Abstract
Background
Vasovagal reactions (VVRs) are commonly experienced in medical situations such as blood donation. Many believe that psychosocial contagion can contribute to the development of VVRs, but this is largely clinical lore.
Purpose
The goal of the present investigation was to examine the physiological effects of observing another experience a reaction, focusing on the potential moderating effects of empathy.
Methods
This study was part of a randomized controlled trial of behavioral techniques on the prevention of VVRs in blood donors. The sample was composed of 530 healthy university students. Measures of symptoms were obtained with the Blood Donation Reactions Inventory (BDRI) and through observation. Physiological variables were measured using respiratory capnometry and a digital blood pressure monitor. The Affective and Cognitive Measure of Empathy was administered to 230 participants.
Results
Donors who witnessed another experiencing a reaction were more likely to spontaneously report symptoms during the blood draw, to be treated for a reaction, to score higher on the BDRI, and to exhibit smaller compensatory heart rate increases. Donors with higher affective empathy reported more symptoms, exhibited hyperventilation, and were more likely to be treated. Donors with higher cognitive empathy were less likely to require treatment if they witnessed a reaction.
Conclusion
These results suggest that psychosocial contagion of physical symptoms can occur. The moderating effects of empathy differed depending on the subtype of empathy. Perhaps a better cognitive understanding of how other people are feeling functions as a coping response, whereas feeling sympathetic about others’ distress increases one’s own.
Keywords: Vasovagal reaction, Empathy, Psychosocial contagion, Blood donation
Blood donors who witness another donor have an adverse reaction are more likely to experience a reaction themselves, especially if they report that they generally feel distressed when seeing another in pain.
Introduction
Mass psychogenic illness, or the spread of physical symptoms within a group despite the lack of an observable, medical cause, has been written about since medieval times [1]. The contagion of symptoms can be traced to several phenomena, including suggestion [2], the perception and monitoring of physiological activity in the body [3], and social communication about the event [4]. Case reports comprise most of the literature on the topic (e.g., [1, 4–8]), which has made it difficult to answer questions about mechanisms or to determine whether the apparent contagion of symptoms was due to psychosocial effects and not an artifact of processes such as elevated base rates in certain groups or exposure to an unknown toxic substance.
Blood donation clinics are a particularly good setting to study the psychosocial contagion of physical symptoms. While the procedure is routine and safe, it can be anxiety-provoking, especially for inexperienced donors, who experience more stress reactions in this setting than repeat donors [9]. Relative to routine diagnostic blood draws, blood donation involves having a needle with a larger bore inserted into the arm for a longer period of time (approximately 12 to 15 min) while donors can observe relatively large volumes of blood (450–500 mL) being withdrawn. The process can also involve aversive physical symptoms such as lightheadedness, nausea, and pain. In addition, blood collections are often conducted in public settings where donation chairs are placed close to one another, such that donors witness others giving blood while they do.
All of these factors could contribute to the psychosocial contagion of vasovagal symptoms in blood donation clinics, which has been described as “epidemic fainting” [10]. While the concept is commonly spoken about by professionals in the field, few studies have examined this phenomenon in a systematic way. Ferguson and Bibby [11] found that donors who had seen others faint reported feeling fainter than those who had not seen any faint. However, only self-report data were obtained in this study.
In another study on the social contagion of vasovagal reactions (VVRs) during blood donation, it was found that witnessing another donor experiencing VVR produced an observable physiological response and higher scores on the Blood Donation Reactions Inventory (BDRI) in repeat blood donors [12]. Although also based on self-report data, the BDRI is a validated measure of presyncopal symptoms including faintness, dizziness, and nausea [13]. As well, observing another donor experience a VVR was associated with a greater likelihood of being treated for symptoms oneself by the nurse and having a smaller compensatory increase in heart rate [12].
Another important question that cannot be addressed adequately in case studies of mass psychogenic illness is who is most likely to be affected. For example, a number of the effects in the Ditto et al. (2014) study were limited to more experienced donors, possibly due to ceiling effects among more generally susceptible novice donors [12]. Another potential moderator is individual differences in empathy. Empathy can be viewed as a multidimensional concept, divided into two subtypes: cognitive empathy, the understanding of the emotions of others, and emotional empathy, an emotional response to the emotions of another individual [14]. A key component and potential precursor of emotional empathy is emotional contagion, the unconscious sharing of emotions between individuals [15]. Emotional contagion has been studied extensively [16–18]. In contrast, little work has explored empathy and the contagion of physical states and illnesses. Given that high trait cognitive and affective empathy can have adaptive or maladaptive effects, depending on the context in which they are studied [19], further research is required to understand their effects in blood donation. Some work has shown that a subset of people with blood-injection-injury phobia who reported avoidance of situations in which they could faint are more affected by other people’s suffering than non-avoiders [20]. In another study, it was found that blood phobics reported more empathic distress when witnessing others’ negative emotional states than nonphobics [21]. They also displayed significantly greater changes in skin conductance and heart rate while watching a video of another person undergo a surgical procedure [21]. Morse and Mitcham [22] described the passing of physical distress from patient to nurse, referring to it as an example of “compathy”, the “physical equivalent to empathy.” In a controlled experiment, Dimitroff et al. [23] showed participants videos of speakers experiencing minimal stress, high stress, or stress recovery. The cardiac activity of observers changed depending on which video they were watching. More specifically, those viewing highly stressful videos experienced cardiac deceleration, while those watching non-stressful videos displayed no changes in autonomic activity. It was found that these cardiovascular changes happened more quickly in more empathic participants [23]. Interestingly, experiencing cardiac deceleration while witnessing another donor in distress could be a direct contributor to increased risk for VVR.
Data from a randomized controlled trial of interventions to prevent VVRs in young, healthy blood donors was examined. The primary goal of the current investigation was to replicate and extend the findings of the social contagion of VVR and the physiological effects of observing another experience a reaction. The secondary aim was to investigate the potential moderating effects of empathy in the social contagion of VVR in blood donors.
Methods
Participants
Similar to a previous study by Ditto et al. [12], we used data concerning the effects of observing another person experience vasovagal symptoms obtained in the context of a randomized controlled trial focusing on the effects of two procedures aimed at reducing the likelihood of a vasovagal reaction during blood donation. However, the present study is a new sample [24], and the analyses controlled for whether or not the participant was asked to practice respiration control and whether or not they were asked to practice applied muscle tension (discussed below). To emphasize recruitment of younger, less experienced donors, data were collected in mobile blood clinics organized by the provincial blood agency in universities and colleges. Following our previous procedure [24], only data from participants below age 30 who had given blood on fewer than 10 previous occasions were analyzed. As well, analyses were limited to those who were able to see other donors while undergoing their own donation. This yielded a sample of 530 generally healthy young adults. Demographic characteristics of the group are presented in Table 1. Participants who saw another person have a reaction did not differ significantly from those who did not in age, sex, body mass index, donation experience, pre-donation anxiety, or treatment condition.
Table 1.
Characteristics of Sample (Mean ± SE)
| Total sample n = 530 | Saw a reaction n = 204 | Did not see a reaction n = 326 | Completed empathy measures n = 230 | Did not complete empathy measures n = 300 | |
|---|---|---|---|---|---|
| Age (years) | 21.1 (0.1) | 21.0 (0.2) | 21.2 (0.1) | 20.8 (0.2) | 21.2 (0.1) |
| Number of previous donations | 1.9 (0.1) | 1.9 (0.2) | 1.9 (0.1) | 2.0 (0.2) | 1.9 (0.1) |
| Sex (% female) | 51.3 | 48.5 | 52.8 | 44.5 | 56.4 |
| First language (% English) | 57.1 | 57.4 | 57.1 | 52.8 | 60.3 |
| Body mass index (kg/m2) | 24.0 (0.2) | 24.0 (0.3) | 24.0 (0.2) | 24.1 (0.3) | 23.9 (0.2) |
| Pre-donation systolic blood pressure (mmHg) | 121.9 (0.5) | 121.9 (0.8) | 121.8 (0.7) | 123.5 (0.8) | 120.7 (0.7) |
| Pre-donation diastolic blood pressure (mmHg) | 71.1 (0.4) | 70.6 (0.6) | 71.4 (0.5) | 71.7 (0.6) | 70.7 (0.5) |
| Pre-donation heart rate (bpm) | 74.9 (0.5) | 74.9 (0.9) | 75.0 (0.6) | 74.2 (0.8) | 75.4 (0.7) |
| Pre-donation respiration rate (bpm) | 19.4 (0.1) | 19.3 (0.2) | 19.5 (0.2) | 19.3 (0.2) | 19.5 (0.2) |
| Pre-donation PETCO2 (mmHg) | 37.2 (0.1) | 37.5 (0.2) | 37.1 (0.1) | 37.5 (0.2) | 37.0 (0.2) |
| Spontaneous report of vasovagal symptoms during donation (%) | 9.7 | 14.2 | 7.1 | 9.6 | 9.9 |
| Requiring vasovagal treatment (%) | 11.8 | 17.6 | 8.3 | 11.8 | 11.8 |
| Observed fainting (%) | 4.7 | 5.9 | 4.0 | 3.5 | 5.6 |
| BDRI score | 4.6 (0.3) | 5.6 (0.6) | 4.1 (0.4) | 4.6 (0.5) | 4.7 (0.4) |
| Systolic blood pressure change (mmHg) | −3.6 (0.5) | −4.4 (0.7) | −3.0 (0.6) | −4.8 (0.8) | −2.7 (0.6) |
| Diastolic blood pressure change (mmHg) | 0.9 (0.4) | 0.4 (0.6) | 1.2 (0.5) | −0.4 (0.6) | 1.9 (0.5) |
| Heart rate change (bpm) | 6.0 (0.4) | 5.0 (0.7) | 6.6 (0.5) | 5.4 (0.6) | 6.5 (0.6) |
| Respiration rate change (bpm) | −0.6 (0.1) | −0.5 (0.2) | −0.7 (0.2) | −0.6 (0.2) | −0.7 (0.2) |
| PETCO2 change (mmHg) | −0.9 (0.1) | −0.7 (0.1) | −1.0 (0.1) | −0.8 (0.1) | −1.0 (0.1) |
BDRI Blood Donation Reactions Inventory; SE standard error.
Approximately halfway through data collection, a personality measure of empathy was added to the post-donation questionnaire packet. Given the potential of empathy to moderate the effects of observing another person experience vasovagal symptoms, additional analyses were conducted using this subgroup of 230 participants. There were no statistically significant differences between those who completed the empathy measure and those who did not on most demographic variables, including age, number of previous donations, first language, pre-donation anxiety, treatment condition, and BMI. Participants who completed the empathy measure were more likely to be male. Given that sex was entered as a routine covariate in all analyses, no additional corrections for potential sample bias were conducted.
Procedure and Measures
Participants were recruited after registering at blood donation clinics in Montreal universities and colleges organized by the provincial blood donation agency, Héma-Québec. They were asked to complete pre-donation measures such as a demographic questionnaire and an abbreviated version of the Spielberger State Anxiety Inventory [25]. While participants were sitting, two measurements (spaced 2 min apart) of systolic (SBP) and diastolic (DBP) blood pressure and heart rate (HR) were obtained using a digital monitor (HEM-432C, Omron). A third measurement was taken only if there was a significant (at least 10-point) discrepancy between the first two readings. Those assigned to one of the treatment conditions then watched a 3-minute video instructing them on how to use the technique. These techniques involved aspects of both respiration control and occasional muscle tension, but were superimposed on the blood donation procedure and did not interact with the effects of observing another person experience vasovagal symptoms [24]. Exposure to another donor experiencing a reaction was not found to affect treatment adherence. The effects of exposure to another donor reacting did not depend on the experimental condition participants were assigned to. Exposure to another donor reacting was equivalent for most donors. Before proceeding with donation as usual, the research assistant attached a portable capnometer (Oridion Microcap Plus, Covidien) to measure respiration rate (RR) and end-tidal carbon dioxide (PETCO2). Disposable lines (Smart Capnoline Plus, Covidien) were used to sample air expired from the nose and mouth. The line was passed over the participant’s shoulder and the capnometer placed in a small pack around their hips to avoid interfering with blood collection. Measures of RR and PETCO2 were obtained continuously throughout the procedure.
While participants were donating blood, a research assistant noted whether they reported any vasovagal symptoms to the phlebotomist, whether they fainted or whether the phlebotomist initiated treatment procedures for syncope or presyncopal symptoms (e.g., stopping donation and reclining the chair). The research assistant also noted whether any other donors in the participant’s vicinity experienced a reaction (fainted or required treatment for VVR symptoms) while the participant was donating. The study was designed to minimize the possibility of research assistants interfering in the usual blood donation procedure, thus also reducing the likelihood that a research assistant might distract the participant from another reacting donor. In the post-donation recovery area, participants completed the BDRI, a measure of the number and severity of VVR symptoms experienced during donation, such as nausea, faintness, and dizziness [13]. Two additional measures of BP and HR were then obtained. Other measures in the post-donation assessment which are not relevant for the present analyses are described elsewhere [24].
As part of the post-donation questionnaire packet, some participants completed the Affective and Cognitive Measure of Empathy (ACME) [26]. One of the main ideas behind the development of the ACME is that empathy is a multidimensional construct. Consistent with this, three subscales were created. Cognitive Empathy is defined as the ability to understand another’s emotions. Affective Resonance is conceptualized as the ability to “feel” another’s emotions, involving an emotional response in the observer that is congruent with the target’s emotional response. This subtype broadly includes the concepts of sympathy, pity, and compassion. The Affective Dissonance subscale was developed originally to reflect the experience of pleasure at someone else’s misfortunes [26]. However, for consistency with the other subscales, the scale is typically reverse-scored such that higher scores reflect discomfort at seeing others in distress. Compared to other common measures of empathy, the ACME has been found to have higher reliability, higher domain coverage, and to be more predictive of both prosocial and antisocial behaviors [26]. Internal consistency of the ACME scales was found to range between 0.85 and 0.91 in the initial validation studies [24]. In the current sample, the internal consistency of the Affective Dissonance subscale was 0.81. Cronbach’s alpha for the Affective Resonance and Cognitive Empathy subscales were 0.77 and 0.89, respectively. The following correlations were found between Cognitive Empathy and Affective Resonance (r = .36, p < .001), Cognitive Empathy and Affective Dissonance (r = .12, p = .065) and Affective Resonance and Affective Dissonance (r = .45, p < .001).
Ethics approval was granted by the Héma-Québec Research Ethics Committee and the McGill University Research Ethics Board.
Data Analysis
Four overlapping but distinct indices of vasovagal symptoms were examined as the primary dependent measures: (1) Spontaneous Report of Vasovagal Symptoms: whether the participant spontaneously reported vasovagal symptoms while in the donation chair, (2) Retrospective Report of Vasovagal Symptoms: retrospective report of vasovagal symptoms on the BDRI administered in the post-donation recovery area, (3) Vasovagal Treatment: whether the participant was treated for vasovagal symptoms in the donation chair, and (4) Observed Fainting: whether the participant was observed to faint. To reduce the impact of the research protocol and possible iatrogenic effects on the donation procedure, participants were not questioned about vasovagal symptoms while in the chair. On the other hand, although administered later, the BDRI measured the strength of 11 common symptoms. While recent research [13] indicates some practical and conceptual advantages to scoring only four key items, the full version was used in the present study to yield more variability in scores, which might be necessary to detect subtle observational effects. The associations between the likelihood of fainting and spontaneously reporting VVR symptoms (phi = 0.289), the likelihood of fainting and likelihood of receiving treatment (phi = 0.583), the likelihood of fainting and BDRI score (r = .545), the likelihood of receiving treatment and spontaneously reporting symptoms (phi = 0.663), the likelihood of receiving treatment and BDRI score (r = .723), and BDRI score and spontaneously reporting symptoms (r = .540), were all statistically significant at the p < .001 level.
To examine possible relationships between vasovagal symptoms and change in physiological activity, the participant’s average PETCO2 and RR prior to arriving at the chair was subtracted from their average values in the chair. Change scores were also calculated for SBP, DBP, and HR, although these were pre- to post-donation change scores as BP and HR were not measured during the actual donation. Analyses of change scores included the person’s pre-donation “baseline” mean as a covariate. All analyses also included the participant’s age, sex, previous blood donation experience, whether or not they were asked to practice respiration control, and whether or not they were asked to practice applied muscle tension as routine covariates. Age, sex, and previous donation experience have previously been found to influence the risk of experiencing a vasovagal reaction during blood donation [27].
Two sets of analyses were conducted—one using the full dataset focusing just on the effects of seeing another donor experience symptoms and another on the subset examining possible interactions with empathy. Regression was used for all analyses—linear regression for the continuous dependent variables (BDRI, physiological change scores) and logistic regression for the dichotomous variables (whether the participant was treated for vasovagal symptoms, etc.). Potential predictors were entered into the equations in a stepwise fashion with the covariates entered first. In the first set of analyses, this was followed by whether or not the participant saw another donor experiencing vasovagal symptoms. In the second set of analyses, the second step consisted of entering the main effects of seeing another donor experiencing vasovagal symptoms and one of the empathy subscale scores. This was followed by entering the interaction consisting of the product of the subtype of empathy and seeing a reaction. These analyses were conducted thrice for each outcome variable, investigating the potential moderating effects of empathy subtypes separately. All reported regression coefficients are unstandardized. The results presented below have not been adjusted for multiple comparisons to reduce the likelihood of obtaining false-negative results. Significant interactions in the empathy analyses were conducted using the PROCESS macro [28] for IBM SPSS [29]. Continuous scores were mean-centered before the product terms were created. The Johnson-Neyman technique was used to determine the value(s) of the moderator at which the interactions became statistically significant.
Results
Consistent with the fact that data were collected in settings catering to younger, less experienced donors, the bedside research assistants noted that a fairly large number of participants (38.2%) were able to observe another donor being treated for syncope or presyncopal symptoms.
Vasovagal Symptoms
In analyses of the full dataset, whether or not the participant saw another donor experience a reaction was a significant predictor of their own symptoms reported on the BDRI, B = 1.608, 95% CI = 0.233 to 2.983, p = .022. Those who witnessed another being treated for symptoms had higher symptom scores. In addition, the logistic regressions showed that this variable also predicted whether the donor spontaneously reported feeling unwell to the phlebotomist during donation (OR = 2.422, 95% CI = 1.337 to 4.385, p = .004) and whether the phlebotomist initiated treatment procedures for vasovagal symptoms (OR = 2.588, 95% CI = 1.497 to 4.475, p = .001).
Seeing a reaction was not a statistically significant predictor of whether the donor fainted. This result may be attributable to the low prevalence of fainting in the sample (4.8%).
Physiological Responses to Donation
Witnessing another donor experience symptoms significantly influenced degree of HR change during the procedure, B = −1.574, 95% CI = −3.145 to −0.004, p = .049. More specifically, donors who saw a reaction had smaller compensatory increases in HR than those who did not see one (5.1 and 6.7 bpm, respectively).
No significant effects of seeing a reaction were found for SBP, DBP, RR, or PETCO2.
Empathy
In the present analyses, Affective Dissonance was reverse-scored, with higher scores reflecting one’s discomfort at seeing others in distress. The mean Cognitive Empathy score for the sample was 44.6 (SD = 8.5). The mean score for Affective Resonance was 49.9 (SD = 6.3) and the mean for Affective Dissonance was 53.5 (SD = 6.6). The regression coefficients from the following analyses are presented in table form in the Supplemental Materials.
In the regression equations using empathy to predict BDRI score, the interaction between seeing a reaction and Affective Dissonance score was significant, B = 0.371, 95% CI = 0.043 to 0.699 p = .027. At low (one standard deviation below the mean) and mean Affective Dissonance scores, the interaction was not significant. At high (one standard deviation above the mean) Affective Dissonance scores, the interaction was significant, B = 4.534, t(218) = 2.90, 95% CI = 1.44 to 7.62, p = .004. Johnson-Neyman analyses showed that this interaction became significant at an Affective Dissonance score of 54.3, B = 2.185, t(218) = 1.97, 95% CI = 0 to 4.37, p = .05. Those who had higher Affective Dissonance scores (thus, experiencing more discomfort at the suffering of others) and who saw a reaction reported the most symptoms. This relationship is represented in Fig. 1. The other ACME subscales, Cognitive Empathy and Affective Resonance, did not predict BDRI score.
Fig. 1.
Blood Donation Reaction Inventory score based on whether participant saw a vasovagal reaction and Affective Dissonance scores.
The chance of requiring treatment was predicted by Affective Resonance, OR = 1.152, 95% CI = 1.021 to 1.299, p = .021. In general, people with higher levels of Affective Resonance were more likely to require treatment for a VVR during donation. The interaction between seeing a reaction and Affective Dissonance (scored as higher distress at others’ suffering) was also statistically significant, OR =.833, 95% CI = 0.720 to 0.963, p = .014, as was the interaction between Cognitive Empathy and seeing a reaction, OR = 1.133, 95% CI = 1.005 to 1.277, p = .041. Interestingly, the direction of these effects differed. Similar to the BDRI finding, seeing another donor experience symptoms increased the chance of being treated oneself among individuals with higher Affective Dissonance scores (Fig. 2). At low (one standard deviation below the mean) Affective Dissonance scores, the interaction was not significant. At mean Affective Dissonance scores, the interaction was statistically significant, B = 1.043, 95% CI = 0.104 to 1.981, p = .029. At high (one standard deviation above the mean) Affective Dissonance Scores, the interaction was significant, B = 2.120, 95% CI = 0.847 to 3.392, p = .001. Johnson-Neyman analyses showed that this interaction became significant at an Affective Dissonance score of 52.86, B = .944, CI = 0 to 1.887, p = .05. On the other hand, higher Cognitive Empathy seemed to buffer the impact of seeing another donor experience symptoms (Fig. 3). At low (one standard deviation below the mean) Cognitive Empathy, the interaction was found to be statistically significant, B = 2.204, 95% CI = 0.625 to 3.784, p = .006. Additionally, at mean Cognitive Empathy scores, the interaction was also significant, B = 1.281, 95% CI = 0.325 to 2.238, p = .009. At high (one standard deviation above the mean), the interaction was no longer significant. Johnson-Neyman analyses showed that this interaction was significant at a Cognitive Empathy score of 48.15, B = .8920, 95% CI = 0 to 1.784, p = .05, and below. There was no observable benefit for donors with Cognitive Empathy scores above 48.15.
Fig. 2.
Risk for treatment based on whether a participant witnessed a vasovagal reaction and Affective Dissonance.
Fig. 3.
Risk for treatment based on whether a participant witnessed a vasovagal reaction and cognitive empathy.
Empathy was not significantly related to a participant reporting symptoms to the phlebotomist during donation.
While associations between empathy and physiological change were modest (there were no significant effects involving empathy and change in SBP, RR, HR, or DBP), for change in PETCO2 significant main effects were observed for both Affective Resonance (B = −.059, 95% CI = −0.109 to −0.009, p = .021) and Cognitive Empathy (B = −.041, 95% CI = −0.078 to −0.004, p = .031). In general, those with higher empathy scores had larger decreases in PETCO2 during blood donation. Since there were no effects on RR, this suggests an increase in deep breathing (increased tidal volume) and thus greater exhalation of CO2 in more empathetic individuals.
Discussion
As social animals, explicit and subtle social stimuli affect many aspects of human behavior and physiology. The potential impact of subtle, perhaps unconscious processes on physiological activity, even to the point of inducing physical symptoms and illness, testifies to the ability of social stimuli to get “under the skin.” For example, nonverbal observational effects of exposure to other people experiencing physical symptoms have been reported for a number of symptoms such as pain [30], coughing [3], nausea [31], yawning and fatigue [32], and vasovagal symptoms [12]. Mass psychogenic illness is likely a dramatic example of psychosocial contagion.
Whether or not the phenomenon of “epidemic fainting” is a true example of mass psychogenic illness, data from a randomized controlled trial of interventions to reduce the risk for VVR suggest that the psychosocial contagion of physical symptoms on an individual basis can, in fact, occur. Donors who witnessed another person experiencing a reaction were more likely to report symptoms both prospectively (in the chair) and retrospectively (on BDRI) and to receive treatment for a VVR during the procedure. While the physiological results are not extensive, they partially corroborate the behavioral results. Smaller compensatory increases in HR were observed in donors who saw another experiencing a VVR than those who did not. In general, these results replicate previous findings as Ditto et al. [12] observed higher BDRI scores, increased risk for being treated for a VVR, and an attenuated increase in HR in donors who witnessed a VVR. While the Ditto et al. [12] findings were restricted to experienced blood donors, the results of the current study extend to both novice and experienced donors. The lack of findings in first-time donors in the previous study may have been due to ceiling effects, which might not have been observed in the new, current sample. In addition, the smaller compensatory increases in HR exhibited by donors who witnessed a reaction are in line with previous research by Dimitroff et al. [23], which found that more empathetic individuals showed a cardiac deceleration response to videos of highly stressed speakers [23].
The results of the secondary analyses also suggest that empathy moderates the relationship between seeing another donor in distress and experiencing symptoms oneself though, interestingly, this may vary with the type of empathy. There were different results for Cognitive Empathy and the affective aspects of empathy (Affective Resonance and reverse-scored Affective Dissonance). Among those who saw another donor experience symptoms, Cognitive Empathy was associated with a reduced chance of being treated by the nurse. In contrast, participants with higher reverse-scored Affective Dissonance (thus feeling more distress at the suffering of another person) who saw another donor experience symptoms obtained higher BDRI scores and had a greater chance of being treated. Similarly, higher Affective Resonance was associated with an increased risk of requiring treatment for VVR. That said, the divergent effects of different types of empathy were not mirrored in the physiological responses to donation though higher levels of Affective Resonance and Cognitive Empathy were both associated with larger decreases in PETCO2 during donation. At this preliminary stage of research, it is difficult to interpret these latter results though one speculative idea is that deeper breathing by more empathetic participants may reflect greater mental engagement in the procedure, albeit with perhaps different effects depending on the type of empathy. It has been found previously that blood phobics, who hyperventilate by taking deep breaths when exposed to blood-related stimuli [8], report more distress when witnessing others’ negative emotional states than nonphobics [21]. The results of the current investigation are consistent with these findings.
Two leading theories attempting to explain how we make sense of the behaviors and experiences of others are theory of mind and simulation approaches [33]. Proponents of the theory of mind explanation suggest that humans attribute mental states to others to understand and predict their behavior in a systematic way [34]. This corresponds with the definition of cognitive empathy. According to simulation theories, people gain a better understanding of how others feel by invoking the mirror neuron system, thus recreating similar states and “feeling” the emotions themselves [26, 35]. This system is likely related to affective empathy. Perhaps a better cognitive understanding of how other people are feeling can function as a coping response, thereby reducing stress. More specifically, greater understanding of how another feels emotionally and physically might allow one to “compartmentalize” the experience and better observe similarities and differences in their own emotional and physical condition. Thus, greater cognitive empathy may allow donors to understand why some donors exhibit VVR, how they themselves feel differently from those donors, and that the same reaction will not occur for them. On the other hand, affective empathy, which involves the sharing of another person’s emotions [34], is almost by definition a more immersive experience that might exacerbate one’s own distress in a situation such as this.
One key strength of the study is the use of both self-report and observational measures. However, there are some limitations in the observational data. While research assistants were provided with criteria as to what constitutes a VVR, inter-rater reliability and the validity of these observations were not formally assessed. Though data on the concordance between research assistants’ observations of whether participants fainted or required treatment for a VVR and participants’ reports of these events was collected, participants were not asked to report whether they witnessed another donor have a reaction.
While the results are limited by the fact that most measures were not obtained continuously, the present investigation supports the conclusion that psychosocial contagion of physical symptoms can occur on an individual level in the blood donation setting. As well, empathy appears to moderate the relationship between witnessing another donor experiencing a VVR and developing symptoms oneself. Although further research is required to specify, for example, the directionality of these effects, this area of study has a number of potentially important clinical and theoretical implications.
If donors witness another donor experiencing an adverse reaction, they are more likely to have one themselves, especially if they have high affective empathy. As a result, they may be less likely to donate blood again. In that case, to ensure repeat donations, it appears that it may be advantageous to limit visual contact between donors by providing them with more privacy. On the other hand, previous research has shown that social support can reduce the likelihood of experiencing a presyncopal reaction and increase the likelihood that the donor will return to donate again within 1 year [36]. One other possibility to improve the donation experience would be to increase cognitive empathy in donors. Interventions have previously been developed to enhance blood donor competence [37]. Perhaps cognitive empathy could be encouraged in a similar manner. Online content such as articles or videos could be created to increase potential donors’ cognitive understanding of emotional and physical responses to blood donation. Further research is required to determine how to tailor the donor experience in light of the findings from the present investigation.
Supplementary Material
Acknowledgments
This research was supported by a grant from the Canadian Institutes of Health Research (MOP-133459).
Contributor Information
Serena Mennitto, Department of Psychology, McGill University, Montreal, QC, Canada.
David D Vachon, Department of Psychology, McGill University, Montreal, QC, Canada.
Thomas Ritz, Department of Psychology, Southern Methodist University, Dallas, TX, USA.
Pierre Robillard, Héma-Québec, Montreal, Quebec, Canada.
Christopher R France, Department of Psychology, Ohio University, Athens, OH, USA.
Blaine Ditto, Department of Psychology, McGill University, Montreal, QC, Canada.
Compliance with Ethical Standards
Authors’ Statement of Conflict of Interest and Adherence to Ethical Standards The authors declare that they have no conflicts of interest.
Ethical Approval Ethics approval was granted by the Héma-Québec Research Ethics Committee and the McGill University Research Ethics Board.
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