Psychological Medicine

Original Articles

The functional neuroanatomy of blood-injection-injury phobia: a comparison with spider phobics and healthy controls

X. Caserasa1a2 c1, V. Giampietroa2, A. Lamasa1, M. Brammera2, O. Vilarroyaa1, S. Carmonaa1, M. Roviraa3, R. Torrubiaa1 and D. Mataix-Colsa2

a1 Department of Psychiatry and Legal Medicine, Institute of Neurosciences, Autonomous University of Barcelona, Catalonia, Spain

a2 King's College London, Institute of Psychiatry, London, UK

a3 CRC Corporació Sanitària, Barcelona, Catalonia, Spain


Background Most neuroimaging studies of specific phobia have investigated the animal subtype. The blood-injection-injury (BII) subtype is characterized by a unique biphasic psychophysiological response, which could suggest a distinct neural substrate, but direct comparisons between phobia types are lacking.

Method This study compared the neural responses during the presentation of phobia-specific stimuli in 12 BII phobics, 14 spider (SP) phobics and 14 healthy controls using functional magnetic resonance imaging (fMRI).

Results Subjective ratings showed that the experimental paradigm produced the desired symptom-specific effects. As in many previous studies, when viewing spider-related stimuli, SP phobics showed increased activation in dorsal anterior cingulate and anterior insula, compared to BII phobics and healthy controls. However, when viewing images of blood-injection-injuries, participants with BII phobia mainly showed increased activation in the thalamus and visual/attention areas (occipito-temporo-parietal cortex), compared with the other two groups. The degree of provoked anxiety and disgust by phobia-relevant images was strongly associated with activation in several common regions across the two phobia groups (thalamus, cerebellum, occipito-temporal regions) but only correlated with activation in the dorsal anterior cingulate gyrus and the anterior insula in the SP phobics.

Conclusions These results suggest partially distinct neurobiological substrates of animal and BII phobias and support their current classification as two distinct subtypes in the DSM-IV-TR. Further research is needed to better understand the precise neurobiological mechanisms in BII phobia and particularly the fainting response.

(Received September 12 2008)

(Revised February 15 2009)

(Accepted March 18 2009)

(Online publication May 13 2009)


c1 Address for correspondence: X. Caseras, Ph.D., Institute of Psychiatry, Box PO69, De Crespigny Park, London SE5 8AF, UK. (Email: