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A study of the effectiveness of a relaxation technique in lessening excessive anxiety of selected psychiatric… Miller, Winifred Margaret 1975

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A STUDY OF THE EFFECTIVENESS OF A RELAXATION TECHNIQUE I N LESSENING EXCESSIVE.ANXIETY OF SELECTED PSYCHIATRIC INPATIENTS by WINIFRED MARGARET M I L L E R B.S.N., U n i v e r s i t y  of British  Columbia,  1968  A THESIS- SUBMITTED I N PARTIAL FULFILMENT THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE I N NURSING-  i n the SCHOOL OF NURSING  We a c c e p t t h i s t h e s i s a s c o n f o r m i n g t o the r e q u i r e d  standard  THE UNIVERSITY OF; B R I T I S H COLUMBIA October,  1975  OF  In p r e s e n t i n g  t h i s thesis in p a r t i a l  f u l f i l m e n t o f the requirements f o r  an advanced degree at the U n i v e r s i t y o f B r i t i s h Columbia, I agree that the L i b r a r y s h a l l make i t f r e e l y  a v a i l a b l e f o r r e f e r e n c e and study.  I f u r t h e r agree t h a t p e r m i s s i o n f o r e x t e n s i v e  copying o f t h i s  thesis  f o r s c h o l a r l y purposes may be g r a n t e d by the Head o f my Department o r by h i s r e p r e s e n t a t i v e s .  I t i s understood that c o p y i n g o r p u b l i c a t i o n  of t h i s t h e s i s f o r f i n a n c i a l written  School o f Nursing  University of B r i t i s h  2075 Wesbrook Place Vancouver, Canada V6T 1W5  Date  shall  permission.  2H5£XM"SSXg3Bf The  gain  8th October,  1975  Columbia  not be a l l o w e d w i t h o u t my  ABSTRACT A Study o f the E f f e c t i v e n e s s o f A R e l a x a t i o n Technique i n L e s s e n i n g E x c e s s i v e of Selected P s y c h i a t r i c I n p a t i e n t s Excessive  anxiety i s a pervasive  problem i n  our s o c i e t y and p a r t i c u l a r l y among p a t i e n t s w i t h a t r i c problems.  Are t h e r e simple  Anxiety  psychi-  t e c h n i q u e s which n u r s e s  can t e a c h p a t i e n t s which w i l l a s s i s t i n a m e l i o r a t i n g  such  anxiety? An e x p e r i m e n t a l  study was conducted t o i n v e s -  t i g a t e the e f f e c t i v e n e s s o f a r e l a x a t i o n technique i n r e l i e v i n g excessive  anxiety.  T h i r t y - s i x selected psychi-  a t r i c i n p a t i e n t s were a s s i g n e d Subjects  a t random t o t h r e e  groups.  i n Group 1 r e c e i v e d i n d i v i d u a l r e l a x a t i o n t r a i n -  i n g by means o f a simple  r e l a x a t i o n technique i n v o l v i n g  c o n t r o l l e d b r e a t h i n g and muscle r e l a x a t i o n e x e r c i s e s . Group 2 s u b j e c t s r e c e i v e d i n d i v i d u a l p l a c e b o t r e a t m e n t s on an e q u i v a l e n t  schedule to Group 1.  Subjects  i n Group 3 r e -  c e i v e d the o r d i n a r y ward care and no s p e c i a l approach. L e v e l - o f ' a n x i e t y was measured by a p h y s i o l o g i c a l i n d e x (twenty-four  hour u r i n a r y p o t a s s i u m e x c r e t i o n ) and a p s y -  c h o l o g i c a l s c a l e (IPAT A n x i e t y  Scale Questionnaire).  measures were t e s t e d a t the b e g i n n i n g day  experimental  Both  and end o f the f i v e  p e r i o d and changes i n l e v e l s between  groups compared s t a t i s t i c a l l y . Non-parametric a n a l y s e s  were u t i l i z e d because  i i i  of  the  lack  of  a  dencies  of  indices  measured  means The  of  level was to  changes  the  n u l l  other  found  between  l o g i c a l l y cebo"  xiety fact  the  Scale that  while  differences  individual  i n  urinary  Questionnaire  the  urinary  Anxiety  Scale  potassium  Group  an  excretion  i s  a  "Con-  3:  of  scores  that  there  both  measure perhaps,  physio-  and  between  of  was  IPAT  "Relaxation"  index  to  difference  response,  arises,  done  Anxiety  consistency  is  were  however,  excretion  hypothesis  groups.  Inspection  scores  n u l l  IPAT  significant  potassium  (p<f.05)  found  with  the  Variance.  were  compared  to  by  percent  between  i n  of  of  the  declines  individual  lack  analyzed  (one-tailed)  suggests,  psychologically The  When  ten-  psychological  five  subjects  groups.  values  and  were  the  Tests  as  central  Analysis  accepted.  scores  difference  and  and  s t a t i s t i c a l l y  approaches. for  tested  greater  potassium  marked  groups  "Relaxation"  1:  Questionnaire  urinary  three  was  s i g n i f i c a n t l y  No  ings  was  individual  t r o l " .  a  the  The  physiological  Mann-Whitney U  Group  is  the  significance  determine  and  for  d i s t r i b u t i o n .  K r u s k a l - W a l l i s One-Way  untenable  Scale  i n  hypothesis  of  exhibit  normal  "Pla-  the  and  find-  An-  from  multiple  the  factors  unitary  physiological  findings  i n  study  to  effective  factor. On technique nurses cessive  (or  the  basis  described others)  anxiety..  is to  of  the  deemed employ  A number  of  as  be a  an  means  this  for  method  r e l i e v i n g  recommendations  for  the for  ex-  further  iv s t u d y were made i n c l u d i n g stress"  the need  p o p u l a t i o n s , f o r example,  to test  to  p a t i e n t s a r e most, l i k e l y  the r e l a x a t i o n  training.  i n d e x , s u c h as u r i n a r y  The  to i d e n t i f y  to respond  units which  favourably  use o f a m u l t i f a c t o r i a l  electrolyte  excretion profiles,  a more a c c u r a t e o v e r a l l m e a s u r e o f p h y s i o l o g i c a l suggested.  "high  p a t i e n t s i n burn  o r p r i o r t o c a r d i a c s u r g e r y , and t h e n e e d individual  other  stress  as is  TABLE OF CONTENTS  ABSTRACT  i  i  L I S T OF TABLES  .ix  L I S T OF FIGURES  •  x i  ACKNOWLEDGEMENTS  ,  x i i  Chapter 1.  2.  Page  INTRODUCTION  1,  Statement o f t h e Problem  .1  S i g n i f i c a n c e o f t h e Problem  .2  REVIEW OF THE LITERATURE  Psychoanalytic Learning  Concepts o f A n x i e t y .  Theories o f Anxiety.....  A n x i e t y - t r a i t and A n x i e t y - s t a t e Physiological  6  6 8 9  and B i o c h e m i c a l  Aspects of Anxiety Manifestations of Anxiety  10 15  Physiological Manifestations of An'xietyV  15  Psychomotor M a n i f e s t a t i o n s o f Anxiety...16 Affective Manifestations of Anxiety v  17  vi  Chapter  '  Pag Cognitive Manifestations Social Manifestations  o f A n x i e t y . . . . . 18  of Anxiety.  A Model F o r Anxiety Biopsychosocial  .19 20  Stimuli  20  P s y c h o b i o l o g i c a l Programme  22  Perceived  22  Anxiety  Threat o r Challenge  Response  23  Defense Mechanisms.  24  Interacting Variables.  25  D e f i n i t i o n o f Anxiety Psychophysiologic  .26  Relaxation. .  Meditation Progressive  27 27  Relaxation. .  . . . . 29  R e c i p r o c a l I n h i b i t i o n and Systematic Desensitization  -30 JI  Autogenic Training T h e r a p e u t i c Use o f R e l a x a t i o n Techniques , 3.  DESIGN AND METHODOLOGY  :  Overview o f t h e Study Design.. D e f i n i t i o n o f Terms  2  -37 37 37  Assumptions  .38  The I n d e p e n d e n t V a r i a b l e s Relaxation  3  A  Technique  .38  The D e p e n d e n t V a r i a b l e s  39  Urinary Potassium IPAT A n x i e t y S c a l e  k-0 kZ  Questionnaire.  vii Chapter.  Page S e t t i n g o f t h e Study  . ..  44  The Sample. . .  .47  Treatment and C o n t r o l Methods Group I s  "Relaxation"  49  Group 2 s  "Placebo"  50  Group 3 :  "Control"  51  S p e c i f i c O b j e c t i v e s o f the Study  51  Hypotheses  52  .  52  A n a l y s i s o f Data 4.  . . . 43  57  FINDINGS OF THE STUDY The U r i n e Potassium  57  Measure....  Group I s  "Relaxation"  Group 2s  "Placebo"  6l  Group 3 s  "Control"  6l  6l  Comparison o f Groupss Potassium  Urinary .62  Excretion Levels.  The IPAT A n x i e t y S c a l e Q u e s t i o n n a i r e  64  Group I s  "Relaxation"  Group 2s  "Placebo"  6.7  Group 3s  "Control"  6?  •  64  Comparison o f Groupss 'IPAT A n x i e t y S c a l e Q u e s t i o n n a i r e Scores .....67 :  5.  DISCUSSION, LIMITATIONS, RECOMMENDATIONS I n t e r p r e t a t i o n of the Findings L i m i t a t i o n s o f t h e Study. Sample S i z e and S e l e c t i o n  75 75 .78 78  viii Chapter  Page Uncontrolled Extraneous S t i m u l i  78  Incomplete Placebo E f f e c t . . . .  79  U r i n e Potassium Measure  79  Recommendations f o r F u r t h e r Study Summary  BIBLIOGRAPHY  79 .80  •  v82  APPENDICES A.  Text o f R e l a x a t i o n Technique  B.  Anxiety  Study:  Experiment  Tape.....  Schedule  91 9k  L I S T OF TABLES  Table  ge  P a  4-1  Changes i n 24 H o u r U r i n a r y P o t a s s i u m E x c r e t i o n B e t w e e n Day 1 a n d Day 5 f o r S u b j e c t s i n G r o u p I s " R e l a x a t i o n " . . . . . 58  4-2  Changes i n 24 H o u r U r i n a r y P o t a s s i u m • E x c r e t i o n B e t w e e n Day 1 a n d Day 5 f o r S u b j e c t s i n Group .2.: " P l a c e b o "  59  4-3  Changes i n 24 H o u r U r i n a r y P o t a s s i u m E x c r e t i o n B e t w e e n Day 1 a n d Day 5 f o r S u b j e c t s i n G r o u p 3: "Control"........60  4-4  K r u s k a l - W a l l i s One-Way A n a l y s i s o f V a r i a n c e by Ranks o f Changes i n Urine Potassium E x c r e t i o n i n M i l l e q u i v a l e n t s o f Groups R e c e i v i n g " R e l a x a t i o n , " " P l a c e b o " and " C o n t r o l " Treatments  63  4-5  Changes i n IPAT A n x i e t y S c a l e Q u e s t i o n n a i r e S c o r e s B e t w e e n Day 1 a n d Day 5 f o r Subj e c t s i n Group I s "Relaxation"............65  4-6  Changes i n I P A T A n x i e t y S c a l e Q u e s t i o n n a i r e S c o r e s B e t w e e n Day 1 a n d Day 5 f o r Subj e c t s i n Group 2s " P l a c e b o "  4-7  Changes i n I P A T A n x i e t y S c a l e Q u e s t i o n n a i r e S c o r e s B e t w e e n Day 1 a n d Day 5 f o r S u b j e c t s i n Group 3 "Control" s  4-8  4-9  K r u s k a l - W a l l i s One-Way A n a l y s i s o f V a r i a n c e by Ranks o f Changes i n IPAT A n x i e t y S c a l e Q u e s t i o n n a i r e S c o r e s o f Groups R e c e i v i n g " R e l a x a t i o n , " " P l a c e b o " and " C o n t r o l " Treatments.  66  68  70  Mann-Whitney U T e s t f o r D i f f e r e n c e s i n Change i n I P A T A n x i e t y S c a l e Q u e s t i o n n a i r e S c o r e s Between Group I s " R e l a x a t i o n " and Group 2s " P l a c e b o " T r e a t m e n t ( N = 2 4 ) , . . ? l ;  ix  X  Table 4-10  4-11  Page M a n n - W h i t n e y (J T e s t f o r D i f f e r e n c e s i n Change i n IPAT A n x i e t y S c a l e Q u e s t i o n n a i r e S c o r e s B e t w e e n Group 1: " R e l a x a t i o n " a n d Group 3: "Control" (N=24) . ....  72  Mann-Whitney U Test f o r D i f f e r e n c e s i n Change i n IPAT A n x i e t y S c a l e Q u e s t i o n n a i r e S c o r e s B e t w e e n Group 2: " P l a c e b o " and Group 3s "Control" (N=24)  73  L I S T OF  FIGURES  Figure 1  Page A Model f o r A n x i e t y (Adapted from L e v i ' s Model f o r P s y c h o s o c i a l l y Mediated Disease)  xi  21  ACKNOWLEDGEMENTS  The c a n d i d a t e e x p r e s s e s g r a t i t u d e t o a number o f i n d i v i d u a l s who p r o v i d e d h e l p f u l a s s i s t a n c e i n t h e conduct o f t h i s  investigation.  A p p r e c i a t i o n i s extended McGuire,  to Barbara  Herrick  Chairman o f t h e T h e s i s Committee, and t o Helen  E l f e r t a n d Mona June H o r r o c k s who f u n c t i o n e d a s C o m m i t t e e members.  T h e s e p e r s o n s g a v e much w i s e c o u n s e l a n d e n -  couragement . A p p r e c i a t i o n i s e x p r e s s e d t o t h e two D i r e c t o r s of Nursing f o r t h e i r w i l l i n g  co-operation i n permitting  access to the h o s p i t a l f a c i l i t i e s  necessary.  Appreciation i s also expressed to the p a t i e n t s , n u r s e s and p h y s i c i a n s , s t u d y was c o n d u c t e d ,  i n t h e h o s p i t a l u n i t s where t h e  f o r t h e i r h e l p and i n t e r e s t .  G r a t i t u d e i s extended  to the s i xstudent  who s e r v e d , w i t h d i l i g e n c e a n d e n t h u s i a s m ,  nurses  as r e s e a r c h  assistants. Finally,  t h a n k s a r e due t o Wendy B e l t r a m o - K r a f f t  f o r her dedicated labours i n typing the manuscript.  xii  Chapter  1  INTRODUCTION Statement o f the Problem The ancient  discomfort  times.  Anxiety"  Our own e r a h a s b e e n c a l l e d  o f t h i s phenomenon.  Is useful,  dividual  and i n d e e d  so t h a t a d a p t i v e  actual or potential  degree o f the i n -  responses are mobilized  t o meet  Excessive  i s d e b i l i t a t i n g because c o n s i d e r a b l e  diminished  to  to alert  threats.  d i s s i p a t e d and t h e l i f e  A certain  essential,  since  "The Age o f  and l i t e r a t u r e , a r t and music g i v e t e s t i m o n y  the p e r v a s i v e n e s s anxiety  o f a n x i e t y h a s t r o u b l e d men  anxiety,  however,  amounts o f e n e r g y a r e  forces of the i n d i v i d u a l  c a n be  and d i s o r g a n i z e d . Because i l l n e s s poses a t h r e a t t o t h e i n t e g r i t y  o f p a t i e n t s and t h e i r  families,  n u r s e s encounter a n x i o u s  people constantly while working i n h o s p i t a l s o r i nthe community. heart  F o r example, c o n s i d e r  surgery,  the person awaiting  open  the f a m i l y o f a s e v e r e l y burned c h i l d o r the  p e r s o n who h a s b e e n i n f o r m e d t h a t he h a s a n i n o p e r a b l e cinoma.  Consider  particularly  car-  p a t i e n t s coming t o acute  J u d d Marmor, " A n x i e t y a n d Worry a s A s p e c t s o f Normal B e h a v i o u r , " C a l i f o r n i a M e d i c i n e . XCVII (October, 1972),  212-15.  1  care  2 psychiatric if  not  units.  "One  o f the  major d i f f i c u l t i e s  a l l , p s y c h i a t r i c patients i s anxiety,"  o f most,  writes  Hilde-  2 gard  Peplau.  anxiety?  How  can n u r s e s h e l p p a t i e n t s w i t h  Are  there  which w i l l  excessive  p h y s i c a l methods o f r e l i e v i n g  supplement i n t e r p e r s o n a l t e c h n i q u e s  anxiety  which  are  used? The the  purpose of t h i s  examine  e f f e c t i v e n e s s of a p h y s i c a l r e l a x a t i o n technique  lessening  the  psychiatric Significance  anxiety  of  s e l e c t e d p a t i e n t s i n two  in  acute  care  settings. o f the  Anxiety and  i n v e s t i g a t i o n i s to  Problem  i s i m p l i c a t e d b o t h i n the  as a c o n c o m i t a n t o f , p h y s i c a l and  problem of e x c e s s i v e  anxiety  development  mental i l l n e s s .  permeates the  field  of  of, The  health  care. . . . p h y s i c i a n s are c o m i n g t o r e a l i z e t h a t emotional r e a c t i o n s are o f primary s i g n i f i c a n c e not o n l y i n f u n c t i o n a l but a l s o i n o r g a n i c d i s o r d e r s such as e s s e n t i a l h y p e r t e n s i o n , c o r o n a r y ~ h e a r t d i s e a s e , p e p t i c u l c e r and hyperthyroidism.  ^Hildegard Peplau, " I n t e r p e r s o n a l Techniques! The Crux o f P s y c h i a t r i c N u r s i n g , " American J o u r n a l o f N u r s i n g , L X I I ( J u n e , 1962), 53-55-^Edmund J a c o b s o n , A n x i e t y and T e n s i o n C o n t r o l (Philadelphia: J.B. L i p p i n c o t t Company, 1964), p . l .  3  Anxiety  i s the dynamic center of neuroses.^  ...we know t h a t p s y c h o s o c i a l s t i m u l i cause p h y s i o l o g i c a l changes which i n t u r n could l e a d to p r e c u r s o r s and d i s e a s e . 5 F u r t h e r , p s y c h o s o c i a l s t i m u l i may a l s o i n f l u e n c e h e a l t h by impeding recovery and a g g r a v a t i n g d i s a b i l i t y , whatever the e t i o l o g y of the primary d i s e a s e . Such a p s y c h o s o c i a l l y induced response may be rooted - e.g. i n an i n t e n s e a n x i e t y over the disease or the situation...° I l l n e s s and attended security.  h o s p i t a l i z a t i o n f r e q u e n t l y are  by f e e l i n g s of h e l p l e s s n e s s , i s o l a t i o n and i n These f e e l i n g s engender a n x i e t y .  Wooldridge,  Skipper and Leonard view r e l i e f of s i t u a t i o n a l a n x i e t y an important  as  area of r e s p o n s i b i l i t y f o r n u r s i n g . '  Anxiety  i n t e r f e r e s with man's b a s i c need f o r  r e l a x a t i o n so t h a t a l l e v i a t i o n o f e x c e s s i v e a n x i e t y i s s i g n i f i c a n t at a l l l e v e l s o f h e a l t h care, from care o f the s i c k to promotion of high l e v e l w e l l n e s s .  Time (New  Dunn s t a t e s :  """Karen Horney, The Neurotic P e r s o n a l i t y of York: W.W. Norton & Company, Inc., 1937),  Our p.41.  ^Lennart L e v i , " I n t r o d u c t i o n : Psychosocial S t i m u l i , Reactions, and Disease," i n S t r e s s and D i s t r e s s i n Response to P s y c h o s o c i a l S t i m u l i , ed. Lennart L e v i , Supplement No.528 to Acta Medica S c a n d i n a v i c a . CXCI (1972), 12. Ibid.,  p.20.  7 'Powhatan J . Wooldridge, James K. Skipper and Robert C. Leonard, B e h a v i o u r a l Science, S o c i a l P r a c t i s e and the Nursing P r o f e s s i o n ( C l e v e l a n d : Press of Case Western Reserve U n i v e r s i t y , 1968), p.10.  4 The n e e d o f t h e mind f o r b a l a n c e and r e l a x a t i o n a s an i n t e g r a l p a r t o f i t s power t o s o l v e p r o b l e m s i s p a r a l l e l e d by t h e n e e d o f t h e body f o r b a l a n c e and r e l a x a t i o n as an i n t e g r a l p a r t o f t h e way i t m a i n t a i n s i t s energy o r g a n i z a t i o n . 8 Since ability  anxiety  i n t e r f e r e s with  t o meet h i s b a s i c n e e d s and  the i n d i v i d u a l ' s  s i n c e the  s o c i e t y ' s p r o f e s s i o n a l n u r t u r e r , methods o f anxiety use  l i e w i t h i n her  comfort measures  techniques  s u c h as  province  (e.g.  those  the  modify  and  anxiety dealt  control anxiety.  when r e c o g n i z e d ,  n  }o '  remains a major problem  with,  b a c k r u b ) and  by  Nurses  interpersonal  P e p l a u and  others  to  12 '  However,  w h i c h i s most the  use  of  commonly  tranquillizers  sedatives.  the  t h r e a t o f p s y c h o l o g i c a l o r p h y s i o l o g i c a l dependency  but  a l s o can  interfere ratio  with  o f time  of anxiety  excessive  and  r u p t i n g the  Chemical r e l i e f  '  is  control of  of r e s p o n s i b i l i t y .  p r o p o s e d by Q  nurse  normal  spent  not  only  sleep patterns  i n the  various  poses  by  dis-  phases  of  o  D.C.:  H a l b e r t L. Dunn, H i g h L e v e l W e l l n e s s ( W a s h i n g t o n , Mount V e r n o n P r i n t i n g Company I n c . , 1 9 6 1 ) , p.213.  ^ M a r g a r e t Kaufmann, "Autonomic R e s p o n s e s as Rel a t e d to N u r s i n g Comfort Measures," Nursing Research, X I I I ( W i n t e r , 1964), 45-55. "^Peplau,  ships  (New  op.cit.  "'""''Ida J e a n O r l a n d o , Dynamic N u r s e P a t i e n t York: G.P. Putnam's Sons, 1961).  Relation-  12 ing,  Joyce Travelbee,, I n t e r p e r s o n a l A s p e c t s o f ( P h i l a d e l p h i a : F.A. D a v i s Company, 1966)1  Nurs-  5  sleep. Do n u r s e s u n k n o w i n g l y d i s r u p t t h e n i g h t c y c l e s o f t h e i r p a t i e n t s by g i v i n g a l l t o o f r e e l y the compromising s l e e p i n g p i l l r a t h e r t h a n i n t e r v e n i n g t o promote s l e e p by t a l k i n g w i t h t h e p a t i e n t t o r e l i e v e a n x i e t y o r by u s i n g t h e r a p e u t i c , p h y s i c a l measures?!3 P h y s i c a l methods a r e , f o r t h e most e m p h a s i z e d by n u r s e s a s methods o f r e l i e v i n g promoting r e l a x a t i o n . rub  a r e assumed  Comfort measures  t o be h e l p f u l ,  part,  under  anxiety  and  such as the back-  but the r e s u l t s  o f the ill  scant  t e s t i n g w h i c h has b e e n done a r e i n c o n c l u s i v e . Nursing  knowledge for in  science  a t the p r e s e n t  encompasses time.  a s m a l l body  C l e a r l y there  the f u r t h e r development o f s c i e n t i f i c the area  of anxiety  of  i s a need  nursing  methods  c o n t r o l t o s u p p l e m e n t t h o s e methods  already developed.  ^ G r a c e . F o s s , "The C y c l e s o f S l e e p , " Current Concepts o f C l i n i c a l N u r s i n g , ed. B e t t y B e r g e r s o n , V o l ,  1 (St. Louis:  C.V. Mosby Company, 1°68), p.102.  14Kaufman,  op.cit.  Chapter REVIEW OF Concepts of  literature  is  overwhelming.  and  definitions  dealing with  There e x i s t of anxiety.  subject of  The  nature  by  and  manifestations  philosophers, novelists,  physiologists, psychiatrists  a model o f a n x i e t y Psychoanalytic  primal  and  and  others.  of tension a r i s i n g  anxiety  Primal  with  the  original  traumatic  anxiety  response  to a l e r t  i n t e r n a l or external threat. defensive  Thus t h e  be  re-  the  state  of h e l p l e s s -  Certain can  individual  'signal' stimuli now to  t h r e a t o f trauma  a c t i o n taken.  The-  can  individual  u s e s as  a means o f  Sigmund F r e u d , I n h i b i t i o n s , Symptoms and H o g a r t h P r e s s , 1936).  6  defines  i s that  situation  l e a r n s m e n t a l d e f e n s e mechanisms w h i c h he  (Londons  Freud  Secondary or  anxiety.  the  a n t i c i p a t e d and  anxiety  privation.  i s a d e r i v a t i v e of primal  associated trigger  1  f r o m the i n f a n t ' s e x p e r i e n c e  ness i n r e s o l v i n g l i b i d i n a l  will  In  presented.  concepts of anxiety.  secondary a n x i e t y .  anxiety  of d e s c r i p t i o n s  s e c t i o n some p e r t i n e n t c o n c e p t s o f a n x i e t y  v i e w e d and  be  the  a multiplicity  have b e e n e x p l o r e d  psychologists, this  LITERATURE  Anxiety  The  of anxiety  THE  2  Anxiety ;  7 coping with Freud,  are  automatic  anxiety.  These m e n t a l d e f e n s e s ,  f o r t h e most p a r t so  individual's the  2  that their use  the  increase.  I f the  usefulness  or  situation  trauma i s massive the results.  fluence  i n the  ego  Freud  limitations.  and  o f d e f e n s e mechanisms i s i n a p p r o p r i a t e  situation will  illness  non-specific,  an  inadequate  has  by  If  mechanisms a r e  situation,  subconscious,  as d e f i n e d  to  cope w i t h  be  unresolved  i s prolonged  can  be  a given and  emotional  threat  overwhelmed and  development o f the  Arthur'Schmale  anxiety  o r the  believed that anxiety  deals with  the  traumatic will of  emotional  i s a key  in-  individual.  genesis  of  affective  4 differentiation. correlative  affects.  undifferentiated, of  affects  are  discomfort the  He  p o s t u l a t e s stages Anxiety,  or disturbance  earliest  stage  of  like  reflects  Freud,  of  newborn.  Concepts of A n x i e t y . anxiety  range  equilibrium during  Harry  as a c r u c i a l  Sigmund F r e u d , Group P s y c h o l o g y and t h e Ego-(New Y o r k : Bantam Books, 1 9 6 5 ) . 3  full  p s y c h i c awareness  of b i o l o g i c a l  regarded  and  t o Schmale, i s t h e  from which the  - awareness o f the  Interpersonal Sullivan,  according  primal prototype  d e r i v e d , and  o f awareness  the  Stack factor  Analysis  Ibid.  4 A r t h u r Schmale, "A G e n e t i c View o f A f f e c t s , " The P s y c h o a n a l y t i c S t u d y o f t h e C h i l d , eds, R u t h E i s s l e r , e t a l . , V o l . 19 (New Y o r k : International U n i v e r s i t i e s Press, I n c . , 1 9 6 4 ) , pp. 287-308.  8  in  the  development o f p e r s o n a l i t y . ^  anxiety in  the  ceived iture  a r i s e s when an context  o f an  indicated  that high  efficiency personal  ing  the  relief  anxiety  of  tension.  i s associated  He  con-  expend-  Further,  with  lack  Drives  hunger or from  disorganized  thinking.  of Anxiety.  Learning  Theories  drive reduction  reduction.  threatened  a s y s t e m whose c h i e f e n e r g y  r e l a t i o n s h i p s and  process.  theory  individual's security i s  that  as  may  an  important  theorists  element i n the  the  need f o r  developed a considerable  d e m o n s t r a t i n g the  inter-  learn-  a r i s e from primary needs such  s e c o n d a r y n e e d s s u c h as  Mowrer has  he  of  i n meeting p h y s i o l o g i c a l needs, d i s t u r b e d  Learning regard  maintained  interpersonal relationship.  p e r s o n a l i t y as i s d i r e c t e d to  He  r e l a t i o n s h i p of anxiety  anxiety  body to  as  of learning.  . . . a n x i e t y i s a l e a r n e d response o c c u r r i n g to 'signals' (conditioned stimuli). Anxiety i s t h u s b a s i c a l l y a n t i c i p a t o r y i n n a t u r e , and has great b i o l o g i c a l u t i l i t y i n that i t adaptively m o t i v a t e s l i v i n g organisms to deal with (prepare f o r , o r f l e e from) t r a u m a t i c e v e n t s i n advance o f t h e i r a c t u a l occurrence. 0  Mowrer p o s i t s a n x i e t y reduction  of anxiety  "...reduction  as  of anxiety  as  an  a c t i v a t i n g agent,  a r e i n f o r c i n g agent i n l e a r n i n g , may  serve  powerfully  to r e i n f o r c e  -'Harry S t a c k S u l l i v a n , The I n t e r p e r s o n a l o f P s y c h i a t r y , eds. H.S. P e r r y and M.L. Gawel (New W.W. N o r t o n & Company, I n c . , 1953)'  Anxiety,"  and  ^O.H. Mowrer, " S t i m u l u s - R e s p o n s e A n a l y s i s P s y c h o l o g i c a l Review, XLVI (1931)» 563.  Theory York:  of  9  behaviour  t h a t b r i n g s about  ... a s t a t e o f ' r e l i e f  or  . 7  ' s e c u r i t y *."  A n x i e t y - t r a i t and A n x i e t y - s t a t e .  C a t t e l l and  S c h e i e r d i f f e r e n t i a t e between a n x i e t y as a p e r s o n a l i t y Q  trait  and a n x i e t y as an e m o t i o n a l  state.  Anxiety  trait  r e f e r s t o a n x i e t y p r o n e n e s s i n an i n d i v i d u a l and i s r e l - . atively  s t a b l e over time.  I t a r i s e s from a combination  the g e n e t i c a t t r i b u t e s and t h e c u m u l a t i v e individual. perienced by  Anxiety  of  l e a r n i n g ofthe  s t a t e i s t h e degree o f a n x i e t y ex-  b y t h e i n d i v i d u a l a t any g i v e n t i m e .  f a c t o r a n a l y s i s has i d e n t i f i e d  sources  Cattell  and p e r s o n a l i t y o  components i n a n x i e t y w h i c h a r e t r a i t  factors.  These  a r e , a) l a c k o f development o f i n t e g r a t e d s e l f - s e n t i m e n t ; b)  ego w e a k n e s s ; c ) s u s p i c i o u s n e s s  and p a r a n o i d  d) g u i l t p r o n e n e s s ; e) t e n s i o n , i d p r e s s u r e ,  insecurity;  frustration  level. J o h n s o n a n d S p e i l b e r g e r d e f i n e t h e two v e r y different  c o n s t r u c t s s u c c i n c t l y as f o l l o w s :  7  'Mowrer, o p . c i t .  Q  R.B. C a t t e l l a n d I.H. S c h e i e r , "The N a t u r e o f Anxiety: A R e v i e w o f T h i r t e e n M u l t i v a r i a t e A n a l y s e s Comp r i s i n g 814 V a r i a b l e s , " P s y c h o l o g i c a l R e p o r t s , I V ( 1 9 5 8 ) , 351-88.  Q  R.B. C a t t e l l , "Advances i n Measurement o f Neuro t i ' c i s m a n d A n x i e t y i n a C o n c e p t u a l Framework o f U n i t a r y t r a i t T h e o r y , " A n n a l s o f t h e New Y o r k Academy o f S c i e n c e , y  xcn  (1963),  815-39.  10  An o r g a n i s m i c s t a t e ( A - s t a t e ) i s c h a r a c t e r i z e d by s u b j e c t i v e c o n s c i o u s l y p e r c e i v e d f e e l i n g s o f a p p r e h e n s i o n and t e n s i o n t o g e t h e r w i t h a c t i v a t i o n o f the autonomic nervous system. As a p e r s o n a l i t y t r a i t , a n x i e t y ( A - t r a i t ) r e f e r s to the degree to which i n d i v i d u a l s are disposed to manifest A-.. s t a t e i n response to v a r i o u s forms of s t r e s s . n  P h y s i o l o g i c a l and  Biochemical  Aspects of  Anxiety.  P s y c h o s o c i a l concepts o f a n x i e t y a l l i n v o l v e the i n d i v i d u a l ' s response to p e r c e p t i o n of a c t u a l or p o t e n t i a l t h r e a t s to h i s security. to  the  A number o f p h y s i o l o g i c a l t h e o r i e s a r e  concept of a n x i e t y s i n c e they  are  relevant  concerned with  p h y s i o l o g i c a l r e s p o n s e s o f o r g a n i s m s when c h a l l e n g e d adapt.  to  Cannon i n v e s t i g a t e d t h e r o l e o f t h e t h a l a m u s .and  hypothalmus i n i n t e g r a t i n g autonomic a c t i v i t y importance of the homeostasis.  1 1  He  sympathetic-adrenal d e s c r i b e s the  and  system i n  fear-anger  noted  He  pressure,  system - i n c r e a s e d p u l s e r a t e , sugar r e l e a s e d from r e s e r v e s  a d r e n a l i n s e c r e t e d by t h e a d r e n a l m e d u l l a ,  to  noted  p h y s i c a l m a n i f e s t a t i o n s o f t h e r e s p o n s e a c t i v a t e d by sympathetic-adrenal  the  maintaining  response  t h r e a t as a n a t u r a l d e f e n s e o f t h e o r g a n i s m .  arterial  the  the  the  increased  i n the  liver,  etc.  Selye proposes a n o n - s p e c i f i c theory  of s t r e s s  D a l e T. J o h n s o n and C h a r l e s D. S p e i l b e r g e r , "The E f f e c t s o f R e l a x a t i o n T r a i n i n g and t h e P a s s a g e o f Time on S t a t e and T r a i t A n x i e t y , " J o u r n a l o f C l i n i c a l Psychology, XXIV (1963), 20. W a l t e r Cannon, The Wisdom o f t h e Body K e g a n P a u l , T r e n c h , T r u b n e r & Co., L t d . , 1 9 3 2 ) .  (London:  as a G e n e r a l A d a p t a t i o n Syndrome t o n o n - s p e c i f i c  stres-  12 sors.  The G.A.S. i s a p h y l o g e n e t i c a l l y  p a r i n g the organism  o l d defense pre-  t o meet c h a l l e n g e by f i g h t  or f l i g h t ,  through a c t i v a t i o n o f a neuroendocrine response which i n volves brain,  nerves, p i t u i t a r y ,  kidney, blood vessels,  thyroid,  connective tissue,  adrenals, l i v e r , white blood  13 cells.  In c o n t r a d i s t i n c t i o n  J  t o the n o n - s p e c i f i c  b o t h L a c e y and Malmo and t h e i r a s s o c i a t e s have some e v i d e n c e o f i n d i v i d u a l  differences  suggest t h a t p a t t e r n s o f autonomic herited. ^'  ^  1  The  1  demonstrated  i n r e s p o n s e and  reactivity  are i n -  6  e v i d e n c e o f m u l t i f o c a l p h y s i o l o g i c a l and  biochemical response to a n x i e t y - p r o v o k i n g s t i m u l i fold.  The e x p r e s s i o n " u p - t i g h t " r e f l e c t s  a t i o n o f i n c r e a s e d muscle  1 3  i s mani-  t h e common  t e n s i o n and a n x i e t y .  H a n s S e l y e , The S t r e s s o f L i f e Book Company, 1956). 1 2  Hill  theory  associ-  Jacobson  (New Y o r k :  McGraw-  Ibid.  14 J o h n I. L a c e y and Ruth Van Lehn, " D i f f e r e n t i a l E m p h a s i s i n S o m a t i c Response t o S t r e s s , " P s y c h o s o m a t i c M e d i c i n e , X I V (March - A p r i l , 1952), 71-81. * 5 J . I , L a c e y and B e a t r i c e C. L a c e y , " V e r i f i c a t i o n and E x t e n s i o n o f t h e P r i n c i p l e o f A u t o n o m i c Response S t e r e o t y p y , " A m e r i c a n J o u r n a l o f P s y c h o l o g y , L X X I (March, 1958), 50-73. :  16  R.B. Malmo and R.C. S h a g r a s s , " P h y s i o l o g i c S t u d i e s o f Symptom Mechanisms i n P s y c h i a t r i c P a t i e n t s Under S t r e s s , " P s y c h o s o m a t i c M e d i c i n e , X I ( J a n . - F e b . , 1949), 50-73.  12 d e f i n e s a n x i e t y i n t e r m s o f t e n s i o n and and  says t h a t  s t r i a t e d m u s c l e t e n s i o n p a t t e r n s mark t h e  smooth  emotional r e 17  a c t i o n i n which v i r t u a l l y Ferris  N.  anxiety  Pitts  lists  t h e whole o r g a n i s m  the f o l l o w i n g  n e u r o s i s i n a s t u d y o f 60  breathlessness,  somatic  patients  chest pain, sighing,  participates. symptoms o f  -  palpitations,  dizziness,  faintness,  h e a d a c h e , p a r e s t h e s i a s , weakness, t r e m b l i n g , s h a k i n e s s , e t c . While  somatic  the autonomic toms w i l l  symptoms a r e m a n i f e s t a t i o n s o f o v e r a c t i v i t y system  s u b s y s t e m s and  ation of anxiety.  may  recognized that  v a r y w i t h the b a l a n c e  sympathetic  exhibit  i t must be  pallor  exhibit  of sympathetic  and  a c c o r d i n g to the l e v e l  F o r example t h e p e r s o n  while the person  flushing.  these  Similarly  have d r y mouths w h i l e i n d i v i d u a l s  acutely  level  anxious  symp-  paraand  i n panic  at a lesser  dur-  may of anxiety  individuals  with chronic anxiety  exhibit  excessive s a l i v a t i o n .  Mahl suggests  anxiety  i s a s s o c i a t e d with sympathetic  anxiety  i s accompanied  that  may  acute  dominance and  by p a r a s y m p a t h e t i c  of  chronic 19  dominance.  "'Edmund J a c o b s o n , A n x i e t y and T e n s i o n C o n t r o l (Philadelphia: J.B. L i p p i n c o t t Company, 1964), p.X. J  1 Pi  F e r r i s N. P i t t s , "The B i o c h e m i s t r y o f A n x i e t y , " S c i e n t i f i c ' A m e r i c a n , CCXX ( F e b r u a r y , 1964), 69-7519 G . F . M a h l , " R e l a t i o n s h i p Between A c u t e and C h r o n i c F e a r and t h e G a s t r i c A c i d i t y and B l o o d S u g a r L e v e l s i n M a c a c a M u l a t t a Monkeys," Psychosomatic Medicine, XIV (May-June, 1952), 182-210. 7  13  As Cannon t h e o r i z e d , anxiety response i s a s s o c i ated with a c t i v a t i o n of sympathoadrenomedullary and c o r t i c a l systems.  S t i m u l a t i o n o f the sympathetic  adrenal  system l e a d s to a marked i n c r e a s e i n a d r e n a l i n and a d r e n a l i n i n the blood.  Increased  nor-  catecholamine e x c r e t i o n  i n i n d i v i d u a l s i n anxiety evoking s i t u a t i o n s has 20 demonstrated i n numerous s t u d i e s .  adreno-  21 '  been  22 '  Urinary  ex-  c r e t i o n of catecholamines r e f l e c t s t h e i r r e l e a s e i n a cons i s t e n t way. reviewed and  These and  other p e r t i n e n t f i n d i n g s have been 23 24  summarized elsewhere.  C l i n i c a l and  lab-  o r a t o r y 'studies have a l s o shown i n c r e a s e s i n a d r e n a l  cortical  activity  such  with 20  s t r e s s induced  by p s y c h o s o c i a l  stimuli  J . Mendelson et a l . , "Catecholamine E x c r e t i o n and Behaviour During Sensory D e p r i v a t i o n , " A r c h i v e s o f General P s y c h i a t r y , I I (January, I960), 37. 21  Lennart L e v i , "The U r i n a r y Output of A d r e n a l i n and N o r a d r e n a l i n During D i f f e r e n t E x p e r i m e n t a l l y Induced Pleasant and Unpleasant Emotional S t a t e s , " Psychosomatic Medicine, XXVII (January - February, 1965), 80-85. 22 W.W. T o l s o n et a l . , "Urinary Catecholamine Responses A s s o c i a t e d with H o s p i t a l Admission i n Normal Human S u b j e c t s , " J o u r n a l of Psychosomatic Research, V I I I (Number 4, 1965), 365* 23 -'S.S. Kety, "Catecholamines i n N e u r o p s y c h i a t r i c S t a t e s , " Pharmacological Review, XVIII (Number 1, P a r t 1,  1966),  787.  24 Jan Froberg e t a l . , " P h y s i o l o g i c a l and B i o chemical S t r e s s Reactions Induced by P s y c h o s o c i a l S t i m u l i , " S o c i e t y , S t r e s s and Disease, ed. Lennart L e v i (London: Oxford U n i v e r s i t y Press, 1971), pp. 280-295.  14 as h o s p i t a l admission and p s y c h i a t r i c i n t e r v i e w s . ^ » ^ » 7 , 28 2  2  2  Conversely r e d u c t i o n i n s t r e s s f u l s t i m u l i o r p r o v i s i o n o f s o o t h i n g s t i m u l i has been accompanied by decrease 29 cortical activity.  7  t a t i o n o f medullary Mason has reviewed pituitary-thyroid  1  i n adrenal  30 J  Rubin and Mandell reviewed  manifes-  s t i m u l a t i o n a s s o c i a t e d with a n x i e t y . ^  1  r e s e a r c h i n t o the p i t u i t a r y - a d r e n a l and systems a c t i v a t i o n i n response  to  the  stressful  2S  ^Gregory Pxncus and Hudson Hoagland, Adrenal C o r t i c a l Responses to S t r e s s i n Normal Men and i n those with P e r s o n a l i t y , D i s o r d e r s , " American J o u r n a l o f P s y c h i a t r y , CVI (February - March, 1 9 5 0 ) , 641-50. 26  J.W. Mason et a l . , " C o r t i c o s t e r o i d Responses to H o s p i t a l Admission," A r c h i v e s o f General P s y c h i a t r y , X I I I (January, 1 9 5 9 ) , 1-8. H . Persky et a l . , " E f f e c t o f Two P s y c h o l o g i c a l S t r e s s e s on A d r e n o c o r t i c a l F u n c t i o n , " A r c h i v e s o f Neurology, LXXXIII (February, 1 9 5 9 ) , 219. 2 7  oo  F.C. B a r t e r and C.S. Delea, "A Map of Blood and U r i n a r y Changes R e l a t e d to C i r c a d i a n V a r i a t i o n s i n Adrenal C o r t i c a l F u n c t i o n i n Normal S u b j e c t s , " Annals o f the New York Academy o f Science, XCVIII (October 30, 1 9 7 0 ) , 969-83.  29 'J.H. Handlon et a l . , " P s y c h o s o c i a l F a c t o r s Lowering Plasma 1 7 - h y d r o x y c o r t i c o s t e r i o d E x c r e t i o n During S t r e s s f u l L i f e E x p e r i e n c e s i n Man," Psychosomatic Medicine, XXIV (November - December, 1 9 6 2 ) , 535-42. 30 Frances L. P r i d e , "An Adrenal S t r e s s Index as a C r i t e r i o n Measure f o r N u r s i n g , " Nursing Research, XVII ( J u l y - August, 1 9 6 8 ) , 292-303. J  R . T . Rubin and A.J. Mandell, "Adrenal C o r t i c a l A c t i v i t y i n P a t h o l o g i c a l Emotional S t a t e s , " American J o u r n a l of P s y c h i a t r y , CXXIII (October, 1 9 6 6 ) , 381-400. 31  e x p e n e n c e s . 3 2 , ' 3 '3 . J J  J  34  M a n i f e s t a t i o n s o f Anxiety From the f o r e g o i n g and from a m u l t i t u d e of other a r t i c l e s and books by authors from a v a r i e t y of d i s c i p l i n e s one can c o n c e p t u a l i z e a n x i e t y as a behaviour i n v o l v i n g the organism as a whole and a l l the subsystems  of the organism.  Anxiety i s thus m a n i f e s t i n terms of p h y s i o l o g i c a l , motor, a f f e c t i v e , c o g n i t i v e  psycho-  and s o c i a l behaviour.  P h y s i o l o g i c a l M a n i f e s t a t i o n s o f Anxiety.  Many  s t u d i e s have been c i t e d d e a l i n g with P h y s i o l o g i c a l b i o c h e m i c a l m a n i f e s t a t i o n s o f s t r e s s i n the p r e v i o u s section.  As mentioned  responses vary with the d u r a t i o n and  i n t e n s i t y of s t r e s s and a c c o r d i n g to the organism's i n d i v i d u a l p a t t e r n s o f responses. P h y s i o l o g i c a l m a n i f e s t a t i o n s of a n x i e t y can i n c l u d e i n c r e a s e d muscle t e n s i o n , i n c r e a s e d p u l s e r a t e ,  hyperven-  t i l a t i o n , d i l a t e d p u p i l s , dry mouth, f l u s h i n g or p a l i n g , sweating ( p a r t i c u l a r l y palmar), frequency o f , or i n v o l u n t a r y ,  32  J.W. Mason, "A Review o f Psychoendocrine Research on the P i t u i t a r y - a d r e n a l C o r t i c a l System," Psychosomatic Medicine, XXX (September-October, 1968), 5 7 6 - 6 0 7 . J  33J.W. Mason, "A Review o f Psychoendocrine Research on the Sympathetic-adrenal Medullary System," Psychosomatic Medicine, XXX (September-October, 1 9 6 8 ) , 6 3 1 - 6 5 3 . •3k  J.W. Mason, "A Review of Psychoendocrine Research on the P i t u i t a r y - t h y r o i d System," Psychosomatic Medicine, XXX;, (September-October, 1 9 6 8 ) , 666-681. J  16  m i c t u r i t i o n and  d e f e c a t i o n , and  increased gastric  secre-  tion.35.36.37 Other p h y s i o l o g i c a l m a n i f e s t a t i o n s , which a l s o reflect and  autonomic a c t i v a t i o n are  u r i n a r y c o r t i c o s t e r i o d s and  increased  catecholamines,  u r i n a r y e x c r e t i o n o f p o t a s s i u m and sodium, i n c r e a s e d  erythrocyte  l e v e l of  increased  decreased s e c r e t i o n of  sedimentation  r a t e , and  crease- . I n p l a s m a l i p i d s . E l e c t r o e n c e p h a l o g r a m show l e s s a l p h a as  activity  compared t o n o r m a l  defense of the  perceived  fearful,  -5  excessive  of Anxiety.  anxious i n d i v i d u a l  t h r e a t i s the p r e p a r a t i o n  Unresolved  states  subjects.-^  r e s p o n s e , w h i c h i s most e a s i l y system.  in-  studies  i n persons s u f f e r i n g anxiety  Psychomotor M a n i f e s t a t i o n s matic  serum  f o r the  The  against  " f i g h t or  observed i n the  auto-  flight"  psychomotor  m u s c l e t e n s i o n i s shown i n  <  -^Wn. J . T u r n e r , G l o s s a r i e s f o r use w i t h t h e O v e r a l l and Gorham B r i e f P s y c h i a t r i c R a t i n g S c a l e , P s y c h o pharmacology S e r v i c e Centre (Bethesda, Maryland: National I n s t i t u t e o f M e n t a l H e a l t h , 1963).  John Wiley  Arnold.H. Buss, Psychopathology and S o n s , I n c . , 1966), p. 51T  (New  York:  - ^ F e r r i s N. P i t t s , "The B i o c h e m i s t r y o f A n x i e t y , " S c i e n t i f i c A m e r i c a n , CCXX ( F e b r u a r y , 1 9 6 9 ) , 69-75. --^Froberg,  op. c i t .  3^A.L. B r o c k w a y e t a l . , "The Use o f a C o n t r o l P o p u l a t i o n i n N e u r o p s y c h i a t r i c Research ( P s y c h i a t r i c , Psychol o g i c a l and E.E.G. E v a l u a t i o n o f a H e t e r o g e n e o u s S a m p l e ) , " A m e r i c a n J o u r n a l o f P s y c h i a t r y , CXI ( F e b r u a r y , 1 9 5 4 ) , 248-62.  17 random, r e s t l e s s movements; muscular i n c o o r d i n a t i o n ; pacing;  squirming;  Rapid,  t r e m b l i n g or shaking;  and  facial  tics.  h i g h e r p i t c h e d , sometimes s t u t t e r i n g speech marks  the v o c a l p a t t e r n s of the anxious i n the panic s t a t e may  individual.  Individuals  p h y s i c a l l y harm themselves or a t t a c k  41 others.  I f psychomotor responses are f u r t h e r d i s o r g a n -  i z e d the person may aroused to  "freeze".  The  o v e r v i g i l a n t and  over-  s t a t e of e x c e s s i v e a n x i e t y tends to cause the  person  o v e r - r e a c t to s t i m u l i with a r e s u l t a n t "jumpiness"  exaggerated tendency to  and  startle.  A f f e c t i v e M a n i f e s t a t i o n s o f Anxiety.  Perhaps the  best d e s c r i p t i o n s o f the a f f e c t i v e m a n i f e s t a t i o n s o f a n x i e t y are to be found Kafka's The  i n f i c t i o n and p h i l o s o p h i c essays.  In  C a s t l e shapeless, d r e a d f u l f o r c e s t h r e a t e n the 42  i n d i v i d u a l and f i l l  him with a n x i e t y .  Kierkegaard,  as  other e x i s t e n t i a l w r i t e r s , c o n s i d e r s a n x i e t y as an i n e s capable  aspect of the human c o n d i t i o n .  Dread Kierkegaard  In The  Concept of  explores the extreme a n x i e t y of the i n -  d i v i d u a l , f i n i t e and  f a l l i b l e , f a c i n g the freedom to choose  40 Buss, o p . c i t . 41 Turner,  op.cit.  42 Franz Kafka, The C a s t l e , t r a n s , by W i l l a Edwin Muir (New York: A l f r e d A Knopf, 1954).  and  18 and  having  to accept  responsibility  f o r his decisions.  Affective manifestations easiness  J  r u n t h e gamut f r o m un-  through f e a r , dread, h o r r o r  and t e r r o r  according  LL to  the l e v e l  level  of anxiety  of anxiety  i n panic  experienced.  t h e more i m m e d i a t e  The h i g h e r t h e the f e a r .  The p e r s o n  i s i n t e r r o r o f h i s imminent d e a t h o r d i s f i g u r e -  ment o r c o m p l e t e l o s s o f c o n t r o l .  Lesser  fears  fear of failure,  fear of loss of a significant  o f making a f o o l  of oneself,  focussed  a n d be p r e s e n t  apprehension.  anxiety  Cognitive  fear  o f t e n he un-  the l e v e l  of fear i s  P h o b i a s a r e an  disproportionate  Manifestations  cognitive aspects  person,  f e e l i n g o f t e n s i o n and  t o the degree o f t h r e a t .  extreme example o f u n r e a l i s t i c ,  categorized  F e a r may  as a g e n e r a l  In excessive  disproportionate  etc.  include  of Anxiety.  fear. P e p l a u has  as r e l a t e d t o degree o f  L< anxiety.  J  Mild  n e s s and a l e r t s tensity a detail tive  anxiety  increases  his attention.  the p e r c e p t u a l  field  t h e i n d i v i d u a l ' s aware-  As a n x i e t y  i s reduced  or scattered details.  increases  so t h a t  focus  The p e r s o n m a n i f e s t s  i n a t t e n t i o n sometimes t o t h e p o i n t  in ini s on selec-  of dissociation i n  43 -"Soren K i e r k e g a a r d , The C o n c e p t o f D r e a d , t r a n s . Walter Lowrie (Princeton: P r i n c e t o n U n i v e r s i t y P r e s s , 1957).  44 Turner, o p . c i t .  45 Nursing  Hildegard Peplau, Interpersonal Relations i n (New Y o r k : G.P. Putnam's Sons, 1952).  19 panic  states.  Learning i s e f f i c i e n t  disrupted  as a n x i e t y i n c r e a s e s .  tractible  and f o r g e t f u l .  i n mild anxiety buti s  The i n d i v i d u a l  R e c e n t memory i s most  T h o u g h t c o n t e n t may be c o n c e r n e d mutiliation,  destruction, disaster,  humiliation,  failure.  going  i sdisimpaired.  with  illness,  death,  pain,  rejection,  The i n d i v i d u a l may b e l i e v e t h a t he i s  c r a z y when a n x i e t y i s s e v e r e .  Nightmares a r e n o t un-  46 common. S o c i a l Manifestations o f Anxiety. S u l l i v a n has d e s c r i b e d the maladaptive ifestations the l e v e l  of anxiety.  and c h r o n i c i t y  common a s p e c t social  '  Harry  i n t e r p e r s o n a l man-  Once a g a i n t h e s e  o f the response.  however, i s t h e t e n d e n c y  i n t e r c o u r s e which r e f l e c t s  ponse t o p e r c e p t i o n o f t h r e a t .  Stack  vary  according to  P e r h a p s t h e most  t o withdraw  the f l i g h t  from  aspect o f r e s -  Another important  aspect i s  o v e r d e p e n d e n c y on o t h e r s b e c a u s e o f f e e l i n g s o f i n s e c u r i t y , inadequacy in  and f e a r o f f a i l u r e .  difficulty  with peer  T h i s overdependency  relationships  results  and w i t h a u t h o r i t y  relationships. Differences  i n cross-cultural  levels  of anxiety  48 have been d e m o n s t r a t e d .  Factor analysis  o f c u l t u r e s with  46 Buss,  loc.cit.  47 'Sullivan,  loc.c i t .  48 C. M o r r i s and L.V. J o n e s , " V a l u e S c a l e s and D i m e n s i o n s , " J o u r n a l o f A b n o r m a l and S o c i a l P s y c h o l o g y . L I (1955), 523 35T I  :  20 compar.atively the  Of  high anxiety l e v e l s  o f the populace  revealed  following characteristics:  the  lower  1.  Low  standard  of  2.  L a c k o f emphasis on  3.  Lack of p o l i t i c a l  4.  Centralized authoritarian structure.  c o u n t r i e s s t u d i e d the was  as  living. education.  and  social  emancipation.  anxiety l e v e l  f o l l o w s - I n d i a , China,  from h i g h e r  to  J a p a n , Norway, U.S.A.  A Model f o r A n x i e t y . W h i l e a model i s a s i m p l i f i c a t i o n assist  i n demonstrating  f a s h i o n and model c a n vent the  a complicated  i n showing a n t e c e d e n t s  also c l a r i f y  the  o f the  o f a n x i e t y and mediated  i s an  overload,  organized  consequences.  A pre-  c h o i c e o f i n d i c e s t o measure The  model shown i n F i g u r e and  by  Levi.  manifestations  Stimuli,  '  These s t i m u l i may  i n n e r o r o u t e r environment o f the electrolyte  i n an  i t can  a d a p t a t i o n o f a model f o r p s y c h o s o c i a l l y  Biopsychosocial  include  and  f o r e g o i n g concepts  disease developed  from the  the  intervention.  1 i s d e r i v e d from the  concept  choice of i n t e r v e n t i o n s to  o r m o d i f y d i s o r d e r and success  of r e a l i t y  inbalance, pain,  emotionally  charged  individual  sensory  situations,  arise and  d e p r i v a t i o n or  inner c o n f l i c t ,  ^ L e n n a r t L e v i , ( e d . ) , " S t r e s s and D i s t r e s s i n Response t o P s y c h o s o c i a l S t i m u l i , " Supplement No. 528 t o A c t a M e d i c a S c a n d i n a v i c a , CXCI ( 1 9 7 2 ) , 12.  etc.  Perceived Threat or Challenge  PsychoBiological Programme  PsychoBioSocial Stimuli  (heredity and environment)  INTERACTING  extrinsic  Stimuli,"  Defense Mechanisms  Physiologcal Psychomotor Affective Cognitive Social  Mental Physical  VARIABLES •physical environment social environment culture  i n t r i n s i c  Figure model  Anxiety Response  1. for  A Model for Anxiety (Adapted from L e v i ' s psychosocially mediated disease).*  *Lennart Levi, Supplement No.  (ed.), to  528  " S t r e s s and D i s t r e s s i n Response to Psychosocial A c t a M e ' d i c a S c a n d i n a v i c a , ' C X C I (1972), 12.  ro  Any  of these  s t i m u l i may  terminology.^  In f a c t ,  become a " s t r e s s o r " i n any  a c t as a s t r e s s o r i n s o f a r as t o a d a p t and  i s thus  b i o - p s y c h o s o c i a l change i t challenges  the  a p o t e n t i a l t h r e a t to  Psychobiological  Selye's  Programme.  individual  homeostasis.  Each i n d i v i d u a l  a p o t e n t i a l to r e a c t i n p a t t e r n e d  sequences which  d e t e r m i n e d by  "learned" f a c t o r s  by  earlier  g e n e t i c f a c t o r s and  environmental  can  influences.^  has  are induced  "Learned" i n  this  s e n s e means a l l f o r m s o f changed b e h a v i o u r  from s u b - c e l l u l a r  to organismic.  be n o n - s p e c i f i c ,  these  p a t t e r n s may  patterns theory  W h i l e o v e r a l l p a t t e r n s may  are both  o f the  be m o d i f i e d phylogenetic  General  organism's g e n e r a l L a c e y and  and  Adaptation  ontogentic.  so  Selye's  Syndrome d e s c r i b e  the  a s s o c i a t e s show i n s t a n c e s o f i d i o s y n c r a t i c  Perceived of c e r t a i n  stimuli  i n several studies.  Threat with  individual results  or Challenge.  the  or-  ^  The  interaction  p s y c h o b i o l o g i c a l programme  i n the  5°Selye, o p . c i t . 5 2  that  response to n o n - s p e c i f i c s t r e s s o r s .  g a n i z a t i o n of response  an  i n each i n d i v i d u a l  perception  p.64  ( w h i c h may  51  be  of con-  l D i d <  Ibid.  53 John I. Lacey, " I n d i v i d u a l D i f f e r e n c e s i n Somatic Response P a t t e r n s , " J o u r n a l o f C o m p a r a t i v e P h y s i o l o g i c a l P s y c h o l o g y . X L I I I ( 1 9 5 0 ) , 338-50. 54 L a c e y and VanLehn, o p . c i t .  23  scious quo.  or  subconscious) of  These t h r e a t s may  social  and  conflict,  may  threat  Perception istic  be  of  be  i n the of  l o s s , or  threat  or  or  challenge  conceived  form o f  as  to  the  biological  even the may  challenge be  realistic  psychobiological  i n t e r a c t i n g v a r i a b l e s which w i l l  of  status  or  unmet n e e d s , d a n g e r  challenge  d e p e n d i n g upon t h e  of the  threat  psychosignals,  change. or  unreal-  programme and  be  described  some  later.  Thus a n x i e t y - t r a i t i s a p e r s o n a l i t y f a c t o r w h i c h augments propensity  to p e r c e i v e  Anxiety lent  of  terms.  anxiety  threats  Response.  state  as  i n any  Anxiety  defined  It i s a multifaceted  by  given  Cattell  individual  perceived  i s a l e r t e d t o meet t h e cerebral' cortex  i s the  in  equiva-  psychological  behavior with p h y s i o l o g i c a l , and  The  situation.  response  psychomotor, a f f e c t i v e , c o g n i t i v e  lenge.  the  social  components. threat  i s a c t i v a t e d v i a the  or  The  chal-  reticular  55 activating as  the  system.  The  autonomic nervous system  organism prepares f o r f i g h t  i n muscles d i l a t e L a d e r n o t e s the enable the excessive  and  general  increased  muscle tone  level  organism to r e a c t  or f l i g h t .  of  i s activated  Blood  increases.  vessels As  a c t i v a t i o n i s intended  appropriately  to  a c t i v a t i o n becomes d i s o r g a n i z i n g and  threat.  to  However,  maladaptive.  -^M.H. L a d e r and L o r n a Wing, P h y s i o l o g i c a l M e a s u r e s , S e d a t i v e D r u g s , and M o r b i d Anxie.ty ( L o n d o n : Oxford Univers i t y P r e s s , 1966) p.12. ^ Ibid, 6  p.16.  2k I n d i v i d u a l differences:',in t o t a l p a t t e r n o f response are e x h i b i t e d . one  Some persons show predominance o f response i n  o r s e v e r a l response systems, i . e . - one person may r e a c t  p r i m a r i l y i n the psychomotor and c o g n i t i v e systems  while  another person might show predominance i n the somatic system (with g a s t r o  i n t e s t i n a l , genito  urinary, r e s p i r a t o r y or cardio-  57  v a s c u l a r complaint). uated i n the r e s e a r c h  A f f e c t i v e responses were not e v a l cited.  Defense Mechanisms. responds to p e r c e i v e d  The a l e r t e d anxious i n d i v i d u a l  t h r e a t by the use o f v a r i o u s  mechanisms both p h y s i c a l and mental. or conscious  and d e l i b e r a t e .  of f i g h t o r f l i g h t the  issue.  A l l can be conceived  o f i n terms  - o f c o n f r o n t i n g the t h r e a t o r o f a v o i d i n g  mental defense mechanisms, which are forms o f  f l i g h t by d e n i a l o f r e a l i t y ,  ization,  These may be automatic,  P s y c h o l o g i c a l defenses a g a i n s t t h r e a t i n c l u d e the  c l a s s i c Freudian  pression,  defense  i n terms o f r e p r e s s i o n ,  s u b s t i t u t i o n , sublimation,  sup-  projection, rational-  e t c . , as w e l l as the f i g h t e q u i v a l e n t  of  conscious  problem s o l v i n g o r working through the t h r e a t . Habituation  i s a p h y s i o l o g i c a l defense mechanism  which the organism uses to adapt to s u c c e s s i v e  57  identical  A.H. Buss, "Two Anxiety F a c t o r s i n P s y c h i a t r i c P a t i e n t s , " J o u r n a l o f Abnormal and S o c i a l Psychology. LXV (December, 1962), 426-27.  2  stimuli and  by  progressively diminished  biochemical  processes  response.^  of adaptation  are  5  Neurological  l a r g e l y dependent 59  upon t h e  p s y c h o b i o l o g i c a l programme o f t h e Interacting Variables.  intrinsic the  and  action)  tend  extrinsic  notes there m o d e l , so  parts  diminish,  i s some d i f f i c u l t y  i n the  present  of  the model.  or prevent  that  are  (i.e. alter  These v a r i a b l e s  anxiety.  i n demarking p a r t s  adapted model t h e r e  i n t e r a c t i o n between p a r t s  7  Interacting variables  f a c t o r s which i n f l u e n c e  of a l l other  t o promote, o r  individual.  As of  Levi his  i s s u c h marked  demarcation i s  exceedingly  6o difficult.  Consequently  be  as  considered  factors noise,  can  be  stimuli  some o f t h e  o r as  physical  forms of defense.  physical, psychosocial,  s e n s o r y d e p r i v a t i o n and factors predisposing  v a r i a b l e s could  or  increase  Extrinsic  s o c i o c u l t u r a l . Heat,  overcrowding are to  also  examples  anxiety.  of  Morris  6l and with the  Jones high  research levels  disclosed cultural  of anxiety.  factors  associated  Sociocultural factors  p s y c h o b i o l o g i c a l programme i n d e t e r m i n i n g  what  influence stimuli  - ^ L a d e r , o p . c i t . , p.13-14. 59 - " R i c h a r d L a z a r u s , "The C o n c e p t s o f S t r e s s and D i s e a s e , ' " i n S o c i e t y , S t r e s s , and D i s e a s e , ed. L e n n a r t L e v i (London: Oxford U n i v e r s i t y P r e s s , 1971), p.57. 6o Levi, Morris  op.cit., and  p.19.  Jones, o p . c i t .  26 are  perceived  sources also  as  threats  rituals,  and  health  practises,  areas of  technique  a nursing  may  modify  an  variables  status  relaxed?  Is h i s  serum l a c t a t e age,  I s he  sex,  a l l intrinsic  of  are  relaxation  i s a s p e c i f i c example  interacting variable  a r i s e from the  the  tired,  elevated  individual.  which  variables  from  Definition; to p e r c e i v e d  threat  or  Anxiety  can  challenge  s t i m u l i i m p i n g i n g upon the  of  i n d i v i d u a l and variables.  influenced The  of  organismic  by  intrinsic  physical  and  psychological  tension.  alerting  the  i n d i v i d u a l to  the  psychologically  and  subjective Anxiety  presence of or  the  model.  the  response  programme extrinsic  i s characterized  a u t o n o m i c a c t i v a t i o n and  disease  psycho-bio-  psychobiological  and  and  drugs,  proposed.  a r i s i n g from  cortical  physiologically  Diet,  a l l parts  be  response  which remains u n r e s o l v e d ,  optimistic?  From e x a m i n a t i o n o f now  physical  concentrat-  absence o f  is a total  social  interacting  I s he  exercise?  influencing  anxiety  immediate  angry, depressed,  pregnancy, presence or  model a d e f i n i t i o n o f  anxiety  recreation  T e a c h i n g the  D e f i n i t i o n of Anxiety.  the  beliefs  anxiety.  ing or  are  as  and  re-  anxiety.  philosophical  i n t h i s study  intervention  psychological  alcohol,  Sociocultural  education,  such r e s o u r c e s .  Intrinsic and  r e l i g i o n s and  care,  investigated  of  challenges.  a s s i s t i n d i v i d u a l s i n coping with  Group s u p p o r t ,  general  or  by  feelings  i s adaptive  a problem.  of in  However,  inadequately resolved, disorganizing  and  thus  is  27 maladaptive.  Psychophysiologic  Relaxation  A review psychophysiologic relaxation been u s e d Eastern breath  ted,  t o examine t h e  control anxiety  composure r e v e a l s t h a t t h e s e  i n both  control,  literature  methods to  E a s t e r n and  disciplines  leading induce  and  of the  Techniques.  Zen  p h y s i c a l e x e r c i s e s and and  t e a c h methods  mental  contemplation.  state of anxiety.  promote  methods have  "The  of  concentration  These p r a c t i s e s  serenity, a state d i a m e t r i c a l l y opposite  aroused  to  of  Western c u l t u r e s f o r c e n t u r i e s .  s u c h as Y o g a and  to m e d i t a t i o n  and  use  Yogi,"  to the  say  aler-  Marques62  Riviere,  "works on  the  sympathetic  nervous  system."  Western p r a c t i s e s of p s y c h o p h y s i o l o g i c w h i c h l e a d t o composure and the  framework o f r e l i g i o u s  medical the  and  techniques  to the  Co.),  and  within  more r e c e n t l y i n  practise,  as w e l l as  in  meditation  general p u b l i c .  employed m e d i t a t i o n  and  beliefs  p o p u l a r i z a t i o n of eastern  Meditation.  sciousness.  s e r e n i t y have o c c u r r e d  psychological c l i n i c a l  i n t r o d u c t i o n and  techniques  as  Mystics  i n most r e l i g i o u s  a means t o an  Christianity,  altered  J u d a i s m and  J. Marques-Riviere, p.81.  Islam  T a n t r i k Yoga  s y s t e m s have  state of  con-  have r e c o r d s  (London;  of  Rider  28 branches with w e l l developed  p r a c t i s e s of m e d i t a t i o n .  U J )  '  u  Transcendental m e d i t a t i o n , an I n d i a n Yoga technique popu l a r i z e d i n the West by M a h a r i s h i Mahesh Yogi i s widely p r a c t i s e d by members of the g e n e r a l p u b l i c . The b a s i c elements of Trnascend'ental M e d i t a t i o n are o u t l i n e d by Wallace  and Benson.  The p r a c t i t i o n e r s i t s i n a comfortable p o s i t i o n with eyes c l o s e d . By a systematic method t h a t he has been taught, he; .perceives a " s u i t a b l e " sound or thought. Without attempting to concent r a t e s p e c i f i c a l l y on t h i s cue he allows h i s mind to experience i t f r e e l y , and h i s t h i n k i n g , as the p r a c t i t i o n e r s themselves r e p o r t , r i s e s to a " f i n e r and more c r e a t i v e l e v e l i n an easy and n a t u r a l manner."66 P h y s i o l o g i c a l aspects of m e d i t a t i o n have been i n v e s t i g a t e d and are now p h y s i o l o g i c a l responses  w e l l documented.  Demonstrated  i n c l u d e r e d u c t i o n i n oxygen con-  sumption and carbon d i o x i d e e l i m i n a t i o n , r e d u c t i o n i n r a t e and volume of r e s p i r a t i o n , decrease  i n blood l a c t a t e  slowing of heartbeat, i n c r e a s e i n g a l v a n i c s k i n  response,  ^ E v e l y n U n d e r h i l l , M y s t i c i s m (London: and Company, L t d . , 1967). ^ G e r s h o n Scholem, Jewish Mysticism Schocken Books Inc., 1 9 6 l ) .  level,  (New  ^ J o h n Trimingham, S u f i Orders i n Islam Clarendon Press, 1971)•  Methuen  York:  (Oxford:  R o b e r t K. Wallace and Herbert Benson, "The Physiology of M e d i t a t i o n , " S c i e n t i f i c American, CCVT (February, 1972), 80-9^. 6 6  and  i n t e n s i f i c a t i o n of  slow a l p h a  61  p a t h e t i c nervous alarm" or  electro-  68  encephalogram p a t t e r n .  The  hypometabolic pattern,  waves i n t h e  authors  suggest  representing quiescence  system,  i s the  "fight-or-flight"  counterpart  that  this  o f the  sym-  o f the  reaction described  by  "defense Walter  Cannon Progressive  Relaxation.  proponents of r e l a x a t i o n therapy for  disease  with  Jacobson.  He  has  psychosomatic  One  o f the  f o r anxiety  foremost reactions  i m p l i c a t i o n s i s Edmund  d e v e l o p e d a scheme o f P r o g r e s s i v e  l a x a t i o n based l a r g e l y  on  and  l e a r n i n g theory  and  Re-  systems  69 theory. in  7  The  subject  s p e c i f i c m u s c l e s and  muscles at w i l l .  first  l e a r n s to r e c o g n i z e  subsequently  J a c o b s o n t e s t s the  e l e c t r i c a l measurements o f t h e He  tension  l e a r n s to r e l a x  those  e f f e c t i v e n e s s by  degree o f muscle  documents a number o f c a s e h i s t o r i e s  tension.^  of patients  suffer-  67 ' W a l l a c e and  Benson, o p . c i t .  68 R o b e r t K. W a l l a c e , H e r b e r t Benson and A r c h i e F. W i l s o n , "A W a k e f u l H y p o m e t a b o l i c P h y s i o l o g i c S t a t e , " A m e r i c a n J o u r n a l o f P h y s i o l o g y , CCI ( S e p t e m b e r , 1971)»  795-99.  69  Edmund J a c o b s o n , A n x i e t y and T e n s i o n (Philadelphia: J.B. L i p p i n c o t t Company, 1964). y  Control,  70 ' Edmund J a c o b s o n , " E l e c t r i c a l M e a s u r e m e n t s C o n c e r n i n g M u s c u l a r C o n t r a c t i o n s ( t o n u s ) and t h e C u l t i v a t i o n o f R e l a x a t i o n i n Man - R e l a x a t i o n Times o f I n d i v i d u a l s , " A m e r i c a n J o u r n a l o f P h y s i o l o g y , C V I I I (Septem-  b e r , 193*). 573-80.  •  0  30 ing  from  s u c h c o n d i t i o n s as  coronary and  infarction,  insomnia,  colitis,  pyloric  ulcer,  early e s s e n t i a l hypertension,  e t c . , whom he  has  post anxiety  t r e a t e d s u c c e s s f u l l y by  71 Progressive  Relaxation  Reciprocal J o s e p h Wolpe has  methods o f t e n s i o n c o n t r o l .  Inhibition  extended  and  Systematic  Jacobson's theory  Desensitization.  of  Progressive  72 Relaxation otic  to a theory  anxiety  responses. evoking  can  be  the  results  scores  unadaptive 82  anxiety  In other  Systematic  same t i m e .  Of  "Apparently 7  by  a total  anxiety-  can  Wolpe  Inhibition  not  be  has  therapy  Willoughby  by  ques-  i.e. persistent o f 210  C u r e d , " 106  (3«3%) r e m a i n e d  patients,  {50.5%)  were  "Unimproved."  7 3  D e s e n s i t i z a t i o n i s a b e h a v i o u r mod-  using p r i n c i p l e s  A heirarchy  or anxiety  the  i s then conditioned  subject  words, one  f o r neuroticism,  reaction).  "much Improved," w h i l e  therapy  used to d e s e n s i t i z e  improvement and  (a t e s t  Neur-  antagonistic physiological  of Reciprocal  (39.0%) were r a t e d  ification  be  by  r e l a x e d a t the  m e a s u r i n g symptomatic tionnaire  can  reactions.  b o t h a n x i o u s and evaluated  inhibited  Relaxation  stimuli  of Reciprocal I n h i b i t i o n . '  evoking  of Reciprocal  stimuli to  Inhibition.  i s constructed  control anxiety  by  and re-  71 Jacobson, o p . c i t . 72 hibition  J o s e p h Wolpe, P s y c h o t h e r a p y by R e c i p r o c a l I n (Stanford:" S t a n f o r d U n i v e r s i t y P r e s s , 1958). 7 3  Ibid.  l a x a t i o n w h i l e c o n f r o n t i n g the l e a s t stimuli  i n the h e i r a r c h y .  p e a t e d m o v i n g up anxiety  the  scale  provoking stimuli Autogenic  laxation  process i s systematically  i t e m by c a n be  Training.  t e c h n i q u e based  d e v i s e d by  The  on  anxiety provoking  item u n t i l  t h e most  tolerated.  Autogenic  Training  i s a re-  s i x psychophysiologic exercises  a German n e u r o l o g i s t  H.  Shutz  and  d e r i v e d from  Walter Hess' theory o f a " t r o p h o t r o p h i c response."' defines this resulting system  response  as a r i s i n g  i n a general decrease  activity.  ^  Hess  i n the hypothalamus i n sympathetic  W a l t e r Luthe-who d e v e l o p e d  T r a i n i n g as a m e d i c a l  re-  t h e r a p y d e s c r i b e s i t as  induced m o d i f i c a t i o n of c o r t i c o d i e n c e p h a l i c  and  nervous Autogenic "...  a  self  interrelation-  76 ships."'  The  stimulating his  eyes  exercises are p r a c t i s e d  environment  closed.  An  b e l i e v e d neceasary, Autogenic  w i t h the  attitude  subject lying  Luthe  i n decreased  and m u s c l e t e n s i o n ;  non-  down w i t h  "Passive concentration" i s  as i n m e d i t a t i o n .  Training resulted  heart rate  of  i n a quiet  and  found  that  respiratory  increased skin  rate,  resistance  77 and  a l p h a wave  1-5  (New  activity.''  ^ W o l f g a n g Luthe ( e d . ) , Autogenic York: Grune and S t r a t t o n , 1 9 6 9 ) .  Therapy,  Vols.  " ^ W a l t e r R. H e s s , F u n c t i o n a l O r g a n i z a t i o n o f D i e n c e p h a l o n (New Y o r k : Grune and S t r a t t o n , 1 9 5 7 ) .  76 ' Luthe, 7 7  Ibid.  op.cit.  p.11.  the  32 Therapeutic methods d e s c r i b e d  Use o f R e l a x a t i o n  above, and m o d i f i c a t i o n s  have b e e n u s e d i n v a r i o u s in  psychiatry,•• and  been used tension,  Techniques.  o f t h e s e methods  treatment s e t t i n g s - patr^icularly  obstetrics.  i n the treatment  Relaxation  therapy has a l s o  o f pulmonary t u b e r c u l o s i s ,  F e r n a n d Lamaze i s w e l l known.7^*79 childbirth  he  hyper-  h e a d a c h e s , and asthma. I n o b s t e t r i c s t h e work o f G r a n t l y  ease  The  employ b r e a t h i n g  childbirth.  Dick  Read a n d  T h e i r methods o f n a t u r a l  and r e l a x a t i o n t e c h n i q u e s t o  A.A. E a r n h a s d e v e l o p e d a t h e r a p y  c a l l s Mental  which  Concentrations  ...a p s y c h o l o g i c a l s k i l l i n which t h e i m a g i n a t i o n and s u g g e s t i o n s t r e n g t h e n m o t i v a t i o n and performance f o r d e s i r e d g o a l s . This s k i l l i s u s e d by t h e s t u d e n t t o p r o d u c e a s t a t e o f h e i g h t e n e d a w a r e n e s s and p u r p o s e . F i r s t , he l e a r n s s e l f - r e l a x a t i o n and then s e l f - c o n d i t i o n ing. He  states  that  individuals cluding  t h i s method h a s b e e n e f f e c t i v e i n h e l p i n g  a c h i e v e r e l a x a t i o n and s e e s i t s u s e f u l n e s s I n -  "relief  of stress of illness  a n d improvement i n  81 mental  health." H. P r o f f i t t ,  7 8  (Toronto:  a nurse  at a psychiatric clinic i n  G r a n t l y D i c k Read, C h i l d b i r t h W i t h o u t B r i t i s h Book Company~ 1961).  Fear,  79  F e r n a n d Lamaze, P a i n l e s s C h i l d b i r t h , t r a n s . L . R. C e l e s t i n ( L o n d o n : B u r k e P u b l i s h i n g Company, 1 9 5 8 ) . 80 A.A. E a r n , " M e n t a l C o n c e n t r a t i o n : A Psychologic a l S k i l l , " C a n a d i a n N u r s e , L I X ( J u n e , 1 9 6 3 ) , 553. 8 l  Ibid,  p.538.  33  Birmingham, E n g l a n d , has d e v e l o p e d a method o f r e l a x a t i o n 82  therapy The  w h i c h he c a r r i e s o u t w i t h gro.ups o f p a t i e n t s .  procedure c o n s i s t s o f teaching  the p a t i e n t s to recognize  m u s c u l a r t e n s i o n and t h e use o f s u g g e s t i o n  t h a t they  will  relax.  M u s c l e s a r e r e l a x e d i n sequence ( i . e . from head t o  feet).  Questionnaires  were f i l l e d  o u t by 50 p a t i e n t s t o  d e t e r m i n e t h e i r v i e w s on r e l a x a t i o n t h e r a p y . believed  4 l patients  t h a t t h e r e l a x a t i o n method had been o f b e n e f i t ,  5 t h o u g h t i t h a d b e e n o f no b e n e f i t a n d 4 were whether they  had been h e l p e d  o r not.  uncertain  No o b j e c t i v e  assess-  ment o f b e n e f i t was made. Johnson and S p e i l b e r g e r measured t h e e f f e c t s o f r e l a x a t i o n t r a i n i n g .(based o n J a c o b s o n ' s a n d W o l p e ' s methods) on a n x i e t y - s t a t e w h i c h t h e y d e f i n e s As a n o r g a n i s m i c s t a t e . . . . a n x i e t y i s c h a r a c t e r i z e d by s u b j e c t i v e c o n s c i o u s l y p e r c e i v e d f e e l i n g s o f a p p r e h e n s i o n s and t e n s i o n , t o g e t h e r w i t h a c t i v a t i o n o f t h e autonomic n e r v o u s system.83 They r e p o r t t h a t a n x i e t y - s t a t e m e a s u r e s d e c l i n e d significantly Their c r i t e r i a tolic  blood  i n response to r e l a x a t i o n t r a i n i n g  procedures.  f o r m e a s u r e m e n t o f a n x i e t y - s t a t e were  pressure,  heart  r a t e , and a m o d i f i e d  sys-  Zuckerman  Affect Adjective Checklist.  - C.D. N e a l a n d H. P r o f f i t t , " R e l a x a t i o n M i r r o r , C X X I I (6 May, 1 9 6 6 ) , 1 1 4 - 1 6 . 8  Nursing  2  Therapy,"  -'Dale T. J o h n s o n a n d C h a r l e s D. S p e i l b e r g e r , "The E f f e c t s o f R e l a x a t i o n T r a i n i n g a n d P a s s a g e o f Time o n M e a s u r e s o f S t a t e and T r a i t A n x i e t y , " J o u r n a l o f C l i n i c a l P s y c h o l o g y , X X I V ( J a n u a r y , 1968), 20.  Crouch i n v e s t i g a t e d the ation with  training  (based  hospitalized  on  e f f e c t i v e n e s s of  J a c o b s o n ' s and  psychiatric  relax-  Wolpe's methods)  p a t i e n t s i n terms o f  changes  Qh  i n maladaptive  behaviour.  He  used t a p e - r e c o r d e d  tions  the  to  subjects.  to t e a c h  technique  effectiveness  o f two  being  schedule  a fixed  schedule,  and  were t e s t e d .  significant vised  schedules  The  the  Henrichs  of M i s s o u r i Medical  tiveness of  systematic  post-operative surgery  and  training,  one  schedule  group  showed  as m e a s u r e d by  the  Re  Scale. d e s c r i b e a study Centre  relaxation  psychiatric  relative  o t h e r a p a t i e n t demand  lowering of anxiety l e v e l  Aitkens University  of r e l a x a t i o n  fixed  Taylor Manifest Anxiety  The  direc-  done a t  to evaluate  as a t e c h n i q u e  c o m p l i c a t i o n s i n open  the to  effec  reduce  heart  p a t i e n t s . They c o n c l u d e s Less post-operative p s y c h i a t r i c complications were f o u n d i n t h e g r o u p t r a i n e d i n r e l a x a t i o n t e c h n i q u e s ; however, d i f f e r e n c e s were a l s o n o t e d b e t w e e n t h e g r o u p s on s e v e r a l s u r g i c a l s t r e s s , factors. Thus, t h e e f f e c t s o f s y s t e m a t i c r e l a x a t i o n on p o s t - o p e r a t i v e p s y c h i a t r i c c o m p l i c a t i o n s were n o t c l e a r l y d e f i n e d , b u t t h e p r e s e n t f i n d i n g s were s e e n as encouraging."5 Budzynski  and  S t o j v a taught  s u b j e c t s deep m u s c l e  P a u l C r o u c h , "An I n v e s t i g a t i o n o f t h e E f f e c tiveness of Relaxation T r a i n i n g with H o s p i t a l i z e d Psychia t r i c P a t i e n t s " ( u n p u b l i s h e d Ed.D. d i s s e r t a t i o n , Auburn U n i v e r s i t y , 1970). ^ L i n d a H. A i t k e n and T h e o d o r e F. H e n r i c h s , "Syst e m a t i c R e l a x a t i o n as a N u r s i n g I n t e r v e n t i o n T e c h n i q u e w i t h Open H e a r t S u r g e r y P a t i e n t s , " N u r s i n g R e s e a r c h , XX (MayJune, 1 9 7 D , 216. 8  r e l a x a t i o n by b i o f e e d b a c k t e c h n i q u e s u s i n g an i n s t r u m e n t which p r o v i d e d immediate a n a l o g i n f o r m a t i o n feedback r e 86 g a r d i n g l e v e l o f muscle t e n s i o n .  After f i v e sessions  s u b j e c t s r e c e i v i n g a n a l o g feedback a c h i e v e d deeper l e v e l s o f muscle r e l a x a t i o n than those r e c e i v i n g e i t h e r no f e e d back o r i r r e l e v a n t  feedback.  The r e v i e w o f the l i t e r a t u r e y i e l d e d a v a r i e t y o f examples o f p s y c h o p h y s i o l o g i c measures f o r r e l i e v i n g a n x i e t y by promoting r e l a x a t i o n , r a n g i n g from the e s o t e r i c p r a c t i s e s o f m y s t i c a l r e l i g i o u s s e c t s to c u r r e n t western t h e r a p e u t i c methods such as " R e c i p r o c a l I n h i b i t i o n " biofeedback techniques.  and  Many o f these methods have been  e v a l u a t e d , u s i n g p h y s i o l o g i c a l and p s y c h o l o g i c a l i n d i c e s , and found t o be e f f e c t i v e .  However, o n l y one  example'  ( A i t k e n and H e n r i c h s ) c o u l d be found o f o b j e c t i v e a s s e s s ment o f a n u r s i n g i n t e r v e n t i o n to promote r e l a x a t i o n . Some methods are time consuming b o t h i n the amount o f time r e q u i r e d t o l e a r n the t e c h n i q u e and i n the amount o f time r e q u i r e d f o r t h e i r p r a c t i s e .  Progressive  R e l a x a t i o n , R e c i p r o c a l I n h i b i t i o n and A u t o g e n i c T r a i n i n g r e q u i r e time and d e d i c a t i o n o f b o t h t e a c h e r and  learner.  T r a n s c e n d e n t a l M e d i t a t i o n i s t a u g h t o n l y by s p e c i a l t r a i n e : Thomas H. B u d z y n s k i and Johann M. S t o j v a , "An Instrument f o r P r o d u c i n g Deep Muscle R e l a x a t i o n by Means o f Analog I n f o r m a t i o n Feedback," J o u r n a l o f A p p l i e d B e h a v i o u r A n a l y s i s , I I ( W i n t e r , 1969), 2 3 I - 3 7 .  36 and  under the a u s p i c e s  back t e c h n i q u e s efficient to  of the  Society.  The  use  t o t e a c h deep m u s c l e r e l a x a t i o n i s m a r k e d l y  i n terms o f time  but r e q u i r e s  d e l i v e r the b i o f e e d b a c k  information.  To be  p r a c t i c a l f o r nurses  of s e t t i n g s a r e l a x a t i o n technique  instrumentation  t o use  in a  panied  by  and  span.  Since  severe  l a c k o f c o n c e n t r a t i o n and  ceptual f i e l d , forward.  i n age  the  technique  variety  w o u l d n e e d t o be  a b l e t o c l i e n t s o f a w i d e r a n g e i n p h y s i c a l and abilities,  of biofeed-  must be  mental  a n x i e t y i s accom-  a narrowing simple  and  of the  Simple Yoga c o n t r o l l e d b r e a t h i n g t e c h n i q u e s  t e n s i n g and  r e l a x i n g o f m u s c l e s meet t h e s e  per-  straight  a m o d i f i e d form o f P r o g r e s s i v e R e l a x a t i o n i n v o l v i n g atic  teach-  and system-  criteria.  Chapter  3  DESIGN AND METHODOLOGY Overview o f t h e Study The  general  Design aim o f t h e study  i s to evaluate the  e f f e c t i v e n e s s o f a p h y s i c a l r e l a x a t i o n technique creasing  anxiety  perience  excessive  anxiety.  a  eclectic  technique  simple  .The  i n a patient population  i n de-  assumed t o e x -  The i n d e p e n d e n t v a r i a b l e . i s designed  t o be t a u g h t by n u r s e s .  d e p e n d e n t v a r i a b l e s measure b o t h p h y s i o l o g i c a l a n d p s y -  c h o l o g i c a l p a r a m e t e r s o f anxiety.. D e f i n i t i o n o f Terms. (i) ceived  threat  excitation  Anxietys  An o r g a n i s m i c r e s p o n s e  characterized  as w e l l  to per-  by a u t o n o m i c a n d c e r e b r o s p i n a l  as s u b j e c t i v e  f e e l i n g s o f apprehension  1 and  tension. (ii)  ceived  comfort,  Relaxations  well  response  s e c u r i t y , o r removal o f t h r e a t ,  i z e d by d e c r e a s e d as  An o r g a n i s m i c  sympathetic  as s u b j e c t i v e  and c e r e b r o s p i n a l  f e e l i n g s o f composure and  to per-  characterexcitation diminution  A n x i e t y , by t h i s d e f i n i t i o n , i s t h e e q u i v a l e n t o f a n x i e t y s t a t e , a s d e s c r i b e d by C a t t e l l , and by J o h n s o n and S p e i l b e r g e r . Their studies are o u t l i n e d i n the previous chapter.  37  38 of  tension. (iii)  Relaxation  p h y s i o l o g i c method o f  A  systematic  controlled breathing  l a x i n g o f muscle groups, and  Technique;  psycho-  followed  by  s e q u e n t i a l l y , i n head, arms,  retrunk  legs. Assumptions. (i)  suffer  Most p a t i e n t s a d m i t t e d  excessive  anxiety.  (ii)  Excessive  (iii)  R e l i e f of excessive  the n u r s e ' s  to p s y c h i a t r i c u n i t s  anxiety  i s maladaptive. anxiety  i s , i n part,  responsibility.  (iv) taught  Nursing  methods w h i c h promote r e l a x a t i o n  can  be  to p a t i e n t s .  The  Independent V a r i a b l e : The  A Relaxation  review o f the  literature  Technique showed t h a t most  p h y s i c a l r e l a x a t i o n methods c o n s i s t p r i m a r i l y o f c a t i o n s o f Jacobson's system o f P r o g r e s s i v e sometimes i n c l u d e b r e a t h i n g Accordingly  the  of Progressive  technique Relaxation  and  s t r u c t i o n s were t a p e - r e c o r d e d teaching technique ting  o f the  technique  i s taught  stimuli  are  breathing i n order  study  to  f o r experimental  and  Y o g a methods. employs  control.  i n a q u i e t environment  minimal.  Relaxation  c o n t r o l b a s e d on  used i n t h i s  modifi-  elements  The  in-  standardize  the  purposes.  The  so  that  distrac-  39 The of slow,  subject i s f i r s t  d i r e c t e d i n s i x timed  s m o o t h l y r e g u l a t e d deep b r e a t h i n g .  s i s t s o f approximately  equal  h o l d i n g , and e x p i r a t i o n .  timed  cycles  One c y c l e  con-  phases o f i n s p i r a t i o n ,  The s u b j e c t i s i n s t r u c t e d t o i n -  s p i r e by r e l a x i n g t h e a b d o m i n a l m u s c l e s so t h a t t h e d i a phragm f a l l s Conversely,  and a i r i s drawn i n t o  the lungs  as they  expand.  e x p i r a t i o n i s a c c o m p l i s h e d by d r a w i n g i n ( c o n -  t r a c t i n g ) t h e a b d o m i n a l m u s c l e s so t h a t t h e d i a p h r a g m and  a i r i s pushed o u t o f t h e l u n g s .  exercise  serves  The i n i t i a l  rises  breathing  t o s h i f t the subject's thought from d i f f u s e  t h i n k i n g t o f o c u s s i n g h i s a t t e n t i o n on p h y s i c a l  process.  Muscle groups are then tensed  and r e l a x e d i n  sequence m o v i n g f r o m head, arms, t r u n k ,  legs, to feet.  subject i s i n s t r u c t e d t o tense cles, recognize as  completely  a m u s c l e o r g r o u p s o f mus-  t h e t e n s i o n , and then t o r e l a x t h e m u s c l e ( s )  as p o s s i b l e .  The i n s t r u c t i o n s were  corded i n a soothing y e t compelling  voice.  attempt t o a v o i d t h e use o f s u g g e s t i o n . recorded The  The  tape-re-  T h e r e was no  The t e x t o f t h e  t a p e i s i n c l u d e d i n A p p e n d i x A.  Dependent V a r i a b l e s Since  manifestations  anxiety i s a t o t a l organismic o f anxiety are expressed  l o g i c a l and p s y c h o l o g i c a l b e h a v i o u r  r e s p o n s e and  i n terms o f p h y s i o -  i t i s appropriate to  m e a s u r e l e v e l s o f a n x i e t y by b o t h p h y s i o l o g i c a l a n d p s y c h o logical choosing  indices.  T h e r e a r e , h o w e v e r , many d i f f i c u l t i e s i n  indices of anxiety to test.  As L e v i n o t e s ,  neither  the  subjective  experiences o f the i n d i v i d u a l nor the b a s i c  neuro-endocrine processes are accessible  t o d i r e c t measure-  2 ment.  While a g e n e r a l  response  to perceived  threat i s  well  established  i n the review o f the l i t e r a t u r e ,  also  established  e v i d e n c e o f some d e g r e e o f p h y s i o l o g i c a l  and in  psychological  individuality  t h e model f o r a n x i e t y  pertinent  research  which i n f l u e n c e action  there  presented  defenses  Potassium.  eosinophils;  increases  increased  wave  provoking,  i n muscle electroen-  s k i n r e s p o n s e and c i r c u l a t i n g  c a t e c h o l a m i n e and a d r e n o c o r t i c o i d  acids:?  excretion.  a r e a t t e n d a n t on t h e i r u s e a s  strumentation o r complicated anxiety  increases  i n serum n o n e s t e r i f i e d f a t t y  measures o f s t r e s s o r a n x i e t y .  are  r e s p o n s e and t h e  I n d i r e c t p h y s i o l o g i c a l and  galvanic  A variety of d i f f i c u l t i e s  pro-  induced.  rate: decreases i n alpha  cephalogram a c t i v i t y ,  and  o f the anxiety  indices of stress include  and p u l s e  inter-  s t i m u l i and b i o p s y c h o l o g i c a l  and p s y c h o l o g i c a l Urinary  tension  s t u d y and f r o m  the course o f e v e n t s from t h e i n i t i a l  of biopsychosocial  biochemical  i n this  F u r t h e r m o r e , ..  a r e many i n t e r r a c t i n g v a r i a b l e s  gramme t o t h e m a n i f e s t a t i o n s physical  o f response.  there i s  Some r e q u i r e  laboratory  e.g. b l o o d  tests.  expensive i n -  procedures.  Many  Others are  Lennart L e v i , "Introduction: Psychosocial Stimu l i , P s y c h o l o g i c a l R e a c t i o n s , and D i s e a s e " i n " S t r e s s and D i s t r e s s i n Response t o P s y c h o s o c i a l S t i m u l i , " e d . L e n n a r t L e v i , S u p p l e m e n t No.528 t o A c t a M e d i c a S c a n d i n a v i c a . CXCI  (1972), 12.  -  41 s t r o n g l y a f f e c t e d by extraneous variables.-* U r i n a r y potassium e x c r e t i o n as an index avoids many of these d i f f i c u l t i e s .  Adrenal c o r t i c a l  response  v a r i e s a c c o r d i n g to s t r e s s and u r i n a r y potassium  excretion,  i n t u r n , i s c l o s e l y t i e d to a d r e n a l c o r t i c a l a c t i v i t y .  , J  *  L. Frances P r i d e d e s c r i b e s a number o f c h a r a c t e r i s t i c s of u r i n a r y potassium which favour i t s use as a measure of auto7  nomic a c t i v a t i o n .  These i n c l u d e :  by serum potassium l e v e l s ; by c a l o r i c r e s t r i c t i o n ; posture and a c t i v i t y ;  (a) I t i s not  affected  (b) I t i s not markedly  affected  (c) I t i s not markedly  (d) Potassium  a f f e c t e d by  i s stable i n solution  so that u r i n e specimens do not r e q u i r e s p e c i a l  treatment.  ^M.H. Lader and Lorna Wing, P h y s i o l o g i c a l Measures, Sedative Drugs, Morbid Anxiety,, (London: Oxford U n i v e r s i t y , 1 9 ^  L  Gregory P m c u s and Hudson Hoagland, "Adrenal C o r t i c a l Responses to S t r e s s i n Normal Men and i n Those with P e r s o n a l i t y D i s o r d e r s , " American J o u r n a l o f Psychology, CVI (March, 1 9 5 0 ) , 641-60. ^Richard P. Doe et a l . , " D i u r n a l V a r i a t i o n of 1 7 H y d r o x y c o r t i c o s t e r i o d s , Sodium, Potassium, Magnesium and C r e a t i n i n i n e i n Normal Subjects and i n Cases of Treated Adrenal I n s u f f i c i e n c y and Cushing's Syndrome," J o u r n a l of C l i n i c a l '. Endocrinology and Metabolism, XX (February, I960), 263-65. ; F r e d e r i c C. B a r t t e r , Catherine S. Delea and Franz Halberg, "A Map of Blood and U r i n a r y Changes, R e l a t e d to C i r c a d i a n V a r i a t i o n s i n Adrenal C o r t i c a l F u n c t i o n i n Normal S u b j e c t s , " Annals o f the New York Academy of Science, XCVII (October 3 0 , 1962), 9 6 9 - 8 3 .  7  'L. Frances P r i d e , "An Adrenal S t r e s s Index as a C r i t e r i o n Measure f o r Nursing," Nursing Research, XVII (July-August, 1 9 6 8 ) , 2 9 9 .  42 A 24 hour measure r e f l e c t s the g e n e r a l l e v e l o f a n x i e t y f o r t h a t p e r i o d whereas measures such as g a l v a n i c s k i n response, heart r a t e and "blood t e s t s r e p r e s e n t  levels  at b r i e f moments i n time and are f u r t h e r complicated i n some cases by c i r c a d i a n rhythms (blood and u r i n e 17 hydroxyc o r t i c o s t e r i o d s , sodium, potassium, e t c . , e x h i b i t d u i r n a l curves). A l l u r i n e potassium t e s t i n g f o r the study was c a r r i e d out by the C l i n i c a l Chemistry D i v i s i o n o f the g e n e r a l hospital laboratory. tassium  Measurements o f 24 hour u r i n a r y po-  e x c r e t i o n i n m i l l e q u i v a l e n t s were made by the s t a n -  dard method o f flame photometry u s i n g an  Instrumentation  L a b o r a t o r i e s Model 143 Flame Photometer. IPAT Anxiety  Scale Q u e s t i o n n a i r e .  i s an e a s i l y administered,  widely used 40 item  I t i s a p p l i c a b l e to a l l but the lowest and  i s appropriate  T h i s measure questionnaire.  educational  levels  f o r s u b j e c t s from 14 o r 15 years and up.  When the s u b j e c t i s d i r e c t e d to answer the questions  accor-  ding to how he f e e l s "right-now" the s c a l e measures a n x i e t y state.  I t i s claimed  to be s e n s i t i v e to changes i n a n x i e t y  l e v e l s due to psychotherapy, medication,  w  change i n s i t u a t i o n ,  Doe et a l . , o p . c i t .  9  R.B. C a t t e l l and I.H. S c h e i e r , "Extension o f Meaning o f O b j e c t i v e Test P e r s o n a l i t y F a c t o r s : E s p e c i a l l y i n Anxiety, Neuroticism, Questionnaire and P h y s i c a l F a c t o r s J o u r n a l o f General Psychology. LXI (Oct., 1959), 287-315  43 etc. The liability. +  .85  with  Construct  to +  nostic  s c a l e has  .90.  ("internal") v a l i d i t y  Clinical  classification  IPAT A n x i e t y  validity.  judgements o f a n x i e t y  Scale r e s u l t s o f the  Dependability  to p r o v i d e  test  and  reat  diag-  correlation  high  i s reported  - reliability  and  i s estimated  o f p a t i e n t s show s t r o n g  Reliability  satisfactory.  a h i g h degree o f v a l i d i t y  "external" as  highly  coefficient  for  11 test  - retest  a t one  S e t t i n g o f the  week i n t e r v a l  health science  a l a r g e urban general the  study  acute  students  nursing,  .93'  the  i n 1971-72.  modalities.  beds) i n a u n i -  and  hospital provided  from a v a r i e t y  social  o f 60  hospital  for adult psychiatric  range o f treatment with  center  which took p l a c e  care  +  Study.  Three u n i t s ( w i t h a t o t a l versity  was  a 41  bed  hospital  has  These s e t t i n g s o f f e r  p a t i e n t s and Both are  offer  private  psychiatrists,  while  the  a  similar  teaching hospitals  of d i s c i p l i n e s  p a t i e n t s admitted  in  settings for  -  medicine,  work, r e h a b i l i t a t i o n m e d i c i n e ,  general  unit  etc.  under the  health science  The  service of center  10 R.B. C a t t e l l and I.H. S c h e i e r , Handbook f o r t h e IPAT A n x i e t y S c a l e Q u e s t i o n n a i r e (Champaign, I l l i n o i s : Ins t i t u t e f o r P e r s o n a l i t y and A b i l i t y T e s t i n g , 1963) p.5« R . B . C a t t e l l , "Formulae and T a b l e f o r O b t a i n i n g V a l i d i t i e s and R e l i a b i l i t i e s o f E x t e n d e d F a c t o r S c a l e s , " E d u c a t i o n a l and P s y c h o l o g i c a l Measurement, X V I I ( F a l l , 1957) 491-98. 1:L  kk p a t i e n t s are t r e a t e d e x c l u s i v e l y by p s y c h i a t r i c r e s i d e n t s and medical students under the s u p e r v i s i o n o f t h e i r directors. centers,  Since both h o s p i t a l s are t e r t i a r y care  clinical referral  p a t i e n t s may come from anywhere i n the Province o f  B r i t i s h Columbia but are mostly from the m e t r o p o l i t a n couver  The  Van-  area.  Sample The  sample was s e l e c t e d from p a t i e n t s admitted to  the a d u l t p s y c h i a t r i c i n - p a t i e n t s e r v i c e s d e s c r i b e d C r i t e r i a f o r s e l e c t i o n were based upon ( i ) e t h i c a l ations,  above. consider-  ( i i ) c e r t a i n p h y s i o l o g i c a l c o n d i t i o n s which a f f e c t  u r i n a r y potassium e x c r e t i o n ,  ( i i i ) psychosocial  conditions  a f f e c t i n g s t r e s s , and ( i v ) c o n d i t i o n s a f f e c t i n g the teacha b i l i t y o f the r e l a x a t i o n method.  These c r i t e r i a  are:  (a)  Consent o f the p a t i e n t ' s  physician.  (b)  Informed c o n s u l t o f the p a t i e n t as d e f i n e d 12  by the Ad Hoc Committee on Rights (c) activity  o f Human  65 years of age o r l e s s .  i s reported  to be lessened  Subjects.  Adrenocortical  i n men over 65 y e a r s  of age. (d)  Absence o f the f o l l o w i n g c o n d i t i o n s , (as  evidenced by the medical h i s t o r y ) a l l o f which a f f e c t  General Statement o f the Ad Hoc Committee on Rights o f Human Subjects, U n i v e r s i t y o f B r i t i s h Columbia School o f Nursing, November 18, 1971.  k5 potassium  excretion:  Endocrine  d i s o r d e r , ( i v ) Kidney  diuretics,  ( v i ) Use  medication),  (i) Alkalosis,  pathology,  of steroids  ( v i i ) Restricted  ( i i )Acidosis, ( i i i ) ( v ) Use  (including birth  Sodium d i e t ,  and  of  control  (viii)  Hypo-  hydration. (e)  Not  menstruating  when u r i n e s p e c i m e n s  Menstrual b l o o d c o u l d contaminate (f) atives, the  No  specimens.  change i n p s y c h o t r o p i c m e d i c a t i o n s  tranquillizers,  study procedure  drugs  taken.  (sed-  a n t i d e p r e s s a n t s ) d u r i n g the time  and  f o r t h r e e days p r e v i o u s l y .  have marked e f f e c t s on  autonomic nervous  of  These  system  11 function.  J  (g)  Hospitalized  f o r t h r e e d a y s o r more, a t  time  lA" 1*5 of  selection,  medical  to exclude  the v a r i a b l e  (h)  English  (i)  In c o n t a c t w i t h r e a l i t y  history,  o f a d m i s s i o n -anxiety. '  speaking.  nurse's notes  and  as i n d i c a t e d  by  diagnosis ( i . e . diagnosis  other than p s y c h o s i s ) .  - L . S . Goodman and A l f r e d B a s i s o f T h e r a p e u t i c s , 3 r d ed. (New Company, 1965)• ±  5  Gilman, P h a r m a c o l o g i c a l York: MacMillan  ik W.W. T o l s o n et a l . , "Urinary Catecholamine R e s p o n s e s A s s o c i a t e d w i t h H o s p i t a l A d m i s s i o n i n Normal Human S u b j e c t s , " J o u r n a l o f P s y c h o s o m a t i c R e s e a r c h , V I I I (Number 3, 1 9 6 5 ) , 365^ R o s l y n E l m s and R.C. L e o n a r d , " E f f e c t s o f N u r s i n g Approaches During Admission," N u r s i n g R e s e a r c h , XV ( W i n t e r , 1 9 6 6 ) , 39-^8. 1  46 The previously  physiological  c r i t e r i a a r e drawn from t h e  c i t e d i n v e s t i g a t i o n by P r i d e , o f t h e e f f e c t  an i n t e r p e r s o n a l n u r s i n g a p p r o a c h i n r e l i e v i n g w h i c h she e m p l o y e d  of  stress, i n  u r i n a r y p o t a s s i u m l e v e l s as a  criterion  16  measure. The  total  sample  o f 36  s u b j e c t s was  drawn f r o m  consecutive admissions to the p s y c h i a t r i c u n i t s who  met  t h e above c r i t e r i a f o r s e l e c t i o n .  dropped out o f the study because t o meet t h e c r i t e r i a o r b e c a u s e u r i n e specimens  S u b j e c t s who  t h e y were f o u n d l a t e r they f a i l e d  to c o l l e c t  the  selected.  a g e s o f t h e s u b j e c t s r a n g e d f r o m 21 t o  y e a r s w i t h an a v e r a g e o f 43^ dard d e v i a t i o n ) .  11.60  64  y e a r s (mean ± one  stan-  T h e r e were 25 f e m a l e s and 11 m a l e s .  d e n c e t h a t s u b j e c t s met  t h e c r i t e r i a was  investigator.  s u b j e c t s were a s s i g n e d t o e a c h o f t h r e e g r o u p s 17  randomized b l o c k d e s i g n .  Evi-  d e r i v e d f r o m med-  i c a l r e c o r d s and p a t i e n t i n t e r v i e w by t h e c h i e f Twelve  not  as d i r e c t e d , were r e p l a c e d i n e a c h c a s e by  t h e n e x t s u b j e c t t o be The  described,  I n d i v i d u a l s i n Group 1  by  ("Re-  l a x a t i o n " ) r e c e i v e d t r a i n i n g i n the r e l a x a t i o n technique. I n d i v i d u a l s i n Group 2 ( " P l a c e b o " ) r e c e i v e d n u r s i n g time devoted to a placebo procedure. Pride,  equivalent Group 3  op.cit.  17 'B.J. Winer, S t a t i s t i c a l P r i n c i p l e s i n E x p e r i m e n t a l D e s i g n . (New Y o r k : M c G r a w - H i l l Book Company, 1971)  47 ("Control") no  special  receiving ceived  i n d i v i d u a l s r e c e i v e d the approach.  a specific  the  specific  were a d m i n i s t e r e d  T r e a t m e n t and 'The  Appendix  design  B .  The  schedule  24  the  "...in  student  i n the  For  completed,  periods."  The  re-  A l l treatments  hour u r i n e  administration  of  i s show i n  s p e c i m e n s were c o l l e c t e d  subject voided first  t o and  tests,  and  m o r n i n g and  in  discarded  collected a l l  including a final  voiding  explained  w o r k i n g on  to  the  study  that  she  was  a  a master's t h e s i s .  same g e n e r a l  explanation:  " I am  t o measure c h a n g e s i n s t r e s s o v e r a  which you  gramme."  24  t e s t s and  period of h o s p i t a l i z a t i o n . "  individuals  was  of  were a l l i n t r o d u c e d  s u b j e c t r e c e i v e d the  day  the  i n v e s t i g a t o r who  a study  subjects  at  f o l l o w i n g morning.  Subjects  ducting  that  i n a group.  hour u r i n e  s u b s e q u e n t v o i d i n g up  uate n u r s i n g  not  or r e l a x a t i o n placebo  a t 0800 h o u r s on  principal  but  subjects  Methods  manner, i . e . the  0800 h o u r s on  "Group" d e n o t e s  but  individually.  training  standard  urine  treatment  scale questionnaire  relaxation  a  term  treatment,  Control  ;  anxiety  The  u s u a l ward c a r e  "Relaxation"  Added t o g r o u p was  this the  "...in general  which you  "Placebo"  the  gradEach confive  sentence  for  statement,  would r e c e i v e a r e l a x a t i o n t r a i n i n g  I n d i v i d u a l s i n the  by  group the  prosentence  would have r e g u l a r r e l a x a t i o n  explanation  continues:  "It will in-  48 volve c o l l e c t i n g a 24 hour u r i n e specimen on the f i r s t and  again on the f i n a l day,  as w e l l as answering a b r i e f  q u e s t i o n n a i r e on the same two t a k i n g p a r t i n the study?  days.  Would you  I f you decide  consider  to do so you  the o p t i o n of d i s c o n t i n u i n g p a r t i c i p a t i o n at any there any q u e s t i o n s you would l i k e to ask?" a l s o informed  day  have  time.  Are  Subjects were  t h a t the r e s u l t s o f the t e s t s would be  ex-  p l a i n e d to them a f t e r the f i n a l r e s u l t s were r e c e i v e d . Six  a s s i s t a n t s as w e l l as the p r i n c i p a l  inves-  t i g a t o r p a r t i c i p a t e d i n i n d i v i d u a l s u p e r v i s i o n o f the l a x a t i o n " and  "Placebo"  i s t e r i n g the Anxiety  treatment s e s s i o n s , and  Scale Q u e s t i o n n a i r e .  i n admin-  The a s s i s t a n t s  were s e n i o r undergraduate student nurses from the h o s p i t a l school of n u r s i n g and nursing. study  and  Scale  experimental, schedule  0800 hours and  concluded  began on Monday mornings  on Saturday mornings at 0800  Each s u b j e c t i n the study  2 and  collected a f i r s t  6.  Questionnaire on F r i d a y (Day  5 to 0800  Each s u b j e c t completed an Anxiety  on the Day 5)  1 evening  evening.  24 hour  1, u n t i l 0800 hours on  a second sample from 0800 hours on Day  hours on Day  the  Questionnaire.  u r i n e sample from 0800 hours on Day Day  before  They a l s o r e c e i v e d i n s t r u c t i o n r e g a r d i n g  of the Anxiety  hours.  the u n i v e r s i t y school of  a s e s s i o n of R e l a x a t i o n Technique t r a i n i n g  The at  general  " A s s i s t a n t s r e c e i v e d a f u l l e x p l a n a t i o n o f the  taking part. use  "Re-  and repeated  Scale  this  test  49 Ward n u r s e s were n o t to  informed  regarding  w h i c h i n d i v i d u a l s u b j e c t s b e l o n g e d and  r e f e r the they  had  s u b j e c t s to the  The  about the  " R e l a x a t i o n " and  s i n g l e room, o r i n a t r e a t m e n t  room i f he  room, o r by  s e m i - p r i v a t e , room and no  o t h e r room was  The  an a c u t e  h o s p i t a l had  r e q u i r e d these  e i t h e r one  o f my  l a x a t i o n technique.  y o u r b r e a t h i n g by  breathing you  The  needed.  this "A  s i t s with  you re-  consists of c o n t r o l l e d  muscle r e l a x a t i o n .  You  control  f o l l o w i n g t h e t i m i n g as d i r e c t e d on  the  f o r s i x complete c y c l e s - a c y c l e c o n s i s t s of  i n , h o l d i n g i t , and  b r e a t h i n g out. the  t e n s i o n and  Following  this  t h e n r e l a x as  as p o s s i b l e , m o v i n g i n s e q u e n c e f r o m m u s c l e g r o u p s i n  l i e on a bed  about twelve three  in a  i n s t r u c t i o n s f o r a simple  t h e h e a d and n e c k t o a r m s , t r u n k , You  other  o f space which  Each s u b j e c t i n  technique  tense muscles, recognize  fully  s u b j e c t was  a s s i s t a n t s or myself,  systematic  tape-recording  a s k i n g the  following additional information:  f o l l o w tape-recorded  b r e a t h i n g and  in a  available--when  shortage  "Relaxation".  group r e c e i v e d the  w h i l e you  was  sessions  l e s s than i d e a l conditions.  Group 1;  nurse,  assistants i f  treatment  p a t i e n t s t o r e m a i n o u t o f t h e room i f t h e  general  to  study.  "Placebo"  were c o n d u c t e d i n t h e p a t i e n t ' s own  group  were r e q u e s t e d  i n v e s t i g a t o r or her  further questions  the  times  t o do  finally  feet.  the r e l a x a t i o n e x e r c i s e s which  minutes per a day  l e g s and  session.  The  - morning, afternoon  s e s s i o n s are and  evening  take  held - for  50  f o u r days.  They a r e  t i m e d so t h a t t h e y d o n ' t i n t e r f e r e  w i t h y o u r r e g u l a r t r e a t m e n t programme.  I will  have a q u i e t room where y o u  interrupted.  Subjects  will  not  be  i n Group 1 r e c e i v e d  "Relaxation"  nique t r a i n i n g sessions morning, afternoon Days 2,  3,  H- and  c l o t h e s and was on  The  s u b j e c t was  d a r k e n e d and  door.  The  initial  a "Do  s u b j e c t was  w i t h h i s e y e s c l o s e d and to the  as  s e s s i o n he  Not  muscles while  the  evening  t o l d to wear  loose  breathing  I t was  out  the  sessions  the  relaxation training  and  and  The  nurse  taped i n s t r u c t i o n s .  w i t h the p a t i e n t b e f o r e  and  ( i f requested)  Subjects  "A n u r s e , e i t h e r one  s i t s w i t h you  are  You  minutes.  w h i l e you  l i e on a bed You  morning, afternoon  f o r the  have t h r e e  and  The  after of  procedure.  or. m y s e l f ,  twelve  "well"  sitting  i n the  "Placebo"  group a l s o r e c e i v e d a d d i t i o n a l i n f o r m a t i o n r e g a r d i n g  able.  these  u n i m p o r t a n t how  exercises.  "Placebo".  treatment schedule.  Prior  to contract  to breathe smoothly  except f o r c l a r i f i c a t i o n s  Group 2:  placed  as p o s s i b l e .  i n and  w i t h the p a t i e n t a l s o f o l l o w e d the n u r s e spoke o n l y b r i e f l y  room  a l s o i n s t r u c t e d to r e l a x h i s  s t r e s s e d t h a t i t was  s u b j e c t performed the  The  D i s t u r b " s i g n was  comfortably  was  on  i n s t r u c t e d t o l a y on h i s b a c k  abdominal muscles while breathing  evenly.  and  to  Tech-  t o remove h i s s h o e s f o r e a c h s e s s i o n .  slightly the  5-  arrange  o f ay  assistants  r e l a x as deeply- as relaxation period  relaxation periods  evening - f o r f o u r days.  their  you of  a day  They  are  -  51 timed  so t h a t  they  ment programme. you  will  don't  I will  the  The  your r e g u l a r  treat-  a r r a n g e t o have a q u i e t room where  i n Group 2 r e c e i v e d  t h e same s c h e d u l i n g subjects  without  with  n o t be d i s t u r b e d . " Subjects  with  interfere  sitting  possible  Treatment  and u n d e r t h e same c o n d i t i o n s a s  i n Group 1 r e c e i v e d r e l a x a t i o n t r a i n i n g , b u t  any i n s t r u c t i o n  nurse  "Placebo  with  and i n f o r m e d  other  than to l i e q u i e t l y  and r e l a x .  t h e p a t i e n t a l s o r e l a x e d a s much a s t h e p a t i e n t when t h e t w e l v e  minutes  p e r i o d had p a s s e d .  Group 3;  "Control".  Subjects  i n the " C o n t r o l "  group r e c e i v e d both the standard  24 h o u r u r i n e  Anxiety  on Day 1 and Day 5-  Scale  Questionnaire  r e c e i v e d no t r e a t m e n t o t h e r the tant  unit.  test  than the usual  They  t r e a t m e n t on  They were s e e n by t h e i n v e s t i g a t o r o r h e r a s s i s -  only  during  explanation  the request  o f the c o l l e c t i o n  forparticipation procedure  mens and a d m i n i s t r a t i o n o f t h e A n x i e t y  Specific  t e s t s and  Objectives (i)  i n this  f o r the urine Scale  study, speci-  Questionnaires.  o f the Study  To t e s t  the e f f e c t i v e n e s s o f the " R e l a x a t i o n "  Technique'  by i n v e s t i g a t i n g changes i n l e v e l  o f autonomic  activation  as r e f l e c t e d  excretion.  (ii)  To t e s t  by u r i n a r y p o t a s s i u m  the e f f e c t i v e n e s s o f the " R e l a x a t i o n "  T e c h n i q u e - by i n v e s t i g a t i n g c h a n g e s i n b e h a v i o u r a l  level  52 of anxiety  as r e f l e c t e d  by IPAT A n x i e t y  Scale  Questionnaire  Scores.  Hypotheses (1)  There w i l l  be no s i g n i f i c a n t  c h a n g e s i n 2k h o u r u r i n a r y p o t a s s i u m equivalents  difference i n  excretion i n m i l l -  between g r o u p s r e c e i v i n g " R e l a x a t i o n "  ment, " P l a c e b o " (2)  t r e a t m e n t and " C o n t r o l "  There w i l l  changes i n IPAT A n x i e t y  groups r e c e i v i n g " R e l a x a t i o n " ment and " C o n t r o l "  treatment.  be no s i g n i f i c a n t Scale  difference i n  Questionnaire treatment,  treat-  scores  "Placebo"  between treat-  treatment.  A n a l y s i s o f Data Tabulations cretion in  were made o f u r i n a r y p o t a s s i u m e x -  i n m i l l e q u i v a l e n t s on Day 1 a n d Day 5 f o r s u b j e c t s  e a c h g r o u p , a n d c h a n g e s i n amount n o t e d .  IPAT A n x i e t y  Questionnaire  5 f o r subjects  Scale  scores  Similarly,  on Day 1 and Day  i n e a c h g r o u p , and c h a n g e s i n s c o r e s ,  were  tabulated. Inspection that  of the d i s t r i b u t i o n  o f scores  t h e g r o u p s have m a r k e d l y u n e q u a l v a r i a n c e s  nonparametric  t e s t s o f t h e h y p o t h e s e s were made.  Kruskal-Wallace hypothesis,  that  One-Way A n a l y s i s o f V a r i a n c e "k" i n d e p e n d e n t  revealed  therefore The  t e s t s the n u l l  s a m p l e s have b e e n drawn  53 from  t h e same p o p u l a t i o n  i n regard to averages.  The  v a r i a b l e m e a s u r e d must have a c o n t i n u o u s d i s t r i b u t i o n be,  at least,  an o r d i n a l measurement.  method i s t e r m e d "k"  independent  The  and  Kruskal-Wallis  t h e most e f f i c i e n t n o n - p a r a m e t r i c t e s t f o r samples  with a power-efficiency  o f 95-5  per  c e n t as compared w i t h t h e most p o w e r f u l p a r a m e t r i c t e s t , the  "F"  test. All  with 2 and  1 8  m e a s u r e s i n a l l samples  the s m a l l e s t so on.  The  s c o r e r a n k e d as 1, sum  are ranked t o g e t h e r the second  smallest  o f the ranks f o r measures i n each  sample i s t h e n computed.  The  f o r m u l a f o r the  Kruskal-  Wallis test i s : k  -3  H  (N +  1)  samples Rj =  sum  of ranks i n 3  t h  sample  k directs  York:  one  t o sum  o v e r the k  samples  Sidney Segal, Nonparametric S t a t i s t i c s . M c G r a w - H i l l Book Company, 1956), 184-194.  (New  as  54  Statistically,  ranks are expected  t r i b u t e d randomly between t h e groups esis i s true.  t o be d i s -  i f the n u l l  hypoth-  F o r samples l a r g e r than 5 t h e c h i - s q u a r e  a p p r o x i m a t i o n t o t h e s a m p l i n g d i s t r i b u t i o n o f "H" i s a d e q u a t e a n d t h e s e t a b l e s were u s e d  f o r t h e purpose o f  19  the p r e s e n t study.  y  Changes i n amount o f p o t a s s i u m e x -  c r e t e d i n twenty-four hours  a n d c h a n g e s i n IPAT A n x i e t y  S c a l e Q u e s t i o n n a i r e s c o r e s o n Day 5 a s c o m p a r e d w i t h Day 1 were r a n k o r d e r e d f o r s u b j e c t s i n a l l t h r e e g r o u p s tested.  being  The s i z e o f "H" c o m p u t e d was c o m p a r e d w i t h t h e  "Table o f C r i t i c a l whether s i g n i f i c a n t  Values o f C h i Square"  to discover  d i f f e r e n c e s i n average  amounts o r  s c o r e s , f o r t h e two m e a s u r e s , e x i s t e d b e t w e e n t h e t h r e e groups.  When "H" was f o u n d t o be l e s s t h a n t h e t a b l e d  value a t the f i v e percent  (p>0.05) l e v e l o f s i g n i f i c a n c e  the d i f f e r e n c e s between t h e groups statistical  significance  was r e g a r d e d a s l a c k i n g  a n d t h e n u l l h y p o t h e s i s was  accepted. When t h e n u l l  h y p o t h e s i s was r e j e c t e d  i s o n s were t h e n made b e t w e e n two g r o u p s c o v e r what d i f f e r e n c e s e x i s t .  compar-  a t a time t o d i s -  Once a g a i n a n o n p a r a m e t r i c  t e s t was e m p l o y e d t o a v o i d t h e r e s t r i c t i v e  requirement o f  n o r m a l i t y and homogeneity o f v a r i a n c e a s s o c i a t e d w i t h t h e The M a n n - W h i t n e y (J T e s t i s d e s c r i b e d a s a p o w e r -  "t"  test.  ful  a n d u s e f u l t e s t o f w h e t h e r two s a m p l e s a r e s i g n i f 1  ^Segal,  op.cit.  p.249.  55 icantly  different.  20  Scores  f o r both groups are  ranked  t o g e t h e r i n t h e same manner as f o r t h e K r u s k a l - W a l l i s test  and,  similarly,  computed.  The  g r o u p has  test  the  sum  one-tailed test refers  smount) i n one  group.  assert that  one  higher s c o r e s t h a n t h e o t h e r , o r t w o - t a i l e d and  (J (or  f o r each group  c a n be o n e - t a i l e d and  assert only that there w i l l The  of the ranks  The  was  be  a difference i n scores.  applied i n this  study.  to t h e number o f t i m e s t h a t a  score  group i s h i g h e r than a score i n  another  f o r m u l a f o r t h e M a n n - W h i t n e y ( / T e s t i s as  follows: n  (J = where  The R^  n  ri  1  2  1  (n  1  +  +  1)  —  - R  (or  1  n^  =  g r o u p p r e s u m e d t o have h i g h e r  n  2  =  g r o u p presumed t o have l o w e r  R^  =  sum  of ranks  a s s i g n e d t o n^  group  Rg  =  sum  o f r a n k s a s s i g n e d t o ng  group  f o r m u l a as used here o r Rg  Rg)  scores scores  a p p l i e s to samples o f e q u a l  i s used a c c o r d i n g to which g i v e s the  size.  smaller  21  v a l u e o f (J • distributed  S t a t i s t i c a l l y , ranks r a n d o m l y b e t w e e n t h e two  hypothesis i s true.  Statistics 1967),  are expected  to  groups i f the  I f the d i s t r i b u t i o n  differs  be  null  beyond  J e a n n e S. P h i l l i p s and R i c h a r d F. Thompson, f o r N u r s e s (New Y o r k : The M a c M i l l a n Company,  p.274.  Ibid,  p.278.  56  c e r t a i n l i m i t s o f chance f o r t h e s i z e o f t h e sample  we  c a n t h e n assume t h a t t h e r e i s a s i g n i f i c a n t d i f f e r e n c e i n s c o r e s b e t w e e n t h e two Changes twenty-four naire  hours,  groups.  i n amount o f p o t a s s i u m  excreted i n  and c h a n g e s i n IPAT A n x i e t y  Question-  s c o r e s , on Day 5 a s compared w i t h Day 1 were  ordered  f o r s u b j e c t s i n t h e two g r o u p s b e i n g t e s t e d .  s i z e o f U computed was Values  rank  compared w i t h t a b l e s o f  The  "Critical  o f (J i n t h e Mann W h i t n e y T e s t " t o d i s c o v e r w h e t h e r  s i g n i f i c a n t d i f f e r e n c e s i n s c o r e s o r amounts  between  22 groups e x i s t e d f o r these of t h i s  two m e a s u r e s .  s t u d y when t h e o b s e r v e d  or l a r g e r than,  the f i v e percent  For the purpose  v a l u e of(J (p <  was  equal t o ,  0.05)  l e v e l the  P h i l l i p s and Thompson, o p . c i t . ,  p.512-14.  n u l l h y p o t h e s i s was r e j e c t e d .  The  Chapter  4  FINDINGS OF  THE  STUDY  f i n d i n g s o f the study w i l l  discussed individually  be p r e s e n t e d  i n t e r m s o f t h e two  variables tested, f i r s t l y ,  The  Urine Potassium The  potassium  independent  u r i n a r y potassium  s e c o n d l y , IPAT A n x i e t y S c a l e Q u e s t i o n n a i r e  and  e x c r e t i o n and,  Scores.'  Measure  normal range of v a l u e s s t a t e d f o r u r i n a r y  e x c r e t i o n i n a twenty-four hour p e r i o d v a r i e s  somewhat f r o m  t e x t to t e x t .  an a v e r a g e v a l u e  White,  Handler  and  Smith  " f o r the American p o p u l a t i o n l i v i n g  give on  i  an o r d i n a r y d i e t " as 35  t o 50 m i l l e q u i v a l e n t s .  v a l u e s f o r each o f the three groups i n the Day  1 and  4-2  and  Day  4-3  The  s t u d y on  5 a r e somewhat a b o v e t h i s norm.  mean both  Tables  show t w e n t y - f o u r h o u r u r i n a r y p o t a s s i u m  ex-  c r e t i o n i n m i l l e q u i v a l e n t s f o r s u b j e c t s i n each group Day  1 and  Day  5 and  a l s o c h a n g e s i n amounts e x c r e t e d  Day  5 as compared- w i t h Day  1.  4-1,  on on  Mean v a l u e s f o r e a c h m e a s u r e  1  Abraham W h i t e , P h i l i p H a n d l e r and E m i l L. S m i t h , P r i n c i p l e s o f B i o c h e m i s t r y . . (New Y o r k : M c G r a w - H i l l Book Company, 1 9 6 9 ) , p. 8 4 1 . 57  58  TABLE  4-1  Changes i n 24 Hour U r i n a r y Potassium E x c r e t i o n Between Day 1 and Day 5 f o r Subjects i n Group Is "Relaxation"  Day 1 meq K  Day 2 meq K  1 .  51  57  +  6  2  79  74  -  5  3  60  57  -  3  4  102  113  +  11  Subject  Change meq K  5  43 .  54  +  11  6  62  47  -  15  7  41  27  -  14  8  67  47  -  20  9  84  72  -  12  10  75  37  -  38  11  33  24  -  9  12  107  84  -  23  ZX:  804  693 .  N:  12  12  X:  67.00  57.75  . Range:  107 to 33  113 to 24  -Ill 12 -  9  +11  to •  59  TABLE  4-2  Changes i n 24 Hour U r i n a r y Potassium E x c r e t i o n B e t w e e n Day 1 and Day 5 for S u b j e c t s i n Group 2: "Placebo"  Day 1 meq, K  Day 2 meq' K  13  103  140  +  37  14  93  109  +  16  15  147  60  -  87  16  87  23  -  64  17  18  17  18  129  93  19  39  20  32  21  Subject  Change meq,:. K  1  -  36  -  14  49  +  17  37  43  +  6  22  36  41  +  5  23  70  78  +  8  24  79  73  -  6  SIX:  870  751  -  119'  N:  12  12  X:  72.50  62.58  Range:  14?  '  to  18  25  140  12  to  9.  17  +37  to  6o  TABLE  4-3  Changes i n 24 Hour U r i n a r y P o t a s s i u m E x c r e t i o n B e t w e e n Day 1 and Day 5 f o r S u b j e c t s i n Group 3s "Control"  Day 1 meq K  Day 5 meq K  25  55  32  26  53  28  -  27  '22  34  +  12  28  39  76"  +  37  29  88  146  +  58  30  53  64  +  11  31  55  45  -  10  32  54  61  +  7  33  92  70  -  22  34  82  88  +  6  .35  60  29  -  31  36  42  64  ZTX:  695  737  Ns  12  12  Xi  57-92  6 l . 42  Subject  Range s  92  t o 22  146  t o 28  Change meq K 23 25  • + 22  +  42 12  + +58  3.  to -  61 have "been computed.  Group Is ranged  "Relaxation".  Values i n t h i s  f r o m 107 t o 33 m i l l e q u i v a l e n t s w i t h a mean o f 67  millequivalents.  On Day 5 t h e v a l u e s  m i l l e q u i v a l e n t s and showed a mean o f Changes i n l e v e l four  group  of urinary  varied  f r o m 113 t o 24  57-75 m i l l e q u i v a l e n t s .  potassium  excretion  f o r twenty-  h o u r s r a n g e d b e t w e e n +11 and -38 m i l l e q u i v a l e n t s , t h e  mean v a l u e  being  -9.25.  Nine  subjects  i n potassium excretion while three  showed a d e c r e a s e  subjects  showed a n i n -  crease. Group 2;  "Placebo".  Subjects  demonstrated wider ranges o f values as  well  as h i g h e r  excretion  group  on Day 1 and on Day 5  mean m i l l e q u i v a l e n t s o f u r i n a r y  potassium  a s compared w i t h Group 1 ( s e e T a b l e 4 . 2 ) .  r a n g e o f change f o r s u b j e c t s t r e a t m e n t was f r o m was f r a c t i o n a l l y had  higher  levels  had  lower  levels.  The mean change,  than that  o f potassium  "Control".  the  smallest  and  t h e l o w e s t mean v a l u e  o f Group 1.  excretion  -9«92  S i x subjects  on Day 5 and s i x  The " C o n t r o l s  g r o u p had  range o f m i l l e q u i v a l e n t s o f potassium  group, u n l i k e  The  r e c e i v i n g the "Placebo"  +37 t o -87.  higher  Group 3s  This  i n this  excreted  (57-9) o f a l l g r o u p s on Day 1.  the other  groups,  showed an i n c r e a s e i n  mean m i l l e q u i v a l e n t s o f p o t a s s i u m  excreted  p a r e d w i t h Day 1.  showed i n c r e a s e d  Seven s u b j e c t s  on Day 5 a s comlevels  62  of potassium e x c r e t i o n while  five  subjects  had d e c r e a s e d  levels. Comparison o f Groups; cretion Levels. that there  Urinary  The f i r s t h y p o t h e s i s  Potassium Ex-  t o be t e s t e d  asserts  w i l l be no s i g n i f i c a n t d i f f e r e n c e i n c h a n g e s i n  2 4 hour u r i n a r y potassium e x c r e t i o n i n m i l l e q u i v a l e n t s between g r o u p s .  T a b l e 4 - 4 shows t h e s t a t i s t i c a l  comparison  u s i n g t h e K r u s k a l - W a l l i s One-Way A n a l y s i s o f V a r i a n c e by Ranks.  The c h a n g e s i n 2 4 h o u r u r i n a r y p o t a s s i u m  excretion  i n m i l l e q u i v a l e n t s o n Day 5 a s compared w i t h Day 1 a r e given  f o r 36 s u b j e c t s  "Relaxation,"  belonging  to the three  " P l a c e b o " and " C o n t r o l . "  groups -  The amounts o f  change h a v e b e e n r a n k e d i n a s i n g l e s e r i e s a s r e q u i r e d by the  test.  the v a l u e  The sums o f r a n k s w i t h i n e a c h g r o u p i s shown a n d o f "H" i s c o m p u t e d .  r e j e c t the n u l l hypothesis i s 5'99 o r g r e a t e r  The v a l u e  o f "H" r e q u i r e d t o  a t t h e 0.05 l e v e l o f p r o b a b i l i t y  according  t o the Table o f C r i t i c a l  2  Values o f C h i Square. is  1.4474  Since  the n u l l hypothesis  the observed value i s accepted.  b e t w e e n t h e g r o u p s c a n be e x p l a i n e d variations  York:  o f "H"  Differences  on t h e b a s i s o f c h a n c e  alone.  S i d n e y S e g a l , N o n p a r a m e t r i c S t a t i s t i c s - . : . (New McGraw H i l l Book Company, 1 9 5 6 ) , p . 2 4 9 .  63  TABLE  4-4  K r u s k a l - W a l l i s One-Way A n a l y s i s o f V a r i a n c e b y R a n k s o f Changes i n U r i n a r y P o t a s s i u m E x c r e t i o n i n M i l l e q u i v a l e n t s o f Groups R e c e i v i n g "Relaxation," "Placebo" and " C o n t r o l " Treatments 7  "Relaxation" Change Rank in Among meq N=36  "Placebo" Change Rank in Among meq N=3^  "Control" Change Rank in Amon^ meq N=36  +  6  23  + 37  34.5  - 23  7.5  -  5  18  + 16  31  - 25  6  -  3  19  - 87  1  + 12  30  + 11.  28  - 64  2  + 37  34.5  + 11  28  -  1  20  + 58  36  - 15  11  - 36  4  + 11  28  - 14  12.5  - 14  12.5  - 10  15  - 20  10  + 17  32  +  7  25  - 12  14  +  6  23  - 22  9  + +  5 8  21  +  6  23  26  - 31  5  -  6  17  + 22  33  - 38 -  3 16  9  - 23  R  H  7-5  l =  =  h=  190.0  12  N (N+l)  \  k  '  224.0 R.  R  3  =  2  n .1 .  3 (N+l)  j=l 12 , 36(37) 1.4474  /190 [ 12  2  , 224  2  12  p >  252 12 0.05  2  3(37)  252.0  64 The  IPAT A n x i e t y S c a l e The  were u s e d .  Questionnaire  raw s c o r e s o f A n x i e t y S c a l e  Questionnaires  S c o r e s c a n r a n g e f r o m 0 t o 80 o n t h e Q u e s t i o n -  naire.  The r a w s c o r e mean f o r t h e g e n e r a l p o p u l a t i o n i s  27.1.3  The mean s c o r e s f o r a l l t h r e e g r o u p s i n t h e s t u d y ,  b o t h on Day 1 a n d Day 5 a r e c o n s i d e r a b l y above t h e norm. (The  s u b j e c t s were, o f c o u r s e ,  s e l e c t e d from a p o p u l a t i o n  d e f i n e d as s u f f e r i n g from e x c e s s i v e a n x i e t y . )  A l l mean  s c o r e s were above t h e e i g h t y - n i n t h p e r c e n t i l e . 4-6 a n d 4-7 show A n x i e t y S c a l e Q u e s t i o n n a i r e  T a b l e s 4-5,  scores f o r  s u b j e c t s i n e a c h g r o u p o n Day 1 a n d Day 5, a s w e l l a s c h a n g e s i n s c o r e s o n Day 5 a s compared w i t h Day 1. Group I s  "Relaxation".  S u b j e c t s i n Group 1  showed a mean s c o r e o f 50 o n t h e A n x i e t y r ceiving  fiela.xa.tion  training.  Scale before r e -  T h i s r e p r e s e n t s a mean  above t h e n i n e t y - s i x t h p e r c e n t i l e f o r t h e g e n e r a l as d e m o n s t r a t e d i n a t a b l e f o r c o n v e r s i o n o f t o t a l  score  population anxiety  4  raw  scores to p e r c e n t i l e s .  The mean s c o r e f o r t h e g r o u p  on Day 5» a f t e r f o u r d a y s o f r e l a x a t i o n t r a i n i n g , 45.5  (eighty-ninth percentile).  f e l l to  The r a n g e f o r Day 1 e x -  t e n d e d f r o m 72 t o 32 a n d f o r Day 5 f r o m 69 t o 22.  Changes  r a n g e d f r o m +4 t o -15 w i t h a mean change o f -4.5-  Three  3 R.B. C a t t e l l a n d I . H . S c h e i e r , Handbook f o r t h e IPAT A n x i e t y S c a l e Q u e s t i o n n a i r e , ( C h a m p a i g n , I l l i n o i s s I n s t i t u t e f o r P e r s o n a l i t y a n d A b i l i t y T e s t i n g , _ 1 9 6 3 ) , p.11, 4  ^Ibid.  65  TABLE  4-5  Changes i n IPAT A n x i e t y S c a l e Q u e s t i o n n a i r e B e t w e e n Day 1 and Day 5 l o r S u b j e c t s i n G r o u p Is "Experimental"  Scores  Subject  Day 1 IPAT S c o r e  Day 2 IPAT S c o r e  1  48  49  +  1  2  40  44  +  4  3  32  28  -  4  4  66  51  -  15  5  48  42  -  6  6  37  22  -  15  7  53  42  -  11  8  46  42  -  4  9  39  42  +  3  10  72  69  -  3  11  60  56  -  4  12  59  59  EXs  6oo  546  Ns  12  12  Xs  50  45-5  Range s  72  .  t o 32  69  Change IPAT S c o r e  0 . 7  t o 22  54 12  +4  4,  t o -1  66  TABLE  4-6  Changes i n IPAT A n x i e t y Scale Q u e s t i o n n a i r e Scores Between Day 1 and Day 5 f o r Subjects i n Group 2 : "Placebo"  Day 1 IPAT Score  Day 2. IPAT Score  13  61  61  0  14  68  60  8  15  50  51  +  16  56  43  -  13  17  5*  60  +  6  18  41  55  +  14  19  36  40  +  4  54  56  +  2  -  Subject  20  •  Change IPAT Score  1  21  62  44  22  32  30  23  56  32  -  24  24  37  39  +  2  6o?  571  2IX:  Range  •  Ns  12  12  Xi  50.58  47.58  68  to 3 2  6l  to 3 0  18 2  -  36 12  -  3  +14 to -  6?  individuals  showed i n c r e a s e d s c o r e s , e i g h t showed d e c r e a s e d •  s c o r e s w h i l e one i n d i v i d u a l m a i n t a i n e d  t h e same s c o r e .  G r o u p 1 s c o r e s o n Day 1 a n d Day 5» a n d c h a n g e s i n s c o r e are found  i n Table  4-5-  G r o u p 2; Table  "Placebo".  Group 2 s c o r e s a s shown i n  4-8 r e v e a l a r a n g e o f 68 t o 32 w i t h a mean v a l u e o f  50.58 b e f o r e r e c e i v i n g t h e " P l a c e b o " and  treatment  approach  a r a n g e o f 6 l t o 30 o n Day 5» w i t h t h e mean v a l u e  i n g d r o p p e d t o 47.58.  The r a n g e o f c h a n g e s i n s c o r e  r e c e i v i n g the "Placebo"  treatment  w i t h a mean change o f -3. scores, f i v e  havafter  a p p r o a c h was +14 t o -24  S i x subjects exhibited increased  showed d e c r e a s e d  s c o r e s a n d one s u b j e c t  showed  no c h a n g e . Group 3;  "Control".  Group 3 mean s c o r e o f 45.58  f o r Day 1 was l o w e r t h a n e q u i v a l e n t s c o r e s f o r t h e o t h e r two g r o u p s . treatment  Also u n l i k e the "Relaxation" o r "Placebo"  groups,  t h e " C o n t r o l " 'group mean s c o r e f o r Day 5  showed a n i n c r e a s e .  The mean i n c r e a s e was +2.5 w h i l e t h e  r a n g e o f change was f r o m +7 t o -5showed d e c r e a s e d  scores while nine  Only three  subjects  subjects displayed i n 1  creased  scores.  :  Comparison o f Groups; tionnaire  Scores.  Hypothesis  IPAT A n x i e t y S c a l e  Ques-  2 s t a t e s t h a t t h e r e w i l l be  no s i g n i f i c a n t d i f f e r e n c e i n c h a n g e s i n l e v e l o f IPAT Anxiety Scale Questionnaire  s c o r e s between groups.  Table  68  TABLE  4-7  Changes i n IPAT A n x i e t y S c a l e Q u e s t i o n n a i r e B e t w e e n Day 1 and. Day 5 l o r S u b j e c t s i n Group 3s "Control"  Scores  Day 1 IPAT S c o r e  Day 2 IPAT S c o r e  25  56  51  -  5  26  45  47  +  2  27  39  38  -  1  28  30  36  +  6  29  61  65  +  4  30  42  41  -  l  31  57  60  +  3  32  28  30  +  2  33  48  55  +  7  34  30  35  +  5  35  57  62  +  5  36  54  59  +  5  547  579  +  32  Ns  12  12  Xi'  45-58  48.25  Subject  231 s  Range s  61  t o 28  65  t o 30  Change IPAT S c o r e  12  + +7  2.67  t o -5  69' 4-8 by  d i s p l a y s t h e K r u s k a l - W a l l i s One-Way A n a l y s i s o f Ranks o f t h e t h r e e g r o u p s .  The  " H " i s c o m p u t e d t o be  a p p r o p r i a t e t a b l e d i s c l o s e s t h a t i f H > 7-82  df = k - 1 = 7  the p r o b a b i l i t y of occurrence  h y p o t h e s i s i s l e s s t h a n 0.02. and  conclude  Therefore,  employed f o r t h i s purpose.  used, where t h e h y p o t h e s i s  groups w i l l  4-9  The  Mann W h i t n e y (J  t e s t e d a s s e r t s the  hypothesis  i . e . t h a t one  dif-  of  the  "Placebo"  Therefore  tested states that  s c o r e s f o r s u b j e c t s who  re-  a s compared w i t h s u b j e c t s  treatment.  e x c e e d s a p r o b a b i l i t y o f 0.05  and  g r e a t e r d e c l i n e i n IPAT  "Relaxation" treatment  chance a l o n e .  groups,  scores.  be no s i g n i f i c a n t l y  r e c e i v e d the  hypothesis  H„  The o n e - t a i l e d t e s t  directional,  Anxiety Scale Questionnaire c e i v e d the  t o be  The  shows t h e f i n d i n g s when Group 1  Group 2 a r e c o m p a r e d . there w i l l  be  have h i g h e r  Table  The (j v a l u e o f 57•5  that differences occurred  the n u l l h y p o t h e s i s  i s tenable  by and  (i) i s rejected. The  will  reject  null  c a r r i e d o u t t o compare  i n d i v i d u a l groups.  ference i n scores w i l l  who  of the  shows o n l y t h e o v e r a l l c o m p a r i s o n b e t w e e n  t h e r e s u l t s shown by  was  with  Since the K r u s k a l - W a l l i s  f u r t h e r t e s t i n g b e t w e e n g r o u p s was  T e s t was  7.8227.  t h a t t h e r e i s a s i g n i f i c a n t d i f f e r e n c e between  g r o u p s i n changes i n IPAT s c o r e s . technique  we  Variance  second h y p o t h e s i s  be a s i g n i f i c a n t l y  tested asserts that there  g r e a t e r d e c l i n e i n IPAT A n x i e t y  70  TABLE  4-8  K r u s k a l - W a l l i s One-Way A n a l y s i s o f V a r i a n c e by Ranks o f Changes i n IPAT A n x i e t y S c a l e Q u e s t i o n n a i r e Scores o f Groups R e c e i v i n g " R e l a x a t i o n , " "Placebo" and " C o n t r o l " Treatments  "Relaxation" Change Rank in Among Score N=36  + +  -  1  19-5  4  28  -  8  7  4  11  +  1  19.5  - 13  5 33.5  0  ' 3-5  15  +  15  3.5  + 14  36  11  6  +  4  28  4  11  +  2  22.5  25.5  - 18  3 - 3  6  2  13 _  -  2  14  4  11  - 24  1  0  17.5  +  R  H  l =  =  =  5  9  +  2  22.5  -  1  15.5  + +  6  33.5  4  28  -  1  + +  3  15.5 25-5  2  22.5  + +  7 5 5 5  35  '208.5  k 12 \ N (N+l) / i=i  36(37)  —  + +  22.5  2  157-5  12  "Control" Change Rank in Among Score N=36  17.5  8  6  +  -  "Placebo" Change Rank in Among Score N=36  R. n .,1 3  j^157.  ((  7.822?  1  2  5  2  R  3  31 31 31  =  3 (N+l)  + 208.5 12  2  , 300 \  p < 0 .02  2  1  2  3(37)  300  71  TABLE 4 - 9 Mann-Whitney (j Test F o r D i f f e r e n c e s i n Change i n IPAT A n x i e t y S c a l e Q u e s t i o n n a i r e Scores Between Group 1: " R e l a x a t i o n " and Group 2 s "Placebo" (N = 24)  Group 1 {n. Change in Subject Score  = 12) Rank Among  Group 2 ( n = 12) Change Rank in Among Subject Score N=24 ?  N=24  1  +  1  16.5  13  2  +  4  21.5  14  -  4  10  3 4 5  -f  7 • 8 9  +  10  -  11  >  =  -  8  7  15  +  1  16.5  3-5  16  -  13  5  8  17  +  6  23  15  3-5  18  +  14  11  6  19  +  4  21.5  4  10  20  +  2  18.5  3  20  21  -  18  2  3  12  22  -  2  13  4  10  23  -  24  1  0  14.5  24  +  2  6  12  z  14.5  15 r  -  6  0  R  135-5  l =  (n  u  =  U  = 144 +  p >  n  l 2 n  0.05  +  78  +  ±  1)  2  z "  - 164.5 = 55  (one-tailed)  R  R  2  2  24  18.5  =  164.5  72  TABLE 4-10 M a n n - W h i t n e y (J T e s t f o r D i f f e r e n c e s i n Change i n IPAT A n x i e t y S c a l e Q u e s t i o n n a i r e S c o r e s B e t w e e n Group I s " R e l a x a t i o n " a n d G r o u p 3s " C o n t r o l " (N = 24)  Group 1 ( n = 12)  Group 3 ( n = 12)  1  Subject  Change in Score  2  Rank Among N=24  Change i n Score  Subject  Rank Among N=24  1  +  1  13  25  -  5  5  2  +  4  18.5  26  +  2  -  4  7  27  -  14.5  1  10.5  1.5  28  +  6  23  4  29  +  4'  18.5  15  1.5  30  1  10.5  11  -  3  31  +  3  16.5  4  7  32  +  •2  14.5  3  16.5  33  +  7  24  3  9  3*  +  5  21  4  7  35  +  5  21  0  12  36  +  5  21  3 4 5 6 7 8 9  +  10  -  11  15 6  12  L  = R  1  u u p  z  100  =  n ri  l2 n  l  = 144 + 78 -  >  0.001  + 1)  (n  +  =  ±  2  -  R  2  200 = 22  < 0.01 ( o n e - t a i l e d )  R  2  =  200  73  TABLE 4-11 M a n n - W h i t n e y U T e s t f o r D i f f e r e n c e s i n Change i n IPAT A n x i e t y S c a l e Q u e s t i o n n a i r e S c o r e s B e t w e e n Group 2: " P l a c e b o " a n d Group $ t " C o n t r o l " (N = 24)  Group 2 ( n = 12)  Group 3 ( n  1  Change in Score  Subject  Rank Among N=24  0  13 .  Subject  5  26  +  2  12.5  10  27  -  1  7-5  3 21 .5  28  6  21.5  29  + +  4  16.5  24  30  -  1  7.5  4  8  15  +  1  16  -  13  17  +  6  18  +  14  19  +  4  16.5  31  20  +  2  12.5  32  21  2  33  6  34  23  -  1  24  +  12.5  22  z  24 2  R  u  =  l 2 n  O = 144 p >  +  3 7  23 •  5  19  35  + +  5  19  36  +  5  19  2  + 78 - 178 = 44  0.05 ( o n e - t a i l e d )  •15 12.5  • + 1) H  + + +  2  122  l =  Rank. Among N=24  5  25  -  18  = 12)  -  9  14  .  Change in Score  2  R  2  R  2  =  178  74  Scale Questionnaire  s c o r e s f o r s u b j e c t s who r e c e i v e  l a x a t i o n " t r e a t m e n t as compared, w i t h s u b j e c t s who  "Re-  receive  " C o n t r o l " treatment.  Table 4 - 1 0 d i s p l a y s the comparison  of changes i n A n x i e t y  S c a l e s c o r e s o f Group I s  and  Group 3 *  "Control".  "Relaxation"  The (/ measure o f 2 2 has a p r o -  b a b i l i t y o f l e s s t h a n one p e r c e n t o f h a v i n g happened by chance. (ii)  The n u l l h y p o t h e s i s  can be r e j e c t e d and  hypothesis  accepted. Mann-Whitney (J Test f o r d i f f e r e n c e s between  Group 2 and Group 3 i s shown i n Table 4 - 1 1 . (iii)  can be s t a t e d as f o l l o w s :  Hypothesis  t h e r e w i l l be a s i g n i f i c a n t -  l y g r e a t e r d e c l i n e i n IPAT A n x i e t y  Scale Questionnaire  scores  f o r s u b j e c t s who r e c e i v e " P l a c e b o " t r e a t m e n t as compared w i t h subjects.who r e c e i v e " C o n t r o l " t r e a t m e n t .  The Mann-  Whitney (J Test f o r d i f f e r e n c e s d i s p l a y s a p r o b a b i l i t y g r e a t e r than 5 p e r c e n t t h a t the d i f f e r e n c e s can be on the b a s i s o f change. and h y p o t h e s i s  The n u l l h y p o t h e s i s  explained  i s supported  ( i i i ) was r e j e c t e d .  A d i s c u s s i o n o f these f i n d i n g and o f i m p l i c a t i o n s a r i s i n g from the f i n d i n g s i s g i v e n i n the f o l l o w i n g  chapter.  Chapter  5  DISCUSSION, LIMITATIONS,  RECOMMENDATIONS  Interpretation of Findings The g o a l o f t h i s s t u d y was t o i n v e s t i g a t e t h e e f f e c t i v e n e s s o f a r e l a x a t i o n technique cessive anxiety, chological and  A physiological  i n r e l i e v i n g ex-  ( b i o c h e m i c a l ) and a psy-  ( a f f e c t i v e ) i n d e x were m o n i t o r e d ,  on t h e f i r s t  l a s t days o f t h e e x p e r i m e n t a l p e r i o d , as measures o f  level of anxiety. Questionnaire  A s m e a s u r e d by t h e IPAT A n x i e t y  Scale  t h e r e was a s i g n i f i c a n t o v e r a l l r e d u c t i o n i n  l e v e l o f a n x i e t y f o r s u b j e c t s i n Group 1 " R e l a x a t i o n " i n c o m p a r i s o n w i t h Group 3 " C o n t r o l . "  Group 2  "Placebo"  showed no s i g n i f i c a n t d i f f e r e n c e f r o m Group 1 o r Group 3 when c h a n g e s i n A n x i e t y S c a l e s c o r e s were c o m p a r e d  statis-  tically. The t w e n t y - f o u r  hour u r i n a r y potassium  excretion  measure d i d n o t d e m o n s t r a t e s i g n i f i c a n t ' d i f f e r e n c e s i n changes i n l e v e l between t h e t h r e e groups a l t h o u g h i n s p e c t i o n shows s i m i l a r t r e n d s i n v a l u e s b e t w e e n t h e t h r e e groups f o r both t h e p h y s i o l o g i c a l and t h e p s y c h o l o g i c a l measure.  The mean c h a n g e s i n a n x i e t y s c a l e s c o r e s a n d  u r i n a r y potassium  excretion were as !  75'  follows:  76  GROUP  IPAT  URINE K  1  -4.5  -9.25  2  -3.0  -9-92  3  +2.5  -3.50  Inspection of direction of individual each group a r e s u g g e s t i v e  also:  IPAT SCORES f  GROUP 1 2  6  3  URINE K EXCRETION SAME+  <y  I  8  1  3  9  0  5  1  6  6  0  4  0  7  5  0  j  3 8  Individual patient profiles i n response. scores  SAME  show a w i d e r a n g e o f d i f f e r e n c e  Some s u b j e c t s i n e a c h g r o u p show i n c r e a s e d  or values  while other  scores i n  indicative of increased anxiety or stress  s u b j e c t s showed d e c r e a s e s .  I n d i v i d u a l s may show  an i n c r e a s e i n one p a r a m e t e r a n d a d e c r e a s e i n t h e o t h e r . The  combined r e s u l t s f o r each group a r e : G r o u p 1:  one s u b j e c t i n c r e a s e d i n b o t h s i x subjects decreased i n both  Group 2:  one s u b j e c t i n c r e a s e d one  G r o u p 3:  five one  i n both  subject decreased i n both subjects increased i n both subject decreased i n both  Once a g a i n i n s p e c t i o n o f s c o r e s  and v a l u e s  suggests a greater  77 reduction  i n  anxiety  for  Evidently the  effects  reasons  of  for  evident.  this  not  of  synomymous  with  anxiety  bably to  there  follow  made  of  back  have  differences  much  assisted  the  subjects  effects other  traneous  variables  stress  -  the  social  situation  is  why  ence  that basic  factors. i n  a  emotional of  question  between did  Group not?  scale 1  and  The  most  such  desire  posed  i n  was  could  have  which  of  psychiatric  such  the  results  of  Group  the  the  Anxiety  Scale  measures  to  anxiety  while  the  induce  unit,  factors  been ex-  might  demonstrated  while  may  feed-  effectively?  questionnaire  answer  measure  the as  caffeine. by  3  learning no  multitude  physical  a  Pro-  Would  more  a  there  subjects  There  setting  as  Is  is  anxiety?  training are  char-  benefit  for  relaxed.  the  the  relaxation  and  relax  There  subject,  Another anxiety  to  The  clearly  identify  chronic  subjects  of  not  anxiety.  a b i l i t y  climate  factors  of  with  c l i n i c a l  the  to  to  others.  technique  relaxation  dietary  the  measure  of  are  relaxation.  how  by  and  for  than  muscle  the  i n  or  The  noise  of  responsive  receive  r e l i e f  compared  directions  whether  submerged  as  needed  Perhaps  with  more  response  would  effectiveness  are  the  are  who  are  technique  i n  training.  i n  acute  studies  subjects  difference  subjects.  1  subjects  difference  relaxation entirely  some  relaxation  Further  acteristics from  the  Group  be a  urinary  the  urinary  derived  composite potassium  from of  the  a l l  measure  study  a'.differpotassium fact factors is  a  78  u n i t a r y f a c t o r and  an  m i g h t more a c c u r a t e l y  i n d i r e c t measure o f s t r e s s . be m e a s u r e d by  a  Stress  multifactorial  approach, i . e . o v e r a l l u r i n a r y e l e c t r o l y t e e x c r e t i o n  pat-  terns. Both the  p h y s i o l o g i c a l and  the  psychological  measure r e v e a l a t e n d e n c y t o i n c r e a s i n g s t r e s s o r o v e r the Is for  five  day  period  this t y p i c a l during t h i s population?  h a v e shown t h a t  f o r members o f t h e  the  anxiety  "Control"  group.  e a r l y weeks o f h o s p i t a l i z a t i o n  Studies  with other  "admission anxiety"  has  patient subsided  populations by  the  end  i o f the  first  week.  L i m i t a t i o n s o f the  Study  Sample S i z e and a small not  Selection.  This  sample o f a s p e c i a l p o p u l a t i o n .  be made b e y o n d t h i s p o p u l a t i o n  p a t i e n t s i n acute care s e l e c t i o n of the statistical  settings).  sample l e d to the  study  involved  Generalizations  can  ( i . e . non-psychotic i n Furthermore, the use  of  size  and  nonparametric  a n a l y s i s w h i c h l a c k s the power o f  parametric  analysis. Uncontrolled  Extraneous S t i m u l i .  v a r i a b l e s were d i f f i c u l t o r i m p o s s i b l e i n c l u d e b o t h p h y s i o l o g i c a l and  1  Many e x t r a n e o u s  to c o n t r o l .  psychological  These  stimuli.  Medi-  R o s l y n E l m s and R.C. L e o n a r d , " E f f e c t s o f N u r s i n g A p p r o a c h e s D u r i n g A d m i s s i o n , " N u r s i n g R e s e a r c h . XV (Winter, 1 9 6 6 ) , 39-4.8. ~~ '  79 c a t i o n s were c o n s t a n t f o r i n d i v i d u a l s u b j e c t s b u t were c o n t r o l l e d a c r o s s g r o u p s by m a t c h i n g s u b j e c t s . stimuli  s u c h as t o b a c c o  a r y i n t a k e , were n o t  not  Physiological  o r c a f f e i n e i n t a k e , as w e l l as  controlled.  Noise,  o t h e r p h y s i c a l s t i m u l i vary from time  temperature  to time.  diet-  and  The  emotional  c l i m a t e o f p s y c h i a t r i c u n i t s a l s o changes markedly w i t h passage of time.  A v a r i e t y of physicans  and  nurses  t h e r e g u l a r c a r e f o r t h e s u b j e c t s so t h a t c a r e was  the  provided f a r from  standardized. Incomplete ment u s e d may  Placebo  The  have p r o v i d e d an i n c o m p l e t e  Hawthorne e f f e c t .  Subjects i n the  e q u i v a l e n t n u r s i n g t i m e and procedure  Effect.  f o r the  "Placebo" measure o f  "Placebo"  environmental  the  group r e c e i v e d  c o n t r o l but  " R e l a x a t i o n " group i n v o l v e d a  •approach, the t a p e - r e c o r d e r .  treat-  the  "machine"  T a p e s were u s e d t o  standardize  instruction. Urine Potassium assurance indeed  t h a t the t w e n t y - f o u r  complete.  t h e i r own  Measure.  T h e r e was  not  h o u r u r i n e s p e c i m e n s were  S u b j e c t s were r e s p o n s i b l e f o r c o l l e c t i n g  specimens.  Recommendations f o r F u r t h e r  Study  In view of the f i n d i n g s o f t h i s  investigation  the f o l l o w i n g recommendations f o r f u r t h e r study 1. s h o u l d be  complete  Subsequent s t u d i e s u s i n g a l a r g e r  c a r r i e d out to support  a r e made. sample  o r r e j e c t the f i n d i n g s i n  80 this investigation. 2.  Use o f m u l t i f a c t o r i a l  urinary electrolyte as more a c c u r a t e 3.  s t r e s s i n d i c e s such as  excretion profiles  s h o u l d be  o v e r a l l measures o f p h y s i o l o g i c a l s t r e s s .  The R e l a x a t i o n T e c h n i q u e s h o u l d  patients i n other  "high  be t e s t e d  rheumatoid a r t h r i t i s , Studies  patients with  cardiac rehabilitation patients, etc. should  p a t i e n t s a r e most l i k e l y laxation  with  s t r e s s " areas o r s i t u a t i o n s , f o r  example, burn u n i t s , p r i o r t o c a r d i a c s u r g e r y ,  4.  instituted  be c o n d u c t e d t o i d e n t i f y  to respond favourably  which  to the r e -  training. 5.  Tape-recorded i n s t r u c t i o n s o f the R e l a x a t i o n  T e c h n i q u e s h o u l d be compared f o r e f f e c t i v e n e s s w i t h  "live"  instruction. 6.  The R e l a x a t i o n T e c h n i q u e s h o u l d  e f f e c t i v e n e s s using d i f f e r e n t schedules  be t e s t e d f o r  a n d numbers o f  treatments.  Summary An e x p e r i m e n t a l the  study  was c o n d u c t e d t o i n v e s t i g a t e  e f f e c t i v e n e s s o f a R e l a x a t i o n Technique i n r e l i e v i n g  excessive  anxiety.  T h i r t y - s i x 'non-psychotic,  i n p a t i e n t s were a s s i g n e d  psychiatric  a t random t o t h r e e g r o u p s .  Sub-  j e c t s i n Group 1 r e c e i v e d i n d i v i d u a l r e l a x a t i o n t r a i n i n g by means o f a s i m p l e  r e l a x a t i o n technique  involving controlled  b r e a t h i n g and m u s c l e r e l a x a t i o n e x e r c i s e s . r e c e i v e d i n d i v i d u a l ,:placebo  treatments  on a n  Group 2 s u b j e c t s equivalent  81 s c h e d u l e t o Group 1. o r d i n a r y ward care  Subjects  i n Group 3 r e c e i v e d t h e  and no s p e c i a l a p p r o a c h .  Level of  a n x i e t y was m e a s u r e d by a p h y s i o l o g i c a l i n d e x f o u r hour u r i n a r y potassium e x c r e t i o n ) scale  (IPAT A n x i e t y  Scale  perimental  and a p s y c h o l o g i c a l  Questionnaire).  were t e s t e d a t t h e b e g i n n i n g  (twenty-  Both measures  and end o f t h e f i v e  day e x -  p e r i o d and c h a n g e s i n l e v e l s b e t w e e n g r o u p s  compared s t a t i s t i c a l l y . G r o u p 1 s u b j e c t s were f o u n d t o e x h i b i t s i g nificantly tionnaire other  g r e a t e r d e c l i n e s i n IPAT A n x i e t y scores  Scale  a s c o m p a r e d w i t h Group 3 s u b j e c t s .  No  s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e was f o u n d b e -  tween g r o u p s .  I n s p e c t i o n o f i n d i v i d u a l IPAT  urine potassium values  scores'and  s u g g e s t s however, t h a t t h e r e  marked d i f f e r e n c e i n i n d i v i d u a l r e s p o n s e , b o t h logically  "Placebo"  approach.  the  two m e a s u r e s ( i . e . t h e change o f u r i n a r y  The l a c k o f c o n s i s t e n c y  factorial  between  sig-  d i f f e r e n t f r o m Group 3) a y be e x p l a i n e d m  f a c t t h a t the Anxiety index  while  Scale  Questionnaire  by  i s a multi-  the urine potassium value  o n l y one p h y s i o l o g i c a l a s p e c t o f a n x i e t y .  and  potassium  e x c r e t i o n l e v e l s f o r Group 1 was n o t f o u n d t o be nificantly  is a  physio-  and p s y c h o l o g i c a l l y , t o t h e " R e l a x a t i o n "  the  the  Ques-  measures  B I B L I O G R A P H Y  82  83  A i t k e n , L i n d a H. and T h e o d o r e F. H e n r i c h s . 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"The P h y s i o l o g y o f M e d i t a t i o n , " S c i e n t i f i c A m e r i c a n , CCVI ( F e b r u a r y , 1 9 7 2 ) , 80-94.' W h i t e , Abraham, P h i l i p H a n d l e r , a n d E m i l L. S m i t h . P r i n c i p l e s o f B i o c h e m i s t r y . New Y o r k : McGraw-Hill Book Company, 1969•  89  Winer, B.J. Design.  S t a t i s t i c a l Principles i n Experimental New Y o r k : M c G r a w - H i l l Book Company, 1971'  Wolpe, J o s e p h . P s y c h o t h e r a p y by R e c i p r o c a l I n h i b i t i o n . Stanford: Stanford University Press, 1958. W o o l d r i d g e , P o w h a t a n , James K. S k i p p e r and R o b e r t C. Leonard. B e h a v i o u r a l S c i e n c e , S o c i a l P r a c t i s e and the N u r s i n g P r o f e s s i o n . C l e v e l a n d : P r e s s o f Case Western Reserve U n i v e r s i t y , 1 9 6 8 .  A P P E N D I  90  C E S  APPENDIX TEXT OF RELAXATION  Breathe Hold  TECHNIQUE TAPE  i n ... b r e a t h e  i t ... h o l d  A  i n ... b r e a t h e i n .  i t ... h o l d i t . i  B r e a t h e o u t ... b r e a t h e Now,  t h e m u s c l e t e n s i n g and r e l a x i n g .  Wrinkle let as  i t go loose  your forehead  ... l o o s e  ... f e e l  and r e l a x e d  the t e n s i o n  ...  ... l o o s e  and r e l a x e d  ...  ... f e e l  the t e n s i o n  ...  as y o u can. Close  let  o u t ... b r e a t h e o u t .  them go  y o u eyes t i g h t l y  ... l o o s e  and r e l a x e d  ... l o o s e  and e a s y  ...  e a s y and r e l a x e d . Open y o u r mouth wide let  i t go  really  ... l o o s e  ... f e e l  and r e l a x e d  the t e n s i o n  ... l o o s e  ...  and r e l a x e d  ...  relaxed. Bend y o u r head f o r w a r d s  ...  l e t i t go  ...  really  ... l o o s e  ... f e e l  and r e l a x e d  the t e n s i o n  ... l o o s e  and r e l a x e d  relaxed. Bend y o u r head f o r w a r d s  ...  l e t i t go  ...  as r e l a x e d Lift  ... l o o s e  ... f e e l  and r e l a x e d  the t e n s i o n  ... l o o s e  and r e l a x e d  as y o u c a n . your shoulders  up t o y o u r e a r s  Repeat from b e g i n n i n g  91  five  times.  ... f e e l '  92  the  tension  loose  ... l e t them go  and heavy  ... heavy  easy  i t go and  ... l o o s e  ... l e t i t go ... r e a l l y  ... f e e l ... l o o s e  the t e n s i o n and e a s y  ...  ...  ... heavy  your r i g h t  forearm  and r e l a x e d  ... f e e l  the t e n s i o n  ... l o o s e  and r e l a x e d  relaxed.  ... l e t i t go  your r i g h t  ... l o o s e  upper  arm  and r e l a x e d  ... f e e l  ... l o o s e  the t e n s i o n  and  heavy  and r e l a x e d . Tighten, your l e f t  ... l e t i t go ... r e a l l y  ... l o o s e  forearm  and r e l a x e d  ... f e e l  the t e n s i o n  ... l o o s e  and r e l a x e d  relaxed. Tighten  your l e f t  ... l e t i t go  ... l o o s e  ... heavy  relaxed.  and  Tighten ... l e t them go ... a s l o o s e  your  arm  ... f e e l  ... l o o s e  chest muscles and r e l a x e d  ... f e e l  the t e n s i o n and  heavy  the t e n s i o n  ... l o o s e  and r e l a x e d  as y o u c a n . your abdominal  ... l e t them go  ... e a s y and Tighten them go  upper  and r e l a x e d  ... l o o s e  Tighten  let  fist  and r e l a x e d  ... l o o s e  Tighten  easy  ...  relaxed. Tighten  tension  and r e l a x e d  and r e l a x e d .  Clench your r i g h t let  ... l o o s e  ... l o o s e  muscles  ... f e e l t h e  and r e l a x e d  ... l o o s e  relaxed. y o u r b u t t o c k s ... f e e l  ... l o o s e  and r e l a x e d  the t e n s i o n  ... l o o s e  ...  and r e l a x e d  and  93 ... r e a l l y  relaxed. Tighten  tension  your r i g h t  . .. l e t them go  and heavy  ... heavy Tighten  tension and  ... l o o s e  your r i g h t  ... a s l o o s e  ... l o o s e  ... l o o s e  away f r o m y o u r head  toes  ...  and r e l a x e d  your l e f t  and r e l a x e d  t o w a r d y o u r head  ... f e e l  ... l e t them go ... l o o s e  and r e l a x e d  Tighten ... l o o s e  and r e l a x e d  ... e a s y and r e l a x e d .  i n your c a l f  ... l o o s e  ... l o o s e  ... f e e l t h e  ... l e t them go ... l o o s e  and e a s y  tension  laxed  c a l f muscles  toes  Point your r i g h t the  and r e l a x e d  as y o u c a n .  Point your right the t e n s i o n  ... f e e l t h e  and r e l a x e d .  ... l e t them go ... l o o s e  relaxed  feel  t h i g h muscles  ... r e a l l y  relaxed.  t h i g h muscles  ... l o o s e  and r e -  ... l e t them go  and heavy  ... heavy and  relaxed. Tighten sion  your l e f t  ... l e t them go ... l o o s e  relaxed  ... a s l o o s e  feel  the t e n s i o n  ... l o o s e  i n your c a l f  ... l o o s e Lie  the ten-  ... l o o s e and  toes  away f r o m y o u r head  ...  and r e l a x e d  ... e a s y and r e l a x e d .  Point your l e f t  laxed  and r e l a x e d  ... l e t them go ... l o o s e  and e a s y  tension  ... f e e l  as you can.  Point your l e f t  the  c a l f muscles  toes  ... f e e l  ... l e t them go ... l o o s e  and r e l a x e d  relaxed  t o w a r d y o u r head  ... r e a l l y  relaxed.  a l l o v e r f o r a few m i n u t e s .  and r e -  APPENDIX ANXIETY STUDY:  B  EXPERIMENT SCHEDULE  DAY 1 0800 hours s t a r t 24 hour Urinary Potassium Excretion Test [ 2100 hours IPAT Anxiety Scale Questionnaire 1  1  Medications: DAY 2 0800 hours complete 24 hour Urinary Potassium Excretion Test |  |  1000 hours |  | 1400 hours |  | 2000 hours |  [i Relaxation Training  1000 hours | Medications:  | 1400 hours I  I 2000 hours |  |; Placebo Treatment  j  [: No Treatment  DAY 3 1000 hours [  1400 hours  2000 hours  ]: Relaxation Training  1000 hours [  1400 hours  2000 hours  ]: Placebo Treatment 1: No Treatment  Medications:  DAY 4 1000 hours [  1400 hours  2000 hours  ]: Relaxation Training  1000 hours f  1400 hours  2000 hours  ]: Placebo Treatment  Medications:  ~|: No Treatment  DAY 5 0800 hours s t a r t 24 hour Urinary Potassium Excretion Test 2000 hours Q ' : Relaxation Training 1000 hours | | 1400 hours 1 1000 hours |  | 1400 hours  2000 hours T  : Placebo Treatment : No Treatment  DAY 6 0800 hours complete 24 hour Urinary Potassium Excretion Test [  94  

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