Manual for the
Blood-Injection Symptom Scale (BISS)
and the
State Blood-Injection Symptom Scale (S-BISS)
Department of
Psychology, University of Western Australia
INDEX
The Blood-Injection Symptom Scale (BISS)
The State Blood-Injection Symptom Scale (S-BISS)
© Andrew C. Page, 1999. This
manual may be copied in an unmodified form by clinicians and researchers for
use with their clients and subjects. This is acceptable to the author, who,
nevertheless, disclaims any responsibility for the consequences of any such use
for this material in clinical practice or research. It is not necessary to
write to the author for permission to make individual copies. This permission
does not extend to making multiple copies for sale.
The BISS was developed in collaboration with Kellie S. Bennett,
Owen Carter, Julia Smith, and Kirrily Woodmore
The State BISS was developed in collaboration with Anna Fagence,
Ilyana Saat, & Nicole Watts
The Blood-Injection Symptom Scale
(BISS; Page, Bennett, Carter, Smith, & Woodmore, 1997) is a scale that is
designed to measure symptoms elicited by blood and injection stimuli. It was
originally conceived to complement the existing questionnaires that assessed:
1.
General fears
and phobias (e.g., the Fear Questionnaire [FQ; Marks & Mathews, 1979] and
the Fear Survey Schedule [FSS; Wolpe & Lang, 1977],
2.
Phobic
situations avoided by people with concerns about blood and injections (e.g.,
the Mutilation Questionnaire [MQ; Klorman, Weerts, Hastings, Melamed, &
Lang, 1974] and the Medical Fears Survey (MFS; Kleinknecht, Thorndike, &
Walls, 1996).]), and
3.
Phobic
responses to situations involving blood, injury, and injections (e.g., the
Medical Avoidances Survey [MAS; Kleinknecht et al., 1996]).
It aimed to complement these
assessments by measuring the symptoms of fear (see Blood Donation Reaction
Inventory [BDRI; Meade, France, & Richardson, 1996]) and faintness that
occurred in situations involving blood or injections. The original BISS aimed
to assess the symptoms that had occurred in the presence of blood and
injections during the one of the worst experiences. Since then, the scale has
been adapted for use as a state instrument (see Hepburn & Page, 1999) and
we are now in the process of developing a state version of the BISS (i.e., the
S-BISS). The S-BISS has larger item set and is sensitive to changes in
symptoms.
This manual is an evolving
document that is intended to capture the state of development of the instrument
at the present time. As the tests are refined and more data become available,
we will continue to revise the manual.
The Blood-Injection
Symptom Scale (BISS)
For a complete account see Page, et al., (1997).
Development
Exploratory factor analysis on an
initial 300 subjects identified six factors with eigenvalues greater than one,
but examination of the scree plot suggested a three factor solution. Given the
greater theoretical coherence of the smaller number of factors suggested by the
scree plot, we favoured the three factor solution that explained 42% of scale
variance. The labels "faintness," "anxiety," and
"tension" seemed to capture the nature of the factors. Four of the
original 21 items failed to load substantially on the three primary factors and
were omitted. The tripartite factor structure was substantiated in a subsequent
confirmatory factor analysis on 300 additional Introductory Psychology
students. The three latent variables were intercorrelated. Faintness correlated
with anxiety (r = .60) and tension (r = .73), and anxiety and
tension were also intercorrelated (r = .80).
The resulting scale is a 17-item scale, with the following items:
The Blood-Injection Symptom Scale.
These questions ask about
sensations that you may experience in situations involving blood or injections.
For each sensation, circle "yes" if you noticed the sensation during
one of your worst experiences involving blood or injections and circle
"no" if you did not notice the sensation during one of your worst
experiences involving blood or injections.
|
1. Did you have tightness, pain or discomfort in your chest? |
No / Yes |
|
2. Were you anxious? |
No / Yes |
|
3. Did you have blurred vision? |
No / Yes |
|
4. Did you have cold or clammy hands? |
No / Yes |
|
5. Were you dizzy or lightheaded? |
No / Yes |
|
6. Did you feel faint? |
No / Yes |
|
7. Were you fatigued? |
No / Yes |
|
8. Did you faint? |
No / Yes |
|
9. Did feel unreal? |
No / Yes |
|
10. Did your heart pound? |
No / Yes |
|
11. Were you particularly irritable? |
No / Yes |
|
12. Did you feel nauseous? |
No / Yes |
|
13. Did the room spin? |
No / Yes |
|
14. Did you sweat? |
No / Yes |
|
15. Did your muscles feel tense, sore, or ache? |
No / Yes |
|
16. Did you tremble? |
No / Yes |
|
17. Did you have trouble walking? |
No / Yes |
Scoring
To score the test, a
"No" response is given a score of zero and a "Yes" response
a score of one.
Normative Information
Table 2 in Page et al. (1997)
displays the conversions to T-scores for each of the three BISS subscales, the
fear subscale (combining anxiety and tension), and the total scale score (summing
across the faintness, anxiety and tension) in the original sample of 605
Introductory Psychology students. Subsequently, additional subjects have
completed the questionnaire and their data have been collated with the original
sample to generate a larger normative sample, now based on 1,251 Introductory
Psychology students. All subjects completed the questionnaire during tutorial
classes as part of screening sessions to identify individuals who were suitable
for participation in further studies. The normative information is available in
three different formats. The data are available as descriptive statistics and
percentiles for the total sample of 1,251 individuals, descriptive statistics
and percentiles for the 1,251 females, descriptive statistics and percentiles
for 1,251 males. The BISS scores did not exhibit any relationship with age in
the present sample (r = -.05 between age and the total BISS score) and
therefore, the sample was not broken down by age.
Descriptive Statistics for Total Sample (n=1,251; Mean age = 19.1)
|
Subscale |
Mean |
SD |
SEM |
|
BISS Fainting |
2.13 |
2.48 |
.07 |
|
BISS Anxiety |
2.48 |
1.68 |
.05 |
|
BISS Tension |
1.10 |
1.27 |
.03 |
|
BISS Fear |
3.58 |
2.58 |
.07 |
|
BISS Total |
5.71 |
4.57 |
.13 |
Cut Points for Percentiles of Total Sample (n=1,251)
|
Percentile |
Faintness |
Anxiety |
Tension |
Fear |
Total |
|
10 |
0 |
0 |
0 |
0 |
0 |
|
20 |
0 |
1 |
0 |
1 |
1 |
|
30 |
0 |
1 |
0 |
2 |
2 |
|
40 |
1 |
2 |
0 |
3 |
3 |
|
50 |
1 |
2 |
1 |
3 |
5 |
|
60 |
2 |
3 |
1 |
4 |
6 |
|
70 |
3 |
3 |
2 |
5 |
8 |
|
80 |
4 |
4 |
2 |
6 |
10 |
|
90 |
6 |
5 |
3 |
7 |
12 |
Descriptive Statistics for Males (n=371; Mean age = 19.6)
|
Subscale |
Mean |
SD |
SEM |
|
BISS Fainting |
1.41 |
1.98 |
.11 |
|
BISS Anxiety |
2.06 |
1.55 |
.08 |
|
BISS Tension |
0.87 |
1.09 |
.05 |
|
BISS Fear |
2.93 |
2.31 |
.12 |
|
BISS Total |
4.36 |
3.91 |
.29 |
Cut Points for Percentiles of Males
|
Percentile |
Faintness |
Anxiety |
Tension |
Fear |
Total |
|
10 |
0 |
0 |
0 |
0 |
0 |
|
20 |
0 |
1 |
0 |
1 |
1 |
|
30 |
0 |
1 |
0 |
1 |
2 |
|
40 |
0 |
1 |
0 |
2 |
2 |
|
50 |
1 |
2 |
0 |
3 |
3 |
|
60 |
1 |
2 |
1 |
3 |
4 |
|
70 |
2 |
3 |
1 |
4 |
5 |
|
80 |
3 |
3 |
2 |
5 |
7 |
|
90 |
4 |
4 |
2 |
6 |
11 |
Descriptive Statistics for Females (n=879; Mean age = 18.9)
|
Subscale |
Mean |
SD |
SEM |
|
BISS Fainting |
2.42 |
2.60 |
.09 |
|
BISS Anxiety |
2.65 |
1.71 |
.06 |
|
BISS Tension |
1.19 |
1.33 |
.05 |
|
BISS Fear |
3.84 |
2.65 |
.09 |
|
BISS Total |
6.27 |
4.71 |
.61 |
Cut Points for Percentiles of Females
|
Percentile |
Faintness |
Anxiety |
Tension |
Fear |
Total |
|
10 |
0 |
0 |
0 |
0 |
1 |
|
20 |
0 |
1 |
0 |
1 |
2 |
|
30 |
0 |
2 |
0 |
2 |
3 |
|
40 |
1 |
2 |
0 |
3 |
4 |
|
50 |
2 |
3 |
1 |
4 |
6 |
|
60 |
2 |
3 |
1 |
4 |
7 |
|
70 |
4 |
4 |
2 |
5 |
9 |
|
80 |
5 |
4 |
2 |
6 |
11 |
|
90 |
7 |
5 |
3 |
8 |
13 |
In Page et al. (1997) subjects
were divided according to gender because females reported more symptoms of
anxiety (F (1, 595) = 16.43; p < .001), tension (F (1,
590) = 9.80; p < .01), fear (F (1, 587) = 18.80; p <
.001), and faintness (F (1, 598) = 23.03; p < .001) than
males. Females reported more symptoms on the total BISS than males (F
(1, 586) = 27.82; p < .001). In the larger sample of 1,251 subjects
females reported more symptoms of anxiety (F (1, 1226) = 32.20; p
< .001), tension (F (1, 1224) = 17.33; p < .01), fear (F
(1, 1216) = 32.23; p < .001), and faintness (F (1, 1183) =
42.20; p < .001) than males (all tests were two-tailed). Females
reported more symptoms on the total BISS than males (F (1, 1170) =
44.10; p < .001).
Page et al. (1997) reported a
reliability analysis (using unit weights to sum subscales) indicated that the
internal consistency, indicated by coefficient alphas, were .86 for the total
scale score, .85 for the nine-item faintness subscale, .68 for the four-item
anxiety subscale, .56 for the four-item tension subscale, and .72 for the
eight-item fear subscale (where anxiety and tension were combined). Bivariate
correlations revealed that the faintness subscale correlated moderately with
the fear subscale (r = .50; p < .01), as well as the anxiety (r
= .41; p < .01) and tension (r = .43; p < .01)
subscales, which in turn correlated moderately with each other (r = .43;
p < .01). In the larger sample of 1,251 subjects the respective
relationships were similar. The faintness subscale correlated moderately with
the fear subscale (r = .60; p < .01), as well as the anxiety (r
= .55; p < .01) and tension (r = .49; p < .01)
subscales, which in turn correlated moderately with each other (r = .52;
p < .01).
Validity
Page et al. (1997) were able to
replicate Öst's (1992) finding that people with concerns about injections
reported greater fearful symptoms than people with concerns about blood.
Further, people with concerns about blood were more likely to report symptoms of
faintness. The replication of this pattern of results goes some way to validate
the BISS.
Hepburn & Page (1999) modified
the BISS into a state instrument and reported some additional psychometric
information. They modified the instructions to refer to a discrete time period.
The wording was: "These questions ask about sensations that you may
experience while watching the slide. For each sensation, circle 'yes'" if
you noticed the sensation while you watched the slide and circle 'no' if you did
not notice the sensation while you watched the slide." To determine if the
modification altered the psychometric properties of the instrument, a group of
91 introductory psychology students were recruited. They examined two colour
slides, depicting an arm with an open and bloody wound and an arm receiving an
injection. Subjects completed the questionnaire before and after each of the
two slides. The slides were presented for two minutes. Slide order was
counterbalanced across subjects with a ten-minute inter-trial interval.
The total scale score demonstrated
satisfactory internal consistency, with coefficient alphas being higher when
reporting about symptoms during the presentation of the slides (a
= .71) than in the period before presentation of the slides (a
= .61). The stability of scores across a short time interval was estimated by
averaging the correlations of the two pre-exposure assessments and the two
post-test exposure assessments. The average correlation of the total score was
.62, indicating stability in the rank ordering of subjects. The total score was
also sensitive to the presence of a blood-injection stimulus. The mean number
of symptoms endorsed increased from .86 to 2.12 (F (1,90) = 42.63; h
2 = .32; p < .001) when the slides were presented. The total fear and
faintness subscales correlated to a moderate degree (r = .38), indicating that
the conceptually distinct subscales were measuring different sets of symptoms.
(See Table 1 in Hepburn & Page, 1999 for more detail).
In the subsequent experiment, they
found that subjects were exposed to a blood-injury phobic slide for twelve
trials (four blocks of three) and listened to narratives designed to elicit
images associated with fear, disgust, or anger. Reductions in both fear and
faintness occurred in every condition, supporting the sensitivity of the index.
Construct validity was supported in part because images of fear increased
symptoms of both fear and faintness relative to a control. Images of disgust
increased symptoms of faintness but not fear.
The State Blood-Injection
Symptom Scale (S-BISS)
Introduction
The State Blood-Injection Symptom
scale (SBISS; Page, Fagence, Saat, & Watts, 1999) is a scale that is
designed to measure the immediate reactions and symptoms that are elicited by
the exposure to blood, injury, and/or injection stimuli. It was developed to
complement the trait BISS by assessing immediate state faintness, anxiety, and
tension felt in the presence of blood, injury, and/or injection stimuli as well
as assessing severity by the use of a five-point Likert type scale.
Development
The SBISS is a modification of the
existing BISS. This was achieved by rewording 16 of the items in the BISS to a
state nature, re-trialing previous items trialed in the BISS but which failed
to make the final measure, adding additional items after a literature search,
and changing the response format from a dichotomous format to a five-point
Likert type scale. For example, Item 2 in the BISS – "Were you
anxious?" was reworded to "To what extent are you feeling
anxious". Item 8 in the BISS ("Did you faint?") could not be
reworded into a state measure however Item 6 in the BISS - "Did you feel
faint?" was reworded to "To what extent are you feeling faint?".
Secondly, 20 items that were previously trialed in the BISS but which failed to
make the final BISS were reworded for inclusion into the SBISS. These were
reworded into a state format as well as being reworded in other ways. For
example, the item "Did you need to go to the toilet?" was reworded
into two items for the SBISS – " To what extent are you feeling the urge
to urinate?" and "To what extent are you feeling the urge to defecate?".
Thirdly, two items were generated by an examination of the blood, injury,
and/or injection phobia literature. Fourthly, the dichotomous response format
of BISS was changed to a five-point Likert scale to assess severity of the
symptoms felt and each item in the SBISS was prefaced with the question –
"To what extent are you feeling….?". The anchor points – "not at
all", "mildly", "moderately", "strongly",
and "severely" were chosen as it was thought that they best
represented the experience of feeling the sensation within the individual as
well as being relatively similar in their perceived cognitive distance.
Sample
Eighty-five participants (53
female, 32 male) were recruited from the general community (Perth, Western
Australia) via advertisement, and conveniently sampled from the University of
Western Australia’s introductory psychology course. Ages ranged from 17 – 52
years (Mdn = 19.0 yr., SD = 8.08). It was found that 11.8% of the sample
fulfilled the DSM-IV criteria for Blood-Injury-Injection Phobia. Forty-two
participants were shown an eight minute mute video of a surgical procedure in
which both blood and injections were present (experimental condition). The
remaining 43 participants were shown an eight minute mute wildlife video which
featured an number of animals in a forest environment (control condition) and
the SBISS was administered pre and post video.
Measure
Of the 37 items trialed, 28 were
included into the final SBISS on the basis of item distribution and correlation
analysis. The SBISS retained the tripartite factor structure observed in the
BISS with items loading on the "faintness", "anxiety", and
"tension" factors. The SBISS is presented below.
The State Blood-Injection Symptom Scale
These questions ask about
sensations which you may or may not be experiencing right now. It is
important that you answer these questions with regard to how you are feeling right
now. For each of the questions you will be asked to rate how strongly you
are feeling that sensation. There are five levels to choose from.
|
0 |
1 |
2 |
3 |
4 |
|
Not at all |
Mildly |
Moderately |
Strongly |
Severely |
For example – if the question does
not describe in any way the sensation you are feeling the circle the 0. If the
question totally describes that way you are feeling then circle the 4.
Please answer every question and remember to answer the questions
with regard to how you are feeling right now.
______________________________________________________________________________________________
To what extent are you feeling:
|
1) tightness, discomfort, or pain in your chest? |
0 |
1 |
2 |
3 |
4 |
|
2) anxious? |
0 |
1 |
2 |
3 |
4 |
|
3) that your vision is blurry? |
0 |
1 |
2 |
3 |
4 |
|
4) that your hands are cold or clammy? |
0 |
1 |
2 |
3 |
4 |
|
5) lightheaded or dizzy? |
0 |
1 |
2 |
3 |
4 |
|
6) faint? |
0 |
1 |
2 |
3 |
4 |
|
7) that you or things around you are unreal? |
0 |
1 |
2 |
3 |
4 |
|
8) that your heart is pounding? |
0 |
1 |
2 |
3 |
4 |
|
9) more irritable than usual? |
0 |
1 |
2 |
3 |
4 |
|
10) nauseous? |
0 |
1 |
2 |
3 |
4 |
|
11) like the room is spinning? |
0 |
1 |
2 |
3 |
4 |
|
12) that you are sweating? |
0 |
1 |
2 |
3 |
4 |
|
13) that your muscles are tense, sore, or achy? |
0 |
1 |
2 |
3 |
4 |
|
14) that you are trembling? |
0 |
1 |
2 |
3 |
4 |
|
15) that if you stood up you would have trouble walking? |
0 |
1 |
2 |
3 |
4 |
|
16) hot flushes? |
0 |
1 |
2 |
3 |
4 |
|
17) chills? |
0 |
1 |
2 |
3 |
4 |
|
18) that you are short of breath? |
0 |
1 |
2 |
3 |
4 |
|
19) that your thoughts are racing? |
0 |
1 |
2 |
3 |
4 |
|
20) like you are about to vomit? |
0 |
1 |
2 |
3 |
4 |
|
21) like your fingers are tingling? |
0 |
1 |
2 |
3 |
4 |
|
22) that you are restless? |
0 |
1 |
2 |
3 |
4 |
|
23) that you are having difficulty swallowing? |
0 |
1 |
2 |
3 |
4 |
|
24) tired? |
0 |
1 |
2 |
3 |
4 |
|
25) muscle weakness? |
0 |
1 |
2 |
3 |
4 |
|
26) headachy? |
0 |
1 |
2 |
3 |
4 |
|
27) that your hearing is fuzzy? |
0 |
1 |
2 |
3 |
4 |
|
28) disgusted? |
0 |
1 |
2 |
3 |
4 |
Scoring
Reliability
The SBISS is observed to be a
reliable measure of the immediate reactions elicited by blood, injury, and/or
injection stimuli. The SBISS has a high level of internal consistency (a = .94). Each of the subscales are also
seen to exhibit good internal consistency (anxiety - a = .86; tension - a = .83; faintness - a = .83). The SBISS appears to be sensitive
to change as there was a significant difference between scores on the SBISS pre
and post video (t (41) = -2.55; p = .01) in the experimental condition (surgical
video).
Validity
Validity was measured by
correlating the SBISS with a number of measures that were administered at the
same time as the SBISS.
Concurrent validity:
Concurrent validity was measured
by correlating scores on the post video administration of the SBISS with scores
on the BISS. It was found that there was a positive correlation (r = .47; p
< .001) between the scores.
Convergent validity:
Convergent validity was measured
by correlating the anxiety and tension subscale scores on the post video
administration of the SBISS with the anxiety and stress subscales scores on the
post video administration of the Depression Anxiety Stress Scale (DASS;
Lovibond & Lovibond, 1995) which was also administered pre and post video.
It was found that both the anxiety and tension subscales of the SBISS
significantly correlated with the anxiety and stress subscales of the DASS
(anxiety-anxiety: r = .76; p < .0001, tension-stress: r = .47; p <
.0001).
Discriminant validity:
Discriminant validity was measured
by comparing the scores on the depression subscale of the DASS with scores on
all three subscales of the SBISS. There were no significant correlations
between the subscales (faintness-depression: r = -.003; p = .98,
anxiety-depression: r = .01; p = .94, tension-depression: r = .09; p = .42).
Construct validity:
Construct validity was measured by
correlating scores on the post video administration SBISS with scores on the
Medical Fears Survey (MFS: Kleinknecht, Thorndike, & Walls, 1996) which was
administered pre video. It was found that the total score on the SBISS was
significantly correlated with the total score on the MFS (r = .56; p <
.0001). Additionally, the SBISS’s subscales were found to be significantly
correlated with subscales ("injection and blood", and
"blood") in the MFS (tension-injections and blood draws: r = .42; p
< .0001, tension-blood: r = .38; p < .0001, faintness-blood: r = .47; p
< .0001, anxiety-injections and blood draws: r = .46; p < .0001).
* Indicates references using the
BISS
* Hepburn, T., & Page, A. C.
(1999). Effects of images about fear and disgust upon responses to blood-injury
phobic stimuli. Behavior Therapy, 30, 63-77.
Kleinknecht, R. A., Thorndike, R.
M., & Walls, M. M. (1996). Factorial dimensions and correlates of blood,
injury, injection and related medical fears: Cross validation of the Medical
Fears Survey. Behaviour Research and Therapy, 34, 323-331.
Klorman, R., Weerts, T., Hastings,
J., Melamed, B., & Lang, P. (1974). Psychometric description of some fear-specific
questionnaires. Behavior Therapy, 5, 401-409.
Lovibond, P., & Lovibond, S.
(1995). The structure of negative emotional states: Comparison of the
Depression Anxiety Stress Scale with the Beck Depression and Anxiety
Inventories. Behavior, Research, and Therapy, 33, 335-343.
Marks, I. M., & Mathews, A. M.
(1979). Brief standard self-rating for phobic patients. Behaviour Research
and Therapy, 17, 263-267.
Meade, M. A., France, C. R., &
Peterson, L. M. (1996). Predicting vasovagal reactions in volunteer blood
donors. Journal of Psychosomatic Research, 40, 495-501.
Öst, L-G. (1992). Blood and
injection phobia: Background and cognitive, physiological, and behavioral
variables. Journal of Abnormal Psychology, 101, 68-74.
Page, A. C. (1994). Blood-injury phobia.
Clinical Psychology Review, 14, 443-461.
* Page, A. C., Bennett, K.,
Carter, O., Smith, J., & Woodmore, K. (1997). The Blood-Injection Symptom
Scale (BISS): Assessing a structure of phobic symptoms elicited by blood and
injections. Behaviour Research and Therapy, 35, 457-464.
Wolpe, J., & Lang, P. J.
(1977). Manual for the Fear Survey Schedule. San Diego, CA: Educational
and Industrial Testing Service.
Address: http://www.psy.uwa.edu.au/user/andrew/biss.htm
Email: / andrew@psy.uwa.edu.au
Last Updated: October 13, 2000