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An Investigation Of The Response To Stress Of Patients Hospitalized For Anxiety State And Peptic Ulcer Patients

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An Investigation Of The Response To Stress Of Patients Hospitalized For Anxiety State And Peptic Ulcer Patients

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Content AN INVESTIGATION OP THE RESPONSE TO STRESS
OP PATIENTS HOSPITALIZED FOR ANXIETY STATE
AND PEPTIC ULCER PATIENTS
by
Martin E. Mendel
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 1958
UNIVERSITY O F SOUTHERN CALIFORNIA
GRADUATE SCHOOL
UNIVERSITY PARK
LOS ANGELES 7
This dissertation, •written by
............
under the direction ofhla.Guidance Committee,
and approved by alt its members, has been pre
sented to and accepted by the Faculty of the
Graduate School, in partial fulfillment of re
quirements for the degree of
D O C T O R O F P H I L O S O P H Y
GUIDANCE COMMITTEE
Chifirman
ti nv., h* ■ )lUe,
..
TABLE OF CONTENTS
CHAPTER PAGE
I. INTRODUCTION ................................... 1
Theoretical background ...................... 1
Anxiety and psychosomatic illness ......... 6
Repression and psychosomatic illness .... 7
Purpose of the study....................... 11
Hypotheses................................... 13
II. REVIEW OF THE LITERATURE...................... 16
Approaches to the study of stress and
anxiety.............................. 16
Studies of autonomic reactivity ............ 19
III. SUBJECTS, TEST BATTERY, AND PROCEDURE .... 36
The subjects and their selection ........... 36
The anxiety g r o u p ........................ 36
The ulcer g r o u p .......................... 37
The hospital-normal group ............... 37
The test battery............................ 38
Systolic blood pressure ................. 38
Heart period.............................. 39
Diastolic blood pressure ................. 39
Palmar skin resistance ................... 39
The self rating s c a l e ................... 40
Procedure................................... 41
IV. RESULTS........................................ 44
Comparison between anxiety, ulcer, and nor
mal groups (resting data) ............... 44
iv
CHAPTER PAGE
Autonomic functioning under stress .......... 48
Systolic blood pressure ............... 51
Heart period.............................. 53
Recovery from stress: the control groups . 55
Systolic blood pressure ................ 55
Heart period.............................. 57
Recovery from stress: the experimental
groups . . . ............................ 59
Systolic blood pressure.................... 62
Heart period.............................. 67
The verbal report of tension............... 69
Resting data.............................. 69
Post-stress data.......................... 72
The anticipated stimulus and its relation
ship to diagnostic grouping ............. 79
V. DISCUSSION AND CONCLUSIONS ................... 84
The anxiety g r o u p .......................... 84
The ulcer g r o u p ............................ 89
The hospital-normal group.................... 95
VI. SUMMARY....................................... 101
BIBLIOGRAPHY ......................................... 105
APPENDIX.............................................. Ill
LIST OF TABLES
TABLE PAGE
1. Means and Standard Deviations of Systolic Blood
Pressure and Heart Period at Resting Level
for Normal, Anxiety, and Ulcer Groups .... 45
2. Analysis of Variance of Systolic Blood Pressure
and Heart Period at Resting Level for Normal,
Anxious, and Ulcer Subjects Analyzed 1) in
Three Diagnostic Groups and 2) in Six Groups,
Each Group Being Divided into Experimental
and Control Group............................. 47
3. Mean Increments at Point of Stimulation on
Measures of Systolic Blood Pressure and
Heart Period................................. 52
4. Analysis of Variance of Normal, Anxiety, and
Ulcer Group on Measures of Systolic Blood
Pressure and Heart Period at Point of Stress,
After Difference Scores Have Been Converted
to T-Scores................................... 5^
5. Mean Trend Differences Between Experimental and
Control Sub-Groups of Each Diagnostic Group
(Normal, Anxiety, and Ulcer), as well as
Between the Total Experimental and Control
Sample........................................ 6l
6. Trend Differences Among the Experimental Normal,
Anxiety, and Ulcer Group on Systolic Blood
Pressure and Heart Period .................... 66
vi
TABLE PAGE
7. Contingency Table of Frequencies of Pre-
Stimulus Self Rating Scale Scores for the
Normal, Anxiety, and Ulcer Groups ............. 71
8. Contingency Table of Shifts in Self Rating
Scale Scores After Stress in the Same
Individuals................................... 73
9. Analysis of Variance of Differences Between
Post-Stimulus Means on the Self Rating Scale
for the Normal, Anxious, and Ulcer Groups . . 73
10. Coefficients of Correlation Between Post-Stress
Self Rating Scale Scores and Two Autonomic
Measures for the Normal, Anxious, and Ulcer
Groups.......................................... 77
11. Contingency Table of the Type of Stimulus
Expected by the Normal, Anxious, and Ulcer
Group............................................. 8l
12. Means of Reactivity Scores on Four Measures
Expressed in T-Scores ......................... 82
13. Means and Standard Deviations of Diastolic
Blood Pressure at Resting Level for Normal,
Anxious, and Ulcer Group ........................ Ill
14. Analysis of Variance of Diastolic Blood
Pressure Means of the Three Groups at Resting
Level............................................ Ill
vii
TABLE PAGE
15. Mean Increment at Point of Stimulation of
Normal, Anxious, and Ulcer Group on Diastolic
Blood Pressure.............................. 112
16. Analysis of Variance of Normal, Anxious, and
Ulcer Group on Diastolic Blood Pressure at
Point of Stress (T-Scores) ................. 112
17. Distributions of Self Rating Scale Before and
After Stress................................ 113
LIST OP FIGURES
FIGURE PAGE
1. Means of Raw Difference Scores for Systolic
Blood Pressure (the Control Groups) ......... 56
2. Means of Raw Difference Scores for Heart
Period (the Control Groups)................. 58
3- Means of Raw Difference Scores for Systolic
Blood Pressure (the Experimental Groups) . . 63
4. Means of Raw Difference .Scores for Heart
Period (the Experimental Groups) .............. 68
5. Frequency Distribution of Resting Systolic
Blood Pressure for the Total Sample of
Anxious, Ulcer, and Normal Patients ........... 114
6. Frequency Distribution of Resting Heart Period
for the Total Sample of Anxious, Ulcer, and
Normal Patients ................................. 115
7. Frequency Distribution of Resting Diastolic
Blood Pressure for the Total Sample of
Anxious, Ulcer, and Normal Patients ........... 116
8. Means of T-Scores of the Control Groups on
Systolic Blood Pressure ......................... 117
9. Means of T-Scores on Systolic Blood Pressure of
the Experimental Groups ......................... 118
10. Means of T-Scores on Heart Period of the
Control Groups ................................. 119
11. Means of T-Scores on Heart Period of the
Experimental Groups ............................. 120
CHAPTER I
INTRODUCTION
Theoretical Background
Theories of psychopathology and psychosomatic dys-
functions have been based on formulations of anxiety concep
tualized either in psychological, cultural, physiological,
or biological frameworks. Theoreticians in the social sci
ences have been concerned with defining anxiety and in dif
ferentiating anxiety from similar concepts. For example,
May, after a masterly review of theories of anxiety, con
cludes that "anxiety is the apprehension cued off by a
threat to some value which the individual holds as central
to his existence as a personality" (49:191). Goldstein,
similarly, sees anxiety as ". . . the subjective experience
of the organism in a catastrophic condition" (28), and as an
emotion without a specific object.
The problem of differentiating between anxiety and
fear has been an elusive one, but most investigators appear
to agree with Grinker and Spiegel (32) that anxiety is an
"objectless" emotion. By contrast, the symbol which cues
off fear is seen as specific and reportable (4, 15, 49).
May emphasized that a distinction needs to be made be
tween normal and neurotic anxiety, observing that
. . . normal anxiety Is that reaction which 1.) is
not disproportionate to the objective threat, 2.) does
not involve repression or other mechanisms of intrapsy
chic conflict and 3.) . • • does not require neurotic
mechanisms for Its management but can be confronted con
structively on the level of conscious awareness or can
2
be relieved if the objective situation is altered. (49)
In his early formulations, Mowrer (50) represented
the view commonly held by learning theorists, that anxiety
is the "conditioned form of the pain reaction," and that be
havior which reduces this anxiety is rewarding and thus be
comes learned.
Freud maintained that anxiety is "the fundamental
phenomenon and the central problem of neurosis" (20:111).
In general, the literature seems to agree that anxiety is
one of the affects aroused by any condition which threatens
the integrity of the organism. Other such affects are fear
and anger. Any condition which is capable of cueing off
such a response in the organism constitutes a stress. Both
physical and psychological stress may be measured by and
correlated with changes in the organism's psychodynamics and
physiodynamics (in response to a disturbed equilibrium).
The term "stress" finds common usage in the psychological,
physiological, and psychiatric areas, having been borrowed
from the physical sciences. Its use remains somewhat un
clear. Some authors use it to represent an assortment of
threatening stimuli, others a type of response, still others
(probably the majority) the stimulus-response sequence, i.e.,
the state of affairs wherein the organism's behavior is
altered as an adaptation to a threat. The stimulus Itself
will here be spoken of as the stressor. the response alone
as the stress response.
3
The organismic processes responding to threat were
first explored extensively by Cannon (5) who saw the periph
eral manifestations as economic to the organism for the pos
sibility for flight or fight. Among these categories are an
increased call for oxygen with hyperglycemia, widened nasal
apertures and Increased nasal secretion, Increased sweating,
rising blood pressure, tachycardia, changes in cardiovascu
lar dynamics, and alterations in the distribution of biochem
ical substances in the circulating blood. However, Cannon's
work on homeostasis largely confined itself to the study of
animal reactions. As Wolff points out,
Man is further vulnerable because he is so consti
tuted that he reacts not only to the actual existence of
danger, but to threats and symbols of danger experienced
in his past which call forth reactions little different
from those to the assault itself. Since his adaptive
and protective abilities are limited, a man's response
to many sorts of noxious agents and events may be simi
lar, the form of the reaction to any one agent depending
more on the individual's nature and past experience than
upon the particular noxious agent evoking it. Moreover,
because of its magnitude and duration, the adaptive pro
tective reaction may be far more damaging to the individ
ual than the effect of the noxious agent per se. (68:3)
The homeostatic functions described above are now
known to be mediated through the autonomic nervous system.
In 1886, Gaskell suggested that the adjustlve capacity of
the internal organs was possible because of a double nerve
supply to these organs (25). This double Innervation served
as a set of checks and balances. In 1915, Eppinger and Hess
published their classic investigations (13), on the basis of
which they coined the terms "vagotonia" and "sympathicotonia"
to characterize individual differences in autonomic function
ing. Since most body organs are innervated antagonistically,
they reasoned, excess stimulation of either branch of the
autonomic nervous system would bring about a state of imbal
ance, and they considered this relevant to the etiology of a
large variety of physical disorders. Vagotonia, or the ten
dency toward parasympathetic overreactivity, was thought to
be associated with such disorders as bronchial asthma, pep
tic ulcer, mucous colitis and other disorders now frequently
referred to as "psychosomatic." The vagotonla-sympathico-
tonia dichotomy of Epplnger and Hess has become somewhat dis
credited, as evidence in Kuntz' critique (38) shows. He
cites studies showing that some patients suffering from such
disorders as peptic ulcer and bronchial asthma have been
found to demonstrate hyperreactivity of both branches of the
autonomic nervous system. However, the frame of reference
has continued to be utilized, in the researches of Wenger
and associates (43, 51, 62) and in the formulations of psy
chosomatic medicine (l), on the basis that the primary symp
tom of the above-named disorders is related to overstimula
tion from the parasympathetic nervous system. Similarly,
cardiac neuroses, as well a3 manifest ("free-floating") anxi
ety states continue to be associated with sympathetic overac
tivity, although recent experimental evidence does not uni
formly support this supposition.
Modern concepts of stress have been changed by the
5
work of Selye (56) who studied the pituitary-adrenalcortical
axis. His work on stress has brought attention to mechanisms
which are considerably more central than those studied by
Cannon. He has described a "general adaptation syndrome,"
consisting of a phase of alarm in which shock and counter
shock mechanisms play a role, a stage of resistance, and fi
nally, a stage of exhaustion. Each one of these phases or
reactions to stress results in processes which are expressed
biologically in different ways but which are intimately con
cerned with disturbances recognized as disease states.
A stress response has been defined as any reaction to
circumstances of threatening significance to the organism
(68, 3); oxygen deprivation constitutes such a threat at the
physiological level; failure experiences serve as an example
of psychological threat. As Wolff (68) points out, the par
ticular adaptation pattern evoked by the noxious agent or
threat is the result of past experience, which conditions
the individual to react in specific ways. The etiology of a
disease, for example, is a function of both the immediate
precipitating incident and the individual's experience.
Wolff further points out that stress evokes entirely
different responses in different persons, and he speaks of
"nose reactors," "stomach reactors," etc., thus emphasizing
that individuals respond in a highly specific pattern to a
variety of stress situations. Lacey and collaborators (39,
40, 4l), in an interesting series of experiments, have
demonstrated the existence and consistency of individual
patterning of autonomic responses in normal persons under
stress. Similarly, Malmo and Shagass (45) have found that
stress activated the particular physiological system in
which psychiatric patients already had somatic complaints
(see Ch. II).
Anxiety and Psychosomatic Illness
Concerning the psychological aspects of psychosomatic
disorders, Alexander (l) holds with Freud that
. . . every neurosis, including organ neuroses, con
sists to a certain degree of withdrawal from action.
Where psychoneuroses occur without physical symptoms,
motor activity is replaced by . . . activity in fantasy
. . . [but] every psychosomatic disorder (by way of con
trast) involves a dislocation in the nervous system.
Where consummatory action (psychic or musculo-skeletal)
is lacking, unrelieved tension Induces vegetative
changes.
His psychosomatic theory maintains that vegetative symptoms
are the result of sustained excitation of the nervous system,
Induced by or concomitant with emotional tension (anxiety).
This occurs whenever tension falls to find discharge in vol
untary behavior. For Alexander (as for Eppinger and Hess),
psychosomatic disease falls into two broad categories. When
sympathetic Innervation is relatively dominant, vegetative
changes prepare the organism for outwardly directed action.
Under the circumstances, appropriate voluntary behavior is
not consummated, and the organism continues in a state of
chronic physiological preparedness. He attributes the dis
turbances of this category to Inhibition or repression of
7
hostile and aggressive impulses.
The second category of diseases is thought by Alexan
der to develop under conditions of parasympathetic dominance.
Patients belonging to this group react to the normal demands
of day-to-day living with an unconscious withdrawal from out
ward action into a condition of passive-dependency, Such
persons retreat, in visceral terms, to the adaptive reactions
of a small child in distress. All gastrointestinal disturb
ances, insofar as they reflect the influence of emotion, be
long to this regressive mode of adaptation which Alexander
labels the "vegetative retreat." Alexander has posited a
specificity theory wherein he hold3 that each psychosomatic
disease entity has a specific psychological conflict as its
basis. He sees the ulcer patient as having conflicts over
dependency and oral aggression. Ruesch (53) challenges the
specificity of the conflict, and holds that the crucial fac
tors about psychosomatic dysfunctions do not lie in their
differences but in their communalltles, but that the salient
features lie in the psychosomatic patient's emotional imma
turity and his tendency to express emotion in "organ lan
guage ."
Repression and Psychosomatic Illness
Dunbar (10) notes that an inverse relationship seems
to exist between an individual's capacity to tolerate con
scious anxiety and the appearance of psychosomatic symptoms.
She found that, in treating ulcer patients
psychotherapeutlcally, these patients were not aware of con
scious anxiety initially. As the anxiety came into con
sciousness, the patient was more severely distressed but the
organ symptom disappeared. Wolff also observed that
. . . anxiety shown in talk and behavior is commonly
absent in persons with bodily disorders associated with
stress. This fact troubles some and has raised the
question as to whether such persons can properly be
termed "neurotic." Suffice it to say . . . that aber
rant behavior, inappropriate attitudes, overt anxiety
and other troublesome feeling states, as well as altera
tions in bodily function are equally manifestations of
stress. They can occur together, or independently.
(68:43)
Rado (52), in discussing the various manifestations
of anxiety, stresses the role of the mechanism of repression
in psychosomatic disorders, the symptom being the end-result
of the repression.
Fenichel states that
. . . a disproportion between the precipitating fac
tor and the affect reaction is an index of the presence
of repression. . . . If affective instability is the
first result of affect defenses, general affective rigid
ity is the second. (I5:l6lf)
He also points out that such somatic symptoms as peptic ulcer
are "affect equivalents," and that the mechanism of repres
sion serves to convert the anxiety or hostility directly into
somatic pathways, without the Individual necessarily becoming
aware of the affect. As shown by Weiss and English (60),
there appears to be a consensus in the literature that pa
tients with psychosomatic disorders are very difficult to
treat in a psychotherapeutic situation, because of the per
vasiveness of their repressions.
9
In contrast to the repressed psychosomatic patient,
the person with a pathological degree of overt anxiety has
been characterized by a "readiness for anxiety . . . general
affective lability . . . heightened inner tension" (15:195)*
In terms of physiological functions, anxiety states are, as
was mentioned, associated with overreactivity of sympathetic
nervous system functions (62). Freeman (18) observed that
the stress response is always a function both of stimulus-
induced excitation and of the amount of energy mobilization
already present, and that a standard stimulus imposed on
high or low energy levels will produce less of an Increment
than on median energy levels. There is some experimental
support for the hypothesis that persons with high anxiety
levels show less physiological responsiveness to a stressor
than normal subjects (51> 17) a3 well as slower recovery.
However, there appears to be lack of confirmation of this
hypothesis (64).
Studies are lacking which would focus on essential
differences between stress responses of persons who are
thought to have little tolerance for anxiety and who convert
anxiety into somatic symptoms, and persons who tend to ex
perience strong anxiety. Psychosomatic patients may show
less autonomic responsiveness to stress than normal Individ
uals, because of their tendency to repress or inhibit expres
sions of anxiety.
Another aspect of repression should be evident in an
10
absence of awareness of anxious feelings In a psychologically
stressful situation. And if persons with a psychosomatic
illness such as a peptic ulcer are characterized by height
ened parasympathetic activity, then manifestations of such
reactivity should be elicited on autonomic tests during
stress. Marked pulse slowing during the recovery phase from
stress would be an indicator of heighened parasympathetic
reactivity, since pulse slowing is a function of vagus in
nervation. In the resting state, no differences between the
pulse rate of ulcer patients and normal control subjects
have been found (43, 62).
The conditions for recovery from psychological stress
have been even less well explored among persons with psycho
pathology. Studies of college students (16, 18) and chil
dren (35) indicate that recovery rate is a function both of
the subject's personality and of the kind of activity inter
posed during the recovery period. There have been no con
trolled studies of the effects of verbal catharsis following
psychological stress among neurotic patients. A study by
Haggard and Freeman (35) indicated that children who tend to
Inhibit motor and verbal responses showed less recovery from
stress under a condition of catharsis than those who do not
inhibit such responses. One is led to ask whether psychoso
matic patients, e.g., ulcer patients, who are thought to in
hibit motor and verbal responses, can utilize a situation of
catharsis to advantage, and whether such a situation would
11
be relatively more helpful to the recovery of persons with
marked "free-floating" anxiety than to the ulcer patients.
An Investigation comparing the response of normal subjects,
subjects with free-floating anxiety, and subjects who re-
press^anxiety would add to knowledge of how catharsis might
be used to help in the dissipation of stress, and of how
well catharsis can be utilized in pathological states.
Purpose of the Study
This study directs itself to the following questions:
(a) What characteristic differences exist in the re
sponses to stress of normal persons, persons characterized
by marked "free-floating" anxiety, and persons characterized
by psychosomatic illness (e.g., peptic ulcer patients}? Do
persons with free-floating anxiety react as strongly to
stress as, or more strongly than, normal persons? There is
some evidence to Indicate that, since their emergency reac
tions are chronically mobilized, anxious persons may not be
as responsive to a circumscribed stress as normal persons
are. However, the alternative possibility--that they may re
act more intensively to some forms of stress (e.g., ego
threats)--needs to be investigated as well. Psychosomatic
patients, because of their asserted tendency to repress anxi
ety, may also be expected to react less strongly than normal
individuals.
(b) A second question concerns conditions for recov
ery. Is there a difference in rate of recovery between the
12
three groups, under conditions of complete post-stress rest?
l) Do persons said to be characterized by excessive sympa
thetic tonus recover as rapidly or regularly as normal per
sons? Preliminary evidence suggests that they do not (17)*
Do persons said to be characterized by excessive parasympa
thetic tonus show more rapid phasic recovery than normal per
sons? 2) Further, is there a difference in recovery rate
among the groups when a condition of "catharsis" is intro
duced following a psychological threat, as compared to a
condition of rest and inactivity? When such a condition of
catharsis is introduced, are there differences in recovery
rate among the three groups? Because of their tendency to
ward repression, are ulcer patients less able than overtly
anxious and normal Individuals to utilize catharsis, to dis
sipate their response to stress?
(c) A third question concerns the extent to which a
correspondence exists between the person's recognition and
verbal report of anxiety and the magnitude of his physiologi
cal manifestations of stress response. Subjects may give a
verbal report ranging from no felt tension to a great deal
of felt tension, in response to a psychological stress. Con
comitantly, their physiological responses may range from low
to high. Various combinations of the two modes of response
are possible, e.g., low verbal response may occur together
with high physiological response, or high verbal response
together with high physiological response, etc.
13
Ulcer subjects, described as inclined toward repres
sion and/or inhibition of affective responses and ideational
content, may show a lower verbal than physiological response,
or they may show both verbal and physiological responses of
lower magnitude than the responses of normal subjects. On
the basis of Fenichel's (15) inferences about repression,
either of these conditions may be expected among psychoso
matic patients. Ulcer patients would also be expected to
report experiencing less initial (pre-stress) felt anxiety
than normal control subjects.
In contrast, subjects with "free-floating” anxiety--
with their proneness to experiencing conscious anxlety--are
expected to report experiencing more initial (pre-stress)
felt anxiety than normal controls. One would also expect
that, although they may start at a verbal report level
higher than that of the ulcer and normal control subjects,
they will nonetheless report a greater increment in felt
anxiety than the ulcer subjects following a psychological
stress. The extent to which the magnitude of the verbal and
physiological stress response of the anxious subjects will
correspond cannot be hypothesized on the basis of theoretical
and clinical considerations. The question will be treated
empirically in the analysis of the data.
Hypotheses
1. If persons with marked free-floating anxiety are
characterized by already chronically heightened sympathetic
14
autonomic reactivity, then an experimentally applied psycho
logical stress will elicit a greater Increment in cardiovas
cular measures of sympathetic reactivity in a group of normal
control subjects than in a group characterized by marked
free-floating anxiety.
2. If persons with a peptic ulcer syndrome are char
acterized by a tendency to repress or inhibit their response
to stress, then an experimentally applied stress will elicit
a greater increment in cardiovascular measures of sympathet
ic reactivity in a group of normal control subjects than in
a group characterized by a peptic ulcer syndrome.
3. If persons with marked free-floating anxiety have
chronically heightened sympathetic autonomic reactivity,
then the return of cardiovascular measures to pre-stress
level will be incomplete and less regular for these persons
than the recovery pattern of normal control subjects, within
a brief circumscribed recovery period.
4. If persons with peptic ulcer manifest a greater
degree of parasympathetic autonomic reactivity than normal
persons, then the return of cardiovascular measures--partic-
ularly of heart rate--to pre-stress level will be more rapid
than that of normal control subjects, and may show a recovery
level below the Initial base level.
5. If persons with a peptic ulcer syndrome are char
acterized by a tendency to repress or inhibit their response
to stress, then they cannot dissipate anxiety as readily as
15
normal persons by verbal techniques. Therefore, a more rap
id and/or more complete recovery to base level on autonomic
measures will be achieved by a group of normal control pa
tients and by patients with free-floating anxiety than by a
group of peptic ulcer patients, in an experimental condition
of ”catharsis."
6. If persons with peptic ulcer are characterized by
proneness to repression and/or inhibition of affective state
and ideational content, then a) their awareness of, or ad
mission of, anxiety felt previous to experimental stress will
be less great than that of normal control subjects; b) their
awareness of, or admission of, felt anxiety increase after
stress will be less great than that of normal subjects; c)
they will show a high correspondence between autonomic
stress-scores and verbal report score, but both scores will
be lower than that of the normal control subjects.
7. If persons with free-floating anxiety are charac
terized by proneness to experiencing (and verbalizing) con
scious anxiety, then a) their awareness of, or admission of,
felt anxiety previous to experimental stress will be greater
than that of normal control subjects; b) their awareness of,
or admission of, felt anxiety increase after stress will be
greater than that of a group of ulcer patients. No predic
tion is made regarding the correspondence between their auto
nomic post-stress scores and their verbal report score.
CHAPTER II
REVIEW OP THE LITERATURE
Approaches to the Study of Stress and Anxiety
The considerable literature on stress and anxiety is
composed of a number of different types of studies. In one
type of study, anxious individuals have been selected and
compared to control subjects on some aspects of psychological
or physiological functioning. A second approach studies
life stress situations, in which the individual's response
to danger, severe loss or injury is evaluated. Military com
bat has provided many opportunities for studying the stress
response, as in the detailed presentation of Grinker and
Spiegel (32). Observations made in concentration camps,
such as those of Groen (33) on former patients of his who
had previously suffered from peptic ulcers, have shed light
on illness under marked stress. The most ambitious of such
studies so far has been an interdisciplinary investigation
(psychology, psychiatry, biochemistry) of stress in para
trooper training (3)-
An extension of this second approach derives from psy
choanalytic theory (15)* which associates an individual's
present functioning with his personal history. Investigators
in the area of psychosomatic medicine have frequently em
ployed an interview situation in which they have attempted
to establish a cauBal relationship between the somatic symp
tom and the individual's life situation and history. As a
17
result of this orientation, historical investigations have
in recent years abounded in publications under such titles
as "Life Situations, Emotions and Chronic Ulcerative Colitis"
(31) and gross relationships are established between dynami
cally meaningful events and exacerbations of the somatic
symptom. Aside from the questionable reliability of the ob
server's reports, these studies have usually made implica
tions on the basis of a very small number of patients.
In a third approach, normal subjects have been sub
jected to laboratory situations which might be expected to
produce stress. Certain operations of very diverse nature
seem to be generally accepted as definitions of stress, and
Include physical pain, the application of electric shock,
the "cold pressor" test, intense sensory stimulation, depri
vation of physiological need, the frustration of goal-
dlrected behavior, the introduction of emotionally disturb
ing material, the induction of conflict and of failure, and
others. The laboratory situation has the advantage of con
trollability and simplicity, but is frequently handicapped
by the circumscribed time-interval studied, which cannot re
produce the chronic character of many life and neurotic
stresses.
Responses to stress have been measured in the labora
tory in psychological, physiological, and biological dimen
sions. The effect of such psychological variables as rate
of conditioning (58) and learning (37> 55)> perceptual
18
functions (l4) and personality organization (11, 57) has
been studied. The induction of stress has also been related
to such diverse biological functions as eosinophil count (9)*
adrenocortical hormone secretion (56), hippuric acid secre
tion (3)* and a great number of functions.
Other studies have investigated the effect of stress
on such physiological factors as cardiovascular functions,
respiratory responses, voluntary muscle potential, gastroin
testinal behavior, skin conductance, pupillary functions,
sexual behavior, nerve conductance, and metabolic functions.
Frequently, the application of a physical stimulus, e.g.,
the cold pressor stimulus, serves as ttfe dependent variable
in studies of autonomic reactivity, and some Investigators
(39/ 51» 64) have then Implied physiological concomitants of
anxiety on the basis of the autonomic reactions to a physical
stress.
These varying approaches to the study of stress and
anxiety have often made for Inconsistent results in the lit
erature. For example, White and Gildea (64) found no differ
ence in the magnitude of systolic blood pressure rise in re
sponse to a cold pressor stimulus between hospitalized anx
ious and control groups, while Funkensteln, et aJL. (21) dem
onstrated a more marked rise in blood pressure among anxious
subjects than among normal controls on injection of epine
phrine. The effects of different operations classified as
stressful appear to lead to different responses. There is
19
some evidence (54)— see below--that the individual's auto
nomic responses to cold pressor stimulation are more like
characteristic responses to pain stimulation than like re
sponses to anxiety-producing ego threats.
Studies of Autonomic Reactivity
Beginning with the classical researches of Cannon (5)>
one finds much evidence which indicates that heightened sym
pathetic autonomic activity is associated with manifesta
tions of fear, anxiety, and other stress responses. The
vagotonia-sympathicotonla concept of Eppinger and Hess (13)>
though weakened by inconclusive experimental evidence, con
tinues to occupy present-day researchers. The reason for
this appears to lie in clinical observations that the symp
toms of such states as chronic anxiety are similar to those
elicited by sympathetic stimulation (e.g., fast pulse and
hyperventilation), while such symptoms as the hyperacidity
in peptic ulcer or the intestinal hypermotility of colitis
are elicited by parasympathetic stimulation.
Wenger and associates (43, 6l, 62), concluding that
the Epplnger-Hess formulation had not received an adequate
test, measured a great number of autonomic functions in chil
dren and adults in a resting state. Wenger concluded on the
basis of a factor analysis of his data that an autonomic fac
tor existed which, when computed for individuals of the child
sample, provided a normal distribution of scores that tended
to be stable over a three-year period. Subsequently, Wenger
20
conducted extensive studies of autonomic variables in Air
Force personnel during World War II (62). He again demon
strated an autonomic factor in both patients with operational
fatigue as well as in a normative group of cadets. The for
mer group deviated in the direction of apparent sympathetic
dominance on many of the variables measured. The measures
were: salivary output, palmar conductance, systolic and di
astolic blood pressure, sinus arrhythmia, heart rate, sub
lingual temperature, finger temperature, respiration rate,
and tidal air mean. Wenger also found that 98 hospitalized
psychoneurotics in an Army hospital, in whom anxiety was in
ferred as a major symptom, demonstrated even greater sympa
thetic dominance than the operational fatigue sample. More
over, he failed to demonstrate resting parasympathetic domi
nance for a group of 16 asthma and 21 peptic ulcer patients.
Gunderson (34) also found marked sympathetic dominance
in a group of early schizophrenics who manifested pronounced
anxiety, when he compared these to Wenger's normative sample.
Parker (51) found that anxious college students were charac
terized by significantly faster heart rate, greater skin con
ductance, and a significantly higher sympathetic autonomic
factor score than non-anxious college students. However,
Little (43), like Wenger, failed to demonstrate greater para
sympathetic dominance in a sample of hospitalized ulcer pa
tients than in Wenger's controls. One may criticize these
resting level studies by Wenger and his students because
21
resting level measures may not take into account precisely
those phasic and chronic alterations of functions which
Wenger himself stresses in his reformulation of the Eppinger-
Hess theory, i..e., they do not concern themselves with reac
tive alterations which these functions undergo in states
other than rest.
Parker's study (51) constitutes an exception, in that
he compared the reactivity of his anxious and non-anxious
college students on palmar conductance, heart period, respi
ration period, systolic blood pressure and cardiac output,
when stress was applied in the form of a cold pressor stimu
lus, and for twelve minutes thereafter. Parker found no
significant differences between the groups on any of the
measures, when the subjects were chosen on the basis of the
Taylor Scale of Manifest Anxiety (59)* However, when he re
grouped his sample on the basis of combined scores from this
scale and the Freeman Test of Manifest Anxiety (19)> the non-
anxious group was found to be more reactive during stress and
recovery periods than the anxious group.
Williams (65) compared responsiveness to psychological
stress in normals and early schizophrenics, and found the
latter to have a heightened level of autonomic activity dur
ing rest which persisted during stress. However, the anxious
schizophrenics showed less variability and less actual re
sponse to specific stimuli than the normal subjects.
Malmo (49) compared eleven normal and 36 acutely
22
anxious patients, as well as eleven early schizophrenics on
physiological responsiveness to a painful stimulus. His
findings showed the best index of degree of anxiety to be in
measures of finger movement, head movement, muscle poten
tials from the side of the neck, and respiratory irregulari
ty. He too found a striking similarity between early schizo
phrenics and anxious patients, In that both groups demon
strated greater motor activity at lower stimulus intensity
than the normal controls, but his measures were closer to
the subject's voluntary control, and his findings may sug
gest less pain and frustration tolerance in anxious and ear
ly schizophrenic subjects. Malmo and Shagass (45) again
demonstrated this close similarity in the two groups, in re
activity to a variety of stress situations: pain, a rapid
discrimination task and mirror drawing.
In a series of studies, Funkenstein, et a^. (21, 22,
23) demonstrated that psychoneurotics and psychotics with
free-floating anxiety show a marked increase in blood pres
sure after injection of epinephrine (a sympathomimetic drug);
the same patients also showed recovery beyond their base lev
el after an initial drop, in systolic blood pressure, after
Injection of mecholyl (a parasympathomimetic drug). Funken
stein divided all subjects studied into seven groups on the
basis of their response to these two drugs. Gellhorn (26)
noted that these seven groups could be reclassified into
three major groups on the basis of their reaction to mecholyl,
23
the first (the "sympathetic hyperreactors") showing the over-
compensatory rise, the second showing a normal recovery to
base level, the third (the "sympathetic hyporeactors") show
ing little recovery over a twenty-five minute period. The
last group Included the depressive syndromes and was consti
tuted of patients who showed the most favorable response to
electric shock treatment. On the basis of these findings,
as well as extensive neurophysiologlcal studies on animals,
Gellhorn formulated a theory of hypothalamic control of over-
and underreactivity of the sympathetic nervous system.
Clemens (7) used a similar approach to that of Funken-
stein in studying differences between patients with fast-
and slow-growing cancer. He demonstrated what appeared to be
sympathetic overactivity for the fast-growing cancer group,
in that they evidenced a marked response to epinephrine and
an overcompensatory response to mecholyl.
Wishner (66) measured resting level and response to a
cold-pressor test of ten normals and eleven psychoneurotics
on systolic blood pressure, heart rate, respiration rate,
and skin resistance. The neurotic group showed a signifi
cantly faster heart rate than the control group after stimu
lation. They also showed a tendency toward faster respira
tion rate. The normal group showed a consistently--though
statistically nonsignificant--higher skin resistance through-
i
i
out the time sampled.
White and Glldea (64) also used the cold-pressor test
24
in a study of anxiety and heart rate. Their subjects were
small groups of psychiatric patients. In comparing a non
psycho tic anxious sample of eleven patients and fourteen
volunteer controls from hospital personnel, they too found
that the anxious group had a faster heart rate during rest
and that cold pressor stimulations caused a greater incre
ment in heart rate in the anxious than in the control sub
jects. The groups did not differ significantly on measures
of blood pressure.
Most of the reactivity studies cited so far have con
fined themselves to the measurement of responses to physical
stimulation, either in the form of adrenergic and choliner
gic drugs or in the form of strong sensory stimulation.
Many of the studies proceed to draw inferences about "the
nature of anxiety" on the basis of this response to a physi
ological stress. Numerous other studies suggest that the
type of autonomic response patterning is a function of the
nature of the stimulus.
Funkenstein, ejb al. (24) reported a study in which
normal subjects demonstrated a clear-cut difference between
cardiovascular functions In expressions of anger directed
outward as contrasted with expressions of anger directed in
ward or anxiety responses. He found that systolic blood
pressure Increase and heart rate increment were significant
ly smaller in anger-out than in anxiety responses, while di
astolic blood pressure showed a greater rise In the anxiety
reaction. Funkenstein, et al., equated the angry response
with a predominantly noreplnephrlne-like reaction, the anx
ious response with an epinephrine-like reaction pattern.
(Both epinephrine and norepinephrine are sympathomimetic
hormones produced in the adrenal medulla. Norepinephrine
has been shown to be present in larger proportions in the
blood of predatory animals than in domestic animals (30).
Goldenberg, ejb ajl. (28) have reported that the injection of
epinephrine results in increased blood pressure and in
creased heart rate--as well as increased stroke volume and
decreased peripheral resistance, while the injection of
norepinephrine results in an increased blood pressure, but a
drop in pulse rate--and a drop in stroke volume and in
creased peripheral resistance.)
Ax (2) described different physiological patterns for
the emotions of fear and anger. He found that the magnitude
of diastolic blood pressure rises and of heart rate falls,
as well as the number of drops in skin resistance and of
muscle potential increases were greater for anger than fear.
In contrast, the magnitude of skin conductance Increases, as
well a§ the number of muscle potential peaks and respiration
rate increases were greater for fear than for anger. He too
suggested that these differences were due to epinephrine and
norepinephrine activity, and went on to show that the re
sponse of five Individuals to norepinephrine Injection was
similar to his anger pattern, while the same individuals'
2 6
response to epinephrine resembled his fear-pattern.
Elmadjian and Hope (12) reported extensive studies on
normal and psychotic subjects and attempted to relate the
urinary excretion of epinephrine and norepinephrine to types
of behavior under stress. The results Indicate that in gen
eral, the aggressive-hostile-active emotional display is re
lated to norepinephrine excretion, while the self-effacing-
fearful passive display is related to epinephrine excretion.
These are apparently the first extensive data on epinephrine-
noreplnephrine excretion in the human subject, and suggest
that such a biochemical assay technique may prove useful in
differentiating emotional responses.
Schachter (54) compared various cardiovascular func
tions of 18 hypertensive individuals and 30 normal persons
under conditions of fear-lnduction and anger-induction. He
noted that, of his 48 subjects, 35 had a predominantly epine
phrine-like response during acute fear; during pain (the
cold-pressor test), 31 of the subjects had a predominantly
norepinephrine-like reaction; in his anger-evoking situation,
19 showed a norepinephrine-like effect, 22 showed an epine
phrine-like effect, and 7 had mixed effects. Schachter
showed evidence which Indicates that the relative predomi
nance of epinephrine-like vs. norepinephrine-like response
to anger may be a function of the Intensity of the reaction
evoked in the subject, the epinephrine-like response appar
ently being elicited at either high or low levels of
27
intensity, the norepinephrine-like response at a moderate or
intermediate level.
Schachter1s finding that the physiological response
to the cold pressor test differs significantly from the re
sponse to his fear stimulus suggests that the rather sweep-
l
ing conclusions made by researchers who utilize the cold
pressor test as a representative sympathetic stimulus are
probably not Justified. However, the current literature ar
gues the matter both ways. Alexander (l) states that "every
emotional state has its own physiological syndrome," and his
specificity theory of psychosomatic disorder is based on
this position. The researches of Punkenstein, Ax, and
Schachter just cited lend support to his hypothesis, at
least insofar as they see Cannon's (5) "fight-flight" syn
drome as consisting of two distinct types of behavior pat
terns, a "fight" syndrome and a "flight" syndrome. So do
the observations of Wolff and Wolf, who studied variations
of the mucous membrane of a subject with a gastric fistula
in a variety of life situations (67, see below).
Another theoretical position, taken by Lacey and co
workers, is based on their observations (39* ^0, 4l) that,
regardless of the nature of the stress, Individuals exhibit
a characteristic and reliable pattern of response. Lacey,
et al., noted marked and consistent individual differences
in the hierarchy of activation of the various physiological
functions (blood pressure, heart rate, heart rate variability,
28
and palmar conductance) of each individual, in stress situ
ations of mental arithmetic, hyperventilation, difficult
word association, and cold pressor, when the various meas
ures were converted into equal units (T-scores). They form
ulated a "principle of relative response specificity": For
a given set of autonomic functions, individuals tend to re
spond with a pattern of autonomic activity in which maximal
activation will be shown by the same physiological function,
whatever the stress. Thus, an Individual may be overreactive
in one function, as compared with group norms, while he may :
be average or underactive in other functions. While the re
liability of autonomic responses has also been demonstrated
elsewhere (6l, 62), Lacey's experimental approach is subject
to criticism in the lack of emotional variety inherent in
the types of stimuli used in his studies. Nowhere is there
a stimulus specifically designed to elicit angry feelings,
or emotional conflict, or even fear. In view of the above-
mentioned findings of Schachter, Funkensteln, and Ax, it is
possible that as a wider range of stimuli is explored,
Lacey's concludions may not hold. His conclusions must
therefore be considered tentative, for the present.
In surveying the literature dealing with the somatic
response to stress, Wolff (68) concludes that somatic dys
functions appear to obey what he terms a "principle of parsi
mony" (or economy):
Hyperfunction of the stomach and duodenum may be as
sociated with average function in adjacent portions of
29
the gastrointestinal tract. During the hyperdynamic
circulatory reaction to stress, heart rate, peripheral
vasomotor function and stroke volume may augment togeth
er, or one or more may increase independently of the
others. . . . These specific and highly localized re
sponses indicate a parsimony in reaction to threat.
While stress reactions may find expression through a
part or segment of a functional somatic system, Wolff also
recognized that different emotional stimuli evoke a variety
of reactions within that organ system. In the Intensive
seven-month long observation of Tom, the patient with a gas
tric fistula, Wolf and Wolff (67) observed that in periods
of fear, Tom's gastric activity was sharply decreased, while
in periods of anxiety he manifested accelerated gastric ac
tivity, i.e., hyperemia of the mucous membrane, hypermotlli-
ty, and hypersecretion of acid. In experiences of hostility
and resentment, as well as periods of happy moods, Tom like
wise exhibited Increased stomach activity. While Tom did
not have a peptic ulcer, the authors hold that his gastric
hyperactivity during conflict situations ("being a man" vs.
"wanting to be cared for") expressed the essential receptive
needs seen in ulcer patients, as well as a form of anger to
ward those who deny the patient the comfort he desires.
While such a longitudinal observational approach has many ad
vantages over a short-period laboratory study, the criteria
of affective states in this particular study were not well
defined.
Mittleman, Wolff, and Scharf (48) conducted an experi
mental study, utilizing the stress interview, of gastric
30
activity (amount of secretion and motility) on 33 patients
with gastritis, duodenitis and peptic ulcer, and 13 normal
control subjects, and report:
. . . In all the patients with peptic lesions it was
possible to demonstrate a chronological parallelism be
tween the onset, recrudescence, and course of gastroduo
denal symptoms, and the occurrence of untoward emotional
reactions. . . . To demonstrate that the above described
emotional states (anxiety, etc.) were relevant to the
gastroduodenal dysfunction and peptic ulcers in the par
ticular patients studied, sutiatlons were experimentally
created which induced destructive emotional reactions
and precipitated symptoms when the patient was free of
symptoms. Moreover, if such affects, symptoms, and tis
sue defects already existed, all increased in intensity
during such experimental procedures. On the other hand,
in situations which engendered feelings of emotional se
curity and assurance, gastric function was restored to
ward normal and symptoms eliminated. (48:58)
They found that the difference between the normal and patho
logical sample was one of degree only.
Mahl and Karpe (44) tapped the stomachs of patients
during psychoanalytic hours and used consensus judgments re
garding the affect expressed by the patients. They found a
direct relationship between gross anxiety and quantity of
hydrochloric acid. The amount of acid secreted was not dif
ferentially related to whether the anxiety was associated
with sex or aggressive rather than oral-dependent material.
In regard to the question of "organ choice" in psycho
somatic conditions, Mittleman, Wolff and Scharf found that
their control subjects demonstrated alterations of gastric
functions in association with stress, just as their ulcer
subjects did, but the amount of modification or lability was
less great in the controls. Schachter's (5^) groups of
31
hypertensives showed significantly greater rises in blood
pressure, as well as significantly greater variability of
blood pressure, during pain, fear, and anger than his group
of normotensives. Malmo and Shagass (45) utilized a painful
heat-stimulus, a rapid discrimination task, and a mirror
drawing task as stress stimuli on psychiatric patients, and
also demonstrated that "cardiovascular lability" is more
characteristic of hypertensives than of other psychoneurot
ics, while variability of striate muscle tension--neck mus
cles, in particular— is more characteristic of persons with
chronic headache than of others.
Freeman and his co-workers conducted a series of
studies directed primarily at exploring the conditions for
recovery from stress. In one such study, Freeman and Pathman
(l6) subjected normal undergraduate students to four stress
ful situations: a startle stimulus, a motor conflict, a
verbal conflict, and a sensory discrimination task. They
measured overt skeletal-muscular movement and galvanic skin
conductance during and after stress, and found that the best
recovery (defined as return of the measures toward pre-stress
level) occurred when excitation was discharged through overt
muscular action, even when this action was non-adaptive. Re
covery tended to be less complete under conditions of "ldeo-
motor or verbal" responses.
Haggard (36), using the GSR as the dependent variable,
studied conditioning and extinction of responses to electric
32
stimulation. Finger movements and comments were also re
corded. The electric shock was administered under two con
ditions, the first being experimenter-induced, the second
self-administered by the subject. Subjects were then studied
for thirty minutes under three conditions analogous to vari
ous forms of therapeutic management: experimental extinc
tion (first session repeated, without shock); catharsis
("discuss feelings, ask questions"); and rest therapy ("relax,
forget about what happened"). Haggard found catharsis the
most effective of the three conditions, rest therapy the
least effective, and recovery from self-induced shock more
complete than experimenter-induced shock. However, his sub
jects were informed that they were to get no more shocks in
the catharsis condition--a factor which may have prejudiced
Haggard's results. He also found that those subjects who
recognized that shock always followed a specific word in the
word association list showed consistently less upset on the
GSR measure and did better in all three recovery-condltions
than the other subjects. Haggard Inferred from this varia
bility in recovery under varying conditions that "cognitive
structure is crucial in the dissipation of anxiety."
In another study, Haggard and Freeman (35) found that,
of children placed in a variety of problem task situations,
those who focus their activity on a relevant problem-task
tended to regain physiological equilibrium more quickly than
those who indulged in non-adaptlve movements. Children who
33
were inclined to inhibit overt skeletal and verbal expres
sions showed the least amount of recovery. The authors
speculate that these latter may be the future neurotics and
"somatizers."
On the basis of factorial studies, Freeman (18) sees
three independent factors related to psychophysiological
homeostasis: "drive arousal," "discharge control," and "dis
criminative capacity." He found that recovery from stimulus-
induced effects is sluggish at high levels of energy mobili
zation, i.e., the more tense a person is, the more sluggish
will be his return to pre-stress level on reactivity meas
ures. Persons with excessive control and inhibition of motor
and verbal responses also tend toward slow recovery. The
term "discriminative capacity" relates to his finding that
persons who discharge excitation through a response leading
toward specific adaptation (or overcoming of the stress) re
cover more completely than persons who respond to stress in a
non-specific or diffuse manner. For example, in the above
cited study with children (35)> the children who had suffi
cient discriminative capacity to concentrate on the problem-
task recovered more quickly than children who made no such
specifically adaptive responses. Finally, Freeman makes the
point that residues from emotionally arousing situations are
likely to affect the stability of physiological functions be
fore they cause fundamental changes in the activity level of
any one autonomic pathway.
34
On the basis of the above-mentioned factors, Freeman
characterizes individual differences in terms of "low arousal
capacity--low inhibitory control," "high arousal--high con
trol," etc. He describes a "somatization type" as having
"median or low arousal capacity" and "excessive inhibitory
control of skeletal activity," while persons with overt anx
iety tend toward "average to high arousal capacity" and "low
skeletal control." While stated as inferences, these formu
lations actually constitute testable hypotheses.
The above-mentioned work of Parker (51), Williams
(65), Malmo (45), and others supports the last-mentioned
hypothesis. The inferences concerning psychosomatic patients
are so far chiefly supported by relatively uncontrolled clin
ical observations. The work of Freeman, Haggard, and associ
ates is subject to criticism primarily on the basis of the
limited number of physiological variables studied, and the
fact that so many of the conclusions are based on measures
of GSR and skeletal muscle activity; these measures have not
been shown to correlate highly with general autonomic reac
tivity. If the theory of "relative response specificity" is
at all applicable, a larger variety of organ systems needs
to be measured simultaneously. However, the hypotheses con
cerning the conditions for recovery would appear to be suf
ficiently challenging to warrant further exploration among
various patient-populations, since they relate to the appli
cability of therapy. The present study is therefore an
35
extension of the work of Freeman and Haggard.
The literature cited above on the whole tends toward
the position that a) different affective states are accom
panied by different physiological as well as psychological
responses; b) in different psychosomatic illnesses, re
sponses to stress are expressed via a circumscribed, specif
ic portion of the body; and c) that recovery from stress is
a function of personality traits as well as of the type of
activity utilized during the recovery period.
CHAPTER III
SUBJECTS, TEST BATTERY, AND PROCEDURE
The Subjects and Their Selection
Three groups of subjects were selected from a popula
tion of hospitalized male veterans between the ages of 20
and 45 years who volunteered to participate in a psychologi
cal study. The groups were labeled The Anxiety Group, The
Ulcer Group, and The Hospital-Normal Group.
The Anxiety Group. This group consisted of patients
characterized by clinically manifest, free-floating anxiety
as diagnosed independently by either a) two psychiatrists,
b) a psychiatrist and a third year psychologist trainee, or
c) a third year psychologist trainee and a psychologist
staff member. Subjects were included in the study only when
both authorities agreed. Anxiety group subjects were chosen
from among veterans admitted to the hospital for the treat
ment of an emotional disturbance, in whom anxiety was the
major or most prominent symptom. Included were patients
previously diagnosed by the chief psychiatrist of the instal
lation as Anxiety Neurotics, Agitated Depressives, Border
line States, or Early Acute Schizophrenics. Excluded from
this group were individuals with a history of cardiovascular
disease, peptic ulcer, asthma, mucous and ulcerative colitis
neurodermatitis and organic brain disease, and Individuals
who at the time of the study manifested a specific disease
entity. The justification for including early schizophrenic
37
came from other Investigations (34, 46, 65) which have con
sistently failed to demonstrate any differences between
groups of anxiety neurotics and early schizophrenics. All
patients were in sufficiently good reality contact to be able
to appear voluntarily at the experimental station at a time
previously agreed on. The mean age of the subjects was 35*4
years.
The Ulcer Group. This group was selected from pa
tients who were hospitalized on the basis of a medical diag
nosis of peptic ulcer, confirmed by at least one positive
picture in a current series of X-rays. The mean age of the
subjects was 35*8 years.
The Hospital-Normal Group. Subjects for this group
were selected from patients hospitalized for minor surgery,
fractures, and tuberculosis. Subjects considered to be
''neurotic" or "psychotic" by the ward physicians were ex
cluded from the study. Twelve of this group were to be oper
ated on for hernia condition, four were to have a hemorrhoid
ectomy, two were hospitalized for leg fractures but were am
bulatory and ready for discharge at the time of the study,
and twelve were men hospitalized for tuberculosis who were
classified as Class IV (inactive TB, patient due to be dis
charged). For descriptive convenience, this group will sub
sequently be referred to as the "normal" group, to avoid
confusion with experimental control subjects of the study.
38
Mean age of the group: 30.0 years.
All of the subjects used were hospitalized at the
Veterans Administration General Medical and Surgical Hospital
in Long Beach, California, except for eight subjects in the
Anxiety sample. These were hospitalized at the Sawtelle VA
NP Hospital in Los Angeles. All subjects were ambulatory at
the time of the study. No subject had received sedative
medication for twenty-four hours prior to the experimental
situation. The test data were gathered between the months
of June and November 195^- At least 30 subjects were to
comprise each of the three groups here described. The final
count was: 32 Anxious subjects, 3^ Ulcer subjects, and 30
Normal subjects. The sample constituted 96 subjects.
The Test Battery
The procedure of the study entailed the physiological
measurement of autonomic activity for each subject as well
as a phenomenological measure of the degree of stress felt
by the subject and the kind of stress anticipated by him.
Physiological measures were obtained a) during an initial
resting state, b) during a one-minute stress period, and c)
during a 15“mlnute recovery period. The specific test vari
ables and procedures were as follows:
Systolic Blood Pressure. Blood pressure was recorded
with a sphygmomanometer which had an extension hose attached
to enable the experimenter to obtain readings behind a
39
screen. The blood pressure cuff, placed upon the right up
per arm of the subject, was Inflated and deflated and the
sounds were picked up with a stethoscope whose diaphragm was
attached Inside the elbow. Measurements were read to the
nearest mm of mercury. Readings were Initiated after the
instruments had been attached and the subject had been In a
state of rest for at least five minutes. The second reading
was taken three minutes later, the third one and one-half
minutes later. The third reading constituted the baseline.
One reading during stress followed. Two readings at one and
one-half minute Intervals followed. Thereafter, readings
were taken every three minutes, for a total of 15 minutes,
post-stress.
Heart Period. The time for ten complete heart cycles,
in seconds, was determined concomitantly with each blood
pressure reading.
Diastolic Blood Pressure. This was read to the near
est mm of mercury corresponding to the cessation of the audi
ble heart-beat. Readings were taken concurrently with sys
tolic blood pressure readings.
Palmar Skin Resistance. A pair of plastic cup elec
trodes, filled with agar-agar jelly over a pad saturated
with one per cent zinc sulfate solution, was fastened to the
palm and corsal surface of the hand with a rubber strap.
Measurements were taken discretely at intervals specified
40
above, concomitantly with the other physiological measures.
Readings represented the voltage required to impress forty
microamperes through the subject. Voltages were converted
to conductance units.
Findings of diastolic blood pressure and palmar skin
resistance measures are not analyzed in this report. All
physiological measures used in this study are considered by
Wenger (62) and others to be Influenced by autonomic activi
ty, usually through direct innervation of the organ system
by sympathetic and parasympathetic nervous system fibers.
When the sympathetic nervous system activity appears to be
dominant, systolic and diastolic blood pressure are high,
heart rate is fast, and palmar conductance high. When there
Is apparent parasympathetic dominance, these values are re
versed .
The Self Rating Scale. This scale, adapted from
Eichler (11), was presented to the subject immediately after
the post-stimulus readings had been taken. Eichler has dem
onstrated the test to be sensitive to increments in felt
anxiety or tension, and Basowltz, et al. (3) have demon
strated very high agreement between this scale and the judg
ments of experts with paratrooper trainees. The subject was
handed a pencil and the rating scale (see Appendix), at
tached to a board, with the following instructions:
We want to find out if the experiment has so far pro
duced certain feelings in you that may influence the re
sults we are getting. Here is an anxiety or tension
41
scale. Would you place a slash through the line to show
in general how tense you just felt. You can put the
slash at any point that you think describes your feel
ing. It need not be directly on a number.--Would you
also put another slash through the scale to show how
tense you felt before you came here today.
A Four-Item Check-Llst. printed on the reverse side
of the rating scale, was presented to the subject when he
had finished with the rating scale. The check-list required
the subject to mark off one of four choices pertaining to
the kind of stimulus he anticipated. The items were:
"strong electric shock," "mild electric shock," "nothing at
all," and "other: write in."
Procedure
Subjects were initially contacted individually on the
ward and requested to volunteer on "an experiment to study
how people relax." As subjects volunteered, they were al
ternately assigned to the experimental group or the control
group of the study. The experimental group was subjected to
the post-stress "catharsis" condition, while the control
group simply rested (see below).
At the time of his appointment, the subject was ad
mitted into the experimental room which was divided by a
large screen in such a manner that the subject was unable to
see the instruments used for the study. He was seated in an
easy-chair in Bemi-prone position. He was told: "This is
an experiment on relaxation. All we want you to do is to
try hard to relax for thirty minutes." The cup electrodes
and the sphygmomanometer cuff and stethoscope diaphragm were
then attached by the experimenter. After this, the experi
menter took his place behind the screen so that the subject
could no longer see him. Questions were answered noncommit
tally. The subject's base level on the autonomic measures
was then established by having him relax for eleven minutes
more after the measures were begun. Systolic and diastolic
blood pressure, pulse rate, and GSR resistance level were
then recorded at the intervals described above. After
eleven minutes, the examiner said to the subject:
You're not afraid of things, are you? As part of
this experiment, something pretty unpleasant will happen
to some patients in the next thirty seconds. For others,
nothing will happen. The experiment does not permit me
to tell you whether you are one of the patients.
A tape recording of a loud, unpleasant, unrecogniza
ble series of noises was run for 30 seconds, then abruptly
turned off. Measures were taken as soon as the sound was
started, and this constituted the stress reading. One min
ute after the cessation of the stimulus, directly after the
first post-stress reading, the subject was given the anxiety
rating scale with the above-cited instructions. The control
group was told nothing more. If there were any questions on
the part of the subject, he was told that the experimenter
would answer his questions later and that he would be told
when he was finished. For the experimental group. the screen
was drawn aside to make the examiner visible, and the subject
was asked: "I wondered if there was anything you wanted to
43
ask me or discuss with me. We could ask about how you just
felt and what you thought might happen to you." The experi
menter answered questions openly and tried to elicit an ex
pression of feelings in the patient. Most of the subjects
talked for five to ten minutes, though some used the entire
fifteen-minute period to talk about diverse matters. At the
end of the measuring period, all subjects were disengaged
from the apparatus and asked to keep the nature of the study
confidential "in order not to spoil our results."
CHAPTER IV
RESULTS
Comparison Between Anxiety. Ulcer, and Normal Groups (Rest
ing Data)
Previous studies of autonomic balance during rest
have found what appeared to be a dominance of sympathetic
activity among hospitalized anxiety neurotics, and a tenden
cy toward parasympathetic dominance among such psychosomatic
groups as ulcer and asthma patients. One would therefore
expect the anxious group used in the study reported to show
a higher initial systolic blood pressure and a faster pulse
than the normal control group, as was reported in other
studies (21, 51> 62, 64). Lower systolic blood pressure and
a slower pulse than the normal group were looked for in the
ulcer group.
Table 1 presents means and standard deviations for
the three diagnostic groups, of systolic blood pressure and
heart period at resting level. The three groups are also
broken down into experimental and control groups on these
measures. The frequency distribution of base level readings
on these measures are given in the Appendix, Figures 5 and 6
Data of autonomic activity are conventionally treated with
parametric statistics, since large samples have satisfied
assumptions regarding normal curve functions (62). The pres
ent data seem to be congruent with such assumptions.
An analysis of variance of the autonomic
45
Table 1
Means and Standard Deviations of Systolic Blood Pressure
and Heart Period at Resting Level
for Normal, Anxiety, and Ulcer Groups
Group
Systolic BP Heart Period
Mean S.D. Mean S.D.
Normal control 112.4
8.3 7-9
1.2
Normal experimental 120.0
9.7 7.1
1.0
NORMAL 116.2 7.8
7.5
1.2
Anxiety control 117.2 12.8 6.8 1.1
Anxiety experimental 123.2 11.8
7.1
1.0
ANXIETY 120.2
12.7
7.0 1.0
Ulcer control
111.7
10.5
7.3
1.1
Ulcer experimental
115-3
8.8 7.6 .6
ULCER
113-5
10.0
7.5 .9
46
(cardiovascular) measures was performed (Table 2). Differ
ences in systolic blood pressure were in the expected direc
tion, the anxiety group having the highest mean reading, the
ulcer group the lowest. The mean of the anxiety group was
also in the expected direction on the heart period measure
(shorter heart period than the control group). The P-ratio
of 2.31 for heart period fails to attain significance at the
5 per cent level of confidence.
The P-ratio of 3*04 for systolic blood pressure so
closely approaches significance at the .05 level of confi
dence that t-ratios appeared justified. The mean of the anx
iety group was significantly higher than that of the ulcer
group. Other differences were not significant. Differences
in systolic blood pressure were therefore in the expected
direction for the three groups, though differences between
the non-anxious and ulcer groups were not significant.
Little (43) and Wenger (62), in their resting data on ulcer
patients, similarly failed to obtain significant differences
between their normal control and their ulcer group on meas
ures of systolic blood pressure and heart rate, though there
was a tendency among the ulcer group in the direction of
lower blood pressure and faster pulse than among the control
group. Interestingly, Little obtained a mean systolic blood
pressure of 113-1 for ulcer patients, Wenger one of 113-5>
which is in striking agreement with the mean of 113-5 ob
tained in this study. (Little's heart period of 8.1 is
47
Table 2
Analysis of Variance of Systolic Blood Pressure and Heart
Period at Resting Level for Normal, Anxious, and Ulcer
Subjects Analyzed 1) in Three Diagnostic Groups and
2) in Six Groups, Each Group Being Divided into
Experimental and Control Group
Variance Table
Measures
& Groups
Source
Sum of
Squares
df
Variance
est.
F
Systolic between 742 2 371.00
BP within 11341
93 121.95
3 Groups total 12083 95
3.04
Systolic between
1573 5
314.60
BP within 10510 90 116.78
6 Groups total 12083
95 2.69*
Heart between 5.07 2 2.54
Period within 102.28
93
1.10
3 Groups total
107.35 95 2.31
Heart between
11.29 5
2.26
Period within 96.06 90 1.07
6 Groups total
107.35 95
2.11
* exceeds significance at the .05 level of confidence.
48
somewhat slower than the 7*5 obtained on the present group
of ulcer patients; however, Wenger also found the mean heart
period of his group to be 7-5*)
A separate analysis of variance was performed for the
six sub-groups at resting level to ascertain whether each
experimental and control sub-group was equated as to base
level on both systolic blood pressure and heart period,
since the reactivity of the control groups was subsequently
to be compared with the reactivity of the experimental (ca
tharsis or "talking out") group. Table 2 also shows the
results of this analysis. On the heart period measure the
six groups do not differ significantly, and can hence be
thought to start near the same base level. Systolic blood
pressure, however, yielded a significant F-test (between .05
and .01 levels). On inspection, the mean resting systolic
blood pressure was higher among the experimental groups than
the control groups, for all three diagnostic groups. A t-
test between all experimental groups combined and all control
groups combined confirmed this impression, yielding a t-ratio
of 2.52, significant between the .02 and .01 levels. The ex
perimental and control groups start out at different base
levels and this constitutes a sampling error.
Autonomic Functioning Under Stress
The operations which follow deal with the reactivity
of the groups. The first operation consisted of obtaining
difference scores for each subject at each point of
49
measurement, by subtracting the subject's base level reading
from his reactivity reading. Six difference scores were
thus obtained for each subject on both systolic blood pres
sure and heart period (at S, S+l 1/2, S+6, S+9, S+12, and
S+15)* All difference scores were next converted into stand
ard scores (T-scores), in order to make subsequent reactivity
scores more meaningful. This operation served the dual pur
pose of correcting for base level and the possible correla
tion of baBe level and reactivity scores--which has been dem
onstrated elsewhere (7)-_and allowing easier intermeasure
comparisons.
The conversion to T-scores was accomplished in the
following manner: Scores for all subjects at each of the
above six points were assigned to one of four groups of ap
proximately equal size, with each group comprising a quartile
of baBe level scores within the total distribution of base
level scores. Thus, if a subject's base level score fell
within the lowest quartile, his reactivity score would be
assigned to group Ij if within the next-lowest quartile, his
reactivity score would be assigned to group II, etc. Next,
for each measuring time and for each quartile (range), a
mean and standard deviation were calculated. The individu
al's raw difference score, minus the mean, divided by the
sigma, yielded his z-score; this was converted to a T-score
by multiplying it by 10 and adding 50. Since a distribution
of z-scores has a standard deviation of unity and a mean of
50
zero, the conversion to T-scores served to make all scores
positive and to give a constant value of 50 to the mean, one
of 10 to the standard deviation.
Conversion from raw difference scores to standard
scores was performed on systolic blood pressure and heart
rate for all difference scores of each individual, since
this investigation focuses on these two autonomic measures.
Since conversion to T-scores was done on the supposition
that a correlation might exist between resting level and re
activity (at least on some measures and for some individu
als), this correlation needed to be demonstrated. Cursory
comparison between resting and reactivity means and sigmas
suggested that the diastolic measure (see Appendix for other
data on this measure) was likely to offer the best demonstra
tion of this. Results yielded a Pearson r of -.385 which is
significant beyond the .01 level for 93 degrees of freedom.
After the difference scores were converted to T-scores, a
second correlation was applied to the same data which failed
to produce a significant expression of correlation. The r
of .0017 demonstrates the effectiveness of the conversion.
Notice should be taken that the first coefficient is in the
anticipated direction, i.e., the higher the resting level,
the smaller the increment tends to be on the diastolic blood
pressure variable.
Turning now to an examination of autonomic functioning
under stress, the initial question to be answered was whether
51
the stimulus had a significant effect on the various groups,
i.e., whether it was a meaningful stimulus. Each subject's
pre-stimulus (resting) score was compared to his stress-
score (S), on both systolic blood pressure and heart period,
and t-ratios for correlated means were obtained (Table 3)-
On the systolic blood pressure measure, an expression
of significance far beyond the .001 level of confidence was
derived for the total sample. Each of the three groups sepa
rately showed very significant increments, clearly demon
strating the meaningfulness of the stimulus. The heart peri
od measure yielded more equivocal results; while the total
group again showed a reaction beyond chance expectation past
the .001 level of confidence, only the normal group showed a
response significant beyond chance (beyond the .01 level of
confidence). The anxious and ulcer group failed to yield a
significant response at the .05 level of confidence. For
the anxious group, this response failure in part confirms
the hypothesis formulated in regard to very anxious individ
uals (Hypothesis No. l). The failure for the ulcer group
will be clarified by the data that follow.
Systolic Blood Pressure. Raw score mean increments
on systolic blood pressure measures were as follows: nor
mals, +8.9 mm Hg; anxious, +7*6 mm Hg; ulcer, +5-8 mm Hg.
These difference scores were converted into standard scores,
in order to test the magnitude of the response, regardless
of base level (the operation was described above). An
52
Table 3
Mean Increments at Point of Stimulation on Measures
of Systolic Blood Pressure and Heart Period
Measure Group
Mean
Diff.
S.E. of
Diff.
N t
Normal
8.9
1.1 30 3.29***
Systolic Anxiety 7.6 1.4 32 6.02***
Blood
Pressure Ulcer 5-8 .8 34 7.44***
TOTAL 7.6 .6 96 11.97***
Normal 3.7
1.2
29 3.15**
Heart Anxiety ro
•
o
1.4 32 1.44
Period
Ulcer
• 5
1.1
33 .49
TOTAL 1.6 .2 94 7.07***
* Significant beyond the .05 level of confidence.
** Significant beyond the .01 level of confidence.
*** Significant beyond the .001 level of confidence.
53
analysis of variance was then applied, to determine whether
significant differences in reactivity among the three diag
nostic groups were present. Differences between the three
groups were not found to be significant within acceptable
limits. Notice should, however, be taken of the sequence of
the three corrected means, the normal group showing the
greatest response, the ulcer group the smallest.
Heart Period. Raw score mean changes in heart period
are presented in Table 3; only the normal group changed sig
nificantly on this measure, in the direction of shorter
heart period. While the anxious and ulcer groups showed no
significant change from base level, it is interesting to
note that the ulcer group not only shows no mean increase in
heart rate at all, but actually a small slowing.
The heart period difference scores were converted to
T-scores, as described above, and an analysis of variance
was performed (Table 4) to test group differences in re
sponse magnitude. The normal group again showed the greatest
response on this measure as it did on systolic blood pres
sure, and the ulcer group the least. The F-test was signifi
cant beyond the .05 level of confidence; t-ratios indicate
that the difference between the normal and ulcer group means
is significant beyond the .01 level of confidence. Differ
ences between the normal and anxious group, and between the
anxious and ulcer group proved not to be significant.
In summary, increments in physiological measures
54
Table 4
Analysis of Variance of Normal, Anxiety, and Ulcer Group
on Measures of Systolic Blood Pressure and Heart Period
at Point of Stress, After Difference Scores
Have Been Converted to T-Scores
Measure Source
Sum of
Squares
df
Variance
Est.
P
SyBtollc between
395-97
2
197.99
Blood
Pressure within 9256.72 93 99.53
total 9652.69 95 1.99
Heart between 617.76 2 308.88
Period
within 8875.28
91 97.53
total 9493.04
93 3.17*
* Significant beyond the .05 level of confidence.
55
following psychological stress are greater in the normal con
trol group than in both the anxious group and the ulcer
group. This finding lends confirmation to Hypotheses No. 1
and No. 2 which state that anxious patients and ulcer pa
tients will fail to show as great a physiological response
to psychological stress as normal persons. Table 12 (see p.
82) summarizes the mean stress scores of the normal, anxious,
and ulcer group on the physiological measures, as well as on
the Self Rating Scale. The scores are expressed in T-scores,
making them comparable in terms of response magnitude. It
may be noted that the group means on all measures show the
normal group to be most reactive, the ulcer group least reac
tive, with the anxiety group falling between the other two.
Recovery From Stress: The Control Groups
Systolic Blood Pressure. The control groups, it may
be recalled, were kept completely inactive during the recov
ery period. In plotting the means of the raw difference
scores (Figure l), inspection Indicates that the recovery
curves are essentially identical on this measure. No tests
of significance were deemed necessary. Hypotheses No. 3 and
No. 4 stated that differences in rate and degree of recovery
from stress (to base level) are to be found between anxious
and normal persons, and between ulcer patients and normal
persons. Neither hypothesis is supported by findings on this
variable. Parker (51) also failed to obtain differences in
reactivity and recovery among anxious and non-anxious college
56
Normal
10
Anxious
Ulcer
mm Hg
— Hr
V
-1
-2
1 1 / 2 6 9
Time, In minutes after stress
12
Figure 1
Means of Raw Difference Scores
For Systolic Blood Pressure
(The Control Groups)
students on the systolic blood pressure variable.
57
Heart Period. Figure 2 represents the means of the
difference scores for the heart period measure. Inspection
suggests that the curves for the ulcer and normal groups
differ. The normal group shows a marked increase in heart
rate at the point of the stress stimulus, and a fairly regu
lar course of recovery to base level thereafter. The ulcer
group shows no response initially, but a gradual rise in
heart rate over the next 9 minutes--during a period of total
Inactivity. To test whether these changes after the point
of stress were significant, t-ratios for correlated means
were applied to the mean difference score, for each group,
between readings at S and S+9' • The reading at S+9' was
chosen because it represents the point of greatest heart
rate Increment for the ulcer group. (No tests of signifi
cance were performed for the anxiety group because inspec
tion showed the difference to be very small.) At S+9'* the
changes for the normal group, in the direction of recovery
to base level, are significant near the .01 level of confi
dence; increase in heart rate scores in the ulcer group
fails to attain significance at the .05 level, though it ex
ceeds the 10 per cent level. The analysis thus lends sup
port to the impression that ulcer subjects respond with grad
ually increasing heart rate over a period of total inactivi
ty. It may be noted, however, that at the end of the 15-
minute post-stress interval, the ulcer patients have again
58
Normal
Anxious
(faster
pulse)
Ulcer
-2
seconds
per 10
heart
cycles
___\
-1
+1
— \ -
(slower
pulse)
1 1/2
Time, in minutes after stress
12
Figure 2
Means of Raw Difference Scores for Heart Period
(The Control Groups)
59
returned to base level or below. (Inasmuch as the above
analysis was based upon the point of maximal Increment for
the ulcer subjects, rather than a randomly selected point,
the expressions of significance should be viewed conserva
tively. )
The above analyses were performed on the raw differ
ence scores rather than the T-scores because the slope of
the recovery curve for the three groups was being considered.
(Because of the nature of the standard score, It can merely
define the groups' relationships to each other in terms of
their deviation from the common mean at any one point on the
recovery curve. Plotting the T-scores thus focuses on these
discrepancies, but fails to give a picture of recovery rela
tive to base level. See Figures 9 to 12, Appendix.)
Recovery From Stress: The Experimental Groups
In discussing the experimental condition, it must
first be asked whether the introduction of the condition (en
couraging the subject to air his feelings) for one-half of
the total sample (i.e., one-half of each diagnostic group)
had any effect on the variables of systolic blood pressure
and heart rate of these groups. This and the following oper
ations will be concerned with only that part of the recovery
curve which follows the introduction of the experimental con
dition, i.e., the readings at S+6, S+9» S+12, and S-M5-
Since a significant difference between experimental and con
trol group resting levels had been demonstrated on the
60
systolic blood pressure measure, the standard scores were
used for this analysis.
A method described by Lindquist (42) for comparing
curve trends was applied to the experimental and control
groups to test for cumulative mean differences among them.
Table 5 contains the significance tests for this and the fol
lowing operations, for systolic blood pressure. The experi
mental and control groups of the total sample showed a trend
difference well beyond the .001 level of confidence. The ex
perimental groups do not recover as rapidly as the control
groups. Talking (or, expressing feelings) apparently keeps
systolic blood pressure from returning to base level, at
least within the circumscribed time interval here measured.
This finding is applicable to each of the three groups
(Table 5), there being an indication that the response of
the experimental ulcer group is particularly greater than
that of the ulcer control group.
Turning to the heart period measure (Table 5)> t-test
of the mean trend differences again shows significant differ
ences between experimental and control subjects. (See Ap
pendix, Figures 11 and 12, for graphs of the T-scores of the
experimental and control sub-groups during the recovery
phase.) Contrary to expectation, however, the control sample
manifests the faster mean heart rate than the experimental
sample, for that part of the recovery curve here being ana
lyzed: S+61 to S+15'. By itself, this finding has little
61
Table 5
Mean Trend Differences Between Experimental and
Control Sub-Groups of Each Diagnostic Group
(Normal, Anxiety, and Ulcer), as well as
Between the Total, Experimental and Control Sample
Groups
Mean
Diff.
S.E. of
Diff.
df t
Ne/Nc 20.04 4.82 28
4.157***
Systolic Ae/Ac
23-94
4.56 30 5.249***
Blood
Pressure Ue/Uc 31.24 4.38 32
7.131***
Te/Tc 25.30 1.49 94 16.980***
Ne/Nc
.47 4.83 28
.097
Heart Ae/Ac 6.62 4.69 30 1.412
Period
Ue/Uc 11.47 4.34 32 2.643*
Te/Tc 6.12 1.49 94 4.105***
*
Significant beyond .05 level of confidence.
**
Significant beyond .01 level of confidence.
■#*#
Significant beyond .001 level of confidence.
6 2
meaning. One must turn to the three groups separately and
compare the curve of the experimental condition with that of
the control condition for each group. Table 5 also shows
that no significant difference is present between Me and Nc
(normal experimental and normal control), nor between Ae and
Ac (anxious experimental and control). There is, however, a
difference between the .02 and .01 level of confidence; this
is in the direction of faster mean pulse for Uc than for Ue.
It should be recalled at this point that earlier the Uc
group was noted to manifest an Increase In heart rate under
the condition of total inactivity, a response opposite to
the gradual slowing down of the Nc heart rate. This In
crease appears to account for the difference between the Uc
and Ue group. The increase did not occur in the Ue group.
To draw some meaningful conclusions about the normal
and pathological groups, one must turn back to the raw dif
ference scores for the three experimental groups, as was
done with the three control groups earlier. This will serve
to focus on the absolute rises and falls of the recovery
curve relative to base level.
Systolic Blood Pressure. Figure 3 represents the re
covery curves for the three experimental groups on systolic
blood pressure. All three groups show an abrupt falling off
of systolic blood pressure immediately after the stimulus.
For these groups the experimental condition was introduced
between the S+ 1 1/2' and the S+61 readings. Both the normal
63
Normal
1C
Anxious
Ulcer
-/— V
-1
Time, In minutes after stress
Figure 3
Means of Raw Difference Scores
for Systolic Blood Pressure
(The Experimental Groups)
64
and the anxious group show a more gradual falling off toward
base level after the 1 1/2 minute reading, i.e., after the
experimental condition has been introduced. In none of the
groups do the measures return entirely to the resting level.
The response of the ulcer group is again unlike that of the
other two. Inspection shows the ulcer group to be character
ized by a second blood pressure rise equal in magnitude to
the first.
It is possible that the experimental condition of
talking was a psychological stress or, at least, that it in
terfered with recovery to base level; it already has been
shown that the three experimental groups maintain a higher
blood pressure level than their controls do over the recov
ery period. A t-test for correlated means was applied to
the difference scores between S+l 1/2' and S+6' for group Ue
in order to ascertain whether the response of the ulcer
group is unique when compared with the normal and anxious
group. The obtained t-ratio is significant between the .02
and .01 level of confidence. Inspection shows similar tests
of the Ne and Ae groups to be unnecessary, both groups show
ing a near-identity of means at these two reading points.
The interpersonal condition appears to have constituted as
great a stress as the initial threat, for the ulcer group.
To round out the picture of the recovery curves for
the three experimental groups, the slope of the curves after
the introduction of "talking" must be examined more closely.
65
First to be noted is that all three groups fail to return to
base level. Since very active talking usually stopped for
most of the subjects after the first five or ten minutes,
the failure to return to base level is subject to specula
tion. The interpersonal situation appears to have inter
fered with recovery to pre-stress level.
Secondly, inspection of the graph shows that the Ue
group, which had shown the least amount of reactivity to the
initial stress, now changes position relative to the other
two groups, sustaining a consistently higher systolic blood
pressure response throughout the experimental period. To
ascertain whether this constitutes a significant finding,
the conversion to T-scores was again employed in order to
compare the groups in relation to one another when scores
are freed from base level. The Lindquist trend-analysis
(Table 6) showed a difference between Ne and Ue, significant
beyond the .05 level. Differences between Ne and Ae, as well
as between Ae and Ue, were not significant, though the lat
ter approaches significance. Thus, when reactivity regard
less of base level is considered, the Ue group demonstrates
a markedly deviant response from that of the normal group
(see Figure 10, Appendix). Ue subjects reacted far less to
the initial stress than the Ne and Ae subjects, but reacted
far more strongly to the experimental (interpersonal) situa
tion than the other two groups, on the systolic blood pres
sure variable.
66
Table 6
Trend Differences Among the Experimental
Normal, Anxiety, and Ulcer Group on
Systolic Blood Pressure and Heart Period
Groups
Mean
Diff.
S.E. of
Diff.
df t
Ne/Ae 3.30
4.95 29
.667
Systolic
Blood Ne/Ue 11.81
5.05 30 2.345*
Pressure
Ae/Ue
8.13 5.02
31
1.620
Ne/Ae 5.80 4.82
29
1.204
Heart
Period Ne/Ue 9-74 4.78 30 2.036/
Ae/Ue 3*94
31
* Significant beyond .05 level of confidence
/ Approaches significance at .05 level of confidence.
67
Heart Period. In order to explore the meaning of the
finding that the ulcer patients responded to the interper
sonal experimental situation in a manner differing from nor
mal and overtly anxious persons, heart period measures were
next plotted (Figure 4). Inspection here suggests a com
plete phase reversal for the ulcer group when compared with
the other two. Whenever the normal and anxious groups
(whose curves are essentially parallel) show a decrease in
heart period in response to a stimulus, the ulcer group
shows an Increase; and where the normal and anxious group
show a falling back to base level, the ulcer group shows a
decrease in heart period. Mean difference scores were de
rived between the measures at S+l 1/2' and S+6', and their
significance subjected to t-tests (for correlated means).
Only the normal group demonstrates a significantly decreased
heart period. The decrease of the anxious group almost at
tains the .10 level of confidence; the increase of the ulcer
group fails to attain even this level.
In order to compare the trends of the recovery curve
of the normal, anxious, and ulcer experimental groups on
heart period, Lindquist's trend analysis was next applied, in
order to ascertain whether cumulative differences among the
three groups could be found. Subjects' T-scores were again
used here; the portion of the curve to be analyzed again con
sisted of the readings taken after the "talking" condition
had been introduced. Results of the trend analysis for the
68
Normal
•— Anxious
Ulcer
(faster
pulse)
-2
seconds
per 10
heart
cycles
(slower
pulse)
+2
1 1/2
Time, in minutes after stress
12
Figure 4
Means of Raw Difference Scores for Heart Period
(The Experimental Groups)
69
heart rate measure may again be found in Table 6. Findings
here parallel those from systolic blood pressure, in that
the only group difference to approach significance was the
difference between Ue and Ne. This very nearly achieves the
5 per cent level of confidence. The impression that the ul
cer group responds with consistently slower pulse rate than
the normal group is sustained by the statistic. No differ
ences of significance were found between the Ae and Ue
groups.
The Verbal Report of Tension
One of the major aims of this study was to attempt to
clarify the relationship between stimulus-produced changes
in physiological functions and conscious awareness of a
change in feeling. That is, the question is raised whether
a physiological response to psychological stress will be ac
companied by a psychological stress report for anxious, ul
cer, and normal subjects. It was hypothesized that the ver
bal reaction would be greater than the physiological reac
tion, for anxious subjects. It was also hypothesized that
ulcer subjects would show evidence of repression either in a
lower verbal than physiological reaction, or in verbal and
physiological reactions which would be lower than those of
normal control subjects. The index of verbal report for
this study is the self rating scale, to be discussed below.
Resting Data. Subjects' scores on the six-point
70
rating scale were read to the nearest quarter of a point,
all scores falling between 0.00 and 6.00. Each subject
placed two scores on the scale, one marlc pertaining to the
amount of tension he felt prior to the stress stimulus, the
other to amount of felt tension after the stimulus.
Before resting level was analyzed for significant
differences among the normal, anxious, and ulcer groups, the
distribution on this variable was examined for goodness of
fit on the normal curve. Inspection of the frequency dis
tribution before stress Indicates a strongly skewed curve
resembling a J-curve (see Table 17, Appendix). The score
1.00 was arbitrarily chosen to dichotomize the total sample,
since approximately one-half of the sample falls between
scores of 0.00 and 1.00, the other half between 1.1 and 6.00.
A contingency table of six cells was applied, the rows being
the dichotomized scores, the columns the three diagnostic
groups. Table 7 details this operation. A chi square of
16.04 was obtained, significant beyond the .001 level of con
fidence for 2 degrees of freedom. Inspection of the ex
pected and obtained frequencies indicates that the normal
and anxious group both show marked deviations from expected
frequencies, while the ulcer group is about evenly split.
Significantly fewer normal subjects have a base level score
before stress of 1.1 or more than have scores of less than
1.0. The anxious group shows the obverse of this, with few
er subjects than expected having a score 1.0 or less, more
71
Table 7
Contingency Table of Frequencies of
Pre-Stimulus Self Rating Scale Scores for the
Normal, Anxiety, and Ulcer Groups
Rating Normal Anxiety Ulcer Total
1.0 or
less
20
(12.5) (ii.8)
16
(15.7)
43
1.1 or
greater
(1^.5)
25
(17-2)
18
(18.3)
50
Total
27
32
34 93
Note: Expected frequencies are in parentheses. The
operation yielded a Chi Square of 16.04, significant beyond
the .001 level of confidence for two degrees of freedom.
72
than expected a score of 1.1 plus. Hypothesis No. 7a thus
finds support in these data: The anxious subjects are either
more conscious of, or readier to admit, their feelings of
tension at the outset. Hence, the groups start out at a dif
ferent base level on this measure also.
Post-Stress Data. The initial question again to be
asked was whether the stress had a significant effect on the
subjects on this measure. A 2 x 2 contingency table (Table
8) was applied to the groups, cell A representing the number
of subjects whose pre- and post-stress scores were both above
1.1; cell B the number of subjects whose pre-stress score
was 1.1 or more and whose post-stress score was 1.0 or less;
cell C the number of subjects whose pre-stress score was 1.0
or less and whose post-stress score was 1.1 or more; and cell
D the number of subjects whose pre- and post-stress scores
were 1.0 or less. This test for correlated proportions (47)
yielded a chi square of 27-46, significant well beyond the
.001 level. A significant shift toward greater anxiety rat
ings occurred after the stress stimulus, for all groups com
bined. The means of the raw-score increments are: normals,
+1.67; anxious, +1.38; ulcer, +1.10 (where the maximal dif
ference score possible would be ±6.00).
Before testing for the significance of these incre
ments in relationship to each other, the distribution of the
post-3tress scores was plotted (see Appendix, Figure 8), to
determine whether parametric or nonparametric statistics were
73
Table 8
Contingency Table of Shifts in Self Rating Scale Scores
After Stress In the Same Individuals
1.1 or
After
more
Stress
1.0 or less
1.1 or
33
12
more A B
Before Stress
1.0 or 46 2
less C D
p
Note: The Chi Square: (A-D) /A+D, for correlated
Bcores (47), was equal to 27*46, significant beyond the .001
level of confidence, for one degree of freedom.
74
applicable. The distribution of the post-stress scores con
forms well to the normal distribution curve, so that the ap
plication of analysis of variance appeared justified. As
with the autonomic reactivity data, subjects' scores were
converted into standard scores to attenuate any possible
correlation between resting level and reactivity, and to
make these data comparable to the autonomic data (see Table
12 for comparison with means of autonomic variables). The
analysis of variance yielded an P of 2.56, significant be
tween the .05 and .10 level of confidence (Table 9)- The t-
ratios elicited only one significant (beyond .05) difference,
that between the ulcer and the normal group: The ulcer pa
tients reported a significantly smaller rise in felt tension
than did the normal group. The differences between the anx
ious group and the two other groups are not significant.
The data therefore do not support part b of Hypothesis No. J:
It has not been demonstrated that anxious subjects report a
greater felt increase In anxiety than the ulcer subjects, in
response to the same psychological stress. Hypothesis No. 6,
which postulates a repression mechanism for ulcer patients,
gains some support from the finding that ulcer patients tend
to show both a lower verbal and physiological response to a
psychological stress than do normal persons. However, scores
on the verbal measure here used need to be correlated with
autonomic reactivity scores to satisfy this hypothesis. An
expression of correlation is also needed to determine to what
75
Table 9
Analysis of Variance of Differences Between
Post-Stimulus Means on the Self Rating Scale
for the Normal, Anxious, and Ulcer Groups
Source Sum of Sauares df Variance Est. F
between
518.79
2 259.40
within 9328.83 92 101.40
total 9847.62 94 2.56/
/ Exceeds .10 level of significance.
76
extent a correspondence exists between verbal and physiologi
cal response magnitudes of anxious and normal subjects.
Table 10 summarizes the results of correlations per
formed for each of the three groups studied, first between
the self rating scale and heart period, next between the self
rating scale and systolic blood pressure, with the autonomic
scores being those at the point of stress (S). None of the
correlation coefficients between rating scale and systolic
blood pressure proved sufficiently large to attain signifi
cance. No linear relationship appeared to exist between
these two measures.
Of the three Pearson r's derived from correlating
heart period and the self rating scale, two appear to be
meaningful: that for the ulcer group is -.40 (well beyond
the 5 per cent fiducial limits); that for the anxious group
is +.34, very close to attaining the .05 level of confidence.
For the normal group, no significant correlation was found.
The striking thing about the findings is that the two signif
icant correlations are in opposite directions. Concerning
the interpretation of the correlations, it must be remembered
that heart period is inversely related to heart rate, that
the faster (greater) the heart rate, the shorter (smaller)
the heart period. Consequently, in the conversion to T-
scores, a low T-score was made to correspond with a great
drop in heart period, a high T-score with a slight drop or an
increment. This was done on an empirical basis, since there
77
Table 10
Coefficients of Correlation Between Post-Stress
Self Rating Scale Scores and Two Autonomic Measures
for the Normal, Anxious, and Ulcer Groups
Measure Group
Pearson
r
.05 Level
of SiKnif.
N
Normal -.200
.367 29
Systolic
Blood Anxious .118
.349 32
Pressure
Ulcer
.177 • 335
34
Normal -.194
.367 29
Heart
Period Anxious • 336/ .349 32
Ulcer -.401* .344
33
TOTAL .118 .203 94
* Significant beyond the .05 level of confidence.
/ Approaches significance at the .05 level of confi
dence.
78
was no way of anticipating the direction in which this meas
ure would go. As it turned out, this operation puts this
measure out of line with the other measures insofar as the
T-scores are concerned. In order to align it, i.e., to as
sign high T-scores to the more reactive patients on this
measure and low T-scores to the less reactive patients, all
scores can be subtracted from 100 (unity). When this is
done with the mean of the ulcer group (on heart period), the
mean is transformed from 53 to 47. Checking back, this val
ue is very similar to the mean ulcer group score on systolic
blood pressure and the self rating scale (see Table 12).
In view of the just-discussed consideration, the fol
lowing interpretation may be placed on the findings: While
the coefficient of correlation is not large, a strong posi
tive relationship does appear to exist for the ulcer group
between verbal report of anxiety increment and the magnitude
of reactivity on the heart period measure. Since the ulcer
group reacted far less than the normal group on both these
variables, the hypothesis that these patients tend to re
press both affective and ideational components of anxiety
gains considerable support.
For the anxious group, a tendency toward an inverse
relationship between these two measures was demonstrated.
That Is, there was some tendency for these patients to report
great distress when the autonomic response was not great,
and to admit to feeling tense less readily when their
79
physiological reaction is higher. It should be kept in mind,
however, that their increment on the verbal report measure
failed to be as great as that of the normal control subjects,
even when the T-score correction for pre-stress level was
applied.
The Anticipated Stimulus and Its Relationship to Diagnostic
Grouping
Since the stress applied was an open-ended threat,
the subjects were free to imagine what might be coming. The
four-item questionnaire given each subject gave him the op
portunity to choose among three stated threats (mild electric
shock, severe electric shock, nothing at all) or allowed him
to write in what he expected. Inspection of the results in
dicated a high frequency of such write-in responses as "did
not know," "anything," "something, but what?" etc., as well
as an assortment of specific stresses. It was therefore de
cided to regroup the categories: the first remained "mild
electric shock," since the Incidence of this response ap
peared most frequently. The next category was thought of as
a diffuse, non-object-oriented response; this included the
statements "did not know" and "anything." The third cate
gory comprised the item "nothing at all"--which seemed to
have a strong element of denial in it not found in other re
sponses. The fourth category was made up of specific named
stresses, other than "mild electric shock," and included the
former "strong electric shock" as well as answers like "loud
8o
noise," "sticking a needle in me," etc. A 3 x 4 contingency
table was then set up, the three experimental groups compris
ing the columns, the conditions the rows. Expected and ob
tained frequencies were entered (Table 11). The resulting
chi square of 18.12 proved significant near the .01 level
for 6 df.
Forty-five per cent of the total sample chose "mild
shock," and distribution of this choice appears to be quite
even among the three groups. The remaining 55 per cent of
the sample distributed itself rather unevenly among the re
maining three conditions. The normal group fell far below
expected frequency on the "did not know--anything" item, far
above expected frequency in the "specific stress" item. For
the ulcer group these two were reversed, i,.e., only one ul
cer patient named a specific stress, while the group response
to "did not know--anything" far exceeded the expected fre
quency. The only thing notable about the anxious group is
their avoidance of the "nothing at all" item. Otherwise they
distribute themselves according to chance expectation. The
interpretation placed on these findings is that normal per
sons seem to show an inclination to attempt mastery of a
stressful situation by binding their feelings to a specific
object or act; they are then Inclined to avoid the state of
"objectless fear" or anxiety. The findings also seem to sug
gest that the ulcer patients differ from the normal subjects
in that the ulcer patients apparently tend to "work in the
81
Table 11
Contingency Table of the Type of Stimulus Expected
by the Normal, Anxious, and Ulcer Group
Type of Stimulus
Expected
Normal Anxious Ulcer Total
Mild Shock 11 16 14 41
(13.1) (14.0)
(15.3)
(45SO
Don't know-- 2
7 13 22
Anything
(6.7) (7.1)
(7-8)
(23$)
Nothing at 2 6
all (4.6) (5.0) (5.4)
(1656)
Other specific
9 v
6 1 16
stress
(4.9) (5.3)
(5.8) (1756)
Note: Statistically expected frequencies are in pa
rentheses. The Chi Square of 18.12 is significant at the
.01 level of confidence, for 6 df.
82
Table 12
Means of Reactivity Scores on Four Measures
Expressed In T-Scores
Measure Normal Anxious Ulcer
Self Rating Scale
52.74 50.77
47.12
Systolic B.P. 52.28
50.67 47.43
Heart Period
1 1
47.00 49.14 53.18
(reflected from 100) (53.00) (50.86) (46.82)
Diastolic B.P.
53.83
48.04
48.19
Note: Heart period means are also reported when re
flected from 100; since a lower score on this measure means
higher reactivity, such a reflection makes it more directly
comparable with the other measures.
83
dark/' i.e., they tend toward an inability to tie their
fears to specific acts or objects. While this finding would
have been anticipated for the anxious group as well, their
sole deviation appeared in a seeming inability to minimize
or deny the threat. The conclusions from this part of the
study should be considered as merely tentative or suggestive,
for two reasons: they are based on responses of a fairly
Bmall number of individuals; and the expected frequencies of
two cells fall below an N of 3 (they are 4.6 and 4.9)> and
thereby fail to meet a basic criterion of the chi square
operation. However, it was felt that the entire procedure
of this part of the study was grossly exploratory--as well
as incidental--and is included here chiefly to shed addition
al light on the remaining findings.
CHAPTER V
DISCUSSION AND CONCLUSIONS
Three groups of hospitalized patlents--one with free-
floating anxiety, a second with peptic ulcer, and a third
with non-psychiatric disorders--were compared with each other
as to resting level, stress level, and recovery from Btress,
on cardiovascular measures of systolic blood pressure and
heart period, as well as to resting and stress level on a
verbal-psychological measure. After the stress stimulus,
each group was divided in two, one-half of each group being
assigned to a control condition of total inactivity, the
other half of each group being assigned to an experimental
condition of catharsis, i.e., they were encouraged to venti
late their feelings concerning what had Just happened to
them. The findings are discussed below.
The Anxiety Group
Under resting conditions, this group manifested higher
systolic blood pressure and a faster pulse rate than the
normal group and the ulcer group during rest. This is con
sistent with Wenger's (62) and Little's (43) normative data.
The systolic blood pressure increased significantly in re
sponse to the stress stimulus. The heart rate showed only a
trend toward increase. Consequently, Hypothesis No. 1 is
not confirmed. The anxious group did not differ significant
ly in magnitude of initial stress response from the other
groups on either systolic blood pressure or heart period.
85
However, on both measures there was a tendency for this
group to be less reactive than the normal group, and some
what more reactive than the ulcer group. These data for the
anxious and non-anxious groups are in essential agreement
with Parker's (51) findings. With total post-stress inac
tivity, the recovery curve of the anxious group was closely
comparable to that of the normal control group on systolic
blood pressure, but showed considerably more variability on
heart period, the variability appearing essentially unre
lated to any external stimulus. The findings therefore fail
to confirm Hypothesis No. 3> which had postulated both great
er variability and slower recovery to pre-stress level for
the anxious than for the normal subjects.
When the experimental condition of catharsis was in
troduced, the anxious group (Ae) did not recover to base
level as rapidly as its own control group (Ac) on systolic
blood pressure. Heart rate was again characterized by marked
variability during the experimental condition, but the anx
ious group responded in a very similar manner to the normal
group for the full length of the recovery curve under this
condition also: Both the anxious and the normal experimental
group showed a significant second rise in heart rate when
talking about their feelings. Because of the great within-
group variance, the anxious group did not differ from either
the normal or the ulcer group on the recovery curve there
after. Hypothesis No. 5 gains support from the finding that
the pattern of the response to catharsis for the anxious
group resembles the pattern of the normal group far more
than it does that of the ulcer group. The marked cardiovas
cular response to catharsis shown by the ulcer group is not
Bhared by the overtly anxious subjects.
On the measure of verbal report the anxious subjects
again started out--as on the autonomic measures--at a higher
base level than either the normal group or the ulcer group.
That is to say, they either felt more tense to begin with
than the other groups, or were readier to admit it, or both.
However, their post-stress verbal report (i.e., the stress-
minus-resting score) was of lesser magnitude than that of
the normals--while greater than that of the ulcer patients.
This result is also directly comparable to reactivity on
both autonomic measures: the increment in stress responses
of the anxiouB patients is consistently less than that of
the normal subjects. This finding contributes toward Hy
pothesis No. 1 that these individuals are already so tense
(or "sympathetically overreactive"), that added stimulation
will yield only small increments in reactivity. Incidental
ly, some of the cold-pressor (51) and drug (21) investiga
tions on similar subjects have differed in this finding.
The difference may be attributable to 1) the meaningfulness
or effectiveness of the stimulus; 2) the selection of the
subjects--criterla for degree of manifest anxiety need much
refinement before a really homogeneous group can be selected
87
and 3) the response modalities measured in the present study.
Another possible explanation might be that anxious
individuals do not respond so much to real as to Imagined
threat and that, while the stress stimulus used in this
Btudy was vague, the events which gave rise to the threat
were the external ones of the experimental situation, rather
than the impulses or motives of the subjects.
Hypothesis No. 7 postulated that manifest anxiety
would be demonstrable in the anxious group in l) higher ini
tial awareness of feeling anxious than the normal control
group, and 2) greater increase of reported anxiety following
stress than ulcer subjects. The first portion of the hypoth
esis wa3 confirmed, the second rejected. A correlation be
tween the verbal measure and heart rate proved significant
and established a tendency toward a negative relationship be
tween physiological and verbal indexes of anxiety. That is,
subjects who showed little increment in heart rate reported
feeling considerably more tense than before, while subjects
Bhowing a greater increment in heart rate tended to give
Bmaller Increments in their verbal report of feeling tense.
One may speculate that the verbal overreaction demonstrates
an excessive sensitization to anxious feelings, and this
would be in line with the above hypothesis as well as with
clinical observation (15) and other experimental evidence
(46). Low verbal reporting with high heart rate increment is
more difficult to explain. An element of denial or conscious
88
suppression may be operative in these subjects, and it is
possible that this is a function of their having been
treated for their disorder (see below). Or it may be that
the presence of denial and suppression is by Itself indica
tive of "inadequate ego defenses" against experiencing anxi
ety.
Regarding the projective check-list, it says little,
quantitatively, about the characteristics of the anxious
subjects except that they seemed more reluctant than the
other two groups to check off the third item: "nothing at
all." Clearly, most of these subjects were prepared for
something. Some of the actual responses written In may,
however, shed a little additional light on the heterogeneity
of their perception of the threat: A subject who gave a
lower stress than pre-stress score on the self rating scale
explained that he was very tense the night before the study
worrying about what would happen in the experimental situa
tion, but felt great relief at the point of stress because
"now it's over." Several subjects expected "insults" or
"prying into my personal affairs," and one subject (who gave
a moderately high response on the scale) said "I thought you
would tell me that I was better." A subject who showed a
low increment on the scale said, "I really feel much better
this week; last week I'd have broken the door down."
This last comment raises a very Important considera
tion, probably germane to a great deal of mental hospital
89
research and research on psychological and physiological
status of psychiatric patients: Most such patients will
have been treated for their emotional disturbance--unless
tested directly on admission. The majority of the subjects
in the present study were in treatment of some sort. There
is good evidence (23, 27) to show that a significant shift
in drug reactivity occurs when emotional disturbances are
treated successfully. In the present study we are thus con
fronted with a sampling error.
The Ulcer Group
The systolic blood pressure of the ulcer subjects was
significantly lower than that of the anxious subjects during
rest. Ulcer subjects also tended to be lower on this meas
ure than the normal group, though not significantly. This
finding agrees with Wenger's (62) and Little's (43) data.
The group's resting heart rate was essentially the same as
that of the normal subjects and slower than that of the anx
ious subjects. The effect on this group of the stress stim
ulus was significant on systolic blood pressure but not on
the heart period measure. The ulcer group tended to be less
reactive on stimulation, i.e., to ’ ’discharge" less than
either the normal or the anxious subjects. On the heart
rate measure, the ulcer subjects essentially failed to re
spond to the stimulus. The reason for the near zero mean
becomes clearer when the distribution of the ulcer scores at
the point of stress (s) is Inspected. More than one-half of
90
the members of this group responded to the stress with a
slowing of heart rate. This phenomenon is repeated, even
more strikingly, after the experimental condition of talking
is introduced, so that this response tendency does not ap
pear to be a spurious one. However, with total post-stimulus
Inactivity, this group next shows a gradual but significant
speeding up of pulse rate for nine minutes, before returning
to pre-stress base level--as contrasted with the normal con
trol group's gradual slowing down of heart rate, back toward
resting level. Thus far, Hypothesis No. 4, stating that ul
cer subjects may recover to base level faster than the nor
mal subjects, needs to be augmented by the observation that
they show more variability during the recovery phase than
normal subjects do.
When the catharsis analogue was introduced, the ulcer
group1s response was again markedly unlike that of the normal
or anxious subjects. The ulcer subjects manifested a second
sharp rise in systolic blood pressure and showed little re
covery toward resting level thereafter--compared with its
own control group, or with the normal and anxious experimen
tal group. Simultaneously, it showed a second phase rever
sal, when compared with the other two experimental groups on
the heart period measure; i.e., it showed a significant slow
ing of the pulse during the experimental condition of "talk
ing it out"--while the other two groups showed a speeding up.
This occurred simultaneously with the marked and continuous
91
elevation in systolic blood pressure. It is also in marked
contrast to the ulcer control subjects' equally atypical
increase in heart rate during inactivity. In effect, the
autonomic patterning of the ulcer group appears to consti
tute a different kind of physiological response pattern than
that of the normal and anxious sample. In regard to Hypoth
esis No. 4, which referred to a slowing of heart rate as an
index of parasympathetic overreactivity, the finding of an
atypical slowing— together with an increase in systolic
blood pressure--lends support to such overactivity, except
that it emerged during the discharge rather than the recov
ery phase.
Goldenberg, et al. (28) have reported that the injec
tion of epinephrine results in increased blood pressure and
increased pulse rate (as well as increased stroke volume and
decreased peripheral resistance), while the injection of
norepinephrine results in increased blood pressure but a drop
in pulse rate (and a drop in stroke volume, and increased
peripheral resistance). Ax (2) found some degree of similar
ity between epinephrine injection and fear response, and be
tween injection of norepinephrine and response to anger.
Funkenstein, et al. (24) similarly demonstrated a clear-cut
difference between cardiovascular reaction to anger and anxi
ety: systolic rise and heart rate increment were consider
ably smaller in anger than in anxiety responses, while dias
tolic blood pressure showed a greater rise under the anxiety
92
condition. Funkenstein, et al., equate the angry response
with a predominant norepinephrine reaction, the anxious re
sponse with an epinephrine reaction. However, so far con
siderable variability is demonstrated in the results of the
various pertinent studies (5*0* Schachter (54) shows evi
dence that the relative predominance of epinephrine-like vs.
norepinephrine-like response to anger may depend on the in
tensity of the reaction evoked in the subject. It appears
that for mild or very severe anger, the response is predomi
nantly epinephrine-like, while a moderately intense range of
anger is associated with a norepinephrine reaction.
While the present study is thus strongly suggestive
of a norepinephrine-like reaction on the part of the ulcer
group, on the basis of the two cardiovascular variables so
far analyzed, this suggestion would be strengthened somewhat
if diastolic blood pressure showed a greater increment for
this group than for the normal control subjects (54). Tables
13# 14, 15# and 16 in the Appendix present the pertinent re
sults of the diastolic blood pressure variable. Group dif
ferences are significantly more pronounced on this measure,
both during rest and reactivity, than on systolic blood pres
sure and heart rate, but the direction of the differences is
parallel to that of the other two measures. However, before
rejecting the concept of norepinephrine-like response, it
needs be remembered that the response to an anger-arousing
situation has failed to prove identical with the actual
93
injection of the drug, in all the studies mentioned. The
administration of the drug consistently produces a drop in
heart rate, while all of the above-cited studies of emotional
state demonstrate a greater or lesser rise in heart rate.
The present study so far is unique in demonstrating a sig
nificant fall in heart rate in response to a psychological
event, and this was demonstrated only in the ulcer group.
There is no record in the literature of observations on car
diovascular reactivity during stress in ulcer patients, but
the data from this study warrant reproduction and validation.
On the measure of verbal response, the ulcer group
again--as on the autonomic measures--started out at a rest
ing level intermediate between that of the normal and the
anxious subjects. And, again as on the physiological meas
ures, this group showed a significantly smaller stress-
increment than the normal subjects did. The ulcer subjects
either did not, or would not, admit to feeling much more
anxious as a result of the stress.
Since the cardiovascular autonomic measures too were
on the order of comparatively little increment, it appears
possible that, as a group, the ulcer patients really failed
to feel very upset. The significant correlation coefficient
between heart rate and self rating allows for postulating a)
a repression hypothesis, or in terms of perceptual processes,
b) a "negative feed-back" hypothesis, as advanced by Calloway
and Thompson (4). These are not mutually exclusive, however.
Why repression rather than simply a higher threshold of re
sponsiveness than normal subjects? Postulating a repression
mechanism is congruent with a vast clinical literature on
psychodynamics based on psychotherapy with ulcer patients
(10, 60) which points to their blocking of ideational and
affective expressions of anxiety and their overreaction to
stress in terms of gastric reaction. The literature tends
to agree that their stress-reactions are not consciously ad
mitted or relieved through psychomotor expression, but chan
neled off via what Alexander (l) calls "body language"; i.e.,
they are repressed and converted into the somatic symptoms
which result in ulcer formation. If this study had measured
gastric secretion and motility, perhaps more marked gastric
reactivity would have been demonstrable in the ulcer pa
tients than in patients with free-floating anxiety, or normal
control subjects. The study by Mlttleman, et aT. (48) dem
onstrated such greatly Increased gastric motility and secre
tion during stress for ulcer patients as compared with normal
control subjects.
Psychoanalytic theory postulates that repression pro
duces derivative responses which, when seen as symptoms, at
test to the fact that repression has occurred (15)* It may
be that the atypical rise in heart rate found in the ulcer
group of this study, under the condition of total inactivity,
is in the nature of such a derivative response. It certainly
constitutes a manifestation of sympathetic autonomic
95
reactivity in response to no obvious external stimulus.
Calloway and Thompson's (4) demonstration of negative
feed-back consisted of an experimental situation in which a
strong sympathetic autonomic response was first elicited in
normal subjects by applying a cold-pressor stimulus and amyl
nitrate inhalations, and then estimates of the size of a dis
tant object were obtained and compared with pre-stress esti
mates. A consistent decrease in the apparent size of the
distant object after stimulation was found to obtain. They
concluded:
We propose that we are observing the operation of a
negative feedback loop between autonomic discharge and
perception. Thus, when behavior cannot immediately re
duce an approaching threat, this system would act to pre
vent panic by reducing to some degree the magnitude of
the perceived threat.
Perhaps such a system of "decreased exteroceptive input" ac
counts for the diminished responses of both the ulcer and
anxious group in the present study.
The "projective" check-list again distinguishes the
ulcer subjects from the normal control subjects, in that ul
cer patients seemed somewhat less inclined to tie their an
ticipatory response to a concrete stimulus, but rather tended
to "work in the dark," ready for "anything." The vagueness
in their responses brings to mind some of the definitions of
anxiety discussed at the outset of this paper.
The Hospital Normal Group
Concerning the normative subjects used in this study--
referred to, rather hopefully, as the "normal group"--they
consistently manifested the greatest amount of reactivity on
all variables studied. This was somewhat contrary to "com
mon sense" expectation, but can be better understood in the
framework of the preceding discussion. The group responded
strongly to threat and recovered in a smooth, fairly regular
curve, back to its pre-stress base level, on the measures
studied. Concerning their awareness and admission of feel
ing anxious, these subjects started out at a low level, as
expected, but admitted to a greater increment in anxiety
than the clinical subjects. However, no significant correla
tion between the autonomic measures and the self ratings was
found, and this detracts from the argument that normal per
sons who feel threatened all freely admit to such a feeling.
The normative group showed a second, smaller peak re
sponse and accompanying failure of systolic blood pressure
level to return to base level, when the catharsis-like con
dition was introduced in the recovery period. This response
was similar to that of the anxious group. It appears that
the talking Interfered with recovery to base level, and con
stituted a second stimulus for all three groups studied.
Perhaps nothing can be said about this pattern except that
it was a function of physical activity associated with talk
ing. The pattern may or may not be related to the expres
sion of emotion.
In regard to the type of stimulus expected by this
97
normative group, the questionnaire elicited one finding that
was unique: More frequently than expected by chance, these
subjects named specific anticipated stresses. Since this
observation is based on the response of only one fourth of
the total normative sample, inferences from it must be con
servative. But the finding may suggest a trend for non
neurotic individuals, as contrasted with neurotics, to try
to affix stress responses to a specific stress, to attempt
to master a stressful situation by "binding1 1 their feelings
to a specific object or act; i.e., they look to reality for
explanations of their anxiety.
More than the other two groups studied, the selection
of persons for the normative group suffered from biased sam
pling. First, being hospitalized veterans, they are not a
random sample from the general population; the pre-operative
factor may have introduced bias; the long-term hospitaliza
tion of the ex-tubercular patients, the possible vascular
disorder of hemorrhoids, the circumstances involving fracture
--all are perhaps in some degree contributory toward bias,
away from the "normal."
In regard to the present study, the design and the
number of variables were not actually equipped to answer con
clusively most of the questions raised. The design suffered
from too great intervals between measurements, from not hav
ing a continuous recording of any variable, from not differ
entiating between anticipatory and stress response, as well
98
as not providing for an independent reliability check (the
experiment, in its present form, cannot be done twice on a
subject). Having a more intense stress-stimulus, as well as
a variety of stimuli aimed at eliciting a variety of affects,
might also differentiate groups more effectively. Stimuli
of varying intensities might elicit totally different re
sponses in the same groups.
The fact that only cardiovascular autonomic variables
were here reported also limits our Inferences about behavior.
For example, a recording of muscle potentials and of gastric
activity might have differentiated between the groups more
drastically; differences in galvanic skin responses between
the groups also need to be explored.
One of the major shortcomings in using blood pressure
as an Indicator of autonomic reactivity is the fact that, as
Kuntz points out,
. . . a rise in blood pressure frequently indicates
Increased sympathetic activity, but an equal rise may
actually be due to a decrease in parasympathetic tonus.
A fall in blood pressure, likewise, may be due to inhibi
tion of sympathetic tonus. The prevailing lack of cor
respondence between changes in blood pressure and
changes in valid sympathetic indicators such as the nic
titating membrane has been emphasized by the results of
various studies. (38:443)
While Clemens (8) has demonstrated a reliable rela
tionship between systolic blood pressure and total sympathet
ic autonomic activity, it cannot be said whether a given
rise in blood pressure was due to adrenergic vasoconstric
tion or cholinergic increase in blood volume, without the
99
benefit of other autonomic indicators, such as stroke volume,
peripheral resistance, skin temperature, etc. The systolic
blood pressure measure, as it now stands, merely highlights
the fact that there appear to be differences on this variable
when two groups are compared which are commonly considered
to be characterized by autonomic imbalance. While drug reac
tivity studies have consistently observed a rise in systolic
blood pressure in response to adrenalin injection and a drop
with mecholyl injection (8, 21), no valid inference can be
made from this to psychological stress.
Another approach which would highlight sympathetic
reactivity might be to block cholinergic mechanisms by ad
ministering atropine and following this with an experimental
ly Induced stress situation such as the one in the present
study.
There remain, in the present study, some unanalyzed
data which will be explored in the near future. An addition
al plan is to return to each patient's clinical folder and
attempt to relate such things as therapeutic management and
response to therapy to the present findings. For example,
one might ask whether ulcer patients who responded to stress
with a drop in heart rate had a longer history of ulcer than
those who responded with heart rate acceleration; or, whether
they responded less well to therapeutic management; or,
whether they were more inclined to block ideational aspects
of anxiety.
100
Despite the above-cited shortcomings of the present
study, It was nonetheless possible to make some meaningful
statements about the stress behavior of anxious and ulcer
patients as well as to formulate some meaningful questions.
The cross-level (physiological and verbal) approach appears
fruitful for future research. A similar study applied to
other psychosomatic disease entities might help to shed
light on differences in reactivity among them and to clarify
the nature of "symptom-choice." Related studies in the in
duction of various emotional states, in a variety of clinical
groups and behavior manifestations, would add immeasurably
to our present incomplete knowledge of emotion and emotional
disturbance.
CHAPTER VI
SUMMARY
Manifest, free-floating anxiety has been associated
in the literature with chronically heightened sympathetic
autonomic activity. Peptic ulcer has been regarded as a
psychosomatic disorder associated with chronically height
ened parasympathetic autonomic activity. The present study
directed Itself to the question whether patients hospital
ized for these two conditions react to stress in a manner
different from normal persons. In order to investigate such
possible differences in the response to stress, 32 subjects
hospitalized for emotional disorders with prominent anxiety
symptoms, and 3^ subjects hospitalized for peptic ulcer were
compared with 30 subjects hospitalized for non-psychiatric
disorders.
The subjects were subjected to a psychological stress
and were compared on two measures of cardiovascular autonom
ic activity (heart period and systolic blood pressure), and
two questionnaire measures (an anxiety self rating and a
question concerning what they had anticipated).
It was predicted that both the anxious and ulcer group
would fail to react to the stress to the same degree as the
normal control subjects on the cardiovascular measures. The
anxious group, it was postulated, was already so mobilized
toward stress that added arousal would be difficult for them.
This could be tested by first comparing their resting level
102
to that of the normal subjects, and then comparing the magni
tude of their response to the stress with that of normal
subjects, after freeing all scores from base level by con
version to standard scores. Significantly higher base lev
els were found to obtain for the anxious subjects. However,
no significant differences were found in initial stress re
sponse, though a consistent tendency toward a smaller re
sponse increment than among the normal subjects was found.
It was also predicted that anxious subjects would
more readily admit to feeling anxious than normal subjects
and ulcer patient subjects, both initially and after the
stress. While their initial verbal report was found to be
one of reported greater tension than that of the other two
groups, they did not report as great an increment of felt
tension as the normal subjects, but the increment was higher
than that of the ulcer group, as predicted. A negative cor
relation between heart rate and the verbal measure indicated
a tendency for low physiological reaction to be associated
with high verbal reaction for the anxious subjects, and high
physiological reaction with low verbal report. This finding
was interpreted in the framework of excessive sensitization
to anxiety.
By way of contrast to the anxious group, the ulcer
subjects started, on the cardiovascular measures, at a base
level similar to the normal group. Their stress response
was significantly lower than that of the other two groups.
103
A mechanism of repression was hypothesized to be operative
if low autonomic response concurred with low verbal response.
This hypothesis was confirmed by the findings on the ulcer
group, as well as by a significant positive correlation be
tween heart rate and verbal report.
The remainder of the study dealt with post-stress re
covery patterns under conditions of rest and of "catharsis."
Predictions that the anxious group would recover more slowly
than the normal group were not confirmed by the data, though
the anxious group responded with a greater degree of recov
ery to base level than the ulcer group under the catharsis
condition. The ulcer group's recovery curve was unlike that
of both the normal and the anxious group. Their initial
tendency to fail to respond to stress was followed by con
siderable reactivity, particularly in the catharsis condi
tion. It was suggested that the findings for this group
were comparable to findings in the literature relating to
physiological expression of anger as contrasted with anxiety.
Implications for future research were discussed in the light
of the present findings.
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A P P E N D I X
Table 13
Means and Standard.Deviations of Diastolic Blood Pressure
at Resting Level for Normal, Anxious, and Ulcer Group
Normal Anxious Ulcer
Mean
64.5
72.0 66.8
S.D. 12.5
9-5 11.3
Table 14
Analysis of Variance of Diastolic Blood Pressure Means
of the Three Groups at Resting Level
Source Sum of Squares df Variance Est. F
between 916.92 2 458.46
within 11036.41 93 118.67
total. . 11953.33 95 3.86**
* Significant beyond .05 level of confidence.
** Significant beyond .01 level of confidence.
112
Table 15
Mean Increment at Point of Stimulation
of Normal, Anxious, and Ulcer Group
on Diastolic Blood Pressure
_________________ Normal_________ Anxious________ Ulcer
Raw Score 7*6 3 . 6 4.8
T-score 53.8 48.0 48.2
Table 16
Analysis of Variance of Normal, Anxious, and Ulcer Group
on Diastolic Blood Pressure at Point of Stress
(T-Scores)
Source Sum of Sauares •df Variance Est. •F ' '
between 264.80 2 132.40
within 27^3.20
93 29-50
total 3008.00
95 4.49*
* Significant beyond the .05 level of confidence.
113
Table 17
Distributions of Self Rating Scale
Before and After Stress
Score Before Stress After Stress
0.0 to .5
27 7
.6 to 1.0 21
5
1.1 to 1.5 12
5
1.6 to 2.0 6 10
2.1 to 2.5 6 12
2.6 to 3*0 6 14
3-1 to 3.5
4 6
3.6 to 4.0
7
12
4.1 to 4.5 0 10
4.6 to 5*0 0 4
5.1 to 5.5
0 1
5.6 to 6.0 2
5
N
91 91
Mean ■
1.25 2.75
114
90
100
110
mm He
120
130
140
150
2 4 ' 6
number of subjects
8 10 12 14 1
(N = 96, Mean = 116.6)
Figure 5
Frequency Distribution of Resting Systolic Blood
Pressure for the Total Sample of Anxious, Ulcer
and Normal Patients
115
5-0
6.0
7-0
seconds
per 10
heart
cycles
8.0
9.0
10.0 -
11.0
2 4 "~l ™ 6
number of subjects
8 10 12 14 16
(N = 96, Mean = 7.3)
Figure 6
Frequency Distribution of Resting
Heart Period for the Total Sample of
Anxious, Ulcer, and Normal Patients
2 4 6 8 10 12 14 16
number of subjects (N = 96, Mean = 67.8)
Figure 7
Frequency Distribution of Resting Diastolic Blood
Pressure for the Total Sample of Anxious, Ulcer
and Normal Patients
Normal
Anxious
Ulcer
T-scores 50 — —
1 1/2 12
Time, in minutes after stress Time in
>
Figure 8
Means of T-scores of the Control Groups
on Systolic Blood Pressure
118
Normal
Anxious
Ulcer
1 1/2 6 0 12
15
Time, In minutes after stress
Figure 9
Means of T-scores on Systolic Blood Pressure
of the Experimental Groups
119
(slower
pulse)
T-scores
(faster
pulse)
Normal
Anxious
— Ulcer
1 1/2 6 12
15 9
0
Time, in minutes after stress
Figure 10
Means of T-Scores on Heart Period
of the Control Groups
(slower
pulse)
T-scores
(faster
pulse)
Normal
Anxious
Ulcer
\ /
1 1/2 6 0 12
Time, in minutes after stress
Figure 11
Means of T-scores on Heart Period
of the Experimental Groups
Completely
relaxed,
no anxiety
or tension
Fairly anxious
or tense
NAME:
I t I
4 5 6
Extremely
anxious or
tense
121

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Asset Metadata

Creator Mendel, Martin E. (author)

Core Title An Investigation Of The Response To Stress Of Patients Hospitalized For Anxiety State And Peptic Ulcer Patients

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 Jacobs, Alfred (committee chair), Klein, David B. (committee member), Mehl, John W. (committee member), Meyer, Mortimer M. (committee member)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c18-16107

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