ASSESSING THE EFFECTIVENESS OF
RELAXATION TECHNIQUES IN MANAGEMENT
OF ANXIETY AND DEPRESSION
THESIS
SUBMITTED FOR THE AWARD OF DEGREE OF
Doctor of Philosophy
In
Psychology
BY
RAMI HABES HAMED ALRAWASHDEH
UNDER THE SUPERVISION OF
Dr. Kr. SAJID ALI KHAN ASSOCIATE PROFESSOR
DEPARTMENT OF PSYCHOLOGY ALIGARH MUSLIM UNIVERSITY ALIGARH, 202002, UP, INDIA
2017
Dated: ____________
CERTIFICATE
I certify that Mr.Rami HabesHamedAlrawashdehhas carried out his research on the topic
“Assessing the effectiveness of relaxation techniques in management of anxiety and
depression”. He has worked under mysupervision; I think his research work up to standard for the
award of Ph.D in Psychology.
Dr. Kr. Sajid Ali Khan
Associate Professor
DEPARTMENT
OFPSYCHOLOGYALIGARH MUSLIM
UNIVERSITY
ALIGARH -20 2002
Dr. Kr. Sajid Ali Khan
Associate Professor
Acknowledgement
Without any doubt, first and foremost, I would like to pay my humble reverence to almighty
ALLAH, the most merciful and beneficent, without the Nourishers’ blessings the work would not
have seen the light of the day. The completion of a research work has never been a ‘one man
show’ but collective efforts of all the well-wishers. This thesis has been very exciting and
challenging for me and I have been accompanied by a great number of people whose
contributions are worth to be acknowledged. Still I attempt to name the few indispensable people
without whose help and timely guidance the work would not have reached this stage.
There are no proper words to convey my deep gratitude and respect for my research supervisor
and my mentor Dr. Kr. Sajid Ali Khan, Associate Professor, Department of Psychology. I can
never manifest the true sense of thanks to his kind support which he has provided throughout the
entire period of my Ph.D. I acclaim his courage, respect his decisions, learn from his knowledge
and reverence the personality he has. The thesis would have not been accomplished successfully
without his kind support and sincere attention.
I acknowledge deep gratitude to Prof. Mohd. Ilyas Khan, Head of the Department of Psychology,
A.M.U., Aligarh, for most honorable and esteemed teacher and a rare combination of knowledge
and delicate human feelings for providing me this opportunity to carry out the study on the
present problem.
I find myself strangulated with feelings to express my thankfulness to all my respected teachers
Prof. Shamim Ahmad Ansari, Prof. Mahmood S. Khan, Prof. Asiya Aijaz, Dr. Nasheed Imtiyaz,
Dr. S. Reshma Jamal, Dr. Salma Kaneez, Dr. Mahvish Fatima and Dr. Mohammad Akram for
their moral endorsement and guidance whenever it was required.
It is delightful for me to thank my dear friends at this juncture for being with me in all my good
and bad times during my long stay at the Aligarh Muslim University. I feel very blessed when I
count few names among them like Masaud Ansari, Razia Saleem, Subooh Yusuf, Shamsul
Siddiqui, Sharik Kazmi, Asif Hasan, Tawfeeq and Munnoo Khna.
I am also immensely grateful to all the members of Seminar Library and Non-teaching Staff,
Department of Psychology, A.M.U., Aligarh, for their support and co-operation during the
completion of my research work.
(Rami Habes Hamed Alrawashdeh)
ASSESSING THE EFFECTIVENESS OF
RELAXATION TECHNIQUES IN MANAGEMENT
OF ANXIETY AND DEPRESSION
ABSTRACT
SUBMITTED FOR THE AWARD OF DEGREE OF
Doctor of Philosophy
In
Psychology
BY
RAMI HABES HAMED ALRAWASHDEH
UNDER THE SUPERVISION OF
Dr. Kr. SAJID ALI KHAN ASSOCIATE PROFESSOR
DEPARTMENT OF PSYCHOLOGY ALIGARH MUSLIM UNIVERSITY ALIGARH, 202002, UP, INDIA
2017
1
ABSTRACT
Topic: “Assessing the effectiveness of relaxation techniques in management of anxiety and
depression”.
The present study was undertaken on anxious and depressive individuals.Relaxation involves
laxity and peace of mind. The surrounding world of individuals is frequently making them tense
leading to various behavioural abnormalities such as anxiety and depression that are most
common among to them. Persons need relaxation in order to get rid of anxiety and depression
like problems.
Practicing relaxation techniques have many benefits such as: Maintaining heart rate, blood
pressure, breathing rate, digestion, blood sugar levels, sleep quality, fatigue, etc.
Anxiety: Anxiety is a part of our normal life. It is a reaction to stress and often beneficial in
some situations. So far as anxiety disorders are concerned, these involve excessive fear or
anxiety and these are the most common of mental disorders and affect a significant proportion of
adults at some point in their lives.
Depression: Depression involves the body, mood, and thoughts and that affects the way a person
eats, sleeps, feels about him or herself, and thinks about things. Without treatment, symptoms
can last for weeks, months, or years. Appropriate treatment, however, can help most people with
depression.
Progressive Muscles Relaxation
Progressive muscle relaxation is a technique for learning to monitor and control the state of
muscular tension. It was developed by American physician Edmund Jacobson in 1920. The
2
technique involves learning to monitor tension in each specific muscle group in the body by
deliberately inducing tension in each group. This tension is then released, with attention paid to
the contrast between tension and relaxation.
Transcendental Meditation Technique
Transcendental meditation is a specific technique using mantra meditation developed
by Maharishi Mahesh Yogi. It is often referred to as Transcendental meditation (TM). This
practice involves the use of a mantra and is practiced for 15–20 minutes twice per day while
sitting with one's eyes closed. It is reported to be one of the most-widely practiced, and among
the most widely researched meditation techniques
In the present study two relaxation techniques namely Progressive Muscle Relaxation
(PMR) and Transcendental Meditation (TM) were undertaken to compare their effect on anxiety
and depression. These two techniques were used in most simple form in such a way that does not
require supervisory care. Moreover, TM was modified to give religious orientation based on
Islamic concept. It was assumed that the focus of attention if shifted from complex social
situation towards God, the person will be away from all kinds of tensions. Repetition of this
practice is supposed to restore normalcy of mental state. It was further assumed that this
modified version of transcendental meditation will be more effective as compared to any other
kind of relaxation exercise because a person having complete faith in God is not supposed to be
worried about anything. As per the Islamic philosophy, the person has to put in his best possible
efforts and he will get results as per the desire of God. Such type of faith is not found in any
other practice. Thus the present investigation was undertaken to test these assumptions. More
specifically, the study was undertaken with following objectives.
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Objectives of the Study
1. To test the effect of PMR on anxiety
2. To test the effect of PMR on depression
3. To test the effect of Transcendental Meditation (TM) (modified) on anxiety
4. To test the effect of Transcendental Meditation (TM) (modified) on depression
5. To test the difference in effectiveness of PMR and Transcendental Meditation (TM)
(modified) in management of anxiety.
6. To test the difference in effectiveness of PMR and Transcendental Meditation (TM)
(modified) in management of depression.
Methodology
As the present study was concerned with the effectiveness of relaxation techniques in
management of anxiety and depression, the main variables involved in the study were anxiety
and depression which served as the dependent variables and the types of relaxation techniques
namely progressive muscle relaxation and transcendental meditation (modified) which served as
the independent variable. Both the dependent variables anxiety and depression were studied
under two conditions, pre-test and post-test, for each of the two independent variables.
Measures
There were two measures of dependent variables namely anxiety and depression. Each variable
was measured under two conditions: 1. Pre-test and 2. Post-test. To measure anxiety, Hamilton
Anxiety Rating Scale (HAM-A) and for depression, Back Depression Inventory BDI-II were
used.
4
Participants
A non-probability sampling method (Purposive Sampling) was used in the present study. The
overall sample size was 80 subjects, consisted of 4 groups having 20 subjects in each group. All
the sample units were selected from the Basman district of Amman city of Jordan.
Data Analysis and Interpretation: Analysis for DV 1 (Anxiety)
A before and after test design was employed in the present study. There were two independent
variables namely progressive muscle relaxation (PMR) and transcendental meditation (TM).
Two groups of subjects, Group 1 & Group 2, participated in investigation. Each was studied
under two conditions:
1. Pre-test/pre-treatment condition.
2. Post-test/post-treatment condition.
Treatment was use of PMR for group 1 and use of TM for group 2. Thus there were four
observations on two groups.
Observation 1 (Cond. A)
Assessment of anxiety score of group 1 before using PMR- Pre-treatment Condition.
Observation 2 (Cond. B)
Assessment of anxiety score of group 1 after using PMR- Post-treatment Condition.
Observation 3 (Cond. C)
Assessment of anxiety score of group 2 before using TM- Pre-treatment Condition.
5
Observation 4 (Cond. D)
Assessment of anxiety score of group 2 after using TM- Post-treatment Condition.
Analysis for DV 2 (Depression)
Analysis for the depression score was carried out in the same way as for anxiety score. A before
and after test design was employed in the present investigation. There were two independent
variables namely progressive muscle relaxation (PMR) and transcendental meditation (TM).
Two groups of subjects, Group 3 & Group 4, participated in investigation. Each group was
studied under two conditions:
1. Pre-test/pre-treatment condition.
2. Post-test/post-treatment condition.
Treatment was use of PMR for group 3 and use of TM for group 4. Thus there were four
observations on two groups.
Observation 1 (Cond. A)
Assessment of depression score of group 3 before using PMR- Pre-treatment Condition.
Observation 2 (Cond. B)
Assessment of depression score of group 3 after using PMR- Post-treatment Condition.
Observation 3 (Cond. C)
Assessment of depression score of group 4 before using TM- Pre-treatment Condition.
6
Observation 4 (Cond. D)
Assessment of depression score of group 4 after using TM- Post-treatment Condition.
Data thus obtained for each of the two dependent variables namely anxiety and depression was
statistically analyzed with the help of analysis of variance. Separate ANOVA was used for
anxiety and depression.
The present study was concerned with the effectiveness of relaxation techniques in management
of anxiety and depression.Main variables involved in the study were anxiety and depression
which served as the dependent variables and the types of relaxation techniques namely
progressive muscle relaxation and transcendental meditation (modified) which served as the
independent variable. Both the dependent variables were studied under two conditions, pre-test
and post-test, for each of the two independent variables.
The main findings of the present research are as follows:
1. Relaxation exercise help reduce the level of anxiety among individuals.
2. There is a differential effect of Progressive muscle relaxation technique and
Transcendental meditation on level of anxiety among individuals.
3. There is an interactional effect of relaxation exercise and type of relaxation
techniques on level of anxiety among individuals.
4. Relaxation exercise help reduce the level of depression among individuals.
5. There is a differential effect of Progressive muscle relaxation technique and
Transcendental meditation on level of depression among individuals.
7
6. There is an interactional effect of relaxation exercise and type of relaxation
techniques on level of depression among individuals.
Implications
The findings of this study have significant implications which are presented in the following
paragraphs.
1. The findings of present piece of research work provide the conceptual implication in
understanding the relationship of relaxation techniques with anxiety and depression. It
was found that using relaxation techniques one can reduce and eliminate anxiety and
depression.
2. Progressive Muscles Relaxation (PMR) and Transcendental Meditation Technique
(TMT) emerged as significant relaxation techniques to help the individuals in reducing
these symptoms (i.e. anxiety and depression).
3. These relaxation techniques also indicate that sympathetic and conducive environment
can also reduce anxiety and depression possibilities. So, that one can also use these
techniques to avoid problematic situations and involvement in these psychological
problems.
Suggestions for Future Research
Research is not the end; it opens new ways for further studies. Therefore, on the basis of
present study the certain suggestions for future research are given in the following
paragraphs:
8
1. Since, the present study was undertaken on a sample of anxious and depressive
individuals only; though one should also include other psychological patients
experiencing different problems.
2. There are many relaxation techniques to reduce anxiety and depressive symptoms so one
should also use other relaxation techniques including Progressive Muscles Relaxation
(PMR) and Transcendental Meditation Technique (TMT). It will help them to compare
the level of effectiveness of these different techniques through which we can say that the
particular relaxation technique is more effective than another.
3. Future studies needs to consider other geographical areas other than the group which has
been studied. So that, one might be find other meaningful impact of these relaxation
techniques. Most of the time the same technique or medicine influence one individual
very effectively while others not, so it may also check that which type of personality get
more benefits by the particular relaxation technique.
1
Contents
Chapter 1 .................................................................................................................................... 4
Introduction ................................................................................................................................ 4
Some Familiar Advantages of Relaxation Techniques .............................................................. 5
Physiological Effects of Relaxation ....................................................................................... 6
Types of ―Relaxation Techniques‖ ..................................................................................... 7
Massage ........................................................................................................................... 8
Progressive Muscles Relaxation ...................................................................................... 9
Deep Breathing .............................................................................................................. 10
Transcendental Meditation technique ........................................................................... 10
Meditation ..................................................................................................................... 11
Biofeedback ................................................................................................................... 11
Autogenic Training ....................................................................................................... 12
Anxiety: Definition & Meaning ............................................................................................... 13
Anxiety Symptoms in Women and Men .................................................................................. 15
Types of Anxiety disorders ............................................................................................... 15
Generalized Anxiety Disorder ....................................................................................... 16
Specific phobia .............................................................................................................. 17
Panic Disorder ............................................................................................................... 17
Obsessive Compulsive Disorder (OCD) ....................................................................... 18
Social Anxiety Disorder ................................................................................................ 19
Some Contributory Factors of ―Anxiety disorders‖ ............................................................. 20
Hereditary Factors ......................................................................................................... 20
Biochemical Factors ...................................................................................................... 20
Life Experiences ............................................................................................................ 21
Personality Styles .......................................................................................................... 21
Thinking Styles ............................................................................................................. 21
Behavioural Styles ......................................................................................................... 21
Depression: Meaning and Definition ....................................................................................... 22
Major Depressive Disorders ................................................................................................. 24
Chronic Depression or Dysthymia .................................................................................... 25
A typical Depression ......................................................................................................... 25
Bipolar Depression or Manic Depression ......................................................................... 26
2
Some Common Signs of Depression ............................................................................. 26
Causes of Depression............................................................................................................ 27
Biological Basis of Depression ..................................................................................... 28
Psychological Basis of Depression ............................................................................... 29
Social Basis of Depression ............................................................................................ 29
The Relationship of Anxiety and Depression .......................................................................... 30
Objectives of the Study ............................................................................................................ 33
Chapter Two ............................................................................................................................. 34
Review of Literature ................................................................................................................ 34
Some Important Studies Related to Relaxation Techniques ................................................ 34
Some important studies related to anxiety ............................................................................ 49
Some Important Studies Related to Depression ................................................................... 59
Chapter Three ........................................................................................................................... 84
Methodology ............................................................................................................................ 84
Description of Variables ....................................................................................................... 85
Dependent Variables (DVs) .............................................................................................. 85
Independent Variables (IVs) ............................................................................................. 85
Progressive Muscle Relaxation ..................................................................................... 85
Some Examples of PMR Exercise ................................................................................ 86
Methods Adopted for PMR in the Present Investigation ......................................................... 87
Transcendental Meditation (TM): ..................................................................................... 88
Method involved in TM: ............................................................................................... 89
Measures used .......................................................................................................................... 91
Hamilton Anxiety Rating Scale (HAM-A) ........................................................................... 91
Back Depression Inventory BDI-II ....................................................................................... 91
Research Design ................................................................................................................... 91
Study Design for DV 1 (Anxiety) ..................................................................................... 92
Study Design for DV 2 (Depression) ................................................................................ 94
Participants ........................................................................................................................... 96
Inclusion Criteria of Participants in the Sample ............................................................... 97
Exclusion Criteria ............................................................................................................. 98
Procedure .............................................................................................................................. 98
Chapter four ........................................................................................................................... 100
3
Data Analysis (results) and Discussion ................................................................................ 100
Analysis for DV 1 (Anxiety) .............................................................................................. 100
Observation 1 (Cond. A) ................................................................................................. 100
Observation 2 (Cond. B) ................................................................................................. 100
Observation 3 (Cond. C) ................................................................................................. 100
Observation 4 (Cond. D) ................................................................................................. 100
Figure 1: Showing effect of factor p on Anxiety ..................................................... 105
Figure 2: Showing effect of factor q on Anxiety .................................................... 106
Figure 3: Showing p & q interactional effect on Anxiety ....................................... 107
Analysis for DV 2 (Depression) ......................................................................................... 107
Observation 1 (Cond. A) ................................................................................................. 108
Observation 2 (Cond. B) ................................................................................................. 108
Observation 3 (Cond. C) ................................................................................................. 108
Observation 4 (Cond. D) ................................................................................................. 108
Figure 4: Showing effect of factor p on level of depression .................................. 112
Figure 5: Showing effect of factor q on level of Depression .................................. 113
Figure 6: Showing p & q interactional effect on level of Depression ..................... 114
Chapter Five ........................................................................................................................... 115
The main findings of the present research ........................................................................ 115
Conclusion .............................................................................................................................. 127
Limitations of the Study ..................................................................................................... 129
Summary ................................................................................................................................ 129
AppendixONE Questionnaires .................................................................................... 137
Appendix TWOResearch Papers Published ................................................................ 143
References .............................................................................................................................. 145
4
Chapter1
Introduction
Relaxation is a lenitive state of body and mind serving as emollient to the straining situation.
The surrounding world of individuals is frequently making them tense leading to various
behavioural abnormalities such as anxiety and depression that are most common among them.
Effective measures are required to alleviate the adverse effect of surrounding situations
leading to anxiety and depression like problems. Relaxation techniques are the effective
measures which therapists use to manage anxiety, depression and behavioural problems
among individuals.
Sweeney (1978) described relaxation as a perceived state in positive direction giving a feel of
relief of tension or strain. The psychological aspects of the relaxation involve the feeling of
pleasantness and a reduced sensation of stressful and uncomfortable thoughts. Most often the
word ‗relaxed‘ is used to refer either to lax muscular body posture purported to peaceful and
comfortable thoughts. According to Titlebaum (1988) relaxation technique is a specific way
of physical movement of body that may include breathing in a rhythmic way, tensing and
relaxing the muscle in categorization or in a specific sequence. This is supposed to be as a
factor of lessening the perception of those stimuli which are stressful. This also calms down
the feeling of anxiety as well as tension, feeling of depression, stress and pain. McCaffery&
Beebe (1989) hold the view that relaxation exercises lead to freedom from anxiety and
skeletal muscle tension‘ while according to Ryman (1995) relaxation creates a state of balance
and peace in the mind of the participants. Whatever the technique is used, the crux of all
techniques include the diversion of attention of the participant from the stress full
environmental stimuli that impinge his thought patterns encompassing his expectations of
ideal life. Once the attention of the participant is diverted from the adversely affecting stimuli
5
of the environment, he feels relaxed and peaceful. Prolonged repetition of the relaxation
techniques help individual to get rid of the state of anxiety and depression. Relaxations
exercises are the supportive therapy that suggesting a way to reestablish a sense of well-being.
It delivers a holistic healing effect in the daily routine, affecting body, mind and spirit.
Therapists invariably use relaxation and imagery to treat various side effects of cancer,
cardiovascular and other major diseases.
In general term relaxation techniques/exercises are the potent means to manage stress and to
deal with psychological problems such as anxiety and depression. These are not merely
concerned with peace of mind nor these are a hobby to enjoying. Rather these techniques are
the process leading to reduce the effects of stress on individual‘s mind and reduce feeling of
anxiety and depression. Relaxation exercises/techniques serve as an aid to cope with routine
work stress and other kinds of feelings of stress related to many health issues.
Some Familiar Advantages of Relaxation Techniques
These are as follows:
Relaxation exercises/techniques help to maintain the rate of heart beat
Relaxation exercises/techniques help to maintain blood pressure
Relaxation exercises/techniques help to maintain rate of breathing
Relaxation exercises/techniques help to improve digestion
Relaxation exercises/techniques help to maintain blood sugar at normal level
Relaxation exercises/techniques help to reduce the activity of stress hormones
6
Relaxation exercises/techniques help to reducing the tension of muscle and
feelings of chronic pain
Relaxation exercises/techniques are helpful to Improve concentration of mind
Relaxation exercises/techniques are helpful to Improve the quality of sleep;
reducing the fatigue, anger and frustration and develop confidence to handle
problems
Physiological Effects of Relaxation
The relaxation response is a hypothalamic response that results into lessening in uproars of
sympathetic nervous system and normalize the consumption of oxygen, decreased muscle
tone, rate of heart, respiratory rate. It also has positive effect on body metabolism that is a
chemical processes that occur within an organism and is essential to maintain life. The
relaxation response is also reflected by decreased level of anxiety and depression (e. g.
Bensen,1975; Goldfried& Trier, 1974).
Benson (1974) emphasized that physiological effects to muscular relaxation are antagonistic
to anxiety and depression which cannot exist together. The relaxation response in man,
therefore, consists of changes to responses of stress that leads to restore normalcy. Wells
(1982) pointed out that there is an affiliation between muscle tension, autonomic hyper
arousal, anxiety and pain. The relaxation techniques help reduce feeling of anxiety and pain.
Researchers argue that the four basic principles are essential to obtain the relaxation response.
These are:
1. An uninterrupted stimulus such as a word, sound, phrase which may facilitate a shifting
from externally oriented thoughts. In other words we can say that the basic rudiment
behind this practice is to divert the attention of individual.
7
2. Secondly a passive attitude and the skill also required to discourage distracting thoughts
and give new direction leading to calmness of mind of individual.
3. A reduced muscle tone to mitigate the effects of distracting thoughts
4. An environment to prevent from all other disturbances.
There are many different kinds of relaxation techniques/exercises. Whatever is the kind of
relaxation exercise, the above four fundamental principles are commonly found in each and
every one. Here we will discuss some important types of relaxation techniques.
Types of “Relaxation Techniques”
Health professionals such as complementary health practitioners, doctors and
psychotherapists use various relaxation techniques. Commonly these exercises/techniques call
for shifting the focusing of attention from stressful events to something calming and
increasing awareness. Which relaxation technique should be adopted is not a matter of
concern. The main thing is that the person should practice relaxation on regular bases to
obtain its benefits. Some of the popularly known relaxation techniques are:
Massage
Progressive Muscle Relaxation (PMR)
Relaxation Response
Autogenic Training
Cue-Controlled Relaxation and Guided Imagery
Guided Somato-Psychic Relaxation (GSPR)
Transcendental Meditation
Yoga
Hypnosis
Biofeedback
8
Deep Rhythmic Breathing
Massage
Trevelyan (1996) pointed out that massage is a widely used harmonizing therapy in nursing
practice helping patients to overcome psychological as well as other health problems.
According to Ching (1993) massage is an essential part of the care of an individual wounded
or sick particularly those who need emotional healing and renewal. He described massage as a
touch therapy (i.e. ―an extended form of touch‖) resulting in exchange of that soothes the pain
and delivers a very real form of tender loving care. According to him massage reduces the
feeling of burden bringing forward the movement of peace producing relaxation thereby
increase pain thresholds and change a person‘s perception of pain. Studies like Ferrell-
Torry& Glick, (1993); Longworth (1982); Stevensen (1994) have indicated that massage
therapy decreases level of anxiety; maintain blood pressure level, heart rate and respiratory
process and reduces feeling of pain. Some other effects of massage that have been intensively
researched show that massage results in easing insomnia, headache and migraine, backache,
bereavement, angina, drug rehabilitation (reducing tension, easing muscle cramps). A gentle
pressure on the hand is one of the most meaningful communications that a nurse can have
with a dying patient(e. g. Kubler-Ross, 1970; Maxwell,1988).
Joachim (1983) during her various practice sessions observed a beneficial effect of massage
while treating the aged patients. She found foot massage a very useful technique. Sims (1998)
argued that massage has positive effect in the treatment of anxiety. Sims emphasized that the
feet are a safe place to massage. A caring, sympathetic touch may communicate security,
reawaken an individual‘s remaining perceptual capacity, facilitate communication and prevent
isolation and social withdrawal. Some researches have shown that the touch of another human
9
being for duration of less than one second can make people feel better (e. g. Doehring, 1989
&Turton, 1989).
Progressive Muscles Relaxation
In a Progressive muscle relaxation exercise participants learn to watch and rein the state of
tension. It was propounded by E. Jacobson in 1920.
There is a variety of publication by Jacobson on Progressive Relaxation. The technique
proposed by Jacobson is a learning session to watch the tension in each distinguished muscle
group in the body that includes intentional induction of tension and releasing it in the each
specified muscle group. In this technique an attention is paid to differentiate tension with
relaxation. These sessions of learning, according to Jacobson, cannot be considered as
exercises or self-hypnosis.
"Biofeedback" is a modified version of the relaxation technique is in which therapists use
external measuring devices to show successfulness of relaxing and then they suggest to use
them without measuring changes within the body.
PMR sessions are organized in a low illuminated room in which the participants position them
in a comfortable situation and keep their eyes closed. Learners are instructed to relax, if they
have any has any distracting thoughts, they are suggested to let it go. They are advised not to
indulge in problem solving. In training sessions an observer reviews the procedure of each
and every participant. Persons slow in learning processes ar given special attention. Learners
are advised to maintain regularity and punctuality in the practice relaxation in their routine
and daily lives. (e. g. Craske& Barlow, 2006).
10
Deep Breathing
―Diaphragmatic breathing, abdominal breathing, belly breathing or deep breathing is
breathing that is done by contracting the diaphragm, a muscle located horizontally
between the thoracic cavity and abdominal cavity. Air enters the lungs and the belly
expands during this type of breathing‖.
Transcendental Meditation technique
It is a specific technique in which mantra play an important role. This technique was
developed by Maharishi Mahesh Yogi which is known as ―Transcendental
meditation‖ (TM). Use of mantras is the base of this practice involving a practice for 15 to
20 minutes twice per day. The participants are required to sit comfortably and their eyes
closed. ―Transcendental meditation‖ is one of the most popular and widely practiced
techniques to manage anxiety and depression. It is also among the most widely researched
meditation techniques. ―Transcendental Meditation‖ technique began in 1965 and has
become essential part of activities of various schools, universities, and.
Some people consider ―Transcendental Meditation technique‖ as a part of religion while
others consider it as non-religious. Over the years ―Transcendental Meditation technique‖
has been praised for its popularity in mass media while, on the other side, some people
criticized for using celebrity and scientific endorsements as a marketing tool. In 1970, the
―Science of Creative Intelligence‖ became the theoretical basis for the ―Transcendental
Meditation technique‖. Some non-believers however, raised questions on its scientific
nature. Supporters of the technique claim that practicing TM in routine manner positively
affects the quality of life. This has been termed as the ―Maharishi Effects‖. Schneider,
Robert; Fields, Jeremy (2006) studied the effect of TM among the patients suffering from
11
heart problem. They found a significantly positive effect of this technique on the heart
patients.
Meditation
In meditation practice persons get acquainted to induce a mode of consciousness either to
become aware of some benefits or to acknowledge the content of meditation without
becoming identified with that content. Meditation includes different types of practices like
techniques developed to promote relaxation, to develop energy or life force within oneself
and to develop compassion, love, patience, generosity and forgiveness. Meditation has the
specific characteristic that it aims at effortlessly sustained single-pointed
concentration meant to enable its practitioner to enjoy an indestructible sense of well-
being while engaging in any life activity. The word meditation carries different meanings
in different contexts. Meditation has been practiced since old age as a part of numerous
religious traditions and beliefs. It commonly involves an internal effort to self-regulate the
mind in some way. Most often it is used to clear the mind and ease many health concerns,
such as high blood pressure, depression, and anxiety.
Biofeedback
A consensus definition of biofeedback was proposed by three organizations in 2008.
These organizations are:
i. ―Association for Applied Psychophysiology and Biofeedback‖
ii. ―Biofeedback Certification International Alliance‖
iii. ―International Society for Neurofeedback and Research‖
According to these organizations biofeedback ―is a process that enables an individual to learn
how to change physiological activity for the purposes of improving health and performance.
In this technique some physiological activities such as heart function, brain waves, breathing,
12
muscle activity, and skin temperature are measured by certain reliable instruments. These
instruments rapidly and accurately give information (feedback) to the user. The presentation
of this information, usually in conjunction with changes in thinking, emotions, and
behaviour, supports desired physiological changes. Over time, these changes can endure
without continued use of an instrument.‖ In other words biofeedback is a process of
improving awareness of physiological reactions within the body. Person realizes these
reactions with the information provided by some scientific instruments. It involves controlling
of some processes such as ―brainwaves‖, ―muscle tone‖, ―skin conductance‖, ―heart rate‖
and ―pain perception‖. This technique is widely used for betterment of health, performance at
work, and the changes in physiological status that usually occur as a result of changes in the
thoughts of a person, changes his emotions and changes in his behaviour. After giving
feedback about physiological functioning (i.e. ―Biofeedback‖) with use of external
equipments for a reasonable time, these changes may eventually be maintained without using
these external instruments. This technique is very useful for the remedy of usual headaches as
well as severe pain of migraines (e. g. Nestoriuc, Martin, Rief, and Andrasik 2008).
Autogenic Training
This training refers to the ―desensitization-relaxation technique developed by
the German psychiatrist Johannes Heinrich Schultz‖. It was published for the first time in
1932. Practice sessions of this technique comprised visualizations inducing a state of
relaxation of 15 minutes duration three times daily usually in morning, at lunch time, and in
evening. In each session a set of visualizations is repeated. There is a set of recommended
positions such as sitting meditation, lying down, or sitting like a ―rag doll‖ etc. Participants
can practice in a position selected from the above recommended set of postures. This
technique has been found useful to alleviate many psychosomatic disorders induced by
stressful events.
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Anxiety: Definition& Meaning
Normally anxiety exists with everyone and it is a part of our routine life. In general way it is
considered as a reaction to stressful events and up to some extent it is beneficial in some
routine matters. The normal anxiety usually alerts individuals for incoming uncertainties. It
helps persons to be ready to face adverse situations. So far as ―anxiety disorders‖ are
concerned, a difference exists between anxiety disorders and normal feelings of anxiety.
Anxiety disorders are characterized by unusual fear which is a most common among mental
disorders. It influences a significant proportion of adults at some point in their lives. It is
commonly observed that anxiety does not go away from an individual having anxiety
disorder. Moreover it can get worse over time. Anxiety among the individuals is detractive to
the routine activities which may include job performance, social relationships and the family
environment. Anxiety disorders are of many kinds such as ―generalized anxiety disorder‖,
―panic disorder‖, and ―social anxiety disorder‖. The anxiety disorders are curable with the
help of a variety of effective treatments.
According to Barlow (1988) ―anxietyis a mood state characterized by marked negative affect
and somatic symptoms of tension in which a person apprehensively anticipates future danger
or misfortune‖. American Psychiatric Association (1994) explains anxiety ―as a state of
uneasiness and apprehension, as about uncertainties of future‖. Many thinkers believe that
―anxiety is a multisystem response to a perceived threat. It reflects an amalgamation of
biochemical situation‖. Though anxiety is a common phenomenon experienced by all of us
from time to time, it is very difficult to give a concrete description of it because of many
potential causes and degrees of intensity of anxiety. Practioners/researchers usually classify
anxiety ―as an emotion or an affect‖. As per an estimation of Surgeon general of US more
than 6 million US children suffer from anxiety, making it the most common problem of US
children. Seligman, Walker &Rosenhan (2001) emphasized that ―anxiety is comprised of
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cognitive, somatic, emotional and Behavioural components‖. The cognitive aspect of anxiety
is related to the expectations of a diffused and uncertain danger. The somatic component is
related to preparedness of organism to face uncertainties and dangers (most often it is referred
to as emergency reactions). It includes an increase in ―blood pressure‖ and ―heart rate‖, raised
level sweating, amplified blood flow to the muscle groups and an inhibition in ―immune and
digestive system‖. Somatic signs of anxiety that can be observed are sweating, pale skin, and
trembling. On the emotional component, anxiety causes a sense of trepidation and
nervousness and on physical aspect it causes nausea, and chills. The behavioural component
may include voluntary as well as involuntary behaviours leading to escape the source of
anxiety. These behaviours are usually maladaptive. The conflict and other types of frustration
that block the persons‘ capabilities also produce anxiety.
Thinkers believe in the pervasive nature of anxiety. It is present in all people not merely some
of the time, rather it is present in all people in some or other form a lot of the time. We all
believe that anxiety is a part of life but some situations give it a form of disorder. Persons
having anxiety may reach to a situation where it become difficult to cope with it, this situation
may leads to anxiety disorder. All of us devise methods at conscious as well as at unconscious
level to overcome the adverse effects of anxiety and most of the time we don‘t realize it to be
excruciating but some persons are not able to devise the methods to cope with it. Since
anxiety is characterized by scary feelings of fear or looming threats reflecting bodily reactions
of persons when confronted with an unmanageable event or situation. Persons under the
circumstances leading to anxiety actively assess the situation, sometimes consciously and
sometime even automatically without paying conscious attention, and develop strategies to
cope with it. Their past experiences form the bases for developing the coping strategies.
15
Anxiety Symptoms in Women and Men
Symptoms of anxiety among male and female persons are similar up to a large extant but in
some cases there is a difference in the anxiety related symptoms of men and women. As for
example, females manifest more symptoms of anxiety particularly related with their
menstruation cycle. Feeling of anxiety is the mainspring accounting for ―stress hormones‖ to
enter the ―bloodstream‖ and reaching the specific places within the organism and produces
some emergency reactions and the person get ready for immediate action with the help of
these reactions. Other hormones are also influenced by the stress hormones and women are
more likely to manifest anxiety symptoms because stress hormones have an impact on those
hormones which affect the menstruation cycle of females. Some biological changes during the
pregnancy period also increase anxiety symptoms among females. Similar position is also
supposed to occur during postpartum recovery, and under menopause situation. Studies show
that females are also more emotionally-centered than males that‘s why symptoms of anxiety
among them appears to be more numerous and acute. Specific conditions are not limited to
women only. Men also face challenges and stress hormones also have an influence on male
hormones. Emotionally-centered male persons are more likely to face more anxiety in a
similar way as women.
Types of Anxiety disorders
Anxiety disorders nowadays have become very common among the people of every walk of
life. No doubt these disorders are a serious psychological problem. Fatigue, terribleness and
fear are constant and overwhelming features for people suffering with anxiety disorders.
There is a variety of anxiety disorders that involves ―generalized anxiety disorder‖, ―social
anxiety disorder‖, ―panic disorder‖, and ―specific phobias‖.
16
Generalized Anxiety Disorder
The generalized anxiety disorder is characterized by the persistent and exorbitant worries.
Most often it is related with daily situations such as family environment, health problems,
office work, etc. Most often people have difficulty to cope with these situations and usually
experience restlessness and bother in sleeping and also feel deficiency in concentration.
Persons having ―generalized anxiety disorder‖ manifest too much concern over minor things
for months and face too many anxiety-related symptoms. ―Generalized anxiety disorder‖
symptoms are many. Some of them are as follows:
―A general feeling of uneasiness‖
―Persistent alert for danger‖
―Persistent tension and worry‖
Over-cautiousness
A constant feeling of being unsafe
over-reactive to things perceived as threatening
Being easily fatigued
Trouble in concentrating
Feeling of blankness in mind
Irritability and irksomeness
Feeling of muscular tension
Sleep problems
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Specific phobia
Persons suffering with specific phobia disorder usually feel higher order fear when come face
to face with a particular feared object or situation. Afraid of something is a common
phenomenon but phobias are the fears of higher order that seem remarkably strong. Common
phobias may include fear of deep water, fear of heights, fear of congested spaces, fear of a
particular animal like dogs, snakes, spiders, etc. Some common symptoms of phobia are as
described below:
Excessive fear of a specific situation, a particular person, an object, etc.
When person come near to the feared subject his sense of danger increases.
Constant worry over the ―feared subject‖
Many of the behavioural symptoms like shivering, trembling, etc.
Panic Disorder
Panic Disorder is caused by sudden surge of looming threats appeared without any signal.
Most often ―panic attacks‖ are short lived continuing for few minutes only, but can occur
repeatedly. Persons suffering from panic disorder experience panic attacks frequently and
unexpectedly which occur all of sudden accompanied by intensive fear leading to increased
palpitation, increased rate of heart beats; sweating and reduced rate of breathing; trembling;
etc. Although the panic attacks and their symptoms are short lived lasting for few moments,
but sometime may continue for few hours. During the attack, most people feel a terrible fear,
nervousness, and foreboding accompanied by a strong urge to escape. Specific symptoms of
panic disorder are as follows:
Feelings of being out of control
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Sudden and repeated attacks of terrible fear
Intensified apprehensions about the next attack
Person usually avoid those places where panic attacks were occurred
Intense feeling of destruction
Light-headedness
Sweating and heart palpitations
Nervous stomach
Trembling and increased stimulation
Feeling overwhelmed
Feeling of pins and needles
Feeling of throat tightness
Obsessive Compulsive Disorder (OCD)
The main characteristic of ―obsessive compulsive disorder‖ is the repeated and upsetting
thoughts called obsessions. For instance, a person can feel the presence of germs everywhere.
He may try to avoid this feeling for which the person repeatedly manifest certain behaviours
which is called compulsions. A person having a feel of germs everywhere may repeatedly
wash the hands or clean the various places. Although people with OCD usually know that
their obsessions and compulsions are an over-reaction but they can't stop them. OCD
symptoms include:
Relentlessly worrying
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Underlying fear of harm
Unusual apprehensions
incapability of self-soothing
Uneasiness
Unusual stimulation
Sleeplessness
Social Anxiety Disorder
Persons suffering with ―social anxiety disorder‖ usually avoid the collective programmes and
public gathering because of the unusual apprehensions of criticism and negatively evaluation
by others. These persons are usually afraid of doing something that leads to awkwardness.
The main characteristic of ―social Anxiety Disorder‖ is over anxiousness in public gathering
or social situation. Persons with this disorder also have greater degree of fear of rejection.
They usually struggle for self-worth and self-esteem. Symptoms of ―social anxiety disorder‖
include:
Acute feelings of uneasiness when come near those who are deemed to be important
Over concern about the thinking of people as what they will think for them
Over cautious for unexpected reactions of others
Hyper sensitive with a fear of being rejected
Over-sensitive for criticism
Excessively criticize others
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Excessively self-conscious when interact with other people
Think excessively with a high degree of perturbation for a long time prior to an event
where other people are expected to be present
Usually take a position away from gathering of people
Feel difficulty in maintaining friendship
Shivering, trembling, sweating is a common manifestation in some specific situations
Have a feeling nauseous or sick in public gathering
Some Contributory Factors of “Anxiety disorders”
There is no well defined explanation about the factors responsible for ―anxiety disorders‖. But
one thing is clear that there is no single cause of high anxiety. There are various factors that
may develop anxious thoughts and behaviour. Some of them are as follows:
Hereditary Factors
Researches show, ―some people with a family history of anxiety are more likely to
experience anxiety‖.
Biochemical Factors
A number of studies suggest, ―people who experience a high level of anxiety may
have an imbalance of chemicals in the brain that regulate feelings and physical
reactions. Medication that helps to correct this imbalance can relieve some symptoms
of anxiety in some people‖.
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Life Experiences
Thinkers argue that ―certain life experiences can make people more susceptible to
anxiety. Events such as a family break-up, abuse, ongoing bullying at school and
workplace conflict can be stress factors that challenge a person's coping resources and
leave them vulnerable to experiencing anxiety‖.
Personality Styles
This is well established that “certain personality types are more at risk of high anxiety
than others. People, who have a tendency to be shy, have low self-esteem, and a poor
capacity to cope is more likely to experience high levels of anxiety‖.
Thinking Styles
“Certain thinking styles make people more at risk of high anxiety than others. For
instance, people who are perfectionist or expect to be in constant control of their
emotions are more at risk of worrying when they feel stress‖.
Behavioural Styles
―Certain ways of behaving also place people at risk of maintaining high anxiety. For
instance, people who are avoidant are not likely to learn ways of handling stressful
situations, fears and high anxiety‖.
A close look into the various symptoms and causes of anxiety reveals that in all kind
of anxiety there is an uneasy and uncomfortable bodily situation. An apprehension of
untoward incidences, threats from others creates a body and mind situation opposite to the
relaxed position. For this reason relaxation techniques have been found useful for the
treatment of anxiety disorder.
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Depression: Meaning and Definition
Depression includes the effect of mood, and thoughts on the person‘s way of sleeping,
eating, or the manner in which he/she thinks about others, himself, about things and objects. It
is not the situation of some weaknesses within one self that can be wished away. Symptoms
of can continue for several weeks, months, or even years, if proper treatment is not taken.
There are many types treatments for depression. Appropriate treatment can reduce the level of
depression. Among the major symptoms of depression trouble in concentrating, remembering,
or making decisions are most common. Constant feeling of anxiety, pessimism, worthlessness
and indifferent attitude for those activities that were interesting or enjoyable at one time are
some other behavioural manifestations of depressive personalities. It may include overeating
followed by weight gain; indigestion and loss of appetite followed by weight loss, inability to
express emotions; feeling of high level fatigue and weakness, sleeping disturbance
like insomnia, or oversleeping; unusual restlessness; social withdrawal; continuous physical
problems like chronic pain or indigestion usually not curable with drugs.
Depression as a mood disorder is well known from ancient times. with continued
efforts to elucidate the nature of this aspect of the human condition. The ancient and modern
concepts of depression have many similarities. Several studies have demonstrated that the
thinking about self among depressed is more negative and depressed persons show less
positive automatic self-referential thinking. Researchers have found that the depressed people
are highly self-critical and negatively evaluate the stimuli other than the self-including
imagined happenings and other people. There is also a growing number of evidences that
emotional states influence memory of the persons having depression (e. g. ―Brown & Taylor,
1986; Grosscup&Lewinsohn, 1980; Hockanson, Hummer, &Gulter, 1990; Ingram, Slater,
Atkinson, & Scott, 1990; Kendall, Howard &Hays 1989‖).
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Singh (1995) emphasized that sentimental state of a person does influence self-
reference effect depressed persons typically and experience high levels of anxiety and anger
that is turned inward to give a feel of low self-esteem, hopelessness and thoughts of death.
Persons with strong level of depression can also manifest some Behavioural and symptoms
such as high level of fatigue up to the bedridden position along with insomnia; frequent
crying and shouting, aches and pain of sever level, too much gain or loss of weight, etc. Thus,
depression is a multifaceted many-sided syndrome that includes a large number of underlying
dimensions which are not temporary or situational in nature. Rather it is characterized by
persistent and pervasive feeling of sadness or hopelessness followed by weight loss or gain;
sleeplessness or oversleeping, constipations/indigestion, disturbances in sexual functioning,
and/or feelings of guilt of self-blame.
According to the ―Diagnostic and Statistical Manual of Mental disorders‖ (DSM-IV), ―the
presence of depressed mood or sadness, or loss of pleasure in life, is an important diagnostic
criterion for depression‖. Feelings of fatigue in routine work, reduced level of energy,
insomnia or hypersomnia are some other indicators of a depression. Various investigators
have reported that about 90% of people with depression feel fatigue in routine work.
Depression may grow over a long period may be accompanied by an increased frequency of
smoking. In a survey carried out in the St. Louis area that covered a sample of 3000
individuals was found that lifetime frequency of major depression is more common among
smokers than non-smokers.
Depression can be observed worldwide in all age groups of men and women both. It has been
found a common emotional disorder and causes notable hardship to patients. At present more
than fifty percent prominent factors of suffering are psychiatric disorders including
depression. On the bases of survey and research findings, thinkers predict that by the time
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2020 depression will be the second largest cause of suffering-next only to heart disease.
Depression is alarmingly predominant in Indian population too. Studies conducted nationwide
have demonstrated prevalence of depression is around 30-35 cases per 1000 population. No
doubt the depression is a serious disease and the availability of effective treatment is not
adequate. Merely around 30% cases receive appropriate care. Furthermore the situation of
availability of effective treatment is much worse in the South East Asian Region. In spite of
its conjoint incidence in the community, depression is not recognized as a serious disease and
often poorly treated even by the doctors. It is, therefore, essential to create awareness among
the general public and also the medical community about the manifestations of illness,
process of diagnosis and proper management of depression. According to an estimate people
born after 1960 are 10 times more prone to become depressed. Ecological factors may also
play a major role. When persons are having lack of social bonds or disrupted relationships
because of a sudden change in status such as joblessness, the depression is more likely to
occur. The family loss and emotional turmoil caused by the death of a family member,
departure or divorce of their parents or child abuse or neglect also have significant impact on
the feeling of depression. Negative life events and circumstances also play a significant role
to increase the risk for depression. These negative life events may include economic and
financial problems, a dangerous disease, or a major loss, abuse, etc. Major depressive disorder
commonly tends to run in families. Immediate and severe stressful situations such as the loss
of a spouse or a job, being unmarried, loneliness & helplessness for a long period, can lead
people in depression. Those persons who are genetically predisposed are more prone to show
depressed behaviour.
Major Depressive Disorders
According to the ―National Institute of Mental Health‖, major depressive disorder is
characterized by multifarious symptoms including persons‘ inability to perform routine work,
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sleeping disturbances, problems in study, eating, etc. It may include problems in all those
activities which person had enjoyed and these were pleasurable activities for him. Normally,
persons can have feeling hopelessness, sadness or loneliness for a short period of time. But
major depression continues for a longer time and put individual out of action. Perturbing the
normal functioning of individuals a clinical depressive episode may occur only once in
lifetime, however possibilities of recurrence are there. Additionally, either a depressed mood
or lack of interest is an essential symptom for major depression. Another aspect of major
depression is that some symptoms of it must persist for about two weeks constantly. Also, the
illness must cause clinically significant deterioration in normal functioning. The deteriorative
effect should not be due to the medications or any other medical condition.
Chronic Depression or Dysthymia
A prolonged depressed mood for about two years or more is a major characteristic of
dysthymia. There are many other symptoms which are also connected with major depression
but they are not sufficient for the diagnosis of this type of depression. Dysthymia is less
severe and somewhat benign than ―major depression‖. It is like persistent serene/mild
depression which usually does not push the person out of action. Dysthymia can lead to one
or more episodes of major depression in person‘s lifetime.
A typical Depression
Some major symptoms of a typical depression may include:
Oversleeping
Overeating
Sensitivity to rejection at extreme level
Unusual fatigue
Moods that worsen or improve in direct response to events.
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Besides the above symptoms typical depression also reflects pervasive sadness difficulty in
sleeping, indigestion and loss of appetite.
Bipolar Depression or Manic Depression
Bipolar depression is a disorder characterized by complex mood which is also referred to as
manic depression. The bipolar depression as described by various researchers a ―alternates
between periods of clinical depression and times of extreme elation or mania‖. Broadly two
categories of bipolar depression are well known. These are as follows:
A. Bipolar I: In this category of depression individual has experienced at least one manic
episode that might have occurred in conjunction with major depressive episodes or
without it.
B. Bipolar II: In this type of depression person have a history major depression along
with hypomanic episode.
Some Common Signs of Depression
Constant feelings of sadness or ―empty‖ mood
Constant feelings of ―hopelessness‖ or ―pessimism‖
Feelings of guilt, worthlessness, and helplessness
―Withdrawal from pleasurable activities‖
―Insomnia/ oversleeping‖
―Restlessness and irritability‖
―Early morning awakening‖
―Loss of appetite followed by loss of weight or overeating followed by weight gain‖
―Feeling of decreased energy/high level of fatigue‖
Constant feeling of being ―slowed down.‖
―Thoughts of death or suicide‖
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―Difficulty in concentrating and remembering accompanied by trouble in decision
making‖
Problems like headaches, digestive disorders, and chronic pain, if not curable by
traditional treatments, may also be signs of depressive illness.
Most often individuals are not able to detect depression in their lives for its gradual creeping
nature. Depression not necessarily occurs all of a sudden. It can develop gradually and even
unnoticeably. Persons with depression may gradually withdraw themselves from active
participation of social and enjoyable events. Some clear incidences such as divorce,
dissolution of long-term relationship or other family problems may cause depression.
Understanding the causes of depression isn‘t as important as its appropriate treatment.
Mourning for demise of beloved is common and not considered as depression. Some usual
mood swings are common among many people particularly youngsters which may resemble
with the symptoms of depression though it is not a depressive episode. Depression usually hit
adults and females are more susceptible to be depressive as compared to males. It is theorized
that ―men express their depressive feelings in more external ways that often don‘t get
diagnosed as depressed‖.
Causes of Depression
Various causes of depression are as follows:
―Abuse‖: The acute past experience of emotional, sexual or physical abuse may call
unwelcome situation causing to the depressive disorder on later stage of life.
―Medications‖: There are various kinds of drugs which have adverse side effects and
may lead to the development of depressive disorders. For instance, corticosteroids use
of corticosteroids for a long time can increase the risk of depression.
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―Conflict‖: Frequent outpour of disputes and conflicts within the family or outside
may result into the development of depression.
―Separation from the beloved‖: Some time separation from the beloved may result into
the depressive disorder because of the persistent grief from the loss of a loved one.
―Genetics‖: It is assumed that ―depression is a complex trait that may be inherited
across generations, although the genetics of psychiatric disorders are not as simple or
straightforward as in purely genetic diseases‖.
―Major events‖: Sometime highly desired events like appointment on a higher
position, marriage with desired one may result into depression.
―Dangerous disease‖: Dangerous disease mostly lead to the feeling of depression
Biological Basis of Depression
According to Emslie (1994) ―biological bases of depressive disorders have been
comprehensively examined in adults and to a more limited extent in children and adolescents.
Our acquaintance of the human brain is still fairly limited; therefore we do not categorically
know what actually happens in the brain to cause depression. It is likely that with most
illustrations of clinical depression, neurotransmitter function is disordered. Neurotransmitters
are supposed to carry signals from one part of the brain to the other. There are many
neurotransmitters helping dissimilar purposes. However, three significant ones that affect a
person‘s mood are serotonin, noradrenalin and dopamine. In normal brain function,
neurotransmitters interrelate with a series of nerve cells, with the signal being as strong in the
second and succeeding cells as it was in the first. However, mood regulating
neurotransmitters do not function normally among those persons who are depressed and the
signal is either depleted or disrupted before passing to the next nerve cell‖.
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Psychological Basis of Depression
Research findings reveal, ―the influence of psychological factors may best be described as the
psychological characteristics, strengths and weaknesses, as well as competence. It is not fully
recognized what is the actual cause of clinical depression for a particular one. Many theories
explain about causes of depression such as biological and genetic factors, environmental
influences, and childhood or progressive proceedings. However, it is commonly supposed that
clinical depression is furthermost often caused by the influence of more than just one or two
factors. As for example, those persons whose mother/father had recurrent major depression
may have inborn a vulnerability to emerging clinical depression (Here genetic factor is
operating). This occurs in conjunction with how the individual thinks about him- or herself
(here psychological influence is working) in response to the stress of going through a divorce
(environmental influence), may put him or her at a greater risk for developing depression than
someone else who does not have such influences. The reasons of clinical depression are likely
to be dissimilar for different people. Sometimes a depressive episode can seem to come out of
nowhere at a time when everything seems to be going fine. Other times, depression may be
connected to noteworthy events such as losing the beloved, experiencing trauma, or battling a
dangerous disease‖.
Social Basis of Depression
The social bases of depression signify the importance of social environmental which is
comprised of a large number of variables. Social influence is encompassed by: stressful
events that may include acute experiences of the past, nuisances and chronic strains in routine
life; interventions of parents that may include accessory, marital disharmony; social support
peer and relational interactions; and a host of social and environmental influences such as
social disadvantage, exposure to violence, maltreatment, peer and social pressures, etc.
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The Relationship of Anxiety and Depression
There is a considerable overlap that seems to exist between the emotional states of
anxiety and depression. It is worthwhile to understand the reactions of anxiety to depression
as there is both similarity and difference between the symptoms and causes of these two
disorders. A number of explanations for this distinction have appeared (Kendell&Waston,
1989) but several theorists have now determined that anxiety and depression are more alike
than they are dissimilar. Considering anxiety and depression alike may appear bizarre as
anxiety and depression sound like dissimilar mood states and thinking of person‘s own
reactions. Persons feel diverse when they are anxious compared to when they are depressed.
However, it is fact that almost everybody who is depressed particularly to the extent of
psychological disorder is also anxious (e.g. Barlow, 1988) but not everybody who is anxious
is depressed. The indication that anxiety and depression are thoroughly connected is relatively
strong, based on neurobiological studies (e.g. Breier, Charney&Heninger, 1985) and family
studies of people with anxiety and depression. If anxiety runs in assumed family, depression
is likely to run in the similar family. If one has a high score on a scale measuring depression is
likely to have a high score on another measuring anxiety. There is a question whether or not
any significant difference exists between the symptoms of anxiety and depression. New
developments from various research centres elucidate a difference between anxiety and
depression. As demonstrated by previous studies, ―almost all depressed patients are anxious,
but not all anxious patients are depressed‖. This implies that there are certain symptoms of
depression that are not found in states of anxiety (e.g. Tellegen, 1985; Watson, Clark, &
Carey, 1988; Kendall&Watson 1989; Clark & Watson, 1991). Cognitive content (what one
thinks about) also seems more negative in depressed persons than in anxious individuals (e.g.
Greenberg & Beck, 1989).
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The foregoing discussion clearly reveals that the problem of anxiety and depression is
day by day becoming a common disease influencing a significantly large proportion of
population. The problem of depression and anxiety not only affect the normal functioning and
performance at individual level but also in some or other ways it will affect productivity at
larger level. Problems related to depression and anxiety are curable as treatment of these
diseases is not too difficult but the availability of forma treatment is inadequate and expensive
that everyone cannot afford. With this point of view the home based curative measures
requiring little or no supervisory care and best suitable to the norms and traditions of a
particular society will of great value to that society.
Relaxation technique, as evident from various studies, is a useful curative measure for
depression and anxiety can be organized under close supervision as well as independently. It
has no side effects. The main aim of the present investigator was to evaluate the effectiveness
of relaxation techniques and to identify the best suitable technique for the people of his home
country ―Jordin‖. For these purposes two relaxation techniques namely ―Progressive Muscle
Relaxation‖ (PMR) and ―Transcendental Meditation‖ (TM) with some modification to make
it suitable for Jordanians were undertaken to compare their effect on anxiety and depression.
These two techniques were used in most simple form in such a way that does not require
supervisory care.
A growing number of studies have demonstrated significant positive effects of
―progressive muscle relaxation‖ and ―transcendental meditation‖ along with some other
relaxation techniques on depression and anxiety (e.g. ―Kaina, Xiaomei, Jin, Miao, Dang,
Wang, and Xia, 2015; Knapen, Sommerijns, Vancampfort, Sienaert, Pieter, Haake, Probst,
and Peuskens, 2009; Gian, Francesco, Gianluca and Enrico, 2008‖). Moreover, ―Farnaz,
Nahid, Negar, Shakeri‖ (2015)recommended that ―due to the relaxation effect on reducing
32
depression, anxiety and stress, and also lack of side effects and its easy applicability, this
method can be used as an approach to reduce depression, anxiety and stress in women during
pregnancy‖.
Various studies related to anxiety and depression reveal differential effect of different
relaxation techniques while few studies show similar effect of different relaxation technique
on anxiety and depression (e.g. ―Gian, Francesco, Gianluca and Enrico, 2008; Morgan,
1998; Allan, and Jonathan, 1989‖. Details of various studies is presented in 2nd
chapter- Review of Literature).
Zautraand Davis (2008) from their research findings indicated that ―the meditation
based therapies and emotion regulation aspects of the treatment were most beneficial to those
with chronic depressive features‖.
Ströhle (2009) critically evaluated a number of researches to find out the effect of
physical activities and exercises to manage anxiety and depression. The author elucidated
that ―there is a lack of knowledge on how to best deal with depression and anxiety related
symptoms which hinder patients to participate and benefit from exercise training‖.
From the available literature it is not clear which relaxation technique is most
effective? Quite a large number of researches show that mediation based relaxation
interventions are more beneficial. Thus it was assumed that ―transcendental meditation‖ as
compared to other relaxation technique will have a greater curative effect on anxiety and
depression. ―Progressive Muscle Relaxation‖ technique was used for the purpose of
comparative analysis. Moreover, TM was modified to give religious orientation based on
Islamic concept. It was assumed that the focus of attention if shifted from complex social
situation towards God, the person will be away from all kinds of tensions. Repetition of this
practice is supposed to restore normalcy of mental state. It was further assumed that this
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modified version of transcendental meditation will be more effective as compared to any
other kind of relaxation exercise because a person having complete faith in God is not
supposed to be worried about anything. As per the Islamic philosophy, the person has to put
in his best possible efforts and he will get good results but as per the desire of God. Such type
of faith is not found in any other practice of relaxation. Thus the present investigation was
undertaken to test these assumptions. More specifically, the study was undertaken with
following objectives.
Objectives of the Study
1. To test the effect of PMR on anxiety
2. To test the effect of PMR on depression
3. To test the effect of TM (modified) on anxiety
4. To test the effect of TM (modified) on depression
5. To test the difference in effectiveness of PMR and TM (modified) in management of
anxiety.
6. To test the difference in effectiveness of PMR and TM (modified) in management of
depression.
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Chapter Two
Review of Literature
In this chapter we will review those studies which are directly or indirectly related with the
variables under study in the present investigation. The main variables of the study were
relaxation techniques (served as independent variable) and anxiety & depression (served as
dependent variable)
Some Important Studies Related to Relaxation Techniques
Benavides S. and Caballero L. (2009) conducted a study to see the effect of relaxation
exercise on type 2 diabetes. They used yoga as relaxation technique with the objective to
determine the effect of yoga on weight in youth at risk of developing type 2 diabetes. The
second objective of the research was to study the impact of participation in yoga on self-
concept and psychiatric symptoms. In a prospective pilot Ashtanga yoga program of 12 weeks
duration, they enrolled twenty children and adolescents. Weight was measured before and
after the yoga program. Participants also completed self-concept, anxiety, and depression
inventories before and after the program. A group of 14 predominantly Hispanic children
aged between 8 to15 years completed the program. Findings revealed an average weight loss
of 2 kg. Four of five children with low self-esteem improved, although two had decreased in
self-esteem. Anxiety symptoms improved in the study. It was concluded that Ashtanga yoga
may be beneficial as weight loss strategy in a predominantly Hispanic population.
Brown and Gerbang (2009) critically evaluated various researches related to relaxation
exercises particularly conducted within the domain of yoga. They stated that Yoga breathing
is an important part of health and spiritual practices in Indo-Tibetan traditions. Considering
fundamentals for the development of physical well-being, meditation, awareness, and
enlightenment, it is both a form of meditation in itself and a preparation for deep meditation.
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They pointed out that Yoga Breathing (pranayama) can rapidly bring the mind to the present
moment and reduce stress. In their research, they reviewed data indicating how breath work
can affect longevity mechanisms in some ways that overlap with meditation and in other ways
that are different form, but that synergistically enhance, the effects of meditation. They also
provide clinical evidence for the use of yoga breathing in the treatment of depression, anxiety,
post-traumatic stress disorder, and for victims of mass disasters. By inducing stress resilience,
breath work enabled them to rapidly and compassionately relieve many forms of suffering.
Chen (2009) conducted a study to examine the effect of relaxation exercises on health related
physical fitness. They used yoga exercise intervention on health related physical fitness in
school-age asthmatic children to investigate its effect on health-related physical fitness of
school-age children with asthma. Quasi-experimental research design was employed in the
study in which a group of 31voluntary children served as subjects. They were purposively
sampled from a public elementary school. These subjects were randomly assigned to exercise
group comprised of 16 subjects and control group consisted of 15 subjects. Age range of the
subjects was 7 to 12years. The exercise group participated in yoga exercise program for a
period of 7 weeks. Frequency of participation was three times per week and time span of each
session was 60-minute. All the yoga sessions comprised of:
i. A warm-up and breathing exercises session of 10 minutes duration.
ii. A session of yoga postures of 40 minutes duration.
iii. A session of cool down exercises of 10 minutes duration.
Fitness scores were assessed before starting the exercise (baseline) and at the seventh and
ninth week after intervention completion. A total of 30 subjects 16 from exercise group; and
14 from control group completed follow-up. Findings of the study revealed that:
36
i. Compared with children in the general population, all the subjects (n = 30) fell
below the 50th percentile in all physical fitness items of interest, There was no
significant difference in scores between the two groups at baseline(i.e., pre-
exercise) for all five fitness items.
ii. A positive association exists between exercise habit after school and muscular
strength and endurance among asthmatic children.
iii. The exercise group exhibit favourable outcomes in terms of flexibility and
muscular endurance as compared to the control group. Such favourable outcomes
remained evident even after adjusting for age, duration of disease and steroid use,
values for which were unequally distributed between the two groups at baseline.
iv. There was a tendency for all item-specific fitness scores to increase over time in
the exercise group.
The GEE analysis showed that yoga exercise indeed improved BMI, flexibility, and muscular
endurance. After 2 weeks of self-practice at home, yoga exercise continued to improve BMI,
flexibility, muscular strength and cardio-pulmonary fitness.
Hafner-Holter, Kopp and Gunter (2009) studied relationship between relaxation exercises and
social competence and wellbeing. They examined the effects of fitness training and yoga on
well-being, social competence and body image. The study describes and compares influences
from physical activity program and a yoga program on well-being, mood, stress coping, body-
image and social competence in healthy people. The sample was consisted of 39 subjects out
of which 18 were attending a gym and 21 persons were participating in a yoga program.
Following questionnaires were administered on all the subjects before entering the program
and taking part for 20 units: Body-Image-Questionnaire (25),Symptom – Checklist – 90 R (8),
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Complaint-List (31), Adjective Mood-Scale (32) and a Visual Analogue Scale for assessing
stress-level (10).
Statistical analyses revealed a significant improvement in social competence in both groups.
The gym-group exhibited a reduction in summarization and body-related anxiety and an
improvement in physical and emotional well-being. Findings of the study supported the
evidence that physical activity in general improves psychological wellbeing, however, gym
and yoga seems to have different psychological implications. Authors suggested for future
researches with a focus on comparing the psychological effects of different physical activity
interventions in prevention programmes as well as exercise prescriptions in patients with
mental illness.
Javnbakht M., HejaziKenari R. and Hisami M. (2009) argued that Yoga, as a relaxation
technique, has often been perceived as a method of stress management tool that can assist in
reducing depression and anxiety disorders. They conducted a study to evaluate the influence
of yoga in relieving symptoms of depression and anxiety in women who were referred to a
yoga clinic. They used a convenience sample of women who were referred to a yoga clinic
from July 2006 to July2007. Investigators evaluated all new cases on admission using a
personal information questionnaire as well as Beck and Spielberger tests. Participants were
randomly assigned into an experimental and a control group. The experimental group was
consisted of 34 subjects who participated in yoga classes of 90 minutes duration for two
months. Frequency was twice weekly. The control group was consisted of 31 subjects who
was assigned to a waiting list and did not receive yoga.
Researchers evaluated both groups again after the two-month study period. The average
prevalence of depression in the experimental group in pretest and post-test conditions showed
statistically insignificant decrease. However, when the experimental group was compared to
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the control group women who participated in yoga classes showed a significant decrease in
state anxiety and trait anxiety. Participation in a two-month yoga class resulted to a significant
reduction in perceived levels of anxiety in women who suffer from anxiety disorders. The
study suggested that yoga can be considered as a complementary therapy or an alternative
method for medical therapy in the treatment of anxiety disorders.
Kosuri M and Sridhar GR. (2009) studied relaxation exercises with respect to aftereffects
related to physical and psychological goodness of persons. Using the yoga practice as a
relaxation technique, they conducted a study to see its effects on Physical and Psychological
outcomes. The main aim of their study was to examine the effect of relaxation exercise (Yoga
practice) on clinical and psychological outcomes among the persons suffering from type 2
diabetes mellitus (T2DM). The practice sessions for about 40 days were organized at the
Institute of Yoga and Consciousness. Sample of the study comprised 35 ambulatory subjects
suffering from type 2 diabetes mellitus who were not having significant complications. The
practice sessions were organized under supervision experts. Investigators studied and
measured clinical, biochemical and psychological well-being of subjects. Results of the study
indicated that after 40 days of exercise, there is a reduction in body mass index and level of
anxiety, and an improvement in total general well-being. Authors concluded that relaxation
exercise will result in reduced body mass index (BMI) and level of anxiety, and an
improvement in total wellbeing.
Hart C.E. and Tracy B.L. (2008) studied relaxation exercise in relation to steadiness
training andmotor variability. They argued that exercise training programs can increase
strength and improve sub-maximal force control, but the effects of relaxation exercise like
yoga as an alternative form of steadiness training are not well described. Keeping in view this
fact they conducted a study using relaxation exercise- Yoga as steadiness training and its
39
effects on motor variability in young adults. ‗Bikram‘, a popular type of yoga, was used as
relaxation exercise to explore its effect of on strength, steadiness and balance. The sample
comprised 21 subjects divided into experimental and control group. The experimental group
was consisted of 10 young adults of age range 29 ± 6 years and the control group comprised
11 subjects of age range 26 ± 7 years. The control group did not receive any exercise while
the experimental group underwent through the practice sessions of ‗Bikram‘ which continued
for 8 weeks, 90 minutes per day. Practice sessions were carried out under supervision of
experts. Before and after test design was employed in the study. Measures, before the practice
and after the practice included:
1. MVC- Maximum Voluntary Contraction
2. EF- Force of the Elbow Flexors
3. KE- Knee Extensors (KE)
4. Steadiness of isometric EF and KE contractions
5. Steadiness of concentric (CON) and eccentric (ECC) KE contractions and
6. Timed balance.
The standard deviation (SD) and coefficient of variation (CV,SD/mean force) of isometric
force and the SD of acceleration during CON and ECC contractions were calculated. After the
practice sessions there was an increase of 14% in MVC force for KE and it was unchanged
for the EF muscles. The CV of force was unchanged for EF but was reduced in the KE
muscles, similarly for experimental and control groups. The variability of CON and ECC
contractions was unchanged.
For the experimental group, improvement in KE steadiness was correlated with pre training
steadiness subjects with the greatest reductions with training. Percent change in balance time
for individual yoga subjects averaged +228% with no change in controls. Authors concluded
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that for the young adults, a short-term exercise program of this type can improve balance
substantially; produce modest improvements in leg strength, and improve leg muscle control
for less-steady subjects.
Chaya (2006) investigated the net change in the basal metabolic rate (BMR of individuals
actively engaging in a combination of yoga practices (asana or yogic postures, meditation and
pranayama or breathing exercises) for a minimum period of six months, at a residential yoga
education and research centre at Bangalore. They measured BMR of individuals practicing
yoga through a combination that was compared with that of control subjects who did not
practice yoga but led similar lifestyles. The study showed that there is significantly reduced
BMR, probably linked to reduced arousal, with the long-term practice of yoga using a
combination of stimulatory and inhibitory yogic practices.
Madanmohan and associates (2005) designed a comparative study of the ―Effect of short term
(three weeks) training in savitri (slow breathing) and bhastrika (fast breathing) pranayama on
respiratory pressures and endurance, reaction time, blood pressure, heart rate, rate-pressure
product and double product‖. They drawn a sample of 30 student volunteers who were
divided into two groups of 15 each. For the Group I training was given in savitri pranayama.
It involves slow, rhythmic, and deep breathing. For the Group II training was given in
bhastrika pranayama. It is similar to bellows which is characterized by rapid and deep
breathing. Using a before and after test design investigators measured parameters before the
training and after three-week of training period. A significant effect of savitri pranayama was
found that produced an increase in respiratory pressures and respiratory endurance. In both
the groups, there was an appreciable but statistically in significant shortening of reaction time.
Heart rate, rate-pressure product and double product decreased in savitri pranayama group but
41
increased significantly in bhastrika group. It was concluded that different types of pranayama
produce different physiological responses in normal young individuals.
Barshankar (2003) examined the effect of yoga on cardiovascular function in subjects above
40 years of age. Investigators studied systolic and diastolic blood pressure, pulse rate, and
Valsalva ratio in 50 control subjects. Control subjects were not involved in any type of
physical exercise. The study group was also comprised of 50 subjects that had been practicing
yoga for 5 years. From the study it was observed that a significant reduction in the pulse rate
occurs in subjects practicing yoga. Difference in mean values of systolic and diastolic blood
pressure of study group and control group was also found significant beyond .01 level of
significance. Systolic and diastolic blood pressure showed reliably positive correlation with
age in the study group as well as in the control group. Investigators also applied Z test and the
significance of difference between correlation coefficient of both the groups was found
significant. Valsalva ratio was found to be significantly higher in yoga practitioners than in
controls. Results of the study indicated that yoga reduced the age related deterioration in
cardiovascular functions.
Virtanen (2003) conducted a study with the purpose of determining psychological factors
associated with blood pressure variability (BPV), heart rate variability (HRV), and bar reflex
sensitivity (BRS) among healthy men and women belonging to middle-age. They drew a
population-based sample comprising of 71 men and 79 women within the age range of 35 to
64 years. During paced breathing, five-minute supine recordings of ECG and beat-to beat
photo plethysmograpic finger systolic arterial pressure and diastolic arterial pressure were
obtained.
Power spectra were commuted using a fact Fourier transforms for low and high frequencies.
The low frequency was 0.01-0.15 Hz and high-frequency was 0.15-0.10 Hz powers. Bar
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reflex sensitivity was calculated by cross-spectral analysis of R-R interval and systolic arterial
pressure variability ties. The Brief Symptom Inventory, and the Toronto Alexithymia Scale
were used to evaluate psychological factors. It was found that anxiety and hostility is related
to reduced bar reflex sensitivity and increased low-frequency power of blood pressure
variability. Reduced bar reflex sensitivity reflects decreased parasympathetic outflow to the
heart and may increase blood pressure variability through an increased sympathetic
predominance.
Karuppasamy (2002) conducted a study to see the effect of physical training and asanas on
selected physiological variable and motor ability component among college men. For this
study, he selected 30 college men age ranging between 18 to 19 years and divided them in
three groups, which underwent six weeks training programme of asana and physical training
and a control group that did not do any training. He used analysis of co-variance and found
that there was significant effect of asana on pulse rate but there is no change in speed.
Selvanayaki (2002) conducted a study on ―Effect of selected asana, pranayama, and
combination of asana and pranayama on systolic and diastolic blood pressure among college
women‖. She drew a sample of 45 college women for this study. The age range of subjects
was between 18 to 22 years. The entire group of selected women was divided in three groups
of 15 each that underwent training for six weeks. Analysis of covariance was applied to obtain
the results. It was concluded that systolic and diastolic blood pressure were not significantly
improved by the influence of asana, pranayama and the combination of asana and pranyama.
Ray(2001) undertook a study to observe the beneficial effects of yogic practices during
training period of the young trainees. A sample of 54 trainees of 20-25 years age group was
divided randomly in two groups i.e. yoga and control group. Yoga group was comprised of 23
males and 5 females. It was administered yogic practices for the five months of the course.
43
The control group was consisted of 21 males and 5 females that did not perform yogic
exercises during training period. After that both the groups performed the yogic practices
from the 6th to 10th months of training period. Researchers recorded physiological
parameters like heart rate, blood pressure, oral temperature, skin temperature in resting
condition: responses to maximal and sub maximal exercise, body flexibility. They also
recorded psychological parameters like personality, learning arithmetic and psychomotor
ability and mental well being. Various parameters were taken before and during the 5th and
10th month of training period. At the initial stage a relatively higher sympathetic activity in
both the groups due to the new work/training environment was found but gradually it
subsided. Later on at the 5th and 10th month, yoga group had relatively lower sympathetic
activity than the control group.
There was improvement in performance at sub maximal level of exercise and in anaerobic
threshold in the yoga group. There was improvement on various psychological parameters
like reduction in anxiety and depression and a better mental function after yogic practices.
Chlan (2000) carried out a study to find the usefulness of muscle relaxation training in
plummeting aggressive behaviour in mentally retarded patients. Using a pretest-post-test
study design he found that there was a diminution of 14.7% in aggressive behaviour in the
subjects after the muscle relaxation training. Hence muscle relaxation training emerged to be
effectual in dropping the frequency of some aggressive behaviour. The techniques appear to
produce a relaxation response that may smash the pain muscle-tension-anxiety and help in
relief through calming effect
Gonzalez and Amigo (2000) conducted an investigation to see the consequence of progressive
relaxation training on cardiovascular variables. The numeral of sessions and the lasting of
training that produced an important reduction on Blood Pressure and Heart Rate were also
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studied. The results of the study showed that progressive relaxation training produced a
momentous reduction on Blood Pressure and Heart Rate in each session. The minimum
number of session in order to active noteworthy difference was five.
Madan Mohan, et al., (2000) studied the effects of yoga training on cardiovascular response to
exercise and the time course of recovery after the exercise. Cardiovascular response to
exercise was determined by Harvard step test using a platform of 45 cm height. The subjects
were asked to step up and down the platform at a rate of 30/min for a total duration of 5 min
or until fatigue, whichever was earlier. Heart rate (HR) and blood pressure response to
exercise were measured in supine position exercise and at 1,2,3,4,5,7 and 10minutes after the
exercise. Rate-pressure product (RPP = (HR x SP)/100) and double product (Do P = HR x
MP), which are indices of work done by the heart were also calculated. Exercise produced a
significant increase in heart rate, systolic pressure, Rate-pressure product and DoP and a
significant decrease in diastolic pressure. After two months of yoga training, exercise induced
changes in these parameters were significantly reduced. It was concluded that after yoga
training a given level of exercise leads to a milder cardiovascular response, suggesting better
exercise tolerance.
Murugesan, Govindarajulu and Bera(2000) Examined a group of 33 hypertensive subjects of
age range 35 to 65 years, selected from Govt. General Hospital, Pondicherry. They conducted
their study with four variables namely systolic and diastolic blood pressure, pulse rate and
body weight. Subjects were randomly assigned into three groups. The experimental group
(Group-I) underwent selected yoga practices, another experimental group (Group-II) received
medical treatment by the physician of the said hospital and the control group (Group III) did
not participate in any of the treatment stimuli. Yoga imparted in the morning and in the
evening with 1 hr/session, day-1 for a total period of 11-weeks. Medical treatment comprised
45
drug intake everyday for the whole experimental period. A pre-test and post-test design was
used and data were analyzed with the help of analysis of covariance. Results of the study
revealed that both the treatment stimuli (i.e. yoga and drugs) were effective in controlling the
variables of hypertension.
Mir and Raich (1999) carried out an investigation on the effects of relaxation and information
provision as a preoperative preparation for surgery. The aims of the investigation were:
i. To reproduce the previous finding on effects of relaxation in preparation for
surgery.
ii. To analyze the contact effect between types of intervention and coping style on
patient‘s pain level and there turn to the normal daily activities.
In their study, ninety cholecystectomy patients were randomly divided into three groups. The
first group expected complete sensory and procedural information. The second group was
trained in relaxation while the third group acted as a control group. The findings of
assessment of coping style confirmed the positive effects of relaxation training in the
preparation of low monitoring patients. Low monitors trained in relaxation experienced less
surgical pain through recovery process and performed at a higher activity level at follow up
compared to controls. No interaction effect was pragmatic when the interaction between
coping style and the type of interaction was studied.
Gavito, Ledezma, Morale, Villalba and Ortegosoto (1999) studied the effect of induced
relaxation on pain and anxiety in thoracotomiesed patients. Objectives of the study were:
1. To discover whether learned muscular relaxation is accommodating in the
pharmacological treatment for retreating the severity of postoperative pain
46
2. To observe whether this pain is associated to anxiety and depressive symptoms present
in patients preoperatively.
They administered Hospital Anxiety and Depression Scale on the chosen patients. The pain
was estimated by means of a Visual Analogue Scale. All the chosen patients were randomly
divided into the two groups. The first group received muscular relaxation training
(Schultz‘stechnique) while, on the other hand, the second was given only the customary
medical treatment. Evaluation of patients continued till the release of them from the hospital.
Findings of the study revealed no significant changes regarding either anxiety or depression.
Scores on Visual Analogue Scale decreased in both groups over time. But the experimental
group accounted decreased pain after relaxation instruction. Correlation of pain with either
anxiety or depression was found insignificant.
Joy and Sreedhar (1998) conducted a study on the efficiency of Guided Somato-Psychic
Relaxation urbanized by Sreedhar (1996) in the administration of indispensable hypertension
and its connected psychological factors like anxiety and depression. The sample consisted of
7 female mild essential hypertensive patients. These patients were under medication with the
same drug and dosage. Out of these patients, 4 constituted the study group. Small-N design
with pre-assessment, mid-assessment and post-assessment was utilized for the study. The
measurements consisted of the measurements of blood pressure (both systolic & diastolic),
anxiety and depression. A total of 10 relaxation sessions was given to each patient in the
study group, and the mid-assessment was done after the 5th
session. The patients in the
comparison group were requested to present themselves only for the various assessments. A
two weeks follow up programme was also included in the study. Findings of the study
exposed that there was a substantial drop in the levels of blood pressure, anxiety and
depression in each patient in the study group. The patients in the contrast group had very little
47
variations in the levels of blood pressure, anxiety and depression. Hence the study found that
Guided Somato-Psychic Relaxation is effectual for patients with essential hypertension and it
is associated psychological factors like anxiety and depression.
Sloman (1995) evaluated the usefulness of relaxation technique on the inpatients admitted in
an oncology ward. He used progressive muscle relaxation and guided imagery as a nursing
intervention for the administration of cancer patients to give them a relieve from pain. The
dependent variables incorporated were the pain sensations using the Short-Form McGill Pain
Questionnaire measured on a visual analogue scale. The total weekly intake of morphine or
associated opioid measured in milligrams and non-opioid PRN analgesia measured in terms of
the number of doses taken weekly by the patients. In all 67 patients were included in the
study. Out of them 48 were males and 19 were females between the age range of 37 to 80
years. The study was a randomized pre-test-post-test control group experimental design,
assigning subjects randomly to one of the three groups that received:
i. Relaxation and imagery by use of audiotapes.
ii. Live training unswervingly from a registered nurse.
iii. No precise training in relaxation or imagery techniques.
The findings showed no noteworthy moderator effects at the 0.05 level using analysis of
covariance for age and separate ANOVA for gender and diagnosis. The study accomplished
that progressive muscle relaxation united with guided imagery produced noteworthy
reductions in pain sensation, present pain intensity, overall pain severity, and non-opioid PRN
analgesia. It was also established that the treatment failed to diminish pain effect or morphine
intake for cancer pain control.
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Schell, Allolio and Schoake(1994) conducted a study on physiological and psychological
effects of Hatha-Yoga exercise in healthy women. They measured heart rate, blood pressure,
the hormones cortisol, prolactin and growth hormones and certain psychological parameters
in a yoga practicing group and a control group of young female volunteers prior and after the
experimental period. There were no substantial differences between the groups concerning
endocrine parameters and blood pressure. The heart rate was significantly different in yoga
group having a significant decrease in heart rate during the yoga practice. In the personality
inventory the yoga group showed markedly higher scores in life satisfaction and lower scores
in excitability, aggressiveness, openness, emotionality and somatic complaints. Significant
differences could also be observed concerning coping stress and mood at the end of the
experiment. The yoga group had significant higher scores in high spirits and extra variedness.
Sitaram (1994) examined in a controlled situation the usefulness of behavioural intervention
(Relaxation & Cognitive Behaviour Therapy) in the administration of chronic pain in cancer
patients. The findings revealed a significant enhancement in pain coping Behavioural
intervention in contrast to medical modes of pain relief.
Cotanch (1983) argued that relaxation may be advantageous in reducing anxiety, nausea and
vomiting related with chemotherapy. Nine out of twelve patients in her study accounted some
assistance connected with chemotherapy. Philip (1988) experienced Progressive Muscle
Relaxation with 46chronic pain sufferers at a pain clinic. The subjects were not cancer patient
but endured from a variety of conditions. His findings showed significant diminution in pain
ratings by treatment subjects compared to those in the control group. He accomplished that
progressive muscle relaxation could relieve chronic pain.
Kaempfer (1982) carried out a study to examine a relation between progressive muscle
relaxation and feeling of pain. Findings of the study revealed that progressive muscle
49
relaxation technique is useful to reduce the feelings of pain but might be very tiring for the
weak since a continuous effort is required to extract the response and the subjects may have
difficulty acquiring the skill.
Some important studies related to anxiety
Knapen, Sommerijns, Vancampfort, Sienaert, Pieter, Haake, Probst, and Peuskens (2009)
undertook a study with the assumption that acute aerobic exercise (a kind of relaxation
technique) is associated with a reduction in state anxiety and an improvement in subjective
well-being. The major objective of their study was to compare and contrast the effects of
aerobic exercise at self-selected intensity versus prescribed intensity on state anxiety and
subjective well-being among patients with depressive and/or anxiety disorders. Using a
sample of 48 subjects (19 men and 29 women) investigators carried out study according to the
main objective. On the basis of results authors concluded that the response in state anxiety
and negative affect was unaffected by the type of aerobic exercise. Self-selected intensity
influenced exercise-induced changes in positive well-being and fatigue in a positive and
negative way, respectively.
Wiltink, Michal, Subic-Wrana, Eckhardt-Henn, Dieterich and Beutel (2009)studied dizziness,
anxiety health care consumption and health behaviour-result from a representative Garman
survey. Symptoms of dizziness were accounted by 15.8% of the participants. Of the
participants with dizziness, 28.3% accounted symptoms of at least one anxiety disorder
(generalized anxiety, social phobia, panic). Persons with dizziness accounted more somatic
problems such as hypertension, migraine, diabetes, etc. Co-morbid anxiety was associated
with increased health care use and impairment. It was concluded that dizziness is a highly
prevalent symptom in the general population. A subgroup with comorbid anxiety was
distinguished by an increased subjective impairment and health care utilization due to their
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dizziness. Because treatment options for distinct neurologic disorders are also acknowledged
to reduce psychological symptoms, and in order to avoid unnecessary medical treatment, early
neurologic and psychiatric/psychotherapeutic referral may be designated.
Carleton, Abrams, Asmundson, Gordon, Antony and McCabe (2009) studied pain linked
anxiety and anxiety sensitivity across anxiety and depressive disorders. On the basis of
findings they recommended that pain-related anxiety is generally comparable across anxiety
and depressive disorders; however, pain related anxiety was significantly higher among
individuals with anxiety and depressive disorders relative to a community sample, but
comparable to or lower than a chronic pain sample. Findings implied that pain-related anxiety
may indeed be a construct independent of other basic fears, warranting subsequent
hierarchical investigations and consideration for inclusion in treatments of anxiety disorders.
Gian, Francesco, Gianluca and Enrico (2008) examined the effect of various relaxation
techniques on anxiety. Using a purposive sample of 68 subjects, investigators carried out a
quesi-experimental study with before and after test design. Findings of their study revealed a
significant effect of relaxation exercises on level of anxiety. Various relaxation exercises were
evaluated for the change in the feelings of anxiety. Most of the relaxation exercises produced
the similar effects except the few only. From the results of their study they concluded that
relaxation exercises help reduce the level of anxiety among individuals leading to normal life.
Worcester and Le Grande (2008) supported that anxiety and depression are frequent after
acute cardiac events. They can have a foremost adverse impact upon outcomes, although past
studies report conflicting results regarding the associations between anxiety, depression and
outcomes such as mortality. Depression has been shown to be linked with non-adherence of
patients. Cardiac rehabilitation programmes conducted during early convalescence provide a
valuable opportunity to recognize and support patients who experience anxiety and
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depression, and encourage adherence to advice. Clinical data shore up the positive effects
upon patients‘ psychological outcomes of cardiac rehabilitation programs offering group
exercise, education and Behavioural interventions. However, more rigorous research is
obligatory to confirm such benefits. Systematic screening of patients should be undertaken on
entry to cardiac rehabilitation to identify high-risk patients and to assist them.
Miles and Wardle (2006) studied the role of health anxiety on the psychological impact of
participating in colorectal cancer screening. It was forecasted that health anxiety would be
connected with more worry about cancer before screening, a greater increase in worry if
polyps were detected and less reassurance after a clear result. As per the expectations, health
cautious participants were more anxious and more worried about bowel cancer both before
and after screening. Findings of this study suggest us that use of relaxation exercises will lead
to reduced level of anxiety because uncomfortable situation produced by health cautiousness
may be converted into the feeling of calm and quite state of mind with the help of relaxation
exercise
Mark (2003) carried out a study on learning and intimacy in the families of anxious children.
The major objective of this study was to review the literature on the role of the family in the
development of anxiety problems in children. Promising confirmation reveal that the specific
social learning processes between parent and child that operates within the context of the
quality and consistency of intimate associations is an imperative in the development of
anxiety problems. These processes interact within child‘s temperament in predicting the
development of anxiety problems. Family with both an inhibited child and anxious parents are
predominantly prone to becoming entrapped in social learning processes that foster escalating
anxiety problems. In the light of these findings we can presume that acute situations faced by
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inhibited child with anxious parents are likely to be pacify with the help of relaxation
techniques
Ora and Avigdor (2003) examined the relationship between family environment,
discrepancies among actual and desirable environment and children‘s test and trait anxiety.
Sample of the study was consisted of 456 respondents. Test and trait anxiety was correlated
with the discrepancies among actual and desirable environment of the family. Findings of the
study revealed that there is a lack of correspondence between the actual and desirable
environment of the family. A higher degree of discrepancy between these two results into the
feelings of anxiety which on later stage can become trait anxiety. Such type of findings may
help in execution of relaxation techniques. If, prior to execute relaxation exercise, we identify
the family environment of subjects and reconcile them accordingly; the outcome of relaxation
will be far better than expected.
Peter, Cor and Miranda (2003) examined association between child and parent reported
behaviour inhibition and symptoms of anxiety and depression in normal adolescents. The
sample of the study involved a large number of young adolescents with age range from11 to
15 years with their parent. Results of the investigation demonstrated that parents and children
agreement for behaviour inhibition and symptoms of anxiety and depression was rather
modest. Furthermore, the data specified that high level of child and parent reported
Behavioural inhibitions were accompanied by high levels of anxiety disorder symptoms and
depression. This finding also suggest that an assessment of subjects‘ background is essential
for the effective execution of relaxation techniques. Knowledge of this kind may be beneficial
to formulate right instructions to the subjects which in turn may lead to better effects of
relaxation techniques.
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Jennifer (2002) examined parent-child relations and anxiety disorder among children. It was
an observational study in which sample comprised of clinically anxious children and
nonclinical anxious children with age ranged from 7 to 15 years. Findings of the study
revealed that mother of anxious children were more negative during the interaction than
mother of nonclinical children. The results supported the relationship between an over
involved parenting style and anxiety among children. All the research findings related to
family environment and anxiety indicate that family environment is a major contributory
factor to the anxiety. The investigator of the present study firmly believe that effects of
relaxation exercises cannot be achieved without taking necessary steps to improve the family
environment.
Erin, Patricia, Hammen and Robyne (2001) examined the role of perceived parenting
behaviour in the affiliation between parent and offspring anxiety disorder in a high risk
sample of adolescent. The sample was consisted of 816 subjects with an average age of 15
years. Results suggested that maternal anxiety disorder significantly exhibited the presence of
anxiety disorder in children, but there was no evidence that perceived parenting played a
mediating role in the connection between mother and child anxiety disorders.
Paz (2001) observed parent and child group therapy for childhood anxiety disorders using a
manual based cognitive-behaviour technique. Sample of the study included 24 children with
age range from 6 to 13 years. These children were having an anxiety disorder (separation
anxiety, over anxious disorder or both). All the children and their parents participated in a 10
session of treatment. Findings of the investigation signified that anxiety symptoms decreased
extensively during the treatment and follow up periods. Children of mothers with an anxiety
disorder enhanced more than children of non-anxious mothers, whereas the anxiety level of
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anxious mothers remained stable. Here too we can conclude that assessment of subjects‘
background will be beneficial to obtain better effects of relaxation exercises.
Paul, Lilienfeld, Ellis and Loney (2000) examined the connection between anxiety and
psychopathy dimension in children. The sample comprised of 143 clinically referred children
age ranged from 6 to 13 years. They reported that (a) measure of trait anxiety, anxiety and
fearfulness (low fearfulness) exhibited low correlation (b) conduct problem tended to be
positively correlated with trait anxiety and fearful inhibitions. These results bear potentially
significant implication for the diagnosis and etiology of psychopathy and antisocial
behaviour.
Jeffery (1999) examined the association between youth and parent perceptions of family
environment and social anxiety. Sample comprised of 2,708 students of 7th
, 8th
, 9th, and 11th,
grade students and 404 of their parents. Subjects countering higher level of social anxiety,
perceived their parents as being more socially isolating overly worried about others‘ opinions,
ashamed of their shyness and poor performance, and less socially active than did youth
reporting lower level of social anxiety, parents perception of child rearing style and family
surroundings however, did not differ between parents of socially anxious and non-socially
anxious children.
Rabian, Embry and MacIntyre(1999) accomplished study on Behavioural validation of the
childhood anxiety sensitivity index (CASI). The sample comprised of 56 children with age
ranged 8 to 11 years old. They were asked to complete the CASI as well as self-report
measure of state anxiety and trait anxiety and subjective fear. Results of the study
demonstrated that the CASI was significant predictor of the degree of state anxiety and
subjective fear reported in response to the challenge task, even after controlling for pre task.
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The results supported that the validity of the CASI in preadolescence children and suggest
that CASI possesses exceptional clinical utility relative to measure of trait anxiety.
Tari (1999) observed genetic and environmental influences on rating of manifest anxiety by
parents and children. The sample comprised of large numbers of children with age ranged 8 to
10 years old. Results showed that substantial difference in genetic effect according to both
gender and informant. For children self-report, temporal stability was mostly a function of
environmental effects.
Fuller, Marrie and David (1998) observed the composition of negative emotions in a clinical
sample of children and adolescents. The authors sought to define the features connected with
childhood anxiety and depression using a structural equations/ confirmatory factor analytic
looms involving multiple information i.e. parents and child reports of symptoms. Sample
comprised of 216 children and adolescents. Results of proportional modeling best supported
3- factors solution (fear, anxiety and depression) that were consisted with current conceptual
models of anxiety and depression.
Mark, Scan and William (1998) examined the relationship among anxiety and social
desirability and self-reported anxiety in young children. Sample included 1,786 children with
age range of 7 to 14 years. Results suggested that anxiety and lie scores did not correlate for
either gender or age grouping, however, anxiety scores interacted with lie scores in a different
way for males and females in term of the conformity between children‘s and teachers‘ rating
anxiety. Indications are that social desirability levels may in part explain the consistent
discrepancies found between child and adults reports of anxiety.
Michael and Morgan (1998) undertook a study with the purpose of comparing the influence
of acute physical activity and meditation on state anxiety. The meditation employed in their
study non-cultic. In this study 75 adult male volunteers served as subjects. The entire
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sample was divided on random basis into three groups each consisted of 25 subjects. The
three groups were exercise, meditation, and control group. The exercise group performed
physical activity at 70% of self-imposed maximal exercise heart rate for 20 minutes. The
meditation group practiced Benson's Relaxation Response for 20 minutes; and subjects in
the control group simply rested quietly in a “Lazy boy” chair for 20 minutes. The state
anxiety was assessed in three ways:
1. Prior to treatment.
2. Immediately after the treatment.
3. After 10 minutes of each treatment.
As confirmatory variables under selected conditions, they also measured heart rate; blood
pressure; oxygen consumption and skin temperature. A two-way repeated measures ANOVA
was employed to analyze the data. Findings revealed a significant reduction in anxiety for
each treatment. This held for both those subjects falling within the normal range for state
anxiety and those subjects regarded as high-anxious. It was also noted that none of the
physiological variables differed significantly following the control and meditation
treatments. The authors concluded that acute physical activity, non-cultic meditation, and a
quiet rest session are equally effective in reducing state anxiety. Here we conclude that this
result could be due to poor execution of the exercise.
Sheila Weber (1996) conducted a study with the purpose to investigate the effects of
relaxation exercises on anxiety levels in an inpatient general psychiatric unit. The conceptual
framework used was holism. A convenience sample of 39 subjects was studied. Anxiety
levels were measured before and after interventions with the state portion of the State-Trait
Anxiety Inventory. Progressive muscle relaxation, meditative breathing, guided imagery, and
soft music were employed to promote relaxation. A significant reduction in anxiety level was
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obtained on the post-test. The author concluded that the findings of the study can be
incorporated by holistic nurses to help reduce anxiety levels of general psychiatric inpatients
by using relaxation interventions.
Kenneth, Allan, and Jonathan (1989) evaluated the differential effects of relaxation techniques
on trait anxiety. Various treatments such as EMG biofeedback, progressive muscle relaxation
and a variety of meditation were used in their study. Findings of the study revealed a similar
effect of different treatments except transcendental meditation. A significantly larger effect of
TM was observed in the study. The meditation involving concentration showed significantly
smaller effect. They also estimated correlations for effect size for many other variables like
duration and hours of treatment, experimental design, age, sex, population, pretest anxiety,
demand characteristics, experimenter attitude, type of publication, attrition, etc. The effect
size of only few variables was found significant. These variables were population, duration,
hours and attrition. Controlling for possible confounding variables did not alter the overall
conclusions. The difference in effect size between treatments was maintained both when only
published studies were included and when only the studies with the strongest design were
included.
Beck (1988) the measurement of parents depression, i.e. child-mother and father – mother
with moderate or high, or depression symptoms results have been revealed that mothers
normally reported more symptoms of depressions in their children than did children or
fathers. Stress and anxiety disorders, fear and anxiety disorders and behaviour problems in
children of parents with anxiety have been accounted (Silverman, 1988), Wandy (1988).
What aspects of anxiety disorders may influence children who live with anxious parents have
been explored and preliminary results propose that avoidance in agoraphobia may be the key
variable connected with child maladjustment‖.Ohja (1986)analyzed inter-group differences of
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anxiety-scores of subjects and accomplished that urban students are higher on anxiety than
their rural counterparts and family size appears to be a noteworthy factor of manifest anxiety.
Rahe, Richard H. (1988) pointed out that cardiovascular disorders, gastrointestinal ailments
troubles with the reproductive system, dermatologic disorders, and other disturbances and
disorders are significantly influenced by anxiety. In addition studies of hostage and prisoners
of war point out that a person‘s reactions to severe stress are predictive of his/her future
physical and mental health.
Robert, Harris, Snyder, Raymond and Jennifer(1986) investigated the levels of test anxiety,
type-A and type-B coronary-borne behaviour, fear of failure and covert self-esteem as
predictors of self-handicapping performance attributions for college women who are
positioned either high or low on evaluative test or task situation. The results designated that
only high levels of test anxiety and high levels of covert self-esteems were related the
women‘s self-handicapping ascriptions.
Halode (1985) anxiety and parental attitudes of acceptance, concentration, overprotection and
avoidance; revealed (i) the anxiety is negatively predisposed with perceived parental
acceptance, (ii) that it is positively inclined with perceived parental, concentrations and
avoidance, (iii) that sex has shown its interaction effect with perceived parental acceptance
upon anxiety (iv) that highly, moderately and poorly avoided boys shown more anxiety as
compared to the highly, moderately and poorly avoided girls, and (v) that out of the three
parental attitudes; the attitude of avoidance engaged first position, concentration second
position and that of acceptance last position in their relative strength; of inducing anxiety in
college students. Thus perceived parental attitude of acceptance seems more encouraging in
making the individuals less anxious and better adjusted in life.
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Some Important Studies Related to Depression
Farnaz, Nahid, Negar, Shakeri (2015) designed a study with an aim to investigate the effect of
progressive muscle relaxation on depression, anxiety and stress of among the women with
first time pregnancy. They carried out trial in two health care centres on a sample of 66
women experiencing first pregnancy. All the subjects were randomly divided into two groups
namely experimental group and control group. The experimental received progressive muscle
relaxation exercise and control group did not. After two sessions of relaxation within two
weeks, the intervention group was doing exercises at home for 4 weeks. Findings of the
study revealed a beneficial effect of progressive muscle relaxation on depression and anxiety
among the women experiencing first pregnancy. Authors recommended that due to the
relaxation effect on reducing depression, anxiety and stress, and also lack of side effects and
its easy applicability, this method can be used as an approach to reduce depression, anxiety
and stress in women during pregnancy.
Kaina, Xiaomei, Jin, Miao, Dang, Wang, and Xia (2015) conducted a study to examine the
effects of music therapy and progressive muscle relaxation training on depression, anxiety
and length of hospital stay among females suffering from breast cancer. They drew a non-
probability sample of 170 female patients diagnosed for cancer. All the subjects were
randomly assigned to one of the two groups each comprised of 85 subjects:
1. Experimental/intervention group that received music therapy, progressive muscle
relaxation training and routine nursing care. Music therapy and progressive muscle
relaxation training were given two time in a day after 48 hrs of mastectomy
(mastectomy is a surgical operation carried out for removing breast). Timings for
music therapy and PMR were 6 to 8 A.M. in morning and 9 to 11 P.M. in evening.
Duration of each session was 30 minutes continued until discharged from the hospital.
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2. Second group was the control group that received routine nursing care.
Findings of the study revealed a beneficial effect of music therapy and progressive muscle
relaxation training on anxiety and depression. Authors concluded that progressive muscle
relaxation training taken in conjunction with music therapy can reduce depression, anxiety
and length of hospital stay in patients suffering from dangerous disease.
Greg, Jef, and Jonna (2010) studied negativity of thoughts and its remedy. Using a sample of
190 undergraduate female subjects examined the effect of progressive muscle relaxation and
meditation on negativity of thoughts. Before and after test design was employed in the study.
Duration of practice sessions was 20 minutes twice a day for about six weeks. Findings of the
study demonstrated a significant decline in negativity of thoughts. The negativity of thoughts
is closely related with depression.
Ströhle (2009) critically evaluated a number of researches to find out the effect of
physical activities and exercises to manage anxiety and depression. It is generally believed
that physical activity and exercise have positive effects on mood and anxiety and a great
number of studies describe an association of physical activity and general well-being, mood
and anxiety. The aim of the research was to critically review the available literature with
respect to:
1. The association of physical activity, exercise and the prevalence and incidence of
depression and anxiety disorders
2. The potential of therapeutic activity of exercise training in patients with depression or
anxiety disorders.
The author argued that the association of physical activity and the prevalence of mental
disorders, including depression and anxiety have been repeatedly described; but only few
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studies examined the association of physical activity and mental disorders prospectively.
Reduced incidence rates of depression and anxiety disorders in exercising subjects raise the
question whether exercise can be used as the remedy of some psychological disorders. Author
pointed out that besides case series and small uncontrolled studies, recent well controlled
studies suggest that exercise training may be clinically effective particularly in major
depression and panic disorder. It was further emphasized that the evidences for advantageous
effects of exercise training on depression and anxiety are growing. However, the clinical use
of exercise training is still at the beginning stage. At least these relaxation exercises should
essentially be used as an auxiliary to established treatment approaches like psychotherapy or
pharmacotherapy. Further studies on the clinical effects of exercise, interaction with standard
treatment approaches and details on the optimal type, intensity, frequency and duration may
further support the clinical administration in patients. The author elucidated that there is a
lack of knowledge on how to best deal with depression and anxiety related symptoms which
hinder patients to participate and benefit from exercise training.
Thorsten and Catherine (2009) investigated the effectiveness of Mindfulness-Based Cognitive
Therapy (MBCT), a treatment combining mindfulness meditation and interventions taken
from cognitive therapy, in patients suffering from chronic-recurrent depression. Patients of
depressive symptoms with at least three previous episodes of depression and a history of
suicidal ideation were randomly allocated to receive either Mindfulness-Based Cognitive
Therapy delivered in addition to treatment-as-usual (TAU) or TAU alone. Number of subjects
in each group was 14. Pre-treatment and post-treatment design was employed to assess
symptoms of depressive and diagnostic status. Self-reported symptoms of depression
significantly decreased from severe to mild levels in the Mindfulness-Based Cognitive
Therapy group while TAU group did not show any significant change. Similarly, numbers of
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patients meeting full criteria for depression decreased significantly more in the MBCT group
than in the TAU group.
Yune, Young, and Eunjung (2009) examined the effectiveness of a stress coping program
based on mindfulness meditation on the stress, anxiety, and depression among the nursing
students. A pretest/posttest design was used with nonequivalent control group. A convenience
sample of 41 nursing students was drawn and randomly assigned to experimental group
comprising of 21 subjects and control group consisted of 20 subjects. Stress was measured
with the help of Chang‘s PWI-SF (5-point) scale and anxiety was assessed with the help of
Spieberger‘s state anxiety inventory. Beck depression inventory was used to measure the
depression level of subjects. The experimental/ intervention group received mindfulness
meditation training in a daily session 90-minutes duration for eight weeks. No intervention
was administered to the control group. Nine participants did not complete the study due to
personal circumstances hence; they were excluded from the analysis. Resultant strength for
the final analysis was 16 participants in each group. Findings of the study are as follows:
1. A significant decline in the stress scores of experimental group
2. A significant decline in the anxiety scores of experimental group
3. No significant difference in depression scores between two groups of subjects
participated in study.
Authors concluded that stress coping program based on mindfulness meditation is an effective
intervention for nursing students to decrease their stress and anxiety.
Boadie and Rachel (2008) presented the case of a 48 year-old woman who developed
significant elevations in creatine kinase and liver enzyme levels after three work-out sessions
consisting of cardiovascular training on an elliptical machine and weightlifting. The
elevations resolved with rest, then recurred when the patient again began exercising. These
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elevations occurred while the patient was participating in a double-blind, placebo-control
phase II clinical trial of an experimental medication for major depressive disorder. This case
highlighted several aspects of the appropriate implementation of exercise recommendations in
the psychiatric setting. Initiation of exercise regimens is not prohibited in clinical trials, and
may be self-initiated by the depressed patient or recommended by the treating physician. This
case also highlighted that the value of placebo controls in clinical trials of experimental
treatments applies to safety as well as efficacy factors. Exercise as a treatment for depression
carries both potential benefit for depressive symptoms and risk for adverse events. Authors
argued that the design of clinical trials would be strengthened by consideration of these
effects of exercise in the future.
Ghafari S, Ahmadi F, Nabavi M and Memarian R (2008) Studied the effect of progressive
muscle relaxation technique on depression, anxiety and stress of multiple sclerosis patients.
Multiple Sclerosis is one of the most common chronic diseases of the Central Nervous System
leading to psychological disorders like depression; anxiety and stress. Muscle Relaxation
Technique is a form of complementary therapy to combat psychological symptoms. Using a
quasi-experimental design they studied 66 multiple sclerosis patients who were selected with
non-probability sampling method. They were randomly assigned to experimental and control
groups each comprised of 33 patients. The experimental group received Progressive Muscle
Relaxation exercise for 63 sessions for a period of eight weeks. The control group did not
receive any intervention. Before and after test design was employed in the study and scores
for depression, anxiety and stress were assessed before the treatment, four weeks and eight
weeks of intervention. Findings of the study suggested that Progressive Muscle Relaxation is
practically feasible and is associated with decrease of depression, anxiety and stress in
patients with Multiple Sclerosis. As this technique can promote wellbeing in these patients,
authors suggested that it should be offered to all patients with multiple sclerosis.
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Lolak, Connors, Sheridan, and Wise (2008) evaluated the effect of progressive muscle
relaxation exercise on anxiety and depression in patients with chronic breathing disorders
receiving pulmonary rehabilitation. They drew a purposive sample comprised of 83 subjects.
All of them were having chronic breathing disorders and were entering the 8-week pulmonary
rehabilitation program. Subjects were randomly assigned to one of these two conditions:
1. Standard care group: The standard program included 2 days per week of exercise,
education and psychosocial support delivered by a multidisciplinary team.
2. Intervention group: It received additional sessions of Progressive Muscle Relaxation
training. A prerecorded tape was used for 25 min/week for duration of 8 weeks.
Primary outcome measures were levels of anxiety and depression evaluated by the Hospital
Anxiety and Depression Scale. The overall results of the study suggested that progressive
muscle relaxation has a beneficial effect on anxiety and depression.
Shu-Shya, LianHua, Shio, Yu Ying, and Li-Lin (2008) carried out a study aimed at examining
the effectiveness of an exercise support program to reduce psychological morbidity after
childbirth. They carried out a controlled trial in a regional hospital of Taiwan. Sample of their
study was consisted of 80 primiparas (primiparas is women giving birth to first child) having
a score above 10 on Edinburgh Postnatal Depression Scale (EPDS) at 4 weeks postpartum.
Subjects were allocated alternately to an intervention group that received exercise support and
control group who received standard care at 6 weeks postpartum. The exercise support
comprised of 60 minutes per week at the hospital and two sessions at home for 12 weeks. Out
80 subjects 63 completed the exercise support programme.
Findings of the study demonstrated that the women underwent the exercise support program
were less likely to have high level depression after childbirth as compared to the control
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group. The exercise support program given to postpartum women appeared to be beneficial
for the psychological well-being of primiparas
Zautra and Davis (2008) conducted a study to examine the effect of cognitive behavioural
therapy and mindfulness interventions (a meditation based technique) on feelings of pain and
depression among arthritis patients. The main objectives of the study were to evaluate the
effectiveness of cognitive Behavioural therapy and mindfulness interventions (independent
variables of the study) with respect to following dependent variables:
1. Responses to chronic stress
2. Feeling of pain
3. Feeling of depression
4. Quality of everyday life
The target group was adults with rheumatoid arthritis (RA). A purposive sample of 144 RA
patients was drawn and randomly assigned to one of three treatment conditions:
i. Cognitive Behavioural therapy(CBT) for pain. This group was denoted as (P)
ii. Mindfulness meditation and emotion regulation therapy. This group was denoted as (M)
iii. Education-only group. This group was denoted as (E) which served as an attention
placebo control.
Findings of the study are as follows:
A. The P group showed the greatest Pre to Post improvement in self-reported pain control
and reductions in the IL-6
B. The group P and M both showed more improvement in coping efficacy as compared to
E group.
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C. Relative value of the treatments varied as a function of depression history. Treatment
M (Mindfulness meditation and emotion regulation therapy) was found most
beneficial to the patients of rheumatoid arthritis with recurrent depression. This benefit
was observed across several measures which included negative and positive affect and
physicians' ratings of joint tenderness.
It indicates that the meditation based therapies and emotion regulation aspects of the
treatment were most beneficial to those with chronic depressive features. From the findings of
this study, we can also infer that meditation based techniques as compared to other techniques
will be more effective for the treatment of depression.
Blumenthal, Michael, and Babyak (2007) examined the effect of aerobic exercise training on
depression. Main objectives of the study were:
To assess the reduction in depression level with the help aerobic exercise training performed
under supervised group setting.
To assess the reduction in depression level with the help aerobic exercise training performed
independently at home.
To assess whether patients receiving aerobic exercise training performed either in a
supervised group setting or independently at home attain reductions in depression comparable
to standard antidepressant medication
To assess whether patients receiving aerobic exercise training performed either in a
supervised group setting or independently at home attain reductions in depression comparable
to placebo controls
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Sample of the study comprised 202 adults including 49 men and 153 women who were
diagnosed with major depression. They performed a prospective, randomized controlled trial
with allocation concealment and blinded outcome assessment in a tertiary care teaching
hospital. Subjects were randomly assigned to one of four conditions:
1. Aerobic exercise training under supervised group setting
2. Aerobic exercise training performed independently at home
3. Standard antidepressant medication
4. Placebo medication
Duration for treatment was 16 weeks. Patients underwent the structured clinical interview
for depression. The depression score was measured on Hamilton Depression Rating Scale.
Results of the study demonstrated that after 16 weeks of treatment, 41% of the
participants attained remission, defined as no longer meeting the criteria for major
depressive disorder and a HAM-D score of <8. It was also found that patients receiving
active treatments tended to have higher remission rates than the placebo controls as shown
below:
The supervised exercise group = 45%
The home-based independent exercise group = 40%
The medication group = 47%
The placebo medication group = 31% (p = .057).
All treatment groups had lower HAM-D scores after treatment; scores for the active treatment
groups were not significantly different from the placebo group. Authors concluded that the
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efficacy of exercise in patients seems generally comparable with patients receiving
antidepressant medication and both tend to be better than the placebo in patients with major
depressive disorder. Placebo response rates were found to be high, indicating that a
considerable portion of the therapeutic response is determined by patient expectations,
ongoing symptom monitoring, attention, and other nonspecific factors.
Bolton and Bass (2007) conducted a study to assess the effect of locally feasible interventions
on depression and anxiety among adolescent survivors of war and displacement in Northern
Uganda. The intervention methods were locally urbanized screening tools that assessed the
usefulness of interventions in reducing symptoms of depression and anxiety. Activity based
intervention Interpersonal Psychotherapy was used with persons wait listed to receive
treatment. Findings of the study revealed a marked reduction in score on a depression
symptom scale.
Brugtein-Klomek (2007) investigated the efficacy of interpersonal Psychotherapy for
depressed adolescents. The study aimed at pioneering the theoretical framework, practical
application and efficacy of interpersonal Psychotherapy for depressed adolescents. Sample of
the study was consisted of 120 school going adolescents including both boys and girls. Beck‘s
Depression Inventory was used to assess the level of depression. The intervention programme
was carried out in hospital-based setting as well as in community outpatient settings. Findings
of the study revealed that interpersonal Psychotherapy is an useful technique to manage the
level of depression among adolescents in both hospital-based and community outpatient
settings.
Horowitz, Garber, Ciesla Young and Mlysort (2007) estimated the efficacy of intervention
programs to control depressive symptoms among adolescents. Sample of their study included
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380 high School students. They were randomly assigned to one of the blow given three
conditions:
Condition 1: It included Cognitive Behavioural Program (denoted as CB group)
Condition 2: It included an Interpersonal Psychotherapy Adolescent Skill Training Program
(denoted as IPX-AST group)
Condition 3: It included a no-intervention control group.
The intervention concerned eight weekly sessions of 90 minutes duration that were run in
small groups during wellness classes. Subjects were assessed for depression score at post
intervention. Students in CB and IPT-AST groups both manifested remarkably lower levels of
depressive symptoms as compared to no intervention control group.
Lynette, Karen, Larry and Frank (2007) carried out a study with two objectives:
1. To compare two exercise programs, varying in their degree of structure, on
improvements in physical activity
2. To compare the two exercise interventions on depressive symptoms, body
composition, and fitness.
Sample of the study was comprised of 32 women purposively selected from greater Boston
area. They were diagnosed as depressed on the basis of their score on Beck Depression
Inventory. All the subjects participated in 3 month intervention study. They were randomly
assigned to one of the below mentioned two conditions:
1. Clinic-based exercise intervention
2. Home-based exercise intervention
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A before and after test design was employed in the study. Subjects were assessed for
depression score with the help of BDI at baseline and after 3-months. Findings of the study
elucidated that both exercise programs are associated with reductions in depressive symptoms
and increased physical activity participation. Findings further suggested that even a home-
based program can benefit women with depressive symptoms. From the findings of this study
we can infer that the problem of anxiety and depression is manageable trough exercise
intervention even at home with or without supervisory care.
Knubben, Reischies and Adli (2007) organized a study with the aim of evaluating the short-
term effects of exercise in patients with major depression. Sample of the study included 38
subjects with a major depression episode. They were under treatment of psychiatrist in a
hospital and receiving standard clinical antidepressant drug treatment. Subjects were
randomly assigned to one of the below given two conditions:
1. Walking exercise group comprised of 20 subjects
2. Placebo group comprised of 18 subjects (receiving low-intensity stretching and relaxation
exercises).
The intervention period was of 10 days. Tools used to measure the severity of depression
were:
A. Bech-Rafaelsen Melancholy Scale (BRMS)
B. The Center for Epidemiologic Studies Depression scale (CES-D)
Results of the study elucidated that after 10 days of intervention there is a significantly large
reduction in depression scores of the exercise group as compared to placebo group. The
proportion of patients with a clinical response (reduction in the BRMS scores by more than
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six points) was also larger for the exercise group as compared to placebo group. Researchers
concluded that endurance exercise may help to achieve substantial improvement in the mood
of selected patients with major depression in a short time.
Newman and Motta (2007) examined the effects of aerobic exercise on children with Post
Traumatic Stress Disorder, Depression and Anxiety. Procedure of measurement included
Children's PTSD Inventory, Children‘s Depression Inventory and the Revised Children's
Manifest Anxiety Scale to assess Post Traumatic Stress Disorder, Depression and Anxiety
respectively. It was a small ‗n‘ study that utilized a staggered baseline pretest posttest design
with repeated measures. The findings show that this study provided support for the positive
effects of aerobic exercise on reducing PTSD, Depression and Anxiety.
Otto, Church, and Craft (2007) described the views of five experts on exercise and psychiatric
disorders discussing the rationale and evidence for using exercise to treat mood and anxiety
disorders. Their discussion concluded a beneficial effect of relaxation exercises on mood,
anxiety and depressive disorders.
Ramsay and Main (2007) carried out a study with quasi-experimental pre-test-post-test design
to evaluate the effectiveness of counseling type, in a sample of individuals diagnosed with
low self-esteem and high in anxiety and depression. Sample of the study comprised 18
females out of whom 9 underwent group peer counseling and remaining 9 underwent person
counseling. Findings revealed that both groups, peer counseling and individual counseling,
considerably improve self-esteem, self-reported levels of overall life satisfaction and reduced
anxiety and depression level.
An assessment of the effectiveness of Cognitive Behaviour Therapy for 12-14 year old school
children was carried out by Habib and Seif (2007). Sample of the study comprised 198 boys
and 136 girls. They were evaluated with the help of Child Depression Inventory and the
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Coopersmith Self-Esteem Inventory. 32 subjects with depression were given Cognitive
Behaviour Therapy. They were assessed 3 months after the intervention using the same tools
and the findings revealed the effectiveness of this therapy with lessening in depressive
symptoms.
Smith, Graham, and Sentinathan (2007) designed a study on Mindfulness-based cognitive
therapy for recurring depression in older people. Mindfulness-based Cognitive Therapy
(MBCT) is a meditation-based intervention designed to reduce frequency of occurrence in
people with histories of relapsing unipolar major depression. Sample of the study comprised
38 subjects aged over 65 years with a history of depression. They underwent an eight-session
course of MBCT. The main aim of the study was to determine whether MBCT is suitable for
older people, and what modifications they may require. Out of entire sample, 30 subjects
completed the MBCT course. Findings revealed that Mindfulness-based Cognitive Therapy- a
meditation-based intervention has beneficial effect on depression.
Ellias and Bernard (2006) conducted a study to examine the effectiveness of cognitive
behavioural therapy to childhood disorders. Results of their study revealed that persons who
can accept events and attributes, no matter how negative, rarely manifest clinical depression.
These persons are likely to experience normal feelings of disenchantment and frustration.
There is an increasing tendency of depression among the children and adolescents. The
cognitive behavioural therapy can easily be used by practitioners and it may be very helpful in
the prevention and treatment of depression in young clients. To encourage school-based
prevention programs that teach the connection between thoughts, feelings and behaviours,
combined with a complete intervention approach will hopefully empower young people to
deal with this serious mental health problem.
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Larun, Nordheim, Ekeland,Hagen and Heian (2006) conducted a research to study anxiety
and depression among children and young people up to 20 years of age. They evaluated the
effect of exercise interventions in dropping or preventing anxiety or depression. The trials
were united using meta-analysis method. Findings of their study revealed that the depression
scores show a statistically significant difference in favor of the exercise group. They conclude
that there appears to be a consequence in favor of exercise in reducing depression and anxiety
scores in the general population of children and adolescents.
Lee and Overholser (2006) invented an integrated treatment plan for person with depression
and personality dysfunction. The confronts encountered by the therapist included:
1. Differentiating borderline personality from depressive symptoms.
2. Maintaining the therapeutic alliance.
3. Managing impulsivity and self-destructive tendencies.
4. Staying focused on long term therapeutic goals and
5. Coping with noncompliance.
The entire course was of 27 sessions that enabled client to make positive changes in mood,
self-image and impulsive tendencies. Although the client‘s border line personality traits
intricate the course of treatment for depression, neglecting these personality problems would
have left the client vulnerable to depressive relapse.
Young, Mufson and Davies, (2006) evaluated the efficacy of Cognitive Behavioural Therapy
(CBT), Adolescent Skill Training - a group specified preventive intervention. Adolescents in
the above two intervention conditions were compared for depression symptoms. Findings of
the study revealed that adolescents who receive Cognitive Behavioural Therapy and
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Adolescent Skill Training have considerably fewer depression symptoms and better overall
functioning at post-intervention and at follow-up.
Richard and Kristin (2006) conducted a meta-analysis of exercise as a treatment for
depression. The empirical evidence is convincing that exercise either alone or in combination
with other evidence-supported treatment is effective in treating clinically significant
depression. On the basis of their analysis authors suggested that patients with depression
should implement and maintain exercise behaviours to improve their moodAniljose and Asha
(2005) evaluated the competence of creativity training among children at risk of depression.
They divided the participants into two groups namely experimental group and control groups.
One month creativity training as a wrap up was given to experimental group. Findings of their
study highlighted that creativity training is effective for children at risk of depression and
experimental group demonstrated more symptom diminution than control group.
Manger and Motta (2005) designed a research to investigate the relationship ofaerobic
exercise program among the subjects with symptoms of Posttraumatic Stress Disorder,
anxiety, and depression. The preliminary study evaluated the impact of aerobic exercise
program of 12-session on the level of Posttraumatic Stress Disorder, anxiety, and depression.
The overall finding of the study did not show symptom reduction during baseline phases but
demonstrated significant reductions in the symptoms of Posttraumatic Stress Disorder,
anxiety, and depression following the exercise intervention. Reductions were maintained
during a 1 month follow-up. Findings of their study suggested that exercise programs may be
valuable resources for managing treatment-resistant participants with Posttraumatic Stress
Disorder and may also have a beneficial effect on anxiety and depression.
Sloman (2002) an Australian psychologist, conducted a study to see the effects of progressive
muscle relaxation and guided imagery on anxiety and quality of life among the patients of
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dangerous disease. The sample was drawn from people with sophisticated cancer. The overall
sample size was 56 patients with complex cancer who were experiencing anxiety and
depression. They were randomly assigned to one of four below mentioned treatment
conditions:
i. Progressive Muscle Relaxation Training group (PMRT group).
ii. Guided Imagery Training group (GIT group).
iii. Both of these treatments (Combined treatment group).
iv. Control group (No treatment group).
A pre/post treatment was employed in the study. Subjects were tested for anxiety, depression
and quality of life before and after intervention programme. Hospital Anxiety and Depression
Scale and the Functional Living Index Cancer Scale were used as the tools of measurement.
Findings of the study suggested that there is no significant change in anxiety level. However,
significant positive changes occurred for depression and quality of life.
Craft and Perna (2004) critically evaluated the literature related to the studies of the treatment
of depressive disorder with help of cognitive –behavioural therapies specifically relaxation
exercises. On the bases of their evaluation they argued that there are evidences to suggest
that the addition of cognitive-Behavioural therapies, specifically exercise, can improve
treatment outcomes for many patients. Exercise is a Behavioural intervention that has shown
great promise in alleviating symptoms of depression.
Ronald, Jane, Roger, David, Sonja, Maria and David (2001) designed a study with the
objective to examine data on the use of complementary and alternative therapies to treat
anxiety and depression in the United States. The data were obtained from a nationally
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representative survey of 2,055 respondents (1997–1998) having information on the use of 24
complementary and alternative therapies for the treatment of specific chronic conditions.
Relaxation exercises were considered as the complementary and alternative therapies. They
perceived helpfulness of these therapies in treating anxiety and depression as similar to that of
conventional therapies. Authors concluded that complementary and alternative therapies are
used more than conventional therapies by people with self-defined anxiety attacks and severe
depression. Most patients visiting conventional mental health providers for these problems
also use complementary and alternative therapies. Use of these therapies is helpful to manage
the level of anxiety and depression.
Marcotte (1996) examined the efficacy of cognitive Behavioural therapy on depression
among adolescent. Findings of their study suggested that short-term group cognitive
Behavioural interventions are efficient with early and late adolescents. Treatment
interventions included relaxation, cognitive restructuring, self-control skills, communication
and problem solving skills. No single strategy seems to be more effective than the other.
Janowick and Hackman (1995) examined the efficacy of assertiveness training and relaxation
in endorsed self-esteem and changes in depressive symptoms among adolescents. They used
two groups, one of them was given assertiveness training and the second was given yogic
relaxation technique- referred to as ‗shavasana‟. Pretest and post-test measures were taken on
the personal orientation inventory and Behavioural relaxation scale. Both groups showed
noteworthy increases in scores on self-esteem and decreased scores on depression.
Alexander (1995) appraised literature in order to compare relaxation and meditation
techniques. The researcher used meta-analysis and demonstrated that transcendental
meditation is significantly more effective than other forms of relaxation or meditation.
Transcendental meditation was found more effective in:
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i. Reducing psycho-physiological arousal.
ii. Dropping stress.
iii. Escalating positive mental health on measures of self esteem.
iv. Reducing alcohol, nicotine, and illicit drug use relative to standard treatment and
prevention programmers.
Randomized controlled traits show that the transcendental meditation technique appreciably
reduced hypertension and mortality in the elderly compared with a mental or physical
relaxation technique.
Broota, Aruna; Dhir, and Rima (1990) evaluated the efficacy of progressive muscle relaxation
technique (E. Jacobson's (1943) progressive relaxation- JPR) and Broota's relaxation
technique (BRT). They used 30 depressed outpatients with an age range of 19 to 48 yrs and
comparison was made with a control group. Subjects were assigned to one of the three
conditions namely:
1. JPR group
2. BRT group
3. No-treatment group.
For the BRT group four exercises based on breathing, spine stretching, leg raising, and
cycling were given. For the JPR group, muscle relaxation technique was involved. A
pretest and post-test design was employed in their study. A symptom check list was
administered twice, pre- and post-relaxation setting. An ANOVA for repeated measures
was used to analyze the data. Both relaxation techniques were found effective compared
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with the no-treatment group. It was concluded that relaxation exercises help to reduce the
level of depression up a normal level.
PysZcynski and Greenberg (1989) analyzed various symptoms and characteristics associated
with depression. From the obtained results they concluded that depression involves the loss of
a person or goal that has served as the basis for security and self-worth. They also argued that
depression occurs to the extent that the individual who experiences such as loss of a person or
goal fails to disengage the cycle and continues to self-focus in the absence of any way to
regain what was lost. But most of the time person does not appears to be careful for the
consequences of an action. The imprudent effects of sadness, disappointment, and self-hate
are closely linked with the low self-esteem of depressive individuals. As the defining
distinctiveness of the ―affective disorder‖ of depression, they are more typically looked on as
needing explanation than as source of explanation in them.
Borkovec and Andrews (1987) studied the effectiveness of progressive muscular relaxation in
order to control the depression. They executed 12 sessions of training in progressive muscular
relaxation on 32 volunteers who were having depressive symptoms. Cognitive therapy was
executed on 16 of them remaining participants were given non directive therapy. The therapy
was supplied by 16 graduate student clinicians. The group as a whole showed sizeable
reductions in depressive symptoms and daily self-monitoring, although relaxation plus
cognitive therapy produced considerably greater development than relaxation plus non-
directive therapy. On several pre-therapy, post-therapy comparisons, relaxation decreases
depression and the findings show noteworthy positive relation between relaxation and
outcomes.
Reynolds, William, Coats and Kevin (1986), undertaken a study to examine the effect of
cognitive-Behavioural treatment relaxation training or a wait-list control condition. 30
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moderately depressed high school students participated in the study. They were randomly
assigned between three conditions namely:
1. Cognitive-Behavioural treatment
2. Relaxation training
3. A wait-list control condition.
Treatment Subjects met in small groups for 10 sessions of 50-min over 5 weeks in a high
school setting. Outcome of all the subjects was measured on a modified Beck Depression
Inventory, the Rosenberg Self-Esteem Scale, and the State-Trait Anxiety Inventory. Findings
of the study revealed that the cognitive-Behavioural and relaxation training groups were
superior to the wait-list control group in the reduction of depressive symptoms at both post-
test and 5-weeks follow-up assessments. Significant difference was not found between active
treatments in their effectiveness for reducing depression. Subjects in the cognitive-
Behavioural and relaxation training conditions went from moderate levels of depression at
pre-test to non-depressed levels at post-test, and they maintained these levels at follow-up.
Study also demonstrated improvements in anxiety and academic self-concept by the active
treatments. Findings of the study suggested that these short-term group-administered therapies
are effective in significantly decreasing depression in adolescents.
Ingram (1984) proposed a more general account of depressive cognition that is based on other
information – processing models. Ingram emphasized on four concepts; network theories,
affect nodes, depth of processing and cognitive capacity. Integrated into cognitive networks
are emotions nodes that, when activated, excite other elements associated with the emotion.
When a network is widespread and complex, information is highly complicated and central in
the individuals‘ awareness. As an outcome, a greater part of the persons cognitive capacity is
occupied, Ingram assumed that depressive individuals possess widespread negative networks
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and that, as a result, negative information will be most complicated and will occupy the
greater proportion of cognitive capacity, when a depression – causing experience occurs,
activation spreads through the individuals loss-associated network, whose contents then come
into conscious awareness. Phenomenologically, it may seen to the individual that negative
memories keep coming back-again and again, thus continued depressive feelings.
Dumbar and Lishman (1984) observed in a research survey that depressed persons selectively
emphasized negative attribution cues in accounting for failure. The hopelessness model
appears to be important. Hopelessness can be seen in people who believe that there is nothing
they can do to either better them nor they feel that they can change an outcome of an
important event. Those believing that future control is possible experience anxiety in an effort
to gain control. If one is convinced that one is helpless in controlling important events but is
not sure if the bad outcome will actually occur, a mixed anxiety/depression syndrome will
probably surface. In contrast, if one is convinced that bad outcomes will definitely occur
regardless of what one does, then helplessness becomes hopelessness and depression sets in.
It is normal to become depressed if one believes that there is nothing one can do to prevent a
negative outcome.
McCann, Lisa, Holmes, and David (1984) organized a study to see the effect of relaxation
exercise on depression among women. 43 depressed undergraduate women participated in the
study. They were randomly assigned to either an aerobic exercise treatment condition, or a
no-treatment condition. In aerobic exercise subjects participated in strenuous exercise, a
placebo treatment condition in which they practiced relaxation exercises. Aerobic capacity
was assessed before and after a 10 week treatment period. Self-reported depression was
assessed three time- before, during, and after the treatment period. Results show that subjects
in the aerobic exercise condition had reliably greater increases in aerobic capacity and reliably
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greater decreases in depression than the subjects in the placebo or no-treatment condition.
There was a reduction in depression that was independent of treatment; it is suggested that a
no-treatment control condition is a necessity in research on depression. It was concluded that
findings provide clear evidence that participation in a program of strenuous aerobic exercise is
effective for reducing depression
Carrington, Collings, Benson, Robinson, Wood, Lehrer, Woolfolk, and Cole (1980) examined
the efficacy of relaxation and meditation for the management of stressed related anxiety and
depression among Working Population. They found that relaxation exercises are very
effective to manage stressed related anxiety and depression.
Sanchoz, Lewinsohn and Larson (1980) carried out a comparative analysis of assertion
training and ‗traditional‘ group psychotherapy. He assigned 32 depressed out patients to either
group assertion training or ‗traditional‘ group psychotherapy. Findings of their study
demonstrated that over a comparatively short period of time, assertiveness training is more
helpful than traditional Psychotherapy in increasing self-reported assertiveness and disburden
the depression.
Hayman and Cope (1980) examined the effectiveness of assertiveness training among
moderately depressed females. 26 moderately depressed females with an average age of 21.3
yrs were allocated randomly to the experimental group (assertiveness training programme)
and control group. Findings of their study supported the effectiveness of treatment.
Experimental subjects became extensively more assertive and engaged in appreciably more
activities than control subjects. After eight weeks of assertiveness training the experimental
subjects‘ scores indicated remarkably less depression. Other results include noteworthy
negative correlations between measures of depression and assertiveness. Recent technologies
involving the brain imaging technology elucidate that among depressed persons, neural
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circuits responsible for the regulation of moods, thinking, sleep, appetite, and behaviour fail
to function properly, and that critical neurotransmitters -- chemicals used by nerve cells to
communicate appears to be out of balance. Assertive training is helpful to provide a balancing
form to it.
Wolpe (1979) on the basis of certain studies, conducted on animals, concluded that depression
is the outcome of stern and prolonged anxiety produced by conditioning, cognition,
interpersonal helplessness, or remembrance.
Rehm‘s (1977) pointed out that the depressive persons weakened capacity to afford positive
emotional experiences for himself or herself. In psychological framework the depression is a
bunch of emotional, physical, and Behavioural symptoms characterized by loss of pleasure,
feeling of low self-esteem, sadness, and difficulty in functioning. Persistence of these
problems for two weeks or more, cause real suffering, and interfere with the business and
pleasure of daily life. Every one of us experiences these emotions and many people ultimately
suffer some adversity or loss that could give them reason to be anxious or depressed at times.
These feelings are just one part of everyday life for most people. However, if the feelings are
overwhelming or persistent, the person may benefit from psychological evaluation and
treatment. Depression of this type can effectively be removed with treatment that is often
relatively simple. Professional intervention in serious depression can diminish suffering and
improve the quality of life. Self-reinforcement is usually used to account for the dejected
mood and low self-esteem of the depressed person.
Beck (1976, 1984) proposed that information networks associated to the self-provide the
paramount memory access and that depressive individual‘s posses negatively toned network
that are associated with self-esteem. In his further study Beck emphasized that depressed
persons are predominantly prone to recognize negative words and scenes, where non
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depressed persons have a positive bias. He argued that there are numerous sub-categories of
depression. The most widespread are major depression and dysthymia. Depression is the most
invasive emotional state among congenital and acquired handicap; this applies to children that
have sensory or orthopedically handicap or any chronic disability. Denial is recurrently
present and may take the form of hyperkinetic behaviour, delinquent or antisocial activities
during adolescence, or a marked increase in passive dependent attitudes.
The foregoing discussion clearly reveals that there is differential effect of different
relaxation techniques on anxiety and depression. No doubt problem of anxiety and depression
is manageable with the help of relaxation technique. All the techniques differ in execution
style but all are based on more or less same principle i.e. influencing two basic psychological
processes- perception and attention. In an effort to manage the level of depression and anxiety
among the individuals, these two psychological processes have been influenced by
therapist/investigators with different methods and different name of relaxation exercise. With
this variation in methods and execution styles the outcome of all techniques is not similar.
Some techniques are more effective while some are less effective. Some studies show
similarity in the results of different relaxation techniques whereas, on the other side, there is a
substantial body of evidence to suggest the varying degree of influence of different relaxation
techniques on anxiety and depression. But from the available literature it is not clear which
relaxation technique is most effective and which technique is best suitable in given society.
The present investigation is a step in this direction. In this study two relaxation techniques
namely Progressive Muscle Relaxation (PMR) and Transcendental Meditation (TM) were
undertaken to compare their effect on anxiety and depression. These two techniques were
used in most simple form in such a way that does not require supervisory care. Moreover
Transcendental Meditation (TM) was modified to ascertain its suitability in an Arabian
country as the investigation was conducted in Jordon.
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Chapter Three
Methodology
As mentioned in the preceding chapter, the present research was designed with an aim
of “Assessing the effectiveness of relaxation techniques in management of anxiety and
depression”. The concept of methodology includes the aspects, namely, variables under
study, participants, measures, procedure and data analysis. These aspects of overall research
methodology can be thought of as forming a case for execution of present study. Additionally,
the methodology provides detailed information about how the subjects were used and what
tools of measurement were applied in the study. As the research is concerned with the
―effectiveness of relaxation techniques in management of anxiety and depression‖, the main
variables involved in the study are anxiety and depression which served as the dependent
variables and the types of relaxation techniques namely progressive muscle relaxation and
transcendental meditation (modified) which served as the independent variable. Both the
dependent variables anxiety and depression were studied under two conditions, pre-test and
post-test, for each of the two independent variables. Following null hypotheses were formed
prior to conduct the study:
H01. Progressive muscle relaxation does not have any effect on anxiety.
H02. Progressive muscle relaxation does not have any effect on depression.
H03. Transcendental meditation does not have any effect on anxiety.
H04. Transcendental meditation does not have any effect on depression.
H05. There is no significant difference in the effectiveness of progressive muscle relaxation
and transcendental meditation in management of anxiety.
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H06. There is no significant difference in the effectiveness of progressive muscle relaxation
and transcendental meditation in management of depression.
Description of Variables
Dependent Variables (DVs)
i. D V 1: Anxiety
ii. D V 2: Depression
Independent Variables (IVs)
Types of Relaxation Techniques
i. I V 1: PMR-Progressive muscle relaxation.
ii. I V 2: TM-Transcendental Meditation (Modified). This technique was used with
certain modifications touching the Islamic faith as the study was conducted in Jordan
where Islamic faith is dominant among all the people. Detailed description of the
techniques is given below.
Progressive Muscle Relaxation
Progressive muscles relaxation isone of the widely used relaxation technique. It is more
popular with modern physical therapists. In this technique persons are required to lie
down and focus on a particular group of muscles. The procedure of this technique
involves three basic steps.
a. The first step is relaxing the group of muscles consciously
b. Second step involves tensing these muscles for few seconds
c. The third stage involves complete relaxation of that group of muscle again.
After completing these steps for a particular group of muscle, the person is required to repeat
them with other muscle groups until the entire body is relaxed. The aim of this practice is to
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obtain a state of relaxation at deep level and to realize subject a difference between relaxed
and tense areas of the body. The learning sessions in progressive muscle relaxation are not
self-hypnosis. Progressive muscle relaxation sessions are usually organized in a low
illuminated room in which participants are required lie down and keep eyes closed. The
person is instructed to relax and avoid everything, disjoining from thoughts or physical
distractions. They are not allowed to make any effort to solve problems. Way of practicing
this exercise is reviewed by instructor in al session. Slow learner, if any, is given special
attention. The subjects are advised to keep continue practice on regular bases in their daily
lives. Some therapists argue that ―progressive muscle relaxation‖ may be done in ways, sitting
or lying down.
Some Examples of PMR Exercise
Hands: ―Subject is instructed to clench fist, tense for 5 seconds, release, and then rest
for 10 seconds‖
Right forearms and hands: ―Subject is instructed to extend arm, elbow locked, and
bend hand back at the wrist tense for 5 seconds, release, and then rest for 10 seconds‖.
Upper right arm: ―Subject is instructed to Bend arms at elbows and flex biceps tense
for 5 seconds, release, and then rest for 10 seconds‖
Forehead: ―Subject is instructed to wrinkle forehead into frown, tense, release, rest,
and/or raise eyebrows, tense for 5 seconds, release, and then rest for 10 seconds‖
Eyes: ―Subject is instructed to close eyes tightly, hold and release, tense for 5 seconds,
release, and then rest for 10 seconds‖.
Mouth: ―Subject is instructed to press lips tightly together tense for 5 seconds,
release, and then rest for 10 seconds‖.
Jaw: ―Subject is instructed to open mouth wide and stick out tongue tense for 5
seconds, release, and then rest for 10 seconds‖.
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Buttocks: ―Subject is instructed to tense the buttocks, tense for 5 seconds, release, and
then rest for 10 seconds‖.
Abdomen: “Subject is instructed to tense for 5 seconds, release, and then rest for 10
seconds‖.
Back: ―Subject is instructed to arch back, tense for 5 seconds, release, and then rest
for 10 seconds‖.
Neck and shoulders: “Subject is instructed to tense for 5 seconds, release, and then
rest for 10 seconds‖.
Thighs: ―Subject is instructed to tense for 5 seconds, release, and then rest for 10
seconds‖.
Lower legs and feet: ―Point toes toward shin tense for 5 seconds, release, and then
rest for 10 seconds‖.
Feet: ―Subject is instructed to Point toes and curl them under tense for 5 seconds,
release, and then rest for 10 seconds‖.
Methods Adopted for PMR in the Present Investigation
At the first stage the subjects were required to tense up a group of muscles and hold
for about 5 to 10 seconds. They could start either from lower to upper side or vice
versa.
As a second steps participants released tension from the muscles all at once followed
by staying relaxed for 10 - 20 seconds.
The third step was of shifting. It involved shifting from one group of muscles to
another group of muscles either from lower to upper side or from upper to lower side.
The fourth stage was of repetition. It involved repetition of same exercise on another
group of muscles.
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Instead of measuring time some persons prefer counting, as for example:
―Tense for count of 5, release all at once, rest for count of 10‖
Or
―Tense for count of 10, release all at once, rest for count of 20‖
These exercises were carried out in a calm and quite environment in a low illuminated room
with the instructions to participants to be attentive to the feeling of relaxation when they are
releasing the tension of muscles.
Progressive muscle relaxation technique is generally safe and doesn‘t require a professional‘s
guidance. Person can practice the techniques at home using the instructions from a book or
website, or any other source. Prior to use this technique the investigator studied it thoroughly
and practiced to gain mastery. Then the participants were trained up to use these exercises at
their home independently.
Transcendental Meditation (TM):
Transcendental meditation has been found very effective to obtain noteworthy practical
benefits in all major areas of life. It is a distinguished method of reaching a state of
rumination leading to a high quality of rest to both body and mind. The technique is supposed
to releases stress and fatigue in a natural way. This type of meditation does not involve nor
require any a particular faith or belief. It simply utilizes the natural tendency of the mind to
calm down, experiencing the least excited state of consciousness, a state of restful alertness
and reflection.
Advocators of TM emphasize, ―The Mantra meditation method is all that is required in
practicing transcendental meditation involves repetition of a certain word consciously which
is satisfying and appealing to the person. It is used to achieve a state of ‗restful alertness‘,
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Mantra actually means ‗revealed sound‘ or a combination of blended sounds that develop
spontaneously‖. Proponents of technique argue that one should not confuse a mantra with a
religious chant. A mantra can be given by a guru or may be a personally chosen sound or
word, nevertheless, the most important thing being, is that it must appeal to the mind. The
technique is said to be very practical and simple to achieve a state of rumination, suitable for
all people, adults and children alike. TM is very useful specifically for those persons who find
it difficult to set aside time. They are very busy and living hectic life. Various other
techniques may require an hour plus to practice and may also require considerably more time
for consideration and contemplation. 15 to 20 minutes two times daily, sitting comfortably
with the eyes closed is all that is needed using the transcendental method. This may even be
practiced in any situation as for example; travelling in a bus or train, during lunch hour,
practically anywhere in fact that is safe and comfortable to sit with closed eyes for those 15-
20 minutes. In the present study this technique was used with certain modifications. It was
used in religious form giving a Islamic touch because the study was conducted in a country
where majority of people have strong faith in Islam.
Method involved in TM:
Person is required to close eyes, hold up a few moments, and afterward begin thinking
the mantra. It is thought over and over just in the first place of contemplation.
Modifications: Mantra was replaced by ‗tasbeeh‟ (remembering and praising The
God)
Both the conditions, sitting and laying down in a relaxed and comfortable manner
were allowed.
After a while the person ought to "let it go" and "permit the mantra to change in any
capacity it needs". And whether it picks up louder or milder, quicker or slower down,
clearer or fainter, it is simply taken it as it comes. It is all the more a "hearing" of the
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mantra than rehashing it, and that is the reason TM development calls the technique
―effortless‖.
Modification: Instead of hearing mantra, subjects were required to recite ‗tasbeeh‟ in
a calm and quiet manner.
Subjects are instructed to allow thoughts to travel every which way alongside the
mantra. There is no attempt to push thoughts crazy or utilize the mantra to override
them.
Modification: There were no instructions regarding the thoughts.
At the end participants are instructed to quit thinking the mantra and hold up around 2
minutes before opening the eyes.
Modification: At the end participants were free to do any thing
Finally the modified procedure for TM was as follows
Participants were advised to take a comfortable position either sitting or laying down.
They were advised to have a complete faith in God
They were advised to recite a „tasbeeh‟ (suhanAllh-e-Wabehamdihi)
Time duration was 15 to 20 minutes.
They were advised to remember the God for their betterment
They were advised to open and close their fist and move feet around during the
recitation of ‗tasbeeh‟.
They were allowed to change their position during the recitation of ‗tasbeeh‟. The
purpose was that the participant must feel relaxed.
At the end participants were free to do anything.
All efforts were made to simplify the technique so that the participant could use it
independently without the supervisory care of an expert.
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Measuresused
There were two measures of dependent variables namely anxiety and depression. Each
variable was measured under two conditions: 1. Pre-test and 2. Post-test. To measure anxiety,
―Hamilton Anxiety Rating Scale‖ (HAM-A) and for depression, Back Depression Inventory
BDI-II were used.
Hamilton Anxiety Rating Scale (HAM-A)
was developed by Hamilton (1959). ―The scale is comprised of 14 items, each defined by a
series of symptoms, and measures both psychic anxiety that includes mental agitation and
psychological stress and somatic anxiety that includes physical complaints related to anxiety.
Every item is scored from 0 (not present) to 4 (sever), with a total score range of 0 to 56,
where less than 17 indicates mild severity, 18-24 mild to moderate severity and 25-30
moderate to severe. The HAM-A does not provide any standardized probe questions. Despite
this, the reported levels of inter-rater reliability for the scale appear to be acceptable‖.
Back Depression Inventory BDI-II
The second scale of the present study was ―Back Depression Inventory Second Edition‖
(BDI-II, 1996). ―BDI-II is a 21 item self report instrument intended to assess the existence
and severity of symptoms of depression as listed in the American Psychiatric Association‘s
Diagnostic and Statistical Manual of Mental Disorders Forth Edition (DSM-IV; 1994). This
new revised edition replaces the BDI and BDI-1A, and includes items intending to index
symptoms of severe depression, which would require hospitalization‖.
Research Design
One of the vital parts of the whole Methodology is the research design. It is a detailed plan
showing how the study will be completed. It includes operationalization of variables,
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selection of the sample of interest, selection of the tools of measurement, procedure of data
collection etc.
In the present study a ―pre-test and post-test‖ design was used for both the dependent
variables viz ―anxiety‖ and ―depression‖. There were four groups of participants. Both the
dependent variables were tested separately. Group 1 and 2 were examined for the
effectiveness of relaxation techniques PMR AND TM for the dependent variable 1 i.e.
anxiety. Group 3 and 4 were examined for the effectiveness of relaxation techniques PMR
AND TM for the dependent variable 2 i.e. depression.
Study Design for DV 1 (Anxiety)
Each member of the group 1 and 2 was tested for anxiety score on ―Hamilton Anxiety
Rating Scale‖ (HAM-A). At the first stage each member of the group 1 was tested for anxiety
score. At the second stage each member of group 1 was trained up for the progressive
muscles relaxation technique and detailed benefits of the technique were also explained to
them. At the third stage this group used progressive muscles relaxation exercise for about 6
weeks, twice in a day, once in early morning and second in night before going to bed.
Immediately after 6 weeks, each member of group 1 was tested again for their anxiety score
on the same anxiety scale. Thus the group 1 was tested under two conditions. One was pre-
treatment condition ( cond. A) and second was post-treatment condition ( cond. B). Similarly
each member of group 2 was tested for anxiety score at stage 1. At the second stage each
member of group 2 was trained up for the modified transcendental meditation technique.
Detailed benefits of the technique were also explained to them. At the third stage this group
used modified transcendental meditation exercise for about 6 weeks, twice in a day, once in
early morning and second in night before going to bed. Immediately after 6 weeks, each
member of group 2 was tested again for their anxiety score on the same anxiety scale. In this
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way the group 2 was also tested under two conditions. One was pre-treatment condition
(cond. C) and second was post-treatment condition (cond. D). Thus there were four
observations on two groups of subjects for DV 1 i.e. anxiety.
Observation 1: Pre-treatment assessment of anxiety score of group 1
Observation 2: Post-treatment assessment of anxiety score of group 1. Treatment was the
effect of independent variable 1 i. e. the use of PMR
Observation 3: Pre-treatment assessment of anxiety score of group 2
Observation 4: Post-treatment assessment of anxiety score of group 2. Treatment was the
effect of independent variable 2 i. e. the use of TM
In this way the design of the study became 2x2 factorial design which can diagrammatically
be presented as below.
Effect of Relaxation Techniques
on Anxiety
Cond.A and Cond. C are same because no treatment was given in these conditions as these are
the pre-treatment conditions. Observation 1 and 2 are the observations on group 1 under pre-
treatment and post-treatment conditions.
Under Effect of I V
2
(TM)
Under Effect of I V
1
(PMR)
Observation 4
(Cond. D)
Observation 3
(Cond. C)
Observation 2
(Cond. B)
Observation 1
(Cond. A)
DV 1
Anxiety
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Cond. B and Cond. D are the post-treatment conditions with the difference of treatment. For
Cond. B, the treatment was ‗PMR‘ and for Cond. D, the treatment was ‗TM‘. Observation 3
and 4 are the observations on group 2 under pre-treatment and post-treatment conditions.
Study Design for DV 2 (Depression)
Study design for DV 2 (Depression) was similar to that of DV 1 (Anxiety). Each
member of the group 3 and 4 was tested for depression score on Back Depression Inventory
BDI-II. At the first stage each member of the group 3 was tested for depression score. At the
second stage each member of group 3 was trained up for the progressive muscles relaxation
technique and detailed benefits of the technique were also explained to them. At the third
stage this group used progressive muscles relaxation exercise for about 6 weeks, twice in a
day, once in early morning and second in night before going to bed. Immediately after 6
weeks, each member of group 3 was tested again for their depression score on the same
depression scale. Thus the group 3 was tested under two conditions. One was pre-treatment
condition (cond. A*) and second was post-treatment condition (cond. B*). Similarly each
member of group 4 was tested for depression score at stage 1. At the second stage each
member of group 4 was trained up for the modified transcendental meditation technique.
Detailed benefits of the technique were also explained to them. At the third stage this group
used modified transcendental meditation exercise for about 6 weeks, twice in a day, once in
early morning and second in night before going to bed. Immediately after 6 weeks, each
member of group 4 was tested again for their depression score on the same depression scale.
In this way the group 4 was also tested under two conditions. One was pre-treatment
condition (cond. C*) and second was post-treatment condition (cond. D*). Thus there were
four observations on two groups of subjects for DV 2 i.e. depression.
Observation 1: Pre-treatment assessment of depression score of group 3
95
Observation 2: Post-treatment assessment of depression score of group 3. Treatment was the
effect of independent variable 1 i. e. the use of PMR
Observation 3: Pre-treatment assessment of depression score of group 4
Observation 4: Post-treatment assessment of depression score of group 4. Treatment was the
effect of independent variable 2 i. e. the use of TM
In this way the design of the study became 2x2 factorial design which can diagrammatically
be presented as below.
Effect of Relaxation Techniques
on Depression
Cond. A* and Cond. C* are same because no treatment was given in these conditions as these
are the pre-treatment conditions. Observation 1 and 2 are the observations on group 3 under
pre-treatment and post-treatment conditions.
Cond. B* and Cond. D* are the post-treatment conditions with the difference of treatment.
For Cond. B*, the treatment was ‗PMR‘ and for Cond. D*, the treatment was ‗TM‘.
DV 2
(Depression)
Under Effect of I V
2
(TM)
Under Effect of I V
1
(PMR)
Observation 4
(Cond. D*)
Observation 3
(Cond. C*)
Observation 2
(Cond. B*)
Observation 1
(Cond. A*)
96
Observation 3 and 4 are the observations on group 4 under pre-treatment and post-treatment
conditions.
Participants
A non-probability sampling method (Purposive Sampling) was used in the present study. The
overall sample size was 80 subjects, consisted of 4 groups having 20 subjects in each group.
All the sample units were selected from the Basman district of Amman city of Jordan.
Amman is the capital and most populous city of Jordan. It is the economic, political and
cultural centre of the country. Amman is situated in north-central area of Jordan. Having a
population of 4,007,526 the city has a land area of 1,680 square kilometers. Amman is
divided into 27 districts. Basman having a population of 373981 and a land area of 13.4
square kilometers is one of 27 district of Amman. All the participants were chosen from the
various localities of Basman. At the initial stage the investigator, on the basis of observation
and information obtained from some directly or indirectly known persons, identified few
persons having a somewhat high level of anxiety. The investigator made contact with these
persons and convinced them to participate in relaxation exercise. Whosoever agreed, the
investigator administered ―Hamilton Anxiety Rating Scale‖ (HAM-A) on them. Person
obtaining 25 or above score was selected in the sample. 24 score on Hamilton Anxiety Rating
Scale (HAM-A) is the moderate level of anxiety. In other words, persons above the moderate
level of anxiety but not very sever level were selected in the sample. Person with very sever
level of anxiety needs hospitalization. The investigator continued this exercise till he finds out
40 subjects. Subjects thus selected were randomly assigned to group 1 and group 2, each
having 20 subjects. All the subjects were selected keeping in mind the main aim of study to
conduct the treatment in homely environment and without supervisory care of experts.
Whatsoever relaxation techniques were used for the treatment of anxiety are not supposed to
have any adverse effect.
97
Sample for the study of DV 2 (depression) was also selected in a similar way from the various
localities of Basman district of Amman. At the initial stage the investigator again identified
few persons having a somewhat high level of depression. In this process the same method was
followed as in case of anxiety patients. The investigator made contact with these persons and
convinced them to participate in relaxation exercise. Whosoever agreed, the investigator
administered Back Depression Inventory BDI-II on them. Person obtaining 31 or above score
was selected in the sample. 30 score on Back Depression Inventory BDI-II is the moderate
level of depression. In other words, persons above the moderate level of depression but not
very sever level were selected in the sample. Person with very sever level of depression needs
hospitalization. The investigator continued this exercise till he finds out 40 subjects of this
category. Subjects thus selected were randomly assigned to group 3 and group 4, each having
20 subjects. All the subjects were selected keeping in mind the main aim of study to conduct
the treatment in homely environment and without supervisory care of experts. Whatsoever
relaxation techniques were used for the treatment of depression is not supposed to have any
adverse effect.
Inclusion Criteria of Participants in the Sample
Prior to select the subject to a criteria was established to form the sample which is as follows:
1. The first thing to consider to include subject in the sample was level of anxiety and
depression. A low level is a normal phenomenon and a very high level of anxiety and
depression may need supervisory care and even hospitalization. The moderate level in
which person has problems in normal functioning but he seldom think about treatment
of it. These problems, on later stage, can take sever turn. Therefore, the persons with
moderate level of either anxiety or depression were included in the sample so that the
relaxation exercises could be conducted little training and without supervisory care.
98
2. Persons, irrespective of their age and gender, having complete faith in God were
included in the sample because modifications made in the transcendental meditation
technique require a complete faith in God.
3. Only those persons who had strong willingness to overcome the problem of anxiety
and depression were included in the sample.
4. Care was also taken to see the intention of subject regarding the relaxation exercises.
Only those persons who were convinced that relaxation exercises can be a means to
overcome the problem of anxiety and depression were included in the sample.
Exclusion Criteria
Persons even falling in the criteria of inclusion were excluded from the sample. These persons
are of following categories:
1. Person with a disease for which he need supervisory care
2. Person with a disease for which he is under treatment of a doctor
3. Persons though interested in relaxation exercise but due to some or other reason were
not able to manage regularity and punctuality
4. Persons not having faith in religion
Procedure
The questionnaires used in the present study included ―Hamilton Anxiety Rating Scale‖
(HAM-A) and ―Back Depression Inventory‖ BDI-II.Before administering the questionnaire,
the purpose was explained to the participants. An assurance was given to the participants that
their responses will not be disclosed and will be used for research and academic purpose only.
A good rapport was established with the participants for obtaining correct responses. Some
necessary instruction and guidelines were provided to them for properly filling the
questionnaire. After this, the questionnaires were provided to them and they were requested to
99
fill it up as per the instructions given in the questionnaire. It took an average of 30 minutes for
the participants to complete the questionnaire. After completion of the questionnaire
participants returned it to the investigator. After carrying out the scoring, investigator got in
touch again with the participants falling under the criteria of selection the sample unit as
stated above. The score obtained for anxiety/depression was used as the anxiety/depression
score for observation 1 and 3. Subjects were not tested again for anxiety/depression for the
pre-treatment conditions. The pre-treatment conditions in the present study are: Cond. A,
and Cond. C, for DV 1 and Cond. A* and Cond. C* for DV 2. All the subjects used
assigned relaxation technique individually and independently. Prior to use the assigned
relaxation exercise they were trained up and each and everything was explained to them.
Participants were suggested feel free to contact the investigator, in case of any doubt/problem.
The investigator also tried to keep in touch with the participants regularly. Progressive muscle
relaxation technique was assigned to group 1 and 3 and transcendental meditation technique
(modified) was assigned to group 2 and 4. Subjects proceeded with the assigned relaxation
technique using the method as stated above. After the 6 weeks of exercise, group 1 & 2 were
tested again for DV 1 (anxiety) and group 3 & 4 for DV 2 (depression). Data thus obtained
were statistically treated with help of analysis of variance separately for DV 1 and DV 2.
Detail of analysis is given in chapter 3.
100
Chapter four
Data Analysis (results) and Discussion
Analysis for DV 1 (Anxiety)
As mentioned in the preceding chapter, a before and after test design was employed in the
present study. There were two independent variables namely ―progressive muscle relaxation‖
(PMR) and ―transcendental meditation‖ (TM). Two groups of subjects, Group 1 & Group 2,
participated in investigation. Each was studied under two conditions:
1. Pre-test/pre-treatment condition.
2. Post-test/post-treatment condition.
Treatment was use of PMR for group 1 and use of TM for group 2. Thus there were four
observations on two groups.
Observation 1 (Cond. A)
Assessment of anxiety score of group 1 before using PMR- Pre-treatment Condition.
Observation 2 (Cond. B)
Assessment of anxiety score of group 1 after using PMR- Post-treatment Condition.
Observation 3 (Cond. C)
Assessment of anxiety score of group 2 before using TM- Pre-treatment Condition.
Observation 4 (Cond. D)
Assessment of anxiety score of group 2 after using TM- Post-treatment Condition.
101
Table 1: Mean Anxiety Score Under Different Conditions:
Conditions Mean Anxiety Score
A 28.40
B 24.10
C 27.65
D 21.30
Table 2: One way ANOVA for Condition A and Condition C
Sources of
Variation df
Sum of
Square
Mean Sum of
Square F Ratio
Between Means
1
5.625
5.625
0.006805
Within Group
Error
38
31410.4
826.59
Conditions A and condition C are the same because both are pre-treatment conditions.
Conditions A pertains to group 1 and condition C pertains to group 2. Both the groups 1 & 2
are similar in characteristics. Mean anxiety score (M= 28.40) obtained by group 1 under
condition A is more or less similar to the Mean anxiety score (M= 27.65) obtained by group 2
102
under condition C. Difference between these two means is insignificant (F = 0.006, df 1/38, P
= NS. Ref. Table 2). To check this difference was essential because group 1 was studied to
see the effect of PMR on anxiety level and group 2 was studied to see the effect of TM on the
same variable i.e. anxiety. To assess the difference in effectiveness of PMR and TM was also
an objective of the present investigation.
Both of the above group 1 and group 2 were studied under two conditions, pre-treatment and
post-treatment conditions, yielding four observations on two groups of subjects. When the
same group is measured more than once, the means are correlated as the two sets of scores are
achieved from the same groups of subjects. When a test is given and repeated, analysis of
variance may be used to determine whether the mean change is significant. In the present
study, anxiety level of group 1 was assessed before the use of PMR and the same test was
repeated after the PMR. Similarly the anxiety level of group 2 was assessed before the use of
TM and the same test was repeated after the TM. Hence, two (p & q) ANOVA for repeated
measures was applied for the analysis of the data of present investigation. Here factor p is the
effect of the use of relaxation exercise and factor q is the differential effect of the two types of
relaxation techniques i.e. PMR & TM. Results of the analysis are given below. Summary of
ANOVA is given in table 4 and means and combined means of anxiety scores under pre-
treatment and post-treatment conditions for PMR and TM are given in table 3. Main effects
and interaction effect is also depicted in figure 1, 2 & 3
103
Table 3: Showing mean anxiety scores and combined mean under pre-treatment and post-
treatment conditions for PMR and TM
Pre-treatment
cond.
Post-treatment
cond.
Mean Comb.
PMR
28.40 24.10 26.25
TM 27.65 21.30 24.47
Mean Comb.
28.02
22.70
104
Table 4: Showing ANOVA for anxiety score
“Sources of Variation” “Sum of
Square” “df”
“Mean
Sum of
Square”
“F Ratio”
Factor p
Effect of Relaxation
Exercise
567.1125 1 567.1125 62.99868
p< 0.01
Factor q
Effect of Type of
Relaxation Technique
63.0125 1 63.0125 6.999854
p< 0.05
p x q Interaction 183.98 1 183.98 20.43774
p< 0.01
Subject
(Indvidual Differences) 134.2375 19 7.065132
Residual
513.1125 57 9.001974
A perusal of table 4 reveals that ‗F‘ ratio for the effect of factor „p‟ i. e. the effect of
relaxation exercise is 62.99 which is significant at 0.01 level of significance. The result
suggests that variation in pre-treatment and post-treatment conditions has differential effect
on level of anxiety. Ignoring the variable ‗type of relaxation technique‘ we find in table 3 that
mean of the means for the post-treatment condition (22.70) is significantly less than the mean
105
of the means (28.02) for the pre-treatment condition (F = 62.99, df 1/57, p < 0.01 Ref. Table
4). On the basis of this finding we can safely conclude that persons having anxiety problems
can manage their anxiety level to the normal or near normal position with the help of
relaxation techniques. This finding is graphically depictured in figure 1
Figure 1: Showing effect of factor p on Anxiety
In the figure 1 the two conditions of observation i. e. pre-treatment and post-treatment
conditions are shown on horizontal axis and mean anxiety scores under these two conditions
are shown on vertical axis. The two points of line show the level of anxiety. Since the line is
sloping downwards from pre-treatment condition to post-treatment condition, it may safely
be concluded that use of relaxation exercise is helpful to reduce the level of anxiety.
Table 4 further reveals that ‗F‘ ratio for the effect of factor „q‟ i. e. the effect of type of
relaxation technique is 6.99 which is reliable at 0.05 level of confidence. The finding suggests
that types of relaxation technique i. e. PMR and TM have differential effect on level of
anxiety. Ignoring the variable ‗pre-treatment and post-treatment conditions‘ we find in table 3
Lev
el
of
An
xie
ty
28.0
2
22.70
Pre-treatment
Condition
Post-treatment
Condition
Figure 1
106
that the mean of the means for the TM (24.47) is significantly less than the mean of the means
(26.25) for PMR (F = 6.99, df 1/57, p < 0.05 Ref. Table 4). The finding shows that
transcendental meditation as compared to progressive muscle relaxation is more effective to
manage the anxiety level up to the normal or near normal level. Figure 2 is graphically
presentation of this finding
Figure 2: Showing effect of factor q on Anxiety
In the figure 2 the two type of relaxation exercise i. e. PMR and TM are shown on horizontal
axis and mean anxiety scores obtained after the use of these two relaxation exercises are
shown on vertical axis. The two points of line show the level of anxiety. Since the line is
sloping downwards from PMR to TM, it may safely be concluded that use of TM as
compared to PMR better helpful to reduce the level of anxiety.
F ratio for p x q interaction is 20.43 which is significant at 0.01 level of significance (F =
20.43, df 1/57, p < 0.01 Ref. Table 4). The finding suggests that an interaction exists between
factor p (effect of relaxation exercise) and factor q (effect of type of relaxation technique. this
finding is graphically presented in figure 3.
Lev
el
of
An
xie
ty
26.2
5
24.47
PMR TM
Figure 2
107
Figure 3: Showing p & q interactional effect on Anxiety
In the figure 3 the two conditions of observation i. e. pre-treatment and post-treatment
conditions are shown on horizontal axis and mean anxiety scores under these two conditions
are shown on vertical axis. L 1 show the level of anxiety with the use of PMR and L 2 show
the level of anxiety with the use of TM. These two lines intersect each other indicating a p x q
interaction.
Analysis for DV 2 (Depression)
Analysis for the depression score was carried out in the same way as for anxiety score. A
before and after test design was employed in the present investigation. There were two
independent variables namely ―progressive muscle relaxation‖ (PMR) and ―transcendental
meditation‖ (TM). Two groups of subjects, Group 3 & Group 4, participated in investigation.
Each group was studied under two conditions:
1. Pre-test/pre-treatment condition.
Lev
el
of
An
xie
ty
L
2
L 2
L
1 L
1
Pre-treatment
Condition
Post-treatment
Condition
Figure 3
108
2. Post-test/post-treatment condition.
Treatment was use of PMR for group 3 and use of TM for group 4. Thus there were four
observations on two groups.
Observation 1 (Cond. A)
Assessment of depression score of group 3 before using PMR- Pre-treatment Condition.
Observation 2 (Cond. B)
Assessment of depression score of group 3 after using PMR- Post-treatment Condition.
Observation 3 (Cond. C)
Assessment of depression score of group 4 before using TM- Pre-treatment Condition.
Observation 4 (Cond. D)
Assessment of depression score of group 4 after using TM- Post-treatment Condition.
Table 5: Mean depression Score Under Different Conditions:
Conditions Mean Depression Score
A 35.40
B 32.05
C 36.20
D 26.85
109
Table 6: One way ANOVA for Condition A and Condition C
Sources of
Variation df
Sum of
Square
Mean Sum of
Square F Ratio
Between Means
1
6.40
6.40
0.36
Within Group
Error
38
666
17.52
Conditions A and condition C are the same because both are pre-treatment conditions.
Conditions A pertains to group 3 and condition C pertains to group 4. Both the groups 3 & 4
are similar in characteristics. Mean depression score (M= 35.40) obtained by group 3 under
condition A is more or less similar to the Mean anxiety score (M= 36.20) obtained by group 4
under condition C. Difference between these two means is insignificant (F = 0.36, df 1/38, P =
NS. Ref. Table 6). Checking of this difference was essential because group 3 was studied to
see the effect of PMR on depression level and group 4 was studied to see the effect of TM on
the same variable i.e. depression. To assess the difference in effectiveness of PMR and TM to
mange the level of depression was also an objective of the present investigation.
Both of the above group 3 and group 4 were studied under two conditions, pre-treatment and
post-treatment conditions, yielding four observations on two groups of subjects. When the
same group is measured more than once, the means are correlated as the two sets of scores are
110
achieved from the same groups of subjects. When a test is given and repeated, analysis of
variance may be used to determine whether the mean change is significant. In the present
study, depression level of group 3 was assessed before the use of PMR and the same test was
repeated after the PMR. Similarly the depression level of group 4 was assessed before the use
of TM and the same test was repeated after the TM. Hence, two factors (p & q) ANOVA for
repeated measures was applied for the analysis of the depression data in the present
investigation. Here factor p is the effect of the use of relaxation exercise and factor q is the
differential effect of the two types of relaxation techniques i.e. PMR & TM. Results of the
analysis are given below. Summary of ANOVA is given in table 8 and means and combined
means of depression scores under pre-treatment and post-treatment conditions for PMR and
TM are given in table 7. Main effects and interaction effect is also depicted in figure 4,5& 6
Table 7: Showing mean depression scores and combined mean under pre-treatment and
post-treatment conditions for PMR and TM
Pre-treatment
cond.
Post-treatment
cond.
Mean Comb.
PMR 35.40 32.04 33.72
TM 36.20 26.85 31.52
Mean Comb.
35.80
29.45
111
Table 8: Showing ANOVA for depression score
“Sources of Variation” “Sum of
Square” “df”
“Mean
Sum of
Square”
“F Ratio”
Factor p
Effect of Relaxation
Exercise
806.45 1 806.45 54.73
p< 0.01
Factor q
Effect of Type of
Relaxation Technique
96.80 1 96.80 6.57
p< 0.05
p x q Interaction 183.97 1 183.97 12.48
p< 0.01
Subject
(Individual Differences) 493.75 19 25.98
Residual
839.75 57 14.73
A perusal of table 8 reveals that ‗F‘ ratio for the effect of factor „p‟ i. e. the effect of
relaxation exercise is 54.73 which is reliable at 0.01 level of confidence. The result suggests
that variation in pre-treatment and post-treatment conditions has differential effect on level of
depression. Ignoring the variable ‗type of relaxation technique‘ we find in table 7 that the
mean of the means for the post-treatment condition (35.80) is significantly less than the mean
112
of the means (29.45) for the pre-treatment condition (F = 54.73, df 1/57, p < 0.01 Ref. Table
8). On the basis of this finding we can conclude that persons having problems of depression
can manage their it to the normal or near normal position with the help of relaxation
techniques. This finding is graphically depictured in figure 4
Figure 4: Showing effect of factor p on level of depression
In the figure 4 the two conditions of observation i. e. pre-treatment and post-treatment
conditions are shown on horizontal axis and mean depression scores under these two
conditions are shown on vertical axis. The two points of line show the level of depression.
Since the line is sloping downwards from pre-treatment condition to post-treatment condition,
it may safely be concluded that use of relaxation exercise is helpful to reduce the level of
depression.
Table 8 further reveals that ‗F‘ ratio for the effect of factor „q‟ i. e. the effect of type of
relaxation technique is 6.57 which is reliable at 0.05 level of significance. The finding
suggests that types of relaxation technique i. e. PMR and TM have differential effect on level
Lev
el
of
De
pre
ss
ion
35.4
0
32.04
Pre-treatment
Condition
Post-treatment
Condition
Figure 4
113
of depression. Ignoring the variable ‗pre-treatment and post-treatment conditions‘ we find in
table 7 that the mean of the means for the TM (33.72) is significantly less than the mean of
the means (31.52) for PMR (F = 6.57, df 1/57, p < 0.05 Ref. Table 8). The finding shows that
transcendental meditation as compared to progressive muscle relaxation is more effective to
manage the depression level up to the normal or near normal level. The finding is graphically
presented in figure 5
Figure 5: Showing effect of factor q on level of Depression
In the figure 5 the two type of relaxation exercise i. e. PMR and TM are shown on horizontal
axis and mean anxiety scores obtained after the use of these two relaxation exercises are
shown on vertical axis. The two points of line show the level of depression. Since the line is
sloping downwards from PMR to TM, it may safely be concluded that use of TM as
compared to PMR better help to reduce the level of anxiety.
F ratio for p x q interaction is 12.48 which is reliable at 0.01 level of significance (F = 12.48,
df 1/57, p < 0.01 Ref. Table 8). The finding suggests that an interaction exists between factor
p (effect of relaxation exercise) and factor q (effect of type of relaxation technique. this
finding is graphically presented in figure 6.
Lev
el
of
An
xie
ty
26.2
5
24.47
PMR TM
Figure 5
114
Figure 6: Showing p & q interactional effect on level of Depression
In the figure 7 the two conditions of observation i. e. pre-treatment and post-treatment
conditions are shown on horizontal axis and mean depression scores under these two
conditions are shown on vertical axis. L 1 show the level of depression with the use of PMR
and L 2 show the level of depression with the use of TM. These two lines intersect each other
indicating a p x q interaction.
Lev
el
of
An
xie
ty
L
2
L 2
L
1 L
1
Pre-treatment
Condition
Post-treatment
Condition
Figure 3
115
Chapter Five
The main findings of the present research
1. Relaxation exercise help reduce the level of anxiety among individuals.
2. There is a differential effect of ―Progressive muscle relaxation‖ technique and
―Transcendental meditation‖ on level of anxiety among individuals.
3. There is an interactional effect of relaxation exercise and type of relaxation
techniques on level of anxiety among individuals.
4. Relaxation exercise results into the decline in level of depression among
individuals.
5. There is a differential effect of ―Progressive muscle relaxation‖ technique and
―Transcendental meditation‖ on level of depression among individuals.
6. There is an interactional effect of relaxation exercise and type of relaxation
techniques on level of depression among individuals.
The first finding of the present study i.e. Relaxation exercise help reduce the level
of anxiety among individuals, lend support to many early findings and can be
interpreted in the light of features associated with anxiety and relaxation exercises.
Anxiety is a normal phenomenon experienced by everyone in routine life.
Therapists say, ―anxiety is not only present in all people some of the time; anxiety in
some form or another is present in all people most of the time‖. Feeling of anxiety or
nervousness is common at the time of facing any problem either at home or at work,
and most of the time before making an important decision. When feeling of anxiety
goes beyond a certain level, it becomes anxiety disorder which is different from the
normal feeling and can perturb person's ability to lead a normal life. Usually,
―anxiety leads to an uncomfortable feeling of fear or proximity to a disaster. It
116
reflects the thoughts and bodily reactions a person has when they are presented with
an event or situation that they cannot manage or undertake successfully‖. In a state of
anxiety the person is over cautious and more actively assess the situation sometimes
automatically without paying conscious attention. Though anxiety is a normal
phenomenon under a stressful situation but when it goes too high, the person may not
come up with an effective way of managing it. (e.g. Seligman, Walker &Rosenhan,
2001; Craske& Barlow, 2006; Barlow, 1988). In short it can be construed that state of
anxiety, psychologically as well as physiologically, is a very uncomfortable and tense
situation. A cognitive response to anxiety includes, ―thoughts about the situation and
the person's ability to cope with it‖. For someone experiencing high anxiety usually
means wrong interpretation of situations looking at negative aspects and having
unhelpful thoughts resulting into an uncomfortable situation. During the relaxation
exercises situation is reversed. The uncomfortable situations are converted into the
comfortable situation. It will be clearer with discussion of the features associated
with relaxation exercises.
According to Titlebaum (1988) relaxation technique is a specific way of physical
movement of body that may include breathing in a rhythmic way, tensing and relaxing the
muscle in categorization or in a specific sequence. This is supposed to be as a factor of
lessening the perception of those stimuli which are stressful. This also calms down the feeling
of anxiety as well as tension, feeling of depression, stress and pain. McCaffery& Beebe
(1989) hold the view that relaxation exercises lead to freedom from anxiety and skeletal
muscle tension‘ while according to Ryman (1995) relaxation creates a state of balance and
peace in the mind of the participants. It is also argued that relaxation exercises are the
supportive therapy postulating a way through which one can re-establish a sense of
well-being. Relaxation delivers a holistic healing effect in the daily routine, affecting
117
body, mind and spirit. Relaxation and imagery are universally used to treat various
side effects during the treatment of dangerous diseases. (e.g.Ryman 1995; Sweeney,
1978). The finding that relaxation exercise helps reduces the level of anxiety among
individuals lend support to the views and findings of the above researchers.
Another explanation of this finding comes from views and findings of some other
researchers like Bensen (1974, 1975); Goldfried&Trier, (1974); Wells, (1982)
McCaffery& Beebe (1989). Arguments of these authors include that ―the relaxation
response is a hypothalamic response that leads to a lessening in the excitement of the
sympathetic nervous system and decrease in oxygen consumption, decreased muscle
tone, heart rate, respiratory rate and body metabolism‖. The relaxation response is
also reflected by decreased level of anxiety. Authors further argued that ―anxiety and
muscular relaxation produce physiological effects opposite to each other hence,
cannot exist together. The relaxation response among persons consists of changes
opposite to those of the flight or fight, or stress response‖. According to these
authors, there are four essential things to elicit the relaxation response. These are:
1. An incessant stimulus such as a word, sound, or phrase which help diverting
attention from externally oriented thought.
2. A passive attitude and the skill to disregard distracting thoughts and redirect
them towards the techniques.
3. A reduced muscle tone.
4. A calm and quite environment
Conditions similar to all above four essential aspects of relaxation exercise were
available in the relaxation exercises used in this investigation. According to Smith &
Jonathan (2007) individuals use various techniques to ameliorate the state of
118
relaxation in order to maintain peace of mind. These techniques can be performed
alone but some may require the help of a trained professional. Relaxation methods
may involve both movement and stillness. Few techniques known as "formal and
passive relaxation exercises" usually carried out in a calm and quiet sitting or lying
position, with minimum possible movement and include "a degree of withdrawal".
The overall purpose is to shift the attention from anxiety producing stimuli to another
situation. Same thing was done in the present study. Participants performed
relaxation exercise alone after obtaining essential training from the investigator and
gradually recovered from the anxiety. This finding lends support to the assumption
that hypothalamic response to relaxation leads to lessening in the excitement of the
sympathetic nervous system and reduced level of anxiety.
The therapeutic effects of relaxation were also discussed by McCaffery& Beebe
(1989). These researchers argued that relaxation techniques appear to reduce the
psychological discomfort of pain. Their research shows that there is an affiliation
between muscle tension, autonomic hyper arousal, anxiety and pain. The usual
response to pain is nervousness and muscle tensing. An interactive cycle can develop
whereby the anxiety, muscle tension and pain work to strengthen each other. This
interactive relationship is depicted in figure below.
Muscle
Anxiety
Tension
Pain
119
The relaxation techniques that result in a lessening of skeletal muscle tension or
anxiety may have the potential to break this cycle and give relief from anxiety and
pain. Finding of the present study also lend support to this assumption.
The 2nd
finding of the present investigation that ―There is a differential effect
of Progressive muscle relaxation technique and Transcendental meditation on level of
anxiety among individuals‖ require careful analysis and can be explained in the light
of various features associated with ―Progressive muscle relaxation‖ technique and
―Transcendental meditation‖. In the present investigation both PMR TM were used in
their most simple form in a way that participants were able to execute them
independently. Such a simplicity of the techniques might have developed a concept in
the mind of participant that their problem is not sever rather it is a simple problem.
After having relief from few trials, this concept further strengthened. There were
hardly few participants who did not get satisfactory recovery. That might be due to
not developing and strengthening this concept. The differential effect of PMR and
TM on anxiety is due to the difference in execution style of these techniques. In
progressive muscle relaxation participants were required to ―focus on slowly tensing
and then relaxing each muscle group‖. This is supposed to help person ―focus on the
difference between muscle tension and relaxation‖. The person can become more
aware of physical sensations. Goleman, Daniel (1986) argued on the basis of research
findings that a relaxation technique some time also termed as relaxation training, ―is
any method, process, procedure, or activity that helps a person to relax and to attain a
state of increased calmness; or otherwise reduce levels
of pain, anxiety, stress or anger‖. Different relaxation techniques involve different
method and procedure but intend the common purpose i.e. getting rid of the
distressing situation. Some of them are more effective while others are somewhat less
120
effective. Hence, outcome of different techniques is different. In other words we can
say that it is not surprising to obtain a differential effect of ―progressive muscle
relaxation‖ technique and ―Transcendental meditation‖ on level of anxiety among
individuals. Relaxation techniques commonly employ calm and quiet environment,
rhythmic breathing and muscular movement. Transcendental meditation included one
additional thing which was not in the progressive muscle relaxation. It was
pronouncing a word pertaining to remembering and praising the God. As we all are
aware that the word ―meditation carries different meanings in different contexts. It
has been practiced since ancient time as a component of numerous religious
traditions and beliefs‖. Meditation is an internal effort of individual to regulate the
mind in order to ease many problems. (e.g.Rainforth, Maxwell; Schneider, Robert;
Nidich; Gaylord-King; Salemo; and Anderson (2008). In the present study a religious
orientation was developed in the process of transcendental meditation. For this
additional factor this technique resulted into a different outcome. The transcendental
meditation as compared to progressive muscle relaxation produced significantly
better effect on anxiety. The finding is in line with results obtained by Kenneth,
Allan, and Jonathan (1989) who evaluated the differential effects of relaxation
techniques on trait anxiety. They also obtained a significantly larger effect of
transcendental meditation as compared to other relaxation exercises.
The third finding of the present investigation that there is a significant
interactional effect of relaxation exercise and type of relaxation techniques on level
of anxiety among individuals simply show that both progressive muscle relaxation
and transcendental meditation help reduce the anxiety level but the size of effect of
transcendental meditation is significantly larger than the effect of progressive muscle
relaxation. The finding is consonant with results of other researches. As for example
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Gian, Francesco, Gianluca and Enrico (2008) examined the effect of relaxation
training for anxiety. Findings of their study revealed a significant effect of relaxation
exercises on level of anxiety. Various relaxation exercises were evaluated for the
change in the feelings of anxiety. Most of the relaxation exercises produced the
similar effects except the few only. From the results of their study they concluded
that relaxation exercises help reduce the level of anxiety among individuals leading
to normal life.The present finding indirectly lend support to the findings of these
researchers. In another study Kenneth, Allan, and Jonathan (1989) evaluated the
differential effects of relaxation techniques on trait anxiety. In their study they
included different treatments like ―Progressive Muscle Relaxation‖, ―EMG
Biofeedback‖, and various forms of meditation.Findings of the study revealed a
similar effect of different treatments except ―transcendental meditation‖ that had a
remarkable greater effect. Present finding is in line with the results obtained by these
authors. However this finding does not support the results obtained by Michael and
Morgan (1998) who undertook a study with theobjective to carry out a comparative
analysis of the influence of acute physical activity and meditation on state anxiety.
Findings of the study revealed that ―acute physical activity‖, ―non-cultic meditation‖,
and a ―quiet rest session‖ are equally effective in reducing state anxiety. It might be
due to the difference in methodology and difference in the variables used these two
studies.
The fourth finding of the present study i.e. Relaxation exercise help reduce the
level of depression among individuals is in agreement to various early findings and
can be interpreted in the light of features associated with depression and relaxation
exercises.
122
A growing number of evidences suggest that depression involves ―the body,
mood, and thoughts and that affects the way a person eats, sleeps, feels about the
self‖. It also involve about the thinking of a person, what a person thinks about
things. Major symptoms of depression involve declined participation in enjoyable
activities that were previously interesting for the person.
As discussed above that Titlebaum (1988) and McCaffery& Beebe (1989)
emphasized that the relaxation techniques set up a condition free from anxiety,
depression and skeletal muscle tension and thereby restoring comfy and peace in
persons‘ mind. The relaxation is a positively perceived state in which a person feels
aside from the tension and straining situation. This comprises psychological aspects
of the relaxation experience like feeling of pleasantness and deficiency in straining
and uncomfortable thoughts. Since relaxation exercises leads to increase in the
feelings of pleasant sensation and decrease in the uncomfortable thoughts, it is not
surprising to obtain a decline in the level of depression after using relaxation
techniques. The finding is in line with that of obtained by Blumenthal, Michael, and
Babyak (2007) who observed reductions in depression with exercise intervention
comparable to standard antidepressant medication and greater reductions in
depression compared to placebo controls. They argued that ―the efficacy of exercise
in patients seems generally comparable with patients receiving antidepressant
medication and both tend to be better than the placebo in patients with major
depressive disorder‖. Gary, Kerry and Gillian(2014) also found that ―exercises are
associated with a greater reduction in depression symptoms compared with no
treatment, placebo, or active control interventions, such as relaxation or meditation‖.
Finding of the present study lend support to the results obtained by these authors.
Similar findings were also obtained by Knubben, Reischies and Adli (2007) who
123
evaluated the short-term effects of exercise intervention among the patients of major
depression. Results of their study are in agreement with the findings of present study.
Effect of exercise intervention on PTSD, depression and anxiety was also examined
by Manger and Motta (2005). Findings of their study suggested that exercise
intervention programs very useful to manage PTSD, depression and anxiety. Otto,
Church, and Craft (2007) described the views of five experts on exercise and
psychiatric disorders discussing the rationale and evidence for using exercise to treat
mood and anxiety disorders. Their discussion concluded a beneficial effect of
relaxation exercises on mood, anxiety and depressive disorders.Findings of the
present study are also in line with that of obtained byCraft and Perna (2004). These
authors critically evaluated the literature related to the studies of the treatment of
depressive disorder with help of cognitive–behavioural therapies specifically
relaxation exercises. On the bases of their evaluation they argued that ―there is
evidence to suggest that the addition of cognitive-Behavioural therapies, specifically
exercise, can improve treatment outcomes for many patients. Exercise is a
Behavioural intervention that has shown great promise in alleviating symptoms of
depression‖. Research findings of Shu-Shyaet. al. (2008)also reveals a beneficial
effect of exercise intervention on depression. In their findings they reported that
―Women receiving exercise support programme were less likely to have high
depression score after child birth when compared to control group. The exercise
support programme given to postpartum women appeared to benefit their
psychological well-being‖. Our findings are in agreement with these results. The
findings ofRichard and Kristin (2006) are also not different with us. These are the
various kinds of exercises having the similar nature and have the beneficial effect on
depressive disorder. So far as the studies specifically related to progressive muscle
124
relaxation and meditation is concerned, there are a growing number of evidences to
suggest the beneficial outcome of ―progressive muscle relaxation‖ and meditation on
depression.
Lolak, et.al. (2008). evaluated the outcome of PMR intervention on anxiety and
depression among the persons suffering from chronic breathing disorders who were
relying on pulmonary rehabilitation. The overall results of the study suggested that
progressive muscle relaxation has a beneficial effect on anxiety and depression.
Similar results were also obtained by Greg, et.al. (2010). They found that PMR and
meditation lead to a significant decline in negativity of thoughts which is closely
related with depression.Kaina,Xiaomei Li, Jin Li, Miao, Dang, Wang, and Xia Xin(2015)
andGhafari,Ahmadi, Nabavi and Memarian(2008) also have obtained advantageous
results of progressive muscle relaxation and meditation based relaxation exercises to
manage depression and anxiety level among the people of different categories.
Farnaz, Nahid, Negar, Shakeri (2015) also examined the outcome of ―progressive
muscle relaxation‖ among primigravida women having the symptoms of depression,
anxiety and stress. Findings of the study revealed a beneficial outcome and on the
bases of results authors recommended that ―due to the relaxation effect on reducing
depression, anxiety and stress, and also lack of side effects and its easy applicability,
this method can be used as an approach to reduce depression, anxiety and stress in
women during pregnancy‖. There are various other investigators whose findings
revealed noteworthy advantages of PMR and meditation based therapies to reduce the
level of depression and anxiety in different categories of individuals. To name few
are Thorsten and Catherine (2009); Yune, Young, and Eunjung (2009); Zautra and
Davis (2008);Smith, Graham, and Sentinathan (2007); Our finding that relaxation
125
exercise results into the decline in level of depression complements and provide
strong support to the findings of the above cited authors.
The fifth finding of the present study that There is a differential effect of ―Progressive
muscle relaxation technique‖ and Transcendental meditation on level of depression among
individuals also require careful analysis and can again be explained in the of various features
associated with Progressive muscle relaxation technique and Transcendental meditation. As
mentioned above that in the present study both Progressive muscle relaxation technique and
Transcendental meditation were used in their most simple form in way that participants were
able to execute them independently. Such a simplicity of the therapy can give a feel to
participants that their problem is not sever rather it is a simple problem. After having relief
from few trials, this concept further strengthened. The greater beneficial effect of differential
effect of Transcendental meditation as compared to Progressive muscle relaxation technique
and on depression is due to the difference in execution style of these techniques. Different
relaxation techniques involve different method and procedure but intend the common purpose
i.e. getting rid of the distressing situation. Some of them are more effective while others are
somewhat less effective. Hence, outcome of different techniques is different. In other words
we can say that it is not surprising to obtain a differential effect of ―progressive muscle
relaxation technique‖ and Transcendental meditation on level of depression among
individuals. Relaxation techniques commonly employ calm and quiet environment, rhythmic
breathing and muscular movement. Transcendental meditation included one additional thing
which was not in the progressive muscle relaxation. It was pronouncing a word pertaining to
remembering and praising the God. As we all are aware that ―the word meditation carries
different meanings in different contexts. It has been practiced since ancient time as a
component of numerous religious traditions and beliefs. Meditation often involves an internal
effort to self-regulate the mind in some way. It is often used to clear the mind and ease many
126
health concerns‖. In the present study a religious orientation was developed in the process of
transcendental meditation. For this additional factor this technique resulted into a better
outcome. The transcendental meditation as compared to progressive muscle relaxation
produced significantly better effect on depression. Broota, Aruna; Dhir, and Rima (1990)
also observed a differential effect of different relaxation techniques on depression. Similar
findings were also obtained by Reynolds, William; Coats and Kevin (1986). Carrington et. al.
(1980) also examined the ―efficacy‖ of meditation and relaxation to manage the stressed
related depression and anxiety among Working Population. They found that relaxation
exercises are very effective to manage stressed related anxiety and depression. Meditation was
found to be more effective. Ströhle (2009) critically evaluated a number of researches to
examine the results of exercises and physical activities to manage anxiety and depression.
They found a differential effect of different relaxation techniques on anxiety and depression.
Our finding provides supportive evidence to the results obtained by the above researchers.
The sixth finding of this investigation reveals a significant interactional effect
of relaxation exercise and type of relaxation techniques on level of anxiety among
individuals simply show that both progressive muscle relaxation and transcendental
meditation help reduce the depression level but the size of effect of transcendental
meditation is significantly larger than the effect of progressive muscle relaxation. The
lager effect of transcendental meditation as compared to progressive muscle
relaxation may be due to an additional factor involved in transcendental meditation.
127
Conclusion
On the basis of the results obtained in present investigation it can be concluded that
the relaxation exercises, PMR as well as transcendental meditation, are useful
techniques to manage the anxiety and depression. So far as effectiveness of the
techniques is concerned, the meditation based relaxation appears to be more
effective. Relaxation techniques involving physical movements lead to benign
perception of agonizing environmental stimuli. These are supposed to establish a
state of mind in which person feel somewhat free from both anxiety and skeletal
muscle tension and bringing a reduction in physiological as well as psychological
imbalance. It is a positively perceived state. These psychological aspects of the
relaxation, change in perception and shift of attention from acrimonious stimuli to the
feelings of pleasantness help person to get rid of the anxiety and depression.
Relaxation exercises are the supportive therapy that delivers a holistic healing effect
in the daily routine, affecting body, mind and spirit and establish a sense of well-
being. The main theme of relaxation exercises is the shift of attention from
uncomfortable feelings to the feeling of pleasantness. Repetition of these exercises
produces conditioning effect thereby help person to get rid of the anxiety and
depression.
As evident from the available literature and the findings of the present investigation that
relaxation technique are useful curative measure for depression and anxiety and can be
organized under close supervision as well as independently. It has no side effects. The main
aim of the present investigator was to evaluate the effectiveness of relaxation techniques and
to identify the best suitable technique for Jordanians that‘s why TM was taken with some
modification to make it suitable for them. Both PMR and TM were used in most simple form
in such a way that does not require supervisory care. This simplicity of the therapy produced
128
very good results. This implies that complexity of treatment and therapies are the
deteriorating factors to the resultant outcome of curative measures. Here we can draw a
conclusion that in the process of treatment of psychological disorders likes depression and
anxiety, therapist must give priority to make feel patients that their problem is not sever, it is
very simple and curable in an easy way. This principle is applicable in other sever diseases
which are not psychological in nature.
Quite a large number of researches including present investigation show that mediation based
relaxation interventions are more beneficial. The assumption that transcendental meditation
as compared to other relaxation technique will have a greater curative effect on anxiety and
depression appears to be true. In the present investigation it was assumed that the focus of
attention if shifted from complex social situation towards God, the person will be away from
all kinds of tensions. Repetition of this practice was supposed to restore normalcy of mental
state. It was further assumed that this modified version of transcendental meditation will be
more effective as compared to any other kind of relaxation exercise because a person having
complete faith in God is not supposed to be worried about anything. As per the Islamic
philosophy, the person has to put in his best possible efforts and he will get good results but
as per the desire of God. Such type of faith is not found in any other practice of relaxation.
This assumption also appears to be very effective. Thus we can argue that the relaxation
techniques employed in the present investigation are useful for the treatment of depression
and anxiety in a country like Jordon. Moreover the meditation based technique is more
effective.
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Limitations of the Study
There are some limitations of the study which are described below:
Because of the small sample size the findings cannot be generalized
The study was conducted in an Islamic country. That‘s why Islamic orientation was
given to the transcendental meditation. To use this technique on the persons of other
religion, certain modification will again be required.
Sample included the subjects of moderate level of anxiety and depression. Findings
of the present study cannot explain how to treat the persons of sever level of anxiety
and depression.
Summary
Topic: “Assessing the effectiveness of relaxation techniques in management of anxiety and
depression”.
Relaxation involves laxity and peace of mind. The surrounding world of individuals is
frequently making them tense leading to various behavioural abnormalities such as anxiety
and depression that are most common among them. Persons need relaxation in order to get rid
of anxiety and depression like problems. Therapists use various techniques for relaxation
often known as relaxation techniques.
Practicing relaxation techniques have many benefits such as: Maintaining heart rate, blood
pressure, breathing rate, digestion, blood sugar levels, sleep quality, fatigue, etc.
130
Progressive Muscles Relaxation
Progressive muscle relaxation is a technique for learning to monitor and control the state of
muscular tension. It was developed by American physician Edmund Jacobson in 1920. The
technique involves learning to monitor tension in each specific muscle group in the body by
deliberately inducing tension in each group. This tension is then released, with attention paid
to the contrast between tension and relaxation.
Transcendental Meditation Technique
Transcendental meditation is a specific technique using mantra meditation developed
by Maharishi Mahesh Yogi. It is often referred to as Transcendental meditation (TMT). This
practice involves the use of a mantra and is practiced for 15–20 minutes twice per day while
sitting with one's eyes closed. It is reported to be one of the most-widely practiced, and among
the most widely researched meditation techniques
Anxiety
Anxiety is a part of our normal life. It is a reaction to stress and often beneficial in some
situations. It can alert us to dangers and help us prepare and pay attention. So far as anxiety
disorders are concerned, a difference exists between anxiety disorders and normal feelings of
nervousness or anxiousness. Anxiety disorders involve excessive fear or anxiety and these are
the most common of mental disorders and affect a significant proportion of adults at some
point in their lives.
Depression
Depression involves the body, mood, and thoughts and that affects the way a person eats,
sleeps, feels about him or herself, and thinks about things. It is not the same as a passing blue
131
mood nor is it a sign of personal weakness or a condition that can be wished away. People
with depression cannot merely 'pull themselves together' and get better. Without treatment,
symptoms can last for weeks, months, or years. Appropriate treatment, however, can help
most people with depression.
In the present study two relaxation techniques namely Progressive Muscle Relaxation
(PMR) and Transcendental Meditation (TM) were undertaken to compare their effect on
anxiety and depression. These two techniques were used in most simple form in such a way
that does not require supervisory care. Moreover, TM was modified to give religious
orientation based on Islamic concept. It was assumed that the focus of attention if shifted from
complex social situation towards God, the person will be away from all kinds of tensions.
Repetition of this practice is supposed to restore normalcy of mental state. It was further
assumed that this modified version of transcendental meditation will be more effective as
compared to any other kind of relaxation exercise because a person having complete faith in
God is not supposed to be worried about anything. As per the Islamic philosophy, the person
has to put in his best possible efforts and he will get results as per the desire of God. Such
type of faith is not found in any other practice. Thus the present investigation was undertaken
to test these assumptions. More specifically, the study was undertaken with following
objectives.
Objectives of the Study
1. To test the effect of PMR on anxiety
2. To test the effect of PMR on depression
3. To test the effect of Transcendental Meditation (TM) (modified) on anxiety
4. To test the effect of Transcendental Meditation (TM) (modified) on depression
132
5. To test the difference in effectiveness of PMR and Transcendental Meditation (TM)
(modified) in management of anxiety.
6. To test the difference in effectiveness of PMR and Transcendental Meditation (TM)
(modified) in management of depression.
Methodology
As the present study was concerned with the effectiveness of relaxation techniques in
management of anxiety and depression, the main variables involved in the study were anxiety
and depression which served as the dependent variables and the types of relaxation techniques
namely progressive muscle relaxation and transcendental meditation (modified) which served
as the independent variable. Both the dependent variables anxiety and depression were
studied under two conditions, pre-test and post-test, for each of the two independent variables.
Measures
There were two measures of dependent variables namely anxiety and depression. Each
variable was measured under two conditions: 1. Pre-test and 2. Post-test. To measure anxiety,
Hamilton Anxiety Rating Scale (HAM-A) and for depression, Back Depression Inventory
BDI-II were used.
Participants
A non-probability sampling method (Purposive Sampling) was used in the present study. The
overall sample size was 80 subjects, consisted of 4 groups having 20 subjects in each group.
All the sample units were selected from the Basman district of Amman city of Jordan.
133
Data Analysis and Interpretation: Analysis for DV 1 (Anxiety)
A before and after test design was employed in the present study. There were two independent
variables namely progressive muscle relaxation (PMR) and transcendental meditation (TM).
Two groups of subjects, Group 1 & Group 2, participated in investigation. Each was studied
under two conditions:
1. Pre-test/pre-treatment condition.
2. Post-test/post-treatment condition.
Treatment was use of PMR for group 1 and use of TM for group 2. Thus there were four
observations on two groups.
Observation 1 (Cond. A): Assessment of anxiety score of group 1 before using PMR-
Pre-treatment Condition.
Observation 2 (Cond. B): Assessment of anxiety score of group 1 after using PMR-
Post-treatment Condition.
Observation 3 (Cond. C): Assessment of anxiety score of group 2 before using TM- Pre-
treatment Condition.
Observation 4 (Cond. D): Assessment of anxiety score of group 2 after using TM- Post-
treatment Condition.
Analysis for DV 2 (Depression)
Analysis for the depression score was carried out in the same way as for anxiety score. A
before and after test design was employed in the present investigation. There were two
independent variables namely progressive muscle relaxation (PMR) and transcendental
134
meditation (TM). Two groups of subjects, Group 3 & Group 4, participated in investigation.
Each group was studied under two conditions:
1. Pre-test/pre-treatment condition.
2. Post-test/post-treatment condition.
Treatment was use of PMR for group 3 and use of TM for group 4. Thus there were four
observations on two groups.
Observation 1(Cond. A): Assessment of depression score of group 3 before using PMR-
Pre-treatment Condition.
Observation 2 (Cond. B): Assessment of depression score of group 3 after using PMR-
Post-treatment Condition.
Observation 3 (Cond. C): Assessment of depression score of group 4 before using TM-
Pre-treatment Condition.
Observation 4 (Cond. D): Assessment of depression score of group 4 after using TM-
Post-treatment Condition.
Data thus obtained for each of the two dependent variables namely anxiety and depression
was statistically analyzed with the help of analysis of variance. Separate ANOVA was used
for anxiety and depression.
The main findings of the present research are as follows:
1. Relaxation exercise help reduce the level of anxiety among individuals.
2. There is a differential effect of Progressive muscle relaxation technique and
Transcendental meditation on level of anxiety among individuals.
135
3. There is an interactional effect of relaxation exercise and type of relaxation
techniques on level of anxiety among individuals.
4. Relaxation exercise help reduce the level of depression among individuals.
5. There is a differential effect of Progressive muscle relaxation technique and
Transcendental meditation on level of depression among individuals.
6. There is an interactional effect of relaxation exercise and type of relaxation
techniques on level of depression among individuals.
Implications
The findings of this study have significant implications which are presented in the following
paragraphs.
1. The findings of present piece of research work provide the conceptual implication in
understanding the relationship of relaxation techniques with anxiety and depression. It
was found that using relaxation techniques one can reduce and eliminate anxiety and
depression.
2. Progressive Muscles Relaxation (PMR) and Transcendental Meditation Technique
(TMT)emerged as significant relaxation techniques to help the individuals in reducing
these symptoms (i.e. anxiety and depression).
3. These relaxation techniques also indicate that sympatheticand conducive environment
can also reduce anxiety and depression possibilities. So, that one can also use these
techniques to avoid problematic situations and involvement in these psychological
problems.
136
Suggestions for Future Research
Research is not the end; it opens new ways for further studies. Therefore, on the basis
of present study the certain suggestions for future research are given in the following
paragraphs:
1. Since, the present study was undertaken on a sample of anxious and depressive
individuals only; though one should also include other psychological patients
experiencing different problems.
2. There are many relaxation techniques to reduce anxiety and depressive symptoms so
one should also use other relaxation techniques including Progressive Muscles
Relaxation (PMR) and Transcendental Meditation Technique (TMT). It will help them
to compare the level of effectiveness of these different techniques through which we
can say that the particular relaxation technique is more effective than another.
3. Future studies needs to consider other geographical areas other than the group which
has been studied. So that, one might be find other meaningful impact of these
relaxation techniques. Most of the time the same technique or medicine influence one
individual very effectively while others not, so it may also check that which type of
personality get more benefits by the particular relaxation technique.
145
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