
message
delay
peek
BITmask
jumpeq
mwait
tenth
kbdstat, 0, temp
shifts, temp
zero, temp, waitloop

113
waitlloop:
startl:
go:
delay
tenth
peek
kbdstat, 0, temp
BITmask
shifts, temp
jumpeq
zero, temp, waitlloop
message
massessbp
delay
thirtysec
jumpeq
dcstart
@usrcnt, three, startl
delay
twentysixsec
message
mstartvideovcr
delay
dcstop
fourhalfsec
jump
dcstart
go
delay
twentysec
message
mstartaudio
delay
dcstop
dcstart
tenhalfsec
message
mstimpres
delay
fiftyeightsec
message
massessbp
delay
dcstop
twohalfsec
portout
vidbit, 71DH;gate for Ss monitor
samrate
zero
linerate
faintleft, faintright, faintcntr
linerate
nauseleft, nauseright, nausecntr
portout
write
zero, 71DH
jumplt
@usrcnt, three, collect
endm
; end macro
begin executable commands here
M ? ? M M f M f M M / / M M / / M M / Í
start:
seta2drange
seta2dstore
asemask
setcount
message
0,1
;for skin conductance and
scltable
;read HR on digital input
zero
mbaseSAM
heart
port A-0
1

114
wait21oop:
delay
peek
BITmask
jumpeq
portout
samrate
linerate
linerate
portout
tenth
kbdstat, 0, temp
shifts, temp
zero, temp, wait21oop
vidbit, 71DH ;gate for Ss monitor
zero
faintleft, faintright, faintcntr, 1
nauseleft, nauseright, nausecntr, 2
zero, 71DH
collect 3 trials of data
f
runloop
message mexpdone
delay twentysec
enddca
vpm ends
end

APPENDIX G
INFORMED CONSENT TO PARTICIPATE IN RESEARCH (STUDY 2)
J. HILLIS MILLER HEALTH CENTER
UNIVERSITY OF FLORIDA
GAINESVILLE, FLORIDA 32610
You are being asked to volunteer as a participant in a
research study. This form is designed to provide you with
information about this study and to answer any of your
questions.
1. TITLE OF RESEARCH STUDY
Exposure to Visual and Verbal Stimuli
2 .
PROJECT DIRECTORS
Name: Barbara G. Melamed, Ph.D.
Mark A. Lumley, M.S.
Telephone Number: 392-0295
or 392-4551
3.
THE PURPOSE OF THE RESEARCH
You have been asked to participate in this research
because you have reported that you find the sight of blood
and injuries to be discomforting. The purpose of this study
is to learn how people respond to scenes which they find to
be aversive, such as an operation in which there is blood.
In addition, we will learn what are the best ways of
presenting the scenes in order to help people be more
comfortable with observing this type of material.
4. PROCEDURES FOR THIS RESEARCH
The study will take place during one two-hour session.
When you arrive at the Behavioral Medicine Laboratory, the
study procedure will be explained to you, and you will be
asked to sign this Informed Consent Form. You will be
briefly interviewed about your history of reactions to
blood-related things and will complete a number of
questionnaires about your thoughts and feelings on several
topics. Following this, you will be seated in a viewing
room where heart rate and skin conductance sensors will be
115

116
connected to your hand and arms to produce a record of
physiological activity. There is no pain or discomfort in
applying or recording with these sensors. A blood pressure
cuff will also be connected to your upper arm. It will
inflate and deflate automatically every minute or two. You
will then rate your feelings using a picture rating system
on a video screen. While you remain seated, you will be
asked to watch a number of short segments of surgical
operations on a person's chest. You may also hear over
headphones a description of surgery or a description of some
everyday activity. Each videotape and auditory presentation
will be separated by a short rest period. During each
presentation, your body's reactions will be recorded and
your behavior will be videotaped. After each presentation,
you will rate how you are feeling. After a number of such
presentations, the study will be over and you will be free
to leave. You may be contacted by telephone after several
months to see whether the experimental participation has had
any affect on your reactions to blood-stimuli encountered in
your daily life.
Feel free to ask questions at any time. You may
withdraw from the study at any time for any reason without a
penalty. All questionnaires, videotapes, and other
materials will remain confidential, and you will be
identified only by number and not by your name. All
information will be destroyed after the data have been
analyzed.
5. POTENTIAL RISKS OR DISCOMFORTS
We expect there to be little risk from this study.
However, you have reported that you find blood-related
stimuli to be aversive; therefore, you might sense some
discomfort, lightheadedness, nausea, and possibly even
faintness from viewing the videos. However, these symptoms
are known to be short-lived.
If you wish to discuss these or any other discomforts
you may experience, you may call the Project Director listed
in #2 of this form.
6. POTENTIAL BENEFITS TO YOU OR TO OTHERS
Both you and society stand to benefit from your
participation in this study. You will learn more about the
blood aversiveness condition which you report having, and
your participation may help you feel more comfortable when
seeing blood-related things.
Society and science also may benefit from your
participation in that this research will show us how to help
people become less afraid or concerned with situations that
they typically avoid because of the fear of feeling too
uncomfortable. Therefore, more people may be able to donate
blood, help others who are injured, and feel comfortable
going to the doctor or dentist. Additionally, this research

117
will help us know which types of people will benefit most
from which type scene presentation.
7. ALTERNATIVE TREATMENT OR PROCEDURES. IF APPLICABLE
If you want treatment for aversion to blood-related
stimuli or any other problems, you have the option of being
seen as an outpatient at the Psychology Clinic.

APPENDIX H
SUBJECT INSTRUCTIONS (STUDY 2)
The goal of this study is to better understand people's
reactions to seeing and hearing things about blood, injury,
or illness. Furthermore, we hope to learn about the process
by which people become more comfortable seeing such things.
Several times during your participation today, this
television in front of you will present a short videotape
showing part of a surgical operation on the chest of a
living human being. At other times, it is possible that you
will hear a description of the surgery over these
headphones, or you may hear a description of an everyday
activity. You definitely will see part of a surgery on the
television, however, whether or not you hear anything over
the headphones and what you hear will depend on which
experimental group you will be assigned to.
At various times today, the television will turn on and
show a one minute presentation of a surgery on a person's
chest. There is a picture but no sound during the
presentation. Whenever the television turns on, you should
watch the surgery until it is over. Please try your best
not to look away or close your eyes. Although it might be
difficult, try to continue watching until the 60-second
presentation ends. Immediately after it ends, your blood
pressure will be taken, and this computer screen will turn
on so that you can rate how you felt during the
presentation. I will explain how to use the computer to
make these ratings in a few moments. After you have
finished rating the feelings you had during the
presentation, you should wait a few moments and remain ready
for the next presentation, which could be either a
television or a headphone presentation.
At other times, the headphones may present a
description without the television turning on. If the
headphones turn on, listen very carefully to what is being
described and think about it. After 60 seconds, the
headphone presentation will end, and your blood pressure
will be taken. The computer screen will turn on, and you
should rate how you felt during the headphone presentation.
Then wait and remain ready for the next presentation.
To determine how you react to the television and
headphone presentations, your body's responses are being
recorded with the sensors and the cuff. The blood pressure
cuff will inflate at various times during your
participation. Please do not be alarmed when it inflates.
In addition to your physiological responses, we are
118

119
interested in the emotional feelings you experienced while
you watched the television or listened to the headphone
presentation. I will now show you how to use the computer
to rate how you felt during a television or headphone
presentation.
(PRESENT SAM INSTRUCTIONS: APPENDIX C)
In order to familiarize you with the procedure, we will
have a practice television presentation of a scene from
nature. With the exception that you will not be seeing a
surgery this time, this practice trial will be just like the
television presentations later. The practice scene will
start in a few moments, so please watch the television and
then use the computer to rate how you felt while watching
the presentation. Any questions that you have about the
procedure will be answered after that.
(PRESENT PRACTICE TRIAL; ANSWER SUBJECT'S QUESTIONS)
In just a few seconds, you will hear through the
headphones a brief set of instructions about the study.
Right after that, the computer screen will turn on. Use the
computer to rate how you felt during the headphone
presentation. After that, you should wait several minutes
before the surgery or everyday activity television and
headphone presentations begin. Remember that after each
presentation, you should use the computer to rate how you
felt during that presentation.
Audiotaped headphone reminders (played via cassette):
In a few minutes the television presentations of a
surgery on the chest of a living human being and the
headphone descriptions of surgery or an everyday activity
will begin. Whenever the television shows an operation, you
should continue to watch it for the entire time that it is
displayed. Please do not close your eyes or look away. It
is very important to the success of this study that you
continue to watch the surgery for as long as it is on.
Again, after the television turns off, you should rate how
you felt during the presentation. At other times, the
headphones may turn on. Please listen carefully and think
about what is being described. After the description is
over, you should rate how you felt during the description.
After you make your ratings, please wait for a few
moments until the videotape or headphone turns on again for
the next presentation. You will have a number of these
presentations until the study is over. The presentations
will begin in a few minutes.

APPENDIX I
DEBRIEFING FORM (STUDY 2)
This study is now over, and I thank you very much for
your participation. This form is intended to explain
further the purpose of the study.
My research team is interested in better understanding
ways to reduce people's fear of or concern with blood-
related sights in order to help them cope with situations
they normally avoid, such as watching an operation. As a
general rule, repeated exposure to upsetting things is the
most effective way of becoming more comfortable around these
things. That is why I repeatedly showed you the same
surgical videotape. I compared three different ways of
presenting such material. Some subjects saw a surgical
videotape repeatedly. Other subjects saw a surgical
videotape on some occasions, but heard a description of the
surgery on other occasions. The remaining subjects saw a
surgical videotape but also heard a neutral, "everyday
activity" description at the same time that other subjects
were hearing a surgical description; these subjects served
as experimental "controls" for hearing something over the
headphones. (Your group assignment was determined randomly
and in no way reflects on your personality). During these
exposures, I monitored how your body was reacting and how
you were feeling. I want to see if people show less
discomfort with more exposures and to determine differences
in the speed of becoming more comfortable for the three
conditions. Also, a different surgery tape was presented at
the end in order to determine the degree to which the change
affected your reactions to seeing new blood-related things.
Because of the nature of the experiment, please do not
discuss this study with any of your classmates. They may be
participating later, and their knowledge about the study
might invalidate the results. I appreciate your
participation. Please ask any questions and tell me your
thoughts before you leave.
Signature of Subject Date
Signature of Experimenter Date
120

APPENDIX J
VPM CONTROL PROGRAM FOR DATA ACQUISITION AND STIMULUS
PRESENTATION (STUDY 2)
title vpm control file for Lumley's dissertation study 2
include macros.vpm
include constnts.vpm
•
t
; one millisec time base
/
BEGINDCA 1000,0,30000,CGA,CGA,ANALOG,2047,LABMASTER
/
comment %
Control file to run exposure paradigm for Lumley's
dissertation study 2 using the VPM and the IBM PC-AT
%
j ump start
; timing
durations
•
t
onemin:
dw
60000
fiftyeightsec
dw
58000
fortysec:
dw
40000
thirtysec:
dw
30000
twentysec:
dw
20000
twelvesec:
dw
12000
tensec:
dw
10000
ninesec
dw
9000
eightsec:
dw
8000
threesec:
dw
3000
twosec:
dw
2000
onesec:
dw
1000
tenth:
dw
100
shifts:
dw
3
temp:
dw
?
itis:
dw
25000,
20000, 30000, 22500, 35000
dw
17500,
32500, 15000, 27500
ititmp:
dw
10
vidbit:
dw
2 ;video bit is bit 1 of Dig Outp
zero:
dw
0
one:
dw
1
two:
dw
2
three:
dw
3
four:
dw
4
121

122
five;
dw
5
six:
dw
6
seven;
dw
7
eight:
dw
8
nine:
•
9
dw
9
9 9 9 9 9 9 9
•
9
9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9
sampling table
9 9 9 9 9 9 9 9 9 9 9
•
9
channel 1: Skin
Conductance
scltable:
storagetable 1 ; sample 1 channels
storagerow 1, 100 ;skin conduct on channel 1 at 10 HZ
999999999999999999999999999999999999999999999999999999999
fainting/nausea rating definitions
faintleft:
dw
2;# lines in left message
defmsg
"Not at all"
defmsg
"faint"
faintright:
dw
2 ;# lines in right message
defmsg
"Extremely"
defmsg
"faint"
faintcntr:
dw
2 ;# lines in center message
defmsg
"How faint did you feel during
defmsg
"the last presentation?"
nauseleft:
dw
2;# lines in left message
defmsg
"Not at all"
defmsg
"nauseous"
nauseright:
dw
2 ;# lines in right message
defmsg
"Extremely"
defmsg
"nauseous"
nausecntr:
dw 2
;# lines in center message
•
9
defmsg "How nauseous did you feel during
defmsg "the last presentation?"
9 9 9 9 9 9 9 9 9 9 9 9
;messages to
9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9
the experimenter
•
9
massessbp:
defmsg "assess
blood pressure"
massessbpl:
defmsg "assess
BP; prepare to start stimulus
massessbp2:
mstartprep:
mstartaudio:
mstartvideo:
defmsg "assess BP; STOP stimulus, VCR"
defmsg "start AUDIOtape or present nothing"
defmsg "start AUDIOtape presentation"
defmsg "start experimental VIDEOtape"
mstartvideovcr: defmsg "start VIDEOtape; RECORD on sm VCR"
mratings: defmsg "ratings being conducted"
mexpdone: defmsg "experiment completed"
mtrialsgo: defmsg "press SHIFT to begin trial"
mitil; defmsg "ITI; preparation trial, disconnect SAM?"
miti2: defmsg "ITI; prepare experimental stimulus"

123
miti3:
miti4:
mstimpres:
mbase:
msignals:
mdemoratings
msessionbase
mquestions:
minstr:
mpause:
moff:
defmsg "ITI; prepare novel stimulus"
defmsg "ITI; prepare visual stimulus"
defmsg "stimulus being presented"
defmsg "BASELINE recordings; Prepare to hit BP"
defmsg "check signals—SHIFT starts baseline"
; defmsg "demonstrate ratings to subject"
: defmsg "presession baseline"
defmsg "answer questions—SHIFT to continue"
defmsg "play instructions—SHIFT starts SAM"
defmsg "10 seconds pause before baseline"
defmsg " "
9999999999999999999999999999999999999999999999999
This is a macro which runs the trial structure
runloop
macro ;
beginning of
macro definition
collect:
upcount
clockreset
j umpeq
@usrcnt,
one, startl
j umpeq
@usrcnt,
three, start2
j umpeq
@usrcnt,
five, start2
j umpeq
§usrcnt,
seven, start2
jumpeq
@usrcnt,
nine, start3
jump
start4
startl:
message
mitil
jump
go
start2:
message
miti2
jump
go
start3:
message
miti3
jump
go
start4:
message
miti4
go:
get
itis, 2,
ititmp, 0
delay
ititmp
get
itis, 2,
ititmp, 0
delay
ititmp
message
mtrialsgo
;waiting
for SHIFT key to
be struck to start pretrial
;baseline
recordings and
start trial
9 * 9 9 9 9 9 9 9
9999999999999999
999999999999
9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9
wait51oop:
delay tenth
peek kbdstat, 0, temp
BITmask shifts, temp
jumpeq zero, temp, wait51oop
9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9
data collection and messages to experimenter

124
dcstart
message
delay
dcstop
message
dcstart
delay
j umpeq
jumpeq
j umpeq
j umpeq
j umpeq
j umpeq
jump
here: message
delay
jump
here2:message
delay
message
jump
herel:delay
message
here3:delay
dcstop
message
dcstart
delay
message
delay
dcstop
delay
portout
samrate
linerate
linerate
portout
write
jumplt
endm
mbase
twentysec
massessbpl
ninesec
@usrcnt, one, here
@usrcnt, two, herel
@usrcnt, four, herel
@usrcnt, six, herel
§usrcnt, eight, herel
@usrcnt, nine, herel
here2
mstartprep
threesec
here3
mstartaudio
threesec
mstartvideo
here3
threesec
mstartvideovcr
eightsec
mstimpres
fiftyeightsec
massessbp2
twosec
onesec
vidbit, 71DH ;open gate for Ss monitor
zero
faintleft, faintright, faintcntr, 1
nauseleft, nauseright, nausecntr, 2
zero, 71DH
@usrcnt, nine, collect
; end macro
9999999999999999999999999999999999999
begin executable commands here
start:
seta2drange
seta2dstore
asemask
setcount
0,1 ;for skin conductance and heart
scltable
1 ;read HR on digital input port A-0
zero
9

125
9
/•program is waiting for experimenter to check signal quality
;prior to starting presession baseline affective and physiol
•
9
message
mquestions
waitlloop:
delay
tenth
peek
kbdstat, 0, temp
BITmask
shifts, temp
j umpeq
zero, temp, waitlloop
message
minstr
delay
onesec
wait21oop:
delay
tenth
peek
kbdstat, 0, temp
BITmask
shifts, temp
iumpeq
zero, temp, wait21oop
portout
vidbit, 71DH ;release gate for Ss monitor
samrate
zero
linerate
faintleft, faintright, faintcntr, 1
linerate
nauseleft, nauseright, nausecntr, 2
portout
zero, 71DH
message
mpause
delay
•
9
tensec
; this is a
one-minute presession physiology baseline
9 9 9 9 9 9 9 9 9 9 9 9 9
9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9
9
message
massessbp
delay
twentysec
message
msessionbase
dcstart
delay
onemin
dcstop
write
message
massessbp
delay
twentysec
999999999999999999*99999999999999999999999999999999999
; collect 9 trials of data with var iti between trials
9999999999999999999*9999999999999999999999999999999999
9
runloop
message
delay
enddca
vpm ends
end
mexpdone
twentysec

APPENDIX K
ORDER EFFECTS (STUDY 1)
Table 11. Study 1 Change in Displeasure During the Surgery
and Neutral Videotapes for Phobics and Nonphobics
by Order of Videotape Presentation
Videotape
Surgery
M (SD)
Stimulus
Neutral
M (SD)
Phobics
9.7
(4.6)
-0.7
(2.6)
Surgery
Neutral
first
first
11.8
7.7
(3.8)
(4.6)
-0.8
-0.6
(2.7)
(2.5)
Nonphobics
2.8
(3.8)
-0.3
(3.2)
Surgery
Neutral
first
first
1.5
4.1
(3.7)
(3.6)
-0.1
-0.5
(3.8)
(2.6)
Table 12.
Study 1 Mean Heart Rate Change During the Surgery
and Neutral Videotapes for Phobics and Nonphobics
by Order of Videotape Presentation
Videotape
Surgery
M (SD)
Stimulus
Neutral
M (SD)
Phobics
2.1
(12.2)
0.4
(3.9)
Surgery
Neutral
first
first
7.8
-3.5
(14.1)
(6.5)
0.9
0.0
(2.8)
(4.7)
Nonphobics
-2.1
(5.2)
-1.7
(5.3)
Surgery
Neutral
first
first
-0.7
-3.6
(4.3)
(5.7)
-3.0
-0.4
(5.5)
(5.1)
126

APPENDIX L
ANOVA TABLES (STUDIES 1 AND 2)
Study Is Affect Across Surgery and Neutral Videotapes
Pleasure:
Between
Subjects
Effects
df
MS
F
E
Group
1
253.50
15.31
.0003
Order
1
4.17
0.25
. 62
Surgery
1
0.67
0.04
.84
Group
X
Order
1
54.00
3.26
. 08
Group
X
Surgery
1
4.17
0.25
. 62
Order
X
Surgery
1
0.67
0.04
.84
Group
X
Order X
Surgery
1
0.00
0.00
1.00
Error
40
16.56
Within
Subject Effects
df
MS
F
E
Video
1
1092.50
118.32
. 0001
Video
X
Group
1
322.67
34.91
.0001
Video
X
Order
1
2.67
0.29
.59
Video
X
Surgery
1
13.50
1.46
.23
Video
X
Group X
Order
1
80.67
8.73
.005
Video
X
Group X
Surgery
1
20.17
2.18
.15
Vidoe
X
Order X
Surgery
1
0.00
0.00
1.00
Video
X
Group X
Order X Surgery 1
4.17
0.45
.51
Error
40
9.24
Arousal:
Between
Subjects
Effects
df
MS
F
E
Group
1
140.17
2.65
.11
Order
1
6.00
0.11
.74
Surgery
1
8.17
0.15
.69
Group X
Order
1
40.04
0.76
.38
Group X
Surgery
1
30.37
0.58
.45
Order X
Surgery
1
345.04
6.54
.014
Group X
Order X
Surgery
1
150.00
2.84
.10
Error
40
52.79
127

128
Within Subject Effects
df
MS
F
E
Video
1
2053.50
152.82
.0001
Video
X
Group
1
198.37
14.76
.0004
Video
X
Order
1
7.04
0.52
.47
Video
X
Surgery
1
26.04
1.94
.17
Video
X
Group X
Order
1
24.00
1.79
.19
Video
X
Group X
Surgery
1
6.00
0.45
.51
Vidoe
X
Order X
Surgery
1
0.17
0.01
.91
Video
X
Group X
Order X Surgery
1
18.37
1.37
.25
Error
40
13.44
Control:
Between
Subjects
Effects
df
MS
F
E
Group
1
173.34
4.47
.04
Order
1
36.26
0.93
.34
Surgery
1
0.26
0.01
.93
Group
X
Order
1
23.01
0.59
.44
Group
X
Surgery
1
17.51
0.45
.51
Order
X
Surgery
1
86.26
2.22
.14
Group
X
Order X
Surgery
1
3.01
0.08
.78
Error
40
38.80
Within
Subject Effects
df
MS
F
E
Video
1
906.51
58.04
.0001
Video
X
Group
1
380.01
24.33
.0001
Video
X
Order
1
17.51
1.12
.30
Video
X
Surgery
1
41.34
2.65
.11
Video
X
Group X
Order
1
15.84
1.01
.32
Video
X
Group X
Surgery
1
0.01
0.00
.98
Vidoe
X
Order X
Surgery
1
3.01
0.19
.66
Video
X
Group X
Order X Surgery 1
5.51
0.35
.56
Error
40
15.62
Skin Conductance
i Level:
Between
Subjects
Effects
df
MS
F
E
Group
1
2.91
2.66
.11
Order
1
1.26
1.16
.29
Surgery
1
0.50
0.46
.50
Group X
Order
1
4.03
3.69
.06
Group X
Surgery
1
4.69
4.30
. 044
Order X
Surgery
1
0.00
0.00
.95
Group X
Order X
Surgery
1
0.34
0.31
.58
Error
40
1.09

129
Within Subject Effects
df
MS
F
E
Video
1
32.30
36.12
.0001
Video
X
Group
1
2.89
3.23
.08
Video
X
Order
1
3.39
3.79
.058
Video
X
Surgery
1
1.19
1.33
.26
Video
X
Group X
Order
1
2.51
2.81
.10
Video
X
Group X
Surgery
1
3.34
3.74
.06
Vidoe
X
Order X
Surgery
1
0.43
0.49
.49
Video
X
Group X
Order X Surgery
1
0.00
0.00
.97
Error
40
0.89
Heart
Rate:
Between
Subjects
Effects
df
MS
F
E
Group
1
249.53
4.90
.032
Order
1
231.77
4.55
.039
Surgery
1
11.60
0.23
.63
Group
X
Order
1
211.96
4.16
.048
Group
X
Surgery
1
154.91
3.04
.09
Order
X
Surgery
1
74.64
1.46
.23
Group
X
Order X
Surgery
1
144.98
2.84
.099
Error
40
50.97
Within
Subject Effects
df
MS
F
E
Video
1
9.65
0.32
.57
Video
X
Group
1
28.09
0.94
.34
Video
X
Order
1
381.35
12.79
.0009
Video
X
Surgery
1
146.51
4.92
.032
Video
X
Group X
Order
1
33.16
1.11
.29
Video
X
Group X
Surgery
1
359.89
12.07
.001
Vidoe
X
Order X
Surgery
1
4.74
0.16
.69
Video
X
Group X
Order X Surgery 1
36.42
1.22
.27
Error
40
29.81
Systolic Blood :
Pressure:
Between
Subjects
Effects
df
MS
F
E
Group
1
157.59
1.80
.19
Order
1
168.01
1.92
.17
Surgery
1
36.26
0.41
.52
Group X
Order
1
21.09
0.24
.63
Group X
Surgery
1
128.34
1.47
.23
Order X
Surgery
1
14.26
0.16
.69
Group X
Order X
Surgery
1
23.01
0.26
.61
Error
40
87.52

130
Within Subject Effects
df
MS
F
E
Video
1
49.59
0.91
.34
Video
X
Group
1
0.09
0.00
.97
Video
X
Order
1
27.09
0.50
.48
Video
X
Surgery
1
21.09
0.39
.54
Video
X
Group X
Order 1
1.26
0.02
.88
Video
X
Group X
Surgery 1
46.76
0.86
.36
Vidoe
X
Order X
Surgery 1
1.26
0.02
.88
Video
X
Group X
Order X Surgery 1
27.09
0.50
.48
Error
40
54.28
Diastolic Blood
Pressure:
Between
Subjects
Effects
df
MS
F
E
Group
1
3.76
0.07
.79
Order
1
201.26
3.98
.053
Surgery
1
0.09
0.00
.96
Group
X
Order
1
114.84
2.27
.14
Group
X
Surgery
1
2.34
0.05
.83
Order
X
Surgery
1
128.34
2.54
.12
Group
X
Order X
Surgery
1
0.26
0.01
.94
Error
40
50.62
Within
Subject Effects
df
MS
F
E
Video
1
27.09
0.39
.53
Video
X
Group
1
14.26
0.20
.65
Video
X
Order
1
61.76
0.88
.35
Video
X
Surgery
1
0.09
0.00
.97
Video
X
Group X
Order
1
8.76
0.13
.72
Video
X
Group X
Surgery
1
36.26
0.52
.47
Vidoe
X
Order X
Surgery
1
137.76
1.97
.17
Video
X
Group X
Order X Surgery 1
12.76
0.18
.67
Error
40
69.97

131
Study 1: Affect During Audiotape Trial (between subjects)
df
MS
F
E
Audio
1
200.08
12.55
.001
Group
1
33.33
2.09
.16
Order
1
14.08
0.88
.35
Surgery
1
0.08
0.01
.94
Audio
X
Group
1
126.75
7.95
.01
Audio
X
Order
1
0.33
0.02
.88
Audio
X
Surgery
1
1.33
0.08
.77
Group
X
Order
1
4.08
0.26
.62
Group
X
Surgery
1
0.08
0.01
.94
Order
X
Surgery
1
0.00
0.00
1.00
Audio
X
Group X
Order
1
5.33
0.33
.57
Audio
X
Group X
Surgery
1
0.00
0.00
1.00
Audio
X
Order X
Surgery
1
0.75
0.05
.83
Group
X
Order X
Surgery
1
8.33
0.52
.47
Audio
X
Group X
Order X Surgery
1
4.08
0.26
.62
Error
32
15.94
Arousal
•
•
df
MS
F
E
Audio
1
776.02
27.03
.0001
Group
1
58.52
2.04
.16
Order
1
20.02
0.70
.41
Surgery
1
15.19
0.53
.47
Audio X
Group
1
4.68
0.16
.69
Audio X
Order
1
22.68
0.79
.38
Audio X
Surgery
1
1.69
0.06
.81
Group X
Order
1
0.02
0.00
.98
Group X
Surgery
1
6.02
0.21
.65
Order X
Surgery
1
295.02
10.28
.003
Audio X
Group X
Order
1
0.19
0.01
.94
Audio X
Group X
Surgery
1
31.69
1.10
.30
Audio X
Order X
Surgery
1
3.52
0.12
.73
Group X
Order X
Surgery
1
46.02
1.60
.21
Audio X
Group X
Order X Surgery
1
35.02
1.22
.27
Error
32
28.71

132
Control
•
•
df
MS
F
E
Audio
1
352.08
19.38
.0001
Group
1
6.75
0.37
.55
Order
1
5.33
0.29
.59
Surgery
1
10.08
0.56
.46
Audio X
Group
1
192.00
10.57
.003
Audio X
Order
1
2.08
0.11
.74
Audio X
Surgery
1
5.33
0.29
.59
Group X
Order
1
60.75
3.34
.07
Group X
Surgery
1
12.00
0.66
.42
Order X
Surgery
1
44.08
2.43
.13
Audio X
Group X
Order
1
12.00
0.66
.42
Audio X
Group X
Surgery
1
6.75
0.37
.54
Audio X
Order X
Surgery
1
21.33
1.17
.29
Group X
Order X
Surgery
1
0.00
0.00
1.00
Audio X
Group X
Order X Surgery
1
10.08
0.56
.46
Error
32
18.17
Skin Conductance
Audio
Group
Order
Surgery
i Level:
df
1
1
1
1
MS
1.08
0.02
0.09
0.30
F
5.06
0.11
0.42
1.40
E
.031
.74
.52
.24
Audio
X
Group
1
0.47
2.18
.15
Audio
X
Order
1
0.00
0.00
.96
Audio
X
Surgery
1
0.29
1.40
.24
Group
X
Order
1
0.19
0.89
.35
Group
X
Surgery
1
0.00
0.00
.96
Order
X
Surgery
1
0.45
2.12
.15
Audio
X
Group X
Order
1
0.19
0.92
.34
Audio
X
Group X
Surgery
1
0.06
0.29
.59
Audio
X
Order X
Surgery
1
0.16
0.73
.39
Group
X
Order X
Surgery
1
0.35
1.62
.21
Audio
Error
X
Group X
Order X
Surgery 1
32
0.70
0.21
3.24
.08

133
df
MS
F
E
Audio
1
0.01
0.00
.97
Group
1
1.19
0.07
.80
Order
1
41.14
2.49
.12
Surgery
1
57.18
3.46
.07
Audio
X
Group
1
32.41
1.96
.17
Audio
X
Order
1
4.45
0.27
.61
Audio
X
Surgery
1
1.77
0.11
.74
Group
X
Order
1
0.00
0.00
.99
Group
X
Surgery
1
17.10
1.04
.32
Order
X
Surgery
1
3.24
0.20
. 66
Audio
X
Group X
Order
1
1.77
0.11
.74
Audio
X
Group X
Surgery
1
0.00
0.00
1.00
Audio
X
Order X
Surgery
1
18.04
1.09
.30
Group
X
Order X
Surgery
1
36.75
2.23
.14
Audio
X
Group X
Order X Surgery
1
6.13
0.37
.55
Error
32
16.51
Systolic Blood Pressure:
df
MS
F
E
Audio
1
46.02
0.56
.46
Group
1
17.52
0.21
.64
Order
1
35.02
0.43
.52
Surgery
1
9.18
0.11
.74
Audio
X
Group
1
50.02
0.61
.44
Audio
X
Order
1
0.52
0.01
.94
Audio
X
Surgery
1
38.52
0.47
.50
Group
X
Order
1
17.52
0.21
.65
Group
X
Surgery
1
38.52
0.47
.50
Order
X
Surgery
1
1.69
0.02
.89
Audio
X
Group X
Order
1
31.69
0.39
.54
Audio
X
Group X
Surgery
1
325.52
3.99
.054
Audio
X
Order X
Surgery
1
20.02
0.25
.62
Group
X
Order X
Surgery
1
117.18
1.44
.23
Audio
X
Group X
Order X
Surgery 1
77.52
0.95
.33
Error
32
81.62

134
Diastolic Blood Pressure:
df
MS
F
E
Audio
1
15.18
0.39
.54
Group
1
0.18
0.00
.94
Order
1
1.02
0.03
.87
Surgery
1
50.02
1.28
.26
Audio
X
Group
1
22.69
0.58
.45
Audio
X
Order
1
15.19
0.39
.53
Audio
X
Surgery
1
25.52
0.65
.42
Group
X
Order
1
1.02
0.03
.87
Group
X
Surgery
1
0.19
0.00
.94
Order
X
Surgery
1
0.19
0.00
.94
Audio
X
Group X
Order
1
6.02
0.15
.70
Audio
X
Group X
Surgery
1
9.18
0.24
.63
Audio
X
Order X
Surgery
1
17.52
0.45
.51
Group
X
Order X
Surgery
1
4.69
0.12
.73
Audio
X
Group X
Order X
Surgery 1
7.52
0.19
.66
Error
32
38.98
Study
2 :
Affect
of Video
Only Group
Across ]
Eight Trials
Pleasure:
df
G-G df
MS
F
E
GrG.p
Trial
7
3.2
38.92
8.61
. 0001
.0001
Error
133
60.3
4.52
Arousal:
df
G-G df
MS
F
E
G-G D
Trial
7
2.8
106.11
10.34
.0001
.0001
Error
133
52.6
10.26
Control:
df
G-G df
MS
F
E
G-G D
Trial
7
3.0
80.32
7.76
.0001
.0002
Error
133
56.7
10.35
Skin Conductance Level:
df
G-G df
MS
F
E
G-G D
Trial
7
2.6
3.94
4.28
. 0003
.012
Error
133
49.1
0.92
Heart Rate:
df
G-G df
MS
F
E
G-G D
Trial
7
3.9
37.58
1.35
.23
.26
Error
133
74.5
27.74
Systolic Blood
Pressure:
df
G-G df
MS
F
E
G-G d
Trial
7
2.9
57.33
0.97
.46
.41
Error
133
56.1
59.33

135
Diastolic Blood Pressure:
df
G-G df
MS
F
E
G-G D
Trial
7
4.2
20.96
0.62
.74
. 66
Error
133
79.4
34.08
Study 2: Comparison between Surgery Audiotape and Neutral
Audiotape Preparation Groups
Pleasure:
Group
Error
Between Subjects Effects
df MS F p
1 453.00 4.40 .042
38 102.87
Within Subject Effects
df
G-G df
MS
F
E
G-G D
Trials
4
3.4
40.79
10.57
.0001
.0001
Trials X Group
Error
4
152
3.4
127.8
5.39
3.86
1.40
.23
.24
Arousal:
Between Subjects Effects
df
MS
F
E
Group
1
14.04
0.09
.76
Error
38
157.02
Within Subject Effects
df
G-G df MS
F
E
G-G D
Trials
4
3.3 202.04
19.27
.0001
.0001
Trials X Group
4
3.3 11.08
1.06
.38
.37
Error
152
126.0 10.48
Control:
Between Subjects
Effects
df
MS
F
E
Group
1
320.04
2.02
.16
Error
38
158.18
Within Subject Effects
df G-G df MS
F
E
G-G D
Trials
4 2.7 114.28
14.04
.0001
.0001
Trials X Group
4 2.7 13.87
1.70
. 15
. 17
Error
152 102.3 8.14
Skin Conductance Level:
Between Subjects Effects
df
MS
F
Group
1
7.34
2.73
Error
38
2.69

136
Within Subject Effects
df G-G df MS F
E
G-G D
Trials
4
2.5
6.22
12.68
. 0001
.0001
Trials X Group
4
2.5
0.54
1.10
.36
.35
Error
152
94.4
0.49
Heart Rate:
Between Subjects
Effects
df
MS
F
E
Group
1
0.45
0.01
.92
Error
38
55.89
Within Subject Effects
df G-G df MS
F
E
G-G D
Trials
4 3.7 26.29
2.22
.069
.073
Trials X Group
4 3.7 19.60
1.66
.16
.17
Error
152 142.7 11.82
Systolic
Blood
Pressure:
Between Subjects :
Effects
df
MS
F
E
Group
1
55.12
0.15
.70
Error
38
362.55
Within Subject Effects
df G-G df MS
F
E
G-G D
Trials
4 3.2 124.72
1.70
.15
.17
Trials X
Group
4 3.2 148.90
2.03
.092
.109
Error
152 131.1 73.23
Diastolic Blood
Pressure:
Between Subjects
Effects
df
MS
F
E
Group
1
19.22
0.15
.70
Error
38
127.29
Within Subject Effects
df G-G df MS
F
E
6=G_p
Trials
4 2.0 49.56
1.01
.41
.37
Trials X Group
4 2.0 11.41
0.23
.92
.79
Error 152 75.6 49.25

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BIOGRAPHICAL SKETCH
Mark Allan Lumley was born on June 4, 1962, in Detroit,
Michigan. The third son of a Presbyterian minster and a
schoolteacher/homemaker, Mark graduated from Temple
Christian High School in 1980 as valedictorian and class
president. He enrolled at Wayne State University in
Detroit, where he was fully supported for five years by a
Merit Scholarship. He earned two Bachelor of Science
degrees, in biology and in psychology with honors. Other
achievements during his undergraduate tenure included
acceptance in Phi Beta Kappa, excellence citations in French
and organic chemistry, research experiences with several
professors in the Department of Psychology, and research
traineeship for two summers at Henry Ford Hospital1s Sleep
Disorder Center. Mark graduated with Highest Academic
Distinction from Wayne State in May, 1985, and he
matriculated into the doctoral program in the Department of
Clinical and Health Psychology at the University of Florida
in Gainesville. He was supported by the prestigious
Presidential Graduate Research Fellowship for three years
and by a research traineeship from the National Institute of
Dental Research for a fourth year. He completed the Master
of Science degree in December, 1987, under the supervision
of Barbara G. Melamed, Ph.D, with a thesis entitled "Age,
145

146
Previous Experience, and Presurgical Behavior as Predictors
of a Child's Reaction to Anesthesia Induction." While a
graduate student, Mark published several articles, taught an
undergraduate course on sleep and dreams, and developed
clinical skills as a health psychologist. He completed a
one-year predoctoral clinical internship in the Department
of Psychiatry at Detroit's Henry Ford Hospital in August,
1990, concentrating on hospital consultation-liaison and on
sleep disorders. Currently, he is a postdoctoral fellow at
the Behavioral Medicine Program in the Department of
Psychiatry at the University of Michigan in Ann Arbor. Mark
married Sheryl Rene Livesey, an accountant, on May 3, 1986.
They have twin sons, Ryan and Joshua, who were born on July
26, 1990.

I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality, as
a dissertation for the degree of Doctor of Philosophy. >
Barbara G. Melamed, Chair
Professor of Clinical and
Health Psychology
I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope ana /quality, as
a dissertation for the degree of Doctor qf^^/lgsophy.
and Health
inical
chology
I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality, as
a dissertation for the degree of Doctpr of Philo^oghy.
Wilse B. Webb
Graduate Research
Professor of Psychology
I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality, as
a dissertation for the degree of Doctor of Philosophy.
Anthony Gi/eene(
Assistant Professor of
Clinical and Health
Psychology

I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality, as
a dissertation for the degree of Doctor of Philosophy.
'Sandra F. Seymour/
Associate Professor
of Nursing
This dissertation was submitted to the Graduate Faculty
of the College of Health Related Professions and to the
Graduate School and was accepted as partial fulfillment of
the requirements for the degree of Doctor of Philosophy.
December 1990
Related Professions
Dean, Graduate School

UNIVERSITY OF FLORIDA
3 1262 08554 3873



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