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Applied Tension and Blood-Injection-Injury Type Phobia

Copyright © Donald Robertson, 2010. All rights reserved.

This article provides a brief overview of the main evidence-based treatment for blood phobia, and related problems. Acute anxiety about either blood, injections, or injuries, falls under the broad heading of “Blood-Injection-Injury Phobia” according to DSM-IV-TR, the main system for classifying psychiatric problems. To meet a full diagnosis of Blood-Injection-Injury (BII) Phobia, the anxiety needs to be severe enough to impact seriously on someone’s quality of life and ability to function normally. This is one of the most common forms of full-blown phobia. The most serious impact is typically upon the individual's ability to obtain appropriate medical treatment for other health problems, i.e., avoiding having necessary injections, blood tests, operations, etc. Lifetime prevalence is 3.5%, which means that if you get on a double-decker bus full of people (n=60) there should theoretically be at least two passengers onboard who have suffered from full-blown Blood-Injection-Injury phobia. However, many more people have somewhat milder (“subphobic”) fears of blood and related things, which can nevertheless be quite distressing at particular times. (For brevity, I’ll refer from now on to “blood phobia” though most of what I say should apply to related phobias of injury, injections, etc.) In fact, although we refer to phobias as involving anxiety and a strong urge to avoid the feared object, many blood phobics appear to experience little fear of blood but rather more feelings of nausea or disgust.

The psychiatric classification shouldn't cause alarm, it just means that like other phobias it's a psychological rather than physical problem. However, it's a relatively “normal” reaction. Most researchers believe that many common phobias occur because people are genetically predisposed to develop them, to varying degrees. In human evolutionary history, for many thousands of years, being born with these deep-seated fears probably served to protect our ancestors from dangers in their primitive environment. For example, it's possible that fainting at the sight of blood helped our ancestors to reduce blood loss and avoid further injury. When lying down, blood mainly flows horizontally rather than vertically, so the heart doesn't have to pump as much against the pull of gravity. Lying down therefore reduces blood pressure, potentially decreasing blood lost as a result of injury, but it also increases the ease with which blood can circulate to the brain, carrying vital oxygen. Moreover, as a last resort “defence mechanism” when things were going badly, it may also have prevented further injury from animal attacks by forcing our primitive ancestors to “play dead.” (Animals that are surprised or defending their territory, rather than hunting prey, will often cease attacking under these circumstances as they no longer feel threatened when their “victim” lies prone and motionless.) In other words, blood phobia is based on a naturalbodily reaction that varies in strength between individuals, depending on a combination of genetic and developmental factors, etc. It may have served an important evolutionary purpose by actually helping our primitive ancestors survive, for most of human history, but frequently becomes unhelpful in our modern environment.

There is a broad consensus among researchers and experts in the field of psychotherapy that most phobias tend to respond quite reliably to a behaviour therapy technique termed “exposure”, in which the subject is asked to repeatedly face their fears in a controlled manner. This is usually done gradually over several sessions, starting with slightly “easier” fears, and it is usually done in the real world (“in vivo”) although sometimes it may be done in imagination (termed “imaginal exposure”). However, blood phobia differs in an important respect from other phobias. It tends to be accompanied by actual fainting or feelings of fainting, termed “emotional fainting” and caused by a physiological mechanism termed the “vasovagal response.” This is very significant because anxiety normally increases blood pressure and heart rate. Fainting, by contrast, is associated with a decrease in heart rate and blood pressure and a drop in cerebral blood flow, i.e., blood flowing to your brain reduces. (A similar experience, called “orthostatic hypotension” occurs when someone stands up too quickly and feels faint or dizzy.) Hence, anxiety normally prevents fainting, even when accompanied by feelings of faintness and disorientation. Blood phobia actually triggers a “biphasic” (aka “diphasic”) response, which begins with an initial rise in blood pressure and heart rate, as in normal anxiety. This may last a minute or more but is soon followed by a very rapid decrease in both heart rate (termed “bradycardia”) and blood pressure (“hypotension”) that may lead to reduced oxygen reaching the brain (“cerebral blood flow”) and cause fainting(“syncope”). Researchers have found that 75% of blood phobics report a history of actual fainting in response to their fear (Ayala, et al., 2009). Treatment for blood phobia is now modified to take account of the different type of physiological reaction that occurs compared to other forms of anxiety.

In clinical trials, treatment for blood phobia usually occurs weekly, takes an average of 5 one-hour sessions (though the range across studies is 1-10 sessions) and requires completion of homework between therapy sessions. Some research has been carried out on more intensive single session (2-hour) methods, although this appears somewhat less effective. Homework usually involves “exposure”, meaning that the client is asked to repeatedly face blood-phobic situations they previously avoided, e.g., handling a phial of blood, or watching a video of an operation. Exposure is usually done in gradual steps and stages, so that the client doesn’t feel overwhelmed. In the “Applied Tension” treatment, discussed below, a special “coping skill” is learned during sessions and used to cope with the feelings aroused during exposure to the feared objects and situations.

Applied Tension (AT)

Applied Tension (AT) is the name of the behaviour therapy approach developed by Öst, based on earlier work by Kozak & Montgomery (1981). The rationale for Applied Tension is that through gradual practice the client learns to spot the earliest signs of their blood pressure decreasing and to use special “coping skills”, involving tensing muscles, to counteract this by raising their blood pressure slightly, i.e., training their body to do the opposite of what normally happens until this becomes habitual. The tension coping skill therefore targets the second phase of the “biphasic” blood phobia response, i.e., the sense of fainting rather than the initial anxiety. This is combined with exposure to a range of feared blood-related situations, termed “exposure therapy”, which is a well-established form of behaviour therapy for phobia, and therefore targets the initial anxiety response that usually precedes the sense of feeling faint. In extreme cases where actual fainting seems likely, the subject may lie down on a couch during exposure as this normally prevents them losing consciousness. The steps of Applied Tension are as follows,

  1. An assessment of the problem is carried out and the sequence of sensations is discussed, e.g., anxiety, dizziness, sweating, nausea, faintness, etc.
  2. A simple tension “coping skill” is demonstrated by the therapist and then copied by the client.
  3. Seated in a chair, the muscles of the arms, chest, and legs are tensed until a slight feeling of warmth develops in the face, which usually takes 10-20 seconds, and signals an increase in blood pressure.
  4. The tension is released to return to a normal physical state, but no attempt is made to relax further than normal.
  5. After a brief, 20-30 second, pause this is repeated, about five times in total during a session, and five sets of five repetitions are completed each day for homework.
  6. At the second session, after a week of practice, the therapist begins systematically “exposing” the client to anxiety-provoking images of blood, etc.
  7. When the client notices the first sensations of faintness they immediately employ the tension coping skill above to prevent their blood pressure from decreasing.
  8. During subsequent sessions, and as homework, the client progressively faces more difficult situations, while using their tension coping skill.
  9. After the fifth session, the client continues to make an effort to face specific feared situations for at least the next 6 months, to maintain their improvement.

Training in the tension coping skill seems to effectively increase blood pressure and heart rate with practice. Previous researchers had done something similar by using imagery to evoke feelings of anger and raise blood pressure to counter fainting (Marks, 1981). Öst reports that even if someone does faint, the amount of time required to recover is dramatically reduced, from 3-4 hours down to 5-10 minutes, by use of the tension coping skill. Tensing can cause headaches sometimes but this is easily avoided by doing it less often and not tensing the muscles as powerfully during the exercise.  The tension coping skill is practised alone for one week so that the client becomes skilled at controlling their blood pressure.  In the second and third sessions the therapist begins exposing the client to a wide range (n=32) of photographs of blood and injuries, etc., training them to spot the earliest sensations of their blood pressure dropping and to use the tension coping skill as quickly as possible in response to this cue.  Common preliminary sensations are cold sweat, dizziness, queasy stomach, nausea, etc.

In the fourth session, Öst’s method involves the therapist taking his client on a trip to the Blood Donor Centre where he first observes others having blood taken before giving a sample of his own, while using the tension coping skill to manage their anxiety and faintness. The client may be trained to relax the arm from which the sample is being taken while simultaneously tensing the other muscle groups, to use the coping skill during the procedure.  (An alternative coping skill is simply to clench the fist of the arm not being used as tightly as possible and focus intensely on this while internally repeating coping statements such as “I can do this…” until the procedure is actually finished, as a form of distraction, although this may constitute a “safety-seeking” behaviour in some cases.)

In the fifth session, they go together to the Dept. of Thoracic Surgery and observe open-heart or lung surgery happening.  Although these would normally be considered powerful tests of improvement and likely to lead to further reduction (“habituation”) of anxiety, they do not seem to be essential to the treatment.  In studies where these encounters were omitted completely, the results were virtually identical. That’s fortunate, because it can be difficult to arrange these sort of trips in other settings.  (Although you can buy animal hearts or livers, etc., from many butchers, handling which could be an alternative for some blood phobics, once they're ready.)

After the treatment has finished, for six months, the client abides by a contract to stop avoiding exposure to the feared situations and to systematically expose themselves in a deliberate manner by viewing photographs of injuries, watching films of surgery, or visiting the blood donor centre, etc., to continue exposure therapy and the use of applied tension in the real world as a way of maintaining improvement.


Research on treating blood phobia has almost exclusively been conducted by one group of researchers: Lars-Göran Öst and his colleagues at the University of Uppsala in Sweden. Recently, a full systematic review was carried out, which identified five treatment outcome studies, all by Öst and his colleagues, and critically evaluated their findings from an independent perspective using careful statistical analysis (Ayala, Meuret & Ritz, 2009). Although the results make comparison rather complex, overall they concluded that both the tension coping skill and exposure to feared encounters with blood, etc., appeared to contribute to clinically significant improvement in 70-80% of blood phobics (Ayala et al., 2009). Where people have other anxieties, they may obtain more general benefit from the exposure part of the treatment (on standard fear surveys) as the tension coping skill only really benefits blood-injection-injury type phobias, although it does appear to do so regardless of whether fainting is a problem (Ayala at al., 2009). However, there has been some debate as to whether certain clients may use the tension coping skill in an unhelpful way (termed a “safety behaviour”). In some studies, clients have agree to follow an ongoing “maintenance programme” following treatment, involving an agreement not to avoid any subsequent exposure to blood-related situations and also to actively engage in regular deliberate exposure exercises. This ongoing homework, involving facing one's fears, seems to make an important contribution to increased improvement over the longer term (Ayala, et al., 2009).

Öst has compared several variations of the treatment for blood phobia to try to determine which aspects are most important. Öst found that 20 out of 30 people (67%) in one group of blood phobics reported having actuallyfainted in response in a feared situation . However, “fainters” improved as much as “non-fainters” from the same treatment (Öst, Fellenius & Sterner, 1991). Measures of blood pressure have provided direct evidence that the tension coping skill described below does indeed lead to an increase in blood pressure, which improves with practice, in the face of situations feared by blood phobics and normally associated with faintness and a drop in blood pressure (Öst, Fellenius & Sterner, 1991). An surprising finding was that “tension only”, which involved training in the tension coping skill but did not require phobics to actually face their fears, was almost as effective as the full Applied Tension treatment, which added this requirement.

The table below shows the percentage of blood phobic individuals who met stringent research criteria for improvement following different types of treatment, in two different studies. These outcomes suggest that the tension coping skill is a very important component of any treatment for blood phobia.

90%80%40%  Öst, Fellenius & Sterner, 1991
90%  60%70%Öst, Sterner & Fellenius, 1989


Öst, Fellenius & Sterner (1991). ‘Applied tension, exposure in vivo, and tension-only in the treatment of blood phobia’, Behav. Res. Ther., vol. 29, no. 6, pp. 561-574.

Öst, Sterner & Fellenius (1989). ‘Applied tension, appplied relaxation, and the combination in the treatment of blood phobia’, Behav. Res. Ther., 27, 109-121.

Öst & Sterner (1986). ‘A specific behavioral method for treatment of blood phobia’, Behav. Res. Ther., vol. 25, no. 1, pp. 25-29.

Ditto B.; France CR.; Holly C. (2010). ‘Applied tension may help retain donors who are ambivalent about needles', Vox Sanguinis. 98(3 Pt 1):e225-30

Ayala ES.; Meuret AE.; Ritz T. (2009). ‘Treatments for blood-injury-injection phobia: a critical review of current evidence', Journal of Psychiatric Research. 43(15):1235-42

About the author | Donald Robertson

Donald is a writer and trainer, with over twenty years’ experience. He’s a specialist in teaching evidence-based psychological skills, and known as an expert on the relationship between modern cognitive-behavioural therapy (CBT) and and classical Greek and Roman philosophy. Donald is the original founder of The UK College of Hypnosis & Hypnotherapy, setting up in 2003 under the name Hypnosynthesis. Donald developed the evidence-based hypnotherapy approach taught in the College. He also has been instrumental in the further integration of hypnosis with CBT – both via the training courses of the College and his publication: The Practice of Cognitive Behavioural Hypnotherapy. He passed the College along to Mark Davis in 2013. He now lives in Canada