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The Effect Of Anxiety And Frustration On Muscular Tension Related To The Temporomandibular-Joint Syndrome

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The Effect Of Anxiety And Frustration On Muscular Tension Related To The Temporomandibular-Joint Syndrome

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Content THE EFFECT OF ANXIETY AND FRUSTRATION
ON MUSCULAR TENSION RELATED TO THE
TEMPOROMANDIBULAR-JOINT SYNDROME
by
Lloyd James Thomas
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 1970
71-7746
THOMAS, Lloyd Janies, 1940-
THE EFFECT OF ANXIETY AND FRUSTRATION ON
MUSCULAR TENSION RELATED TO THE TEMPORO
MANDIBULAR-JOINT SYNDROME.
University of Southern California, Ph.D., 1970
Psychology, clinical
University Microfilms, Inc., Ann Arbor, Michigan
© 1971
Lloyd James Thomas
ALL RIGHTS RESERVED
THIS DISSERTATION HAS BEEN MICROFILMED EXACTLY AS RECEIVED
UNIVERSITY O F S O U T H E R N CALIFORNIA
THE GRADUATE SCHOOL
UNIVERSITY PARK
LOS ANGELES, CALIFORNIA 9 0 0 0 7
This dissertation, w ritten by
..... LLOYD. . J A WE S.. T HO WAS..........
u nder the direction of h.is... D issertation C o m
mittee, and a p p r o v e d by all its m em bers, has
been p resen ted to an d a c c e p te d by T h e G r a d u
ate S ch ool, in p artial fu lfillm en t of re q u ire
ments o f the d e y r e e of
D O C T O R O F P H I L O S O P H Y
/f /n^i c
Dean
7
D a t e Au^stl97P.
I) IS S ERTATI ON COMMITTEE
r r l < 1 y —
« / ' / * Chairman
/V U - + --
ACKNOWLEDGMENTS
For his continual support and wise suggestions,
sincere appreciation is expressed to Norman Tiber, Ph.D.
For their valued assistance in the completion of
this dissertation, gratitude is extended to Sylvan
Schireson, D.D.S., Gary Galbraith, Ph.D. and Milton Wolpin,
Ph.D.
For her love and patience and support, this research
is dedicated to Carol.
TABLE OF CONTENTS
ACKNOWLEDGMENTS ......................................... ii
LIST OF T A B L E S ......................................... v
Chapter
I. INTRODUCTION ................................... 1
II. REVIEW OF THE LITERATURE..................... 3
The Temporomandibular-Joint Syndrome . . . 3
Anxiety and Muscular- Tension in TMJ
Syndrome ................................... 9
Frustration.................................. 13
Occurance.................................. 13
Individual Effects ....................... 17
Reactions.................................. 17
Further Theoretical Considerations . . . 24
III. METHOD.......................................... 26
D e s i g n....................................... 26
Hypotheses.................................. 27
Subjects..................................... 28
Apparatus..................................... 30
Procedure and Instructions ................ 31
Post Procedure Interview .................. 36
IV. RESULTS.......................................... 38
Total Tension T i m e ......................... 39
Average Time of Tensional Episode ......... 42
Intensity of Tension ....................... 45
Percent Tensional Time for Non-TMJ
Controls................................... 47
iii
Chapter
i V. DISCUSSION
! Total Time of Masticatory Muscular
Tension ..................................
Mean Time of Tensional Episode ...........
Intensity of Total Tension ................
The Problem of Definition of Conditions
Theoretical Considerations................
VI. SUMMARY .......................................
APPENDIX A ..............................................
APPENDIX B ..............................................
LIST OF REFERENCES
LIST OF TABLES
Table Page
1. Summary of Analysis of Variance of Total
Time of EMG Activity Above Baseline
Measured in Seconds/90-Second Sequence . . . 40
2. Comparison of Ordered Means for Total Time
of EMG Activity Above Baseline Using the
Newman-Kuels Method ......................... 41
3. Summary of Analysis of Variance of Mean
Time of EMG Activity Per Episode of
Activity Above Baseline/90 Seconds ......... 43
4. Comparison of Ordered Means for Mean Time
of EMG Activity Per Episode of Activity
Above Baseline/90-Second Sequence Using
the Newman-Kuels Method ..................... 44
5. Summary of Analysis of Variance of Maximum
Amplitude of EMG Activity Reached Per
90-Second Sequence in Millimeters ......... 46
6. Comparison of Ordered Means for Maximum
Amplitude of EMG Activity Reached Per
90-Second Sequence Using the Newman-
Kuels Method................................... 48
7. Student-_t Test of Differences in Total
Percentage of Time of EMG Activity Above
Baseline Between Frustration Sequence
and Motor Task for Non-TMJ Controls .... 49
8. Total Time of EMG Activity Above Baseline
Per 90-Second Sequence Measured in
Seconds..........................................106
v
Table Page
9. Mean Time of EMG Activity Per Episode of
Activity Above Baseline Per 90-Second
Sequence in Seconds......................... 107
10. Maximum Amplitude of EMG Activity Reached
Per 90-Second Sequence Measured in
Millimeters.................................. 108
11. Percent of Time of EMG Activity Above
Baseline for Non-TMJ Controls Between
Motor Task and Frustration Task............. 109
vi
CHAPTER I
INTRODUCTION
The musculoskeletal area where the mandibular con
dyle articulates in relation to the temporal bone of the
skull is called the temporomandibular joint (TMJ). Disor
ders of the TMJ, giving rise to pain, poor occlusion, loss
of eating ability, etc., have been recorded since the fifth
century B. C. (Schwartz, 1959).
Contemporary dental theories concerning the etiology
of TMJ pathology include: malocclusion (Costen, 1934), lax
ligaments (Shultz and Schriner, 1943), stress and anxiety
(Schwartz, 1959), and masticatory muscular discoordination
and spasm (Schireson and Robinson, 1961; Schireson, 1966).
The majority of conclusions drawn by dental researchers,
however, indicate that the primary etiologic factor in TMJ
syndrome is muscular tension, whether due to occlusal prob
lems, organic stress, pain, or emotional disturbance.
Accordingly, treatment, whether dental, biochemical, physi
cal exercise, or retraining of masticatory muscle control,
is generally aimed toward tensional relief in the mastica
tory musculature.
1
Despite speculative conclusions regarding anxiety
and TMJ muscular tension (Schwartz, 1959), no research has
attempted to experimentally demonstrate a direct relation
ship between anxiety and increased tension in the mastica
tory musculature of those persons suffering from TMJ prob
lems. Furthermore, anxiety is an experimentally ambiguous
concept and not the only possible factor which might lead
to persistent increased tension in the masticatory muscles.
Schireson (1966) has made the statement that TMJ
patients often demonstrate anger and hostility in the dental
situation significantly more than patients with other dental
problems. A great amount of psychological research has been
reported regarding the relationship between anger, frustra
tion, aggression, and muscular tension (Dollard et al.,
1939; Hokanson and Burgess, 1962a, 1963, 1964; Miller, 1948).
It is possible there exists a relationship between frustra
tion and masticatory muscle tension in TMJ-syndrome pa
tients .
The present investigation was designed to collect
basic information relevant to masticatory muscle tension in
persons suffering from TMJ disorders, and the relationship
of anxiety and frustration to such tension.
CHAPTER II
REVIEW OF THE LITERATURE
The Temporomandibular-Joint Syndrome
The temporomandibular joints are bilateral and
function simultaneously. Therefore, the functional rela
tionships between the masticatory muscles, ligaments, car
tilage, and bone make the TMJ one of the most complex
joints of the body.
Disorders of the TMJ, including pain, malfunction,
malocclusion, loss of chewing and eating ability, and head
ache, have been recorded as early as the fifth century
B. C. (Schwartz, 1959).
However, until about 1920, TMJ problems were cate
gorized into one of two general types of disorders common
to all joints: dislocations and "fixations" (Schwartz,
1959). The latter consisted of extra-articular pathology
such as trismus or intra-articular disorders such as
ankylosis, trauma, or arthritis.
During the early part of the 1920’s, a general
change in thinking about the TMJ took place. Prentiss
(1918), an anatomist, hypothesized that "atrophy" of the
3
4
miniscus was the major cause of TMJ disorders. The minis-
cus is a biconcave "disk" which rests upon the head of the
mandibular condyle and serves as a cushion between the con
vex superior and posterior surfaces of the condyle and the
convex posterior surface of the articular tubercle of the
temporal bone against which the condylar head articulates.
The presence of the miniscus prevents these two convex sur
faces of the condyle and the articular tubercle from imme
diate contact. Atrophy of the miniscus would mean that the
articulating surface of the TMJ might become highly painful,
worn, or traumatized (Sicher, 1951, 1965).
Shortly after 1918, dentists interested in occlu
sion (Nonson, 1920; Wright, 1920) applied Prentiss* concept
to deafness. Thus, instead of conceptualizing any TMJ
problems as disorders of the joint in and of themselves,
TMJ problems became symptoms of the TMJ which might be
related to other bodily problems. Goodfriend (1934) placed
heavy emphasis on the idea that loss of teeth and "change
in occlusion" were the cause of TMJ symptoms. Until 1934
then, problems concerning the TMJ were classified as dislo
cations, fixations, atrophication, and finally symptoms
related to occlusion and tooth loss.
It was J. B. Costen who, in 1934, first began to
classify the symptoms of the TMJ into a "syndrome" concern
ing the "sinus" and the ear (Costen, 1934). His diagnosis
and treatment suggestions were
5
. . . the lack of molar teeth, or badly fitting
dental plates, permitting overbite; mild catarrhal
deafness, improved at once by inflation of eusta-
chian tubes; dizzy spells, relieved by inflation of
tubes; tenderness to palpation of mandibular joints;
marked discomfort to patient from interposing a flat
object between jaws; presence of the typical head
ache after sinus or eye involvement when sinuses or
eyes are found to be negative. (Costen, 1934)
Costen then postulated that the mechanism for the
syndrome was the compression of the eustachian tubes re
sulting in deafness and that general "looseness" of the
mandibular joint pushing tissue toward the tube was the
cause (Costen, 1934). Thus, "Costen’s Syndrome” was due
primarily to poor occlusion and the prognosis was dependent
on the
. . . accuracy with which refitted dentures relieve
abnormal pressure on the joint, the entent of the
injury to the eustachian tube, the condyle, the
meniscus, and the joint capsule. (Costen, 1934)
Following 1934, there was little debate on Costen’s
concepts. In general, his ideas dominated thought concern
ing the TMJ. In 1937, however, L. W. Shultz reported, when
. . . the ball of the index finger is placed in
front of the tragus and the patient is instructed to
open the mouth wide enough to cause the head of the
condyle to subluxate, or to produce the "click" or
abnormal movement of the fibrocartilaginous disk
. . . , (Shultz, 1937)
that the syndrome described by Costen could be duplicated.
The term "subluxation" was defined in 1943 as a "self-
reducing incomplete dislocation" and therefore, "lax liga
ments" were considered to be the etiologic factor (Shultz
and Shriner, 1943).
Regardless of the validity of Shultz’s position,
symptoms were presumed to be of the joint itself, and
therefore, treatment of the joint was called for. This was
in direct contrast to Costen’s position which described the
symptoms associated with the TMJ, but recommended treatment
of occlusion.
The positions taken by Costen and Shultz are con
trasted in other ways. Basically, Costen emphasized the
position of the TMJ when the mouth was closed and tension
on the musculature of the TMJ was great. Shultz related
his views to the open mandible and emphasized the "laxness"
of the TMJ musculature. Treatment according to Costen was
dental, while Shultz recommended "tightening the lax liga
ments through fibrogenesis induced by the intra-articular
injection of a sclerosing agent" (Shultz, 1947).
In 1949, a clinic was evolved for the study of the
TMJ disorders at the Columbia-Presbyterian Medical Center.
At this time Laszlo Schwartz concluded that it was evident
a "scientific basis for their [Costen’s and Shultz’s] con
cepts was lacking" (Schwartz, 1959). During the next ten
years at this Medical Center, a study of over 2,500 pa
tients in the "Temporomandibular Joint Clinic" culminated
in the derivation of twelve major conclusions drawn by
Schwartz (1959). Briefly, these conclusions were the fol
lowing: (1) symptom complexes found in TMJ disorders were
not those described by Costen, and even where individual
7
symptoms of Costen’s syndrome were present, they did not
relate to "bite closure." (2) Symptoms of the TMJ were
not due to any "excessive" range of condylar movement, and
therefore, sclerosing agents have little clinical applica
tion. (3) Organic disorders common to all joints were
found, but the incidence of organic disease was small.
(4) The disorder found most was a "pain-dysfunction
syndrome," usually appearing in an earlier form as clicking,
subluxation, or dislocation and lack of coordinated masti
catory musculature probably due to increased muscle tension
causing symptoms to appear. (6) Such muscle incoordina
tion results in painful, limited movement of the mandible
caused by muscular spasm and when it is not relieved by
treatment, such spasm can become cyclic. (7) It is not
known whether muscular spasm is caused by painful nerve
impulses originating in the TMJ or whether they arise from
the musculature itself. (8) There is no single cause of
the pain-dysfunction syndrome, but rather a "constellation"
of etiologic factors, including the occlusion of the teeth.
However, Schwartz goes on to emphasize that "what the pa
tient does with his occlusion in reacting to stress seems
to be more important than any malocclusion that he may
have" (Schwartz, 1959). (9) When increased tension in the
masticatory muscles occurs due to stress, the following
types of disturbances have occurred: ". . . the pain-
dysfunction syndrome, occlusal wear, tooth mobility, pulp
death, or none" (Schwartz, 1959). (10) Schwartz developed
a diagnostic procedure for the TMJ which included joints,
occlusion, musculature, electromyographic and roentgeno-
graphic work and a history. (11) A request was made for
contributions from medical specialties and other biologic
sciences to aid in the management of TMJ disorders and make
treatment procedures less dependent on altering occlusion.
(12) Disturbances currently labeled ’’disorders" of the TMJ
can only be considered as such if the term "joint" includes
the masticatory musculature.
In 1954, Schwartz concluded from a study of 256 TMJ
patients that there are generally two presenting symptoms
of the TMJ disorders: pain and dysfunction (Schwartz,
1954). Therefore, he coined the term, "Temporomandibular
joint Pain-Dysfunction Syndrome" (TMJPDS). He then postu
lated an etiologic and functional mechanism for the TMJPDS
which began with "stress and anxiety" as the prime etio
logic factor. His model proceeded in cyclic fashion
through: the development of increased masticatory-muscle
tension, occlusal abnormalities, sudden stretch or proprio
ceptive changes, to this pain-dysfunction syndrome and its
concomitant symptoms of incoordination, clicking, spasm,
pain, subluxation, and dislocation. This might be followed
chronologically by an alarming diagnosis or "traumatic
treatment" which then adds to the general stress and/or
anxiety, thereby leading to completion of the cycle which
then becomes a kind of self-perpetuating syndrome.
But for the first time, the basic etiologic factor
contributing to the development of the syndrome was postu
lated to be general stress or anxiety leading to general
increase in the tensional state of the masticatory muscula
ture.
However, since that time, no one has attempted
experimentally to demonstrate that patients suffering from
TMJ disorders show any greater tension in the masticatory
musculature in stressful situations than do those with no
TMJ problems. Therefore, the question needs to be consid
ered: do persons suffering from TMJ pain and/or dysfunc
tion show significantly greater tension in the TMJ area due
to stress or anxiety than those who have no history of TMJ
disorder. A study of this question was one aspect of this
investigation.
Anxiety and Muscular Tension
in TMJ Syndrome
The role of emotional factors such as stress reac
tions and anxiety, and their affects on dental problems in
general, and TMJ disorders in particular, has been studied
by Borland (1935, 1956). He concluded that production of
hysterical pain where anxiety leads to pain with no evidence
of peripheral dysfunction, must be taken into consideration
when diagnosing and treating TMJ disorders.
Ruth Moulton (1955, 1966) did extensive study of
10
the role anxiety plays in the development of non-organic
TMJ pain, as well as oral manifestations of such anxiety.
She hypothesized that patients suffering from TMJPDS are
"not only anxious, but also tend to express their anxieties
with physical symptoms” (Moulton, 1955a).
Based on interviews with thirty-five patients,
Moulton concluded that non-organic TMJPDS patients were
"suffering from a functional disorder; a prolonged, self-
perpetuating, tensional ’Charley horse’ of the jaw"
(Schwartz, 1959). Moulton (1955a) compared this TMJPDS to
the "functional low-back pain often resulting from either
overstretching or sudden over-contraction which leads to
spasm and pain . . ." She asserted that dental therapy and
prevention of TMJ problems should "take into consideration
not only the patient’s dental, but also his personality
problems" (Moulton, 1955a).
A study of "personality problems" was made by Lupton
of female TMJ-dysfunction patients (Lupton, 1966). He
reported that such patients appeared to be highly reactive
to stress, and tended to demonstrate concomitant emotional
symptoms such as hostility, dependency, and irritability.
Lupton (1966) and Schireson (1966) are the only investi
gators to mention hostility as a possible personality char
acteristic of TMJ patients.
A study of the relationship between stress and
tension of the masticatory muscles was performed by Perry
11
et al. (I960). An electromyographic examination was per
formed, studying the relation between mental stress and
clenching of teeth during the day. Based upon the electro
myographic analysis of the tensional state of the mastica
tory musculature of four dental students being interviewed
unexpectedly by the dean of the dental school, the relevant
conclusions were: during stressful situations there was
increased muscular activity in predisposed persons with
probable long-term emotional stress buildup, and there was
evidence for ’’tensions and aches within the masticatory
musculature of persons under emotional stress" (Perry
et al., 1960). Specifically what type of emotional stress
was not determined.
A dramatic demonstration of the role of anxiety in
the TMJ syndrome was reported by William Kydd (1959).
Thirty subjects with TMJ syndrome were evaluated as to
occlusion, emotionality and muscular tension. On the basis
of electromyographic readings of action potentials arising
from the masticatory musculature, Kydd demonstrated that
such potentials disappeared when the subjects were relaxed
and their skeletal muscles were at ease in the test environ
ment. He also reported that 76 percent of the subjects were
"significantly emotionally disturbed" (Kydd, 1959). The
conclusion about such disturbance was derived from evalua
tion of a subject’s written history of origin and progress
of pain; a single interview or a series of interviews
12
conducted to determine if there were any emotional stress
ful incidents concurrent with the onset of pain; and
finally, a personality evaluation based on the Cornell
Medical Index, Minnesota Multiphasic Personality Inventory,
and Edwards Personality Profile.
Kydd (1959) concluded that a possible etiologic
factor in TMJ syndrome was oral trauma, enhanced when it
occurred in a setting characterized by a threatening life
situation due to social and interpersonal adjustments which
created general muscle hyperfunction. However, Kydd did
not demonstrate that TMJ patients have greater tension in
the masticatory musculature under experimental stress than
when relaxed.
Schireson and Robinson (1961) evaluated the problem
of the "non-surgical" TMJ syndrome and concluded that the
primary etiologic factor was muscle spasm due to various
tensional responses in the patients’ masticatory muscles.
However, Schireson (1966) mentioned, while describing TMJ
patients that they seemed to be "hostile," and hinted at the
possibility that this attitude might play a role in muscular
tension or discoordination in the TMJ area.
Most dental research conducted regarding the role
of emotional factors in TMJ syndrome conclude that patients
suffering from TMJ, non-organic symptomatology are experi
encing pain and/or dysfunction as a function of muscular
tension due to emotional stress. Dental researchers have
13
made no effort to define the type of stress or stress situ
ation to which TMJ patients seem to be responsive, merely
referring to it as "stress” or "anxiety." It is possible
that TMJ patients respond differentially with increased
tension in the masticatory musculature dependent upon the
type of stressful situation. Such differential response
also might be characteristic of TMJ patients alone when
compared with non-TMJ patients. This current investigation
represented a beginning at more adequately defining situa
tions to which TMJ patients characteristically respond with
tensional increase in masticatory musculature.
Frustration
Occurance
There are many varied uses of the term, "frustra
tion" within psychological literature and research (Lawson
and Marx, 1958). "Frustration" has been used to mean
merely simple deprivation, delay of reinforcement, and even
a "process-product confusion" (Hall, 1961).
Most research concerning frustration seems to use
the term in one of three conceptual ways which have been
categorized by Britt and Janus (1940). These include:
(1) a description of a particular situation, stimulus con
dition, or instigating condition, (2) the effects of stimu
lus conditions upon the individual, e.g., physiological
arousal, and (3) the behavioral manifestations of such
effects, e.g., aggression, withdrawal, etc. Despite the
obvious difficulty in clearly differentiating between the
ambiguous borderlines of these three conceptualizations of
frustration, each will be discussed in turn.
Cofer and Appley (1964) conclude that there are two
necessary "preconditions to frustration." They are:
(1) the presence of an unfulfilled drive or motive (equated
with arousal), and (2) some type of blocking or thwarting
of drive gratification.
The presence of a drive, need, or tension which has
not been alleviated is usually referred to as "deprivation"
or "privation," but not frustration. Rosenzweig (1944) was
the first to emphasize the distinction when he referred to
deprivation alone as "primary frustration" and the thwarting
of a motive as "secondary frustration." Marx (1956) made a
similar distinction noting that deprivation does not involve
"prior instrumental or consumatory behavior."
The classic work by Dollard et al. (1939) demon
strated the second precondition required to operationally
define frustration. According to their hypothesis, frustra
tion occurs when a "goal-response suffers interference to
its occurance." Such a definition presumes the prerequisite
occurance of an unfulfilled drive to account for the onset
of a goal-response. The blocking or thwarting of an
attempted goal-response then leads to frustration (Dollard
et al., 1939) .
15
It must be noted, however, that the interruption of
any goal-seeking behavior does not necessarily lead to
frustration. Zander (1944), after reviewing the studies in
the field, concluded that frustration occurs only when the
goal toward which the organism responds is "believed to be
important and attainable." Rosenzweig (1944) and Sargent
(1948) have also emphasized that the individual must per
ceive the goal to be important before thwarting leads to
frustration. Both Maslow (1943) and Rosenzweig (1944) pro
pose a distinction between mere deprivation states and con
ditions which pose a threat or are important to the indi
vidual. The latter are described as "ego-threatening" or
"ego-involving."
The use of ego involvement as an experimental vari
able was reviewed by Iverson and Reuder (1956) and Hall
(1961). They report the majority of research done on ego-
involvement concerns performances on retention, set, level
of aspiration, problem-solving, perception, and motor
responses.
Cofer and Appley (1964) cite an example of instruc
tional procedures intended to "ego-involve" a subject.
They state
. . . a group of college students can become in
volved by instructing them that they are about to
take an intelligence test, the results of which
would be made a part of their permanent records.
Such instructions arouse an important motive, and
information that they are failing or have failed
constitutes a thwarting of the aroused
16
ego-protective behavior. (Cofer and Appley, 1964)
The use of such instructions and subsequent infor
mation that the subject was failing was used in relation to
the motor task required during the frustration condition of
this investigation.
Brown (1961) proposes three criteria for determining
that thwarting has actually taken place. These criteria
are: (1) efforts made by the organism to continue an
interrupted behavior, (2) the recurring of the blocked
response upon removal of the thwarting agent, and (3) the
omission of behaviors previously and regularly engaged in
even though the stimuli are present which formerly elicited
them. This last criterion, Brown reports, is more relevant
in the determination of conflict-induced frustration.
The conclusion can be drawn, based on this review,
that any set of stimulus conditions or situation which
meets the two preconditions of drive occurance and thwart
ing, and behaviorally fulfills at least one of Brown's
criteria for determining frustration occurance, can be
termed frustrating.
The frustration condition of this investigation met
both preconditions and Brown's first two criteria of behav
ior continuation and the recurrance of the blocked response
(Brown, 1961).
17
Individual Effects
Sargent (1948), after critically reviewing the
dearth of research on individual effects of frustration,
characterizes the state of frustration to be an "unpleasant
emotional state against which the affected individuals’
energies are more or less strongly mobilized."
Unfortunately, except for the implication of frus
tration through general physiological arousal measured by
heart rate (Doerr and Hokanson, 1965; Burgess and Hokanson,
1964), or systolic blood pressure (Hokanson, Burgess, and
Cohen, 1963), there have been no reliable correlations
demonstrated between particular frustration conditions and
individual state variables (Thetford, 1951; Child and
Waterhouse, 1953; Marx, 1956; Cofer and Appley, 1964).
Thus, if one wishes to experimentally demonstrate the
effect of frustration as an internal variable, he is forced
to use physiological arousal measures, verbal report,
inference from stimulus conditions and/or forms of behav
ioral reactions.
No research has attempted to demonstrate a relation
ship between frustration and a specific muscular tensional
response, e.g., in the masticatory musculature. This
investigation did.
Reactions
How an individual responds to frustrating stimulus
18
conditions can generally be divided into four major hypo
thetical constructs characterized as: (1) frustration-
repression, (2) frustration-fixation, (3) frustration-
regression, and (4) frustration-aggression. Each of these
concepts will be reviewed in turn.
The concept of repression postulated by Sigmund
Freud (1936) and extensively elaborated upon by Anna Freud
(1936), states that those events which evoke anxiety in an
individual are often forgotten or "placed in the uncon
scious" (Freud, A., 1936). Forgetting or repression of
events serves the individual as a defense mechanism against
anxiety aroused by such events.
It was noted above (pp. 15-16) that blocking of
"ego-involved" behaviors could lead to frustration. The
concept of frustration-repression is evoked when such ego-
threatening events nevertheless occur and are responded to
retroactively by "motivated forgetting or repression"
(Rosenzweig, 1943).
Rosenzweig (1943) experimentally demonstrated that
"repression" could be a consequence of frustration brought
about by the continued occurance of ego-threatening events.
He divided a group of college students into an "ego-
defensive" and "need-persistive" group by informing the
former that they were being tested for intelligence and the
latter that the task was being evaluated. The task was to
complete a series of jig-saw puzzles, only half of which
19
were allowed to be finished. Significantly more subjects
in the need-persistive group recalled the unfinished
material compared to the ego-defensive group. The inabil
ity of the subjects in this latter group to remember the
unfinished puzzles was interpreted as a function of
"repression" to protect their integrity regarding their
intelligence (Rosenzweig, 1943).
Similar studies have been reviewed by Glixman
(1948) demonstrating the apparent generality that after
failure there is often better recall for completed than for
uncompleted tasks, when the subjects are "ego-involved."
This is especially true when the subjects perceive failure
itself as threatening (Atkinson, 1953; Eriksen, 1954).
The conclusion may be drawn from this review that
one possible individual reaction to frustration is forget
ting or "repression" of the circumstances which lead to, or
are involved with, frustration.
The frustration-fixation concept was postulated and
studied extensively by N. R. F. Maier (1949, 1956). His
basic hypothesis was that responses which are frustration-
induced are not motivated, nor goal-directed, nor adaptive,
but rather, stereotyped, highly resistant to modification,
without a goal, and ends in themselves; in short, they are
fixated responses.
The basic experiments Maier performed involved the
use of shock to force hooded rats, previously trained to
20
discriminate the correct choices on a Lashley jumping stand,
to respond to a non-soluable situation. The procedure he
used was to initially train rats to discriminate one of two
doors toward which they jumped from a stationary platform
across a space of approximately eighteen inches. If the
correct choice was made, the door opened, the rats passed
through, and were rewarded by food on the other side. If
the incorrect choice were made, the rats hit their noses on
the closed door and fell to a level several feet below.
After discrimination was accomplished, the problem
was changed so that the reward of the open door and food
was distributed randomly, regardless of the choice. The
rats soon ceased to jump at all. Immediately thereafter,
an electric shock, prodding, or air blasts were introduced
to force a jump. Frustration was implied by the requirement
to respond to a non-soluable choice situation. The results
of this procedure led the rats to begin making a stereotyped
jump toward one door regardless of the reward contingency
and persisting over hundreds of trials (Maier, 1949).
Maier went on to demonstrate that once such fixated
behavior was established he could make the solution to the
problem completely apparent by opening the door, and yet the
rats persisted in jumping in such a way as not to enter.
Thus, Maier concluded that frustration-induced
behavioral responses are fixated ones, ones without goal-
directedness, and non-adaptive (Maier, 1956).
21
Mowrer (1960) challenged the validity of Maier’s
theory on the basis that perhaps even the stereotyped re
sponse might be an avoidance response and, therefore,
motivated. This position led to considerable controversy
and ultimate clarification of the relationship of frustra
tion to fixated responses awaits further research. Regard
less of the validity of Maier’s theory, the possibility
exists that an individual response to frustration might be
of a stereotyped or "fixated" nature.
The concept of regression being consequent to frus
tration was first conceived by Sigmund Freud (1920). He
postulated that persons developed through "psychosexual
stages." Once a person has progressed to a relatively
mature level, the occurance of "insurmountable obstacles"
or traumatic events resulted in regression to earlier stages
of development where coping behaviors were successful
(Freud, 1920).
Numerous experimental studies, interpreted as demon
strating regression in animals to previously learned habits,
have been subsequently performed and reviewed (Mowrer, 1940;
Perkins and Tilton, 1954; Hall, 1961). Basically, regres
sion experiments follow three procedural steps: (1) train
ing of an animal to habitually perform a single response to
a set of stimulus conditions, (2) training the animal to
habitually perform a second response to the same set of
stimulus conditions, and (3) making the performance of the
second response aversive through punishment or impossible
to perform.
Rats who have trained in such procedures return to
the performance of the response they learned first as com
pared to control groups who generally continue to perform
the punished responses or cease to respond altogether.
The classic demonstration of "regression" as a
response to frustration in children was performed by Barker,
Dembo, and Lewin (1941). Behavioral "ratings" were made on
thirty nursery school children under two conditions:
(1) playing with ordinary toys, and (2) playing with the
same toys after a period of playing with more attractive,
new toys, now seen only through a mesh screen. The "con
structiveness of play" rated during this latter "frustra
tion" period, where the newer toys could be seen but not
played with, showed considerable "dedifferentiation" (the
Lewinian concept of regression to more "primitive" or less
"differentiated" patterns of behavior). Barker et al.
reported that twenty-two of the thirty children regressed
to less constructive play, three showed no change, and two
demonstrated increased constructiveness.
Child and Waterhouse (1953) proposed an alternative
interpretation of the Barker et al. data. They postulated
that the frustration condition elicited responses in the
children which were incompatible with constructive play.
They concluded that the "aggressive responses" aroused by
23
frustration were the cause of play deterioration, not
regression. They experimentally demonstrated their position
by taking college students and subjecting them to a variety
of frustrating tasks. Then they criticized the subjects
regarding their performance. Such criticism produced either
a decrement or an increment in performance as a function of
the amount of frustration-produced response interference.
Clarification of the variables involved in the
frustration-regression construct requires further research.
However, evidence indicates that one possible reaction to
frustration might be "regression."
The fourth hypothetical construct, and probably the
most generally accepted hypothesis regarding individual
reaction to frustration, is the frustration-aggression
hypothesis.
Dollard et al. (1939), as discussed above (p. 14),
proposed that the natural consequence of interference of
ego-involved goal responses was anger and attacking behav
ior. They postulated that the strength of aggression is
related to three variables: (1) the amount of motivation
toward the goal, (2) the amount or strength of the inter
ference, and (3) the frequency of interruption.
Others have demonstrated that the strength of
aggression might be related to such variables as arbitrari
ness of interference (Pastore, 1952), the perceived status
or authority of the agent of interference (Cohen, 1955;
24
Stagner, 1961; Hokanson and Burgess, 1962), the assumed
consequences of aggression (Dollard et al., 1939; Miller,
1948), and the choice of object of aggression (Stagner,
1961).
However, Berkowitz (1962) has reviewed the field
and has concluded, despite the temptation to postulate that
aggression always results from frustration and that frustra
tion always leads to aggression (Dollard et al., 1939),
that there is considerable evidence indicating this recipro
cal relationship is by no means invariate. This present
review amply supports such a conclusion. Aggression is
only one possible individual response to frustration.
Further Theoretical Considerations
Review of the relevant literature indicates that
stress in the form of "anxiety" leads to increased tension
in the masticatory musculature which, in turn, leads to
non-organic pain and/or dysfunction referred to as
temporomandibular-joint syndrome. However, no experimental
evidence has been gathered to demonstrate that TMJ patients
show significant increases in musculature tension in a spe
cific anxiety-provoking situation as compared to non-TMJ
control subjects. This investigation was designed to make
that comparison.
It is possible that increased muscular tension in
the masticatory musculature of TMJ patients might be a
25
determinable differential response to some specific type of
stress other than ’’anxiety," e.g., "frustration." It has
been shown that persons respond in a variety of ways to
frustration. It might be that TMJ patients respond to a
frustrating situation, in part, through increased mastica
tory musculature tension and engage in this activity more
so than non-TMJ persons. Exploration of this possibility
was a second aspect of this study.
This investigation was concerned with determining
the relationship of stress in the form of anxiety and frus
tration to temporomandibular-joint syndrome. The variables
under investigation included: (1) the amount of tensional
increase above a relaxed-state baseline in the masticatory
musculature of TMJ patients and non-TMJ controls in an
anxiety-provoking situation, (2) the difference in amount
of tensional increase in masticatory musculature between
TMJ patients and non-TMJ controls when experiencing a
frustrating situation, and (3) a comparison of any differ
ence in the amount of tensional increase in the masticatory
musculature of TMJ patients and non-TMJ controls between an
anxiety-provoking situation and a frustration condition.
CHAPTER III
METHOD
Design
The primary purpose of the present investigation
was to evaluate tensional responses in the masticatory
musculature of persons suffering from TMJ syndrome and
compare these responses with those of persons with no
history of TMJ disorders under two sets of stimulus condi
tions: (1) when frustrated, and (2) when anxious.
Electromyographic recordings were made and evalu
ated of the electric potentials arising from the masseter
and temporal muscles of each subject. A baseline of relax
ation was recorded for each subject, the deviations from
which were measured and recorded under the following three
conditions:
Condition I--Anxious. Subjects were informed
of, and exposed to, painful electric shocks
to the medial side of the left forearm at
unknown random intervals. A 90-second record
ing of EMG activity commenced at the first
shock onset and continued for ten seconds
26
27
after last shock onset.
Condition II--Frustration. Subjects were
blindfolded and instructed to complete a
timed, motor-task "related to intelligence"
(i.e., placing various-shaped blocks in a
form board). Subjects were told they were:
not cooperating, failing, to begin again,
and were prevented from completing the task.
A 90-second recording of EMG activity com
menced ninety seconds prior to task termina-
ti on.
Condition III--Motor Task. A third condi
tion was given the control subjects. They
performed the same motor task of Condition
II, but with no blindfold and no experimenter
comment.
Behavioral observations were made on each subject
during each condition. Following the completion of the
entire procedure, each subject was asked to report his
feelings during each of the experimental conditions.
Anecdotal records of these observations and verbal reports
were kept for all subjects and appear in Appendix A.
Hypotheses
(1) The total amount of time of electromyo
graphic activity above baseline will signif
icantly differ between TMJ patients and
28
non-TMJ controls over Conditions I--Anxiety
and II--Frustration. TMJ activity will be
greater.
(2) The total amount of time of electromyo
graphic activity above baseline will signif
icantly differ between Condition I--Anxiety
and Condition II--Frustration for both TMJ
patients and non-TMJ controls combined. The
frustration condition will be greater.
(3) The mean episodic time of electromyo
graphic activity above baseline will signif
icantly differ between TMJ patients and non-
TMJ controls over Conditions I--Anxiety and
II--Frustration. TMJ means episodic time
will be greater.
(4) The mean episodic time of electromyo
graphic activity above baseline will signif
icantly differ between Condition I--Anxiety
and Condition II--Frustration over TMJ pa
tients and non-TMJ controls combined. Con
dition II will be greater.
(5) The maximum amplitude of electromyo
graphic activity reached will significantly
differ between TMJ patients and non-TMJ
controls over Conditions I--Anxiety and II--
Frustration. TMJ will be greater.
(6) The maximum amplitude of electromyo
graphic activity reached will significantly
differ between Condition I--Anxiety and
Condition II--Frustration over TMJ patients
and non-TMJ controls combined. Condition
II will be greater.
(7) The percentage of time of electromyo
graphic activity above baseline will signif
icantly differ between Condition II--Frus-
tration and Condition III--Motor Task for
non-TMJ controls. Condition II will be
greater.
Subjects
The experimental subjects were ten dental patients--
four males and six females. Each subject was currently
29
seeking treatment for temporomandibular-joint pain and/or
dysfunction at the Temporomandibular Joint Clinic of the
University of Southern California Dental School. An indi
vidual appointment for participation in this investigation
was made for each subject after his complaint had been
professionally diagnosed as TMJ syndrome.
Control subjects were matched with the experimental
subjects on the variables of sex and age. Each control
subject reported no incidence of TMJ disorder during his
lifetime. Participation in the study for all subjects was
voluntary.
Upon keeping his research appointment, each subject
was required to sign a form which read:
RESEARCH PARTICIPATION FORM
I, the undersigned, voluntarily agree to
participate in the research project of the
Temporomandibular Joint Clinic of the
University of Southern California Dental
School.
I understand that this research is to
provide information for diagnosis and
treatment of temporomandibular-joint
problems.
signature
(date)
30
Apparatus
The apparatus consisted of a "shock box" capable of
delivering a direct electrical current of varying intensity;
six shielded, surface electrodes (Biocom Biodes, Model
#1083EX) for gathering myographic potentials; two Biocom
Model 121 amplifiers for amplification of the electromyo
graphic potentials; a Sony Stereo Tape Recorder Model
TC-105, for recording the amplified potentials; a Gilson
Direct Polygraph inkwriter for printing the recorded poten
tials on graph paper; and a form-board from the Reitan Test
Battery for provision of the frustrating motor-task.
The shock box was placed behind the subject and was
constantly set to deliver a direct current of 3.0 millam-
peres to two electrodes attached with surgical tape to the
medial side of the left forearm of each subject and spaced
approximately two inches apart. Onset and amplitude of the
electric current was controlled manually by a switch and
dial, respectively, located on the front of the box. Dura
tion of the current flow was approximately one-half second
and ceased automatically.
The electromyographic electrodes were twenty-three
millimeters in diameter, weighed three grams and made con
tact with the skin area of ten millimeters. Each electrode
and attached connecting cable of thirty inches in length
was shielded to minimize electrostatic interference. The
EMG electrodes consisted of two pick-up electrodes and a
31
grounded electrode, secured to the skin by double-backed
adhesive disks (Biocom Model #10808), with contact medium
between the electrode and skin surface.
Each differential amplifier was designed specifi
cally for acquisition and amplification of bioelectrical
events. It was .9 x .9 x 2.5 inches in size, weighed 1.25
ounces, and contained all silicone resistors for stability.
It had a differential gain of 6,000 with an input impedance
of 2 megohms and output impedance of 30,000 ohms. The
frequency response ranged from 0.1 cps to 5 Kc (plus or
minus 3 db). The noise level was 5 micro-volts peak to
peak over band width of DC to 100 cps as measured with a
10 K ohm source impedance. Each amplifier required a power
source of ±9 volts @0.5 ma. Such power is contained in a
common battery available in any store.
The tape recorder was a Sony Stereocorder Model
TC-105. Potentials were recorded at a speed of 19 cm per
second on 1.0 mil. x l/4 in. x 1200 ft., acetate recording
tape.
The recorded potentials were taken from the tape
and printed on graph paper moving at a constant speed of 25
millimeters per second on a Gilson Direct Polygraph.
Procedure and Instructions
Each subject was greeted in the Patient Lobby on
the first floor of the University of Southern California
32
Dental School and led to a private treatment room on the
second floor. Each subject was seated in a regulation
dental chair which reclined so that the subject was in a
semi-prone position. All equipment was behind and out of
the view of the subject.
When the subject was comfortable, he was asked to
read and sign the Research Participation Form described
above (p. 29). Immediately after receipt of the signed
form, the experimenter stood behind the subject and read
aloud the following instructions:
The following information and instructions are
for your participation in this procedure. If you
have any questions after these instructions are read
to you, remember them, and I will spend as much time
as you wish answering them and explaining the pro
cedure after the necessary data has been gathered.
Electrodes will be placed on your right forearm
and on the muscles of your face where you are cur
rently experiencing the problem. These are to moni
tor the muscle activity in these areas.
You will then be subjected to a series of five
very painful, but harmless, electric shocks to your
left forearm. Please do not talk at all during the
experiment while you have the electrodes attached to
your face.
Following the conclusion of the series of elec
tric shocks, you will be given a fifteen-minute rest
period. Do not speak during this period.
After the fifteen-minute rest period, you will
be given a simple motor task to perform while
blindfolded. You will receive further instruction
at that time.
Following these instructions, the experimenter
placed the EMG recording electrodes on the skin above the
33
masseter and temporal muscles, with the grounded electrode
on the cheek-bone directly below the eye of the painful
and/or dysfunctioning side of the subject’s face. Identi
cal, sham electrodes were placed on the right forearm of
the subject.
As the shock electrodes were taped in placed on the
medial side of the left forearm, the experimenter said:
This is the set of electrodes which will carry
the painful electric shock. The others you need not
worry about in any way.
Now take a deep breath and relax all the muscles
of your body, especially the muscles of your face
and j aw.
Following this procedure, the Biocom amplifier,
tape recorder, and shock box (previously set to deliver the
3.0 millamperes) were turned on, emitting highly audible
clicks.
The potentials emanating from the masticatory
musculature were recorded for five seconds and an Mat rest"
baseline of EMG activity was then determined by recording
while instructing the subject as follows:
Now please clench your teeth as tight as you
can. (Pause) That’s fine, now relax. Please
clench your right fist as tight as you can. (Pause)
That’s fine, now relax. Remember, do not speak at
all during the experiment.
Following these instructions, a period of eight
seconds to twenty-three seconds elapsed followed by the
onset of the first shock to the subject’s forearm. EMG
potentials were measured and recorded from the onset of the
34
first shock.
Shocks were delivered at 8, 17, 36, 50, and 80
seconds, respectively, following the above instructions.
Recordings of EMG activity were continued for ten seconds
after the last shock onset, then recording was terminated
and the following instructions were read aloud:
Now relax. You will receive no more shocks
during this experiment. I want you to remain re
laxed and quiet for fifteen minutes. Please do not
speak during this time.
The shock electrodes were removed from the left
forearm. The subject and experimenter remained silent for
t
fifteen minutes.
After the fifteen-minute interval, the tape recorder
was turned on for the control subjects only and the follow
ing instructions were read to all subjects.
The break is over. I am now going to blindfold
you and ask that you perform a motor task. Please
remain silent during the entire procedure.
(The blindfold was put in place and tied around the
head of the subject with string.)
Here is a rather large board. (The empty form-
board was placed in subject's lap.)
Notice that the board contains a series of holes
or indentations. Now here are a lot of pieces.
(All the form pieces were placed in subject's lap.)
Each piece fits into one of the holes on the board.
I want you to place every one of the pieces in its
correct place on the board. This is often used as a
test of intelligence, so you will want to work as
quickly and efficiently as possible. You will be
rated on your willingness to cooperate, your atti
tude, and your accuracy. You have three minutes to
complete the task. Remember, you must not talk dur
ing this time. (Pause) Ready, begin.
35
25 seconds--You aren’t doing too well, please start
over. (Any blocks in place were removed.)
40 seconds--You aren’t doing it right because you
obviously don't want to cooperate.
45 seconds--(The tape recorder was turned on for the
experimental subjects.)
65 seconds--If you would just try a little harder,
you could do a lot better. Start again. (Any
blocks in place were removed.)
80 seconds--Oops. You made a mistake with this, so
here, try again. (One block removed and handed to
the subject.)
105 seconds--Your time is running out, and you
aren1t doing very good. I wish you were more will
ing to cooperate with this.
120 seconds--Hurry, your time is getting short.
You’ve made another mistake. Try this once again.
(One block removed and handed to subject.)
205 seconds--STOPI Time is up. (Blindfold was
removed and tape recorder stopped.)
Following this last instruction, and removal of the
blindfold, it was noted whether or not the subject pursued
the task until all the blocks were in place on the form-
board. Then the board was removed from the experimental
subject’s lap and while the experimenter began removing the
EMG recording electrodes he stated the following:
That is all, you may talk now while I’m
removing your electrodes.
Following the removal of the blindfold for the con
trol subjects only, the tape recorder was turned off and
the following instructions were read:
Now I want you to relax and remain quiet for
five minutes and then you may do the task over again
36
without the blindfold.
(The blocks and board were removed and the blocks
were restacked the same as during the Frustration
Condition.)
(Five-minute break)
Now here is the board and here are the blocks.
(They were placed in subject’s lap.) Begin when you
are told to do so.
(Tape recorder turned on.)
Ready, Begin.
Upon completion of the task the tape recorder was
turned off and while the experimenter removed the EMG
electrodes he stated the following:
That is all. You may talk now while I'm
removing your electrodes.
Post-Procedure Interview
Following the completion of the procedure described
above, the experimenter asked each subject "how he felt"
during the first part of the procedure, during the shock
sequence, and finally during the motor-task aspect. These
records were annotated and appear in Appendix A.
The experimenter proceeded to explain the project
in detail to each subject and indicated to the experimental
subjects which condition he had increased tension in his
masticatory muscles. Each subject heard the recording of
the EMG activity under both conditions. Noted increases in
activity were pointed out and each subject was informed how
this increase in tension might contribute to his problem.
37
The experimenter explained the nature of the re
search to all control subjects and expressed appreciation
to them for their participation in the project.
CHAPTER IV
RESULTS
The results can be grouped according to the three
measures used to evaluate masticatory muscular tension be
tween TMJ patients (A^) and non-TMJ controls (A2) for the
two conditions: Anxiety (B^) and Frustration (B2). These
measures were: (1) the total amount of time of electromyo
graphic activity above relaxed baseline for the 90-second
intervals during the two experimental conditions: (2) the
average amount of time of electromyographic activity above
relaxed baseline for each episode of tensional activity
during the 90-second sequence of the two conditions; and
(3) the maximum amplitude of electromyographic activity
reached during each 90-second interval of the two condi
tions. These measures respectively reflect the behavioral
manifestation of: (1) total amount of time of masticatory
muscular tension per condition, (2) the mean amount of time
of muscular tension per tensional episode during either
condition, and (3) the intensity of masticatory muscular
tension for each of the two conditions.
38
39
A final result was calculated to determine if there
was a difference of the percentage of time non-TMJ controls
demonstrated electromyographic activity between Condition
II--Frustration and Condition III--Motor Task.
Total Tension Time
Table 1 summarizes the results of the two-way anal
ysis of variance performed for comparing the total time of
masticatory muscular tension manifested during the two
experimental conditions for both groups. The resulting F
value of 6.71 for the main affect between groups and A2
was significant at the .05 level supporting hypothesis (1).
In order to determine the specific source of the
significant mean difference between groups, a planned com
parison of ordered means was performed using the Newman-
Kuels method for determining the critical difference value.
The results of this comparison are summarized in Table 2.
This table shows the primary source of variation relevant
to hypothesis (1) to be accounted for by the difference of
43.57 between groups A^ and A2 during condition B2--Frus-
tration. However, the difference of 7.23 between groups
for condition — Anxiety also was above the critical value
of 4.71, indicating that this also was a source of main
effect variance.
Table 1 also shows the resulting F value of 43.4 to
be highly significant for main affect B, supporting
40
TABLE 1
SUMMARY OF ANALYSIS OF VARIANCE OF TOTAL TIME OF EMG
ACTIVITY ABOVE BASELINE MEASURED IN SECONDS/90
SECOND SEQUENCE
df Mean Squares F
Between Subjects (A) 1 6451.60 6.71*
Subjects Within Groups 18 959.88
Between Conditions (B) 1 7890.48 43.40**
Interaction (AB) 1 3301.49 18.16***
Conditions x Subjects 18 181.77
* p<.05
** pc.OOl
*** p<.01
41
TABLE 2
COMPARISON OF ORDERED MEANS FOR TOTAL TIME OF EMG
ACTIVITY ABOVE BASELINE USING THE
NEWMAN-KUELS METHOD
A2B1 A1B1 A2B2 A1B2
Steps 1 2 3 4
Means
o
•
o
7.23 9.92 53.49
Relevant Hypothesis Comparison Difference'
(2)
A1B2-A1B1
46.26
(1)
A1B2-A2B2
43.57
(2)
A2B2"A2B1
9.92
(1)
A1B1"A2B1
7.23
Critical Difference Value = 4.71
42
hypothesis (2). The planned comparison for between condi
tions B^ and B2 (Anxiety and Frustration respectively), and
summarized in Table 2, indicate the TMJ patients under the
condition B2~-Frustration to be the primary source of main
affect variation difference. The difference of 9.92 for
non-TMJ controls between Conditions B^ and B2 was also
above the critical difference value of 4.71 and therefore
accounts for some of the main variation effects between
conditions.
Table 1 also shows a significant interaction affect
(F value of 18.16) for between Subjects and Conditions.
This F value was significant above the .01 level.
Average Time of Tensional Episode
Table 3 summarizes the results of the two-way anal
ysis of variance performed for comparing the mean time per
tensional episode over the two conditions for both groups.
The resulting F value of 10.67 for the main effect between
groups was significant at the .01 level supporting hypothe
sis (3).
The planned comparison to determine the primary
source of variance for between groups using the Newman-
Kuels method is summarized in Table 4. The difference of
11.39 is above the critical difference value of 4.71 and
shows the primary source of variation relevant to hypothe
sis (3) to be between groups during the frustration
43
TABLE 3
SUMMARY OF ANALYSIS OF VARIANCE OF MEAN TIME OF EMG
ACTIVITY PER EPISODE OF ACTIVITY ABOVE
BASELINE/90 SECONDS
Source df Mean Squares F
Between Subjects (A) 1 398.79 10.67**
Subjects Within Groups 18 37.35
Between Conditions (B) 1 845.78 20.87**
Interaction (AB)
1 257.26 6.34*
Conditions x Subjects 18 40.52
* p<.05
** p<.01
44
TABLE 4
COMPARISON OF ORDERED MEANS FOR MEAN TIME OF EMG
ACTIVITY PER EPISODE OF ACTIVITY ABOVE
BASELINE/90-SECOND SEQUENCE USING THE
NEWMAN-KUELS METHOD
A2B1 A1B1
A2B2 A1B2
Steps 1 2 3 4
Means 0.0 1.24 4.12 15.51
Relevant Hypothesis Comparison Difference
(4)
A1B2“A1B1
14.27
(3)
A1B2-A2B2
11.39
(4)
A2B2“A2B1
4.12*
(3)
A1B1-A2B1
1.
*
'3-
CM
Critical Difference Value = 4.71
* Below critical difference value
45
condition, B2 and not during the anxiety condition, B^.
The latter comparison resulted in the difference value of
1.24, considerably below the critical difference value
required for determining the source of main effect varia
tion .
The F value in Table 3 of 20.87 for comparing dif
ferences between conditions was significant at the .01 level
supporting hypothesis (4). Table 4 also shows the only
source of variation to be Condition B2 (Frustration) for
the A^ group (TMJ patients) only. This difference being
14.27 was above the critical value of 4.71. The difference
value of 4.12, comparing group (non-TMJ controls) over
conditions B^ and B^ is below the critical difference value.
The interaction affect between subjects within
groups and conditions was significant at the .05 level.
The F ratio shown in Table 3 is 6.34.
Intensity of Tension
Table 5 summarizes the results of the two-way anal
ysis of variance performed for comparing the maximum ampli
tude of electromyographic activity during the 90-second
intervals of Condition B^--Anxiety and Condition B2 ~-Frus-
tration for both groups.
The F value for main effect A (between groups) was
24.43 and significant above the .01 level supporting hypoth
esis (5).
46
TABLE 5
SUMMARY OF ANALYSIS OF VARIANCE OF MAXIMUM
AMPLITUDE OF EMG ACTIVITY REACHED PER
90-SECOND SEQUENCE IN MILLIMETERS
Source df Mean Squares F
Between Subjects (A) 1 3802.5 25.43*
Subjects Within Groups 18 149.5
Between Conditions (B) 1 4840 .0 17.95*
Interaction (AB) 1 592.9 2.19
Conditions x Subjects 18 269.6
* p<.01
47
The planned comparison to determine the primary
source of variance between groups using the Newman-Kuels
method is summarized in Table 6. Both the difference be
tween groups and A 2 for Condition of 11.8 and the
difference value between groups A^ and A^ for Condition B2
of 27.2 contributed to the overall between-group variance.
Both difference values were above the critical difference
value of 4.71.
The main effect between conditions (B) shown in
Table 5 was also significant above the .01 level. The F
value was 17.95 and supported hypothesis (6).
Summary of the primary source of variation between
conditions B^ and B 2 using the Newman-Kuels method is con
tained in Table 6. Both the difference values between
condition B^ and B2 for both groups, 29.7 and 14.3 respec
tively, were above the critical difference value of 4.71.
Table 5 also shows that the interaction value of
2.19 was not significant.
Percent Tensional Time for
Non-TMJ Controls
Table 7 summarizes the difference in the total per
centage of time non-TMJ control subjects spent in tensional
activity above relaxed baseline between Condition II--Frus-
tration and Condition III--Motor Task. The student _t test
for differences between means was used. The value was
6.74 and was significant at the .01 level.
48
TABLE 6
COMPARISON OF ORDERED MEANS FOR MAXIMUM AMPLITUDE
OF EMG ACTIVITY REACHED PER 90-SECOND SEQUENCE
USING THE NEWMAN-KUELS METHOD
A2B1 Vi
A B
2 2
A1B2
Steps 1 2 3 4
Means 0.0 11.8 14.3 41.5
Relevant Hypothesis Comparison Difference
(6)
A1B2~A1B1
29.7
(5)
A1B2_A2B2
27.2
(6)
A2B2“A2B1
14.3
(5)
A1B1"A2B1
11.8
Critical Difference Value = 4.71
49
TABLE 7
STUDENT-t TEST OF DIFFERENCES IN TOTAL PERCENTAGE
OF TIME OF EMG ACTIVITY ABOVE BASELINE BETWEEN
FRUSTRATION SEQUENCE AND MOTOR TASK FOR
NON-TMJ CONTROLS
________________Mean________Sf_______S_______Est. Diff.______t
Frustration 11.49 136.9 11.7
1.35 6.74*
Motor Task 2.56 23.04 4.8
* p<.01
CHAPTER V
DISCUSSION
Total Time of Masticatory
Muscular Tension
The primary purpose of this investigation was to
examine the relationship of anxiety and frustration on the
tensional level of masticatory musculatore of persons suf
fering from Temporomandibular-joint Syndrome.
Review of the dental literature regarding TMJ syn
drome postulates a model using "anxiety" as the primary
etiologic factor contributing to muscle tension and spasm
and further TMJ problems leading to TMJ syndrome (Schwartz,
1959).
Results of this investigation supported the hypoth
esis (1) that there is a difference between TMJ patients
and non-TMJ controls in the total amount of time spent in
tensional activity during conditions which are anxiety-
provoking and/or frustrating. Tensional activity is behav-
iorally defined as isometric contraction of the masticatory
musculature and/or clenching of the teeth.
Results indicated that the main source of the
50
51
difference between the two groups using the total time
measure, was accounted for by their difference in the frus
trating condition rather than the anxiety-provoking one.
However, the difference between the total tension time of
the two groups during the anxiety condition was above the
critical value of 4.71 (Table 2). This indicates that
there also might be a difference between the two groups
during the anxiety condition. Examination of the raw data
in Table 8 (Appendix A) demonstrates that there was no
increase in tension in six of the ten TMJ patients during
the shock sequence. It also shows that only one TMJ pa
tient (7E) experienced masticatory tension for any great
length of time during the anxiety condition. If this sin
gle value (54.8) was removed, the mean value for the group
would drop sufficiently to make the difference value be
tween the two groups 1.75, which is below the critical
difference value required to assume a source of variance.
Results also confirm the hypothesis (2) that there
is a significant difference in the amount of time subjects
engage in tensional responses between anxiety-provoking
conditions and frustrating ones. Here again, the main
source of that difference appears to be the frustration
condition. Table 8 (raw data) shows that only four sub
jects engaged in tensional activity during the anxiety
condition, whereas sixteen subjects experienced masticatory
tension during the frustration condition. It is noteworthy
52
that the only subjects to experience tension during the
anxiety condition were TMJ patients.
Table 2 shows that the total tension time differen
tial between conditions was much greater for TMJ patients
than for non-TMJ controls, the mean differences being 9.92
and 46.26 seconds respectively. This result would indicate
that despite the fact that 9.92 is above the critical value
required for determining a source of main effect variation,
the primary source of variation between conditions lies
within the TMJ patients during the frustration condition
and not the anxiety-provoking sequence.
The significant interaction effect for total ten
sion time (Table 1) indicates that there were instances
within the total experiment wherein the non-TMJ controls
demonstrated greater total tensional time than did individ
ual TMJ patients. Table 8 (raw data) shows that with the
exception of TMJ subject 5E, who did not tense at all dur
ing the frustration sequence, the longest period of ten
sional time for non-TMJ controls during the frustration
condition (35.2 seconds) was still shorter than the short
est tensional time for the TMJ patients (40.7 seconds).
Therefore, the interaction effect is primarily accounted
for by the individual non-TMJ controls during the frustra
tion condition engaging in longer periods of tension than
did TMJ patients in the anxiety condition.
Based on the confirmation of the first two
53
hypotheses and subsequent data analysis discussed above,
the following conclusions might be indicated: (1) it
appears that both TMJ patients and non-TMJ controls do not
engage in significantly long periods of masticatory tension
when in an anxiety-provoking situation; (2) both TMJ
patients and non-TMJ controls do engage in rather long
periods of masticatory muscular tension during the condi
tion of frustration; and (3) TMJ patients engage in signif
icantly longer periods of tensional activity in the TMJ
area during the frustration condition than non-TMJ controls.
Mean Time of Tensional Episode
Since TMJ patients do engage for a total length of
time in longer tensional activity during frustrating condi
tions than do non-TMJ controls, it would be informative to
determine if TMJ patients tend to tense continually or for
many brief periods of time and compare this variable to
non-TMJ controls. To make this comparison, the mean time
of tension per episode of tensional activity for all sub
jects was used.
The results confirm the hypothesis (3) that there
is a significant difference in the mean time per episode of
tension between TMJ patients and non-TMJ controls (Table 3).
Table 4 demonstrates that the main source of difference can
be accounted for by the TMJ patients’ mean episodic time
during the frustration condition. The difference of 11.39
54
derived by comparing TMJ patients with non-TMJ controls
over the frustration condition (I^) was above the critical
difference value, whereas the difference of 1.24 derived by
comparing the groups over the anxiety condition (B.^) was
below the critical difference value.
Results also support the hypothesis (4) that there
is a significant difference in the mean time per episode
between the two conditions of anxiety and frustration
(Table 3). Table 4 also indicates that the main source of
this variation was the frustration condition for the TMJ
patients. The difference of mean episodic time for TMJ
patients between the anxiety condition and the frustration
condition was 14.27 and above the critical difference value.
However, the difference of the mean episodic time for non-
TMJ controls between conditions (4.12) was not above the
critical difference value. This indicates that TMJ pa
tients during the frustration condition were more apt to
tense for longer episodes than in an anxiety condition or
than non-TMJ controls over both conditions.
The significant interaction effect for the mean
episodic time was also significant (Table 3). Similar to
the total tension time, this means that during the entire
experiment, some individual non-TMJ controls* mean episodic
time was significantly greater than that of TMJ patients*
individual time. Table 9 (raw data) confirms this effect
in that several of the mean scores of the non-TMJ controls
55
during the frustration sequence were above the TMJ patients’
scores during both conditions. However, it was also noted
that the longest mean obtained by a non-TMJ control during
the frustration sequence (S5C, 11.7 seconds) was only a
second above the shortest mean of a TMJ patient during that
same sequence (S3E, 10.1 seconds), provided that 5E is
again omitted.
The results and subsequent analysis of the data
discussed above leads one to conclude that TMJ patients
have the tendency to tense longer per episode of tensional
activity than do non-TMJ controls, especially during the
frustration condition.
Intensity of Total Tension
Since TMJ patients tense their masticatory muscles
for longer total periods of time and for a longer time each
occasion they do tense, as compared to non-TMJ controls,
this does not necessarily mean that the intensity of the
tension is greater. To determine this relationship, the
maximum amplitude of tensional activity reached over each
90-second condition for all subjects was used.
Hypotheses (5) and (6) were both supported by the
results (Table 5). Since all differences between the mean
ingful comparisons of means were above the critical differ
ence value (Table 6), it is difficult to determine which
differences account for the main effects differences.
56
However, the interaction effect was not significant
on this measure (Table 5). This indicates that at no time
during the two procedures did the intensity of the tensional
activity for non-TMJ control group significantly surpass
that of the TMJ patierit group.
Based on these results the conclusion can be drawn
that when TMJ patients tense their masticatory musculature,
they do so with significantly greater intensity than do
non-TMJ controls.
A summary of the conclusions indicated by the re
sults of this investigation show that compared to non-TMJ
controls, persons suffering from TMJ syndrome tend to tense
their masticatory musculature longer when frustrated, for
longer periods of time per tensional episode, and more in
tensely .
The Problem of Definition
°^ Conditions
The terms "anxiety” and "frustration" appear often
in psychological literature as experimental variables. In
this investigation as well as in others, the assumption was
made that the Anxiety Condition was anxiety arousing. A
similar assumption was made concerning the Frustration Con
dition, that it was, in fact, frustrating. This latter
assumption was based on the criteria for defining a frus
trating situation proposed by Brown (1961) and discussed in
Chapter I as well as the anecdotal records which appear in
57
Appendix A. The assumption regarding the Anxiety Condition
was based on behavioral observations and verbal reports of
the subjects (Appendix A).
However, the literature remains ambiguous regarding
the exact nature of "anxiety" and "frustration" and even
more vague in defining the exact stimulus conditions which
supposedly evoke these variables for a specific experiment.
Often a delineation is not made between conditions
which arouse anxiety or frustration (stimulus condition)
and the nature of the anxious or frustrated response
(response condition).
The definition of psychological stressors or stress,
whether "anxiety" or "frustration," is highly problematic,
primarily because these words are generally used as the
individual author stipulates, with no general agreement
between them.
Cofer and Appley (1964) review the various uses of
the term "stress" and isolate no fewer than seven "critical
features" regarding psychological stress: (1) it is an
organismic state; (2) it includes an interaction between
the organism and the environment; (3) it differs from the
ordinary "motivated state" in that it is more extreme and
may be synonymous with severe frustration, anxiety, or con
flict; (4) a threat must be present; (5) the threat must be
perceived; (6) the organism’s integrity must be involved;
and (7) a usual coping response or defensive response is
58
not available. Cofer and Appley (1964) go on to define
psychological stress in light of these seven categories as
"the state of an organism where he perceives that his well
being or integrity is endangered and that he must devote
all his energies to its protection." It was obvious that
in this investigation, if such a definition of psychologi
cal stress were adopted, one could conclude that neither
Condition I nor Condition II were psychologically stressful.
Indeed, it would be an experimental rarity, if not unethi
cal, to use any experimental conditions which evoked "psy
chological stress" under that definition.
However, Cofer and Appley do not specify whether
they would consider a stimulus condition "stressful," if
such a subject response was not forthcoming. But, if that
were indeed the case, the vast majority of research with
regard to psychological anxiety and frustration has most
certainly been faulty in the demonstration of such a
response.
With regard to the nature of the stimulus condi
tions that evoke an anxious response or a frustration
response, the literature is even more ambiguous and, upon
review (Chapter I), leads one to conclude that the occur
rence of any stimulus condition, regardless of its nature,
might be anxiety-provoking or frustrating. Thus, the chirp
of a bird becomes frustrating if it keeps one awake at
night, and the presence of water arouses anxiety in a
59
hydrophobic person. But by the same token, it is just as
obvious that no stimulus serves as an inducer of psychologi
cal anxiety or frustration in all individuals exposed to it.
Therefore, the literature remains consistently unclear
regarding "anxiety" and "frustration" and the specific and
explicit experimental variables that evoke such a psycho
logical response.
The present investigation is, unfortunately, unable
to delineate the precise variables which might have served
each subject as anxiety-provoking or frustrating. Were
they the instructions, the dental chair, the expectations
of the subject, the electric shocks, the blindfold, the
experimenter’s harassment, or the motor task alone? The
latter was briefly investigated for the non-TMJ controls.
Table 7 demonstrates that at least for the control subjects,
there was a significant difference in the subjects’ ten
sional responses between the Frustration Condition and the
Motor Task alone.
However, the problem of definition of anxiety or
frustration conditions remains prevalent throughout the
literature, with little or no attempt to experimentally
clarify the situation.
Psychological researchers are still very much
dependent on behavioral observations and verbal reports
from which to infer the presence of a psychological, inter
nal state. Appendix A contains the anecdotal records of
60
the subjects’ behavioral responses and verbal reports during
the two conditions. Given these records, the Brown criteria
for frustration which were generally met in this study, and
the response difference between the Frustration Condition
and the Motor Task alone for non-TMJ controls, one can infer
that the current experimental conditions were, indeed, gen
erally anxiety-provoking and frustrating.
Theoretical Considerations
Regardless of the exact psychological nature of the
two experimental conditions, the response of the TMJ pa
tients to them was a differential one. TMJ patients do
generate greater tension in the musculature of the TMJ area
under specifiable conditions than do non-TMJ persons.
If one assumes that Condition II was frustrating,
and therefore is one condition under which greater tensional
responses in TMJ patients occur, then certain questions
arise which require further research. Such questions in
clude: (1) if tension in the masticatory muscles is a
response peculiar to TMJ patients when they are frustrated,
would other learned responses to frustration alleviate the
masticatory muscular tension which contributes to the con
tinuation of the TMJ syndrome?; (2) what might be the rela
tionship between "internalized aggression" due to frustra
tion and masticatory tension in TMJ patients?; and (3) would
treatment of TMJ syndrome include the learning of
61
appropriate outlets of aggression? TMJ patient 5E, who was
the only TMJ patient who demonstrated no tension during the
frustrating condition and who slapped the experimenter
(Appendix A), reported that during the frustration sequence
she was rehearsing Min her mind" how she was going to ag
gress against the experimenter. Might not the mere
imagining of aggression tend to lessen tension in mastica
tory musculature for TMJ patients? Finally, the question
of what other specific stimulus conditions might there be
wherein TMJ patients respond with greater masticatory
muscular tension needs to be examined.
The above are all questions which require further
research and the answers should bear heavily on the diagno
sis and treatment of dental patients suffering from
Temporomandibular-Joint Syndrome.
CHAPTER VI
SUMMARY
The purpose of the investigation was to examine the
relationship of masticatory muscular tension in persons
suffering from Temporomandibular-Joint (TMJ) Syndrome to
experimental conditions of anxiety and frustration.
The subjects were ten patients currently diagnosed
as experiencing TMJ syndrome, matched in age and sex with
ten controls with no history of TMJ problems. Each subject
group consisted of four males and six females.
The experimental conditions were Anxiety, Frustra
tion, and Motor Task. The Anxiety condition was instruc
tions about, and the experiencing of, a series of five
painful electric shocks to the medial side of the left
forearm. The Frustration condition was a motor task of
placing various shaped blocks into a form board while
blindfolded. Each subject was harassed by the experimenter
and was not allowed to complete the task. The Motor Task
condition was for non-TMJ controls and replicated the motor
task of the Frustration condition but without a blindfold
or experimenter comment.
62
63
It was hypothesized that patients experiencing TMJ
syndrome would experience greater tensional time, longer
periods of tension per tensional episode, and greater ten
sional intensity than the non-TMJ controls over the condi
tions of Anxiety and Frustration. It was further hypothe
sized that each group would differ significantly between
the two experimental conditions and that non-TMJ controls
would differ significantly between the Frustration condi
tion and the Motor Task.
Results confirmed the hypotheses and further analy
sis of the data revealed that TMJ patients, when compared
to non-TMJ controls, demonstrate tensional responses in the
masticatory musculature when frustrated rather than anxious,
for a longer duration per tensional episode, and more
intensely.
The results were discussed and the problem of the
definition of psychological stressors such as "anxiety" and
"frustration" was reviewed. Some further theoretical con
siderations regarding future research of the TMJ syndrome,
frustration, aggression, diagnosis, and treatment were
presented.
APPENDIX A
ANECDOTAL RECORDS
64
SUBJECT IE
65
Date: 3-10-70
Observations
As initial directions were being read, she inhaled
deeply and stated, "I’m really scared of being shocked, I
sure hope it doesn’t hurt too much."
As shock electrodes were being attached to left arm,
she began to squirm continually in the chair.
During the shock sequence, she inhaled through her
teeth often, teared, and often made small whimpering sounds
in her throat. Her hands were shiny with perspiration.
She exhibited a startle response at each shock onset.
Shook bodily occasionally through the break period after
the shock electrodes were removed. Deep sighs continuously
throughout the break.
Seemed hesitant to begin task. Once she began, she
was erratic in her approach. Her body obviously tensed in
rigid fashion as the task and harassment continued. Com
pleted the task upon removal of the blindfold and stated
immediately, "Oh, I’m sorry, I didn't know these were up
here" (referring to the top row of holes in the board). "I
didn’t know that this was such a big board."
Verbal Report
E: "How did you feel during the shock sequence?
S: "I was so scared, I couldn’t think, I mean it was just
terrible, I just kept waiting for the next one."
66
E: "How did you feel during the motor task period?"
"Well, of course I felt dumb and frustrated with that
damn board, I mean really, what did a thing like that
have to do with this?" (touching her left cheek).
The experimenter explained the entire procedure and
let the subject listen to the tape recording and see the
results on an oscilloscope.
SUBJECT 2E
67
Date: 2-17-70
Observations
Did not seem concerned and made no comment during
the reading of the initial instructions.
While electrodes were being attached, he said, "You
know I’m a Psychology major and I’ve never been zapped
myself before. I guess I'll know what the poor rats feel
like now. How bad is the shock anyway? Will my hair fall
out with the shock? (laughs slightly)." Experimenter made
no comments during the electrode placement.
During the shock sequence subject made no audible
sounds. Perspiration appeared on his upper lip and somewhat
on his forehead. His left arm from shoulder down, jerked
spasmodically, at onset of each shock. Eyes were closed
during the entire sequence.
During the break period, perspiration appeared on
left hand and upper lip. He moved to settle in more com
fortably in the chair and sighed at approximately l-l/2
minutes after break onset.
Smiled on two occasions during motor task. Was
flacid and loose on his grip of the blocks and seemed more
so as the harassment proceeded. Dropped block(s) on several
occasions. Completed task upon removal of the blindfold.
Verbal Report
E: "How did you feel during the shock sequence?"
68
S: MHow many shocks did you say there were?"
E: "Five."
S: "Well, I counted six, the first one was really light,
but when the second one hit, it was a lot stronger . . .
(Possible that small current passed to electrodes when
the equipment was checked for intensity of delivery)
But after the third one, I decided it wasn’t so bad."
E: "How did you feel during the motor task?"
S: "Really frustrated. These electrodes on my arm
hampered me and I couldn’t reach what I wanted to with
my right hand. By the time you said ’hurry up,’ didn’t
bother me cause I didn’t give a damn about it.
Experimenter explained the whole experiment and
subject made the suggestion: "You know it might be better
if you don’t tell them that they aren’t doing too well, I
know it would be more applicable when I tell myself I’m not
doing well."
SUBJECT 3E
69
Date: 1-20-70
Observations
Her husband is a dental student at USC. She seemed
eager to cooperate. Made no noticeable changes in body
position or observable response to the initial directions.
While electrodes were being put in place she asked,
"What does this have to do with my jaw locking halfway
open?" She was informed again that the experimenter would
answer all her questions at the end of the entire procedure.
She exhibited a startle response at Shock #1 onset.
She shifted the position of her legs twice during the se
quence. She kept her eyes closed during the entire se
quence.
She sighed deeply at conclusion of shock #5 and
seemed completely calm during the entire break period.
She giggled as she began the task and dropped three
blocks on the floor. Experimenter placed them back on her
lap. She smiled during the initial approach to the task.
When the experimenter accused her of not cooperating, the
smiling stopped. She went about the task in rather system
atic fashion and was successful in placing six blocks in
the correct position by the end of the time. She completed
the task when the blindfold was removed with no comment.
Verbal Report
E: "How did you feel during the shock sequence?"
|C/> |P1
70
S: "Well, I was nervous about when the shock would come.
I closed my eyes and counted them very carefully. I
just kept saying to myself that it was almost over and
that it really wasn’t so bad after all.”
: "How did you feel during the motor task?”
: "It was amusing at first, reminded me of a psychiatrist
trying to put round pegs in square holes. And I was
all right until you started pushing me, then it got me
upset."
Experimenter explained procedure and played the
tape and let her see her data on the scope.
SUBJECT 4E
71
Date: 1-14-70
Observations
Remained calm while initial directions were read.
Commented continually during the period while electrodes
were being placed, e.g., "this is just like an EKG I had
once isn’t it"; "I sure hope the pain doesn’t last too long
during this thing," etc.).
She exhibited a startle response on first shock
onset. Seemed to become sensitive to the shock as they
proceeded. Said "ummm" on the last four shocks with pro
gressive intensity. Began to fidget in the chair during
pause between shock #4 and #5. Left hand began shaking
upon shock #3 onset.
Sighed as shock electrodes were removed. Seemed to
"settle down" into the chair during break. Closed eyes and
seemed calm during the break period.
Began motor task systematically when told to do so,
not before. As harassment continued, her approach became
more erratic. She dropped two blocks on one occasion, and
single blocks at three other times. Experimenter picked
them up and replaced them on the board with the rest of the
unplaced blocks. Completed task upon removal of the blind
fold. Said "ummm, it can be done" upon completion of task.
Verbal Report
E: "How did you feel during the shock sequence?"
72
S: "Nervous, I mean really nervous about when the next
shock would be. I kept thinking just three more, just
two more until it’s all over."
E: "How did you feel during the motor task?"
S: "I felt like a complete idiot. Thanks a lot for all
your encouragement there. Boy, did I feel dumb."
Experimenter showed her the recordings on the scope
and let her listen to sections of the tape and explained
the entire procedure.
SUBJECT 5E
73
Date: 1-20-70
Observations
Interrupted the initial directions several times
with questions and statements such as: "Will this hurt?"
"I don’t like to be hurt," "I am very sensitive to pain,"
etc. Made obvious attempts to appear calm while electrodes
were being attached. Kept pulling down on the hem of her
skirt and readjusting her position.
Emitted a high-pitched yelp at the onset of each
shock. Head rolled from side to side. An occasional moan
between shock. Perspiration appeared on forehead and under
eyes.
Emitted deep sigh approximately every twenty sec
onds during the rest break. Engaged in continual squinting
of her eyes.
Did not seem too interested initially in performing
the task. Began to bang the forms down on the board when
harassment began. Dropped single blocks on two occasions.
Completed the task when blindfold was removed while stating,
"Does this really mean I'm stupid?"
Verbal Report
E: "How did you feel during the shock sequence?"
S: "You told me it wouldn’t hurt, well I’ll show you what
I think!" (She got up from the chair while stating
this. Upon the completion of that statement she slapped
the experimenter on the left cheek fairly gently.)
"And that’s not as hard as I wanted to either." The
experimenter took both her hands between his and sub
ject began to tremble and tears appeared in her eyes.
Experimenter encouraged her to sit down. She did and
when seated again, looked up and stated, "I hope you’re
still my friend, but I was told I should learn to ex
press my anger. I’ve never done anything like that in
my life. I’m a good Christian and I was told I
shouldn’t be that way." She began to cry and reached
in her purse for a tissue.
Upon questioning as to who told her to express her
anger, she reported that she had begun seeing a "psy
chologist" two weeks earlier and he had told her she
"was neurotic and shouldn’t keep her anger in all the
time."
She stopped crying and as she did so volunteered
the information: "When you told me it wouldn’t hurt
and it did, you lied to me, and then when you kept on
buggin’ me to do that task better, all I could do was
sit there and rehearse in my mind how I was going to
slap you when all this was over, and I did. I couldn’t
really concentrate because I kept thinking about hit
ting you, does this mean I’m stupid?"
The experimenter spent fifty minutes reassuring her
and explaining to her the whole nature of the study.
75
She seemed genuinely interested. She took notes and
compulsively asked the experimenter to repeat certain
things he said.
Finally she felt calm enough and left. On the way
out of the door she apologized "for acting the way I
did." She was again reassured that it was "perfectly
understandable" and that it was all right. She thanked
the experimenter and left.
SUBJECT 6E
76
Date: 12-3-69
Observations
Kept shifting and pulling the hem of her skirt down
while the initial instructions were being read. Said
nothing while the electrodes were being attached to her
face and arms. Stared a long time at her left forearm
after the shock electrodes had been attached and clenched
her left fist slightly.
Upon removal of the shock electrodes, she sighed
deeply and adjusted her position in the chair. During the
shock sequence, she continuously clenched and unclenched
her left fist. No other noted behavior during the shock
sequence.
She was very hesitant to begin task. She kept her
left hand around the stack of blocks and very gingerly
picked up an individual block with her right hand. Only
managed to place one block in board during the entire
period. Several others were on the board, but not in place.
Completed task upon removal of blindfold. When the blind
fold was removed, she spontaneously exclaimed, ’'I’ll be
darn,” then laughed a little.
Verbal Report
E: ”How did you feel during the shock sequence?”
S: ’’Well, I was really scared for a while. I kept waiting
for the next one. I guess I was really nervous because
77
my hands got clammy like they do when I get nervous.
But after that, it didn't bother me."
E: MHow did you feel during the motor task?”
S: "I thought you were pulling my leg. I didn't really
believe there were enough spots for all those pieces
and I was afraid I would drop the pieces. (Pause) I
got mad when you kept pushing me because I really
thought it wasn't possible to do them all."
Experimenter explained the results and played the
tape for her.
SUBJECT 7E
78
Date: 1-13-70
Obser vati ons
Seemed relaxed and calm during the reading of in
structions. Crossed and recrossed legs three times during
electrode placement. Began to ask question on two occa
sions and experimenter didn’t answer and asked that he
remain quiet while electrodes were attached.
Uttered an audible "ummm" at each shock onset.
Exhibited startle response on onset of shock #1 and #2, and
not thereafter. Perspiration formed on upper lip and
slightly on upper forehead. Fidgeted in chair during shock
sequence.
Sighed deeply upon shock electrode removal and
twice again during break period.
Began task before told to do so. Dropped a block
on three occasions. Seemed in a great hurry. Hands moved
rapidly from place to place with no apparent reason. Often
felt the accurate form and board indentation and then
passed over it. Said "wow" when told to stop. Completed
task when blindfold was removed.
Verbal Report
E: "How did you feel during the shock sequence?"
S: "Well, I kinda kept expecting the next one, wondering
when it was going to hit. I felt sort of a nervous
expectation, and I counted them and was really glad
79
when that fifth one came around."
E: "How did you feel during the motor task?"
S: "Pretty stupid. I kept on dropping them. Wondered why
you were pushing me so hard. Really felt dumb near the
end."
The experimenter explained the purpose and proce
dure of the research. Since he was a dental student, he
seemed very interested and seemed to understand the whole
thing.
SUBJECT 8E Date: 1-27-70
80
Observations
Had shaved his sideburns as requested when the date
for his participation was originally set up. Seemed eager
to cooperate. Asked how long each shock would last during
the reading of the initial instructions. Experimenter said,
"approximately one-half second." Remained behaviorally
calm during the electrode placement.
Emitted a loud "mmm" at onset of shocks #1, #2, and
#4. Perspiration formed on upper lip during shock sequence.
Recrossed his ankles twice during shock sequence.
Closed eyes and did not move during the break
period.
Was slow in approach to motor task. Dropped two
blocks on one occasion and one block immediately after the
first two were replaced in his lap. This was accompanied
by the second experimenter comment in the frustration
sequence.
Did not complete the task upon removal of the
blindfold.
Verbal Report
E: "How did you feel during the shock sequence?"
S: "I know my hands got clammy when I got shocked, and I
counted them. (Pause) I guess I was sort of nervous
waiting for the next one."
81
j£: "How did you feel during the motor task?"
S: "Well, what really made me mad is when you kept pushing
me that way. I mean I felt stupid enough without you
saying I wasn’t cooperating and things like that."
E: "I noticed you didn’t complete the task when the blind
fold was removed. Why?"
S: "I felt, hell, if he is so anxious to get the job done,
let him do it. I’ve had it."
Experimenter explained the entire procedure and
purpose of it to the subject.
SUBJECT 9E
82
Date: 3-3-70
Observations
He was a staff member of the dental school and
familiar with research. Sat quietly during the reading of
initial instructions. Did not speak during electrode
placement and seemed very calm. Left arm jumped at onset
of shock #1 and #2, but no thereafter. Slight perspiration
appeared high on forehead during sequence.
During the break, remained calm after an initial
sigh and positional shift in the chair.
Approached the motor task very systematically and
efficiently, despite frustration method; was able to place
all but two blocks in board before time was up. Completed
the task after blindfold was removed.
Verbal Report
E: "How did you feel during the shock sequence?"
S: "OK, I guess. It wasn’t as bad as I thought it would
be."
E: "How did you feel during the Motor task?"
S: "Felt as if I didn’t do as well as I should have, and
it was frustrating to me. Wasn’t anxious about finish
ing until you said to hurry up."
Experimenter explained the entire research proce
dure to him and he seemed quite interested and asked many
83
questi ons.
SUBJECT 10 E Date: 11-9-69
84
Observations
Interrupted the reading of the instructions with,
"You mean you’re gonna shock me? Wow, what does that have
to do with this?" (Indicated the side of her head where
she feels pain.) Experimenter answered with, "I will an
swer all your questions after the procedure is complete if
you will please remember them." Subject replied, "Well I
don’t like being shocked, it scares me.” With this, she
turned in the chair, leaned back and crossed her arms in
protesting resignation. Allowed her arms to be uncrossed
one at a time for electrode placement. When experimenter
told her that the shock electrodes were the ones on her
left arm, she said, "Oh dear, mmmm."
During the shock sequence, she perspired on upper
lip. Left arm jumped at each shock and she said "mmm" at
each shock.
When shock electrodes were removed, she said, "Boy
I'm glad that's over." She was reminded to remain quiet.
She said, "Oh there's more?" Experimenter replied, "Um,
mm." She sighed and leaned her head back and closed her
eyes.
No movement noted during the rest period.
During the motor task she kept making a clicking
sound with her tongue against the roof of her mouth (Tsk
85
Tsk), followed by "mmm." Completed the task when blindfold
was removed.
Verbal Report
E: "How did you feel during the shock sequence?"
S: "Boy, I was really nervous you know. They really hurt,
I thought you were just kidding you know. It was . . .
it really got me upset you know."
E: "How did you feel during the motor task?"
S: "I guess I felt you were deliberately pestering me you
know and it made me mad because I couldn’t do it all
you know and you know . . . other than that . . . I
don’t know."
Experimenter explained the whole thing and played
the tapes of the data for her.
SUBJECT 1C
86
Date: 4-10-70
Observations
Was quiet during initial instructions. While
electrodes were being placed, she said, "I want you to know
I’ve never felt so weird in my life. It’s like being pre
pared for brain surgery or something. (Pause) How long
will the shocks last? You did say they would be painful
didn’t you?” Experimenter replied, ’’Please remain silent
now that these are attached.”
Subject jumped in startled fashion at each shock
onset. She recrossed her ankles on four occasions during
the shock sequence. Sighed deeply when told shock sequence
was over. Settled down in chair for rest period, closed
her eyes and sighed again.
Worked at task with apparent desire. Dropped one
block on one occasion.
When blindfold was removed, she completed task,
banging pieces into place and saying, ’’That was totally
unfair, you throw all these all in my lap and expect me to
find the holes when I can’t even find the pieces, I’m
frustrated you know, my IQ must be zero."
Did the motor task in fifteen seconds without com
ment .
Verbal Report
E: "How did you feel during the shock sequence?"
87
S_: "Well, that hurt a lot you know and I was sure glad
when it was over. I was kind of nervous.”
No verbal report on the motor task was felt neces
sary since the spontaneous remarks upon blindfold
removal.
Experimenter explained the entire procedure and
played the tapes for her and let her view the data on the
oscilloscope.
SUBJECT 2C Date: 4-7-70
88
Observations
Remained calm and relaxed throughout the initial
instructions, electrode placement, and shock sequence. Had
slight perspiration on upper forehead. Left forearm
twitched upon each shock onset.
Relaxed and still during break period. Perspira
tion disappeared.
Worked with fervor during task period. Dropped
three blocks on one occasion, two on another. Experimenter
replaced them on his lap.
When blindfold was removed, he completed the task
and spontaneously said, "I have a complaint. You should
have this on a flat surface and not on my lap so I could
feel both blocks and board without having the blocks fall
all over. Oh I’m sorry, I’m not supposed to talk."
Completed the motor task alone in twelve seconds.
Verbal Report
E: "How did you feel during the shock sequence?"
S: "Interested. I’ve never been shocked before except by
an electric cord in the house you know. Every time I
wasn’t prepared for each one.”
E: "How did you feel during the motor task?”
S>: "I was pretty tense, I didn’t like it and would have
liked it if I could feel the pieces and board at the
89
same time. I tried too long to put one on one section
too long. I was really having difficulty and it was
really frustrating you know."
Experimenter explained the procedure and purpose of
the research and played the data tapes for the subject.
90
SUBJECT 3C
Observations
Did not speak during the initial instructions.
After they were read she asked, "Just how painful are these
shocks?" Experimenter replied, "Some people are more sen
sitive than others." She shifted in her chair and said,
"Oh dear."
While the electrodes were being placed she said,
"These look just horrible, like fish-eyes. I guess it's
the wires coming out of them that make them look so bad."
Perspiration was on her forehead and hands.
Exhibited the startle response on onset of shock
#1. Made no noticeable bodily movements during the remain
ing sequence of four shocks.
Remained relaxed and quiet during the break.
Was systematic in approach to task and did not
change behavior during the harassment. When experimenter
said, "Stop," she laughed. Completed the task when blind
fold was removed and spontaneously asked, "That was a test
of intelligence? Wow!"
Verbal Report
E: "How did you feel during the shock sequence?"
S: "Mad, cause they hurt. Upset cause they were really
painful."
E: "How did you feel during the motor task?"
91
S: "Kind of frustrated and confused; I just couldn't seem
to figure out where to place my hands, on the blocks or
on the indentations."
Experimenter explained the entire purpose and pro
cedure and let her listen to her data tape.
SUBJECT 4C
92
Date: 4-27-70
Observations
Subject was pregnant. Before the initial instruc
tions were read, subject said, "Ooh, I hate dentists.” She
did not speak during instructions nor while electrodes were
being attached. Made no move at shock onset and no audible
sounds. Kept eyes closed during shock sequence.
Remained quiet and motionless during break period.
During the frustration sequence she laughed loudly
on four occasions. Before blindfold was removed and after
she was told to stop she asked, "How many did I get in,
three?” Laughed again when blindfold was removed. Com
pleted the task.
Made no comment during motor task alone. Finished
it in twelve seconds.
Verbal Report
E: "How did you feel during the shock sequence?”
S: "I really wanted to say that that shock hurt. After
the first one I wanted to say don’t do it anymore. I
counted them in my head and was really glad when it was
all over."
E: "How did you feel during the motor task?"
S: "I felt really clumsy. How come . . . how come the
shocks did anything? I guess I was frustrated and
nervous because I felt so clumsy."
93
Experimenter explained the procedure and played the
tape.
SUBJECT 5C Date: 4-17-70
Observations
Subject was a Catholic Nun. She sat quietly while
initial instructions were read. Following the reading of
instructions she said, "Will I be shocked on the left arm?”
Experimenter answered, "Yes." She responded, "I sure hope
it doesn’t hurt too much because I have a pain there
already. Doctor says it is bursitis, but I’m sure it’s
cancer." (Laughed)
Was quiet after that while electrodes were being
placed.
Left arm twitched at #1 onset. Exhibited a slight
startle movement of head and left arm for shocks #2, #3, #4
and #5. Did not otherwise move during shock sequence.
Remained relaxed with eyes closed during rest
period.
Uttered a "Tsk" on four occasions during the task
and smiled each time.
Completed task after removal of blindfold and re
mained quiet until after motor task alone.
Following the motor task said, "All that means is
that my visual cues is what I rely on and not my tactual,
it doesn’t mean I’m stupid!"
Verbal Report
E: "How did you feel during the shock sequence?"
S: "It burned and went clear down to the end of my thumb.
You lied to me. Didn’t feel tense because I trusted
you, but I’m not so sure about next time."
E: "How did you feel during the motor task?"
S: "Like I didn’t have three minutes and therefore I
didn’t need to get frustrated. I didn’t think you'd be
as mad as all that if I didn’t finish.”
Experimenter explained the procedure and played
the data tape.
SUBJECT 6C
Date: 4-17-70
96
Observations
During the reading of the initial instructions, she
said sarcastically, "Oh how nice!" (This was immediately
after she was told of the shocks.) After instructions were
read she asked, "Just a little shock?" And while the
electrodes were being placed, "I hate doctors and men in
little white coats."
Exhibited an extreme startle response at shock #1
onset. Less of a startle response for #2, and almost no
bodily response for shocks #3-#5.
She remained quiet during break. Did not move, but
her eyes remained open.
When harassment began, she began to bang the blocks
down on the board. She threw up her hands on one occasion
and thereby dropped two blocks. She laughed and said, "Oh
dear.”
When blindfold was removed she exclaimed, "Dear
Lord! That was wild, it’s impossible, simply impossible.
But now I can get it for crying out loud. Is this really a
test of intelligence?" She completed the task then.
Did not speak during motor task by itself.
Verbal Report
E: "How did you feel during the shock sequence?”
S: "Tense, more anxious than that damn task."
97
E: "How did you feel during the motor task?"
S: "Frustrated, I mean really, what kind of intelligence
test was that anyway? I just don’t believe it."
Experimenter explained the procedure and played the
data tape.
SUBJECT 7C
98
Date: 4-14-70
Observations
Subject remained silent during the reading of the
initial instructions and while electrodes were being at
tached. Seemed relaxed and quiet during the entire period.
Exhibited the startle response at shock #1 onset. Clenched
his right fist on #2 onset, then remained still for shocks
#3, 4, and 5. Left arm remained relaxed and still except
for forearm jerk at shock onset. Seemed quiet throughout
sequence.
Did not move during break. Remained quiet with
eyes closed.
He worked very carefully and systematically.
Dropped two blocks on two occasions. Approach deteriorated
as harassment continued.
As blindfold was removed and he completed the task
remarked, "You know you really need a table for that; it is
so hard to keep the blocks here and still reach over here."
His face flushed considerably for a long time.
Did the motor task alone without comment.
Verbal Report
E: "How did you feel during the shock sequence?"
S: "Shocked, I mean I didn’t expect it to be as painful as
it was. And the pain lingered longer each time."
E: "How did you feel during the motor task?"
99
S: "Very awkward and clumsy. It was really tough and I
got agitated and felt like saying, ’Well then you do it
if it means that much to you!’"
Experimenter explained the procedure and played the
data tape.
SUBJECT 8C
100
Date: 4-16-70
Observations
Subject did not speak during the reading of the
initial instructions. After they were read, he said, MWow,
how painful will the shock be? Wow, God I" Experimenter
replied, "It depends on your sensitivity, but you’ll find
out won’t you." Subject replied, "God, oh wow!"
At this point, Dr. Schireson walked into the room
and was introduced to subject. The subject said, "I’m
about to get zapped with electric shock." Dr. Schireson
replied, "I’m sure you’ll survive" and moved out of view of
the subject.
Subject remained quiet during the electrode place
ment. He jumped at shock onset #1. Left arm moved on
shocks #2 and 3, but not on 4 and 5.
He breathed a deep sigh when told there would be no
more shocks and remained quiet during the break.
Attempted task and dropped one block on two occa
sions. Did not complete the task when blindfold was re
moved, but said, "Wow, I don’t think I was going about that
the right way." Did not speak during the eighteen seconds
he took to do the motor task without the blindfold.
Verbal Report
E: "How did you feel during the shock sequence?"
101
S: "I thought it was going to really hurt at first, but
was surprised.”
E: ”How did you feel during the motor task?"
S: "Which time?"
E: "The first time when you were blindfolded."
S: "Why I didn’t feel my hands were holding back, but it
was kind of hard to do. (Pause) I guess I was a lit
tle bit frustrated cause I didn’t feel like I did as
good as I could. I was anxious about my performance I
guess."
Experimenter explained the procedure and played the
data tape.
SUBJECT 9C
102
Date: 4-30-70
Observations
Did not move or speak during the initial instruc
tions. After they were read, he spontaneously said, "No
questions." Remained quiet and physically still during
electrode placement. Exhibited a startle response at #1
onset--not thereafter. His left forearm characteristically
jerked at shock onset.
Approach to frustration task was jerky and hap
hazard. Completed the task when blindfold was removed and
said, "Mm mm."
During motor task alone, he hummed and whistled.
Verbal Report
E: "How did you feel during the shock sequence?"
S: "The first time it happened, it hurt and increased as
it went along. By the third one I hardly knew if it
was there. Didn’t feel too anxious at all. Just shut
it all out."
E: "How did you feel during the motor task?"
S: "It was hard, worked too much with my hands. I don’t
know that I felt anything. Was annoyed cause my hands
couldn’t touch the blocks. It kinda bothered me when I
couldn’t finish it all."
Experimenter explained the procedure and played the
10 3
data tape.
SUBJECT IOC
104
Date: 4-10-70
Observations
After initial instructions were read she asked,
"How long will these shocks last? I’m scared of this you
know." Experimenter did not reply. Subject said no more
during electrode placement.
Subject jumped at shock #1 onset, but not there
after. Slight perspiration appeared on forehead.
Did not move during rest period. Eyes remained
open.
Did not speak after task, but did complete task
upon blindfold removal. Remained quiet until experimenter
began the questioning.
Verbal Report
E: "How did you feel during the shock sequence?"
S: "It wasn’t as bad as I thought, but I was pretty up
tight there for awhile you know."
E: "How did you feel during the motor task?"
S: "What did that make me, a high-grade moron? I only got
two in and that was frustrating."
Experimenter explained the procedure and played the
data tape.
APPENDIX B
RAW DATA
105
TABLE 8
TOTAL TIME OF EMG ACTIVITY ABOVE BASELINE PER
90-SECOND SEQUENCE MEASURED IN SECONDS
S# Anxiety (B^) Frustration (B^)
IE 0.0 60.9
2E 2.2 46.2
3E 9.6 40.7
TMJ 4E 0.0 41.0
(A,) 5E 5.7 0.0
1
6E 0.0 70.0
7E 54.8 72.0
8E
0.0 84.2
9E
0.0 64. 3
10 E 0.0 55.6
1C 0.0 12.4
2C 0.0 10.1
3C
0.0 20.2
4C 0.0 5.3
Non- 5C 0.0 35.2
TMJ 6C 0.0 12.0
(A_ ) 7C 0.0 0.0
8C 0.0 4.0
9C 0.0 0.0
IOC 0.0 0.0
AB SUMMARY TABLE
B1 B2
A Total
A1
72.3 534.9 607.2
A2
0.0 99.2 99.2
B Total 72.3 634.1 706.4
TABLE 9
107
MEAN TIME OF EMG ACTIVITY PER EPISODE OF ACTIVITY ABOVE
BASELINE PER 90-SECOND SEQUENCE IN SECONDS
S# Anxiety (B^) Frustration (B^)
IE 0.0 8.7
2E 2.2 5.7
3E 1.9 10.1
4E 0.0 20 .5
5E 2.8 0.0
TMJ 6 E 0.0 14.0
(Aj) 7E 5.5 24.0
8E 0.0 42.1
9E 0.0 16.1
10 E 0.0 13.9
1C 0.0
3.1
2C 0.0 5.0
3C 0.0 10.1
4C 0.0
5.3
Non- 5C 0.0 11.7
TMJ 6C 0.0 4.0
(A„ ) 7C 0.0 0.0
8C 0.0 2.0
9C 0.0 0.0
IOC 0.0 0.0
AB SUMMARY TABLE
B1 B2
A Total
A1
12.4 155.1 167.5
A2
0.0
41.2 41.2
B Total 12.4 196.3 208.7
TABLE 10
108
MAXIMUM AMPLITUDE OF EMG ACTIVITY REACHED PER
90-SECOND SEQUENCE MEASURED IN MILLIMETERS
S# Anxiety (B^) Frustration
IE 0 51
2 E 17 32
3E 17 28
4E 0 56
TMJ 5E 40 0
(A ) 6E 0 61
1 7E 44 59
8E 0 62
9E 0 35
10 E 0 31
1C 0 30
2C
0 20
3C 0 40
4C 0 20
Non- 5C 0 16
TMJ 6C 0 11
(A9) 7C 0 0
8C 0 6
9C 0 0
10C 0 0
AB SUMMARY TABLE
Bi B2
A Total
A1
118 415 533
A2
0 143 143
B Total 118 558 676
109
TABLE 11
PERCENT OF TIME OF EMG ACTIVITY ABOVE BASELINE
FOR NON-TMJ CONTROLS BETWEEN MOTOR TASK AND
FRUSTRATION TASK
s# Motor Task Frustration Task
1C
0 13
2C
0 11
3C 0
' i O
4C 0 5
5C
0 39
6C 0 13
7C
0 0
8C
0 4
9C
0 0
10C 16 0
Total 16 107
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110
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Asset Metadata

Creator Thomas, Lloyd James (author)

Core Title The Effect Of Anxiety And Frustration On Muscular Tension Related To The Temporomandibular-Joint Syndrome

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 Tiber, Norman (committee chair), Galbraith, Gary C. (committee member), Schireson, Sylvan (committee member), Wolpin, Milton (committee member)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c18-452061

Unique identifier UC11363064

Identifier 7107746.pdf (filename),usctheses-c18-452061 (legacy record id)

Legacy Identifier 7107746

Dmrecord 452061

Document Type Dissertation

Rights Thomas, Lloyd James

Type texts

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

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

Repository Name University of Southern California Digital Library

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