Relaxation Training for Anxiety: A Ten-Years Systematic Review With Meta-Analysis

Gian Mauro Manzoni; Francesco Pagnini; Gianluca Castelnuovo; Enrico Molinari


BMC Psychiatry 

In This Article

Abstract and Background

Background: Relaxation training is a common treatment for anxiety problems. Lacking is a recent quantitative meta-analysis that enhances understanding of the variability and clinical significance of anxiety reduction outcomes after relaxation treatment.
Methods: All studies (1997-2007), both RCT, observational and without control group, evaluating the efficacy of relaxation training (Jacobson's progressive relaxation, autogenic training, applied relaxation and meditation) for anxiety problems and disorders were identified by comprehensive electronic searches with Pubmed, Psychinfo and Cochrane Registers, by checking references of relevant studies and of other reviews. Our primary outcome was anxiety measured with psychometric questionnaires. Meta-analysis was undertaken synthesizing the data from all trials, distinguishing within and between effect sizes.
Results: 27 studies qualified for the inclusion in the meta-analysis. As hypothesized, relaxation training showed a medium-large effect size in the treatment of anxiety. Cohen's d was .57 (95% CI: .52 to .68) in the within analysis and .51 (95% CI: .46 to .634) in the between group analysis. Efficacy was higher for meditation, among volunteers and for longer treatments. Implications and limitations are discussed.
Conclusion: The results show consistent and significant efficacy of relaxation training in reducing anxiety. This meta-analysis extends the existing literature through facilitation of a better understanding of the variability and clinical significance of anxiety improvement subsequent to relaxation training.

In recent years, it has been increasingly acknowledged that anxiety disorders are highly prevalent in the general adult population. Recent worldwide estimates for the 1-year and lifetime prevalence of any anxiety disorders are 10.6% and 16.6%, respectively, with a ratio indicating that a large number of people experience anxiety disorders on a continuing or recurring basis. Prevalence is approximately twice among women, with overall age-specific rates remaining relatively stable or increasing across the lifespan.[1]

Moreover, anxiety disorders constitute only the tail of the curve representing the general anxiety distress that affects the population. According to Zigmond and Snaith,[2] psychiatric disorder cannot be considered either present or absent since the degrees is continuously distributed in the population. In fact, complaints of anxiety are common among healthy individuals and have been associated with numerous negative health consequences,[3,4] absenteeism and decreased work productivity.[5] Studies have persistently shown that anxiety disorders produce morbidity, utilization of health care services, sometimes for long time, functional impairment[6] and personal distress, leading to a burden of both private and public health care costs.

The prevalence of anxiety disorders, both in their severe and mild forms, is certainly high also in medical and surgical departments.[6,2] Emotional distress presented by in- and out-patients may be a result of the stress caused by physical illness and, more subtle, somatic symptoms presented may be a manifestation of anxiety states, with no basis in organic pathology.[7]

A broad understanding of the etiology of anxiety problems includes a multiplicity of factors, such as biological, psychological, and social determinants, which are mediated by a range of risk and protective factors.[1] The old debate over the primacy of these factors, overall biological or psychological, is gradually being replaced by a pragmatic model considering all the relative contributions.[8]

Clinical trials have shown that anxiolytic drugs alone have limited long-term efficacy.[9] Moreover, they often have adverse side effects including dependency, drowsiness,[10] impaired cognition and memory[10,11] and sexual dysfunction.[11,12,13] Consequently, clinical community has begun to consider alternative old and new approaches targeting anxiety problems and to examine the merits of combined and tailored somatic and psychological treatments.

Huge progress has been made (and still goes on) in the nonpharmacological treatment of anxiety disorders.[14] In this direction, relaxation techniques represent one of the most used approach in anxiety management worldwide, both as a stand-alone treatment or included in a more complex therapy.

Even if there are many relaxing methods that have received scientific attention, they could be defined globally as a cognitive and/or behavioral treatment approach which emphasizes the development of a relaxation response to counteract the stress response of anxiety. The relaxation response is defined by a set of integrated physiological mechanisms and 'adjustments' that are elicited when a subject engages in a repetitive mental or physical activity and passively ignores distracting thoughts.[15]

Many studies support a good efficacy of relaxation trainings in reducing anxiety. For example, in a study by Kanji, White and Ernst,[16] fifty-nine patients were randomly assigned to receive regular autogenic training or no such therapy as an adjunct to standard care for 5 months. State Anxiety showed a significant intergroup difference both at 2 and 5 months. This finding was corroborated by secondary outcome measures, for example quality of life, and by qualitative information about patients' experiences, suggesting that autogenic training may have a role in reducing anxiety of patients undergoing coronary angioplasty.

Moreover, in a general review on therapeutic use of relaxation response in stress-related diseases, Esch et al.[15] declare that relaxation techniques appear to be highly recommendable. Many studies have been conducted that have shown a positive clinical outcome of the relaxation techniques in connection with anxiety.[17,18,19,20,21,22,23,24,25,26] A review conducted by Kanji and Ernst,[27] considering 8 studies, suggests that autogenic training seems to reduce stress and anxiety, but few conclusion can be drawn from those studies. Carlson and Hoyle[28] wrote a quantitative review focused on progressive relaxation training,[29] indicating a good potential of progressive relaxation in the treatment of various diseases (i.e. migraine, hypertension, chemotherapy side effects...) but without specific consideration about anxiety.

An old meta-analysis,[30] published in 1989 about the effects of relaxation trainings on trait anxiety found that relaxation techniques had a medium effect size, while transcendental meditation had significantly larger effect size.

Applied Relaxation has been adopted for uses in treatment of generalized anxiety disorder.[31] In two recent studies, applied relaxation has proven to be equally as effective in treating GAD as Cognitive therapy, which demands much more of the therapist.[31,32]

Though there is much research which has combined meditation therapy with conventional treatment in anxiety disorders, there is still a lack of reviews that provide substantial evidence on the effectiveness of meditation therapy programs, both for short-term and long-term effects and for acceptability in terms of practicality, feasibility, difficulty and concerns about the adverse effects.

Meditation is sometimes considered to be a form of relaxation therapy, however meditation not only creates a relaxation response but also produces an altered state of consciousness which facilitates the meta-cognitive mode of thinking which make possible the expectation of cognitive-behavioral benefits. Meditation is effective against anxiety, both if considered as a single treatment[8,33] or inserted into a cognitive therapy. For example, Finucane and Mercer[34] applied Mindfulness Based Cognitive Therapy (MBCT) in an 8-week course that integrates mindfulness meditation practices and cognitive theory to patients with recurrent depression or recurrent depression and anxiety, finding a great average reduction of anxiety, as well as depression.

The aim of this meta-analytic study was to investigate the efficacy of relaxation training programs which are currently used to treat anxiety disorders and to reduce anxiety in general. This idea derived from a need we had in our clinical practice, to collect some information about the relaxation methods recently most used in clinical trials, both randomized or observational, and about their relative efficacy in reducing anxiety in different samples. During the preliminary search of the literature, we decided to organize a review of the studies published in the last ten years. We chose this span of time because we thought that ten years are an appropriate timeframe to make a picture of the current situation in the field of relaxation techniques for anxiety management. Further, we thought that in ten years there would have been enough studies to allow meta-analytical calculations.

This study employed a meta-analytic approach to test several hypotheses derived from the extant literature. Hypothesis 1: Post-treatment anxiety would be lower than baseline level, and relaxation training would outperform control conditions (where presents) on anxiety-specific measures. Hypothesis 2: there would be significant differences between the different relaxing approaches considered. Hypothesis 3: there would be a difference in anxiety reduction between subjects with physical and psychological diseases. Hypothesis 4: there would be a dose-response relationship for relaxation training. Hypothesis 5: the suggestion of practicing relaxation exercises at home would enhance the efficacy of the training. Hypothesis 6: the context of application (individual or group sessions) would moderate the outcome. Hypothesis 7: Different anxiety questionnaires would present different sensitivity to anxiety changing.


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