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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 IN LESSENING EXCESSIVE.ANXIETY OF SELECTED PSYCHIATRIC INPATIENTS by WINIFRED MARGARET MILLER B.S.N., U n i v e r s i t y o f B r i t i s h Columbia, 1968 A THESIS- SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING-i n the SCHOOL OF NURSING We a c c e p t t h i s t h e s i s as c o n f o r m i n g to the r e q u i r e d s t a n d a r d THE UNIVERSITY OF; BRITISH COLUMBIA October, 1975 In presenting t h i s t h e s i s in p a r t i a l f u l f i l m e n t of the requirements f o r an advanced degree at the U n i v e r s i t y of 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 reference and study. I f u r t h e r agree that permission for extensive copying of t h i s t h e s i s f o r s c h o l a r l y purposes may be granted by the Head of my Department or by h i s rep r e s e n t a t i v e s . It i s understood that copying or 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 gain s h a l l not be allowed without my w r i t t e n permission. 2H5£XM"SSXg3Bf School o f Nursing The U n i v e r s i t y of B r i t i s h Columbia 2075 Wesbrook Place Vancouver, Canada V6T 1W5 Date 8th October, 1975 ABSTRACT A Study of the E f f e c t i v e n e s s of A Rela x a t i o n Technique i n Lessening Excessive Anxiety 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 p s y c h i -a t r i c problems. Are there simple techniques which nurses can teach 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 anxiet y ? An experimental study was conducted to in v e s -t i g a t e the e f f e c t i v e n e s s of a r e l a x a t i o n technique i n r e -l i e v i n g excessive a n x i e t y . T h i r t y - s i x s e l e c t e d p s y c h i -a t r i c i n p a t i e n t s were assigned at random to three groups. Subjects 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 of 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 breathing and muscle r e l a x a t i o n e x e r c i s e s . Group 2 subjects r e c e i v e d i n d i v i d u a l placebo treatments on an equivalent schedule to Group 1. Subjects i n Group 3 r e -ceived the ordinary ward care and no s p e c i a l approach. Lev 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 index (twenty-four hour u r i n a r y potassium excretion) and a psy-c h o l o g i c a l scale (IPAT Anxiety Scale Questionnaire). Both measures were t e s t e d at the beginning and end of the f i v e day experimental 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 analyses were u t i l i z e d because i i i o f t h e l a c k o f a n o r m a l d i s t r i b u t i o n . T h e c e n t r a l t e n -d e n c i e s o f c h a n g e s i n t h e 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 i n d i c e s m e a s u r e d f o r t h e t h r e e g r o u p s w e r e a n a l y z e d b y m e a n s o f t h e K r u s k a l - W a l l i s O n e - W a y A n a l y s i s o f V a r i a n c e . T h e n u l l h y p o t h e s i s w a s t e s t e d a n d t h e f i v e p e r c e n t ( p < f . 0 5 ) l e v e l o f s i g n i f i c a n c e w a s a c c e p t e d . W h e n t h e n u l l h y p o t h e s i s w a s u n t e n a b l e M a n n - W h i t n e y U T e s t s ( o n e - t a i l e d ) w e r e d o n e t o d e t e r m i n e i n d i v i d u a l d i f f e r e n c e s b e t w e e n g r o u p s . G r o u p 1: " R e l a x a t i o n " s u b j e c t s w e r e f o u n d t o e x h i b i t 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 s 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 a s c o m p a r e d w i t h G r o u p 3: " C o n -t r o l " . N o o t h e r 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 w a s f o u n d b e t w e e n i n d i v i d u a l g r o u p s . I n s p e c t i o n o f I P A T s c o r e s a n d u r i n a r y p o t a s s i u m v a l u e s s u g g e s t s , h o w e v e r , t h a t t h e r e i s a m a r k e d 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 p h y s i o -l o g i c a l l y a n d 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 " a n d " P l a -c e b o " a p p r o a c h e s . T h e l a c k o f c o n s i s t e n c y b e t w e e n t h e f i n d -i n g s f o r t h e 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 m e a s u r e a n d 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 a r i s e s , p e r h a p s , f r o m t h e f a c t t h a t t h e A n x i e t y S c a l e i s a n i n d e x o f m u l t i p l e f a c t o r s w h i l e 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 s a u n i t a r y p h y s i o l o g i c a l f a c t o r . O n t h e b a s i s o f t h e f i n d i n g s i n t h i s s t u d y t h e t e c h n i q u e d e s c r i b e d i s d e e m e d t o b e a n e f f e c t i v e m e t h o d f o r n u r s e s ( o r o t h e r s ) t o e m p l o y a s a m e a n s f o r r e l i e v i n g e x -c e s s i v e a n x i e t y . . A n u m b e r o f r e c o m m e n d a t i o n s f o r f u r t h e r i v study were made i n c l u d i n g the need t o t e s t o t h e r " h i g h s t r e s s " p o p u l a t i o n s , f o r example, p a t i e n t s i n burn u n i t s o r p r i o r t o c a r d i a c surgery, and the need t o i d e n t i f y which i n d i v i d u a l p a t i e n t s are most, l i k e l y t o respond f a v o u r a b l y to the r e l a x a t i o n t r a i n i n g . The use o f a m u l t i f a c t o r i a l i n d e x , such as 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 p r o f i l e s , as a more a c c u r a t e o v e r a l l measure o f p h y s i o l o g i c a l s t r e s s i s s u g g e s t e d . TABLE OF CONTENTS ABSTRACT i i LIST OF TABLES . i x LIST OF FIGURES • x i ACKNOWLEDGEMENTS , x i i Chapter Page 1. 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 2. REVIEW OF THE LITERATURE 6 P s y c h o a n a l y t i c Concepts o f A n x i e t y . 6 L e a r n i n g T h e o r i e s o f A n x i e t y . . . . . 8 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 9 P h y s i o l o g i c a l and B i o c h e m i c a l A s p e c t s o f A n x i e t y 10 M a n i f e s t a t i o n s o f A n x i e t y 15 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 An'xietyV 15 Psychomotor M a n i f e s t a t i o n s o f A n x i e t y . . . 1 6 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 17 v v i Chapter ' Pag C o g n i 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 . . . . . 18 S o c i a l M a n i f e s t a t i o n s o f A n x i e t y . .19 A Model F o r A n x i e t y 20 B i o p s y c h o s o c i a l S t i m u l i 20 P s y c h o b i o l o g i c a l Programme 22 P e r c e i v e d T h r e a t o r C h a l l e n g e 22 A n x i e t y Response 23 Defense Mechanisms. 24 I n t e r a c t i n g V a r i a b l e s . 25 D e f i n i t i o n o f A n x i e t y .26 P s y c h o p h y s i o l o g i c R e l a x a t i o n . . 27 M e d i t a t i o n 27 P r o g r e s s i v e R e l a x a t i o n . . . . . . 29 R e c i p r o c a l I n h i b i t i o n and S y s t e m a t i c D e s e n s i t i z a t i o n -30 A u t o g e n i c T r a i n i n g JI 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 2 3 . DESIGN AND METHODOLOGY : -37 Overview o f the Study D e s i g n . . 37 D e f i n i t i o n o f Terms 37 Assumptions .38 The Independent V a r i a b l e s A R e l a x a t i o n Technique .38 The Dependent V a r i a b l e s 39 U r i n a r y P o t a s s i u m k-0 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 . kZ v i i Chapter. Page S e t t i n g of the Study . .. . . . 43 The Sample. . . 44 Treatment and Control Methods .47 Group I s "Relaxation" 49 Group 2 s "Placebo" 50 Group 3 : " C o n t r o l " 51 S p e c i f i c Objectives of the Study 51 Hypotheses . 52 A n a l y s i s of Data 52 4. FINDINGS OF THE STUDY 57 The Urine Potassium Measure.... 57 Group I s "Relaxation" 6l Group 2s "Placebo" 6l Group 3 s " C o n t r o l " 6l Comparison of Groupss Urinary Potassium E x c r e t i o n L e v e l s . .62 The IPAT Anxiety Scale Questionnaire 64 Group I s "Relaxation" • 64 Group 2s "Placebo" 6.7 Group 3s " C o n t r o l " 6? Comparison of Groupss :'IPAT Anxiety Scale Questionnaire Scores . . . . . 6 7 5. DISCUSSION, LIMITATIONS, RECOMMENDATIONS 75 I n t e r p r e t a t i o n of the Findings 75 L i m i t a t i o n s of the Study. .78 Sample Size and S e l e c t i o n 78 v i i i C h apter Page U n c o n t r o l l e d E x t r a n e o u s S t i m u l i 78 Incomplete P l a c e b o E f f e c t . . . . 79 U r i n e P o t a s s i u m Measure 79 Recommendations f o r F u r t h e r Study 79 Summary .80 BIBLIOGRAPHY • v82 APPENDICES A. Text o f R e l a x a t i o n Technique Tape..... 91 B. A n x i e t y Study: Experiment Schedule 9k LIST OF TABLES Table P a g e 4-1 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 Between Day 1 and Day 5 f o r S u b j e c t s i n Group Is " R e l a x a t i o n " . . . . . 58 4-2 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 Between Day 1 and 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 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 Between Day 1 and Day 5 f o r S u b j e c t s i n Group 3: " C o n t r o l " . . . . . . . . 6 0 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 U r i n e 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 " 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 Between Day 1 and Day 5 f o r Sub-j e c t s i n Group Is " R e l a x a t i o n " . . . . . . . . . . . . 6 5 4-6 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 Between Day 1 and Day 5 f o r Sub-j e c t s i n Group 2s " P l a c e b o " 66 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 Scores Between Day 1 and Day 5 f o r S u b j e c t s i n Group 3 s " C o n t r o l " 68 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 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. 70 4-9 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 Between Group Is " R e l a x a t i o n " ;and Group 2s " P l a c e b o " Treatment (N=24),..?l i x X Table Page 4-10 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 S cores Between Group 1: " R e l a x a t i o n " and Group 3: " C o n t r o l " (N=24) . . . . . 72 4-11 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 Between Group 2: " P l a c e b o " and Group 3s " C o n t r o l " (N=24) 73 LIST OF FIGURES F i g u r e Page 1 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 M e d i a t e d D i s e a s e ) 21 x i 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 the conduct o f t h i s i n v e s t i g a t i o n . A p p r e c i a t i o n i s extended t o B a r b a r a H e r r i c k McGuire, Chairman o f the T h e s i s Committee, and to Helen E l f e r t and Mona June H o r r o c k s who f u n c t i o n e d as Committee members. These persons gave much wise c o u n s e l and en-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 the two D i r e c t o r s o f N u r s i n g f o r t h e i r w i l l i n g c o - o p e r a t i o n i n p e r m i t t i n g a c c e s s t o the h o s p i t a l f a c i l i t i e s n e c e s s a r y . A p p r e c i a t i o n i s a l s o e x p r e s s e d t o 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 , i n the h o s p i t a l u n i t s where the study was conducted, 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 t o the s i x s t u d e n t n u r s e s who s e r v e d , w i t h d i l i g e n c e and enth u s i a s m , as r e s e a r c h a s s i s t a n t s . F i n a l l y , thanks a re due t o Wendy B e l t r a m o - K r a f f t f o r h e r d e d i c a t e d l a b o u r s i n t y p i n g the m a n u s c r i p t . x i i Chapter 1 INTRODUCTION Statement o f the Problem The d i s c o m f o r t o f a n x i e t y has t r o u b l e d men s i n c e a n c i e n t t i m e s . Our own e r a has been c a l l e d "The Age o f A n x i e t y " 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 t o the p e r v a s i v e n e s s o f t h i s phenomenon. A c e r t a i n degree o f a n x i e t y I s u s e f u l , and i n d e e d e s s e n t i a l , t o a l e r t the i n -d i v i d u a l so t h a t a d a p t i v e r e s p o n s e s are m o b i l i z e d t o meet a c t u a l o r p o t e n t i a l t h r e a t s . E x c e s s i v e a n x i e t y , however, 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 amounts o f energy are d i s s i p a t e d and the l i f e f o r c e s o f the i n d i v i d u a l can be d i m i n i s h e d 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 the 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 f a m i l i e s , n u r s e s encounter a n x i o u s p e o p l e c o n s t a n t l y w h i l e w o r k i n g i n h o s p i t a l s o r i n the community. F o r example, c o n s i d e r the p e r s o n a w a i t i n g open h e a r t s u r g e r y , 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 has been i n f o r m e d t h a t he has an i n o p e r a b l e c a r -cinoma. C o n s i d e r p a r t i c u l a r l y p a t i e n t s coming t o ac u t e care Judd Marmor, " A n x i e t y and Worry as 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 ( O c t o b e r , 1972), 212-15. 1 2 p s y c h i a t r i c u n i t s . "One of the major d i f f i c u l t i e s of most, i f not a l l , p s y c h i a t r i c p a t i e n t s i s a n x i e t y , " w r i t e s H i l d e -2 gard Peplau. How can nurses help p a t i e n t s with e x c e s s i v e a n x i e t y ? Are there p h y s i c a l methods of r e l i e v i n g a n x i e t y which w i l l supplement i n t e r p e r s o n a l techniques which are used? The purpose of t h i s i n v e s t i g a t i o n i s to examine the 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 i n l e s s e n i n g the a n x i e t y of s e l e c t e d p a t i e n t s i n two acute care p s y c h i a t r i c s e t t i n g s . S i g n i f i c a n c e of the Problem Anxie t y i s i m p l i c a t e d both i n the development of, and as a concomitant o f , p h y s i c a l and mental i l l n e s s . The problem of e x c e s s i v e a n x i e t y permeates the f i e l d o f h e a l t h 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 of 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 , coronary ~ heart d i s e a s e , p e p t i c u l c e r and h y p e r t h y r o i d i s m . ^ H i l d e g a r d Peplau, " I n t e r p e r s o n a l Techniques! The Crux of P s y c h i a t r i c Nursing," American J o u r n a l of Nursing, LXII (June, 1962), 53-55--^Edmund Jacobson, Anxiety and Tension C o n t r o l ( P h i l a d e l p h i a : 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 that psychosocial stimuli cause physiological changes which i n turn could lead to precursors and disease.5 Further, psychosocial stimuli may also influence health by impeding recovery and aggravating d i s a b i l i t y , whatever the etiology of the primary disease. Such a psychosocially induced response may be rooted - e.g. i n an intense anxiety over the disease or the situation...° Il l n e s s and h o s p i t a l i z a t i o n frequently are attended by feelings of helplessness, i s o l a t i o n and i n -security. These feelings engender anxiety. Wooldridge, Skipper and Leonard view r e l i e f of s i t u a t i o n a l anxiety as an important area of r e s p o n s i b i l i t y for nursing.' Anxiety i n t e r f e r e s with man's basic need for relaxation so that a l l e v i a t i o n of excessive anxiety i s s i g n i f i c a n t at a l l l e v e l s of health care, from care of the sick to promotion of high l e v e l wellness. Dunn states: """Karen Horney, The Neurotic Personality of Our  Time (New York: W.W. Norton & Company, Inc., 1937), p.41. ^Lennart Levi, "Introduction: Psychosocial Stimuli, Reactions, and Disease," i n Stress and Distress i n  Response to Psychosocial Stimuli, ed. Lennart Levi, Supple-ment No.528 to Acta Medica Scandinavica. CXCI (1972), 12. Ibid., p.20. 7 'Powhatan J. Wooldridge, James K. Skipper and Robert C. Leonard, Behavioural Science, Social Practise  and the Nursing Profession (Cleveland: Press of Case Western Reserve University, 1968), p.10. 4 The need of the mind f o r balance 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 i t s power to solve problems i s p a r a l l e l e d by the need of the body f o r balance 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 of the 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 a n x i e t y i n t e r f e r e s with the i n d i v i d u a l ' s a b i l i t y to meet h i s b a s i c needs and s i n c e the nurse i s 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 of c o n t r o l o f a n x i e t y l i e w i t h i n her p r o v i n c e of r e s p o n s i b i l i t y . Nurses use comfort measures (e.g. the backrub) and i n t e r p e r s o n a l techniques such as those proposed by Peplau and others to Q }o n 12 modify and c o n t r o l a n x i e t y . ' ' ' However, exce s s i v e a n x i e t y remains a major problem which i s most commonly d e a l t with, when rec o g n i z e d , by the use o f t r a n q u i l l i z e r s and s e d a t i v e s . Chemical r e l i e f o f a n x i e t y not only poses 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 i n t e r f e r e with normal sl e e p p a t t e r n s by d i s -r u p t i n g the r a t i o of time spent i n the v a r i o u s phases of o H a l b e r t L. Dunn, High L e v e l Wellness (Washington, D.C.: Mount Vernon P r i n t i n g Company Inc., 1961), p.213. ^Margaret Kaufmann, "Autonomic Responses as Re-l a t e d to Nursing Comfort Measures," Nursing Research, XIII (Winter, 1964), 45-55. "^Peplau, o p . c i t . "'""''Ida Jean Orlando, Dynamic Nurse P a t i e n t R e l a t i o n -s h i p s (New York: G.P. Putnam's Sons, 1961). 12 Joyce Travelbee,, I n t e r p e r s o n a l Aspects of Nurs-i n g , ( P h i l a d e l p h i a : F.A. Davis Company, 1966)1 5 s l e e p . Do nurses unknowingly d i s r u p t the 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 too 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 than i n t e r v e n i n g to promote sl e e p by t a l k i n g with the p a t i e n t to r e l i e v e a n x i e t y or 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 are, f o r the most p a r t , under emphasized by nurses as methods o f r e l i e v i n g a n x i e t y and promoting r e l a x a t i o n . Comfort measures such as the back-rub are assumed to be h e l p f u l , but the r e s u l t s of the i l l scant t e s t i n g which has been done are i n c o n c l u s i v e . Nursing s c i e n c e encompasses a sma l l body of knowledge at the present time. C l e a r l y there i s a need f o r the f u r t h e r development of s c i e n t i f i c n u r s i n g methods i n the area of a n x i e t y c o n t r o l to supplement those methods al r e a d y developed. ^Grace.Foss, "The Cycles of Sleep," Current  Concepts of C l i n i c a l Nursing, ed. Be t t y Bergerson, Vol, 1 ( S t . L o u i s : C.V. Mosby Company, 1°68), p.102. 14 Kaufman, o p . c i t . Chapter 2 REVIEW OF THE LITERATURE Concepts of Anxiety The l i t e r a t u r e d e a l i n g with the s u b j e c t o f a n x i e t y i s overwhelming. There e x i s t a m u l t i p l i c i t y of d e s c r i p t i o n s and d e f i n i t i o n s o f a n x i e t y . The nature and m a n i f e s t a t i o n s of a n x i e t y have been expl o r e d by p h i l o s o p h e r s , n o v e l i s t s , p s y c h o l o g i s t s , p h y s i o l o g i s t s , p s y c h i a t r i s t s and o t h e r s . In t h i s s e c t i o n some p e r t i n e n t concepts of a n x i e t y w i l l be r e -viewed and a model of a n x i e t y presented. P s y c h o a n a l y t i c concepts of a n x i e t y . Freud d e f i n e s p r i m a l and secondary a n x i e t y . 1 Primal a n x i e t y i s t h a t s t a t e of t e n s i o n a r i s i n g from the i n f a n t ' s experience of h e l p l e s s -ness i n r e s o l v i n g l i b i d i n a l p r i v a t i o n . Secondary or ' s i g n a l ' a n x i e t y i s a d e r i v a t i v e of p r i m a l a n x i e t y . C e r t a i n s t i m u l i a s s o c i a t e d with the o r i g i n a l t r aumatic s i t u a t i o n can now t r i g g e r the a n x i e t y response to a l e r t the i n d i v i d u a l to i n t e r n a l or e x t e r n a l t h r e a t . Thus the t h r e a t o f trauma can be a n t i c i p a t e d and d e f e n s i v e a c t i o n taken. The- i n d i v i d u a l l e a r n s mental defense mechanisms which he uses as a means of Sigmund Freud, I n h i b i t i o n s , Symptoms and Anxiety ;-(Londons Hogarth Press, 1936). 6 7 2 coping with a n x i e t y . These mental defenses, as d e f i n e d by Freud, are f o r the most p a r t subconscious, n o n - s p e c i f i c , and automatic so t h a t t h e i r u s e f u l n e s s has l i m i t a t i o n s . I f an i n d i v i d u a l ' s use of defense mechanisms i s i n a p p r o p r i a t e or the mechanisms are inadequate to cope with a g i v e n traumatic s i t u a t i o n , the s i t u a t i o n w i l l be unresolved and a n x i e t y w i l l i n c r e a s e . I f the s i t u a t i o n i s prolonged or the t h r e a t of trauma i s massive the ego can be overwhelmed and emotional i l l n e s s r e s u l t s . Freud b e l i e v e d t h a t a n x i e t y i s a key i n -f l u e n c e i n the emotional development of the i n d i v i d u a l . Arthur'Schmale dea l s with the g e n e s i s o f a f f e c t i v e 4 d i f f e r e n t i a t i o n . He p o s t u l a t e s stages o f awareness and c o r r e l a t i v e a f f e c t s . Anxiety, a c c o r d i n g to Schmale, i s the u n d i f f e r e n t i a t e d , p r i m a l prototype from which the f u l l range of a f f e c t s are d e r i v e d , and r e f l e c t s p s y c h i c awareness o f d i s c o m f o r t or d i s t u r b a n c e of b i o l o g i c a l e q u i l i b r i u m d u r i n g the e a r l i e s t stage - awareness of the newborn. I n t e r p e r s o n a l Concepts of A n x i e t y . Harry Stack S u l l i v a n , l i k e Freud, regarded a n x i e t y as a c r u c i a l f a c t o r Sigmund Freud, Group Psychology and the A n a l y s i s  of the Ego-(New York: Bantam Books, 1965). 3 I b i d . 4 A r t h u r Schmale, "A Genetic View of A f f e c t s , " The P s y c h o a n a l y t i c Study of the C h i l d , eds, Ruth E i s s l e r , et a l . , V o l . 19 (New York: I n t e r n a t i o n a l U n i v e r s i t i e s Press, Inc., 1964), pp. 287-308. 8 i n the development of p e r s o n a l i t y . ^ He maintained t h a t a n x i e t y a r i s e s when an i n d i v i d u a l ' s s e c u r i t y i s threatened i n the context of an i n t e r p e r s o n a l r e l a t i o n s h i p . He con-c e i v e d p e r s o n a l i t y as a system whose c h i e f energy expend-i t u r e i s d i r e c t e d to the r e l i e f of t e n s i o n . F u r t h e r , he i n d i c a t e d t h a t high a n x i e t y i s a s s o c i a t e d with l a c k of e f f i c i e n c y 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 i n t e r -p e r s o n a l r e l a t i o n s h i p s and d i s o r g a n i z e d t h i n k i n g . L e a r n i n g T h e o r i e s o f A n x i e t y . L e a r n i n g t h e o r i s t s r e g a r d d r i v e r e d u c t i o n as an important element i n the l e a r n -i n g p r o c e s s . D r i v e s may a r i s e from primary needs such as hunger or from secondary needs such as the need f o r a n x i e t y r e d u c t i o n . Mowrer has developed a c o n s i d e r a b l e body of theory demonstrating the r e l a t i o n s h i p o f a n x i e t y to l e a r n i n g . ...anxiety i s a l e a r n e d response o c c u r r i n g to ' s i g n a l s ' ( c o n d i t i o n e d s t i m u l i ) . Anxiety i s thus b a s i c a l l y a n t i c i p a t o r y i n nature, and has g r e a t b i o l o g i c a l u t i l i t y i n t h a t i t a d a p t i v e l y motivates l i v i n g organisms to deal with (pre-pare f o r , or f l e e from) traumatic events i n advance of t h e i r a c t u a l o c c u r r e n c e . 0 Mowrer p o s i t s a n x i e t y as an a c t i v a t i n g agent, and r e d u c t i o n of a n x i e t y as a r e i n f o r c i n g agent i n l e a r n i n g , " . . . r e d u c t i o n o f a n x i e t y may serve p o w e r f u l l y to r e i n f o r c e -'Harry Stack S u l l i v a n , The I n t e r p e r s o n a l Theory  of P s y c h i a t r y , eds. H.S. Perry and M.L. Gawel (New York: W.W. Norton & Company, Inc., 1953)' ^O.H. Mowrer, "Stimulus-Response A n a l y s i s o f A n x i e t y , " P s y c h o l o g i c a l Review, XLVI (1931)» 563. 9 b e h a v i o u r 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 o r . 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 t r a i t and a n x i e t y as an e m o t i o n a l s t a t e . A n x i e t y t r a i t r e f e r s t o a n x i e t y proneness i n an i n d i v i d u a l and i s r e l - . a t i v e l y s t a b l e o v e r t i m e . I t a r i s e s from a c o m b i n a t i o n o f the g e n e t i c a t t r i b u t e s and the c u m u l a t i v e l e a r n i n g o f the i n d i v i d u a l . A n x i e t y s t a t e i s the degree o f a n x i e t y ex-p e r i e n c e d by the i n d i v i d u a l a t any g i v e n t i m e . C a t t e l l by 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 s o u r c e s and p e r s o n a l i t y o components i n a n x i e t y which are t r a i t f a c t o r s . 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 weakness; c) s u s p i c i o u s n e s s and p a r a n o i d i n s e c u r i t y ; d) g u i l t proneness; e) t e n s i o n , i d p r e s s u r e , f r u s t r a t i o n l e v e l . Johnson and S p e i l b e r g e r d e f i n e the two v e r y d i f f e r e n t 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 and I.H. S c h e i e r , "The Nature o f A n x i e t y : A Review 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 Com-p 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 , IV (1958), 351-88. Q yR.B. C a t t e l l , "Advances i n Measurement o f Neur-oti'cism and 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 Theory," A n n a l s o f t h e New Yo r k Academy o f S c i e n c e , x c n (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 t o which i n d i v i d u a l s are d i s p o s e d to m a n i f e s t A-..n s t a t e i n response to v a r i o u s forms o f s t r e s s . P h y s i o l o g i c a l and B i o c h e m i c a l A s p e c t s o f A n x i e t y . P s y c h o s o c i a l c oncepts 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 o f a c t u a l o r p o t e n t i a l t h r e a t s to h i s s e c u r i t y . 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 are r e l e v a n t t o the concept o f a n x i e t y s i n c e they are concerned w i t h the p h y s i o l o g i c a l r e s p o n s e s o f organisms when c h a l l e n g e d t o adapt. Cannon i n v e s t i g a t e d the r o l e o f the thalamus .and hypothalmus i n i n t e g r a t i n g autonomic a c t i v i t y and n o t e d the i mportance o f the s y m p a t h e t i c - a d r e n a l system i n m a i n t a i n i n g h o m e o s t a s i s . 1 1 He d e s c r i b e s the f e a r - a n g e r response t o t h r e a t as a n a t u r a l defense o f the organism. He n o t ed the p h y s i c a l m a n i f e s t a t i o n s o f the response a c t i v a t e d by the s y m p a t h e t i c - a d r e n a l system - i n c r e a s e d p u l s e r a t e , i n c r e a s e d a r t e r i a l p r e s s u r e , sugar r e l e a s e d from r e s e r v e s i n the l i v e r , a d r e n a l i n s e c r e t e d by the a d r e n a l m e d u l l a , e t c . S e l y e proposes a n o n - s p e c i f i c t h e o r y o f s t r e s s Dale T. Johnson 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 the Passage 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 P s y c h o l o g y , XXIV (1963), 20. W a l t e r Cannon, The Wisdom o f the Body (London: Kegan P a u l , Trench, Trubner & Co., L t d . , 1932). as a General A d a p t a t i o n Syndrome to n o n - s p e c i f i c s t r e s -12 so r s . The G.A.S. i s a p h y l o g e n e t i c a l l y o l d defense pre-p a r i n g the organism to meet challenge 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 -v o l v e s b r a i n , nerves, p i t u i t a r y , t h y r o i d , a d r e n a l s , l i v e r , kidney, blood v e s s e l s , connective t i s s u e , white blood 13 c e l l s . J In c o n t r a d i s t i n c t i o n to the n o n - s p e c i f i c theory both Lacey and Malmo and t h e i r a s s o c i a t e s have demonstrated some evidence o f i n d i v i d u a l d i f f e r e n c e s i n response and suggest t h a t p a t t e r n s of autonomic r e a c t i v i t y are i n -h e r i t e d . 1 ^ ' ^ 1 6 The evidence of m u l t i f o c a l p h y s i o l o g i c a l and bi o c h e m i c a l 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 i s mani-f o l d . 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 the common a s s o c i -a t i o n o f i n c r e a s e d muscle t e n s i o n and a n x i e t y . Jacobson 1 2 H a n s Selye, The S t r e s s o f L i f e (New York: McGraw-H i l l Book Company, 1956). 1 3 I b i d . 14 John I. Lacey and Ruth Van Lehn, " D i f f e r e n t i a l Emphasis i n Somatic Response to S t r e s s , " Psychosomatic  Medicine, XIV (March - A p r i l , 1952), 71-81. * 5 J . I , Lacey and Beatrice C. Lacey, " V e r i f i c a t i o n and Ex t e n s i o n o f the P r i n c i p l e o f Autonomic Response Stereotypy," American J o u r n a l o f Psychology, LXXI (March, :1958), 50-73. 1 6 R.B. Malmo and R.C. Shagrass, " 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 , " Psychosomatic Medicine, XI (Jan.-Feb., 1949), 50-73. 12 d e f i n e s a n x i e t y i n terms of t e n s i o n and says t h a t smooth and s t r i a t e d muscle t e n s i o n p a t t e r n s mark the emotional r e -17 a c t i o n i n which v i r t u a l l y the whole organism p a r t i c i p a t e s . F e r r i s N. P i t t s l i s t s the f o l l o w i n g somatic symptoms of a n x i e t y n e u r o s i s i n a study of 60 p a t i e n t s - p a l p i t a t i o n s , b r e a t h l e s s n e s s , chest p a i n , s i g h i n g , d i z z i n e s s , f a i n t n e s s , headache, p a r e s t h e s i a s , weakness, trembling, shakiness, e t c . While somatic symptoms are 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 of the autonomic system i t must be r e c o g n i z e d t h a t these symp-toms w i l l vary with the balance of sympathetic and para-sympathetic subsystems and a c c o r d i n g to the l e v e l and dur-a t i o n of a n x i e t y . For example the person i n panic may e x h i b i t p a l l o r while the person a t a l e s s e r l e v e l of a n x i e t y may e x h i b i t f l u s h i n g . S i m i l a r l y a c u t e l y anxious i n d i v i d u a l s have dry mouths while i n d i v i d u a l s with c h r o n i c a n x i e t y may e x h i b i t e x c e s s i v e s a l i v a t i o n . Mahl suggests t h a t acute a n x i e t y i s a s s o c i a t e d w i t h sympathetic dominance and c h r o n i c 19 a n x i e t y i s accompanied by parasympathetic dominance. J"'Edmund Jacobson, A n x i e t y and Tension C o n t r o l ( P h i l a d e l p h i a : J.B. L i p p i n c o t t Company, 1964), p.X. 1 Pi F e r r i s N. P i t t s , "The Biochemistry of A n x i e t y , " S c i e n t i f i c ' American, CCXX (February, 1964), 69-75-19 7G.F. Mahl, " R e l a t i o n s h i p Between Acute and Chronic Fear and the G a s t r i c A c i d i t y and Blood Sugar L e v e l s i n Macaca M u l a t t a Monkeys," Psychosomatic Medicine, XIV (May-June, 1952), 182-210. 13 As Cannon theorized, anxiety response i s associ-ated with a c t i v a t i o n of sympathoadrenomedullary and adreno-c o r t i c a l systems. Stimulation of the sympathetic adrenal system leads to a marked increase i n adrenalin and nor-adrenalin i n the blood. Increased catecholamine excretion i n individuals i n anxiety evoking situations has been 20 21 22 demonstrated i n numerous studies. ' ' Urinary ex-cretion of catecholamines r e f l e c t s t h e i r release i n a con-sistent way. These and other pertinent findings have been 23 24 reviewed and summarized elsewhere. C l i n i c a l and lab-oratory 'studies have also shown increases i n adrenal c o r t i c a l a c t i v i t y with stress induced by psychosocial stimuli such 20 J. Mendelson et a l . , "Catecholamine Excretion and Behaviour During Sensory Deprivation," Archives of  General Psychiatry, II (January, I960), 37. 21 Lennart Levi, "The Urinary Output of Adrenalin and Noradrenalin During Different Experimentally Induced Pleasant and Unpleasant Emotional States," Psychosomatic  Medicine, XXVII (January - February, 1965), 80-85. 22 W.W. Tolson et a l . , "Urinary Catecholamine Responses Associated with Hospital Admission i n Normal Human Subjects," Journal of Psychosomatic Research, VIII (Number 4, 1965), 365* 23 -'S.S. Kety, "Catecholamines i n Neuropsychiatric States," Pharmacological Review, XVIII (Number 1, Part 1, 1966), 787. 24 Jan Froberg et a l . , "Physiological and Bio-chemical Stress Reactions Induced by Psychosocial Stimuli," Society, Stress and Disease, ed. Lennart Levi (London: Oxford University Press, 1971), pp. 280-295. 14 as hospital admission and psychiatric interviews. 2^» 2^» 27, 28 Conversely reduction i n s t r e s s f u l stimuli or provision of soothing stimuli has been accompanied by decrease i n adrenal 29 30 c o r t i c a l a c t i v i t y . 7 1 J Rubin and Mandell reviewed manifes-t a t i o n of medullary stimulation associated with anxiety.^ 1 Mason has reviewed research into the pituitary-adrenal and the p i t u i t a r y - t h y r o i d systems a c t i v a t i o n i n response to s t r e s s f u l 2S ^Gregory Pxncus and Hudson Hoagland, Adrenal C o r t i c a l Responses to Stress i n Normal Men and i n those with Personality,Disorders," American Journal of Psychiatry, CVI (February - March, 1950), 641-50. 26 J.W. Mason et a l . , "Corticosteroid Responses to Hospital Admission," Archives of General Psychiatry, XIII (January, 1959), 1-8. 2 7H. Persky et a l . , "Effect of Two Psychological Stresses on Adrenocortical Function," Archives of Neurology, LXXXIII (February, 1959), 219. oo F.C. Barter and C.S. Delea, "A Map of Blood and Urinary Changes Related to Circadian Variations i n Adrenal C o r t i c a l Function i n Normal Subjects," Annals of  the New York Academy of Science, XCVIII (October 30, 1970), 969-83. 29 'J.H. Handlon et a l . , "Psychosocial Factors Lowering Plasma 17-hydroxycorticosteriod Excretion During S t r e s s f u l L i f e Experiences i n Man," Psychosomatic Medicine, XXIV (November - December, 1962), 535-42. 30 J Frances L. Pride, "An Adrenal Stress Index as a C r i t e r i o n Measure for Nursing," Nursing Research, XVII (July - August, 1968), 292-303. 3 1R.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 Pathological Emotional States," American Journal  of Psychiatry, CXXIII (October, 1966), 381-400. 3 2 , 3 3 . 3 4 expenences. ' J J ' J Manifestations of Anxiety From the foregoing and from a multitude of other a r t i c l e s and books by authors from a variety of d i s c i p l i n e s one can conceptualize anxiety as a behaviour involving the organism as a whole and a l l the subsystems of the organism. Anxiety i s thus manifest i n terms of physiological, psycho-motor, a f f e c t i v e , cognitive and s o c i a l behaviour. Physiological Manifestations of Anxiety. Many studies have been c i t e d dealing with Physi o l o g i c a l -biochemical manifestations of stress i n the previous section. As mentioned responses vary with the duration and int e n s i t y of stress and according to the organism's i n -div i d u a l patterns of responses. Physiological manifestations of anxiety can include increased muscle tension, increased pulse rate, hyperven-t i l a t i o n , d i l a t e d pupils, dry mouth, flushing or paling, sweating ( p a r t i c u l a r l y palmar), frequency of, or involuntary, 3 2 J J.W. Mason, "A Review of Psychoendocrine Research on the Pituitary-adrenal C o r t i c a l System," Psychosomatic  Medicine, XXX (September-October, 1968), 5 7 6 - 6 0 7 . 33J.W. Mason, "A Review of Psychoendocrine Research on the Sympathetic-adrenal Medullary System," Psychosomatic  Medicine, XXX (September-October, 1 9 6 8 ) , 6 3 1 - 6 5 3 . • 3 k J 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. 1 6 m i c t u r i t i o n and d e f e c a t i o n , and i n c r e a s e d g a s t r i c s e c r e -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 , w h i c h a l s o r e f l e c t autonomic a c t i v a t i o n are i n c r e a s e d l e v e l o f serum and u r i n a r y c o r t i c o s t e r i o d s and c a t e c h o l a m i n e s , i n c r e a s e d 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 d e c r e a s e d s e c r e t i o n o f sodium, i n c r e a s e d e r y t h r o c y t e s e d i m e n t a t i o n r a t e , and i n -crease- .In plasma 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 s t u d i e s show l e s s a l p h a a c t i v i t y i n p e r s o n s s u f f e r i n g a n x i e t y s t a t e s as compared t o normal s u b j e c t s . - ^ Psychomotor M a n i f e s t a t i o n s o f A n x i e t y . The a u t o -m a t i c defense o f the f e a r f u l , a n x i o u s i n d i v i d u a l a g a i n s t p e r c e i v e d t h r e a t i s the p r e p a r a t i o n f o r the " f i g h t o r f l i g h t " r e s p o n s e , which i s most e a s i l y o b s e r v e d i n the psychomotor system. U n r e s o l v e d e x c e s s i v e muscle t e n s i o n i s shown i n -5 < -^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 the  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 , Psycho-pharmacology S e r v i c e Centre ( B e t h e s d a , M a r y l a n d : N a t i o n a l I n s t i t u t e o f M e n t a l H e a l t h , 1963). A r n o l d . H . Buss, P s y c h o p a t h o l o g y (New York: John W i l e y and Sons, I n c . , 1966), p. 51T - ^ 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 American, CCXX ( F e b r u a r y , 1969), 69-75. --^Froberg, op. c i t . 3^A.L. Brockway e t a l . , "The Use o f a C o n t r o l Popu-l a t i o n i n N e u r o p s y c h i a t r i c R e s e a r c h ( P s y c h i a t r i c , Psycho-l o g i c a l and E.E.G. E v a l u a t i o n o f a Heterogeneous Sample)," American 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 , 1954), 248-62. 17 random, r e s t l e s s movements; muscular incoordination; pac-ing; squirming; trembling or shaking; and f a c i a l t i c s . Rapid, higher pitched, sometimes stuttering speech marks the vocal patterns of the anxious i n d i v i d u a l . Individuals i n the panic state may physically harm themselves or attack 41 others. If psychomotor responses are further disorgan-ized the person may "freeze". The overvigilant and over-aroused state of excessive anxiety tends to cause the person to over-react to stimuli with a resultant "jumpiness" and exaggerated tendency to s t a r t l e . A f f e c tive Manifestations of Anxiety. Perhaps the best descriptions of the a f f e c t i v e manifestations of anxiety are to be found i n f i c t i o n and philosophic essays. In Kafka's The Castle shapeless, dreadful forces threaten the 42 i n d i v i d u a l and f i l l him with anxiety. Kierkegaard, as other e x i s t e n t i a l writers, considers anxiety as an ines-capable aspect of the human condition. In The Concept of  Dread Kierkegaard explores the extreme anxiety 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 , facing the freedom to choose 40 Buss, op.cit. 41 Turner, op.cit. 42 Franz Kafka, The Castle, trans, by Willa and Edwin Muir (New York: Alfred A Knopf, 1954). 18 and having to accept r e s p o n s i b i l i t y f o r h i s d e c i s i o n s . J A f f e c t i v e m a n i f e s t a t i o n s run the gamut from un-eas i n e s s through f e a r , dread, h o r r o r and t e r r o r a c c o r d i n g LL to the l e v e l o f a n x i e t y experienced. The h i g h e r the l e v e l o f a n x i e t y the more immediate the f e a r . The person i n panic i s i n t e r r o r o f h i s imminent death or d i s f i g u r e -ment or complete l o s s o f c o n t r o l . L e s s e r f e a r s i n c l u d e f e a r o f f a i l u r e , f e a r o f l o s s o f a s i g n i f i c a n t person, f e a r o f making a f o o l o f o n e s e l f , e t c . Fear may o f t e n he un-focussed and be presen t as a g e n e r a l f e e l i n g o f t e n s i o n and apprehension. In ex c e s s i v e a n x i e t y the l e v e l o f f e a r i s d i s p r o p o r t i o n a t e t o the degree o f t h r e a t . Phobias are an extreme example of u n r e a l i s t i c , d i s p r o p o r t i o n a t e f e a r . C o g n i t i v e M a n i f e s t a t i o n s o f An x i e t y . Peplau has c a t e g o r i z e d c o g n i t i v e aspects as r e l a t e d to degree of L< a n x i e t y . J M i l d a n x i e t y i n c r e a s e s the i n d i v i d u a l ' s aware-ness and a l e r t s h i s a t t e n t i o n . As a n x i e t y i n c r e a s e s i n i n -t e n s i t y the p e r c e p t u a l f i e l d i s reduced so t h a t focus i s on a d e t a i l o r s c a t t e r e d d e t a i l s . The person m a n i f e s t s s e l e c -t i v e i n a t t e n t i o n sometimes to the p o i n t o f d i s s o c i a t i o n i n 43 -"Soren Kierkegaard, The Concept of Dread, t r a n s . Walter Lowrie ( P r i n c e t o n : P r i n c e t o n U n i v e r s i t y Press, 1957). 44 Turner, o p . c i t . 45 H i l d e g a r d Peplau, I n t e r p e r s o n a l R e l a t i o n s i n  Nursing (New York: G.P. Putnam's Sons, 1952). 19 p a n i c s t a t e s . L e a r n i n g i s e f f i c i e n t i n m i l d a n x i e t y but i s d i s r u p t e d as a n x i e t y i n c r e a s e s . The i n d i v i d u a l i s d i s -t r a c t i b l e and f o r g e t f u l . Recent memory i s most impaired. Thought content may be concerned with death, m u t i l i a t i o n , d e s t r u c t i o n , d i s a s t e r , i l l n e s s , p a i n , r e j e c t i o n , h u m i l i a t i o n , f a i l u r e . 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 going crazy when a n x i e t y i s severe. Nightmares are not un-46 common. S o c i a l Manifestations o f Anxiety. Harry Stack S u l l i v a n has d e s c r i b e d the maladaptive i n t e r p e r s o n a l man-i f e s t a t i o n s o f a n x i e t y . ' Once again these vary a c c o r d i n g to the l e v e l and c h r o n i c i t y of the response. Perhaps the most common aspect however, i s the tendency to withdraw from s o c i a l i n t e r c o u r s e which r e f l e c t s the f l i g h t aspect o f r e s -ponse to p e r c e p t i o n o f t h r e a t . Another important aspect i s overdependency on ot h e r s because of f e e l i n g s o f i n s e c u r i t y , inadequacy and f e a r o f f a i l u r e . T h i s overdependency r e s u l t s i n d i f f i c u l t y with peer r e l a t i o n s h i p s and with a u t h o r i t y r e l a t i o n s h i p s . D i f f e r e n c e s i n c r o s s - c u l t u r a l l e v e l s o f a n x i e t y 48 have been demonstrated. F a c t o r a n a l y s i s o f c u l t u r e s with 46 Buss, l o c . c i t . 47 ' S u l l i v a n , l o c . c i t . 48 C. M o r r i s and L.V. Jones, "Value S c a l e s and Dimensions," J o u r n a l o f Abnormal and S o c i a l Psychology. LI (1955), 523 I35T :  20 compar.atively high a n x i e t y l e v e l s of the populace r e v e a l e d the f o l l o w i n g c h a r a c t e r i s t i c s : 1. Low standard o f l i v i n g . 2. Lack of emphasis on education. 3 . Lack of p o l i t i c a l and s o c i a l emancipation. 4. C e n t r a l i z e d a u t h o r i t a r i a n s t r u c t u r e . Of the c o u n t r i e s s t u d i e d the a n x i e t y l e v e l from h i g h e r to lower was as f o l l o w s - I n d i a , China, Japan, Norway, U.S.A. A Model f o r A n x i e t y . While a model i s a s i m p l i f i c a t i o n of r e a l i t y i t can a s s i s t i n demonstrating a complicated concept i n an o r g a n i z e d f a s h i o n and i n showing antecedents and consequences. A model can a l s o c l a r i f y the choice of i n t e r v e n t i o n s to p r e -vent or modify d i s o r d e r and the choice of i n d i c e s to measure the success of the i n t e r v e n t i o n . The model shown i n F i g u r e 1 i s d e r i v e d from the f o r e g o i n g concepts and m a n i f e s t a t i o n s of a n x i e t y and i s an a d a p t a t i o n of a model f o r p s y c h o s o c i a l l y mediated d i s e a s e developed by L e v i . ' B i o p s y c h o s o c i a l S t i m u l i , These s t i m u l i may a r i s e from the i n n e r or o u t e r environment of the i n d i v i d u a l and i n c l u d e e l e c t r o l y t e i n b a l a n c e , p a i n , sensory d e p r i v a t i o n or o v e r l o a d , e m o t i o n a l l y charged s i t u a t i o n s , i n n e r c o n f l i c t , e t c . ^Lennart L e v i , (ed.), " 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 , " Supplement No. 528 to A c t a Medica Sc a n d i n a v i c a , CXCI (1972), 12. P s y c h o -B i o -S o c i a l S t i m u l i P s y c h o -B i o l o g i c a l P r o g r a m m e ( h e r e d i t y a n d e n v i r o n -m e n t ) P e r c e i v e d T h r e a t o r C h a l l e n g e A n x i e t y R e s p o n s e P h y s i o l o g c a l P s y c h o m o t o r A f f e c t i v e C o g n i t i v e S o c i a l D e f e n s e M e c h a n i s m s M e n t a l P h y s i c a l I N T E R A C T I N G V A R I A B L E S i n t r i n s i c • p h y s i c a l e n v i r o n m e n t e x t r i n s i c s o c i a l e n v i r o n m e n t c u l t u r e F i g u r e 1. A M o d e l f o r A n x i e t y ( A d a p t e d f r o m L e v i ' s m o d e l f o r p s y c h o s o c i a l l y m e d i a t e d d i s e a s e ) . * * L e n n a r t L e v i , ( e d . ) , " S t r e s s a n d D i s t r e s s i n R e s p o n s e t o P s y c h o s o c i a l S t i m u l i , " S u p p l e m e n t N o . 528 t o A c t a M e ' d i c a Scandinavica,' C X C I (1972), 12. ro Any o f these s t i m u l i may become a " s t r e s s o r " i n S e l y e ' s t e r m i n o l o g y . ^ In f a c t , any b i o - p s y c h o s o c i a l change can a c t as a s t r e s s o r i n s o f a r as i t c h a l l e n g e s the i n d i v i d u a l to adapt and i s thus a p o t e n t i a l t h r e a t to homeostasis. P s y c h o b i o l o g i c a l Programme. Each i n d i v i d u a l has 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 are determined by g e n e t i c f a c t o r s and " l e a r n e d " f a c t o r s induced by e a r l i e r environmental i n f l u e n c e s . ^ "Learned" i n t h i s sense means a l l forms o f changed behaviour from s u b - c e l l u l a r to organismic. While o v e r a l l p a t t e r n s may be n o n - s p e c i f i c , these p a t t e r n s may be m o d i f i e d i n each i n d i v i d u a l so t h a t p a t t e r n s are both p h y l o g e n e t i c and o n t o g e n t i c . Selye's theory o f the General A d a p t a t i o n Syndrome d e s c r i b e the organism's g e n e r a l response to n o n - s p e c i f i c s t r e s s o r s . Lacey and a s s o c i a t e s show i n s t a n c e s of i d i o s y n c r a t i c o r -g a n i z a t i o n o f response i n s e v e r a l s t u d i e s . ^ P e r c e i v e d Threat or Challenge. The i n t e r a c t i o n of c e r t a i n s t i m u l i with the p s y c h o b i o l o g i c a l programme of an i n d i v i d u a l r e s u l t s i n the p e r c e p t i o n (which may be con-5°Selye, o p . c i t . p.64 5 1 l D i d <  5 2 I b i d . 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 of Comparative P h y s i o l o g i c a l Psychology. XLIII (1950), 338-50. 54 Lacey and VanLehn, o p . c i t . 23 s c i o u s or subconscious) of t h r e a t or c h a l l e n g e to the s t a t u s quo. These t h r e a t s may be conceived as b i o l o g i c a l or psycho-s o c i a l and may be i n the form of unmet needs, danger s i g n a l s , c o n f l i c t , t h r e a t of l o s s , or even the c h a l l e n g e of change. P e r c e p t i o n of t h r e a t or c h a l l e n g e may be r e a l i s t i c or u n r e a l -i s t i c depending upon the p s y c h o b i o l o g i c a l programme and some of the 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 be d e s c r i b e d l a t e r . 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 which augments the p r o p e n s i t y to p e r c e i v e t h r e a t s i n any g i v e n s i t u a t i o n . A n x i e t y Response. Anxiety response i s the equiva-l e n t of a n x i e t y s t a t e as d e f i n e d by C a t t e l l i n p s y c h o l o g i c a l terms. I t i s a m u l t i f a c e t e d behavior with p h y s i o l o g i c a l , psychomotor, a f f e c t i v e , c o g n i t i v e and s o c i a l components. The i n d i v i d u a l i s a l e r t e d to meet the p e r c e i v e d t h r e a t or c h a l -lenge. The c e r e b r a l ' c o r t e x i s a c t i v a t e d v i a the r e t i c u l a r 55 a c t i v a t i n g system. The autonomic nervous system i s a c t i v a t e d as the organism prepares f o r f i g h t or f l i g h t . Blood v e s s e l s i n muscles d i l a t e and g e n e r a l muscle tone i n c r e a s e s . As Lader notes the i n c r e a s e d l e v e l of a c t i v a t i o n i s intended to enable the organism to r e a c t a p p r o p r i a t e l y to t h r e a t . However, exc e s s i v e 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 maladaptive. -^M.H. Lader and Lorna Wing, P h y s i o l o g i c a l Measures, Sedative Drugs, and Morbid Anxie.ty (London: Oxford Univer-s i t y Press, 1966) p.12 . ^ 6 I b i d , p.1 6 . 2k Individual differences:',in t o t a l pattern of response are exhibited. Some persons show predominance of response i n one or several response systems, i . e . - one person may react primarily i n the psychomotor and cognitive systems while another person might show predominance i n the somatic system (with gastro i n t e s t i n a l , genito urinary, respiratory or cardio-5 7 vascular complaint). A f f e c t i v e responses were not eval-uated i n the research c i t e d . Defense Mechanisms. The alerted anxious i n d i v i d u a l responds to perceived threat by the use of various defense mechanisms both physical and mental. These may be automatic, or conscious and deliberate. A l l can be conceived of i n terms of f i g h t or f l i g h t - of confronting the threat or of avoiding the issue. Psychological defenses against threat include the c l a s s i c Freudian mental defense mechanisms, which are forms of f l i g h t by denial of r e a l i t y , i n terms of repression, sup-pression, substitution, sublimation, projection, r a t i o n a l -i z a t i o n , etc., as well as the f i g h t equivalent of conscious problem solving or working through the threat. Habituation i s a physiological defense mechanism which the organism uses to adapt to successive i d e n t i c a l 5 7 A.H. Buss, "Two Anxiety Factors i n Psychiatric Patients," Journal of Abnormal and Social Psychology. LXV (December, 1962), 426-27. 25 s t i m u l i by p r o g r e s s i v e l y d i m i n i s h e d r e s p o n s e . ^ N e u r o l o g i c a l and b i o c h e m i c a l processes of a d a p t a t i o n are l a r g e l y dependent 5 9 upon the p s y c h o b i o l o g i c a l programme of the i n d i v i d u a l . 7 I n t e r a c t i n g V a r i a b l e s . I n t e r a c t i n g v a r i a b l e s are i n t r i n s i c and e x t r i n s i c f a c t o r s which i n f l u e n c e ( i . e . a l t e r the a c t i o n ) of a l l other p a r t s of the model. These v a r i a b l e s tend to promote, or d i m i n i s h , or prevent a n x i e t y . As L e v i notes there i s some d i f f i c u l t y i n demarking p a r t s of h i s model, so i n the present adapted model there i s such marked i n t e r a c t i o n between p a r t s t h a t demarcation i s exceedingly 6o d i f f i c u l t . Consequently some of the v a r i a b l e s could a l s o be considered as s t i m u l i or as forms of defense. E x t r i n s i c f a c t o r s can be p h y s i c a l , p s y c h o s o c i a l , or s o c i o c u l t u r a l . Heat, n o i s e , sensory d e p r i v a t i o n and overcrowding are examples of p h y s i c a l f a c t o r s p r e d i s p o s i n g to i n c r e a s e a n x i e t y . M o r r i s 6 l and Jones r e s e a r c h d i s c l o s e d c u l t u r a l f a c t o r s a s s o c i a t e d with h i g h l e v e l s of a n x i e t y . S o c i o c u l t u r a l f a c t o r s i n f l u e n c e the p s y c h o b i o l o g i c a l programme i n determining what s t i m u l i -^Lader, o p . c i t . , p.13-14. 59 - " R i c h a r d Lazarus, "The Concepts of S t r e s s and Disease,'" i n 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), p.57. 6o L e v i , o p . c i t . , p.19. M o r r i s and Jones, o p . c i t . 26 are p e r c e i v e d as t h r e a t s or c h a l l e n g e s . S o c i o c u l t u r a l r e -sources a l s o a s s i s t i n d i v i d u a l s i n coping w i t h a n x i e t y . Group support, r i t u a l s , r e l i g i o n s and p h i l o s o p h i c a l b e l i e f s and p r a c t i s e s , h e a l t h care, education, and r e c r e a t i o n are g e n e r a l areas of such r e s o u r c e s . Teaching the r e l a x a t i o n technique i n v e s t i g a t e d i n t h i s study i s a s p e c i f i c example of a n u r s i n g i n t e r v e n t i o n as an i n t e r a c t i n g v a r i a b l e which may modify a n x i e t y . I n t r i n s i c v a r i a b l e s a r i s e from the immediate p h y s i c a l and p s y c h o l o g i c a l s t a t u s of the i n d i v i d u a l . Is he c o n c e n t r a t -i n g or r e l a x e d ? Is he t i r e d , angry, depressed, o p t i m i s t i c ? Is h i s serum l a c t a t e e l e v a t e d from e x e r c i s e ? D i e t , drugs, a l c o h o l , age, sex, pregnancy, presence or absence of d i s e a s e are a l l i n t r i n s i c v a r i a b l e s i n f l u e n c i n g a l l p a r t s of the model. D e f i n i t i o n of Anxiety. From examination of the model a d e f i n i t i o n of a n x i e t y can now be proposed. D e f i n i t i o n ; Anxiety i s a t o t a l organismic response to p e r c e i v e d t h r e a t or challenge a r i s i n g from psycho-bio-s o c i a l s t i m u l i impinging upon the p s y c h o b i o l o g i c a l programme of the i n d i v i d u a l and i n f l u e n c e d by i n t r i n s i c and e x t r i n s i c i n t e r a c t i n g v a r i a b l e s . The response i s c h a r a c t e r i z e d by c o r t i c a l and autonomic a c t i v a t i o n and s u b j e c t i v e f e e l i n g s of p h y s i c a l and p s y c h o l o g i c a l t e n s i o n . Anxiety i s adaptive i n a l e r t i n g the i n d i v i d u a l to the presence of a problem. However, an x i e t y which remains unresolved, o r i n a d e q u a t e l y r e s o l v e d , i s p h y s i o l o g i c a l l y and p s y c h o l o g i c a l l y d i s o r g a n i z i n g and thus 27 maladaptive. P s y c h o p h y s i o l o g i c R e l a x a t i o n Techniques. A review of the l i t e r a t u r e to examine the use of p s y c h o p h y s i o l o g i c methods to c o n t r o l a n x i e t y and to promote r e l a x a t i o n and composure r e v e a l s t h a t these methods have been used i n both E a s t e r n and Western c u l t u r e s f o r c e n t u r i e s . E a s t e r n d i s c i p l i n e s such as Yoga and Zen teach methods of b r e a t h c o n t r o l , p h y s i c a l e x e r c i s e s and mental c o n c e n t r a t i o n l e a d i n g to m e d i t a t i o n and contemplation. These p r a c t i s e s induce s e r e n i t y , a s t a t e d i a m e t r i c a l l y opposite to the a l e r -ted, aroused s t a t e of a n x i e t y . "The Y o g i , " say Marques-62 R i v i e r e , "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 techniques which l e a d to composure and s e r e n i t y have o c c u r r e d w i t h i n the framework of r e l i g i o u s b e l i e f s and more r e c e n t l y i n medical and p s y c h o l o g i c a l c l i n i c a l p r a c t i s e , as w e l l as i n the i n t r o d u c t i o n and p o p u l a r i z a t i o n of e a s t e r n m e d i t a t i o n techniques to the g e n e r a l p u b l i c . M e d i t a t i o n . M y s t i c s i n most r e l i g i o u s systems have employed m e d i t a t i o n as a means to an a l t e r e d s t a t e of con-s c i o u s n e s s . C h r i s t i a n i t y , Judaism and Islam have r e c o r d s of J . Marques-Riviere, T a n t r i k Yoga (London; Rider and Co.), p . 8 1 . 28 branches with well developed practises of m e d i t a t i o n . U J ) ' u Transcendental meditation, an Indian Yoga technique pop-ularized i n the West by Maharishi Mahesh Yogi i s widely practised by members of the general public. The basic elements of Trnascend'ental Meditation are outlined 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 position with eyes closed. By a systematic method that he has been taught, he; .perceives a "suitable" sound or thought. Without attempting to concen-trate s p e c i f i c a l l y on t h i s cue he allows his mind to experience i t f r e e l y , and his thinking, as the p r a c t i t i o n e r s themselves report, r i s e s to a"finer and more creative l e v e l in an easy and natural manner."66 Physiological aspects of meditation have been investigated and are now well documented. Demonstrated physiological responses include reduction i n oxygen con-sumption and carbon dioxide elimination, reduction i n rate and volume of r e s p i r a t i o n , decrease i n blood lactat e l e v e l , slowing of heartbeat, increase i n galvanic skin response, ^ E v e l y n Underhill, Mysticism (London: Methuen and Company, Ltd., 1967). ^Gershon Scholem, Jewish Mysticism (New York: Schocken Books Inc., 196l). ^ J o h n Trimingham, Sufi Orders i n Islam (Oxford: Clarendon Press, 1971)• 6 6Robert K. Wallace and Herbert Benson, "The Physiology of Meditation," S c i e n t i f i c American, CCVT (February, 1972), 80-9^. and i n t e n s i f i c a t i o n o f slow a l p h a waves i n the e l e c t r o -61 68 encephalogram p a t t e r n . The authors suggest t h a t t h i s hypometabolic p a t t e r n , r e p r e s e n t i n g quiescence of the sym-p a t h e t i c nervous system, i s the c o u n t e r p a r t of the "defense alarm" or " f i g h t - o r - f l i g h t " r e a c t i o n d e s c r i b e d by Walter Cannon P r o g r e s s i v e R e l a x a t i o n . One of the foremost proponents of r e l a x a t i o n therapy f o r a n x i e t y r e a c t i o n s and f o r d isease with psychosomatic i m p l i c a t i o n s i s Edmund Jacobson. He has developed a scheme o f P r o g r e s s i v e Re-l a x a t i o n based l a r g e l y on l e a r n i n g theory and systems 69 theory. 7 The s u b j e c t f i r s t l e a r n s to r e c o g n i z e t e n s i o n i n s p e c i f i c muscles and subsequently l e a r n s to r e l a x those muscles at w i l l . Jacobson t e s t s the e f f e c t i v e n e s s by e l e c t r i c a l measurements of the degree of muscle t e n s i o n . ^ 0 He documents a number of case h i s t o r i e s of p a t i e n t s s u f f e r -67 'Wallace and Benson, o p . c i t . 68 Robert K. Wallace, Herbert Benson and A r c h i e F. Wilson, "A Wakeful Hypometabolic P h y s i o l o g i c S t a t e , " American J o u r n a l of P h y s i o l o g y , CCI (September, 1971)» 795-99. 69 yEdmund Jacobson, Anxiety and Tension C o n t r o l , ( P h i l a d e l p h i a : J.B. L i p p i n c o t t Company, 1964). 70 ' Edmund Jacobson, " E l e c t r i c a l Measurements Concerning Muscular C o n t r a c t i o n s (tonus) and the 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 of In-d i v i d u a l s , " American J o u r n a l o f P h y s i o l o g y , CVIII (Septem-ber, 193*). 573-80. • 30 i n g from such c o n d i t i o n s as c o l i t i s , p y l o r i c u l c e r , post coronary i n f a r c t i o n , e a r l y e s s e n t i a l h y p e r t e n s i o n , a n x i e t y and insomnia, e t c . , whom he has t r e a t e d s u c c e s s f u l l y by 71 P r o g r e s s i v e R e l a x a t i o n methods o f t e n s i o n c o n t r o l . R e c i p r o c a l I n h i b i t i o n and Systematic D e s e n s i t i z a t i o n . Joseph Wolpe has extended Jacobson's theory of P r o g r e s s i v e 72 R e l a x a t i o n to a theory of R e c i p r o c a l I n h i b i t i o n . ' Neur-o t i c a n x i e t y can be i n h i b i t e d by a n t a g o n i s t i c p h y s i o l o g i c a l responses. R e l a x a t i o n can be used to d e s e n s i t i z e a n x i e t y -evoking s t i m u l i r e a c t i o n s . In o t h e r words, one can not be both anxious and r e l a x e d a t the same time. Wolpe has e v a l u a t e d the r e s u l t s of R e c i p r o c a l I n h i b i t i o n therapy by measuring symptomatic improvement and by Willoughby ques-t i o n n a i r e scores (a t e s t f o r n e u r o t i c i s m , i . e . p e r s i s t e n t unadaptive a n x i e t y r e a c t i o n ) . Of a t o t a l of 210 p a t i e n t s , 82 (39.0%) were r a t e d "Apparently Cured," 106 {50.5%) were "much Improved," while 7 (3«3%) remained "Unimproved." 7 3 Systematic D e s e n s i t i z a t i o n i s a behaviour mod-i f i c a t i o n therapy u s i n g p r i n c i p l e s of R e c i p r o c a l I n h i b i t i o n . A h e i r a r c h y or a n x i e t y evoking s t i m u l i i s c o n s t r u c t e d and the s u b j e c t i s then c o n d i t i o n e d to c o n t r o l a n x i e t y by r e -71 Jacobson, o p . c i t . 72 Joseph Wolpe, Psychotherapy by R e c i p r o c a l In-h i b i t i o n ( S t a n f o r d : " S t a n f o r d U n i v e r s i t y Press, 1958). 7 3 I b i d . l a x a t i o n while c o n f r o n t i n g the l e a s t a n x i e t y provoking s t i m u l i i n the h e i r a r c h y . The process i s s y s t e m a t i c a l l y r e -peated moving up the s c a l e item by item u n t i l the most an x i e t y provoking s t i m u l i can be t o l e r a t e d . Autogenic T r a i n i n g . Autogenic T r a i n i n g i s a r e -l a x a t i o n technique based on s i x p s y c h o p h y s i o l o g i c e x e r c i s e s d e v i s e d by 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 of a " t r o p h o t r o p h i c response."' Hess d e f i n e s t h i s response as a r i s i n g i n the hypothalamus and r e s u l t i n g i n a g e n e r a l decrease i n sympathetic nervous system a c t i v i t y . ^ Walter Luthe-who developed Autogenic T r a i n i n g as a medical therapy d e s c r i b e s i t as "... a s e l f induced m o d i f i c a t i o n o f c o r t i c o d i e n c e p h a l i c i n t e r r e l a t i o n -76 s h i p s . " ' The e x e r c i s e s are p r a c t i s e d i n a q u i e t non-s t i m u l a t i n g environment with the s u b j e c t l y i n g down with h i s eyes c l o s e d . An a t t i t u d e of "Passive c o n c e n t r a t i o n " i s b e l i e v e d neceasary, as i n m e d i t a t i o n . Luthe found t h a t Autogenic T r a i n i n g r e s u l t e d i n decreased r e s p i r a t o r y r a t e , h e art r a t e and muscle t e n s i o n ; and i n c r e a s e d s k i n r e s i s t a n c e 77 and alpha wave a c t i v i t y . ' ' ^ W o l f g a n g Luthe (ed.), Autogenic Therapy, V o l s . 1-5 (New York: Grune and S t r a t t o n , 1 9 6 9 ) . "^Walter R. Hess, F u n c t i o n a l O r g a n i z a t i o n o f the  Diencephalon (New York: Grune and S t r a t t o n , 1 9 5 7 ) . 76 ' Luthe, o p . c i t . p. 1 1 . 7 7 I b i d . 32 T h e r a p e u t i c Use of R e l a x a t i o n Techniques. The methods d e s c r i b e d above, and m o d i f i c a t i o n s o f these methods have been used i n v a r i o u s treatment s e t t i n g s - p a t r ^ i c u l a r l y i n psychiatry,•• and o b s t e t r i c s . R e l a x a t i o n therapy has a l s o been used i n the treatment of pulmonary t u b e r c u l o s i s , hyper-t e n s i o n , headaches, and asthma. In o b s t e t r i c s the work o f G r a n t l y Dick Read and Fernand Lamaze i s w e l l known.7^*79 T h e i r methods of n a t u r a l c h i l d b i r t h employ b r e a t h i n g and r e l a x a t i o n techniques to ease c h i l d b i r t h . A.A. Earn has developed a therapy which he c a l l s Mental Concentrations ...a p s y c h o l o g i c a l s k i l l i n which the imagin-a t i o n and sugge s t i o n strengthen 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 . T h i s s k i l l i s used by the student to produce a s t a t e o f heightened awareness and purpose. 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 -i n g . He s t a t e s t h a t t h i s method has been e f f e c t i v e i n h e l p i n g i n d i v i d u a l s achieve r e l a x a t i o n and sees i t s u s e f u l n e s s I n -c l u d i n g " r e l i e f o f s t r e s s o f i l l n e s s and improvement i n 81 mental h e a l t h . " H. P r o f f i t t , a nurse at a p s y c h i a t r i c c l i n i c i n 7 8 G r a n t l y Dick Read, C h i l d b i r t h Without Fear, (Toronto: B r i t i s h Book Company~ 1961). 7 9 Fernand 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 (London: Burke P u b l i s h i n g Company, 1958). 80 A.A. Earn, "Mental C o n c e n t r a t i o n : A P s y c h o l o g i -c a l S k i l l , " Canadian Nurse, LIX (June, 1963), 553. 8 l I b i d , p.538. 33 Birmingham, E n g l a n d , has deve l o p e d a method o f r e l a x a t i o n 8 2 t h e r a p y w h i c h he c a r r i e s out w i t h gro.ups o f p a t i e n t s . The p r o c e d u r e c o n s i s t s o f t e a c h i n g the p a t i e n t s t o r e c o g n i z e m u s c u l a r t e n s i o n and the use o f s u g g e s t i o n t h a t they w i l l r e l a x . M u s c l e s are r e l a x e d i n sequence ( i . e . from head t o f e e t ) . Q u e s t i o n n a i r e s were f i l l e d o u t by 50 p a t i e n t s t o determine 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 . 4 l p a t i e n t s b e l i e v e d t h a t the r e l a x a t i o n method had been o f b e n e f i t , 5 thought i t had been o f no b e n e f i t and 4 were u n c e r t a i n whether they had been h e l p e d o r n o t . No o b j e c t i v e a s s e s s -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 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 .(based on Jacobson's and Wolpe's methods) on a n x i e t y - s t a t e which they d e f i n e s As an 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 the autonomic nervous 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 measures d e c l i n e d s i g n i f i c a n t l y i n response t o r e l a x a t i o n t r a i n i n g p r o c e d u r e s . T h e i r c r i t e r i a f o r measurement o f a n x i e t y - s t a t e were s y s -t o l i c b l o o d p r e s s u r e , h e a r t r a t e , and a m o d i f i e d Zuckerman A f f e c t A d j e c t i v e C h e c k l i s t . 8-2C.D. N e a l and H. P r o f f i t t , " R e l a x a t i o n Therapy," N u r s i n g M i r r o r , CXXII (6 May, 1 9 6 6 ) , 114 - 1 6 . -'Dale T. Johnson 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 Passage o f Time on Measures 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 , XXIV ( J a n u a r y , 1968), 20. Crouch i n v e s t i g a t e d the e f f e c t i v e n e s s of r e l a x -a t i o n t r a i n i n g (based on Jacobson's and Wolpe's methods) wit h h o s p i t a l i z e d p s y c h i a t r i c p a t i e n t s i n terms of changes Qh i n maladaptive behaviour. He used tape-recorded d i r e c -t i o n s to teach the technique to s u b j e c t s . The r e l a t i v e e f f e c t i v e n e s s of two schedules of r e l a x a t i o n t r a i n i n g , one being a f i x e d schedule and the o t h e r a p a t i e n t demand schedule, were t e s t e d . The f i x e d schedule group showed s i g n i f i c a n t l o w e r i n g of a n x i e t y l e v e l as measured by the Re v i s e d T a y l o r M a n i f e s t Anxiety S c a l e . A i t k e n s and Henrichs d e s c r i b e a study done at U n i v e r s i t y of M i s s o u r i M e d i c a l Centre to evaluate the e f f e c t i v e n e s s of systematic r e l a x a t i o n as a technique to reduce 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 i n open heart surgery p a t i e n t s . They concludes Less 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 found i n the group t r a i n e d i n r e l a x a t i o n techniques; however, d i f f e r e n c e s were a l s o noted between the groups on s e v e r a l s u r g i c a l s t r e s s , f a c t o r s . Thus, the e f f e c t s o f systematic 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 compli-c a t i o n s were not c l e a r l y d e f i n e d , but the present f i n d i n g s were seen as encouraging. " 5 Budzynski and S t o j v a taught s u b j e c t s deep muscle Paul Crouch, "An I n v e s t i g a t i o n of the E f f e c -t i v e n e s s of R e l a x a t i o n T r a i n i n g with H o s p i t a l i z e d P s y c h i -a t r i c P a t i e n t s " (unpublished 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). 8 ^ L i n d a H. A i t k e n and Theodore F. Henrichs, "Sys-tematic R e l a x a t i o n as a Nursing I n t e r v e n t i o n Technique with Open Heart Surgery P a t i e n t s , " Nursing Research, XX (May-June, 197D, 216. r e l a x a t i o n by biofeedback techniques using an instrument which provided immediate analog i n f o r m a t i o n feedback r e -86 garding l e v e l of muscle t e n s i o n . A f t e r f i v e sessions subjects r e c e i v i n g analog feedback achieved deeper l e v e l s of 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 feed-back or i r r e l e v a n t feedback. The review of 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 of examples of psychophysiologic measures f o r r e l i e v i n g anxiety by promoting r e l a x a t i o n , ranging from the e s o t e r i c p r a c t i s e s of m y s t i c a l r e l i g i o u s sects to current western th 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 " and biofeedback techniques. Many of these methods have been evaluated, using 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 to be e f f e c t i v e . However, only one example' ( A i t k e n and Henrichs) could be found of o b j e c t i v e assess-ment of 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 both i n the a-mount of time r e q u i r e d to l e a r n the technique and i n the amount of 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 Re 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 Autogenic 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 of both teacher and l e a r n e r . Transcendental M e d i t a t i o n i s taught only by s p e c i a l t r a i n e : Thomas H. Budzynski and Johann M. St o j v a , "An Instrument f o r Producing Deep Muscle Relaxation by Means of Analog Information Feedback," Journal of Applied  Behaviour A n a l y s i s , I I (Winter, 1969), 23I - 3 7 . 36 and under the a u s p i c e s o f the S o c i e t y . The use o f b i o f e e d -back t e c h n i q u e s t o t e a c h deep muscle r e l a x a t i o n i s markedly e f f i c i e n t i n terms o f time but r e q u i r e s i n s t r u m e n t a t i o n t o d e l i v e r the b i o f e e d b a c k i n f o r m a t i o n . To be p r a c t i c a l f o r n u r s e s t o use i n a v a r i e t y o f s e t t i n g s a r e l a x a t i o n t e c h n i q u e would need t o be t e a c h -a b l e t o c l i e n t s o f a wide range i n p h y s i c a l and m e n t a l a b i l i t i e s , and i n age span. S i n c e severe a n x i e t y i s accom-p a n i e d by l a c k o f c o n c e n t r a t i o n and a n a r r o w i n g o f the p e r -c e p t u a l f i e l d , the t e c h n i q u e must be s i m p l e and s t r a i g h t f o r w a r d . 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 and 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 system-a t i c t e n s i n g and r e l a x i n g o f muscles meet these c r i t e r i a . Chapter 3 DESIGN AND METHODOLOGY Overview o f the Study Design The g e n e r a l aim of the 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 i n de-c r e a s i n g a n x i e t y i n a p a t i e n t p o p u l a t i o n assumed to ex-peri e n c e e x c e s s i v e a n x i e t y . The independent v a r i a b l e . i s a simple e c l e c t i c technique designed to be taught by nurses. .The dependent v a r i a b l e s measure both p h y s i o l o g i c a l and psy-c h o l o g i c a l parameters o f anxiety.. D e f i n i t i o n of Terms. ( i ) Anxietys An organismic response to per-c e i v e d t h r e a t c h a r a c t e r i z e d by autonomic and c e r e b r o s p i n a l e x c i t a t i o n as w e l l as s u b j e c t i v e f e e l i n g s of apprehension 1 and t e n s i o n . ( i i ) Relaxations An organismic response to per-c e i v e d comfort, s e c u r i t y , o r removal of t h r e a t , c h a r a c t e r -i z e d by decreased sympathetic and c e r e b r o s p i n a l e x c i t a t i o n as w e l l as s u b j e c t i v e f e e l i n g s o f composure and d i m i n u t i o n Anxiety, by t h i s d e f i n i t i o n , i s the e q u i v a l e n t of a n x i e t y s t a t e , as d e s c r i b e d by C a t t e l l , and by Johnson and S p e i l b e r g e r . T h e i r s t u d i e s are o u t l i n e d i n the pr e v i o u s chapter. 37 38 of t e n s i o n . ( i i i ) R e l a x a t i o n Technique; A systematic psycho-p h y s i o l o g i c method o f c o n t r o l l e d b r e a t h i n g f o l l o w e d by r e -l a x i n g of muscle groups, s e q u e n t i a l l y , i n head, arms, trunk and l e g s . Assumptions. ( i ) Most p a t i e n t s admitted to p s y c h i a t r i c u n i t s s u f f e r e x c e s s i v e a n x i e t y . ( i i ) E x c e s s i v e a n x i e t y i s maladaptive. ( i i i ) R e l i e f o f e x c e s s i v e a n x i e t y i s , i n p a r t , the nurse's r e s p o n s i b i l i t y . ( i v ) Nursing methods which promote r e l a x a t i o n can be taught to p a t i e n t s . The Independent V a r i a b l e : A R e l a x a t i o n Technique The review o f the l i t e r a t u r e 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 m o d i f i -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 R e l a x a t i o n and sometimes i n c l u d e b r e a t h i n g c o n t r o l based on Yoga methods. A c c o r d i n g l y the technique used i n t h i s study employs elements of P r o g r e s s i v e R e l a x a t i o n and b r e a t h i n g c o n t r o l . The i n -s t r u c t i o n s were tape-recorded i n order to s t a n d a r d i z e the t e a c h i n g of the technique f o r experimental purposes. The technique i s taught i n a q u i e t environment so t h a t d i s t r a c -t i n g s t i m u l i are minimal. 39 The s u b j e c t i s f i r s t d i r e c t e d i n s i x t i m e d c y c l e s o f slow, smoothly r e g u l a t e d deep b r e a t h i n g . One c y c l e con-s i s t s o f a p p r o x i m a t e l y e q u a l timed phases o f i n s p i r a t i o n , h o l d i n g , and e x 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 the abdominal muscles so t h a t the d i a -phragm f a l l s and a i r i s drawn i n t o the l u n g s as they expand. C o n v e r s e l y , 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 drawing i n ( c o n -t r a c t i n g ) the abdominal muscles so t h a t the diaphragm r i s e s and a i r i s pushed out o f the l u n g s . The i n i t i a l b r e a t h i n g e x e r c i s e s e r v e s 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 p r o c e s s . M uscle groups are t h e n t e n s e d and r e l a x e d i n sequence moving from head, arms, t r u n k , l e g s , t o f e e t . The s u b j e c t i s i n s t r u c t e d t o t e n s e a muscle o r groups o f mus-c l e s , r e c o g n i z e the t e n s i o n , and th e n t o r e l a x the m u s c l e ( s ) as c o m p l e t e l y as p o s s i b l e . The i n s t r u c t i o n s were t a p e - r e -corded i n a s o o t h i n g y e t c o m p e l l i n g v o i c e . There was no attempt t o a v o i d the use o f s u g g e s t i o n . The t e x t o f the r e c o r d e d tape i s i n c l u d e d i n Appendix A. The Dependent V a r i a b l e s S i n c e a n x i e t y i s a t o t a l o r g a n i s m i c response and m a n i f e s t a t i o n s o f a n x i e t y a re e x p r e s s e d i n terms o f 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 b e h a v i o u r i t i s a p p r o p r i a t e t o measure 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 and psycho-l o g i c a l i n d i c e s . There a r e , however, many d i f f i c u l t i e s i n c h o o s i n g i n d i c e s o f a n x i e t y t o t e s t . As L e v i n o t e s , n e i t h e r the s u b j e c t i v e 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 a c c e s s i b l e to d i r e c t measure-2 ment. While a g e n e r a l response to p e r c e i v e d t h r e a t i s w e l l e s t a b l i s h e d i n the review o f the l i t e r a t u r e , there i s a l s o e s t a b l i s h e d evidence o f some degree o f 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 v i d u a l i t y o f response. Furthermore, .. i n the model f o r a n x i e t y presented i n t h i s study and from p e r t i n e n t r e s e a r c h there are many i n t e r r a c t i n g v a r i a b l e s which i n f l u e n c e the course o f events from the i n i t i a l i n t e r -a c t i o n o f b i o p s y c h o s o c i a l s t i m u l i and b i o p s y c h o l o g i c a l pro-gramme to the m a n i f e s t a t i o n s o f the an x i e t y response and the p h y s i c a l and p s y c h o l o g i c a l defenses induced. U r i n a r y Potassium. I n d i r e c t p h y s i o l o g i c a l and bio c h e m i c a l i n d i c e s of s t r e s s i n c l u d e i n c r e a s e s i n muscle t e n s i o n and pulse r a t e : decreases i n alpha wave e l e c t r o e n -cephalogram a c t i v i t y , g a l v a n i c s k i n response and c i r c u l a t i n g e o s i n o p h i l s ; i n c r e a s e s i n serum n o n e s t e r i f i e d f a t t y acids:? and i n c r e a s e d catecholamine and a d r e n o c o r t i c o i d e x c r e t i o n . A v a r i e t y o f d i f f i c u l t i e s are attendant on t h e i r use as measures o f s t r e s s o r a n x i e t y . Some r e q u i r e expensive i n -stru m e n t a t i o n o r complicated l a b o r a t o r y procedures. Many are a n x i e t y provoking, e.g. blood t e s t s . Others are Lennart L e v i , " I n t r o d u c t i o n : P s y c h o s o c i a l Stim-u l i , P s y c h o l o g i c a l 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 Act a Medica S c a n d i n a v i c a . CXCI (1972), 12. -41 strongly affected by extraneous variables.-* Urinary potassium excretion 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 varies according to stress and urinary potassium excretion, i n turn, i s closely t i e d to adrenal c o r t i c a l a c t i v i t y . , J * L. Frances Pride describes a number of c h a r a c t e r i s t i c s of urinary potassium which favour i t s use as a measure of auto-7 nomic ac t i v a t i o n . These include: (a) It i s not affected by serum potassium l e v e l s ; (b) It i s not markedly affected by c a l o r i c r e s t r i c t i o n ; (c) It i s not markedly affected by posture and a c t i v i t y ; (d) Potassium i s stable i n solution so that urine specimens do not require special treatment. M^.H. Lader and Lorna Wing, Physiological Measures, Sedative Drugs, Morbid Anxiety,, (London: Oxford University, 1 9 ^ L Gregory Pmcus and Hudson Hoagland, "Adrenal C o r t i c a l Responses to Stress i n Normal Men and i n Those with Personality Disorders," American Journal of Psychology, CVI (March, 1 9 5 0 ) , 641-60. ^Richard P. Doe et a l . , "Diurnal Variation of 1 7 Hydroxycorticosteriods, Sodium, Potassium, Magnesium and Creatininine i n Normal Subjects and i n Cases of Treated Adrenal Insufficiency and Cushing's Syndrome," Journal of  C l i n i c a l '. Endocrinology and Metabolism, XX (February, I960), 263-65. ; Frederic C. Bartter, Catherine S. Delea and Franz Halberg, "A Map of Blood and Urinary Changes, Related to Circadian Variations i n Adrenal C o r t i c a l Function i n Normal Subjects," Annals of the New York Academy of Science, XCVII (October 3 0 , 1962), 9 6 9 - 8 3 . 7 'L. Frances Pride, "An Adrenal Stress Index as a C r i t e r i o n Measure for 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 general l e v e l of anxiety for that period whereas measures such as galvanic skin response, heart rate and "blood tests represent l e v e l s at b r i e f moments i n time and are further complicated i n some cases by circadian rhythms (blood and urine 17 hydroxy-corticosteriods, sodium, potassium, etc., exhibit duirnal curves). A l l urine potassium te s t i n g f o r the study was carried out by the C l i n i c a l Chemistry D i v i s i o n of the general hospital laboratory. Measurements of 24 hour urinary po-tassium excretion i n millequivalents were made by the stan-dard method of flame photometry using an Instrumentation Laboratories Model 143 Flame Photometer. IPAT Anxiety Scale Questionnaire. This measure i s an e a s i l y administered, widely used 40 item questionnaire. It i s applicable to a l l but the lowest educational l e v e l s and i s appropriate f o r subjects from 14 or 15 years and up. When the subject i s directed to answer the questions accor-ding to how he f e e l s "right-now" the scale measures anxiety-state. It i s claimed to be sensitive to changes i n anxiety l e v e l s due to psychotherapy, medication, change i n si t u a t i o n , wDoe et a l . , op.cit. 9 R.B. C a t t e l l and I.H. Scheier, "Extension of Meaning of Objective Test Personality Factors: E s p e c i a l l y i n Anxiety, Neuroticism, Questionnaire and Physical Factors Journal of General Psychology. LXI (Oct., 1959), 287-315 43 e t c . The s c a l e has a h i g h degree of v a l i d i t y and r e -l i a b i l i t y . C o nstruct ( " i n t e r n a l " ) v a l i d i t y i s estimated a t + .85 to + .90. C l i n i c a l judgements of a n x i e t y and d i a g -n o s t i c c l a s s i f i c a t i o n of p a t i e n t s show s t r o n g c o r r e l a t i o n with IPAT Anxiety Scale r e s u l t s to provide high " e x t e r n a l " v a l i d i t y . R e l i a b i l i t y of the t e s t i s r e p o r t e d as h i g h l y s a t i s f a c t o r y . D e p e n d a b i l i t y - r e l i a b i l i t y c o e f f i c i e n t f o r 11 t e s t - r e t e s t at one week i n t e r v a l was + .93' S e t t i n g of the Study. Three u n i t s (with a t o t a l o f 60 beds) i n a u n i -v e r s i t y h e a l t h s c i e n c e center h o s p i t a l and a 41 bed u n i t i n a l a r g e urban g e n e r a l h o s p i t a l p r o v i d e d the s e t t i n g s f o r the study which took p l a c e i n 1971-72. These s e t t i n g s o f f e r acute care f o r a d u l t p s y c h i a t r i c p a t i e n t s and o f f e r a s i m i l a r range o f treatment m o d a l i t i e s . Both are t e a c h i n g h o s p i t a l s with students from a v a r i e t y of d i s c i p l i n e s - medicine, n u r s i n g , s o c i a l work, r e h a b i l i t a t i o n medicine, e t c . The g e n e r a l h o s p i t a l has p a t i e n t s admitted under the s e r v i c e o f p r i v a t e p s y c h i a t r i s t s , while the h e a l t h s c i e n c e c e n t e r 10 R.B. C a t t e l l and I.H. S c h e i e r , Handbook f o r the  IPAT Anxiety Scale Q u e s t i o n n a i r e (Champaign, I l l i n o i s : In-s 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« 1 : LR.B. C a t t e l l , "Formulae and Table f o r Obtain-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 of Extended 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, XVII ( F a l l , 1957) 491-98. kk patients are treated exclusively by psy c h i a t r i c residents and medical students under the supervision of t h e i r c l i n i c a l d i r e ctors. Since both hospitals are t e r t i a r y care r e f e r r a l centers, patients may come from anywhere i n the Province of B r i t i s h Columbia but are mostly from the metropolitan Van-couver area. The Sample The sample was selected from patients admitted to the adult psychiatric in-patient services described above. C r i t e r i a f o r selection were based upon ( i ) e t h i c a l consider-ations, ( i i ) certain physiological conditions which aff e c t urinary potassium excretion, ( i i i ) psychosocial conditions a f f e c t i n g stress, and (iv) conditions a f f e c t i n g the teach-a b i l i t y of the relaxation method. These c r i t e r i a are: (a) Consent of the patient's physician. (b) Informed consult of the patient as defined 12 by the Ad Hoc Committee on Rights of Human Subjects. (c) 65 years of age or l e s s . Adrenocortical a c t i v i t y i s reported to be lessened i n men over 65 years of age. (d) Absence of the following conditions, (as evidenced by the medical history) a l l of which a f f e c t General Statement of the Ad Hoc Committee on Rights of Human Subjects, University of B r i t i s h Columbia School of Nursing, November 18, 1971. k5 potassium e x c r e t i o n : ( i ) A l k a l o s i s , ( i i ) A c i d o s i s , ( i i i ) Endocrine d i s o r d e r , ( i v ) Kidney pathology, (v) Use o f d i u r e t i c s , ( v i ) Use of s t e r o i d s ( i n c l u d i n g b i r t h c o n t r o l m e d i c a t i o n ) , ( v i i ) R e s t r i c t e d Sodium d i e t , and ( v i i i ) Hypo-h y d r a t i o n . (e) Not menstruating when u r i n e specimens taken. Menstrual b l o o d c o u l d contaminate specimens. ( f ) No change i n p s y c h o t r o p i c medications (sed-a t i v e s , t r a n q u i l l i z e r s , a n t i d e p r e s s a n t s ) d u r i n g the time of the study procedure and f o r three days p r e v i o u s l y . These drugs have marked e f f e c t s on autonomic nervous system 11 f u n c t i o n . J (g) H o s p i t a l i z e d f o r three days or more, at time lA" 1*5 of s e l e c t i o n , to exclude the v a r i a b l e of admission -anxiety. ' (h) E n g l i s h speaking. ( i ) In c o n t a c t with r e a l i t y as i n d i c a t e d by medical h i s t o r y , nurse's notes and d i a g n o s i s ( i . e . d i a g n o s i s other than p s y c h o s i s ) . ±- 5L.S. Goodman and A l f r e d Gilman, Pharmacological  B a s i s o f T h e r a p e u t i c s , 3rd ed. (New York: MacMillan Company, 1965)• ik 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 o f Psychosomatic Research, VIII (Number 3, 1965), 365-1 ^ R o s l y n Elms and R.C. Leonard, " E f f e c t s of Nurs-i n g Approaches During Admission," Nursing Research, XV (Winter, 1966), 39-^8. 46 The p h y s i o l o g i c a l c r i t e r i a a r e drawn from the p r e v i o u s l y 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 the e f f e c t o f an i n t e r p e r s o n a l n u r s i n g approach i n r e l i e v i n g s t r e s s , i n which she employed u r i n a r y p o t a s s i u m l e v e l s as a c r i t e r i o n 16 measure. The t o t a l sample o f 36 s u b j e c t s was drawn from c o n s e c u t i v e a d m i s s i o n s t o the p s y c h i a t r i c u n i t s d e s c r i b e d , who met the above c r i t e r i a f o r s e l e c t i o n . S u b j e c t s who dropped out o f the s t u d y because t h e y were found l a t e r n o t to meet the c r i t e r i a o r because they f a i l e d t o c o l l e c t the u r i n e specimens as d i r e c t e d , were r e p l a c e d i n each case by the n e x t s u b j e c t t o be s e l e c t e d . The ages o f the s u b j e c t s ranged from 21 t o 64 y e a r s w i t h an average o f 43^ 11.60 y e a r s (mean ± one s t a n -d a r d d e v i a t i o n ) . There were 25 females and 11 males. E v i -dence t h a t s u b j e c t s met the c r i t e r i a was d e r i v e d from 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 the c h i e f i n v e s t i g a t o r . Twelve s u b j e c t s were a s s i g n e d to each o f t h r e e groups by 17 randomized b l o c k d e s i g n . I n d i v i d u a l s i n Group 1 ("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 t h e r e l a x a t i o n t e c h n i q u e . I n d i v i d u a l s i n Group 2 ("Placebo") r e c e i v e d e q u i v a l e n t n u r s i n g time devoted t o a p l a c e b o p r o c e d u r e . Group 3 P r i d e , o p . c i t . 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 York: M c G r a w - H i l l Book Company, 1971) 47 ("Control") i n d i v i d u a l s r e c e i v e d the u s u a l ward care but no s p e c i a l approach. The term "Group" denotes s u b j e c t s r e c e i v i n g a s p e c i f i c treatment, but not t h a t s u b j e c t s r e -c e i v e d the s p e c i f i c treatment i n a group. A l l treatments were administered i n d i v i d u a l l y . Treatment and C o n t r o l Methods ;'The design schedule o f 24 hour u r i n e t e s t s , 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 e s t s and a d m i n i s t r a t i o n of r e l a x a t i o n t r a i n i n g or r e l a x a t i o n placebo i s show i n Appendix B . The 24 hour u r i n e specimens were c o l l e c t e d i n a standard manner, i . e . the s u b j e c t voided and d i s c a r d e d u r i n e a t 0800 hours on the f i r s t morning and c o l l e c t e d a l l subsequent v o i d i n g up to and i n c l u d i n g a f i n a l v o i d i n g at 0800 hours on the f o l l o w i n g morning. Subjects were a l l i n t r o d u c e d to the study by the p r i n c i p a l i n v e s t i g a t o r who e x p l a i n e d t h a t she was a grad-uate n u r s i n g student working on a master's t h e s i s . Each s u b j e c t r e c e i v e d the same g e n e r a l e x p l a n a t i o n : "I am con-d u c t i n g a study to measure changes i n s t r e s s over a f i v e day p e r i o d of h o s p i t a l i z a t i o n . " Added to t h i s sentence f o r i n d i v i d u a l s i n the " R e l a x a t i o n " group was the statement, " . . . i n which you 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 p r o-gramme." For I n d i v i d u a l s i n the "Placebo" group the sentence was completed, " . . . i n which you would have r e g u l a r r e l a x a t i o n p e r i o d s . " The g e n e r a l e x p l a n a t i o n continues: " I t w i l l i n -48 volve c o l l e c t i n g a 24 hour urine specimen on the f i r s t day and again on the f i n a l day, as well as answering a b r i e f questionnaire on the same two days. Would you consider taking part i n the study? If you decide to do so you have the option of discontinuing p a r t i c i p a t i o n at any time. Are there any questions you would l i k e to ask?" Subjects were also informed that the r e s u l t s of the tests would be ex-plained to them after the f i n a l r e s u l t s were received. Six assistants as well as the p r i n c i p a l inves-t i g a t o r participated i n i n d i v i d u a l supervision of the "Re-laxation" and "Placebo" treatment sessions, and i n admin-i s t e r i n g the Anxiety Scale Questionnaire. The assistants were senior undergraduate student nurses from the general hospital school of nursing and the university school of nursing. "Assistants received a f u l l explanation of the study and a session of Relaxation Technique t r a i n i n g before taking part. They also received i n s t r u c t i o n regarding the use of the Anxiety Scale Questionnaire. The experimental, schedule began on Monday mornings at 0800 hours and concluded on Saturday mornings at 0800 hours. Each subject i n the study collected a f i r s t 24 hour urine sample from 0800 hours on Day 1, u n t i l 0800 hours on Day 2 and a second sample from 0800 hours on Day 5 to 0800 hours on Day 6. Each subject completed an Anxiety Scale Questionnaire on the Day 1 evening and repeated t h i s test on Friday (Day 5) evening. 49 Ward n u r s e s were n o t i n f o r m e d r e g a r d i n g the group t o which i n d i v i d u a l s u b j e c t s belonged and were r e q u e s t e d t o r e f e r the s u b j e c t s t o the i n v e s t i g a t o r o r her a s s i s t a n t s i f t h e y had f u r t h e r q u e s t i o n s about the s t u d y . The " R e l a x a t i o n " and " P l a c e b o " t r e a t m e n t s e s s i o n s were conducted i n the p a t i e n t ' s own room i f he was i n a s i n g l e room, o r i n a t r e a t m e n t room, o r by a s k i n g the o t h e r p a t i e n t s t o remain out o f the room i f the s u b j e c t was i n a s e m i - p r i v a t e , room and no o t h e r room was available--when needed. The g e n e r a l h o s p i t a l had an a c u t e s h o r t a g e o f space which r e q u i r e d t h e s e l e s s t h a n i d e a l c o n d i t i o n s . Group 1; " R e l a x a t i o n " . Each s u b j e c t i n t h i s group r e c e i v e d the f o l l o w i n g a d d i t i o n a l i n f o r m a t i o n : "A n u r s e , e i t h e r one o f my a s s i s t a n t s o r m y s e l f , s i t s w i t h you w h i l e you f o l l o w t a p e - r e c o r d e d i n s t r u c t i o n s f o r a s i m p l e r e -l a x a t i o n t e c h n i q u e . The t e c h n i q u e c o n s i s t s o f c o n t r o l l e d b r e a t h i n g and s y s t e m a t i c muscle r e l a x a t i o n . You c o n t r o l y o u r b r e a t h i n g by f o l l o w i n g the t i m i n g as d i r e c t e d on the t a p e - r e c o r d i n g 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 o f b r e a t h i n g i n , h o l d i n g i t , and b r e a t h i n g o u t . F o l l o w i n g t h i s you t e n s e m u s c l e s , r e c o g n i z e the t e n s i o n and t h e n r e l a x as f u l l y as p o s s i b l e , moving i n sequence from muscle groups i n the head and neck t o arms, t r u n k , l e g s and f i n a l l y f e e t . You l i e on a bed to do the r e l a x a t i o n e x e r c i s e s which t a k e about t w e l v e m i n u tes p e r s e s s i o n . The s e s s i o n s are h e l d t h r e e t i m e s a day - morning, a f t e r n o o n and e v e n i n g - f o r 50 f o u r days. They are t imed so t h a t they don'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 w i l l a r r ange t o have a q u i e t room where you w i l l n o t be i n t e r r u p t e d . S u b j e c t s i n Group 1 r e c e i v e d " R e l a x a t i o n " Tech-n i q u e t r a i n i n g s e s s i o n s morning, a f t e r n o o n and e v e n i n g on Days 2, 3, H- and 5- The s u b j e c t was t o l d to wear l o o s e c l o t h e s and t o remove h i s shoes f o r each s e s s i o n . The room was s l i g h t l y darkened and a "Do Not D i s t u r b " s i g n was p l a c e d on the door. The s u b j e c t was i n s t r u c t e d t o l a y on h i s back w i t h h i s eyes c l o s e d and as c o m f o r t a b l y as p o s s i b l e . P r i o r t o the i n i t i a l s e s s i o n he was a l s o i n s t r u c t e d to r e l a x h i s abdominal muscles w h i l e b r e a t h i n g i n and t o c o n t r a c t t h e s e muscles w h i l e b r e a t h i n g out and to b r e a t h e smoothly and e v e n l y . I t was s t r e s s e d t h a t i t was u n i m p o r t a n t how " w e l l " the s u b j e c t performed the e x e r c i s e s . The n u rse s i t t i n g 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 t a p e d i n s t r u c t i o n s . The nurse spoke o n l y b r i e f l y w i t h the p a t i e n t b e f o r e and a f t e r the s e s s i o n s e x c e p t f o r c l a r i f i c a t i o n s ( i f r e q u e s t e d ) o f the r e l a x a t i o n t r a i n i n g p r o c e d u r e . Group 2: " P l a c e b o " . S u b j e c t s i n the " P l a c e b o " 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 t h e i r t r e a t m e n t s c h e d u l e . "A n u r s e , e i t h e r one o f ay a s s i s t a n t s or. m y s e l f , s i t s w i t h you w h i l e you r e l a x as deeply- as you are a b l e . You l i e on a bed f o r the r e l a x a t i o n p e r i o d o f t w e l v e m i n u t e s . You have t h r e e r e l a x a t i o n p e r i o d s a day -morning, a f t e r n o o n and e v e n i n g - f o r f o u r days. They are 51 timed so t h a t they don't i n t e r f e r e with your r e g u l a r t r e a t -ment programme. I w i l l arrange to have a q u i e t room where you w i l l not be d i s t u r b e d . " Subjects i n Group 2 r e c e i v e d "Placebo Treatment with the same s c h e d u l i n g and under the same c o n d i t i o n s as the s u b j e c t 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 , but without any i n s t r u c t i o n other than to l i e q u i e t l y and r e l a x . The nurse s i t t i n g with the p a t i e n t a l s o r e l a x e d as much as p o s s i b l e and informed the p a t i e n t when the twelve minutes p e r i o d had passed. Group 3; " C o n t r o l " . Subjects i n the " C o n t r o l " group r e c e i v e d both the standard 24 hour u r i n e t e s t s and Anxiety Scale Q u e s t i o n n a i r e t e s t on Day 1 and Day 5- They r e c e i v e d no treatment o t h e r than the us u a l treatment on the u n i t . They were seen by the i n v e s t i g a t o r o r her a s s i s -t a n t only d u r i n g the request f o r p a r t i c i p a t i o n i n t h i s study, e x p l a n a t i o n o f the c o l l e c t i o n procedure f o r the u r i n e s p e c i -mens and a d m i n i s t r a t i o n o f the Anxiety Scale Q u e s t i o n n a i r e s . S p e c i f i c O b j e c t i v e s o f the Study ( i ) 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 a c t i v a t i o n as r e f l e c t e d by u r i n a r y potassium e x c r e t i o n . ( i i ) 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 b e h a v i o u r a l l e v e l 52 of a n x i e t y as r e f l e c t e d by IPAT Anxiety Scale Q u e s t i o n n a i r e Scores. Hypotheses (1) There 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 changes i n 2k 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 groups r e c e i v i n g " R e l a x a t i o n " t r e a t -ment, "Placebo" treatment and " C o n t r o l " treatment. (2) There 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 changes i n IPAT Anxiety Scale Q u e s t i o n n a i r e scores between groups r e c e i v i n g " R e l a x a t i o n " treatment, "Placebo" t r e a t -ment and " C o n t r o l " treatment. A n a l y s i s o f Data T a b u l a t i o n s were made of u r i n a r y potassium 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 on Day 1 and Day 5 f o r s u b j e c t s i n each group, and changes i n amount noted. S i m i l a r l y , IPAT Anxiety Q u e s t i o n n a i r e Scale scores on Day 1 and Day 5 f o r s u b j e c t s i n each group, and changes i n scores, were t a b u l a t e d . I n s p e c t i o n o f the d i s t r i b u t i o n o f scores r e v e a l e d t h a t the groups have markedly unequal v a r i a n c e s t h e r e f o r e nonparametric t e s t s o f the hypotheses were made. The Kruskal-Wallace One-Way A n a l y s i s o f Variance t e s t s the n u l l h y p o t h e s i s , t h a t "k" independent samples have been drawn 53 from the 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 measured must have a continuous d i s t r i b u t i o n and be, a t l e a s t , an o r d i n a l measurement. The K r u s k a l - W a l l i s method i s termed the most e f f i c i e n t non-parametric t e s t f o r "k" independent samples with a p o w e r - e f f i c i e n c y of 95-5 per cent as compared with the most powerful parametric t e s t , the "F" t e s t . 1 8 with the s m a l l e s t score ranked as 1, the second s m a l l e s t as 2 and so on. The sum of the ranks f o r measures i n each sample i s then computed. The formula f o r the K r u s k a l -W a l l i s t e s t i s : A l l measures i n a l l samples are ranked together k H - 3 (N + 1) samples Rj = sum of ranks i n 3 t h sample k d i r e c t s one to sum over the k samples Sidney Segal, Nonparametric S t a t i s t i c s . (New York: McGraw-Hill Book Company, 1956), 184-194. 54 S t a t i s t i c a l l y , r a n k s a re ex p e c t e d t o be d i s -t r i b u t e d randomly between the groups i f the n u l l h y p o t h -e s i s i s t r u e . F o r samples l a r g e r t h a n 5 the c h i - s q u a r e a p p r o x i m a t i o n t o the 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 adequate and these t a b l e s were used f o r the purpose o f 1 9 the p r e s e n t s t u d y . y Changes i n amount o f p o t a s s i u m ex-c r e t e d i n t w e n t y - f o u r hours and 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 on Day 5 as compared w i t h Day 1 were rank 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 groups b e i n g t e s t e d . The s i z e o f "H" computed was compared w i t h the "Table o f C r i t i c a l V a l u e s o f C h i Square" t o d i s c o v e r whether s i g n i f i c a n t 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 measures, e x i s t e d between the t h r e e groups. When "H" was found t o be l e s s t h a n the t a b l e d v a l u e a t the f i v e p e r c e n t (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 the groups was r e g a r d e d as l a c k i n g s t a t i s t i c a l s i g n i f i c a n c e and the n u l l h y p o t h e s i s was a c c e p t e d . When the n u l l h y p o t h e s i s was r e j e c t e d compar-i s o n s were th e n made between two groups a t a time t o d i s -c o v e r what d i f f e r e n c e s e x i s t . 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 employed t o a v o i d the r e s t r i c t i v e r e q u i r e m e n t 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 the " t " t e s t . The Mann-Whitney (J T e s t i s d e s c r i b e d as a power-f u l and u s e f u l t e s t o f whether two samples a re s i g n i f -1 ^ S e g a l , o p . c i t . p.249. 55 20 i c a n t l y d i f f e r e n t . S c ores f o r b o t h groups are ranked t o g e t h e r i n the same manner as f o r the K r u s k a l - W a l l i s t e s t and, s i m i l a r l y , the sum o f the r a n k s f o r each group computed. The t e s t can be o n e - t a i l e d and a s s e r t t h a t one group has higher s c o r e s t h a n the o t h e r , o r t w o - t a i l e d and a s s e r t o n l y t h a t t h e r e w i l l be a d i f f e r e n c e i n s c o r e s . The o n e - t a i l e d t e s t was a p p l i e d i n t h i s s t u d y . (J r e f e r s to the number o f t i m e s t h a t a s c o r e ( o r smount) i n one group i s h i g h e r t h a n a s c o r e i n a n o t h e r group. The f o r m u l a f o r the Mann-Whitney ( / T e s t i s as f o l l o w s : n 1 ( n 1 + 1) (J = n 1 r i 2 + — - R 1 ( o r Rg) where n^ = group presumed t o have h i g h e r s c o r e s n 2 = group presumed t o have l o w e r s c o r e s R^ = sum o f r a n k s a s s i g n e d to n^ group Rg = sum o f r a n k s a s s i g n e d to ng group The f o r m u l a as used here a p p l i e s to samples o f e q u a l s i z e . R^ o r Rg i s used a c c o r d i n g t o which g i v e s the s m a l l e r 21 v a l u e o f (J • S t a t i s t i c a l l y , r a n k s are e x p e c t e d t o be d i s t r i b u t e d randomly between the two groups i f the n u l l h y p o t h e s i s i s t r u e . I f the d i s t r i b u t i o n d i f f e r s beyond Jeanne S. P h i l l i p s and R i c h a r d F. Thompson, S t a t i s t i c s f o r Nurses (New York: The M a c M i l l a n Company, 1967), p.274. I b i d , p.278. 56 c e r t a i n l i m i t s o f chance f o r the s i z e o f the sample we can 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 between the two groups. 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 t w e n t y - f o u r h o u r s , and changes i n IPAT A n x i e t y Q u e s t i o n -n a i r e s c o r e s , on Day 5 as compared w i t h Day 1 were rank o r d e r e d f o r s u b j e c t s i n the two groups b e i n g t e s t e d . The s i z e o f U computed was compared w i t h t a b l e s o f " C r i t i c a l V a l u e s o f (J i n the Mann Whitney T e s t " to d i s c o v e r whether 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 two measures. F o r the purpose o f t h i s s tudy when the o b s e r v e d v a l u e of(J was e q u a l t o , o r l a r g e r t h a n , the f i v e p e r c e n t (p < 0.05) l e v e l the n u l l h y p o t h e s i s was r e j e c t e d . P h i l l i p s and Thompson, o p . c i t . , p.512-14. Chapter 4 FINDINGS OF THE STUDY The f i n d i n g s o f the study w i l l be p r e s e n t e d and d i s c u s s e d i n d i v i d u a l l y i n terms o f the two independent v a r i a b l e s t e s t e d , f i r s t l y , 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, 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 Scores.' The U r i n e P o t a s s i u m Measure The normal range o f v a l u e s s t a t e d f o 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 i n a t w e n t y - f o u r hour p e r i o d v a r i e s somewhat from t e x t to t e x t . White, H a n d l e r and Smith g i v e an average v a l u e " f o r the American p o p u l a t i o n l i v i n g 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 . The mean v a l u e s f o r each o f the t h r e e groups i n the study on b o t h Day 1 and Day 5 are somewhat above t h i s norm. T a b l e s 4-1, 4-2 and 4-3 show t w e n t y - f o u r hour 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 on Day 1 and Day 5 and a l s o changes i n amounts e x c r e t e d on Day 5 as compared- w i t h Day 1. Mean v a l u e s f o r each measure 1 Abraham White, P h i l i p H a n d l e r and E m i l L. Smith, 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 York: M c G r a w - H i l l Book Company, 1969), p. 841. 57 58 TABLE 4-1 Changes i n 24 Hour Urinary Potassium Excretion Between Day 1 and Day 5 for Subjects i n Group Is "Relaxation" Day 1 Day 2 Change Subject meq K meq K meq K 1 . 51 57 + 6 2 79 74 - 5 3 60 57 - 3 4 102 113 + 11 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 . - I l l N: 12 12 12 X: 67.00 57.75 - 9 . Range: 107 to 33 113 to 24 +11 to • 59 T A B L E 4 - 2 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 E x c r e t i o n B e t w e e n D a y 1 a n d D a y 5 f o r S u b j e c t s i n G r o u p 2 : " P l a c e b o " D a y 1 D a y 2 C h a n g e S u b j e c t m e q , K meq ' K meq,:. K 13 103 1 4 0 + 3 7 1 4 9 3 109 + 16 15 147 60 - 87 16 8 7 23 - 6 4 17 1 8 17 1 1 8 129 9 3 - 36 19 3 9 ' 25 - 1 4 2 0 32 4 9 + 17 21 3 7 4 3 + 6 2 2 36 4 1 + 5 23 7 0 7 8 + 8 2 4 7 9 7 3 - 6 SIX: 8 7 0 751 - 1 1 9 ' N : 1 2 1 2 1 2 X: 72.50 6 2 . 5 8 9 . R a n g e : 1 4 ? t o 1 8 1 4 0 t o 1 7 +37 t o 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 Between Day 1 and Day 5 f o r S u b j e c t s i n Group 3s " C o n t r o l " Day 1 Day 5 Change S u b j e c t meq K meq K meq K 25 55 32 - 23 26 53 28 - 25 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 • + 22 ZTX: 695 737 + 42 Ns 12 12 12 X i 57-92 6 l . 42 + 3. Range s 92 to 22 146 t o 28 +58 t o -61 have "been computed. Group Is " R e l a x a t i o n " . Values i n t h i s group ranged from 107 to 33 m i l l e q u i v a l e n t s with a mean of 67 m i l l e q u i v a l e n t s . On Day 5 the value s v a r i e d from 113 to 24 m i l l e q u i v a l e n t s and showed a mean of 57-75 m i l l e q u i v a l e n t s . Changes i n l e v e l o f u r i n a r y potassium e x c r e t i o n f o r twenty-f o u r hours ranged between +11 and -38 m i l l e q u i v a l e n t s , the mean value b e i n g -9.25. Nine s u b j e c t s showed a decrease i n potassium e x c r e t i o n while three s u b j e c t s showed an i n -crease. Group 2; "Placebo". Subjects i n t h i s group demonstrated wider ranges of value s on Day 1 and on Day 5 as w e l l as high e r 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 e x c r e t i o n as compared with Group 1 (see Table 4.2). The range of change f o r s u b j e c t s r e c e i v i n g the "Placebo" treatment was from +37 to -87. The mean change, -9«92 was f r a c t i o n a l l y h i g h e r than t h a t of Group 1. S i x s u b j e c t s had h i g h e r l e v e l s o f potassium e x c r e t i o n on Day 5 and s i x had lower l e v e l s . Group 3s " C o n t r o l " . The "Controls group had the s m a l l e s t range o f m i l l e q u i v a l e n t s o f potassium e x c r e t e d and the lowest mean value (57-9) of a l l groups on Day 1. Th i s group, u n l i k e the oth e r 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 potassium excreted on Day 5 as com-pared with Day 1. Seven s u b j e c t s showed i n c r e a s e d l e v e l s 62 o f p o t a s s i u m e x c r e t i o n w h i l e f i v e s u b j e c t s had d e c r e a s e d l e v e l s . Comparison o f Groups; U r i n a r y P o t a s s i u m Ex- c r e t i o n L e v e l s . The f i r s t h y p o t h e s i s t o be t e s t e d a s s e r t 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 changes i n 2 4 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 i n m i l l e q u i v a l e n t s be-tween groups. Table 4 - 4 shows the 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 changes i n 2 4 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 i n m i l l e q u i v a l e n t s on Day 5 as compared w i t h Day 1 are g i v e n f o r 36 s u b j e c t s b e l o n g i n g t o the t h r e e groups -" 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 . " The amounts o f change have been ranked i n a s i n g l e s e r i e s as r e q u i r e d by the t e s t . The sums o f r a n k s w i t h i n each group i s shown and the v a l u e o f "H" i s computed. The v a l u e o f "H" r e q u i r e d t o r e j e c t the n u l l h y p o t h e s i s a t the 0.05 l e v e l o f p r o b a b i l i t y i s 5'99 o r g r e a t e r a c c o r d i n g t o the Table o f C r i t i c a l 2 V a l u e s o f C hi Square. S i n c e the obser v e d v a l u e o f "H" i s 1 . 4 4 7 4 the n u l l h y p o t h e s i s i s a c c e p t e d . D i f f e r e n c e s between the groups can be e x p l a i n e d on the b a s i s o f chance v a r i a t i o n s a l o n e . Sidney S e g a l , Nonparametric S t a t i s t i c s - . : . (New York: McGraw H i l l Book Company, 1956), 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 by Ranks 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 7 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 " R e l a x a t i o n " Change Rank i n Among meq N=36 " P l a c e b o " Rank i n Among meq N=3^ Change " C o n t r o l " Change Rank i n 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 - 38 3 + 5 21 + 6 23 - 9 16 + 8 26 - 31 5 - 23 7-5 - 6 17 + 22 33 R l = 190.0 h = 224.0 R 3 = 252.0 k R. 2 .1 H = 12 \ ' 3 (N+l) N (N+l) n . j = l 12 , /190 2 36(37) [ 12 , 2 2 4 2 252 2 12 12 3(37) 1.4474 p > 0.05 64 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 The raw s c o r e s o f 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 were used. Scores can range from 0 to 80 on the Q u e s t i o n -n a i r e . The raw s c o r e mean f o r the 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 groups i n the s t u d y , b o t h on Day 1 and Day 5 are c o n s i d e r a b l y above the 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 the e i g h t y - n i n t h p e r c e n t i l e . T a b l e s 4-5, 4-6 and 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 s c o r e s f o r s u b j e c t s i n each group on Day 1 and Day 5, as w e l l as changes i n s c o r e s on Day 5 as compared w i t h Day 1. Group Is " R e l a x a t i o n " . S u b j e c t s i n Group 1 showed a mean s c o r e o f 50 on the A n x i e t y S c a l e b e f o r e r e -r c e i v i n g fiela.xa.tion t r a i n i n g . T h i s r e p r e s e n t s a mean s c o r e above the n i n e t y - s i x t h p e r c e n t i l e f o r the g e n e r a l p o p u l a t i o n as demonstrated 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 a n x i e t y 4 raw s c o r e s t o p e r c e n t i l e s . The mean s c o r e f o r the group on Day 5» a f t e r f o u r days o f r e l a x a t i o n t r a i n i n g , f e l l t o 45.5 ( e i g h t y - n i n t h p e r c e n t i l e ) . The range f o r Day 1 ex-tended from 72 t o 32 and f o r Day 5 from 69 to 22. Changes ranged from +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 and I.H. S c h e i e r , Handbook f o r 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 , (Champaign, 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 and A b i l i t y T e s t i n g , _ 1 9 6 3 ) , p.11, 4 ^ I b i d . 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 S c o r e s Between Day 1 and Day 5 l o r S u b j e c t s i n Group Is " E x p e r i m e n t a l " Day 1 Day 2 Change S u b j e c t IPAT Score IPAT Score IPAT Score 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 0 EXs 6oo 546 . 54 Ns 12 12 7 12 Xs 50 45-5 - 4, Range s 72 t o 32 69 to 22 +4 to -1 66 TABLE 4 - 6 Changes i n IPAT Anxiety Scale Questionnaire Scores Between Day 1 and Day 5 for Subjects i n Group 2 : "Placebo" Day 1 Day 2. Change Subject IPAT Score IPAT Score IPAT Score 13 61 61 0 14 68 60 8 15 50 51 + 1 16 56 43 - 13 17 5 * 60 + 6 18 41 55 + 14 19 36 40 + 4 20 • 54 56 + 2 21 62 44 - 18 22 32 30 2 23 56 32 - 24 24 37 39 + 2 2IX: 6o? 571 - 36 Ns 12 12 12 X i 5 0 . 5 8 4 7 . 5 8 - 3 Range • 68 to 32 6 l to 30 +14 to -6? i n d i v i d u a l s 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 the same s c o r e . Group 1 s c o r e s on Day 1 and Day 5» and changes i n s c o r e are found i n Table 4-5-Group 2; " P l a c e b o " . Group 2 s c o r e s as shown i n Table 4-8 r e v e a l a range o f 68 to 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 the " P l a c e b o " t r e a t m e n t approach and a range o f 6 l to 30 on Day 5» w i t h the mean v a l u e hav-i n g dropped to 47.58. The range o f changes i n s c o r e a f t e r r e c e i v i n g the " P l a c e b o " t r e a t m e n t approach was +14 t o -24 w i t h a mean change o f -3. S i x s u b j e c t s e x h i b i t e d i n c r e a s e d s c o r e s , f i v e showed d e c r e a s e d s c o r e s and one s u b j e c t showed no change. Group 3; " C o n t r o l " . 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 groups. A l s o u n l i k e the " R e l a x a t i o n " o r " P l a c e b o " t r e a t m e n t groups, t h e " C o n t r o l " 'group mean s c o r e f o r Day 5 showed an 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 the range o f change was from +7 t o -5- Only t h r e e s u b j e c t s showed d e c r e a s e d s c o r e s w h i l e n i n e s u b j e c t s d i s p l a y e d i n -1 c r e a s e d s c o r e s . : Comparison o f Groups; IPAT A n x i e t y S c a l e Ques-t i o n n a i r e S c o r e s . H y p o t h e s i s 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 changes i n l e v e l o f 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 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 S c o r e s Between Day 1 and. Day 5 l o r S u b j e c t s i n Group 3s " C o n t r o l " S u b j e c t Day 1 IPAT Score Day 2 IPAT Score Change IPAT Score 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 + 5 231 s 547 579 + 32 Ns 12 12 12 X i ' 45-58 48.25 + 2.67 Range s 61 to 28 65 to 30 +7 to -5 69' 4-8 d i s p l a y s the 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 the t h r e e groups. "H"is computed t o be 7.8227. The 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 w i t h d f = k - 1 = 7 the p r o b a b i l i t y o f o c c u r r e n c e o f the n u l l h y p o t h e s i s i s l e s s t h a n 0.02. T h e r e f o r e , we r e j e c t H„ and conclude 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 groups i n changes i n IPAT s c o r e s . S i n c e the K r u s k a l - W a l l i s t e c h n i q u e shows o n l y the o v e r a l l comparison between groups, f u r t h e r t e s t i n g between groups was c a r r i e d out t o compare the r e s u l t s shown by i n d i v i d u a l groups. The Mann Whitney (J T e s t was employed f o r t h i s purpose. The o n e - t a i l e d t e s t was used, where the h y p o t h e s i s to be t e s t e d a s s e r t s the d i f -f e r e n c e i n s c o r e s w i l l be d i r e c t i o n a l , i . e . t h a t one o f the groups w i l l have h i g h e r s c o r e s . Table 4-9 shows the f i n d i n g s when Group 1 and Group 2 are compared. The h y p o t h e s i s t e s t e d 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 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 S c a l e Q u e s t i o n n a i r e 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 d the " R 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 r e c e i v e d the " P l a c e b o " t r e a t m e n t . The (j v a l u e o f 57•5 exceeds a p r o b a b i l i t y o f 0.05 t h a t d i f f e r e n c e s o c c u r r e d by chance a l o n e . T h e r e f o r e the n u l l h y p o t h e s i s i s t e n a b l e and h y p o t h e s i s ( i ) i s r e j e c t e d . The second h y p o t h e s i s t e s t e d a s s e r t s t h a t 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 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 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 " R e l a x a t i o n " Change Rank i n Among Score N=36 " P l a c e b o " Change Rank i n Among Score N=36 " C o n t r o l " Change Rank i n Among Score N=36 + 1 19-5 0 17.5 — 5 9 + 4 28 - 8 7 + 2 22.5 - 4 11 + 1 19.5 - 1 15.5 - 15 ' 3-5 - 13 5 + 6 33.5 - 6 8 + 6 33.5 + 4 28 - 15 3.5 + 14 36 - 1 15.5 - 11 6 + 4 28 + 3 25-5 - 4 11 + 2 22.5 + 2 22.5 + 3 25.5 - 18 2 + 7 35 - 3 13 _ - 2 14 + 5 31 - 4 11 - 24 1 + 5 31 0 17.5 + 2 22.5 + 5 31 R l = 157-5 '208.5 R 3 = 300 k R . ,1 H = 12 \ 3 (N+l) N (N+l) / n. 12 j i= i 1^57. 52 3 + 208.5 2 , 300 2 \ 3(37) 36(37) ( ( 1 2 12 1 2 = 7.822? p < 0 .02 71 TABLE 4 - 9 Mann-Whitney (j Test For D i f f e r e n c e s i n Change i n IPAT Anxiety Scale Questionnaire Scores Between Group 1: "Relaxation" and Group 2 s "Placebo" (N = 24) Group 1 {n. = 12) Group 2 ( n ? = 12) Subject Change i n Score Rank Among N=24 Subject Change i n Score Rank Among N=24 1 + 1 1 6 . 5 13 0 14 . 5 2 + 4 2 1 . 5 14 - 8 7 3 - 4 10 15 + 1 1 6 . 5 4 - 15 3 - 5 16 - 13 5 5 - f r> 6 8 17 + 6 23 6 - 15 3 - 5 18 + 14 24 7 • - 11 6 19 + 4 2 1 . 5 8 - 4 10 20 + 2 1 8 . 5 9 + 3 20 21 - 18 2 10 - 3 12 22 - 2 13 11 - 4 10 23 - 24 1 12 0 14 . 5 24 + 2 18.5 z = R l = u = 1 3 5 - 5 n l n 2 + z (n± + 1) 2 " R 2 R 2 = 1 6 4 . 5 U = 144 + 78 - 164.5 = 55 p > 0 . 0 5 ( o n e - t a i l e d ) 72 TABLE 4-10 Mann-Whitney (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 cores Between Group Is " R e l a x a t i o n " and Group 3s " C o n t r o l " (N = 24) Group 1 ( n 1 = 12) Group 3 ( n 2 = 12) Change Rank Change Rank i n Among i n Among S u b j e c t Score N=24 S u b j e c t Score N=24 1 + 1 13 25 - 5 5 2 + 4 18.5 26 + 2 14.5 3 - 4 7 27 - 1 10.5 4 - 15 1.5 28 + 6 23 5 - 6 4 29 + 4' 18.5 6 - 15 1.5 30 - 1 10.5 7 - 11 3 31 + 3 16.5 8 - 4 7 32 + •2 14.5 9 + 3 16.5 33 + 7 24 10 - 3 9 3* + 5 21 11 - 4 7 35 + 5 21 12 0 12 36 + 5 21 L = R u 1 = 100 n l riln2 + (n± + 2 z 1) - R2 = R2 = 200 u = 144 + 78 - 200 = 22 p > 0.001 < 0.01 ( o n e - t a i l e d ) 73 TABLE 4-11 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 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 2: " P l a c e b o " and Group $ t " C o n t r o l " (N = 24) Group 2 ( n 1 = 12) Group 3 ( n 2 = 12) Change Rank Change Rank. i n Among i n Among S u b j e c t Score N=24 S u b j e c t Score N=24 13 . 0 9 14 - 8 . 4 15 + 1 10 16 - 13 3 17 + 6 21 .5 18 + 14 24 19 + 4 16.5 20 + 2 12.5 21 - 18 2 22 - 6 23 - 24 1 24 + 2 12.5 z R l = 122 u = H l n 2 • + 2 + 1) O = 144 + 78 - 178 = 44 p > 0.05 ( o n e - t a i l e d ) 25 - 5 5 26 + 2 12.5 27 - 1 7-5 28 + 6 21.5 29 + 4 16.5 30 - 1 7.5 31 + 3 •15 32 + 2 12.5 33 + 7 23 • 34 + 5 19 35 + 5 19 36 + 5 19 - R2 = 178 R2 7 4 Scale Questionnaire scores f o r subjects who r e c e i v e "Re-l a x a t i o n " treatment as compared, with subjects who r e c e i v e " 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 Anxiety Scale scores of Group I s "Relaxation" and Group 3 * " C o n t r o l " . The (/ measure of 2 2 has a pro-b a b i l i t y of l e s s than one percent of having happened by chance. The n u l l hypothesis can be r e j e c t e d and hypothesis ( i i ) 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 . Hypothesis ( i i i ) can be sta t e d as f o l l o w s : there w i l l be a s i g n i f i c a n t -l y g r eater d e c l i n e i n IPAT Anxiety Scale Questionnaire scores f o r subjects who r e c e i v e "Placebo" treatment as compared with subjects.who re c e i v e " C o n t r o l " treatment. 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 percent that the d i f f e r e n c e s can be explained on the b a s i s of change. The n u l l hypothesis i s supported and hypothesis ( i i i ) was r e j e c t e d . A d i s c u s s i o n of these f i n d i n g and of 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 given i n the f o l l o w i n g chapter. Chapter 5 DISCUSSION, LIMITATIONS, RECOMMENDATIONS I n t e r p r e t a t i o n o f F i n d i n g s 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 t e c h n i q u e i n r e l i e v i n g ex-c e s s i v e a n x i e t y , A p h y s i o l o g i c a l ( b i o c h e m i c a l ) and a psy-c h o l o g i c a l ( 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 the f i r s t and l a s t days o f the e x p e r i m e n t a l p e r i o d , as measures o f l e v e l o f a n x i e t y . As measured by 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 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 comparison w i t h Group 3 " C o n t r o l . " Group 2 " P l a c e b o " showed no s i g n i f i c a n t d i f f e r e n c e from Group 1 o r Group 3 when changes i n A n x i e t y S c a l e s c o r e s were compared s t a t i s -t i c a l l y . The t w e n t y - f o u r 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 measure d i d n o t demonstrate 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 the 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 between the t h r e e groups f o r b o t h the p h y s i o l o g i c a l and the p s y c h o l o g i c a l measure. The mean changes i n a n x i e t y s c a l e s c o r e s and 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 w e r e ! a s f o l l o w s : 75' 76 GROUP IPAT URINE K 1 2 3 -4.5 -3.0 +2.5 -9.25 -9-92 -3.50 I n s p e c t i o n o f d i r e c t i o n o f i n d i v i d u a l s c o r e s i n each group a re s u g g e s t i v e a l s o : IPAT SCORES  GROUP f j 1 3 8 2 6 5 3 8 4 URINE K EXCRETION SAME+ <y I SAME 1 3 9 0 1 6 6 0 0 7 5 0 I n d i v i d u a l p a t i e n t p r o f i l e s show a wide range o f d i f f e r e n c e i n r e s p o n s e . Some s u b j e c t s i n each group show i n c r e a s e d s c o r e s o r v a l u e s i n d i c a t i v e o f i n c r e a s e d a n x i e t y o r s t r e s s w h i l e o t h e r 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 parameter and a decrease i n the o t h e r . The combined r e s u l t s f o r each group a r e : Group 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 s u b j e c t s d e c r e a s e d i n bo t h Group 2: one s u b j e c t i n c r e a s e d i n b o t h one s u b j e c t d e c r e a s e d i n bo t h Group 3: f i v e s u b j e c t s i n c r e a s e d i n b o t h one s u b j e c t d e c r e a s e d i n bo t h 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 s u g g e s t s a g r e a t e r 77 r e d u c t i o n i n a n x i e t y f o r G r o u p 1 s u b j e c t s . E v i d e n t l y s o m e s u b j e c t s a r e m o r e r e s p o n s i v e t o t h e e f f e c t s o f t h e r e l a x a t i o n t e c h n i q u e t h a n o t h e r s . T h e r e a s o n s f o r t h i s d i f f e r e n c e i n r e s p o n s e a r e n o t c l e a r l y e v i d e n t . F u r t h e r s t u d i e s a r e n e e d e d t o i d e n t i f y t h e c h a r -a c t e r i s t i c s o f s u b j e c t s w h o w o u l d r e c e i v e m o s t b e n e f i t f r o m r e l a x a t i o n t r a i n i n g . P e r h a p s m u s c l e r e l a x a t i o n i s n o t e n t i r e l y s y n o m y m o u s w i t h r e l i e f o f a n x i e t y . I s t h e r e a d i f f e r e n c e i n e f f e c t i v e n e s s o f t h e t e c h n i q u e f o r s u b j e c t s w i t h a c u t e a n x i e t y a s c o m p a r e d w i t h c h r o n i c a n x i e t y ? P r o -b a b l y t h e r e a r e d i f f e r e n c e s i n a b i l i t y a n d d e s i r e i n l e a r n i n g t o f o l l o w t h e d i r e c t i o n s f o r r e l a x a t i o n . T h e r e w a s n o m e a s u r e m a d e o f w h e t h e r o r h o w m u c h s u b j e c t s r e l a x e d . W o u l d f e e d -b a c k h a v e a s s i s t e d t h e s u b j e c t s t o r e l a x m o r e e f f e c t i v e l y ? 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 c o u l d h a v e b e e n s u b m e r g e d b y o t h e r f a c t o r s . T h e r e a r e a m u l t i t u d e o f e x -t r a n e o u s v a r i a b l e s i n a c l i n i c a l s e t t i n g w h i c h m i g h t i n d u c e s t r e s s - t h e e m o t i o n a l c l i m a t e o f t h e p s y c h i a t r i c u n i t , t h e s o c i a l s i t u a t i o n o f t h e s u b j e c t , p h y s i c a l f a c t o r s s u c h a s n o i s e a n d d i e t a r y f a c t o r s s u c h a s c a f f e i n e . A n o t h e r q u e s t i o n p o s e d b y t h e r e s u l t s o f t h e s t u d y i s w h y t h e 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 d e m o n s t r a t e d a ' . d i f f e r -e n c e b e t w e e n G r o u p 1 a n d G r o u p 3 w h i l e t h e u r i n a r y p o t a s s i u m m e a s u r e d i d n o t ? T h e a n s w e r m a y b e d e r i v e d f r o m t h e f a c t t h a t t h e A n x i e t y S c a l e m e a s u r e s a c o m p o s i t e o f a l l f a c t o r s b a s i c t o a n x i e t y w h i l e t h e u r i n a r y p o t a s s i u m m e a s u r e i s a 78 u n i t a r y f a c t o r and an i n d i r e c t measure o f s t r e s s . S t r e s s might more a c c u r a t e l y be measured by a m u l t i f a c t o r i a l 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 p a t -t e r n s . B o th the 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 r e v e a l a tendency t o i n c r e a s i n g s t r e s s o r a n x i e t y o v e r the f i v e day p e r i o d f o r members o f the " C o n t r o l " group. I s t h i s t y p i c a l d u r i n g the e a r l y weeks o f h o s p i t a l i z a t i o n f o r t h i s p o p u l a t i o n ? S t u d i e s w i t h o t h e r p a t i e n t p o p u l a t i o n s have shown t h a t " a d m i s s i o n a n x i e t y " has s u b s i d e d by the end i o f the f i r s t week. L i m i t a t i o n s o f the Study Sample S i z e and S e l e c t i o n . T h i s s t u d y i n v o l v e d a s m a l l sample o f a s p e c i a l p o p u l a t i o n . G e n e r a l i z a t i o n s can n o t be made beyond t h i s p o p u l a t i o n ( i . e . n o n - p s y c h o t i c i n -p a t i e n t s i n a c u t e care s e t t i n g s ) . F u r t h e r m o r e , the s i z e and s e l e c t i o n o f the sample l e d t o the use o f n o n p a r a m e t r i c s t a t i s t i c a l a n a l y s i s which l a c k s the power o f p a r a m e t r i c a n a l y s i s . U n c o n t r o l l e d E x t r a n e o u s S t i m u l i . Many e x t r a n e o u s 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 to c o n t r o l . These 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 p s y c h o l o g i c a l s t i m u l i . M edi-1 R o s l y n Elms and R.C. L eonard, " E f f e c t s o f N u r s i n g Approaches D u r i n g A d m i s s i o n , " N u r s i n g Research. XV ( W i n t e r , 1966), 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 but were not c o n t r o l l e d a c r o s s groups by m a t c h i n g s u b j e c t s . P h y s i o l o g i c a l s t i m u l i such as t o b a c c o o r c a f f e i n e i n t a k e , as w e l l as d i e t -a r y i n t a k e , were not c o n t r o l l e d . N o i s e , temperature and o t h e r p h y s i c a l s t i m u l i v a r y from time to t i m e . The e m o t i o n a l 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 the passage o f t i m e . A v a r i e t y o f p h y s i c a n s and n u r s e s p r o v i d e d the r e g u l a r care f o r the s u b j e c t s so t h a t c a r e was f a r from s t a n d a r d i z e d . Incomplete P l a c e b o E f f e c t . The " P l a c e b o " t r e a t -ment used may have p r o v i d e d an i n c o m p l e t e measure o f the Hawthorne e f f e c t . S u b j e c t s i n the " P l a c e b o " group r e c e i v e d e q u i v a l e n t n u r s i n g time and e n v i r o n m e n t a l c o n t r o l b u t t h e p r o c e d u r e f o r the " R e l a x a t i o n " group i n v o l v e d a "machine" •approach, the t a p e - r e c o r d e r . Tapes were used t o s t a n d a r d i z e i n s t r u c t i o n . U r i n e P o t a s s i u m Measure. There was not complete as s u r a n c e t h a t the t w e n t y - f o u r hour u r i n e specimens were i n d e e d complete. 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 t h e i r own specimens. Recommendations f o r F u r t h e r Study I n v i e w o f the f i n d i n g s o f t h i s i n v e s t i g a t i o n the f o l l o w i n g recommendations f o r f u r t h e r study are made. 1. Subsequent s t u d i e s u s i n g a l a r g e r sample s h o u l d be c a r r i e d out to s u p p o r t o r r e j e c t the f i n d i n g s i n 80 t h i s i n v e s t i g a t i o n . 2. Use o f m u l t i f a c t o r i a l s t r e s s i n d i c e s such as 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 p r o f i l e s s h o u l d be i n s t i t u t e d as more a c c u r a t e 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 . 3. The R e l a x a t i o n Technique s h o u l d be t e s t e d w i t h p a t i e n t s i n o t h e r " h i g h s t r e s s " a r e a s 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 , p a t i e n t s w i t h r heumatoid a r t h r i t i s , c a r d i a c r e h a b i l i t a t i o n p a t i e n t s , e t c . 4 . S t u d i e s s h o u l d be conducted t o i d e n t i f y which p a t i e n t s a re most l i k e l y t o respond f a v o u r a b l y t o the r e -l a x a t i o n t r a i n i n g . 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 Technique 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 " l i v e " i n s t r u c t i o n . 6. The R e l a x a t i o n Technique s h o u l d be t e s t e d f o r e f f e c t i v e n e s s u s i n g d i f f e r e n t s c h e d u l e s and numbers o f t r e a t m e n t s . Summary An e x p e r i m e n t a l study was conducted to 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 e x c e s s i v e a n x i e t y . T h i r t y - s i x 'non-psychotic, p s y c h i a t r i c i n p a t i e n t s were a s s i g n e d a t random t o t h r e e groups. 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 t e c h n i q u e 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 ,:placebo t r e a t m e n t s on an e q u i v a l e n t 81 s c h e d u l e t o Group 1. S u b j e c t s i n Group 3 r e c e i v e d the o r d i n a r y ward car e 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 ( t w e n t y -f o u r 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 S c a l e Q u e s t i o n n a i r e ) . Both measures were t e s t e d a t the b e g i n n i n g and end o f the f i v e day ex-p e r i m e n t a l 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 . Group 1 s u b j e c t s were found t o e x h i b i t 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 s i n IPAT A n x i e t y S c a l e Ques-t i o n n a i r e s c o r e s as compared w i t h Group 3 s u b j e c t s . No o t h e r 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 found be-tween groups. I n s p e c t i o n o f i n d i v i d u a l IPAT s c o r e s ' a n d u r i n e p o t a s s i u m v a l u e s s u g g e s t s however, t h a t t h e r e i s a 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 p h y s i o -l o g i c a l l y and p s y c h o l o g i c a l l y , t o the " R e l a x a t i o n " and the " P l a c e b o " approach. The l a c k o f c o n s i s t e n c y between the two measures ( i . e . the change o f 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 l e v e l s f o r Group 1 was n o t found to be s i g -n i f i c a n t l y d i f f e r e n t from Group 3) m a y be e x p l a i n e d by the f a c t t h a t the 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 i s a m u l t i -f a c t o r i a l i n d e x w h i l e the u r i n e p o t a s s i u m v a l u e measures 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 . B I B L I O G R A P H Y 8 2 83 A i t k e n , L i n d a H. and Theodore F. H e n r i c h s . " S y s t 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 Technique w i t h Open Heart Surgery P a t i e n t s , " N u r s i n g R e s e a rch , XX (May-June, 1971)' B a r t t e r , F r e d e r i c C , C a t h e r i n e S. D e l e a and F r a n z H a l -b e r g . "A Map o f B l o o d and U r i n a r y Changes, R e l a t e d t o C i r c a d i a n V a r i a t i o n s i n A d r e n a l 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 , " A n n a l s o f the New York Academy  o f S c i e n c e , X C V I I I ( O c t o b e r 30, 1962), 969-83. B e r g e r s o n , B e t t y ( e d . ) . C u r r e n t Concepts o f C l i n i c a l  N u r s i n g . V o l . 1. S t . L o u i s : C.V. Mosby Company, 1961T Brockway, A.L.'et a l . 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New York: M c G r a w - H i l l Book Company, 1971' Wolpe, Joseph. 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 . S t a n f o r d : S t a n f o r d U n i v e r s i t y P r e s s , 1 9 5 8 . W o o l d r i d g e , Powhatan, James K. S k i p p e r and Robert 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 C E S 9 0 APPENDIX A TEXT OF RELAXATION TECHNIQUE TAPE Breathe i n ... breathe i n ... breathe i n . Hold i t ... h o l d i t ... h o l d i t . i Breathe out ... breathe out ... breathe out. Now, the muscle t e n s i n g and r e l a x i n g . Wrinkle your forehead ... f e e l the t e n s i o n ... l e t i t go ... loose and r e l a x e d ... loo s e and r e l a x e d ... as loose as you can. Close you eyes t i g h t l y ... f e e l the t e n s i o n ... l e t them go ... loose and r e l a x e d ... loo s e and easy ... easy and r e l a x e d . Open your mouth wide ... f e e l the t e n s i o n ... l e t i t go ... loose and r e l a x e d ... loo s e and r e l a x e d ... r e a l l y r e l a x e d . Bend your head forwards ... f e e l the t e n s i o n ... l e t i t go ... loo s e and r e l a x e d ... loose and r e l a x e d ... r e a l l y r e l a x e d . Bend your head forwards ... f e e l the t e n s i o n ... l e t i t go ... loose and r e l a x e d ... loose and r e l a x e d ... as r e l a x e d as you can. L i f t your shoulders up to your ears ... f e e l ' Repeat from beginning f i v e times. 91 92 the t e n s i o n ... l e t them go ... lo o s e and r e l a x e d ... lo o s e and heavy ... heavy and r e l a x e d . Clench your r i g h t f i s t ... f e e l the t e n s i o n ... l e t i t go ... loose and r e l a x e d ... lo o s e and easy ... easy and r e l a x e d . T i g h t e n your r i g h t forearm ... f e e l the t e n s i o n ... l e t i t go ... loose and r e l a x e d ... lo o s e and r e l a x e d ... r e a l l y r e l a x e d . T i g h t e n your r i g h t upper arm ... f e e l the t e n s i o n ... l e t i t go ... loose and r e l a x e d ... l o o s e and heavy ... heavy and r e l a x e d . Tighten, your l e f t forearm ... f e e l the t e n s i o n ... l e t i t go ... lo o s e and r e l a x e d ... lo o s e and r e l a x e d ... r e a l l y r e l a x e d . T i g h t e n your l e f t upper arm ... f e e l the t e n s i o n ... l e t i t go ... loose and r e l a x e d ... loose and heavy ... heavy and r e l a x e d . T i g h t e n your chest muscles ... f e e l the t e n s i o n ... l e t them go ... lo o s e and r e l a x e d ... loose and r e l a x e d ... as lo o s e as you can. Ti g h t e n your abdominal muscles ... f e e l the t e n s i o n ... l e t them go ... lo o s e and r e l a x e d ... loose and easy ... easy and r e l a x e d . T i g h t e n your buttocks ... f e e l the t e n s i o n ... l e t them go ... loose and r e l a x e d ... loose and r e l a x e d 93 ... r e a l l y r e l a x e d . T i g h t e n your r i g h t t h i g h muscles ... f e e l the t e n s i o n . .. l e t them go ... loose and r e l a x e d ... loose and heavy ... heavy and r e l a x e d . T i g h t e n your r i g h t c a l f muscles ... f e e l the t e n s i o n ... l e t them go ... loose and r e l a x e d ... loose and r e l a x e d ... as loo s e as you can. P o i n t your r i g h t toes away from your head ... f e e l the t e n s i o n ... l e t them go ... loo s e and r e l a x e d ... l o o s e and easy ... easy and r e l a x e d . P o i n t your r i g h t toes toward your head ... f e e l the t e n s i o n i n your c a l f ... l e t them go ... l o o s e and r e -la x e d ... loose and r e l a x e d ... r e a l l y r e l a x e d . T i g h t e n your l e f t t h i g h muscles ... l e t them go ... lo o s e and r e l a x e d ... l o o s e and heavy ... heavy and r e l a x e d . T i g h t e n your l e f t c a l f muscles ... f e e l the te n -s i o n ... l e t them go ... loo s e and r e l a x e d ... loose and r e l a x e d ... as loose as you can. P o i n t your l e f t toes away from your head ... f e e l the t e n s i o n ... l e t them go ... loo s e and r e l a x e d ... l o o s e and easy ... easy and r e l a x e d . P o i n t your l e f t toes toward your head ... f e e l the t e n s i o n i n your c a l f ... l e t them go ... loose and r e -lax e d ... loo s e and r e l a x e d ... r e a l l y r e l a x e d . L i e r e l a x e d a l l over f o r a few minutes. APPENDIX B ANXIETY STUDY: EXPERIMENT SCHEDULE DAY 1 0800 hours start 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 | | 1400 hours I I 2000 hours | |; Placebo Treatment j [: No Treatment Medications: DAY 3 1000 hours [ 1000 hours [ Medications: DAY 4 1000 hours [ 1000 hours f 1400 hours 1400 hours 1400 hours 1400 hours Medications: DAY 5 0800 hours start 24 hour Urinary 1000 hours | | 1400 hours 1 1000 hours | | 1400 hours 2000 hours 2000 hours ]: Relaxation Training ]: Placebo Treatment 1: No Treatment 2000 hours 2000 hours ]: Relaxation Training ]: Placebo Treatment ~|: No Treatment Potassium Excretion Test 2000 hours Q ' 2000 hours T : Relaxation Training : Placebo Treatment : No Treatment DAY 6 0800 hours complete 24 hour Urinary Potassium Excretion Test [ 94 

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