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The Effect Of Personalized Emotional Stimuli On Asthmatic Reactions

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The Effect Of Personalized Emotional Stimuli On Asthmatic Reactions

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Xerox University Microfilms
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75-6446
SINGER, Esthr Marlene, 1937-
TOE EFFECT OF PERSONALIZED EMOTIONAL
STIMULI CM ASIH4ATIC REACTIONS.
University of Southern California, Ph.D., 1974
Psychology, clinical
Xerox University Microfilms , Ann Arbor, Michigan 48106
THIS DISSERTATION HAS BEEN MICROFILMED EXACTLY AS RECEIVED.
THE EFFECT OF PERSONALIZED EMOTIONAL
STIMULI ON ASTHMATIC REACTIONS
by
Esthr Marlene Singer
A Dissertation Presented to the
FACULTY OF THE GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
(Psychology)
August 1974
UNIVERSITY O F SO U T H E R N C A LIFO R N IA
THE GRADUATE SCHOOL
UNIVERSITY PARK
LOS ANGELES. CALIFORNIA 8 0 0 0 7
This dissertation, written by
Esthr Jtorlene S inger..............
under the direction of h.9.X... Dissertation Com
mittee, and approved by all its members, has
been presented to and accepted by The Graduate
School, in partial fulfillment of requirements of
the degree of
D O C T O R O F P H I L O S O P H Y
DISSERTATION COMMITTEE
ACKNOWLEDGMENTS
I would like to express my sincere thanks to
Dr. Norman Tiber for his guidance and encouragement
throughout my graduate career and particularly for his
help in this current study. I would also like to extend
my appreciation to Drs. A1 Marston and Steve Frankel,
members of my dissertation committee.
Special thanks go to Dr. John Woodbury, without
whose example the first steps toward this degree would
never have been attempted.
Finally, I must express my deepest gratitude to
Bob, Dan and Molly Singer, my husband and children,
without whose patience and continued support this task
would never have been completed.
ii
TABLE OF CONTENTS
Page
ACKNOWLEDGMENTS ................................. ii
Chapter
I. INTRODUCTION ........................... 1
II. REVIEW OF LITERATURE................... 4
The Effect of Psychological Factors
on Asthma
Psychological Treatment of Asthma
Physiological Measures of Asthmatic
Responses
Asthma as a Conditioned Response
III. METHODOLOGY............................... 27
Subjects
Measures
Procedure
IV. RESULTS....................................33
Base Measures
Change Scores
Within Group Scores
V. DISCUSSION............................... 37
BIBLIOGRAPHY ................................. 44
APPENDICES......................................47
Appendix A. Raw Scores of Steadwell
Vital Capacity
Appendix B. Raw Scores of Wright Peak Flow
iii
CHAPTER I
INTRODUCTION
The relationship between emotional disturbances
and asthmatic reactions has long been taken for granted
and repeated throughout the ages. Hippocrates is reputed
to have said, "If the asthmatic is to master his
condition, he must guard against his own anger [Adams,
1939]." Galen (Glendening, 1942) assumed that "bad”
humors descended from the head to the chest. The idea of
psychological factors affecting asthmatic attacks was
again brought up in the seventeenth century (Floyer,
1698), and in the nineteenth century by Salter (1860) who
referred to asthma as a "nervous disorder." After
analysis of his own and hundreds of other cases of
asthmatic attacks, Salter concluded that the asthmatic
attack was far more difficult to endure than the inter
personal situation which precipitated it. In his own
words, "If the patient knows anything about the nature of
his complaint, he knows that his suffering may terminate
in a closing scene worse only them the present."
In the twentieth century evidence has been
presented regarding the personality factors in asthmatics
(Weiss, 1966; Knapp and Nemetz, 1960; French and
1
2
Alexander, 1941), and their families (Block, 1968; Block,
Jennings, Harvey and Simpson, 1964; Mitchell, Frost and
Marx, 1953). During this period, various psycho
therapeutic measures have been taken with asthmatic
patients, ranging from group therapy (Groen and Pelser,
1960; Sclare and Crocket, 1957) and counselling of
parents of asthmatic children (Selesnick, Friedman, and
Augenbraun, 1964) to separation of asthmatic children
from their families (Peshkin, 1959; Purcell, Brady, Chai,
Muser, Molk, Gordon and Means, 1969) to the use of
reciprocal inhibition with individuals 'Moore, 1965;
Cooper, 1964; Walton, 1960).
Studies of conditioned stimuli leading to
asthmatic reactions have traveled from animal research
(Ottenberg, Stein, Lewis and Hamilton, 1958; Noelpp and
Noelpp-Enschenhagen, 1951) to humam research (Turnbull,
1962; Luparello, Lyons, Bleecker, and McFadden, 1969;
Weiss, 1970). Specific "emotional" stimuli were
investigated as the precipitating events for asthmatic
attacks (Dekker amd Groen, 1956; Selesnick, Malmstrom,
Younger and Lederman, 1969). The latter two studies
focused, respectively, on reactions to inamimate objects
and a generalized interpersonal situation.
The use of personalized emotional stimuli to
produce asthmatic reactions has not been previously
3
researched. This study will attempt to systematically
evaluate the effect of interpersonal relationships on
asthmatic behavior and will include controls lacking in
previous studies.
CHAPTER II
REVIEW OF LITERATURE
THE EFFECT OF PSYCHOLOGICAL
FACTORS ON ASTHMA
Various psychological factors have been proposed
as predispositional to asthma. Block (1968) and Block,
Jennings, Harvey, and Simpson (1964) reported on children
divided into two subgroups by the Allergic Potential
Scale, a scale comprised of the weighted scores of family
history of allergy, blood eosinophile percentage, skin
test reactivity, total number of allergies in patient,
and ease of diagnosability of specific allergens.
Psychogenic factors were found significantly more often in
the low-APS group than in the high-APS group. More
psychopathology was found in the mothers, and more con
flict was observed in the marriages of the families of
the low-APS group. Mothers of the low-APS group appeared
to over-identify with the child on whom they were
overly-dependent for satisfaction of their own needs.
Finally, the mother-child relationship seemed to provide
less satisfaction for both mothers and children of the
low-APS group.
5
Mitchell, Frost and Marx (1953) also presented
evidence regarding the families of asthmatic children.
The mothers of twenty-two allergic children were
characterized as strong and active compared to the
fathers. The mother's marital frustration led to
searching for satisfaction from the child. Allergic
children identified more closely with the mothers, and
exhibited strong dependency needs.
On the basis of skin testing, one hundred thirty
two women with diagnoses of bronchial asthma, perennial
rhinitis, or seasonal hay fever were classified as non
reactors, weak reactors, moderate and strong reactors
(Freeman, Gorman, Singer, Affelder, and Feingold, 1967).
The Minnesota Multiphasic Personality Inventory (MMPI)
revealed that nonreactors and weak reactors experienced
considerable personal discomfort and unhappiness and
characterized themselves as depressed, uneasy, with
drawn, and incompetent. Stronger reactors appeared more
active, optimistic, confident, and much less troubled.
These differences were evidenced by higher scores for
the non- and weak reactors on the scales for hypo
chondriasis, depression, psychasthenia, schizophrenia
and hypomania.
Measurement of mood states of asthmatic children
were taken on 56 pre-teen and teenagers during and
6
between asthmatic attacks (Weiss, 1966). Children at
CARIH (Children's Asthma Research Institute and Hospital,
Denver, Colorado) must obtain medical treatment for
relief of asthmatic attacks from the nurses. During the
two or three minutes necessary for preparation of the
medicine, the Mood Adjective Checklist (Nowlis and Nowlis,
1956) was administered. The checklist is comprised of
twenty-eight adjectives distributed among five categories:
concentration, depression, aggression, deactivation and
anxiety. Mood states were also assessed by the same
checklist on days when the children had been asthma-free
since awakening. During asthmatic attacks there were
significant decreases on 11 out of the 14 positive mood
states on the checklist. Increases in negative states
were limited to the negative poles of Deactivation (i.e.,
sluggish, drowsy, lively, alert), Concentration, and
Anxiety, with no significant changes in Aggression or
Depression. For all subjects, positive moods always pre
dominated over negative moods, even during asthma.
In contrast, the mood states preceding and
accompanying four hundred and six asthmatic attacks in
nine patients showed depressive emotional concomitants in
approximately half the asthmatic attacks (Knapp and
Nemetz, 1960). In less than half of the attacks there
were prodromal emotional manifestations, the principal
7
feature of which was excitement, usually with an angry or
anxious coloring. The two most prominent antecedent
changes before the attacks were concerned with loss of a
person and closeness to a person.
French and Alexander (1941) studied twenty-seven
cases of bronchial asthma over four years. They hypo
thesized that conflict regarding excessive unresolved
dependence on the mother was such that a threat of
separation from her could precipitate an asthmatic attack.
They felt that an attack represented a suppressed cry
for the mother. Personality patterns in their patients
indicated preoccupation with themes of maternal rejection
and wishes to be protected and loved.
Working closely with French and Alexander, Leon
Saul (1941) presented his observations on the relations
of emotions and allergy. He suggested that in studies of
symptoms of an allergic nature in which emotional factors
were found to play a role, the central emotion related to
the symptom was strong longing for love, usually from the
mother. The specific factors determining the site of the
symptoms in the asthma cases were judged to be 1) the
sudden threat to the attachment to the mother, and 2) the
repression of the tendency to cry out. That these
libidinal longings were symptom specific was supported by
the observation that studies of emotional factors in
8
essential hypertension indicated hostility and struggle
with an unsolved conflict situation as the chief emotional
tendencies related to the symptoms.
Kenneth Purcell (1963) explored the hypothesis
that asthma is more often employed as a "learned/
defensive-adaptive response" to emotional arousal by
"anxiety, anger, depression, and other negatively toned
affect" by rapidly remitting then by steroid dependent
asthmatic children and found that rapidly remitting
children would more often report emotional arousal with
negative affect as provocative of asthma than steroid
dependent children. He also noted that crying was re
ported by five of the thirty-eight children in the study
as a precipitant of asthmatic attacks. It was then
postulated, in opposition to French and Alexander (1941),
that inability of the subject to cry, or the silent,
suppressed manner of crying, may reflect a learned
attempt to avoid provoking an asthmatic attack.
The idea that there is a specific unique
personality associated with asthmatic children was
disputed by Neuhaus (1958). Neuhaus felt, rather, that
the personality attributes of asthmatic children were due
to the fact of being chronically ill. He compared
asthmatic children with cardiac children and normal
healthy children and found no significant differences
9
between the chronically ill children on the Rorschach,
Brown Personality Inventory and Despert Fables. The
asthmatic and cardiac children as a group were, however,
significantly more maladjusted or neurotic them were the
children of the normal control group. In addition, no
significant differences in test results were obtained
between the sick children and their well siblings.
Neuhaus suggests that the personality pattern of the
siblings of the sick children may be the result of the
presence of a chronically ill child in the home, or,
possibly, that similar constitutional factors produce or
contribute to the similar personality deviations of the
sick children and their siblings.
Leigh and Marley (1956) administered the Cornell
Medical Index, an inventory of medical complaints
including neurotic symptoms, to four groups: outpatient
asthmatics, hospitalized asthmatics, neurotics in
psychiatric treatment, and department store workers.
Comparison of the inventories showed that asthmatics and
neurotics in psychiatric treatment had similar scores;
asthmatics in medical treatment mentioned fewer neurotic
symptoms than the former groups but significantly more
them the department store workers.
10
PSYCHOLOGICAL TREATMENT OF ASTHMA
On the basis of the preceding theories on the
psychological causes of asthma, various treatment
programs have been designed. Group therapy, in com
bination with whatever drug therapy was deemed necessary,
was provided for thirty-three asthmatic patients in two
groups (Groen and Pelser, 1960). Comparisons of these
patients with patients treated medically only were made
after four years. The patients joined and left the group
at different times so that no two patients received
exactly the same group therapy. The groups were under the
leadership of physicians who received psychiatric
collaboration. The principles of the group psychotherapy
were similar to those used in the treatment of psycho
neurotic patients. A significant difference was found in
favor of the patients treated by group psychotherapy.
The psychotherapy groups, taken as a whole, showed a 57%
"index of benefit," while the medication-only groups
showed decreases of 21% and 17% respectively.
Counseling for the parents of asthmatic children
was discussed by Selesnick, Friedman, and Augenbraun
(1964). The article suggests that parents need to deal
with feelings of inadequacy which prohibit them from
giving support to the child and prompts them to com
municate their anxiety to the child. A second concern is
11
that parents of asthmatic children are somewhat unaware
of age-appropriate behavior for their children and expect
more mature levels of achievement from the child. The
result is to deny the child the opportunity to recognize
his or her position of dependence on the parents.
Finally the authors suggest various methods of dealing
with separation, the threat of which is felt to be a
precipitant to asthmatic attacks. Sudden separations
should be avoided; when separations in the family occur
in the context of anger, the child should be reassured
that the anger is not directed toward him; the child
should be encouraged to talk about things that make him
feel guilty in order to alleviate separation anxiety.
John Reckless (1971) analyzes the group therapy
treatment for asthmatic patients in behavioral terms.
He suggests that the talking about individual conflicts in
the group situation leads to "unsystematic desensi
tization" for those specific conflicts. In addition,
inhibition of asthmatic attacks within the group setting
serves to provide positive reinforcement for the in
hibitory responses. The physical tenderness shown by
other patients to an individual who appears to be
developing asthmatic symptoms serves to decrease the
patient's level of alertness to the environment and
produce a state of emotional and physical relaxation.
12
Reckless sums up his description of the group processes
as a treatment method "which trains the patient to in
hibit and extinguish the respiratory symptoms without
recourse to pharmacological treatment."
Systematic desensitization was the treatment used
by three investigators. In a study of six adults and six
children (Moore, 1965), patients were treated with
1) relaxation, 2) relaxation with suggestion, and
3) relaxation with reciprocal inhibition. While improve
ment in vital capacity measures occurred with all three
treatments, the change during reciprocal inhibition was
significantly greater than the changes due to other
treatments.
The case history of a young woman with intractable
bronchial asthma was presented (Cooper, 1964), in which
the patient reported that any minor upset was capable of
producing an asthmatic attack, to the extent of several
attacks each day. She was desensitized to the anxiety
evoked by the emotional states of anger and excitement.
In the sixteen month follow-up, the patient had suffered
only four attacks. A similar case history was presented
by Walton (1960), in which the type of response chosen
to inhibit anxiety was the assertive response. The
patient showed a rapid response to eight sessions of
treatment and remained asthma-free for the eight months
13
between treatment and publication of the results.
Another treatment program would seem to be in
direct opposition to the theoretical view that
separation from or loss of loved ones is the precipitant
to asthmatic attacks. At the Children's Asthma Research
Institute and Hospital (Peshkin, 1959), 99% of the
children with intractable asthma recovered substantially
or completely from asthma. After reviewing the results
of children sent to convalescent homes for brief to
lengthy stays, Peshkin arrived at the conclusion that
"separation of the child from his home environment very
often broke the vicious crippling phase of asthma called
intractable asthma, making it either milder or curable."
Further investigation (Purcell, Brady, Chai,
Muser, Molk, Gordon, and Means, 1969) revealed that it
was indeed the separation from the family and not other
factors that might be involved in moving the child from
one physical environment to another. Twenty-five
asthmatic children and their families were involved in a
study in which the child was left in his home and the
family was removed for a period of two weeks. Children
were cared for in their own homes by parent substitutes
who made every attempt to replicate physical properties
of the parents (e.g., perfume, smoking, food choice,
etc.). The children were assigned to one of two
14
categories, one for whom emotional factors appeared
highly relevant to asthma, and the other for whom
emotional problems were less relevant or irrelevant. On
the basis of these categorizations, predictions were
made whether the children would show improvement as a
result of the separation or whether they would remain
unaffected. Of the twenty-five predictions made, all but
one were correct. One child for whom the prediction was
made that he would show little or no reaction to the
separation, improved during the two week period. There
was no increase in asthmatic symptoms in the two week
period prior to separation. The authors maintain that it
is emotional states, rather than patterns of inter
personal relationships, which are the most relevant
psycho-physiological variable in relation to asthma.
An attempt to explain the disparity between these
results and the theoretical view that separation anxiety
is at the root of asthmatic attacks was made by a
proponent of the latter view (Selesnick, 1963). He
reports that:
. . . separation anxiety refers not only to
actual separation, but to anticipatory
anxiety or fear of separation. As in most
anticipatory anxieties, once the fear
evolves into reality there may be a lessening
of the anxiety. Specifically the child who
fears separation from a partially gratifying
mother may be relieved when he is placed in an
environment away from the mother and in
15
association with unambivalent mothering
persons.
PHYSIOLOGICAL MEASURES OF
ASTHMATIC RESPONSES
Asthmatic reactions have been defined by such
measures as airway resistance and thoracic gas volume
measured in a body plethysmograph (McFadden, Luparello,
Lyons, and Bleecker, 1969; Luparello, Lyons, Bleecker,
and McFadden, 1968). Respiratory function has also been
recorded utilizing the movements of the thorax as
measured by a pneumograph attached to the subjects chest
around the lower ribs (Stevenson and Ripley, 1952).
Spirometric measurements of vital capacity were made by
Herxheimer (1949, 1951), Herxheiroer and Prior (1952),
Dekker and Groen (1956), and Moore (1965). Moore reported
that vital capacity was used as the measure of respi
ratory function in her study although it was not directly
relevant to airway obstruction. She felt that Maximum
Peak Flow was a better measure of the latter.
Variations in respiration during changes in
emotional states was investigated by Stevenson and
Ripley (1952). Twenty-two outpatients with symptoms of
respiratory disorder had recordings made of the action of
a pneumograph during interviews covering various topics
16
and attitudes known to be of relevance to the subjects'
life and illness. Respiratory patterns, as measured by
the pneumograph, were found to vary closely with the
emotional state. Increased rate or depth of breathing
were found chiefly with anxiety, but sometimes during
nager and resentment. Decreased rate or depth were found
when patients felt tense and on guard. Discussions of
attitudes and conflicts known to be associated with
respiratory symptoms evoked such symptoms in thirteen of
the patients, and the symptoms were related to changes in
the respiratory pattern.
Wright and McKerrow (1959) described the use of
the Wright Peak Flow Meter and their decision to use an
interval of 10 milliseconds as being the shortest time
period which lent itself to reasonably accurate measure
ment of the pefek on a pneumotachograph record. There
was an attempt made to study the relationship between the
peak expiratory flow rate and the maximum voluntary
ventilation (MW), but the results were not very
satisfactory. At the time of the development of the Peak
Flow Meter, the authors state that use of the M W had
practically been abandoned because it was a complex and
tiring procedure.
Three measures of respiratory change were used on
sixteen asthmatic children (Weiss, Martin, and Riley,
17
1970). These Included the Wright Peak Flow Meter,
respiratory pattern monitored with a mercury-filled
guage placed around the chest, and maximum expiratory
flow rate measured with a Fleisch Pneumotach. The
authors note that maximum expiratory flow rate in normal
breathing correlated positively with peak flow when
bronchospasm was induced in the laboratory with
medication. It was not noted what degree of correlation
existed.
Spirometric determination of vital capacity, as
well as strain guage respirator- tracings of expiratory
cogwells, was used by Selesnick, Malmstrom, Younger and
Lederman (1969). With the exception of the Weiss, et al.
study (1970) correlating peak flow measurements with
maximum expiratory flow rate, the literature does not
contain evidence of the systematic correlation of the
various measurements used to determine extent of
asthmatic reactions. In a review article of two hundred
studies of allergic disorders (Freeman, Feingold,
Schlesinger, and Gorman, 1964), it is suggested that
methodological factors need to be reliably reported and
consistently used in specifying whether patients are
demonstrably allergic.
18
ASTHMA AS A CONDITIONED RESPONSE
The question of whether emotional arousal or
generalized anxiety is sufficient to produce asthmatic
attacks was considered by animal study (Ottenberg, Stein,
Lewis and Hamilton, 1958). Asthmatic reactions were
conditioned and extinguished in guinea pigs. The animals
received nebulized egg white in the experimental chamber
until they had respiratory difficulty in the chamber for
ten consecutive days. Extinction occurred during the
thirteen days following the last respiratory attack. At
that point none of the animals had respiratory diffi
culties when placed in the experimental chamber.
Attempts were made to evoke the respiratory response out
side the experimental chamber by loud noises, pain and
shock with no success. The authors interpret this
finding to negate the suggestion that generalized
anxiety or fear can produce "asthmatic" attacks.
Noelpp and Noelpp-Eschenhagen (1952) exposed
eight guinea pigs to egg-white spray paired with an
auditory signal. After repeated pairings, four of the
original eight animals reacted with respiratory diffi
culties to the sound of the tone alone. Stressful
sensory stimuli before and during the induced
"asthmatic" reactions increased the frequency and
duration of the conditioned asthmatic reactions.
In a theoretical paper, Turnbull (1962) explored
the possibility that human asthmatic behavior can be
produced by learning. He suggested that an asthma-like
breathing pattern may be produced by a noxious stimulus
along with the appropriate escape response. After a
series of trials, some aspect of the environment (a
conditioned stimulus) elicits both the asthma-like
breathing and the avoidance response. If the asthma
like breathing were sufficient in itself to avoid the
noxious stimulus, anxiety reduction would reinforce the
response. Early respiratory learning reinforces the
crying response with attention, food, and removal of
noxious stimuli. A child who is allowed to cry for a
long period of time before receiving attention may have
his or her post-crying responses (sighing, gasping,
wheezing, coughing) reinforced by maternal attention.
These responses bear a strong resemblance to asthmatic
behavior and through repeated reinforcement could become
a substitute response for crying, particularly if the
mother is more apt to respond to the asthma-like
behavior than to crying. Asthma-like responses would
also be highly reinforced with maternal attention when
they occur along with respiratory illnesses, allergic
reaction, colds or bronchitis. Once the asthma-like
20
response is learned to a particular stimulus, stimulus
generalization could increase the number of objects and/or
situations in which the response occurs. Turnbull goes
on to say that human beings can be trapped in anxiety
provoking situations by being strongly motivated to
approach a stimulus which elicits intense anxiety.
Studies of the influence of suggestion on
breathing patterns illustrate the generalization
phenomenon Turnbull hypothesized. In two studies,
subjects were led to believe that they would be inhaling
irritants or allergens. The actual substance used was
nebulized saline solution. One study (Luparello, Lyons,
Bleecker, and McFadden, 1968) compared 40 asthmatic
subjects with 40 non-asthmatic subjects. Nineteen of the
asthmatic subjects reacted with airway resistance, while
twelve of these subjects developed full-blown asthma
attacks. The attacks were reversed with a saline
solution placebo which the subjects were told was a
bronchodilaUor. The forty control subjects did not
react to either suggestion. McFadden, Luparello, Lyons,
and Bleecker (1969) told twenty-nine asthmatic subjects
that they would be receiving five different con
centrations of an allergen. Fifteen of the subjects
developed bronchospasm. Of the original fifteen
responders, thirteen developed bronchospasm when the test
21
was repeated a week later. All of the non-responders
remained unaffected on the second trial. There was no
reported difference of responding to the five supposed
levels of allergen.
Different results were found in a study of
sixteen asthmatic children at CARIH (Weiss, 1970).
Again, subjects were told that they would inhale potent
allergens, and again physiologic saline was in fact the
inhalent. Prior to receiving the supposed allergens,
the subjects were asked to inhale a pure saline solution
"to get a control measure." On the three measures of
respiratory change used, 1) peak flow, 2) maximum
expiratory flow rate, and 3) respiratory pattern, only
one subject responded with decreased flow rate and
wheezing. None of the other subjects showed consistent
respiratory changes between the saline and "allergen"
solutions. Weiss suggests several reasons for the
disparity between his results and the results of the two
preceding studies: Weiss' subjects were institu
tionalized, chronically severe asthmatic children, while
Luparello's subjects were outpatient adults; different
response measures were used; Weiss' subjects were
familiar with bronchial challenges and may have been
aware that this was not a real test while Luparello's
subjects were not aware; and, if the responses occurring
22
in Luparello1s group were mediated by anxiety, Weiss'
children may have been less anxious inasmuch as they
lived in a hospital setting where the earliest indi
cations of asthma attacks received prompt attention. Of
these possible reasons, Weiss perceives methodologic
differences to be the most likely factors resulting in
the different results.
Asthmatic attacks were conditioned in two subjects
with allergens to which the patients were sensitive as
the unconditioned stimulus and the apparatus through
which the allergens were delivered as the unconditioned
stimulus (Dekker, Pelser and Groen, 1957). Initially,
the allergens were delivered to the patients until one or
more positive reactions had occurred. A positive re
action was defined as a reduction of the vital capacity
by 10% or more. The next phase of the study involved
replacing the allergens with neutral substances and pure
oxygen without the knowledge of the patients. Initially,
this procedure produced only a slight reduction in the
vital capacity of the patients. Over time, however,
reactions to the neutral solvents and to the oxygen
resulted in dyspnoea (shortness of breath) and asthma
attacks. Finally, introducing the mouthpiece of the
apparatus or appearing to connect the mouthpiece with
the inhilation apparatus was enough to produce severe
23
asthma attacks.
Emotional stimuli obtained from interviews of
twelve asthmatic patients were used in an attempt to
produce asthmatic behavior in the laboratory (Dekker and
Groen, 1956). Of the twelve, six patients were unaffected
by the artificial reproduction of the "emotional" stimuli,
three were minimally affected with slight decrease in
vital capacity, and three had full blown asthmatic
attacks with considerable reduction in their vital
capacity. The last group of three responded to obvious
imitations of the stimuli that they had indicated pro
duced asthma attacks; toy goldfish in a bowl, and a photo
graph of a horse. Dekker and Groen noted that producing
emotional reactions alone seldom causeJ a decrease in
vital capacity. They felt that the emotional setting must
not only be of a specific intensity, but also of a
specific quality. The authors go on to say that "it was
quite obvious that the environmental asthmatogenic
stimulus was associatively realted to former traumatic
life experiences."
The theory of French and Alexander (1941) that
arousal of the central emotional conflict (threat of
separation from, or loss of a loved one) leads to
asthmatic attacks, led to investigation of induced
asthmatic reactions by Selesnick, Malstrom, Younger, and
24
Lederman (1969). Three techniques were used to assess
the subjects' allergic potential and their respiratory
indices. Twenty-eight adult asthmatics were tested on
the allergic Potential Scale (Block et al., 1964), a
spirographic measurement of vital capacity, and
expiratory cogwheels (irregularities of the expiration
pattern). The MMPI was also administered and subjects
were randomly assigned to groups given diazepam or a
placebo. A week later, a shortened version of the film,
"Now Voyager," was shown to the patients to evoke
feelings of separation from and threats of loss of a
loved one. During the screening, heart rate, respiration
rate, expiratory cogwheels, finger temperature, neck
temperature and skin conductance were recorded simul
taneously. Measurements of vital capacity were taken
immediately before and after the movie. Of the physio
logical measurements taken, only the two respiratory
measures showed significant differences between drug and
placebo. The drug-treated group produced significantly
fewer expiratory cogwheels and better vital capacity
scores them did the placebo group. Results of the MMPI
indicated that Depression was the highest score for the
low-APS group. All the subjects in this study were shown
the same emotional stimulus in accordance with the theory
that separation or fear of separation is the main conflict
25
producing the emotional reaction of asthmatic attacks.
The animal studies previously mentioned have
indicated that stressful stimuli are not sufficient to
produce asthmatic reactions in and of themselves, although
such stimuli are capable of exacerbating the reactions.
The Dekker and Groen study (1956) used subject-specific
inanimate objects which were only occasionally and
indirectly linked to interpersonal relationships to
produce asthmatic reactions in the laboratory. The
Selesnick et al. study (1969) provided the general
interpersonal relationship of separation as a stimulus
to produce asthmatic reactions in all of their subjects.
This study relied heavily on the psychoanalytic
assumption that separation is the cause for psycho
somatic reactions which specifically occur in the
respiratory system. In neither study were there control
groups to which were shown different interpersonal
situations.
The following study will systematically analyze
the effects of personalized emotional stimuli on
asthmatic patients. It is predicted that watching an
emotion-laden interpersonal scene will produce different
respiratory activity in asthmatic patients for whom the
subject matter is pertinent them it will in those
patients for whom it has no relevemce. The individual
26
who has previously indicated that such a situation
induces asthmatic attacks will show greater reduction in
respiratory functioning than an individual whose
prodromal stimuli lie in other areas.
CHAPTER III
METHODOLOGY
SUBJECTS
Subjects were asthmatic patients referred by
physicians from the Los Angeles County-USC Medical
Center on the basis of physicians assessment that the
patients' asthma was due in part to psychosomatic
factors. All referrals had undergone standard scratch
and interdermal tests and specific allergic agents had
been identified for them. All referrals were clearly
diagnosed as asthmatics.
Each referral was asked if he were willing to
participate in a study to evaluate some of the factors
that might contribute to his asthma. All referrals
agreed to participate in such a study. Interviews were
conducted with the referrals concerning the patients'
asthmatic reactions and notations were made whenever the
patient indicated that there was a relationship between
his asthmatic attacks and some kind of interpersonal
situation or experience. Twenty patients for whom an
interpersonal situation relating to asthmatic attacks
could be identified were chosen to participate in the
study.
27
28
The ages of the subjects ranged from 23 to 35
years. Subjects were randomly divided into experimental
and control groups of five men and five women each.
Each experimental subject was yoked with a control subject
of the same sex and same approximate age to whom the
stimulus was presented. The stimulus was a scene derived
from the interview with the experimental subject, one
which had been specified as a precipitant for asthmatic
attacks. From the interviews with the yoked control
subjects, it was clear that there was no overlapping of
asthma-producing situations. The scenes watched by yoked
control subjects in no way resembled situations which
precipitated asthmatic attacks in their own lives.
MEASURES
Two measures were used to assess asthmatic
reactions: Peak Flow and Vital Capacity.
Vital Capacity is the amount of air that can be
expelled by the greatest effort following the deepest
possible inspiration. A Steadwell spirometer is used to
take this measurement. The patient breathes through a
disposable mouth piece on the end of a hose attached to
the spirometer. The spirometer is filled with atmos
pheric air and fitted with a drum for making a continuous
record of air movement in the circuit. This provides a
29
measure of the volume of air inhaled and exhaled.
Peak Flow is a measure of the volume of air
expired per period of time. The Wright Peak Flow Meter
(Wright and McKerow, 1959) was used to measure to
maximum forced expiratory flow rate for each patient.
The subject is asked to take a deep breath, place the
disposable mouth piece in his mouth, and then to blow
into the instrument as hard as he can. The pressure on a
vane inside the device caused by the patient's expiration
deflects a pointer on the dial. The instrument is fitted
with a ratchet which holds the vane and pointer in the
position of maximum deflection and which can only be
returned to zero by pressing a release button.
PROCEDURE
Each subject was contacted and asked to come for
a session. At the beginning of the session, the subject
was told that the experimenter was going to evaluate the
effect of asthma on his breathing, and that the two
measures were going to be used. Subjects were told that
the instruments were going to measure "how much air your
lungs can hold." The first measure was Peak Flow. The
subject was shown the Wright Peak Flow Meter and was told
that he would be asked to take a deep breath and then
expel the air as quickly and as forcefully as possible.
30
The instructions were repeated and the experimenter
demonstrated the procedure. The subject was asked if he
had any questions and then three Peak Flow readings were
taken. Verbal instructions were given during the
procedure: "I want you to take in as much air as you can
and then blow it out as fast and as hard as you can."
If at least two readings were within ten percent of each
other, it was taken to represent maximum effort and the
average of these two became the Peak Flow measurement.
Subjects were very cooperative and all had at least two
readings within ten percent of each other.
The Vital Capacity measure was taken next.
Subjects were told that they would be asked to insert
the mouth piece of the Steadwell apparatus and given the
following instructions:
When I tell you to, I want you to breathe
out all of the air from your lungs, then I want
you to inhale as much air as you can, and then
lastly I'm going to ask you to breathe out as
much air as you can as fast as you can.
The instructions were repeated:
Remember, first breathe out as much air
as you can. Second, breathe in as much air
as you can; and third, breathe out as much air
as you can as fast as you can.
Again, the subject was asked if he had any questions, and
the experimenter demonstrated the procedure. The mouth
piece was changed and the subject was asked to insert the
new one in his mouth. There were verbal instructions as
31
the subject performed the procedure. The subject was
asked to relax and breathe normally. When a regular
pattern was obtained, the subject was told to "breathe
out, out, out, as far as possible," until asymptote was
reached. He was then instructed to "breathe in, in, in,
as hard as possible," until asymptote was reached, and
lastly he was instructed to breathe out as quickly as
possible. The procedure was repeated twice and the two
measures were averaged to provide a base measure of Vital
Capacity.
The subjects were then told that the experimenter
wanted them to watch a play through a one-way vision
mirror. Each subject observed a five-minute scene which
was performed by medical students unknown to the subjects.
The scenes were not scripted, but the "actors" were given
the plot line and asked to develop a scene around it.
This procedure helped to maintain spontaneity of the
performances. The experimental subjects observed scenes,
the plot for which was drawn from the original inter
views, and which involved a situation they had said
produced asthmatic attacks for them. The yoked control
subjects watched similar scenes, with the same theme and
the same actors. The emotional content was the same for
the control subjects, but the scene was not personally
stressful as it had been for the experimental subjects.
32
There was no overlapping of stressful situations for
experimental subjects and their yoked controls. A nurse
was on hand to handle any possible asthmatic
emergencies.
The following ten plots were acted out for the
experimental and yoked control subjects:
1. Mother and son arguing over the boy's use of
the family car and the boy's irresponsibility.
2. Husband attempting to console his wife over
the death of her father. This results in an argument.
3. Husband and wife arguing because the husband
works at night and leaves his wife alone.
4. Man expressing his inadequacy because he can
no longer engage in active sports with his family.
5. Sister arguing with her younger sibling who
will not obey her when she is baby sitting her.
6. Mother, father and daughter arguing over
restrictions placed on family due to mother's asthma.
7. Husband and wife arguing over husband's
drinking and extramarital affairs.
8. Husband accusing wife of using asthma to
avoid responsibility.
9. Wife accusing husband of not caring about her.
10. Husband and wife arguing over how to bring up
children.
33
At the end of the scene, the experimenter came in and
repeated the measures for each of the subjects. Subjects
were asked if they had any questions. The main subject
concern was whether they would be able to get some help
for their asthma. That the scenes were successfully
stressful for the experimental subjects and nonstressful
for the control subjects is demonstrated by the comments
made by the subjects. Control subjects noted that
"That's not the kind of situation that bothers me," while
experimental subjects made comments to the effect that
"that's the same thing that happens at home."
CHAPTER IV
RESULTS
The data were analyzed using 2-tailed Student's
t tests.
BASE MEASURES
The mean for the pretest experimental group on
the Peak Flow measure was 193.0. The mean for the pre
test control group was 193.6. The Student t test was
.0015. This value is not significant at the .05 level.
The mean for the pretest experimental group on
the Vital Capacity measure was 2.65. The mean for the
pretest control group was 2.61. The Student t test was
.166. This value is not significant at the .05 level.
CHANGE SCORES
The mean for the difference between pretest and
posttest scores on the Peak Flow measure for the
experimental group was -28.4. The mean for the dif
ference between pretest and posttest scores for the
control group was 6.4. The Student t test for change
scores was 1.75, p<.05. The required t value with
18 df, p<.05 is 1.73. Raw scores, mean values, and
34
35
standard deviations for the Peak Flow measure will be
found in Appendix A.
The mean for the difference between pretest and
posttest scores on the Vital Capacity measure for the
experimental group was -.32. The mean for the difference
between pretest and posttest scores for the control group
was .13. The Student t test for change scores was 3.15/
p<.01. The required t value with 18 df, p<.01 is 2.88.
Raw scores, mean values, and standard deviations for the
Vital Capacity measure will be found in Appendix B.
WITHIN GROUP SCORES
The mean for the experimental group on the Peak
Flow pretest was 193.0. The mean for the experimental
group on the Peak Flow pretest was 193.0. The mean for
the experimental group on the Peak Flow posttest was
164.6. The Student t test for the pre-posttest
difference was -1.85, p<.10. The required t value with
9 df, p<.10 is ±1.83.
The mean for the control group on the Peak Flow
pretest was 193.6. The mean for the control group on
the Peak Flow posttest was 200.0. The Student t test for
the pre-posttest difference was .512. This value is not
significant at the .10 level.
The mean for the experimental group on the Vital
36
Capacity pretest was 2.65. The mean for the experimental
group on the Vital Capacity posttest was 2.33. The
Student t test for the pre-posttest difference was -2.34,
p<.05. The required t value with 9 df, p<.05 is ±2.26.
The mean for the control group on the Vital
Capacity pretest was 2.61. The mean for the control
group on the Vital Capacity posttest was 2.74. The
Student t test for the pre-posttest difference was 3.02,
p<.02. The required t value with 9 df, p<.02 is ±2.82.
CHAPTER V
DISCUSSION
While both Peak Flow and Vital Capacity have
been used in other studies, either as the sole measure of
respiratory function or in combination with other
measures, there is no evidence in the literature of the
two measures being used at the same time. Measures of
volume of air inhaled and exhaled have been used for a
longer period of time using such instruments as the body
plethysmograph, pneumotach and spirometer. The main
advantage of the Peak Flow measurement is its ease of
administration and easy transportation of apparatus. The
two indices, however, measure different aspects of
apparatus. The two indices, however, measure different
aspects of respiratory function. For that reason, both
measures were used in this study.
Neither of the obtained t values for pretest
comparisons betwene experimental and control groups was
significant, indicating that the groups were essentially
the same with respect to respiratory function prior to
the experimental manipulation.
The significant differences found on the t tests
of change scores for both measures supports the hypo-
37
38
thesis that respiratory function is negatively affected
by exposure to personally significant emotional inter
personal relationships. The yoked control subjects
viewed scenes with the same emotional theme as did the
experimental subjects, but showed no similar decrease in
their respiratory functions.
Comparisons of the within group changes for
experimental and control groups on both measures offers
additional support for the hypothesis. Significant
reductions in respiratory functioning was found in the
experimental groups for both measures. The control group
on the Peak Flow measure showed no significant change.
The significant change in the control group on the Vital
Capacity measure was in the direction of improved
respiratory functioning, thus highlighting the reduction
in the experimental group.
Although no systematic records were kept of overt
asthmatic symptoms, several of the experimental subjects
were affected severely enough to necessitate the use of
inhalators to relieve their asthmatic symptoms. There
were no such occurrences in the yoked control subjects.
Animal research (Ottenberg et al., 1958? Noelpp-
Eschenhagen, 1952) has demonstrated that respiratory
reactions may be conditioned to specific stimuli, but
arousal of emotional states or generalized anxiety are
39
not enough to maintain the production of such reactions.
Stressful stimuli may, however, exacerbate the
respiratory reactions. Asthmatic reactions were quickly
extinguished when they were no longer paired with
allergenic substances.
The findings of the present study are in agreement
with Dekker and Groen (1956) in terms of production of
asthmatic reactions by specific interpersonal relation
ships. Although the stimuli used by Dekker and Groen
were inanimate reproductions of non-humans, the authors
noted that these stimuli were related to "former
traumatic life experiences," and also indicated that
production of emotion, in and of itself, was not enough
to induce asthmatic attacks. Prodromal asthmatic stimuli
also needed to be of specific quality.
The present study would seem to contradict the
Purcell et al. (1969) study in which the authors state
that emotional states rather than patterns of inter
personal relations are the most relevant psycho-
physiological variable in relation to asthma. The terms
"emotional states" and "interpersonal relations" must,
however, be understood in the context in which they
appeared. It will be remembered that the children were
separated from their families by the removal of the
family from the home, and predictions were made based on
40
whether it was felt that emotional problems were or were
not relevant to asthma. In this sense "emotional states"
would mean difficult interrelations, specifically with
family members. "Interpersonal relations" would then mean
those interpersonal relations which were not difficult.
Since we are studying the effects of difficult inter
personal relationships, the two studies would seem to be
in agreement.
There has been much clinical evidence in the
literature relating asthmatic reactions with inter
personal relationships, but the only systematic attempt
to produce such reactions was made by Selesnick et al.
(1969) in which all his subjects were shown the same
stimulus. The 1942 movie, Now Voyager, has as its main
character the unwanted 28-year old daughter of a
domineering, quarrelsome, short-tempered socialite.
This ugly duckling daughter is driven to the edge of
insanity by her unloving mother and a spiteful,
tormenting niece. Placed in a sanitorium, the daughter
meets a psychiatrist who transforms her into a warm,
attractive woman. She then goes on a worldwide cruise
where she meets and falls in love with a married mem.
The two separate unhappily but bravely. It is not
surprising that all of Selesnick's subjects sustained
some degree of respiratory reduction while viewing this
41
film. There are a large number of Interpersonal
situations with which the subjects may have identified
and it is difficult to specify which one of them was the
specific precipitant for respiratory reduction in any
particular subject.
The results of the Selesnick study are not
consistent with the lack of asthmatic reactions for some
of the subjects in the present study. On the hasis of
the conditioning model, demonstrated by animal studies
and by several therapeutic case histories (Walton, 1960;
Cooper, 1964? Moore, 1965), it would be expected that
asthmatic reactions are related to specific emotional
stimuli. This author has focused on the subject-
specific interpersonal relationships that precipitated
asthmatic attacks for her subjects. It has been reliably
demonstrated by this study that an interpersonal situ
ation sufficient in intensity to produce asthmatic
responses in one individual does not necessarily produce
asthmatic responses in another individual. The subjects
in this study were yoked so that experimental subjects
saw scenes which they had identified as stimuli which
were related to their asthmatic attacks. The control
subjects saw the same scenes, but were unable to
identify with them.
Separation anxiety was, indeed, the precipitation
42
interpersonal situation for several of the experimental
subjects discussed in this study. A more predominant
theme, however, was argument and hostility. Nine of the
ten plots shown to subjects involved an argument.
Hostility and argument also appeared in the film shown
to Selesnick's subjects. The nature of asthma-producing
interpersonal situations for the control subjects was
similar to that of the experimental subjects. It is
suggested that future studies in this area might produce
even more compelling evidence for the hypothesis if both
groups first watched scenes based on themes from the
experimental subjects, and on a separate occasion, viewed
scenes based on themes from the control subjects.
At present, physicians make their decisions
regarding emotional factors based on gross, overt patient
behaviors. It wouls seem particularly appropriate to
combine the services of physician and psychologist in
the reduction of asthmatic respiratory patterns. The use
of measurements such as those used in this study to
correctly identify pre-asthmatic interpersonal relation
ships is encouraging for the application of behavioral
techniques to reduce asthmatic symptoms. Moore (1965),
Cooper (1964), and Walton (1960) all used various forms
of reciprocal inhibition to reduce asthmatic symptoms
in their patients. The systematic assessment of
43
asthmatogenic situations could lead to prompt treatment
to reduce the stress of such situations and alleviate
much of the needless suffering that now continues to
dominate the lives of asthmatic patients and their
families.
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Block, J. "Further Consideration of Psychosomatic
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Floyer, Sir J. A. A Treatise of the Asthma. London:
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Groen, J., and Pelser, H. E. "Experiences With, and
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______ , and Prior, F. N. "Further Observations on
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Knapp, P. H., and Nemetz, S. J. "Acute Bronchial Asthma:
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Leigh, D., and Marley, E. "A Psychiatric Assessment of
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Luparello, T., Lyons, H. A., Bleecker, B. A., and
McFadden, E. R. Jr. "Influences of Suggestion on
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McFadden, E. R. Jr., Luparello, T., Lyons, H. A., and
Bleecker, E. "The Mechanism of Action of Suggestion
in the Induction of Acute Asthma Attacks,"
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Mitchell, A. J., Frost, L., and Marx, J. R. "Emotional
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II, 744-751.
Moore, N. "Behavior Therapy in Bronchial Asthma: A
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Noelpp, B., and Noelpp-Eschenhagen, I. "Experimental
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Neuhaus, E. C. "A Personality Study of Asthmatic and
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Nowlis, V., and Nowlis, H. H. "The Description and
Analysis of Mood," Annals of the New York Academy
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Ottenberg, P., Stein, M., Lewis, J., and Hamilton, C.
"Learned Asthma in the Guinea Pig," Psychosomatic
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Peshkin, M. M. "Intractable Asthma of Childhood:
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Purcell, K. "Distinctions Between Subgroups of
Asthmatic Children: Children's Percpetions of
Events Associated with Asthma," Pediatrics, 1963, 31,
486-494.
________, Brady, K., Hyman, C., Muser, J., Molk, L.,
Gordon, N., and Means, J. "The Effect of Asthma in
Children of Experimental Separation from the
Family," Psychosomatic Medicine, 1969, 31,
144-164.
Reckless, J. B. "A Behavioral Treatment of Bronchial
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Saul, L. J. "Some Observations on the Relations of
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Sclare, A. B., and Crocket, J. A. "Group Psychotherapy
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Ledeman, A. R. "Induced Somatic Reactions in
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Stevenson, I., and Ripley, H. S. "Variations in
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Weiss, J. H. "Mood States Associated with Asthma in
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_________, Martin, C., and Riley, J. "Effects of
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APPENDIX A
RAW SCORES OF STEADWELL VITAL CAPACITY
EXPERIMENTAL
SS PRE POST DIFFERENCE
1 3.37 2.16 -1.21
2 2.11 2.20 + .09
3 2.47 1.53 - .94
4 2.82 2.37 - .46
5 2.74 2.65 - .09
6 1.48 1.30 - .18
7 2.16 2.06 - .10
8 2.79 2.83 + .04
9 3.42 3.10 - .32
10 3.15 3.10 - .05
26.52 23.30 -3.22
X=2.65 X=2.33 X=-.32
sd=.61 sd=.61 sd=.43
CONTROL
SS PRE POST DIFFERENCE
1 2.02 1.89 - .13
2 2.88 3.19 + .31
48
SS
3
4
5
6
7
8
9
10
49
PRE
2.20
3.14
2.92
2.43
1.93
2.70
2.65
3.24
26.11
X=2.61
sd=.45
POST
2.25
3.23
3.06
2.70
2.11
2.70
2.88
3.37
27.38
X=2.74
sd=.51
DIFFERENCE
+ .05
+ .09
+ .14
+ .27
+ .18
.00
+ .23
+ .13
+1.27
X= .13
sd-.13
50
APPENDIX B
RAW SCORES OF WRIGHT PEAK FLOW
EXPERIMENTAL
SS PRE POST
1 226 198
2 85 39
3 258 113
4 45 10
5 125 110
6 225 232
7 261 242
8 216 167
9 110 128
10 379 407
1930 1646
X= x 9 3.0 X=164.6
sd=100.64 sd-114.06
CONTROL
SS PRE POST
1 297 270
2 225 242
3 211 234
DIFFERENCE
- 28
- 46
-145
- 35
- 15
+ 7
- 19
- 49
+ 18
+ 28
-284
X=28.4
sd=48.56
DIFFERENCE
- 27
+ 17
+ 23
51
CONTROL
SS
4
5
6
7
8
9
10
PRE
88
155
126
216
212
102
304
1936
X=193.6
sd=74.98
POST
91
91
211
218
239
80
324
2000
X=200.0
sd=83.88
DIFFERENCE
+ 3
- 64
+ 85
+ 2
+ 27
- 22
+ 20
+ 64
X=6.4
sd=40.26

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Asset Metadata

Creator Singer, Esthr Marlene (author)

Core Title The Effect Of Personalized Emotional Stimuli On Asthmatic Reactions

Degree Doctor of Philosophy

Degree Program Psychology

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag OAI-PMH Harvest,Psychology, clinical

Language English

Contributor Digitized by ProQuest (provenance)

Advisor Marston, Albert R. (committee chair), Frankel, Andrew Steven (committee member), Lammers, William W. (committee member)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c20-526869

Unique identifier UC11226200

Identifier 7506446.pdf (filename),usctheses-c20-526869 (legacy record id)

Legacy Identifier 7506446.pdf

Dmrecord 526869

Document Type Dissertation

Rights Singer, Esthr Marlene

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus, Los Angeles, California 90089, USA