Assessment of coping strategies associated with syncope in blood donors

JournslofPsychosomatic Printed in Great Britain.

ASSESSMENT

OF COPING

WITH SYNCOPE DANNY

0022-3999185 S3.00+ .oO 0 1985 Pergamon Press Ltd.

Research, Vol. 29, No. 2, pp. 207-214, 1985.

G. KALouPEK*f’,

STRATEGIES

ASSOCIATED

IN BLOOD DONORS

JOHN R. SCOTT*

and VALERIE KHATAMI*

(Received 12 June 1984;accepted in revised form 21 September 1984) Abstract-Characteristics associated with vasovagal syncope in blood donors were investigated in two studies. An initial goal was to examine the potential role of physical and health variables. The primary goal was to assess coping strategies that might be related to the second phase (i.e., bradycardia; hypotension) of the vasovagal reaction pattern. Findings in both studies revealed that physical characteristics and health variables were unrelated to syncope. Donors who exprienced reactions were characterized, however, by fewer prior blood donations and a greater likelihood of previous syncope. Multivariate analysis also indicated that in the context of the variables just noted, reacting donors reported less awareness of anxiety-related physiological cues. Other findings suggested that Suppression, a coping strategy that has been previously associated with heart rate decrease in blood donors, may be linked to syncope. Prospective assessment of coping is suggested for future studies of psychological factors involved in syncope.

INTRODUCTION VAS~VAGAL syncope is a relatively common reaction to medical procedures that involve injection, venipuncture, and/or the sight of blood [ 1, 21. It is particularly evident during and after blood donation where the incidence is estimated at between 2 and 9% [ 3,4] , with at least one report as high as 15% [S].$ Although much of the existing research on the psychological aspects of syncope has involved blood donors, we found only one investigation that specifically matched nonreacting control donors to syncopal donors in terms of attending personnel [ 41. This is an impotant consideration because both Williams [6] and Ogata et al. [7] have found that donors reacted more frequently with experienced (rapid and noncommunicative) attendants as compared to inexperienced (slow and communicative) attendants. Therefore, unless subjects are matched in terms of the attending personnel, differences between groups may reflect attendant characteristics or their interaction with donor characteristics. Another potentially important consideration is that very few investigations have as yet included an array of demographic, physical, and health variables so that the impact of nonpsychological influences can be ascertained. For example, lack of recent food intake [ 81, low body weight [ 71, and presence of chronic or acute medical conditions [ 61 have been suggested as factors that contribute to syncope. Variables of this type must be assessed in order to establish a context for interpreting concurrent psychological data. Finally, investigation has not advanced much in terms of attempts to quantify the psychological processes associated with syncope. Research has concentrated an the first phase of the vasovagal reaction, during which anxiety seems to predominate [5]. *Department of Psychology, Concordia University, Montreal, Quebec, Canada. TAddress correspondence and reprints requests to: Danny G. Kaloupek, Department of Concordia University, 1455 de Maisonneuve Blvd. W., Montreal, Quebec, Canada H3G *Callahan et al. [3] noted that a syncope rate of 4.5% was consistent with most reports, rate for actual loss of consciousness was between 1 and 3%. Other reports [4] indicate consciousness occurs in less than 1% of all donors. 207

Psychology, 1M8. and that the that loss of

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D. G. KALOUPEK, J. R. SCOTT and V. KHATAMI

There is need for more assessment aimed at the coping maneuvers (e.g., denial of threat, inhibition of flight [9, lo]) ascribed to syncopal individuals. Conceptually, this type of assessment focuses on the critical second phase of the reaction pattern

[ill. Despite reservations about the situational and temporal stability of coping characteristics [ 121, we selected trait measures for our initial investigation because they were potentially relevant to the research question and they could be readily integrated into the blood donation protocol. The choices were the RepressionSensitization Scale [ 13 ] , an index of the widely applied coping dimension developed by Byrne [e.g., 141, and the Autonomic Perception Questionnaire [ 151. This latter index was selected under the assumption that autonomic awareness is either an element or a covariate of emotion-focused coping maneuvers [ 121. The first study tested the ability of these coping measures to distinguish blood donors who experienced symptoms associated with vasovagal syncope from those who did not. A set of demographic and physical characteristics was also assessed in order to examine the role of nonpsychological factors. It was tentatively predicted that the coping measures would distinguish between the two donor groups. In addition, variables for age, prior donation experience, predonation anxiety, and prior vasovagal reactions were expected to differ between the groups because they had done so in previous studies [e.g., 3,4,5]. Physical and health characteristics were expected to be generally unrelated to syncope symptoms.

METHOD

1

Subjects Participants were drawn from a group of 602 volunteer blood donors at a mobile clinic conducted by the Candian Red Cross on the Sir George Williams campus of Concordia University. Donors who experienced a vasovagal reaction (Reactors)* were identified when, during phlebotomy, their chair was moved from the standard semi-reclined position to a fully reclined position (with feet elevated) by the attending nurse. There were 24 individuals who met this criterion: 15 males and 9 females. A matched control group (NonReactors) was comprised of 24 individuals who were each the first nonreacting (i.e., semi-reclined throughout phlebotomy) donor of the same sex to be served by the same nurse following identification of a reacting subject. Procedure

All donors were processed according to a standard mobile clinic protocol [ 171. This included a preliminary finger-tip blood sample, a 1 or 2 min waiting period, venipuncture and phlebotomy conducted in a semireclined chair (5-15 min duration for a 450 cc. donation), mandatory post-phlebotomy rest on a cot away from the donor chairs (5 min minimum), and refreshments (e.g., fruit juice) followed the rest period. Subjects were met by an experimenter (J.S. or V.K.) as they moved from the cot to the refreshment area. They were asked to participate in a survey of reactions to blood donation. A general description of the study was provided by a consent form, which included a summary of the information that the survey materials requested. It also stated that participation was voluntary, that it was not required as part of the Red Cross procedure, and that all information was confidential. All donors who signed the consent form? were provided with a packet of questionnaires that they completed while they consumed refreshments. The packets were then returned to the experimenter.

*In the absence of a physiological index such as heart rate, the vasovagal syncope designation is open to challenge. Other studies involving blood donors [3, 1 l] support the reasonableness of this assumption, however, and the situation and reported symptoms do not readily reconcile with other types of syncope 1161. tFew individuals declined to participate when requested, but some reactors left before being contacted by an experimenter.

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Assessment information The following information was provided by each subject. (1) Personal characteristics-Age, sex, height, weight. (2) Nutrition and health-Time since last meal, type and amount of food consumed, chronic physical conditions (e.g., epilepsy, hypertension; from a 7-item checklist), and acute physical conditions (e.g., flu, menstruation; from a 5-item checklist). (3) Previous experience-Number of prior blood donations, previous syncope due to emotional reactions (including a brief description of the circumstances), and general anxiety (i.e., whether or not they viewed themselves as generally anxious or nervous). (4) Current blood donation-Syncope symptoms during donation (e.g., weakness, lightheadedness; from a 9-item checklist), anxiety level prior to donation (an 1 l-point scale), relief following donation (an 1 l-point scale), a request to list four terms to describe the attending nurse, and a rating of the probability of donating blood again within one year (0 to 100 scale with lo-point intervals). In addition, subjects completed the modified version of the Repression-Sensitization Scale (R-S; [13] and the modified version of the Autonomic Perception Questionnaire (APQ; [I 5). The R-S Scale had a possible range of scores from 0 to 30, with low scores indicative of coping with threat via repression (e.g., inattention or denial) and high scores indicative of coping via sensitization (e.g., vigilance or information seeking; [14]. The APQ had a possible range of scores from 0 to 180, with higher scores indicative of greater awareness of bodily reactions when anxious.

RESULTS

AND DISCUSSION

1

Initial analysis involved comparison of the Reactor and Non-Reactor groups with regard to all of the variables assessed. t tests were used for comparisons based on continuous variables, and a test for differences between proportions [ 181 was used for dichotomous variables. The results of these analyses are presented in Table I.

TABLE I.-COMPARISONS BETWEEN VASOVAGAL REACTORS AND MATCHED REACTORSONALLVAMABLES FROM STUDY 1 Reactors Mean = 24)

Continuous variables

SD

Age Height (ins) Weight (lbs.) Hours since meal Prior blood donations Predonation anxiety Relief rating Repeat donation probability R-S Scale

APQ Number

of symptoms

Dichotomous variables

2.4 3.8 23.6 2.2 1.5 2.9 3.4 32.0 3.3 31.5 1.6

Reactors

Previous syncope Generally anxious Ate a full meal Chronic health condition Acute health condition Positive nurse description* Negative nurse description* *Combined of adjectives.

21.3 67.5 141.2 3.8 1.7 2.5 4.8 70.8 13.0 75.4 3.1

percentages

33% 25% 58% 13% 21% 92% 29% exceed 100% because

NON-

Non-reactors Mear = 24) SD

t-value

22.6 67.0 148.5 3.5

4.1 3.8 26.0 2.9

1.26
NS NS NS NS

::; 3.9 89.6 13.4 90.8 0.5

2.8 7.8 3.3 17.8 4.3 33.4 0.6


0.05 NS NS 0.03 NS NS 0.01

p<

Non-Reactors

z-value

n<

13% 17% 66% 4% 13% 88% 29%

1.65
0.10 NS NS NS NS

some subjects

f;‘:

listed both types

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D. G. KALOUPEK. J. R. SCOTT and V. KHATAMI

As indicated in the table, individuals in the Reactor group averaged fewer previous donations and had a marginally higher frequency of at least one prior syncope episode, consistent with initial predictions. They also rated a lower likelihood of repeat donation and endorsed more symptoms associated with vasovagal reactions, thereby supporting the criterion used to establish group membership. Contrary to expectation, there were no differences in terms of age, predonation anxiety, or coping as indicated by the R-S Scale or the APQ. As predicted, however, none of the physical variables such as weight, time since eating, and chronic or acute health conditions were significantly different between the groups. The next stage of analysis involved step-wise discriminant analysis [19] with two sets of predictor variables. The first set was comprised of personal characteristics (age; height; weight) and nutrition and health variables (time since last meal; amount consumed; acute and chronic physical conditions). These variables did not generate a statistically significant discriminant function. The second set of predictors was comprised of experience variables (number of prior donations; previous syncope), anxiety variables (general anxiety; predonation anxiety), and coping measures (R-S Scale; APQ). A significant discriminant function 0) < 0.01) was based on three variables: number of prior donations, previous syncope, and APQ scores. Individuals who experienced vasovagal reactions during current donation were identified by fewer prior donations, at least one prior syncope episode, and lower APQ scores. Classification of individual subjects on the basis of the function was 64.5% accurate overall, with 58 and 71% accurate classification of donors in the Reactor and Non-Reactor groups, respectively. STUDY

2

The lack of association between the R-S Scale and vasovagal reactions in Study 1 prompted the addition of an index of coping more specifically tied to blood donation. A checklist of coping strategies, introduced by Billings and Moos [ 201 and modified to accomodate blood donation by Kaloupek et al. [ 171, was selected. Factors derived from this scale have been found to relate to the amount of distress experienced by blood donors [ 17,211, suggesting its potential value with regard to the identification of coping maneuvers associated with syncope. METHOD 2 Subjects Participants were drawn from a group of 787 volunteer blood donors at a Canadian Red Cross mobile clinic on the Loyola campus of Concordia University. Twenty-four donors (13 males and 1 I females) who experienced vasovagal reactions were identified according to the same criterion used in Study 1. Matched control subjects were also selected as in the previous study. Procedure The procedure and measures were identical to Study 1, with the addition of the state coping checklist to the packet of questionnaires. This measure was a 19-item list, with a true-false format, completed so as to reflect coping efforts throughout the blood donation procedure. It was scored in terms of five factors previously identified by Kaloupek et al. [ 171: Worry, Suppression, Behavioral Action, Rational Cognition, and Denial. RESULTS

AND DISCUSSION

2

Analysis again started with simple comparsions between Reactor groups. Information relevant to these comparisons

the Reactor and Nonis listed in Table II.

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syncope

TABLE II.-COMPARISONS BETWEEN VASOVAGAL REACTORS AND MATCHED NONREACTORSONALLVARIABLESFROMSTUDY~ Continuous variables

Age Height (ins) Weight (lb) Hours since meal Prior blood donations Predonation anxiety Relief rating Repeat donation probability R-S Scale

Reactors (n=24) SD 21.6 68.0 146.5 4.0 0.8

3.0 3.7 23.3 3.9 1.3 2.5 3.4 28.4 4.1 21.9 20.1 26.9 34.1 32.6 20.8 1.9

Non-Reactors (n=24) SD I-value Mean 23.3 68.0 150.6 3.2 4.6 2.1 3.0 79.6 14.1 78.3 18.4 25.8 65.3 58.3 68.7 0.5

Worry factor* Suppression factor* Behavioral Action factor* Rational Cognition factor* Denial factor* Number of symptoms

::: 64.6 14.1 76.9 23.2 41.5 66.1 83.3 61.4 3.3

Dichotomous variables

Reactors

Non-reactors

Previous syncope Generally anxious Ate a full meal Chronic health condition Acute health condition Positive nurse description? Negative nurse description?

38% 29% 50% 0% 29% 100% 21%

8% 25% 38% 4% 25% 100% 13%

APQ

3.3 3.2 32.9 1.8 6.4 2.6 3.0 23.9 3.8 22.5 16.0 21.7 33.3 35.8 23.6 0.7

I .85
z-value

2.47
P<

0.10 NS NS 0::

0:05 0.01 0.05 E 0:: NS 0.03 NS 0.01

P<

0.03 NS NS Es” ::

*Factor values refer to the percent of items endorsed. Item totals: Worry = 7, Suppression = 5, Behavioral Action = 3, Rational Cognition = 3, Denial = 4. tcombined percentages exceed 100% because some subjects listed both types of descriptions.

Examination of the table reveals that individuals in the Reactor group averaged fewer prior donations, had a higher frequency of at least one prior syncope episode, rated a lower likelihood of repeat donation, and endorsed more symptoms associated with vasovagal reactions. These differences replicate the findings of Study 1. Furthermore, predonation anxiety was rated higher by donors in the Reactor group and these individuals were (marginally) younger than individuals in the Non-Reactor group. These latter two findings are unlike the results of Study 1, but they are consistent with previous findings [ 51. There is also evidence of greater relief experienced by the Reactor group when donation was completed. This probably reflects the passing of both anxiety and physical symptoms. Product-moment correlations support this view since both predonation anxiety and number of symptoms were positively related to the relief rating (both r >0.38, p
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D. G. KALOLJPEK, J. R. SCOTTaad V. KHATAMI

imagining that I was elsewhere (Suppression), (3) I tried to relax myself (Suppression and Rational Cognition), and (4) I tried to step back from the situation and be more objective (Rational Cognition). The other measures of coping, the R-S Scale and the APQ, were not different between the groups. The final aspect of the comparisons was the replication of no differences with regard to characteristics such as height, weight, food intake, or health status. These physical variables did not appear to be related to vasovagal reactions during blood donation. Step-wise discriminant analysis was conducted on the same sets of variables as in Study 1. The first set of predictors (e.g., age, weight, time since last meal) again did not produce a statistically significant function. The second set of predictors (e.g., prior donations, general anxiety, R-S Scale) replicated the significant discriminant function based on prior donations, previous syncope, and APQ variables. The overall classification based on this function was 81% accurate, with 88 and 75% correct classification of subjects in the Reactor and Non-Reactor groups, respectively. An additional discriminant function was generated with the three variables just discussed and the Suppression factor from the state coping checklist. All four variables contributed reliably @ < 0.01) to a function that was itself significant (p < 0.01). Higher Suppression scores were associated with membership in the Reactor group. In order to reduce the impact of sample-specific error, a further test of the discriminating variables was undertaken by applying unweighted criterion-based scores to subject classification. The criteria were: (a) no prior blood donations, (b) at least one prior syncope episode, (c) an APQ score less than 56 (i.e., at least one standard deviation below the mean), and (d) endorsement of three (60%) or more of the items from the Suppression factor. Individuals who met two or more of these criteria were classified as likely Reactors. This system resulted in accurate identification of 78% of the Reactor group and 88% of the Non-Reactor group.

GENERAL

DISCUSSION

The results of the discriminant analyses were consistent with the simple comparisons with regard to the absence of physical characteristics that could differentiate between the groups. One simple conclusion is that physical considerations relating to body size, food intake, and health status are not related to syncope in blood donors. Although Red Cross screening probably eliminates some individuals for whom these variables might contribute to vasovagal reactions, their general impact does not appear to be great. Previous research has suggested that anxiety is an important antecedent to syncope episodes [ 51. There is limited support for this contention in the current findings since only in Study 2 was predonation anxiety reported to be greater for the Reactor group. There are, however, clear and reliable findings with respect to fewer prior donations reported by Reactors. Given that our previous research [ 17,211 has consistently found higher anxiety reported by less experienced donors before donation, there is reasonable likelihood that, by virtue of less experience in the situation, reacting donors in both studies were more anxious. Unfortunately, the retrospective nature of the predonation anxiety rating used in the present studies may have reduced its validity. Also in relation to experience with blood donation, we recently found that inexperienced donors were more likely to engage in coping strategies that were

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relatively ineffective [ 211. Specifically, in anticipation of venipuncture, they appeared to focus on and ruminate about potentially distressing aspects of the situation or their emotional reaction to it. Unpublished data from our laboratory indicate that when coping is assessed prior to syncope episodes, similar strategies are often found. Approximately 35% of the donors in the Reactor groups report previous reactions, compared with approximately 10% of the Non-Reactor groups. This finding is consistent with results reported by other investigators [ 3,4]. The limited magnitude of this difference and the report of previous syncope by some nonreacting donors indicates, however, that experience with syncope is neither necessary nor sufficient for vasovagal reactions during blood donation. The APQ, a measure of autonomic awareness, was included in order to reflect emotion-focused coping. The findings for the two studies indicate that only in the context of few blood donations and/or previous syncope is low autonomic awareness associated with vasovagal reactions during blood donation. This suggests the possibility that coping in the form of inattention to somatic cues [ 153 contributes to vasovagal reactions without being either necessary or sufficient. Therefore, despite the restricted contribution of the APQ, it may be of theoretical importance to explore the role of low autonomic awareness in the elicitation of vasovagal reactions. The R-S Scale did not provide a parallel indication that repression or inattention to external threat is associated with vasovagal episodes. This may be due to its trait focus or lack of content relevant to the immediate situation. In either case, it does not appear to offer information relevant to vasovagal syncope. The coping checklist was administered only in Study 2, but it appeared to assess something of relevance to vasovagal reactions. Average scores on both the Suppression and Rational Cognition factors distinguished between Reactor and Non-Reactor groups, and the Suppression factor contributed significantly to a reliable discriminant function. Our recent study with non-reacting blood donors [21] revealed that Suppression scores were inversely related with the magnitude of heart rate reduction between anticipatory and venipuncture periods. Given that the second phase of a vasovagal reaction involves pronounced reduction in heart rate [ 1I], the link with the Suppression coping strategy may be quite important. In summary, the current studies replicated previous findings which suggest that less experience with blood donation and a history of vasovagal reactions are predictive of vasovagal syncope. Greater predonation anxiety for donors who experience vasovagal reactions was also indicated in one study, although there was indirect evidence for its general importance. Physical and health characteristics were unrelated to vasovagal reactions, highlighting the importance of psychological variables. Low reported awareness of autonomic cues was associated with vasovagal reactions during blood donation, but only in the context of variables reflecting previous experience with blood donation and syncope. Scores on Suppression and Rational Cognition factors from a coping checklist were significantly higher for reacting donors, and the Suppression factor contributed to multivariate classification. Future investigation should focus on prospective measures that allow more definitive isolation of the antecedent variables associated with vasovagal reactions, especially those related to coping efforts. Acknowledgemenrs-We are grateful for the help and cooperation

of Dr. Raymond Cuevin, Ms. Beatrice Jean, and the nurses from the Canadian Red Cross. We also wish to thank Dr. George Curtis for providing an enlightening introduction to the literature on syncope.

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D. G.

KALOUPEK,

J. R. SCOTT and V. KHATAMI REFERENCES

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