ACQUISITION OF BLOOD AND INJECTION PHOBIA AND ANXIETY...

Behov. Res. Thu. Vol. 29, No. 4, PP. 323-332, 1991 0005-7967/91 $3.00 + 0.00 Printed in Great Britain. All rights reserved Copyright C 1991 Pergamon Press plc

ACQUISITION OF BLOOD AND INJECTION PHOBIA AND ANXIETY RESPONSE PATTERNS IN CLINICAL PATIENTS

Department of Psychiatry, University of Uppsala, UllerBker, S-750 17 Uppsala, Sweden

(Received 30 October 1990)

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

INTRODUCTION

Recent epidemiological studies in U.S.A. have shown that the lifetime prevalence of phobias is 12.5% (Regier, Boyd, Burke Jr, Rae, Myers, Kramer, Robins, George, Karno and Locke, 1988), second only to substance use disorder (16.4%). Among women phobias is the most prevalent disorder. A New Zealand study (Oakley-Brown, Joyce, Wells, Bushnell and Hornblow, 1989) yielded a 6-month prevalence of 7.5%, which is very similar to the American figure of 7.7% (Regier et al., 1988). In consideration of the high prevalence rates comparatively little research has been carried out into the etiology of phobias. Our current knowledge regarding the behavioral and cognitive treatments of phobias (e.g. Barlow, 1988) is much more advanced than our knowledge of the causes of these disorders.

The etiology of phobias can be studied in various ways, which are complementing to each other. One way is the longitudinal study in which a fairly large group of individuals, randomly selected from the population, is followed with regular and multiple assessments from an early age, e.g. 4, to young adulthood, e.g. 30. Such a study would, however, be so prohibitingly expensive and time-consuming that it is difficult to imagine it ever being carried out.

Another way is to subject non-fearful individuals to various, presumably fear-instigating stimuli in the laboratory for long enough to experimentally produce a phobia. The research on Seligman’s (1971) preparedness theory, primarily carried out by ijhman and co-workers (see McNally, 1987, for a review), is a mini example of this strategy. However, more diversified and longer-lasting reactions than the fairly short lived skin conductance response used as the dependent variable in these studies need to be assessed. There are obvious ethical problems with this approach which explains why it has not been developed further.

One rarely used strategy, because of its difficulty, is the systematic inquiry into the effects of naturally occurring traumatic events. A good example of this is the study by Dollinger, O’Donnell and Staley (1984) investigating the effects of a lightning-strike disaster on children’s fears and worries. During a soccer game for children the lightning bolt killed one child and injured several others. One to two months later the children were interviewed, and answered a fear questionnaire and were compared to a control sample. The results were consistent with the classical conditioning theory of fear acquisition and generalization. Other studies using this strategy come from Saigh (1984) studying anxiety reactions during the civil war in Lebanon, and Thompson (1989) investigating psychological problems resulting from the King’s Cross underground fire in London.

BRT 29 bB 323

324 LAM-GORAN 0s~

This strategy suffers from the problem of uncontrollability of the aversive traumatic event. However, it ought to be used more often than it has been so far.

A fourth strategy is the retrospective interview/questionnaire study in which patients coming for treatment are asked to describe what they recollect about the onset of their phobia. The foremost problem with this strategy is the obvious risk of memory distortion that can take place since the onset, which on the average is 8 (agoraphobia) to 24 (animal phobia) years earlier (ijst, 1987). Using other people, e.g. parents as informants is not really feasible since they usually either are dead or do not remember anything about the onset. Despite its shortcomings this strategy was used in the present study.

Rachman (1968) described the conditioning theory of fear and avoidance. Briefly, the theory states that anxiety is a conditioned response (CR) that is elicited in the presence of a conditioned stimulus (CS). When elicited the CR energies instrumental behavior to avoid or escape the situation. The instrumental behavior is negatively reinforced by the disappearance of anxiety contingent upon its execution. In 1977 Rachman reviewed the evidence for and against the conditioning theory as the single explanation of the etiology of phobias. He proposed that there are at least three different pathways to fear acquisition: (a) conditioning, (b) vicarious acquisition, and (c) through transmission of information and/or instruction.

Furthermore, Rachman suggested that physiological and behavioural reactions would be the most prominent ones in fears acquired through a process of conditioning. In fears transmitted indirectly (vicariously or through information) negative cognitions would be most predominant. Finally, Rachman (1978) also suggested that fears acquired through information are more likely to be mild than severe.

The empirical studies on fear acquired can be divided into those studying clinical patients and those inveatipatine non-clinical, analog Ss.

Clinical studies. In dentul phobics Stroben and Borland (1954) found that 62% of 15 phobics reported conditioning experiences, while Lautsch (1971) reported that all 34 patients that he studied had a traumatic experience at the start of their phobia. In my own study (ost & Hugdahl, 1985) 69% of 51 dental phobics ascribed the onset to conditioning experiences, 12% to vicarious experiences and 6% to transmission of information/instruction. In animalphobics &t and Hugdahl (198 1) found that 48% of 40 patients reported conditioning experiences, 28% vicarious experiences and 15% information/instruction. McNally and Steketee (1985) studied 22 patients and 23% reported conditioning experiences 4% vicarious experiences and 4% information/instruction. However. when the large group of patients (15) that could not recall the onset of their phobia was deleted 71% (5/7) had conditioning experiences. dst and Hugdahl (1981) found that 69% of their 35 claustrophobics had conditioning experiences, 9% vicarious experiences and 11% information/ instruction, while in 22 bloodphobics (&t and Hugdahl, 1985) 46% had conditioning experiences, 32% vicarious experiences and 9% information/instruction. Munjack (1984) studied 30 patients with driving phobia and found that 70% had a traumatic conditioning experience at the onset of their phobia. He also reported unpublished data on 5 earthquake phobics who all “had been conditioned during the 1971 ‘Sylmar Quake’ in the terrifying experience of houses rocking and children crying”. In a small sample of 10 thunderstorm phobics Liddell and Lyons (1978) reported only 10% conditioning experiences.

There is only one study on social phobics, which found that 58% of the 31 patients reported conditioning experiences, 13% vicarious experiences, and 3% information/instruction (ost and Hugdahl, 198 1).

In agoruphobics ijst and Hugdahl(1983) found that 81% of the 80 patients reported conditioning experiences, 9% vicarious experiences, but none ascribed their phobia onset to information/ instruction. This figure is in sharp contrast to the 13% with conditioning experiences reported by Goldstein and Chambless (1978) in a study of 32 agoraphobics. However, our figure is corroborated by a recent study by Merckelbach, de Ruiter, van den Hout and Hoekstra (1989) on 91 patients, 75 of which were agoraphobics. They found that 78% of the sample ascribed the onset to conditioning experiences. Finally, Wolpe (1981) in a sample of 40 patients with various phobias found that 65% had conditioning experiences at the onset of their phobias.

Thus, with two exceptions (Liddell and Lions, 1978; Goldstein and Chambless, 1978) all the studies of clinical Ss found that conditioning experiences is the predominant pathway to fear

Acquisition of blood and injection phobia 325

with proportions ranging from 46% (blood phobics, &t and Hugdahl, 1985) to 100% (dental phobics, Lautsch, 1971).

Analog subjects. Studying dental phobia in college students Kleinknecht, Klepac and Alexander (1973) found that 14% had experienced much painful dental work and 17% reported ‘perceived mistakes, poor management, and physical abuse on the part of the dentist’ as the origin of their fear. Bernstein, Kleinknecht and Alexander (1979) found that 22% attributed their dental anxiety to a single traumatic incident in the dental chair, while 19% mentioned vicarious factors. Regarding animal phobics Fazio (1972) studied college students with phobia of insects, finding that 17% described traumatic experiences involving pain and 19% negative information from the mother at the acquisition of their phobias. Rimm, Janda, Lancaster, Nahl and Dittmar (1977) investigated female undergraduate students and 36% had conditioning experiences, 6% vicarious experiences, and 9% verbal instructions. Murray and Foote (1979) studied two samples of undergraduate students, but did not classify the Ss into different ways of acquisition. They concluded though, that different observational or instructional experiences were responsible for the acquisition of fear of snakes in their samples. Kleinknecht (1982) studied a group of members of the American Tarantula Society. Among those reported having been fearful of tarantulas, none reported a direct traumatic experience, while 34% reported vicarious experiences, and 61% information/instruction as the source of their fear. Hekmat (1987) investigated 56 students with phobias of various animals and 23% of these reported conditioning experiences, 4% vicarious experiences, and 57% information/ instruction. Finally, DiNardo, Guzy, Jenkins, Bak, Tomasi and Copland (1988a, b) studied 16 dog phobic students and 56% of them reported conditioning experiences, but the other 44% were not classified.

Thus, in the non-clinical samples the majority of the Ss have acquired their phobias indirectly as between 0% (Murray and Foote, 1979) and 36% (Rimm et al., 1977) ascribe their phobias to conditioning experiences. The only exception is the 56% in dog phobias reported by DiNardo et al. (1988b).

In conclusion then, most clinical patients have acquired their phobias through direct conditioning experiences, while the situation is reversed for non-clinical Ss where the indirect pathways to fear dominate.

The conditioning experiences can be subdivided into two categories (McNally and Steketee, 1984): (a) S-S conditioning which involves painful stimulation, and (b) S-R conditioning, involving extreme fear without pain. McNally and Steketee found that all their patients could be interpreted as cases of S-R conditioning. DiNardo et al. (1988b) in a replication study of dog phobic students, found that in 6 out of 9 conditioning Ss there was a S-S event in 2 a S-R, and in 1 both types of conditioning events. These differences in result is probably due to the fact that only 2/22 patients (9%) in the McNally and Steketee (1985) study were dog phobics, while the others were snake (IO), cat (4), bird (4), and spider (2) phobics; animals which rarely bite or scratch people.

The primary purpose of the present study was to retrospectively investigate the ways of acquisition in clinical samples of blood and injection phobics, and to replicate the earlier study (&t and Hugdahl, 1985) concerning blood phobics. A second purpose was to establish the frequency of S-S and S-R conditioning in these specific phobias. A third purpose was to study the relationship between different pathways of fear and the anxiety components in phobics (Lang, 1968; Rachman, 1976). Finally the hypothesis that phobias acquired vicariously are milder than those acquired through conditioning will be tested.

METHOD

Subjects

One-hundred and thirty seven phobic outpatients who had received, or were currently under- going treatment within a research project on behavioral treatment for phobias (Ost, Lindahi, Sterner and Jerremalm, 1984; &t, Sterner and Fellenius, 1989; &t, Feilenius and Sterner, 199la; &t, Hellstrom and Kavert 1991 b) served as Ss for this study. They belonged to two groups of phobias: blood phobia (n = 81) and injection phobia (n = 56), and all Ss fulfilled the DSM-III R criteria for simple phobia. Among blood phobics there were 53 females (65.4%) and 28 males, and in the injection phobia group there were 43 females (76.8%) and 13 males.

326 LAM-G&CAN &T

The samples’ mean ages were 31.14 (SD = 8.60, range 16-55) for the blood phobics and 28.63 (SD = 10.42, range 17-58) for the injection phobics, a non-significant difference [t(135) = 1.561. Mean age at onset was 8.58 (SD = 3.92, range 2-20) for the blood phobics and 8.06 (SD = 4.90, range 2-35) for the injection phobics [t(135) = 0.711. The mean duration of their phobias was 22.56 years (SD = 8.30, range 5543) for the blood phobics and 20.41 (SD = 10.77, range 3-50) for the injection phobics [t(l35) = 1.281.

All subjects in the present study experienced debilitating degrees of anxiety in and/or avoidance of their respective phobic situations. Their phobic problems also led to negative consequences in the daily lives of most Ss. All Ss were outpatients at the Ullerlker mental hospital and had applied for treatment voluntarily.

Background information

Marital status. In the blood phobics 70.4% were married or living with a steady partner, 27.2% single, and 2.4% divorced. The corresponding figures for injection phobics were 64.4%, 32.2%, and 3.4%, respectively.

Occupational status. Of the blood phobics, 67.9% were working full-time, 12.4% part-time, and 19.7% were full-time students. In the injection phobics the proportions were very similar; 67.8%, 10.2%, and 22.0%, respectively.

Family history of phobia. In the blood phobia group 61% had a first-degree relative with the same phobia, which was significantly higher than the 29% reported by the injection phobics [x*(l) = 12.51, P < O.OOl].

Assessment

Questionnaire. The Ss were given a questionnaire consisting of four sections. The first is concerned with the origin of phobia and consists of nine questions, which are answered yes or no. Two of these are about conditioning experiences, three concern instructional learning and four questions tap different vicarious experiences. Before answering sections 2-4 the patient has to write down the phobic situation that he/she experiences as the most anxiety arousing. All questions in the following sections are answered in relation to this specific situation. Section 2 consists of 11 items concerning physiological reactions, and the patient has to rate (O-4) the extent to which he/she experiences these reactions while being in the phobic situation. The third section is about how much anticipatory worry the patient usually experiences. This part has five questions, three of which are answered yes or no, and two of which have four alternatives. The final section concerns negative thoughts while in the phobic situation, and consists of 10 items for which the patient rates the frequency of thoughts (O-4).

Behavioral test. As part of the pretreatment assessment for the treatment studies the Ss were given a behavioral avoidance test during which their overt behavior, heart rate (HR) and subjectively experienced anxiety were recorded. The blood phobics were shown a 30 min film of thoracic operations, displaying quite large amounts of blood and were instructed that they could terminate the showing of the film if it became too uncomfortable (see &t et al., 1984). The injection phobics went through a test consisting of 20 steps, from cleaning a fingertip to withdrawing a blood sample through venipuncture. The experimenter described each step to the patient who was to say yes or no to that step being performed. The test ended when the patient said no or performed the last step. The measures obtained from these behavioral tests are a self-rating (O-10) of the degree of anxiety experienced in the situation, AHR (i.e. the difference between a rest period and the mean of the test period) and a behavioral score. The latter had a range of O-30 (min) for the blood phobics and O-20 (discrete steps) for the injection phobics.

Speczjic fear scales. Both groups were given the Mutilation Questionnaire (30 true-false items; Klorman, Weerts, Hastings, Melamed and Lang, 1974). The blood phobics were also answering the FSS-III (Wolpe and Lang, 1964) from which 8 blood/injury items were picked out (range 8-40). The injection phobics were given the Injection Phobia Scale, constructed by the author (bst et al., 1991b) and consisting of 18 items that are rated on a O-4 scale for anxiety and a O-2 scale for avoidance.

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The subdivision of the conditioning Ss showed that among blood phobics 13 (32.5%) had a S-S type and 27 (67.5%) a S-R form of conditioning experience. In the injection phobia group 17 (50%) had a S-S and 17 (50%) a S-R conditioning event. The difference between the phobias was, however, not significant [x2( 1) = 1.671.

Anxiety components and acquisition of phobias

The question of whether the different ways of acquiring phobias result in different degrees of anxiety in the three anxiety components was studied in two ways. First, by analyzing the data from sections 2-4 of the questionnaire, and secondly from the results of the pretreatment behavioral tests. Due to the comparatively small number of Ss in the Vicarious Experiences and Instruction/ Information categories, they were grouped together in an ‘Indirect Acquisition’ category for all the following analyses.

Questionnaire data. The results of the patients’ ratings of degree of physiological reactions and negative thoughts in the worst phobic situation, and degree of anticipatory worrying before this situation occurs, are presented in Table 3. The two-way (type of phobia vs type of acquisition) analyses of variance on these data yielded no significant F-values on any section of the questionnaire.

When the same analyses were made separately for the conditioning subgroups there was no significant difference between S-S and S-R on any of the measures in Table 3.

In order to find out if there was any difference between the ways of acquisition concerning the number of Ss with higher scores on either the physiological component or the subjective component (negative thoughts) binomial tests were performed. The percentage of patients in different groups are presented in Table 4. As can be seen from this table there was a tendency that Conditioning Ss among blood phobics have a larger proportion of patients with higher scores on the physiological component, while the Indirect Acquisition group had a la1 ger proportion with higher scores on the subjective component. Among the injection phobics both the Conditioning and the Indirect group had a tendency towards a larger proportion of Ss scoring higher on the physiological component. However, none of these differences was significant.

Behavioral test data. The results from the behavioral tests are presented in Table 5. The t-tests yielded no significant difference between the Conditioning and the Indirect Acquisition categories for any of the phobic groups.

The corresponding results for the two conditioning types are presented in Table 6. There was no difference between the types of the behavioral scores or self-rating of anxiety. However, on AHR

Table 3. Mean scores (and SDS) on physiological reactions, negative thoughts and anticipatory worrying for the different ways

of acquisition and ~TOUDS of ohobias

Type of phobia Blood Injection

Way of acquisition

Conditioning Indirect



Mean SD Mean SD

Physiological reactionsa 2.21 0.67 2.57 0.76 1.91 0.65 2.42 0.80

Negative thoughtsb 2.01 0.83 2.33 0.90 1.92 0.80 2.19 1.05

Anticipatory worrying’ 3.58 1.21 3.69 1.40 2.92 1.55 3.40 1.50

“Mean across 11 items (O-4 scale): ‘mean across 10 items (O-4 scale), %um across 5 items (range O-5).

Table 4. Percentage of Ss in the different acquisition groups and types of phobias with higher scores on either physiological (P) or

subjective (S) items


Wav of acauisition P>S S>P P>S SIP

Conditioning 61 39 58 42 Indirect 40 60 53 47


Table 5. Means (and SDS) on behavioral scores, self-rating of anxiety, and AHR from the behavioral tests for the different ways

of acauisition and arouos of uhobias

Way of acquisition

Conditioning Indirect *

Conditioning Indirect f

Conditioning Indirect I


Mean SD Mean SD

Behavioral scores 7.16 8.39 6.09 5.88 6.51 6.79 5.93 5.56 0.33 0.09

Serf-rafing of anxiety 7.17 2.10 6.72 2.37 6.78 1.97 6.81 1.89 0.76 -0.21

AHR 0.06 12.93 5.69 20.83

-1.92 16.92 4.27 18.35 0.54 0.23

Table 6. Means (and Sds) on behavioral scores, self-rating of anxiety, and AHR from the behavioral tests for the different conditioning

twes and erouos of uhobias

Way of acquisition


Mean SD Mean SD

S-S 5.46 S-R 7.99 f -0.89

s-s 7.82 S-R 6.62 f 1.52

s-s 1.80 S-R -0.78 I 0.70

Behavioral scores 8.35 5.53 8.45 7.18

-0.78 Se[f-rating of anxiety

1.93 6.89 2.51 6.47

0.51 AHR

8.56 16.12 14.65 -2.35

2.75*

4.71 7.27

2.23 2.45

17.68 21.35

*P < 0.01.

the injection phobics with a S-S conditioning experience had a significantly higher AHR increase, while the S-R group in fact showed a small decrease compared to baseline. There was a non-significant tendency in the same direction for the blood phobics.

In order to make a more direct test of Rachman’s hypothesis concerning the relationship between pathways of fear and anxiety components, the data from the behavioral tests were transformed to z-scores. Then t-tests were performed for each acquisition group separately, between the subjctive component on one hand and the physiological and behavioral components, respectively, on the other. These yielded no significant differences between the components.

Severity of the phobia and way of acquisition

Rachman (1978) posited that fears acquired indirectly are more likely to be mild than severe. This hypothesis was tested in two ways. First by comparing the two ways of acquisition on the specific-fear scales and secondly by comparison on the sum of z-scores from the behavioral test data.

Specific-fear scales. The results on the specific-fear scales are presented in Table 7. For blood phobics and injection phobics (on 2/3 measures) there was a non-significant tendency for the Indirect group to have higher scores, i.e. to be more severely phobic, than the Conditioning group. The subdivision of the Conditioning group did not yield any significant difference between the S-S or S-R type of events.

Behavioral test. The results obtained on the index of severity sum of z-scores across the three components from the behavioral test are shown in Table 8. There was no difference between the groups for the injection phobics, while there is a non-significant tendency for the Conditioning group among the blood phobics to have higher z-scores. Dividing the Conditioning group into subtypes did not yield any significant difference on this measure.

Table 7. Means (and SDS) on the specific-fear scales for the different ways of acquisition and groups of phobias

Wav of acquisition


MO FSS-91 MO 1NJ:ANX 1NJ:AVO

Conditioning 19.6 (4.7) 31.3 (5.8) 18.1 (5.7) 45.8 (10.0) 22.8 (6.1) Indirect 22.3 (3.89) 31.4 (5.2) 17.0(6.1) 47. I (9.3) 23.7 (4.5) I -0.61 -0.10 0.58 -0.39 - 0.49

Table 8. Means and SDS on the severity index (z-scores) for the different ways of acquisition and groups of phobias

Wav of acauisition


Mean SD Mean SD

Conditioning 0.17 1.34 0.01 1.75 Indirect -0.24 1.56 - 0.02 1.74 f I.15 0.06

DISCUSSION

The results of the present study showed that blood and injection phobics ascribe their phobias to conditioning experiences in a large majority of the cases, 49% and 57%, respectively. Vicarious experiences and Instruction/Information were found to account for less. The results for blood phobics replicated almost exactly the ways of acquisition found in the earlier study on blood phobia (ijst and Hugdahl, 1985).

The obtained results are in accordance with our own previous studies on various clinical phobias (&t and Hugdahl, 1981, 1983, 1985), and those of others reviewed in the introduction. The results are in contrast to the studies on non-clinical, analog Ss where the indirect pathways to fear dominate (see Introduction). Thus, the present study is a further piece of evidence that the conditioning theory can accommodate a majority of the cases when it comes to clinical patients. However, in order to draw a firm conclusion on this issue it is necessary to investigate the acquisition of fear in Ss that have the same phobia but differ in severity from mild to severe, within the same study. Such a study is difficult to carry out in a clinic which only attracts patients on the severe end of the scale, but would be feasible in an academic setting using both students and community residents recruited via advertisements in the local media.

The second purpose of this study was to establish the frequency of S-S and S-R events in the acquisition of fear for the conditioning Ss. The results showed that there was 67.5% S-R and 32.5% S-S among blood phobics, and 50% of both categories among injection phobics. In total 59% of the patients had S-R events. This figure is in between the 100% reported by McNally and Steketee (1985) and the 22% in the DiNardo et al. (1988b) study. The somewhat higher proportion of painful stimulation (S-S) in the injection phobics (50%) compared to the blood phobics (32.5%) makes sense since the former usually are subjected to some degree of pain when it comes to taking injections and having venipunctures.

The subclassification of the Conditioning subjects did not, with one exception, yield any significant differences on the dependent variables. The only exception was on AHR during the behavioral test. On this measure the injection phobics with a S-S conditioning event had a significantly higher HR increase, while the S-R group in fact had a small HR decrease. However, as this was the only difference to emerge from 21 significance tests it may vary well be a chance phenomenon, which needs to be replicated before any conclusions can be drawn.

The third purpose was to test Rachman’s (1978) hypothesis that the different pathways of fear show different loadings in the anxiety components. This hypothesis was not corroborated by the present study as there was no significant difference between the component scores on any of the dependent measures. These results are in accordance with our previous studies on animal, claustro- and social phobia (&.t and Hugdahl, 1981), agoraphobia (dst and Hugdahl, 1983) and blood and dental phobia (&t and Hugdahl, 1985). The only exception to this general trend is the claustrophobia patients from our first study (&t and Hugdahl, 1981). In this specific phobia the Conditioning group had a larger physiological reaction and the Indirect group a larger subjective


reaction as predicted by Rachman (1978), but contrary to his prediction the Indirect group also had a stronger behavioral reaction. The present results are also in accordance with the recent study by NiNardo, Guzy and Bak (1988) that found no relationship between conditioning events and physiological arousal, subjective anxiety or behavioral reactions during the behavioral test.

The final purpose of this study was to test another of Rachman’s hypothesis, namely that phobias acquired indirectly will be less severe than those acquired through a conditioning process. Neither the data from the specific-fear questionnaire, nor from the behavioral tests corroborated Rach- man’s prediction. This result is in accordance with our previous findings on social phobics, claustrophobics (ijst and Hugdahl, 1981), agoraphobics (&t and Hugdahl, 1983), and blood phobics and dental phobics (bst and Hugdahl, 1985). The only group of phobic patients studied in our laboratory that reacted in accordance with Rachman’s hypothesis is the animal phobics, but the difference in severity on the self-report scale was only 2 points and is without clinical significance.

The general conclusion that can be drawn from the present study is that the conditioning theory seems to accommodate the way a majority of both the injection phobics (57%) and blood phobics (49%) have acquired their phobias. The high percentage of blood phobics (61%) who report having first-degree relatives with the same fear (bst, 1991), could together with the unique physiological pattern (&t, Sterner and Lindahl, 1984b) mean that a heredity component is of importance. Naturally, the influence of vicarious experiences must also be taken into account. The blood phobics in this study has a fairly high proportion (26%) ascribing their phobias to modelling experiences. This is, together with animal phobics (ost, 1987), the highest in this series of clinical phobias. One could wonder why the proportion of vicarious acquisition is not higher than 26% in the blood phobics, since 61% have close relatives with the same fear (tist, 1990). The primary reason is that in order to be classified as vicarious acquisition the patient must be aware of the relative’s phobia before the start of his/her own. Many of the patients relate that the relative, usually a parent, tried his/her best not to show the phobic reaction in front of the children in order not to scare them or make them phobic, and it was not until the patient developed his/her own blood phobia that the parent disclosed their own problems in this respect. It is, however, not uncommon that the Conditioning Ss have had vicarious experiences after the onset of their own phobia which most probably have reinforced it.

Further research in this area should investigate the distribution of ways of acquisition across the entire spectrum of severity as discussed above. Another issue that needs to be investigated is the question of why some individuals develop a phobia after a traumatic experience and others don’t despite having had the same experience. Related to this is the issue of why a person develops a phobia at a certain point in time, after experiencing a traumatic event OY not, but did not develop it earlier after events that were as traumatic as, or even more traumatic than the current one. Both of these issues, however, probably need the longitudinal design to be answered in an unequivocal way.

Another issue is whether there is a fourth way of acquisition since between 11% (agoraphobia) and 25% (social phobia) cannot recall anything about the onset of their phobias (ijst, 1987). Are these patients just having worse memory than the others, or are our questionnaire and way of interviewing not good enough to elicit their recollections. In many instances, though the patients report memories of phobic behavior as early as 4, but can not recollect the first situation.

Finally, one could ask whether it is useful at all to known in what way the patient’s phobia was acquired. There is some evidence (ijst, 1985; Wolpe, 1981) that it may make a small difference in treatment outcome~onditioning based treatments yielding better results for conditioning acquisition patients and cognitively based treatments better effects for the indirectly acquired phobias- but the differences are not overwhelming. In general, though, increased knowledge in this area can perhaps via media information and teaching in schools help preventing future generations from developing phobias to the same extent as the current one. Because, even if our knowledge of treatment of phobias exceeds the knowledge about etiology, we still fail to achieve adequate results with IO-20% of specific phobics and 25-35% of social and agoraphobics.

Acknowledgemenrs-This research was supported by grant 05452 from the Swedish Medical Research Council. The help of Ulf Sterner, Jan Fellenius, Kerstin Hellstriim and Anna Kgver in the assessment of the patients is gratefully acknowledged.

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