relationships between some psychological assessments, and ...for the taylor manifest anxiety scale...

Journal of Neurology, Neurosurgery, and Psychiatry, 1973, 36, 839-845

Relationships between some psychologicalassessments, body-build, and physiological

stress responses

P. K. BRIDGES AND M. T. JONES

From the Regional Neurosurgical Centre, Brook General Hospital, Shooters Hill Road,and

Sherrington School ofPhysiology, St. Thomas's Hospital, London

SUMMARY A number of physiological responses to the psychological stress of an oral academicexamination were observed, including heart rate, respiration rate, blood pressure, urinary 17-oxogenic steroid excretion, and plasma corticosteroid concentration. The results were related tobody-build and to four psychological tests: Eysenck Personality Inventory, Taylor Manifest AnxietyScale, IPAT Anxiety Scale, and Stimulus-Response Inventory. No significant associations werefound between the psychological test results and anticipatory physiological activity just before theexamination began, including excretion of 17-oxogenic steroids. Respiration rate was not increasedby anticipatory stress, unlike the other variables, which were significantly higher than control valuestaken under resting conditions three months later. The students of primarily linear physique hadsignificantly higher plasma corticosteroid values than the predominantly muscular subjects at thetime of the examination, as found previously. They also had significantly higher analogue measuresof the degree of anxiety experienced at the examination (assessed both by the subject and by an

observer). Therefore, linear subjects appear to experience more anxiety than muscular students ina similar situation of psychological stress. Both the IPAT Scale and S-R Inventory results were

significantly higher for the linear group but there were no significant differences for the EPI andTMAS scores, as used in previous studies. The importance of constitutional factors associated withbody-build in relation to at least some aspects of personality is strongly suggested by the findings.

We have previously described investigations intopossible relationships between constitutional fac-tors and some physiological responses to apsychological stress. For example, it was shownthat plasma corticosteroid concentrations pro-duced by the stress were significantly related tobody-build but not to the results obtained fromsome personality tests (Bridges and Jones, 1968).However, it must be expected that the resultsfrom suitable psychological tests, if they havevalidity, should predict those subjects experi-encing relatively more anxiety in stressful situ-ations and thus relationships with the physio-logical responses are to be anticipated. This wasnot found to be so for the Eysenck PersonalityInventory (EPI) (Eysenck and Eysenck, 1964) orfor the Taylor Manifest Anxiety Scale (TMAS)

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(Taylor, 1953) used in previous studies. But itremained possible that other personality meas-ures designed for anxiety-proneness might provemore relevant to the experimental situation andshow relationships with the physiological para-meters. Therefore, further psychological testswere given to another group of students in asimilar situation as before.

In the present study the opportunity was alsotaken to observe possible differential associationsbetween responses to anticipatory anxiety, oc-curring before the examination, and those dueto the anxiety produced during the period of theexamination itself. This report considers therelationships between the various physiologicalmeasures, their associations with body-build andwith some of the psychological test results.

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P. K. Bridges and M. T. Jones

METHODS

The study was restricted, as in previous investiga-tions, to male students at one medical school, allaged about 20 years. All 46 taking the second MBanatomy oral examination on one occasion agreedto take part but the data were complete only for 42.

Shortly before the examination was due to begineach student voided urine, which was discarded.While waiting to enter the examination the studentsat quietly and immediately before it began the firstobserver counted the heart rate and respiration rate,each over one minute, and the blood pressure wastaken. It was noted that the respiration rate was

affected if the subject became aware of it being re-corded so the wrist was palpated with apparent con-

centration on this by the observer while countingboth the pulse and respiration rates. Each examina-tion lasted between 10 and 20 minutes and immedi-ately at its conclusion the heart rate, respiration rate,and blood pressure were again recorded. It had pre-viously been found that these variables deceleratedor fell rapidly as soon as the stress was over, sosecond and third observers were available. Thesecond took the heart rate over 30 seconds and therespiration rate over 30 seconds, while the third ob-server recorded the blood pressure at the same time.

Each student then drank 250 ml. water to facilitatediuresis and sat quietly until 30 minutes after thestart of the examination when 10 ml. blood was

collected into a tube with heparin. This was immedi-ately centrifuged and the plasma stored deep frozenfor later assay of corticosteroids. Haematocrit read-ings were carried out in duplicate. The subject con-

tinued resting until one hour after the commencementof the examination when the bladder was emptied andthe urine stored deep frozen for later measurementof 17-oxogenic steroids. The weight of each studentwas taken at the time of the examination.

While it would have been desirable, it was notpossible to insist that the subjects refrain fromsmoking or drinking caffeine beverages before theexamination, although this would not be allowedduring the period after the examination while thespecimens were collected. However, each student wasasked about his recent smoking habits and alsowhether there had been vomiting or diarrhoea in thefortnight before the examination.

Three months after the examination, control ob-servations were obtained. An attempt was made tocarry these out as near as possible to the same timeof day at which the examination was taken in orderto avoid effects resulting from diurnal variation inphysiological activity. The mean difference betweenthe time of day at which the stress and control

readings were recorded for each student proved tobe - 2-64 minutes (SD ± 109 9 minutes).The control period began with the subject voiding

urine, which was discarded; each then drank 250 ml.water and rested. The blood specimen was taken30 minutes later for measurement of plasma cortico-steroids and one hour later urine was collected forassay of 17-oxogenic steroids. Physical measurementswere then recorded for the purpose of assessing thephenotype by the method of Parnell (1958) and thepsychological test forms were completed. These in-cluded the EPI, TMAS, IPAT Anxiety Scale (Cattelland Scheier, 1963) and the Stimulus-Response (S-R)Inventory (Endler, Hunt and Rosenstein, 1962). Thelatter is a complicated test with many subscores butonly the total scores are considered here. A moredetailed analysis of the results from the psychologicaltests will be reported separately (Bridges, 1973).A visual linear analogue scale (Aitken, 1969) was

also used to assess the degree of anxiety experiencedduring the examination and to quantify any anxietyfelt during the collection of control data. The ob-servers, in taking previous stress recordings, wereaware of perceiving the degree of disturbance eachstudent appeared to show. It was not known howreliable these assessments were, so it was decidedthat, while no structuring of the opinion was attemp-ted, the second observer would make a similar ana-logue measurement of the state of each student'sanxiety as it appeared immediately after the examina-tion. Each analogue scale was 100 mm long with anindication of 'no anxiety' at one end and 'the mostanxiety you can imagine' at the other, a mark alongthe line being the assessment of the degree of anxiety.These scales were marked by each student and bythe second observer at the time of the stress and bythe student only on the occasion of the collection ofcontrol data, when some anxiety was possible, especi-ally due to the venepuncture involved.

In our previous studies corticosteroids were as-sayed by a modification of the method of Zenkerand Bernstein (1958). More specific methods are nowavailable and therefore the method of Townsend andJames (1968) was used for all blood samples, controland stress, while the stress samples were also meas-ured by the modified Zenker and Bernstein methodfor comparison. Urinary 17-oxogenic steroids weremeasured by the method of Gray, Baron, Brooks,and James (1969).

RESULTS

Tables 1 and 2 show that, using t tests of differ-ences, all the physiological measures were signifi-cantly higher at the time of the stress compared

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TABLE 1PHYSICAL, URINARY AND ADRENOCORTICAL MEASURES (MEAN VALUES)

Weight Haema- Plasma corticosteroids 17-O.rogenic Urine flow(kg) tocrit (1sg per 100 ml.) steroids (m7l./hr)

(%,) (M4g/hr)

Townsend and ZenkerandJames method Bernstein

mnethod

Con. Stress Stress Con. Stress Stress Con. Stress Con. Stress decrease

Lgroup(n=13) 6650 6777 4562 846 18-23 35-19 541 761 11692 8738 74-7M group (n= 23) 71-57 72-00 45 61 7 96 13-74 30 77 451 586 98-87 60-17 60 9

P (L v. M) NS NS NS NS <0-01 <0 05 NS NS NS NS -

All subjects (n=42) 70-54 71-14 45 50 8-17 15 12 31-80 464 693 97 57 66 07 67-72P (control v. stress) NS < 0 001 <0 01 < 0-02

TABLE 2RESPIRATORY AND CARDIOVASCULAR MEASURES (MEAN VALUES)

Respiration per min Heart rate per min Blood pressure (mm Hg)

Systolic Diastolic Pulse pressure

Stress Stress Stress Stress StressCon. Con. Con. Con. Con.

pre- post- pre- post- pre- post- pre- post- pre- post-

L group 13-92 15-31 19-38 68-69 102-00 106-23 114-62 145-00 135 00 70-38 81-92 86 92 44-23 63-08 48 08(n = 13)

M group 15-26 15-78 17-57 66-65 97-17 97 30 116-09 144-78 114-13 66 52 78 48 86-96 49-13 67-17 57-17(n = 23)

All subjects 15 02 15-86 17-95 67 48 97 10 99 79 116-55 144-29 140-60 68-45 79 05 86 19 48-10 65 24 54 40(n = 42)

P (control v.pre-stress) NS < 0 001 < 000 <0001 <00001

(control v.post-stress) < 0 001 < 0 001 < 0 001 < 0001 < 0-02

(pre-stress v.post-stress) < 0-02 NS NS < 0 001 < 0-001

TABLE 3PSYCHOLOGICAL MEASURES (MEAN VALUES)

Analogue scale (%) EPI TMAS IPAT S-RScale Inventory

Stress E NControlSubject Subject Observer

L groupn= 13 10-31 51-92 45 00 12-92 9 77 15-88 30-08 343

M groupn=23 6 22 33-43 31-00 12-13 8-13 11-78 22-22 297

P (MvL) NS < 0 05 < 0 05 NS NS NS < 0-05 < 0-01All n=42 7-41 39-67 34-12 12-60 9 05 13-77 26-26 317



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with control values, except that urine flow wassignificantly reduced.The phenotype is a measure of body-build

expressed in terms of three components; linearityor thinness (L), muscularity (M), and fatness (F).Subjects were grouped into those with each com-ponent predominant. Therefore, the results werecalculated to give separate mean values for thoseof primarily linear physique (L, Lm, Lf: n= 13)and also for the predominantly muscular students(M, Mf, Ml: n=23). Six subjects remained out-side these categories, of whom two were pri-marily fat (both Fm) and four showed equalmain components (2= FL, 2= ML). The lowincidence of primary fatness among universitystudents has been noted before (Bridges andJones, 1968).

PSYCHOLOGICAL TESTS Table 3 gives the meanresults of the psychological tests for the totalgroup of students and also for each of the twomain phenotype groups. The subjects' analogueassessments for all the students were highlysignificantly increased at the time of the stresscompared with the control values, using a t testof differences (t= 8-84, P < 0O001). The meanstress analogue assessments, both subjects' andobserver's, were significantly higher for the lineargroup than for the primarily muscular subjects.All the psychological measures produced ahigher mean value for the linear subjects thanthe muscular group but the differences weresignificant only in the case of the IPAT scaleand the S-R Inventory. It is noteworthy thatthe observer and subject analogue ratings carriedout at the time of the examination correlatedsignificantly together (r=0O4203; P= <001).

None of the three analogue assessmentsshowed significant correlations with the otherpsychological tests, except that between thesubjects' stress analogue ratings and the S-RInventory (r=0O3721; P<005). As reported byseveral other workers (Jensen, 1958), using theclosely related Maudsley Personality Inventory,the neuroticism (N) score of the EPI correlatedhighly significantly with the TMAS (r=0O8892;P<0001). In addition, the IPAT scale resultscorrelated significantly both with the N scoresof the EPI (r=07417; P<0001), and theTMAS (r=07680; P<0001). The total S-Rvalues also correlated significantly with the Nscores (r=06449; P<0001), the TMAS (r=0-6355; P<0001) and the IPAT values (r=0-6433; P<0001).

ADRENOCORTICAL RESPONSES The only signifi-cant differences found between the two pheno-type groups for the physiological variables oc-curred in the plasma corticosteroid values at thetime of the stress. Measured by both methods ofassay, the linear group had significantly highermean values compared with the muscular sub-jects, while the control values were closely simi-lar. The linear subjects also showed higher meanexcretion rates of 17-oxogenic steroids in bothcontrol and stress conditions, but the differenceswere not significant. The 17-oxogenic steroidexcretion values at the time of the stress corre-lated significantly with the control figures (r=03988; P<001), but this was not so of theplasma corticosteroid results, and there were nosignificant relationships between the urinary andplasma steroid results.

Significant correlations were found between

ILE 4

SUMMARY OF PRINCIPAL INTERCORRELATIONS

1 2 3 4 5 6

I IPAT Scale2 S-R Inventory 0 6433*3 Subject Stress Analogue 0-2728 0-3721t4 Observer Stress Analogue 0 1243 0 2549 0 4203t5 Muscularity - 0-3743t 0 3948t -0-1593 - 0-09866 Linearity 0-1675 0-2828 0 3099t 0 2065 -07115*7 Plasma corticosteroids 0 1829 0 4586t 0-4400t 0 4363t -0 2183 0 3395t

* P<0-001. t P<0-01. t P<0-05.

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the stress plasma corticosteroid values and threeof the psychological measures (S-R Inventory,observer's and subjects' stress analogue ratings),as shown in Table 4. The stress plasma corti-costeroid values measured by the two differentmethods correlated together highly significantly(r=0-6035; P < 0001) and therefore the plasmacorticosteroid results are generally comparablewith those in our previous studies. The correla-tion coefficient between the linear phenotypescores and the stress corticosteroid values meas-ured by the Townsend and James method was03395 (P<0 05), while that between the latterand the muscularity ratings was -0O2183 (NS).

OTHER PHYSIOLOGICAL MEASURES A previousfinding (Jones, Bridges, and Leak, 1968) is con-firmed that urine flow decreases significantly inresponse to a psychological stress. The decreaseis greater for subjects of linear build than forprimarily muscular individuals, although thesedifferences did not reach significance. The resultsfor other variables are given in Table 2, fromwhich it is apparent that there are no significantdifferences between the mean values for the twophenotype groups.

PERSONAL VARIABLES It had been consideredpossible that anticipatory anxiety over a periodof time before the examination might have ledto general metabolic changes which could in-fluence the results. The haematocrit values weretaken as an indication of hydration and thesewere all normal. Weight was not found to besignificantly different at the time of the examina-tion compared with control values. There wereno significant differences in the reported inci-dence of smoking, of diarrhoea, and of vomitingbetween the phenotype groups.

In view of the significant relationships foundbetween plasma corticosteroid values and pheno-type ratings, as well as with some of the psycho-logical tests, it is to be expected that the pheno-type values would correlate significantly withsome of the personality measures and this wasso as shown in Table 4.

DISCUSSION

The pre-stress recordings were considered to bea possible indication of anticipatory anxiety, as

opposed to the post-stress values which weremore directly produced by the examination. Inthe present study the urinary steroid values wereintended as a possible measure of anticipatorystress occurring in the period before the exami-nation, while the plasma values were regardedas an assessment of the emotional stimulus pro-duced by the examination and thus urinary oxo-genic steroid excretion was not included fordirect comparison with the plasma cortico-steroid values. The latter is a more immediateassessment of adrenocortical activity and it isalso an assessment at a single point of time,reflecting events about 30 minutes before. Thedelay between stimulus and increased urinarysteroid excretion is a good deal longer anddepends upon various factors such as the magni-tude of the stimulus and the method of assay,but the interval will be more like three hours(Doe, Vennes, and Flink, 1960). It appears thatanticipatory anxiety, as measured by urinarysteroid output, produces values which are sig-nificantly increased over control figures. But thisparticular measure of anticipation does not showrelationships with the stress responses occasionedby the examination, as measured by plasmacorticosteroid concentration and other aspectsof physiological activity. Furthermore, none ofthe psychological tests significantly correlatedwith the stress 17-oxogenic steroid values andtherefore no relationships were found to differ-entiate psychological factors associated withanticipatory physiological activity from thoseassociated with the stress responses.However, it is clear that respiration rate was

not affected by anticipatory anxiety, as the meanrate increased significantly over control valuesonly after the stress. This finding probably re-lates to the fact that respiration is not controlledby the autonomic nervous system and it obviouslywas not involved in the increased autonomicactivity before the examination. It may be thatits acceleration was more directly related toarousal produced by the examination itself.By contrast, all the cardiovascular variables

taken before the stress were increased signifi-cantly over control values. Heart rate and sys-tolic blood pressure did not significantly increasefurther after the examination, compared with theresults taken just before it began. But this wasnot so of diastolic blood pressure, which was

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found to be even higher at the end of the exami-nation. This could be explained in terms of in-creased sympathetic tone but observer errorcannot be excluded as the pre-stress values weretaken by the first observer, while the later re-cordings were carried out by the third observer.

Adrenocortical activity is known to be relatedboth to parameters of body size (Borth, Linder,and Riondel, 1957; Tanner, Healey, Whitehouse,and Edgson, 1959) and to psychological arousal(Martin, 1961; Levi, 1969). Rose, Poe, andMason (1968) and Poe, Rose, and Mason (1970)found that the combined use of assessments ofpsychological state and of body build gave thebest predictions of 17-hydroxycorticosteroid ex-cretion rates during various activities carried outby military recruits under training. Segraves(1970) did not study stress responses but foundrelationships between resting steroid excretion,measures of personality, and parameters ofbody-build. The results of our previous studies wentsomewhat further in suggesting a positive rela-tionship between linearity and plasma steroidlevels, and a negative association with muscu-larity, indications being that the latter is themore important (Bridges, Jones, and Leak, 1970)but it is difficult to decide this point as muscu-larity and linearity in any case have a highlysignificant negative relationship (in the presentstudy r= -07115; P < 0-001). With our severalprevious investigations, as well as the presentfindings, there are now 122 subjects for whomplasma corticosteroid results have been obtainedin similar stress conditions. In the case of these122 subjects the correlations between their plasmacorticosteroid values (Zenker and Bernsteinmethod) and linearity was 0-2173 (P < 0 05); withmuscularity it was - 0-2007 (P < 0-05).One explanation of the differences in stress

corticosteroid values between subjects of differ-ent phenotype groups might be a variation inthe sensitivity of adrenocortical responsivenessbut it has been shown that the response of theadrenal cortex of both phenotype groups totetracosactrin is closely similar (Jones andBridges, 1970). Among other explanations of thedifferences is the likelihood that linear subjectstend to experience relatively more anxiety understress than do muscular individuals. This waspreviously suggested by some observations re-ported by Parnell (1957) and there is now evi-

dence from the present analogue assessmentsthat the linear students experienced significantlyhigher levels of anxiety than the muscular sub-jects, assessed both by themselves and by anobserver. These findings also confirm the obser-vation of Bloch and Brackenridge (1972) thatself-ratings of anxiety can be employed withconfidence in research of this kind.Having established that there are differences

in the physiological responses between phenotypegroups under a similar stress, it is of interest tonote the psychological tests which relate to thesedifferences. It is apparent that the EPI andTMAS do not, while the IPAT and the S-RInventory appear to do so, an aspect consideredfurther in the separate study (Bridges, 1973).These tests are all relevant to anxiety-pronenessand the latter two appear to measure this withsome reliability, even to the extent, in the caseof the S-R Inventory, that scores obtained threemonths later correlated significantly with stressplasma corticosteroid values and also with thesubjects' analogue assessments of the anxietyexperienced. Thus, while our previous studieshave shown significantly different physiologicalstress response patterns between subjects ofdifferent body-builds, evidence is now availablewhich more clearly suggests that these physio-logical differences are related to psychologicaldifferences in anxiety responsiveness betweenphenotype groups. This demonstration thatanxiety responses relate to body-build and,probably as an aspect of this, that certain psycho-logical tests correlate with body-build, has rele-vance to frequently suggested associations be-tween physique and temperament (Sheldon,1942; Rees, 1960).

For advice and help with this study we thank Profes-sor V. H. T. James, Professor P. Venables, Dr. R. V.Brooks, Dr. F. Imms, Mr. R. Neame, Mr. M. Piercy,and the medical students of St. Thomas' HospitalMedical School. The support of the Royal FreeHospital Endowment Fund and the South EastMetropolitan Regional Hospital Board is gratefullyacknowledged.

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Bloch, S., and Brackenridge, C. J. (1972). Psychological,performance and biochemical factors in medical students

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