Rachel Jackson
It must have looked like this: a woman walked into a coffee shop. She was limping a little, slightly pale, and as she stood in line, she struck up a conversation with one of the two paramedics in line in front of her. They chatted briefly and she lifted the cuff of her jeans to point to her left foot where a large bruise was blooming along the swollen, exposed ridge visible above her moccasin. The paramedic winced and began explaining something using a snapping motion with his hands. The woman looked away—at the floor first, then the ceiling, then the pastry case. She looked worried. She leaned over and put her hands on her knees and appeared to be gasping. The paramedic stared and reached over to tap his partner, who was in the middle of ordering a drink. The woman straightened, smiled, and turned to walk away, but as she did, her eyes widened and rolled back in her head, her body stiffened, and she fell hard, like a cut tree, barely missing the display of discount holiday mugs.
On the floor, facedown, she began to convulse. The paramedics scrambled to either side of her and attempted to turn her on her side. Her arms flailed and her legs shuffled and her wide-open eyes showed only white. A recording of John Coltrane’s “My Favorite Things” played softly overhead, and as one paramedic ran outside for the gurney, the other called to the woman in a loud voice, as if she was far away, “Ma’am, are you on anti-seizure medication? Ma’am? Easy, easy. I need to know if you’re epileptic. Can you hear me?”
The woman went limp, and as the paramedic with the gurney asked a couple to scoot their table aside to make way, the other paramedic squatted next to her and held her wrist, frowning at his watch. “I’m having trouble finding a radial,” he said to his partner.
At this, the woman stirred. Her eyes opened and she sucked at the air loudly, greedily. She slowly pushed herself to a sitting position and said, “Oh no.”
“Ma’am, it’s OK. Are you on any anti-seizure medication? Anything for epilepsy?”
“No,” she said. “No, I…I do this all the time.”
And it’s true. I do. This is what happens occasionally when I get really upset and freak out over something, usually a relatively minor injury or a routine blood test. At least once a year, a pattern of thoughts turns into a series of chemical reactions, and I lose consciousness, crash into something, have rapid muscle spasms that look for all the world like an epileptic seizure, and then I lie limp and unresponsive for a while with dangerously low blood pressure, a weak, sluggish heartbeat, and a thready pulse. It scares the hell out of everyone. As for me, I’ve done it so many times and under so many circumstances that it’s mostly just humiliating. I have a refrain for these post-faint moments, and I’m usually saying it as I come to: “I’m sorry, I’m sorry, I’m sorry.”
Vasovagal syncope (vazo-vaygul sin-ko-pee) is the technical name for it, a “neurally-mediated, self-limited loss of consciousness.” “Vaso” means “vein,” and “vagal” refers to the vagus nerve, which in turn gets its name from the Latin word for “wandering.” It wanders from either side of the throat all the way down to the colon. Incidentally, it was the vagus nerve that was to blame for George W. Bush’s pretzel-induced faint—the pretzel got lodged in his throat and poked into this nerve, triggering a chemical reaction that knocked him out and sent him face-first into his coffee table and then to the floor where he awoke to find his dogs, Barney and Spot, staring at him.
“Neurally-mediated” or “neurogenic” are terms used to indicate that, unlike Mr. Bush’s incident where something jabbed him in the vagus nerve, and unlike faints that result from cardiac anomalies or loss of orthostatic pressure (i.e. standing up too fast), this type of faint is initiated purely by the brain. Thoughts, in other words, emotions, perceptions, have caused enough distress to trigger the brain’s ancient “fight or flight” response, and this response, for me, sometimes gets out of hand.
“Syncope” is a word with two meanings, one grammatical: “The shortening of a word by omission of a sound, letter, or syllable from the middle of the word; for example, bos’n for boatswain,” and one pathological: “A brief loss of consciousness caused by a temporary deficiency of oxygen in the brain; a swoon.”
Sometimes what I am thinking causes me to freak out so badly that my vagus nerve is triggered and all the blood leaves my brain, with the effect that short portions are edited out of my life.
So what triggers an overactive “fight or flight” response that then leads to vasovagal syncope? It’s different for everyone. Some people experience it when they hear particularly shocking or overwhelming news. This has been a convenient plot device for heroines in old movies. Others pass out at the sight of blood, or at graphic descriptions of injuries, or in situations in which they themselves are superficially injured or are undergoing a procedure involving needles. My mother’s response to my brother knocking out his two front teeth on the corner of the couch when he was six was to lie on the kitchen floor with her feet up, issuing instructions to my Uncle Dan about ice packs and bandages. My brother, all grown up and attending his first Wilderness First Responder course, hit the floor with a massive bang when the instructors described compound tibial fractures. I am my family’s champion fainter, claiming all pain-related medical events—blood draws, appendicitis, vaccinations, and once, spectacularly, right after I was being helped into our pick-up after wisdom tooth surgery. (I was sitting in the truck’s middle seat and the pseudo-seizure I had when I fainted caused my leg to slam down onto the accelerator. My brother was in the driver’s seat and wrestled my leg loose and stomped on the brake, causing me to bounce my swollen face off the dashboard, briefly come to and hit him as though the whole thing were his fault, and then pass out again. I wish I were making this up.)
This tendency in all of us is called Blood-injection-injury Type-specific phobia, or BIITS phobia. Of all the phobias currently recognized in the Diagnostic and Statistical Manual—Fourth Edition—Text Revision (DSM-IV-TR), BIITS phobia is the only one that often results in full-out fainting. Other phobias recognized by the DSM-IV-TR, like coulrophobia (fear of clowns), textophobia (fear of certain fabrics), or chorophobia (fear of dancing) typically cause only an “arousal response,” meaning the beginnings of “fight or flight,” and stop short of triggering the vagus nerve. Interestingly, BIITS phobia is also the only phobia with a marked pattern of family occurrence. No one agrees whether this is an example of a hereditary phenomena or conditioned learning.
The chemical mechanism at work in a classic, “neurogenic,” faint is a lightning fast choreography of overreactions. Distress signals from the brain cause a wave of adrenaline to crash through the body, which in turn kicks the heart into high gear, or tachycardia, narrows the blood vessels, raises blood pressure, and floods the heart and lungs with blood. These are the body’s “oh shit” responses, developed over the ages to prepare humans to recognize and flee from predators or fight for their lives. A true state of panic, however, one where the brain and body react as though the threat were genuinely lethal, can only be sustained for so long.
In people with a history of vasovagal syncope, the “fight or flight” response seems especially prone to overheating and then triggering a response from the body’s emergency pressure valve, the vagus nerve. From its privileged position close to the brain, this nerve sends up a message authorizing the release of massive amounts of the neurotransmitter acetylcholine, adrenaline’s opposite. The overactive heart gets ice water thrown on it and moves to its opposite extreme, bradycardia, and all the major blood vessels in the gut and legs suddenly dilate. Blood volume plunges and pools in the legs, leaving the brain with too little circulation to keep functioning. Musculoskeletal control is lost and the body collapses. It is the brain’s last-ditch effort to reclaim the blood it needs—if the heart is suddenly too weak or slow to pump blood upwards, the body must be brought down.
And here the response usually ends. Sometimes it even looks graceful, more accurately fitting the word “swoon”—wrist to forehead, a gentle crumbling perhaps brought on by a too-tight corset. There were even special couches for this purpose in the Victorian age, “fainting sofas,” on which one could elegantly recline while smelling salts were held beneath the nose. But in an even smaller subset of the already small percentage of the population prone to vasovagal syncope, an exclusive club to which I and a few members of my family belong, the fun continues with a sudden, violent stiffness in the limbs or uncontrolled shaking that resembles, but is not, a seizure.
A seizure is defined by the abnormal, rhythmic discharge of cortical neurons. So many times I’ve wished for the verbal command and presence of mind to reassuringly explain the difference between a seizure and what I have, which is described as a “paroxysmal event.” “Paroxysmal event,” after all, sounds so much more dignified, and maybe even a little exciting. A “paroxysm” is 1) a sudden outburst of emotion, and 2) a convulsion. An “event” is 1) something that happens, or is regarded as happening; an occurrence, especially one of some importance. Meteor showers are an astronomical event. My uncontrolled spasms on the ground during a brain-based faint are an emotional event. Maybe we should all feel a little bit awed and grateful.
There are several theories about the evolutionary origin of BIITS phobia and vasovagal syncope and their advantages, if any, to humans. Until recently, emotion-based fainting was thought to be part of wider, pan-mammalian defense response. Consider the opossum: small, slow moving, and poorly armed with sub-par vision, small teeth, and weak jaws. Against dogs, cats, shovel-wielding people, and cars, the opossum is significantly out-gunned. “Playing ’possum,” therefore, or tonic immobility, is a canny counter-maneuver “because the visual cortex and retina of most mammalian carnivores (and, to a lesser extent, of male Homo sapiens) evolved primarily for detecting moving objects and not color.” Additionally, if captured or cornered, the opossum bets on the predator concluding that its prey is already dead, and thus losing interest. (Obviously, a little more evolution needs to happen to account for vehicles.) Tonic immobility, however, is not the same as fainting because the opossum chooses when to enact it and never actually loses consciousness. EEG readings indicate that opossums in tonic immobility are, in fact, in a state of hypervigilance, keenly aware of their environment and able to react to the approach of further threats with increased brain activity, changes in heart rate, and ear twitching.
Neither is the Tennessee Fainting Goat, alternately known as the Myotonic Goat, Tennessee (Meat) Goat, Nervous Goat, Stiff-leg Goat, Wooden-leg Goat, and Tennessee Scare Goat, an accurate mammalian model for why some human brains short out under stress. What causes these goats to stiffen and fall over on their sides when startled is instead a genetic mutation of muscle fibers known as “myotonia congenita.” Older goats learn to spread their legs or lean against something when startled, but they too fail to lose consciousness when they collapse. It is theorized that handlers bred these goats to accompany other types of livestock, such as sheep, during travel because their condition caused them to “sacrifice” themselves to approaching predators, allowing the handler and the livestock to escape unharmed.
Hog-nosed snakes take the whole “feigned death” or thanatosis response even further, thrashing their bodies and gaping their mouths before turning belly-up and oozing a foul-smelling oil from glands on either side of their bodies. Researchers were able to recreate this response in captured snakes, often with as little provocation as a hard, eye-to-eye stare, but unable to make it happen in lab-hatched snakes, thus strengthening the theory that thanatosis in snakes is hereditary.
In fact, nowhere does the animal kingdom truly provide an analogous model to neurogenic loss of consciousness in humans. Not that it hasn’t been extensively, and perhaps absurdly, tested, to whit: A giraffe undergoing several hours of blood pressure experiments in a holding pen in which it could not lie down eventually became agitated and died; arboreal snakes strapped to tilt tables fared impressively well against their land- and water-based counterparts when tested for their sensitivity to passing out due to orthostatic change, but no one came out on top when scientists tossed them into a giant spinner to recreate “centrifugally-induced hypergravity”; inexperienced stallions may ‘faint’ when servicing a mare for the first time; there is one report of a squirrel monkey fainting after 16 hours of fasting; and both sharks and piglets exhibit tonic immobility when flipped onto their backs. In fact, the longer piglets are kept in this position, the more docile they will be as adult pigs.
It turns out there are all kinds of ways to make all kinds of animals pass out, but all of them rely on genetic or cardiac abnormalities, sudden, physically-induced changes in blood pressure, or the animal’s deliberate decision to “play dead” while remaining alert. You cannot upset, humiliate, frighten, or intimidate an animal into losing consciousness. And not for lack of trying, it would seem.
One theory about the evolution of BIITS phobia and other emotion-based fainting looks to the mid-Paleolithic era and the beginnings of intra-group and inter-group violence. By this time, man had evolved enough to form social groups as protection against animal predators, and there were enough humans in the world for them to afford to start killing each other. In his article “Freeze, Flight, Fight, Fright, Faint: Adaptionist Perspectives on the Acute Stress Response Spectrum,” H. Stefan Bracha, MD, elaborates:
…consider a sympathetically activated non-combatant on the losing side of a Paleolithic conflict. In these circumstances, observing an approaching sharp object, experiencing skin-penetration by that object, or witnessing fresh blood on oneself (or on a fellow group member) is a crucial turning point. From this point on, continued sympathetic arousal may be an ineffective survival response (e.g., adversaries have moved from posturing to actually killing members of one’s group).
In other words, anyone without a spear in the Paleolithic era learned pretty quickly how to tell when things were going south for their side in a conflict. Better, if the raid is heading more towards a massacre, to go ahead and appear dead. Keep in mind that humans at this point were pre-verbal, and had no means of communicating through sounds or symbols. A convincing appearance of death was truly the only way of saying, “please stop stabbing me.”
The ones most likely to benefit from this response were women and children, since invaders in past human populations typically killed post-pubertal males but frequently took females and pre-pubertal individuals captive. Unfortunately, BIITS phobia and the fainting response proved terribly inconvenient to male children as they matured into adulthood and took up arms, resulting in a significantly lower occurrence of the response in men. Numbers bear this hypothesis out—3% of the United States population suffers from BIITS phobia, but the ratio of women to men in that group is 4:1.
Dr. Bracha goes on to speculate that a faint echo of Paleolithic warfare may exist in the results of a study of experienced versus inexperienced phlebotomists at blood donation sites. Contrary to expectations, the experienced phlebotomist is far more likely to have a patient faint than the inexperienced one. The study ventures the guess that inexperienced blood-drawers are “slow and communicative” while veterans are “rapid and non-communicative” and Bracha amplifies on this point: “A sharp object held by a rapidly moving non-communicative stranger shares enough stimulus properties with a life-threatening middle Paleolithic assault to elicit a response appropriate to a lethal stimulus.”
I find it fascinating that a non-lethal trigger, something as tiny as a needle’s prick, the sight of someone else’s blood, a convincing or elaborate description of gore, or even a strong emotion, can cause an uncontrolled, if brief, shut down of the brain and the superficial appearance of death in the body. The situation is not “fight or flight,” not a confrontation between predator and prey, but my imagination, my emotions, my mental pictures of split bones, pierced veins, and swelling, empty tooth sockets that have convinced my brain that the stakes are life and death. The stress of lost control plays a huge part as well, the knowledge that whether or not I approve, painful and invasive things either must be done or have already happened to my body.
That morning in the coffee shop, I had just come from an electronics recycling facility, which was really just an open freight container in the middle of a field with old, yellowing CPUs, monitors, and microwaves tossed in next to a laminated sign that warned against scavenging. I had dropped an ancient, 27-inch box television on the bridge of my moccasin-clad foot trying to wrangle it out of the back of my pick-up. The TV was probably too heavy for me to begin with, but my husband had shipped out just days earlier on his first eight-month deployment with the Navy, and I had only a few loose friendships in town and no family in the state. The foot hurt terribly, yes, but it was the image of what the paramedic described as a “green stick fracture,” the sharp, wet angles of a bone snapped but not broken cleanly, and the knowledge that whatever the foot’s status, I would be dealing with it alone, that finally sent me to the floor.
Over the years, I’ve come up with a few strategies to try to avoid it—I lie down for blood tests and beg for the smaller-bore “butterfly needle,” and if I’m hurt in a way that feels like it might tip me close to margins, I sit down and start trying to remember the Gettysburg Address so I can distract myself and calm down. I give all of my doctors a heads-up, even if they don’t appear at all likely to poke or cut me for any reason, just in case. I’ve even had to excuse myself politely from graphic tales of personal injury. My predators are stress and my own imagination, which seem to me to make a pretty good argument that my fainting is an evolved response, logical in its own way, and above all, uniquely human.
References:
- “Vasovagal Syncope.” Medical Dictionary. http://www.thefreedictionary.com/vasovagal+syncope. Copyright 2009, Farlex, Inc. 31 January, 2009.
- “Vasovagal Syncope.” Subsection: Heart Disease. http://www.mayoclinic.com/health/vasovagal-syncope/DS00806. Copyright 1998 – 2009 Mayo Foundation for Medical Education and Research (MFMER). 30 January 2009.
- “Encyclopedia> George W. Bush pretzel incident.” http://nationmaster.com/encyclopedia/George-W.-Bush-pretzel-incident. Copyright NationMaster.com 2003 – 5. 29 January 2009.
- “Non-epileptic seizure.” http://en.wikipedia.org/wiki/non-epileptic-seizure. Copyright Wikipedia 2009. 29 January 2009.
- “Paroxysmal event.” Medical Dictionary. http://www.thefreeictionary.com/paroxysmal+event. Copyright 2009, Farlex, Inc. 31 January 2009.
- Bracha, H. Stefan, MD. “Freeze, Flight, Fight, Fright, Faint: Adaptationist Perspectives on the Acute Stress Response Spectrum.” CNS Spectrums: The International Journal of Neuropsychiatric Medicine, Vol. 9, Num. 9, September 2004 (pp. 679-685).
- van Dijk, J. Gert, MD, Ph.D. “Fainting in Animals.” Clinical Autonomic Research, Vol. 13, 5 May 2003 (pp.247-255).
- “Fainting Goat.” http://en.wikipedia.org/wiki/Fainting-goat. Copyright Wikipedia 2009. 31 January 2009.
- “Tonic Immobility.” http://en.wikipedia.org/wiki/tonic-immobility. Copyright Wikipedia 2009. 3 February 2009.
Rachel Jackson is working on her MFA at California State University, Fresno. She lives at Lemoore Naval Air Station with her husband. “Paroxysmal Event” is her first publication.
“My favorite front porch was in Austin in the 80’s. It was on a raised foundation, higher than the level of the yard by eight concrete steps, and its wooden boards were painted a glassy dark green. To get the dust and the pollen off in the summers, my mom rinsed it with the hose and water pooled in the warped troughs of the boards and I would skid across them in my bare feet. Also, during summer thunderstorms at night, she would sit on the porch swing and drink a beer, watching the rain. If I couldn’t sleep, and if I was very quiet, I was sometimes allowed to sit with her. It’s one of my best memories.”