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Freeze, Flight, Fight, Fright, Faint: Adaptationist Perspectives on the Acute Stress Response Spectrum

  • H. Stefan Bracha

This article reviews the existing evolutionary perspectives on the acute stress response habitual faintness and blood-injection-injury type-specific phobia (BIITS phobia). In this article, an alternative evolutionary perspective, based on recent advances in evolutionary psychology, is proposed. Specifically, that fear–induced faintness (eg, fainting following the sight of a syringe, blood, or following a trivial skin injury) is a distinct Homo sapiens-specific extreme-stress survival response to an inescapable threat. The article suggests that faintness evolved in response to middle paleolithic intra-group and inter-group violence (of con-specifics) rather than as a pan-mammalian defense response, as is presently assumed. Based on recent literature, freeze, flight, fight, fright, faint provides a more complete description of the human acute stress response sequence than current descriptions. Faintness, one of three primary physiological reactions involved in BIITS phobia, is extremely rare in other phobias. Since heritability estimates are higher for faintness than for fears or phobias, the author suggests that trait-faintness may be a useful complement to trait-anxiety as an endophenotype in research on the human fear circuitry. Some implications for the forthcoming Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition as well as for clinical, health services, and transcriptomic research are briefly discussed.

Corresponding author
Please direct all correspondence to: H. Stefan Bracha, MD, U.S. Department of Veterans Affairs, Pacific Islands Health Care System, Spark M. Matsunaga Medical Center, National Center for PTSD, 1132 Bishop Street, #307, Honolulu, HI 96813-2830. Tel: 808-566-1650, Fax: 808-566-1885.
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1. Gray, JA. The Psychology of Fear and Stress. 2nd ed. New York, NY: Cambridge University Press; 1988.
2. Gray, JA. The Neuropsychohgy of Anxiety: An Enquiry into the Functions of the Septo-Hippocampal System. 2nd ed. New York, NY: Oxford University Press; 2003.
3. Nesse, RM. Proximate and evolutionary studies of anxiety, stress and depression: synergy at the interface. Neurosci Biobehav Rev. 1999;23:895903.
4. Page, AC. Blood-injury phobia. Clinical Psychology Review. 1994;14:443461.
5. Cannon, WB. Bodily Changes in Pain, Hunger, Fear and Range: An Account of Recent Research into the Function of Emotional Excitement. 2nd ed. New York, NY: Appleton-Century-Crofts; 1929.
6. Vaiva, G, Brunet, A, Lebigot, F, et al. Fright (effroi) and other peritraumatic responses after a serious motor vehicle accident: prospective influence on acute PTSD development. Can J Psychiatry. 2003;48:395401.
7. Vaiva, G, Ducrocq, F, Jezequel, K, et al. Immediate treatment with propranolol decreases posttraumatic stress disorder two months after trauma. Biol Psychiatry. 2003;54:947949.
8. Kraepelin, E. Psychiatry: A Textbook for Students and Physicians. New York, NY: Science History Publications; 1990.
9. Marks, I. Blood-injury phobia: a review. Am J Psychiatry. 1988;45:12071213.
10. Graham, DT. Prediction of fainting in blood donors. Circulation. 1961;23:901906.
11. Bracha, HS, Williams, AE, Ralston, TC, Bracha, AS, Matsukawa, JM. Does “fight or flight?” need updating? Psychosomatics. 2004;45:448449.
12. Perry, BD, Pollard, R. Homeostasis, stress, trauma, and adaptation. A neurodevelopmental view of childhood trauma. Child Adolesc Psychiatr Clin N Am. 1998;7:33.
13. Kaloupek, DG, Scott, JR, Khatami, V. Assessment of coping strategies associated with syncope in blood donors. J Psychosom Res. 1985;29:207214.
14. Grubb, BP, Olshansky, B. Syncope: Mechanisms and Management. 1st ed. New York, NY: Futura Publishing Company; 1998.
15. Daroff, RB, Carlson, MD. Faintness, syncope, dizziness, and vertigo. In: Braunwald, E, Fauci, AS, Kasper, DL, Hauser, SL, Longo, DL, Jameson, JL, eds. Harrison's Principles of Internal Medicine. New York, NY: McGraw-Hill Medical Publishing Division; 2001;111118.
16. Diagnostic and Statistical Manual of Mental Disorders. 4th ed-rev. Washington, DC: American Psychiatric Association; 2000.
17. Bienvenu, OJ, Eaton, WW. The epidemiology of blood-injection-injury phobia. Psychol Med. 1998;28:11291136.
18. Page, AC, Martin, NG. Testing a genetic structure of blood-injury-injection fears. Am J Med Genet. 1998;81:377384.
19. McGuire, MT, Troisi, A. Evolutionary biology and psychiatry. In: Sadock, BJ, Sadock, VA, eds. Comprehensive Textbook of Psychiatry. New York, NY: Lippincott Willians & Wilkins; 2000;484491.
20. Kendler, KS. Setting boundaries for psychiatric disorders. Am J Psychiatry. 1999;156:18451848.
21. Agras, S, Sylvester, D, Oliveau, D. The epidemiology of common fears and phobia. Compr Psychiatry. 1969;10:151156.
22. Costello, CG. Fears and phobias in women: a community study. J Abnorm Psychol. 1982;91:280286.
23. Grubb, BP, Karas, BJ. The potential role of serotonin in the pathogenesis of neurocardiogenic syncope and related autonomic disturbances. J Interv Card Electrophysiol. 1998;2:325332.
24. Victor, M, Ropper, AH. Faintness and Syncope. Adams and Victor's Principles of Neurology. New York, NY: McGraw-Hill; 2001;390403.
25. Engel, GL. Psychologic stress, vasodepressor (vasovagal) syncope, and sudden death. Ann Intern Med. 1978;89:403412.
26. Kleinknecht, RA. Vasovagal syncope and blood/injury fear. Behav Res Ther. 1987;25:175178.
27. Neale, MC, Walters, EE, Eaves, LJ, Kessler, RC, Heath, AC, Kendler, KS. Genetics of blood-injury fears and phobias: a population-based twin study. Am J Med Genet. 1994;54:326334.
28. Berntson, GG, Cacioppo, JT, Binkley, PF, Uchino, BN, Quigley, KS, Fieldstone, A. Autonomic cardiac control. III. Psychological stress and cardiac response in autonomic space as revealed by pharmacological blockades. Psychophysiology. 1994;31:599608.
29. Appenzeller, O. The Autonomic Nervous System: An Introduction to Basic and Clinical Concepts. Amsterdam, Netherlands: Elsevier; 1990.
30. Merckelbach, H, Muris, P, de Jong, PJ, de Jongh, A. Disgust sensitivity, blood-injection-injury fear, and dental anxiety. Clinical Psychology and Psychotherapy. 1999;6:279285.
31. Berntson, GG, Cacioppo, JT. Anxiety and cardiovascular reactivity: the basal forebrain cholinergic link. Behav Brain Res. 1998;94:225248.
32. Berntson, GG, Cacioppo, JT, Quigley, KS. Autonomic determinism: the modes of autonomic control, the doctrine of autonomic space, and the laws of autonomic constraint. Psychol Rev. 1991;98:459487.
33. Berntson, GG, Cacioppo, JT, Quigley, KS, Fabro, VT. Autonomic space and psychophysiological response. Psychophysiology. 1994;31:4461.
34. Miller, GF. The Mating Mind: How Sexual Choice Shaped the Evolution of Human Nature. New York, NY: Anchor Books; 2001.
35. Miller, GF. Mate choice: from sexual cues to cognitive adaptations. Ciba Found Symp. 1997;208:7182.
36. Miller, GF. Mental traits as fitness indicators. Expanding evolutionary psychology's adaptationism. Ann N Y Acad Sci. 2000;907:6274.
37. Gould, JL, Gould, CG. Sexual Selection. New York, NY: Scientific American Library; 1997.
38. Campbell, A. Staying alive: evolution, culture, and women's intrasexual aggression. Behav Brain Sci. 1999;22:203214.
39. Darwin, C. The Descent of Man and Selection in Relation to Sex. New York, NY: Crowell; 1874.
40. LeBlanc, SA, Register, KE. Constant Battles: The Myth of the Peaceful, Noble Savage. New York, NY: St. Martin's Press; 2003.
41. Keeley, LH. War Before Civilization: The Myth of the Peaceful Savage. New York, NY: Oxford University Press; 1996.
42. Larsen, CS. Bioarchaeology: Interpreting Behavior From the Human Skeleton [paper-back]. 1st ed. Cambridge, Mass: Cambridge University Press; 1999.
43. Morgan, E. The Scars of Evolution. London, England: Oxford University Press; 1990.
44. Diamond, J. The Third Chimpanzee: The Evolution and Future of the Human Animal. New York: Harper Perennial; 1992.
45. Klein, RG, Edgar, B. The Dawn of Human Culture. New York, NY: John Wiley & Sons, Inc.; 2002.
46. Ortner, DJ, Putschar, WGJ. Identification of Pathological Conditions In Human Skeletal Remains. Washington, DC: Smithsonian Institution Press; 1985.
47. Snow, CE. Early Hawaiians: An Initial Study of Skeletal Remains from Mokapu, Oahu. Lexington, Ky: The University Press of Kentucky; 1974.
48. Lacey, R, Danziger, D. The Year 1000: What life Was Like at the Turn of the First Millennium. New York, NY: Little, Brown and Company; 1999.
49. Salazar, CF. The Treatment of War Wounds in Graeco-Roman Antiquity (Studies in Ancient Medicine). Boston, Mass: Brill Academic Publishers; 2000.
50. Porges, SW. Cardiac vagal tone: a physiological index of stress. Neurosci Biobehav Rev. 1995;19:225233.
51. Bracha, HS, Yamashita, JM, Ralston, T, et al. Clinical research histomarkers for objectively estimating premorbid vagal tone chronology in Gulf War Veterans' Illnesses and in acute stress reaction. In: Nation, J, Trofimova, I, Rand, JD, Sulis, W, eds. Formal Descriptions of Developing Systems. Dordrecht, Netherlands: Kluwer Academic Publishers; 2003.
52. Bracha, HS. Can premorbid episodes of diminished vagal tone be detected via histological markers in patients with PTSD? Int J Psychophysiol. 2004;51:127133.
53. Shalev, AY, Sahar, T, Freedman, S, et al. A prospective study of heart rate response following trauma and the subsequent development of posttraumatic stress disorder. Arch Gen Psychiatry. 1998;55:553559.
54. Shalev, AY. Acute stress reactions in adults. Biol Psychiatry. 2002;51:532543.
55. Bryant, RA. Early predictors of posttraumatic stress disorder. Biol Psychiatry. 2003;53:789795.
56. Bryant, RA, Harvey, AG, Guthrie, RM, Moulds, ML. A prospective study of psychophysiological arousal, acute stress disorder, and posttraumatic stress disorder. J Abnorm Psychol. 2000;109:341344.
57. Nixon, RD, Bryant, RA. Peritraumatic and persistent panic attacks in acute stress disorder. Behav Res Ther. 2003;41:12371242.
58. Bryant, RA, Moulds, ML, Guthrie, RM. Acute Stress Disorder Scale: a self-report measure of acute stress disorder. Psychol Assess. 2000;12:6168.
59. Porges, SW. The polyvagal theory: phylogenetic substrates of a social nervous system. Int J Psychophysiol. 2001;42:123146.
60. Pitman, RK, Sanders, KM, Zusman, RM, et al. Pilot study of secondary prevention of posttraumatic stress disorder with propranolol. Biol Psychiatry. 2002;51:189192.
61. Jehel, L, Paterniti, S, Brunet, A, Duchet, C, Guelfi, JD. Prediction of the occurrence and intensity of post-traumatic stress disorder in victims 32 months after bomb attack. Eur Psychiatry. 2003;18:172176.
62. Underhill, PA, Passarino, G, Lin, AA, et al. Maori origins, Y-chromosome haplotypes and implications for human history in the Pacific. Hum Mutat. 2001;17:271280.
63. Seielstad, MT, Minch, E, Cavalli-Sforza, LL. Genetic evidence for a higher female migration rate in humans. Nat Genet. 1998;20:278280.
64. Pires, LA, Ganji, JR, Jarandila, R, Steele, R. Diagnostic patterns and temporal trends in the evaluation of adult patients hospitalized with syncope. Arch Intern Med. 2001;161:18891895.
65. Nesse, RM. Testing evolutionary hypotheses about mental disorders. In: Stearns, SC, ed. Evolution in Health and Disease. Oxford, England: Oxford University Press; 1999;260266.
66. McColl, G, Jenkins, NL, Walker, DW, Lithgow, GJ. Testing evolutionary theories of aging. Ann N Y Acad Sci. 2000;908:319320.
67. Marsella, AJ, Friedman, MJ, Gerrity, E, Scurfield, RM. Ethnocultural Aspects of Posttraumatic Stress and Related Stress Disorders. Washington, DC: American Psychological Association Press; 1996.
68. Friedman, MJ, Schnurr, PP, Sengupta, A, Holmes, T, Ashcraft, M. The Hawaii Vietnam veterans project: is minority status a risk factor for posttraumatic stress disorder? J Nerv Ment Dis. 2004;192:4250.
69. Mohr, C, Hubener, F, Laska, M. Deviant olfactory experiences, magical ideation, and olfactory sensitivity: a study with healthy German and Japanese subjects. Psychiatry Res. 2002;111:2133.
70. Bracha, HS, Williams, AE, Haynes, SN, Kubany, ES, Ralston, TC, Yamashita, JM. The STRS (shortness of breath, tremulousness, racing heart, and sweating): a brief checklist for acute distress, with panic-like sympathetic indicators; development and factor structure. Ann Gen Hosp Psychiatry. 2004;3:8.
71. Bracha, HS, Williams, AE, Ralston, TC. Criterion A3 for PTSD: incorporating a proposed diagnostic criterion into clinical practice. Current Psychiatry. In press.
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