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Psychophysiological Effects of Applied Relaxation
in Generalized Anxiety Disorder



Dissertation
der Fakultät für Informations- und Kognitionswissenschaften
der Eberhard-Karls-Universität Tübingen
zur Erlangung des Grades eines
Doktors der Naturwissenschaften
(Dr. rer. nat.)



vorgelegt von
Dipl.-Psych. Ansgar Conrad
aus Coesfeld


Palo Alto/USA
2006 Psychophysiology, Applied Relaxation, & GAD

Tag der mündlichen Qualifikation: 20.12.2006

Vorsitzender des Promotionsausschusses: Prof. Dr. Georg Carle
Mitglied des Promotionsausschusses: Prof. Dr. Martin Hautzinger otionsausschusses: Prof. Dr. Walton Roth
Mitglied des Promotionsausschusses: PD Dr. Philip Brömer

ii Psychophysiology, Applied Relaxation, & GAD
Selbstständigkeitserklärung

Ich versichere hiermit, dass ich die vorliegende Arbeit selbstständig verfasst
und keine anderen als die angegebenen Quellen oder Hilfsmittel benutzt habe.

_________________________
Ansgar Conrad
Palo Alto, im September 2006
iii Psychophysiology, Applied Relaxation, & GAD
Acknowledgements

This study was conducted at the Department of Psychiatry and Behavioral
Sciences at the Stanford University School of Medicine and the Department of
Veteran Affairs, Palo Alto Health Care System under the supervision of Walton T.
Roth, M.D. I am grateful to Dr. Roth for giving me the opportunity to work in his
research group and letting me profit from his expertise in the field of
psychophysiology. Many thanks also to Linda Isaac, Eva Naumann, and Julia
Altenburg for all their hard work in all phases of this project and their comments on
prior versions of this manuscript. I could not have accomplished this project without
the support of the student therapists of the Pacific Graduate School of Psychology -
Stanford Consortium (Linda Sattler, Daniel Batiuchok, Lynda Vaterlaus, Danny
Chenoweth). I would also like to thank my supervisor at the University of Tübingen,
Prof. Dr. Martin Hautzinger, for supporting my intention to conduct research and
write my Diplomarbeit (German equivalent to Master of Science degree thesis) and
dissertation in collaboration with Stanford University.

A very big hug goes to my parents Gerhild and Manfred Conrad for all their
love and support during my studies abroad. Finally, words alone cannot express the
thanks I owe to Courtney Conrad, my wife, for her patience, forbearance,
encouragement, and love.

This research was supported by grants of the National Institutes of Health
(MH066953-01) and the Department of Veterans Affairs (ROT0042825) awarded to
Dr. Roth.
iv Psychophysiology, Applied Relaxation, & GAD
Table of contents

Selbstständigkeitserklärung ......................................................................................... iii
Acknowledgements.......................................................................................................iv
Table of contents............................................................................................................v
Acronyms................................................................................................................... viii
List of Tables and Figures..............................................................................................x
Summary......................................................................................................................xii
Zusammenfassung.......................................................................................................xiv
Introduction....................................................................................................................1
Method .........................................................................................................................16
Inclusion Criteria...................................................................................................16
Sample Size Considerations and Randomization Procedures ...............................17
Participant Characteristics....................................................................................18
Attrition..................................................................................................................20
Procedure...............................................................................................................22
Treatment22
Applied Relaxation...........................................................................................22
Therapists.........................................................................................................23
Integrity Checking............................................................................................24
Psychological Assessment......................................................................................25
Diagnostic Interview........................................................................................25
Treatment Outcome Questionnaires ................................................................25
Relaxation Test Questionnaires .......................................................................28
Therapeutic Quality Measures.........................................................................28
v Psychophysiology, Applied Relaxation, & GAD
Physiological Assessment ......................................................................................29
Relaxation Test.................................................................................................29
Physiological Measures...................................................................................29
Physiological Data Reduction .........................................................................32
Statistical Analysis.................................................................................................33
Demographic, Clinical, and Control Measures...............................................34
Pre-Treatment Measures .................................................................................34
Treatment Outcome Measures .........................................................................35
Treatment Expectancy and Therapeutic Relationship Measures.....................35
Physiological Change with Treatment.............................................................36
Follow-Up Outcome and Physiological Change .............................................36
Correlational Analyses ....................................................................................37
Effect Size Calculations and Adjustments for Multiple Tests ..........................38
Results..........................................................................................................................39
Pre-Treatment Differences Between GAD Patients and Non-Anxious Controls...39
Pre-Treatment Differences Between AR and WLC Participants ...........................45
Pre-Treatment Differences Between GAD Completers and Dropouts ..................45
Correlational Analyses at Pre-Treatment..............................................................46
Post-Treatment Improvement.................................................................................47
Treatment Expectancy and Therapeutic Relationship Measures...........................49
Psychophysiological Change With Treatment in the Relaxation Tests .................50
Follow-Up Improvement........................................................................................58
Correlational Analyses for Treatment Progress....................................................59
Discussion....................................................................................................................61
Activation in GAD patients ....................................................................................61
vi Psychophysiology, Applied Relaxation, & GAD
Improvement in GAD Patients With AR.................................................................65
Activation Change in GAD Patients with AR ........................................................71
Statistical Considerations ......................................................................................73
Methodological Limitations...................................................................................77
Summary, Implications, and Outlook.....................................................................79
References....................................................................................................................82
Appendix100
vii Psychophysiology, Applied Relaxation, & GAD
Acronyms

ADIS-IV = Anxiety Interview Schedule for DSM-IV
ANCOVA = analysis of covariance
ANOVA = analysis of variance
AR = Applied Relaxation
AR1 = first-order autoregressive variance covariance structure with homogenous
variances
BAI = Beck Anxiety Inventory
BDI = Beck Depression Inventory
BP = blood pressure
CBT = Cognitive-Behavior Therapy
CMQ = Customized Mood Questionnaire (s = short, l = long)
CSAQ = Cognitive and Somatic Anxiety Questionnaire (c = cognitive subscale, s =
somatic subscale)
CT = Cognitive Therapy
EMG = surface electromyogram
ES = effect size
GAD = Generalized Anxiety Disorder
HR = heart rate
HRV = heart rate variability
MANOVA = multivariate analysis of variance
MRT = muscle relaxation therapy
NAC = non-anxious control
NSF = non-specific fluctuation
viii Psychophysiology, Applied Relaxation, & GAD
PD = Panic Disorder
PMR = Progressive Muscle Relaxation
PSS = Perceived Stress Scale
PSWQ = Penn State Worry Questionnaire
QS = quiet sitting segment of the Relaxation Test
R = relaxation segm
RI = Relationship Inventory
RR = respiration rate
RRAQ = Reaction to Relaxation and Arousal Questionnaire
RRI = respiratory rate instability
SAD = Social Anxiety Disorder
SCL = skin conductance level
TV = tidal volume
TVI = tidal volume instability
WAI = Working Alliance Inventory
WLC = waiting list control
WW-II = Why Worry Scale II

ix Psychophysiology, Applied Relaxation, & GAD
List of Tables and Figures

Table 1 Demographic Characteristics by Group......................................................................19

Table 2 Psychometric Measures at Pre-Treatment by Group .................................................40


Figure 1. Means plus standard errors for anxiety, worry, relaxation, and sleepiness during the
Relaxation Test (randomized order; speech [sp], at the beginning [b], during [d], and at the
end [e] of quiet sitting [QS]; speech [sp], at the beginning [b], during [d], and at the end [e] of
relaxation [R]) in Generalized Anxiety Disorder (GAD) patients and non-anxious controls
(NAC) at pre-treatment.............................................................................................................41

Figure 2. Means plus standard errors for the left and right gastrocnemius EMG, heart rate
(HR), and skin conductance level (SCL) during the Relaxation Test (randomized order; 1 min
before speech [b], 2 min speech [s], 5 min quiet sitting [QS]; 1 min before speech [b], 2 min
speech [s], 5 min relaxation [R]) in Generalized Anxiety Disorder (GAD) patients and non-
anxious controls (NAC) at pre-treatment. ................................................................................42

Figure 3. Means plus standard errors for end-tidal pCO , respiratory rate (RR), tidal volume 2
(TV), and respiratory rate instability (RRI) during the Relaxation Test (randomized order; 1
min before speech [b], 2 min speech [s], 5 min quiet sitting [QS]; 1 min before speech [b], 2
min speech [s], 5 min relaxation [R]) in Generalized Anxiety Disorder (GAD) patients and non-
anxious controls (NAC) at pre-treatment. ................................................................................44

Figure 4. Means plus standard errors for anxiety and worry before (Pre), during, and after
(Post) treatment, and at follow-up (FU) in the Applied Relaxation (AR), waiting list control
(WLC), and non-anxious control (NAC) groups. ......................................................................48

x

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