A Cognitive Behavioural Intervention for the Treatment of Vasovagal and Unexplained Syncope


Vasovagal syncope and unexplained syncope are the most commonly observed types of syncope in outpatient and hospital settings. Medical interventions usually target at the physiological mechanisms responsible for loss of consciousness in an attempt to limit the frequency of recurrences. However, this type of intervention does not take into account the psychological and functional impact of syncope, nor the importance of psychological variables in triggering and maintaining syncope. In the present pilot study, four participants presenting significant psychological distress and recurrent syncope were treated using a multimodal intervention targeting at both the medical and psychological aspects of the problem. Results showed a significant reduction in the frequency of syncope/presyncope, in the level of emotional distress experienced, as well as improved functional status in three of the four participants. Several recommendations are made to medical practitioners and psychologists, in view of identifying patients likely to benefit from this type of intervention or components thereof.

Share and Cite:

Bedard, F. , Marchand, A. , Kus, T. , Thibault, B. and D’Antono, B. (2014) A Cognitive Behavioural Intervention for the Treatment of Vasovagal and Unexplained Syncope. International Journal of Clinical Medicine, 5, 584-598. doi: 10.4236/ijcm.2014.510080.

Conflicts of Interest

The authors declare no conflicts of interest.


[1] Sheldon, R., Koshman, M.L., Wilson, W., Kieser, T. and Rose, S. (1998) Effect of Dual-Chamber Pacing with Automatic Rate-Drop Sensing on Recurrent Neurally Mediated Syncope. The American Journal of Cardiology, 81, 158-162.
[2] Olde Nordkamp, L.R.A., van Dijk, N., Ganzeboom, K.S., Reitsma, J.B., Luitse, J.S.K., Dekker, L.R.C., et al. (2009) Syncope Prevalence in the ED Compared to General Practice and Population: A Strong Selection Process. The American Journal of Emergency Medicine, 27, 271-279.
[3] Savage, D.D., Corwin, L., McGee, D.L., Kannel, W.B. and Wolf, P.A. (1985) Epidemiologic Features of Isolated Syncope: The Framingham Study. Stroke, 16, 626-629.
[4] Mathias, C.J., Deguchi, K. and Schatz, I. (2001) Observations on Recurrent Syncope and Presyncope in 641 Patients. Lancet, 357, 348-353.
[5] Krahn, A.D., Klein, G.J., Norris, C. and Yee, R. (1995) The Etiology of Syncope in Patients with Negative Tilt Table and Electrophysiological Testing. Circulation, 92, 1819-1824.
[6] Krahn, A.D., Klein, G.J., Yee, R. and Norris, C. (1998) Final Results from a Pilot Study with an Implantable Loop Recorder to Determine the Etiology of Syncope in Patients with Negative Noninvasive and Invasive Testing. The American Journal of Medicine, 82, 117-119.
[7] Calkins, H., Byrne, M., el-Atassi, R., Kalbfleisch, S., Langberg, J.J. and Morady, F. (1993) The Economic Burden of Un-Recognized Vasodepressor Syncope. American Journal of Medicine, 95, 473-479.
[8] Sun, B.C., Emond, J.A. and Camargo Jr., C.A. (2005) Direct Medical Costs of Syncope-Related Hospitalizations in the United States. American Journal of Cardiology, 95, 668-671.
[9] Linzer, M., Pontinen, M., Gold, D.T., Divine, G.W., Felder, A. and Brooks, W.B. (1991) Impairment of Physical and Psychosocial Function in Recurrent Syncope. Journal of the American College of Cardiology, 44, 1037-1043.
[10] St-Jean, K., Kus, T., Dupuis, G., Levesque, K., Thibault, B. and D’Antono, B. (2009) Quality of Life in Patients with Re-Current Vasovagal or Unexplained Syncope: Influence of Sex, Syncope Type and Illness Representations. Applied Quality of Life Research, 3, 235-249.
[11] D’Antono, B., Dupuis, G., St-Jean, K., Lévesque, K., Nadeau, R., Guerra, P. and Thibault, B. (2009) Prospective Evaluation of Psychological Distress and Psychiatric Morbidity in Re-Current Vasovagal and Unexplained Syncope. Journal of Psychosomatic Research, 67, 213-222.
[12] Giada, F., Silvestri, I., Rossillo, A., Nicotera, P.G., Manzillo, G.F. and Raviele, A. (2005) Psychiatric Profile, Quality of Life and Risk of Syncopal Recurrence in Patients with Tilt-Induced Vasovagal Syncope. EP Europace, 7, 465-471.
[13] Romme, J.J.C.M., van Dijk, N., Go-Schon, I.K., Casteelen, G., Wieling, W. and Reitsma, J.B. (2001) Association between Psychological Complaints and Recurrence of Vasovagal Syncope. Clinical Autonomic Research, 21, 373-380.
[14] Kapoor, W.N., Fortunato, M., Hanusa, B.H. and Schulberg, H.C. (1995) Psychiatric Illnesses in Patients with Syncope. The American Journal of Medicine, 99, 505-512.
[15] Hupert, N. and Kapoor, W.N. (1997) Syncope: A Systematic Search for the Cause. Journal of Psychosomatic Research, 31, 136-139, 143-146, 149-150.
[16] Linzer, M., Felder, A., Hackel, A., Perry, A.J., Varia, I., Melville, M.L. and Krishnan, K.R. (1990) Psychiatric Syncope: A New Look at an Old Disease. Psychosomatics, 31, 181-188.
[17] Engel, G.L. (1978) Psychologic Stress, Vasodepressor (Vasovagal) Syncope, and Sudden Death. Annals of Internal Medicine, 89, 403-412.
[18] Gracie, J., Baker, C., Freeston, M.H. and Newton, J.L. (2004) The Role of Psychological Factors in the Aetiology and Treatment of Vasovagal Syncope. Indian Pacing and Electrophysiology Journal, 4, 79-84.
[19] Gracie, J., Newton, J.L., Norton, M., Baker, C. and Freeston, M. (2006) The Role of Psychological Factors in Response to Treatment in Neurocardiogenic (Vasovagal) Syncope. EP Europace, 8, 636-643.
[20] Bonk, V.A., France, C.R. and Taylor, B.K. (2001) Distraction Reduces Self-Reported Physiological Reactions to Blood Donation in Novice Donors with a Blunting Coping Style. Psychosomatic Medicine, 63, 447-452.
[21] Steptoe, A. and Wardle, J. (1988) Emotional Fainting and the Psychophysiologic Response to Blood and Injury: Autonomic Mechanisms and Coping Strategies. Psychosomatic Medicine, 50, 402-417.
[22] Brignole, M., Alboni, P., Benditt, D.G., Bergfeldt, L., Blanc, J.J., Bloch Thomsen, P.E., et al. (2004) Guidelines on Management (Diagnosis and Treatment) of Syncope. Revue Espanola de Cardiologia, 58, 175-193.
[23] Bedard, F., Marchand, A., Kus, T. and D’Antono, B. (2010) Vasovagal Syncope and Unexplained Syncope: Concepts, Treatments, and Future Perspectives. Canadian Psychology/Psychologie Canadienne, 51, 257-268.
[24] Wieling, W., Colman, N., Krediet, C.T. and Freeman, R. (2004) Nonpharmacological Treatment of Reflex Syncope. Clinical Autonomic Research, 14, i62-i70. http://dx.doi.org/10.1007/s10286-004-1009-x
[25] Aydin, M.A., Mortensen, K., Salukhe, T.V., Wilke, I., Ortak, M., Drewitz, I., et al. (2012) A Standardized Education Protocol Significantly Reduces Traumatic Injuries and Syncope Recurrence: An Observational Study in 316 Patients with Vasovagal Syncope. EP Europace, 14, 410-415. http://dx.doi.org/10.1093/europace/eur341
[26] Croci, F., Brignole, M., Menozzi, C., Solano, A., Do-nateo, P., Oddone, D., Puggioni, E. and Lolli, G. (2004) Efficacy and Feasibility of Isometric Arm Counter-Pressure Manoeuvres to Abort Impending Vasovagal Syncope during Real Life. EP Europace, 6, 287-291.
[27] Sabin, N. (2001) The Use of Applied Tension and Cognitive Therapy to Manage Syncope (Common Faint) in an Older Adult. Aging and Mental Health, 5, 92-94.
[28] Alboni, P., Brignole, M., Menozzi, C., Raviele, A., Del Rosso, A., Dinelli, M., Solano, A. and Bottoni, N. (2001) Diagnostic Value of History in Patients with Syncope with or without Heart Disease. Journal of the American College of Cardiology, 37, 1921-1928.
[29] McGrady, A.V., Bush, E.G. and Grubb, B.P. (1997) Outcome of Biofeedback-Assisted Relaxation for Neurocardiogenic Syncope and Headache: A Clinical Replication Series. Applied Psychophysiology and Biofeedback, 22, 63-72.
[30] McGrady, A.V., Kern-Buell, C., Bush, E., Devonshire, R., Claggett, A.L. and Grubb, B.P. (2003) Biofeedback-Assisted Relaxation Therapy in Neurocardiogenic Syncope: A Pilot Study. Applied Psychophysiology and Biofeedback, 28, 183-192.
[31] Newton, J.L., Kenny, R.A. and Baker, C.R. (2003) Cognitive Behavioural Therapy as a Potential Treatment for Vasovagal/Neurocardiogenic Syncope: A Pilot Study. EP Europace, 5, 299-301.
[32] Koenig, D., Linzer, M., Pontinen, M. and Divine, G.W. (1992) Syncope in Young Adults: Evidence for a Combined Medical and Psychiatric Approach. Journal of Internal Medicine, 232, 169-176.
[33] Reiss, S., Peterson, R.A., Gursky, D.M. and McNally, R.J. (1986) Anxiety Sensitivity, Anxiety Frequency and the Prediction of Fearfulness. Behavior Research and Therapy, 24, 1-8.
[34] Beck, A.T., Epstein, N., Brown, G. and Steer, R.A. (1988) An Inventory for Measuring Clinical Anxiety: Psychometric Properties. Journal of Consulting and Clinical Psychology, 56, 893-897.
[35] Beck, A.T. and Steer, R.A. (1993) Manual for the Beck Anxiety Inventory. 2nd Edition, Psychological Corporation, San Antonio.
[36] Beck, A.T., Steer, R.A. and Brown, G.K. (1996) Manual for the BDI-II. 2nd Edition, Psychological Corporation, San Antonio.
[37] Bouvard, M. and Cottraux, J. (2005) Protocoles et échelles d’évaluation en psychiatrie et en psychologie. 4th Edition, Masson, Paris.
[38] Freeston, M. (1998) Questionnaire sur l’évaluation du fonctionnement actuel. Unpublished Manuscript, Centre de recherche Fernand-Seguin de l’Hôpital Louis-H. Lafontaine, Montréal.
[39] Ware, J.E., Kosinski, M. and Keller, S.D. (1996) A 12-Item Short-Form Health Survey: Construction of Scales and Preliminary Tests of Reliability and Validity. Medical Care, 34, 220-233.
[40] Brazier, J.E., Harper, R., Jones, N.M., O’Cathain, A., Thomas, K.J., Usherwood, T. and Westlake, L. (1992) Validating the SF-36 Health Survey Questionnaire: New Outcome Measure for Primary Care. British Medical Journal, 305, 160-164.
[41] Jacobson, N.S. and Truax, P. (1992) Clinical Significance: A Statistical Approach to Defining Meaningful Change in Psychotherapy Research. In: Kazdin, A.E., Ed., Methodological Issues and Strategies in Clinical Research, American Psychological Association, Washington DC, 631-648.
[42] Cohen, J. (1988) Statistical Power Analysis for the Behavioral Sciences. Lawrence Erlbaumm, Hillsdale.
[43] Ware, J.E., Kosinski, M. and Keller, S.D. (1996) A 12-Item Short-Form Health Survey: Construction of Scales and Preliminary Tests of Reliability and Validity. Medical Care, 34, 220-233.
[44] Cook, T.D. and Campbell, D.T. (1979) Quasi-Experimentation: Design & Analysis Issues for Field Setting. Rand Mc-Nally College Publishing Company, Chicago.
[45] Ladouceur, R. and Bégin, G. (1986) Protocoles de recherche en science appliquée et fondamentale [Research Protocols in the Applied and Fundamental Sciences]. Edisem, St-Hyacinthe.

Copyright © 2022 by authors and Scientific Research Publishing Inc.

Creative Commons License

This work and the related PDF file are licensed under a Creative Commons Attribution 4.0 International License.