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Cognitive Behaviour Therapy

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Stress Management: A Randomized Study of Cognitive Behavioural Therapy and Yoga

Jens Granath , Sara Ingvarsson , Ulrica von Thiele & Ulf Lundberg

To cite this article: Jens Granath , Sara Ingvarsson , Ulrica von Thiele & Ulf Lundberg (2006) Stress Management: A Randomized Study of Cognitive Behavioural Therapy and Yoga, Cognitive Behaviour Therapy, 35:1, 3-10, DOI: 10.1080/16506070500401292

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Stress Management: A Randomized Study of Cognitive Behavioural Therapy and Yoga

Jens Granath, Sara Ingvarsson, Ulrica von Thiele and Ulf Lundberg

Department of Psychology and Centre for Health Equity Studies (CHESS), Stockholm University, Stockholm, Sweden

Abstract. In this study, a stress management program based on cognitive behavioural therapy principles was compared with a Kundaliniyoga program. A study sample of 26 women and 7 men from a large Swedish company were divided randomly into 2 groups for each of the different forms of intervention; a total of 4 groups. The groups were instructed by trained group leaders and 10 sessions were held with each of groups, over a period of 4 months. Psychological (self-rated stress and stress behaviour, anger, exhaustion, quality of life) and physiological (blood pressure, heart rate, urinary catecholamines, salivary cortisol) measurements obtained before and after treatment showed significant improvements on most of the variables in both groups as well as medium-to-high effect sizes. However, no significant difference was found between the 2 programs. The results indicate that both cognitive behaviour therapy and yoga are promising stress management techniques. Key words: stress management; intervention; cognitive behavioural therapy; yoga; catecholamines; cortisol

Received January 30, 2003; Accepted October 10, 2005

Correspondence address: Ulf Lundberg, Department of Psychology and CHESS, Stockholm University, SE-106 91 Stockholm, Sweden. Tel: +468163874. Fax: +468167847. E-mail: [email protected]

Stress-related health problems, such as chronic fatigue, muscular pain and burnout, have increased dramatically in modern socie- ties in recent years (European Commission, 2000). A variety of stress-management tech- niques is used to address this problem. In a meta-analysis of occupational stress-reducing interventions, van der Klink and colleagues (2001) distinguished 4 intervention types: cognitive-behavioural interventions, relaxa- tion techniques, multimodal programs, and organization-focused interventions. They con- cluded that all of the intervention types were effective, but cognitive-behavioural interven- tions were more effective than the other types. In a review of work-site stress management interventions, including muscle relaxation, meditation, biofeedback, cognitive-behavioural skills and combinations of these techniques, Murphy (1996) concluded that the effective- ness of the interventions varied accord- ing to the health-outcome measure used.

Cognitive-behavioural skills were more effec- tive for psychological outcomes, whereas muscle relaxation techniques were more effective for physiological outcomes. Using a combination of techniques (e.g. muscle relaxation plus cognitive-behavioural skills) seemed to be more effective across outcome measures than using a single technique. A similar recommendation is given by Jones and Johnston (2000), who concludes that a stress management intervention should include psycho-education and analyses of individual reaction in combination with management techniques, such as relaxation, assertiveness training, time management and cognitive restructuring.

Yoga is an ancient Indian practice focusing on breathing and physical exercises, thereby combining muscle relaxation, meditation and physical workout. There is a plethora of yoga schools, of which one of the most common is Kundaliniyoga. Kundaliniyoga is characterized

# 2006 Taylor & Francis ISSN 1650-6073 DOI 10.1080/16506070500401292

Cognitive Behaviour Therapy Vol 35, No 1, pp. 3–10, 2006

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by exercises (kriyas) that stimulate the blood flow and energy supply to the brain, the nervous system and the glands in the end- ocrine nervous system (Singh-Khalsa, 1998). Although there is a lack of controlled studies, yoga is regarded as a promising method for the treatment of stress-related problems (Fersling, 1997). Several studies have shown yoga to be promising for both physiological (Murugesan, Govindarajulu, & Bera, 2000) and psychologi- cal outcome measures (Malathi, Damodaran, Shah, Patil, & Maratha, 2000).

In many randomized controlled studies a comparison is made between an active treat- ment and a wait list control group, which enables control for history, spontaneous recovery and other confounders (Sackett, Haynes, Tugwell, & Guyatt, 1991). Although this a common approach with many advan- tages, it has also been criticized. From medicine, a common criticism is that it is unethical to withhold a treatment from a patient who needs it (Feldman, Wang, Willan, & Szalai, 2003). Others emphasize that the possibility of being in a control group might be regarded as unacceptable to potential participants, hence increasing the risk of non-compliance and drop-out (Schafer, 1982). This is particularly true for interven- tions in the workplace, where organizations rarely agree to participate in true experiments and randomized controlled trails with non- treatment or wait list control groups.

In the present randomized study, 2 active methods for stress management, cognitive behaviour therapy and Kundaliniyoga, are compared. It is hypothesized that both methods have positive effects on perceived stress, stress behaviour, vital exhaustion, anger, quality of life, blood pressure, heart rate, catecholamine and cortisol levels, but that cognitive behaviour therapy and yoga have different impacts on various outcome measures.

Method

Design Following recruitment and informed consent and before assessment, the participants were assigned randomly to 1 of 2 conditions: yoga and cognitive behaviour therapy, in either an all-female group or a mixed group (making 4 groups in total). Data were collected pre- and

post-treatment. The study was approved by the local ethics committee.

Participants Participants were recruited from a large Swedish company in the financial sector. All personnel received information about the design of the project and the 2 methods, and were invited to participate through the com- pany’s personnel department. Participation in the study was free of charge, but the company provided financial means for analyses of the physiological data. It was emphasized that there was no opportunity to choose between the 2 methods, and the participants were requested not to share information about the specific content of the methods with each other during treatment. Twenty-seven women and 10 men with self-reported stress-related problems agreed to participate in the study. Four individuals dropped out. In all, 33 participants completed the treatments: 17 on the cognitive behaviour therapy program, and 16 on the yoga program. Two participants missed the physiological measurements after treatment. Accordingly, physiological data are available for only 31 of the 33 individuals, despite all participants having completed the questionnaire. The main characteristics of the participants are presented in Table 1.

Table 1. Characteristics of study participants.

Cognitive behaviour therapy Yoga

n519 n518

Gender Male 5 (26%) 5 (28%) Female 14 (74%) 13 (72%)

Level of education Swedish high school 6 (44%) 7 (35%) University 11 (56%) 9 (65%)

Marital status Married/cohabiting 11 (65%) 14 (88%) Single 3 (18%) 1 (6%) Divorced/widowed 3 (18%) 1 (6%)

Number of children 0 9 8 1 2 5 >2 6 3

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Procedure The 10 sessions in each program ranged over a 4-month period during the winter and spring of 2000. There was a difference in preferences with regard to the scheduling of the sessions. Yoga was held weekly (with 1 week’s interrup- tion between sessions 6 and 7 due to the school vacation), whereas cognitive behaviour ther- apy was initially held weekly (first 4 weeks), followed by 3 sessions held once every other week, and finally by 3 sessions once every 3 weeks. In order to end the 2 training programs at approximately the same time, the yoga groups started a few weeks later than the cognitive behaviour therapy groups. The all- female cognitive behaviour therapy group had 2 female instructors (SI, UvT), whereas the mixed group had just 1 male instructor (JG). A trained yoga instructor led both yoga groups. The cognitive behaviour therapy sessions were performed at the company premises and the yoga sessions at locations nearby.

Measurements for all participants were taken 2 weeks prior to the first cognitive behaviour therapy group session and 2 weeks after the final group sessions. Measurements took place in a room at the company’s premises. Upon arrival for the measurements, the participants returned a questionnaire that they had completed at home. Following a short explanation of procedures, they were instructed to sit down and relax for 5 minutes before measurements of blood pressure and heart rate were taken. The measurements were repeated after 5 and 10 minutes. Finally, urine samples for catecholamines and saliva sam- ples for cortisol determinations were obtained. During the measurements, relaxing classical music (The Four Seasons by Vivaldi and Cello Suites by Bach) was played on a compact disk player. The conditions were the same for pre- and post-measurements.

Following post-measurements, all partici- pants were offered individual feedback on the outcomes of their tests.

Intervention programs The cognitive behaviour therapy program consists of a modified version of a treatment used for coronary heart disease (Burell, 1996). Each session in the cognitive behaviour therapy program was divided into 5 sections: relaxation, discussion on home assignments, psycho-education, management techniques,

and introduction of new home assignments. For relaxation, the principles of ‘‘applied relaxation’’ (Öst, 1987) were used. The home- work assignments followed the same basic structure, including 4 parts: registration tasks (e.g. stress behaviour, anger and irritation, problems, etc.), daily drills (training new management techniques, such as listening without interrupting, eating slowly, etc.), case studies, and relaxation training. The psycho- education section consisted in the presenta- tion of stress-related topics, such as the psychophysiology of stress, theoretical stress models, time urgency, irritation and anger. The management methods employed con- cerned problem-solving, assertiveness train- ing, goal setting, time management, cognitive and behavioural restructuring and relapse prevention. To ensure a high degree of control over the content of the sessions, they followed a pre-set manual (including a written manu- script). Each session was followed by a meet- ing in which group leaders evaluated the content of the session.

The main focus of the yoga program was on physical exercise. Sessions 1–3 had their origin in a yoga program designed for back treatment. In sessions 4–6 a program invol- ving basic movements, normally used as an introduction to Kundaliniyoga, was implemented. Sessions 7–9 were aimed at balancing body, energy and mind. The final session involved exercises that can be used daily to alleviate tension in the shoulders, neck and head, or when some extra energy is needed. At each session, participants were given a compendium that contained a theore- tical account of a specific theme, and advice, suggestions and yoga exercises relevant to that theme. Each session included a 15- minute discussion of different topics, such as life behaviours, restoration, reflection, self- respect, physical exercise and food/eating habits. The yoga participants also received home assignments, which involved physical exercises and reading through the compen- dium in question. Various themes were presented, including personal goals, breath- ing, body postures, meditation and mantra knowledge and intuition.

To ensure that the 2 treatments differed, both were manual-based. Group leaders were informed of the necessity of closely following the manuals.

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Questionnaires Five scales covering different aspects of stress were used for the outcome measures. The first dependent measure, for general stress level, consisted in a Swedish translation of the ‘‘Perceived Stress Scale’’ (PSS) (Cohen, Kamarck, & Mermelstein, 1983; Eskin & Parr, 1996). The PSS is a 14-item scale designed to measure the degree to which life situations are appraised as stressful. The internal consistency reliability for the Swedish version is 0.82 (Cronbach’s alpha). The second dependent measure, concerning the extent of Type-A behaviour, was the 20- item scale ‘‘Daily Stressors’’ (Burell, 1996). The third dependent measure was a Swedish version of the ‘‘Maastricht Questionnaire’’ (Appels, Höppener, & Mulder, 1987), which measures exhaustion. The scale, consisting of 19 items, was designed to measure the degree of vital exhaustion. As a fourth dependent measure, a Swedish version of the MMPI-2 Anger Sub-scale was used (Graham, 1990). Since 1 question was misinterpreted by a large number of participants, the original 15-item scale was transformed into a 14-item scale, with 1 item removed for statistical analysis. The fifth dependent measure was quality of life, which was measured using the Quality of Life Inventory (QOLI) (Frisch, Cornell, Villanueva, & Retzlaff, 1992). The QOLI consists of questions of importance and satisfaction regarding 16 areas in life (in total 32 items). Unfortunately, no data on relia- bility are available for the present versions of ‘‘Daily stressors’’, ‘‘exhaustion’’, ‘‘MMPI-2 Anger sub-scale’’ and QOLI. In order to make the scales more homogeneous, all items except those on the ‘‘Quality of Life Inventory’’ were presented with 5 response categories, regardless of the original number.

Physiological measures Urinary catecholamine. Subjects were instructed not to smoke, use snuff or drink coffee or alcohol, and to avoid any activities that might expose them to stress during the 3 hours preceding the time of measurement.

They were instructed to empty their blad- ders, and note the exact time of voiding, about 2 hours before the time of measurement. Urine was voided again at the time of measurement, and the exact period in time

from previous voiding was calculated. Following measurement of sample volume, the pH of the sample was adjusted to 3.0 with 6 M HCl. A 20 ml volume was frozen (218 ˚C) prior to analysis for adrenaline and noradrenaline by high-pressure liquid chro- matography (HPLC) (Riggin & Kissinger, 1977). After determining the concentration of catecholamines in the sample, values were multiplied by volume and divided by time (pmol/min). Cortisol in saliva. Cortisol in saliva was measured through use of a standard centri- fugation tube (Salivette; Sarstedt Inc., Rommelsdorf, Germany), which contains a small cotton roll that is ‘‘chewed’’ upon for a couple of minutes to obtain a sufficient amount of saliva. Tubes with saliva samples were frozen (218 ˚C) until centrifuged and analysed for cortisol by radioimmunoassay (RIA). Blood pressure and heart rate. Systolic and diastolic blood pressure and heart rate were measured by an automatic digital blood pressure device (DS-140, A&D Company, Japan). The median of 3 measurements was used for the statistical analyses.

Statistical analysis SPSS, version 9.0, was used for the statistical analysis. Mean scores on the outcome mea- sures at pre- and post-treatment for both groups were analysed by means of a 2-way repeated measures ANOVA. Group differ- ences at pre- and post-treatment were tested using an independent-samples t-test. Two- tailed tests were used. Effect sizes were calculated according to Cohen’s (1988) d statistic. For each scale the magnitude of change from pre- to post-treatment was defined as (Mpre2Mpost)/SDpooled, where, SDpooled5![(SDpre2+SDpost2)/2]. Positive effect sizes represent improvements in stress and other symptoms (e.g. reductions in problems)) with the exception of QOLI, where negative effect sizes represent improvements.

Results

Questionnaire data The changes in scores on the various variables following the intervention programs are sum- marized in Table 2.

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Perceived stress (PSS) decreased signifi- cantly among participants on both programs (cognitive behaviour therapy: t(16)56.14, pv0.001; yoga: t(15)52.89, pv0.01). Rat- ings on the stress behaviour scale (cognitive behaviour therapy: t(16)54.80, pv0.001; yoga: t(15)52.66, pv0.05) and of exhaustion (cognitive behaviour therapy: t(16)53.69, pv0.01; yoga: t(15)52.91, pv0.01) also decreased significantly for both programs. Ratings of anger decreased significantly for cognitive behaviour therapy but not for yoga (cognitive behaviour therapy: t(16)53.61, p50.0002; yoga: t(15)51.97, p50.07). The increase in QOLI was non- significant in both cognitive behaviour ther- apy and yoga (cognitive behaviour therapy: t(16)521.80, p50.09; yoga t(15)521.25, p50.23).

Effect sizes varied from d520.44 (QOLI) to d51.42 (PSS) for cognitive behaviour therapy and from d520.19 (QOLI) to d50.87 (Exhaustion) for yoga.

Physiological measures The results from the measures of catechola- mines in urine (adrenaline and noradrenaline), salivary cortisol, systolic blood pressure, diastolic blood pressure and heart rate are presented in Table 3.

In the yoga group, the noradrenaline levels decreased significantly between pre- and post- measurements, t(14)53.15, p50.007, but not in the cognitive behaviour therapy group (t(15)51.12, p50.20). The decrease in adrena- line was not significant for any of the 2 treatments but approach significance in the cognitive behaviour therapy group (cognitive behaviour therapy: t(15)52.07, p50.06; yoga t(14)50.44, p50.66). The difference for nor- adrenaline between the groups approached significance (F(1,29)53.18, p50.085), but this was not the case for adrenaline (F(1,29)50.48, p50.495). For cortisol there was no significant change in either group (cognitive behaviour therapy: t(15)51.27, p50.22; yoga: t(14)51.59, p50.13).

Table 2. Means and standard deviations of questionnaire data for the cognitive behaviour therapy and yoga treatment at pre- and post-treatment and effect sizes (Cohen’s d) from pre- to post-treatment.

Cognitive behaviour therapy Yoga

Pre n517 Post n517 Pre n516 Post n516

M SD M SD d M SD M SD d

PSS 2.19 0.40 1.54 0.51 1.42 2.06 0.48 1.67 0.47 0.82 Stress behaviour 2.25 0.49 1.72 0.41 1.17 2.26 0.52 1.92 0.45 0.70 Exhaustion 1.85 0.62 1.28 0.68 0.88 1.82 0.74 1.25 0.56 0.87 Anger 1.15 0.46 0.81 0.45 0.75 1.23 0.51 0.96 0.44 0.57 QOLI 1.95 0.92 2.46 1.34 20.44 2.21 1.32 2.46 1.37 20.19

PSS5Perceived Stress Scale; QOLI5Quality of Life Inventory.

Table 3. Means and standard deviations of physiological data for the cognitive behaviour therapy and yoga treatment at pre- and post-treatment and effect sizes (Cohen’s d) from pre- to post-treatment.

Cognitive behaviour therapy Yoga

Pre n516 Post n516 Pre n515 Post n515

M SD M SD d M SD M SD d

HR 64.4 11.89 60.9 8.30 0.34 66.2 9.57 61.4 7.47 0.56 SBP 117.6 13.71 112.9 8.78 0.41 115.5 11.88 113.7 12.23 0.15 DBP 79.4 9.22 76.6 7.74 0.33 76.6 8.28 78.4 9.94 20.20 Adrenaline 40.9 22.0 31.2 13.7 0.53 48.2 18.6 44.7 25.0 0.16 Noradrenaline 238.3 81.57 216.8 66.3 0.29 273.6 87.4 197.4 46.6 1.09 Cortisol 8.77 5.41 10.76 7.23 0.31 8.73 3.89 12.8 9.48 0.56

HR5heart rate, SBP5systolic blood pressure; DBP5diastolic blood pressure.

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Heart rate was not significantly lower after either of the 2 programs, but approaching significance in the yoga group (yoga t(14)51.99, p50.07; cognitive behaviour ther- apy t(15)51.51, p50.15). The reverse was true for the decrease in systolic blood pressure (SBP) (cognitive behaviour therapy t(15)51.99, p50.07; yoga t(14)50.69, p50.50). Mean diastolic blood pressure (DBP) after cognitive behaviour therapy had decreased from 79.4 to 76.6 mmHg, but this change was not significant (t(15)51.48, p50.16). Mean diastolic blood pressure after yoga had increased from 76.6 mmHg to 78.4, but again the change was not significant (t(14)520.88, p50.39). The difference between the 2 programs did not reach significance (F(1,29)52.72, p50.11).

Effect sizes varied from d50.29 (noradrena- line) to d50.53 (adrenaline) for cognitive behaviour therapy and from d50.15 (SBP) to d51.09 (noradrenaline) for yoga. Cortisol had a negative effect size, implicating an increased value, of d520.31 for cognitive behaviour therapy and d520.56 for yoga.

Discussion

In this study, both cognitive behaviour therapy and yoga programs resulted in a statistically significant reduction in scores on almost all stress-related subjective and phy- siological variables. Overall, the effect size for the questionnaire data was generally medium to large (Cohen, 1992), whereas the effect size for the physiological measures was lower, ranging from small to medium (with the exception of yoga and noradrenaline, where the effect size was large). Thus, the hypothesis was confirmed. No statistically significant difference between the 2 intervention pro- grams was found for any of the variables, but they differed in effect size: cognitive behaviour therapy had larger effect size on all ques- tionnaire data whereas there was a more complex picture regarding the physiological data. The failure of showing a statistical significant difference between the 2 treatments could be due to the differences in effect size, which can be caused by the small group sizes, and thereby low statistical power.

Unlike the other variables, cortisol levels increased, although non-significantly. Cortisol levels are known to vary considerably between

individuals and over time (Cummins & Gevirtz, 1993), and due to seasonal fluctua- tions (Maes et al. 1997). It has also been shown that individuals exposed to chronic stress (Yehuda, Teicher, Trestman, Levengood, & Siever, 1996) or report a stressful work situation (Kurina, Schneider, & Waite, 2004) may have markedly reduced cortisol levels, thereby suggesting that an increase in cortisol levels could be considered an improvement. The contradictory findings make it difficult to interpret the results. Further studies are needed.

Given the difference in approaches to stress management in the 2 interventions – one mainly physical, the other mainly mental and behavioural – and drawing on the conclusions of Murphy (1996), the 2 treatments might have different effects on different outcome measures. Although our results do not pro- vide enough evidence for any firm conclusions to be drawn, the larger effect of cognitive behaviour therapy on adrenaline and that of yoga on noradrenaline along, suggests that the specific contribution of cognitive beha- viour therapy is mental relaxation, whereas the specific contribution of yoga is physical relaxation (Lundberg, 2000).

Even though arguments can be presented for the benefits of comparing 2 active treat- ments – most importantly the added value of comparing a new treatment with an existing treatment rather than with no treatment at all – the choice of design does have disadvan- tages. The most important lies in the lack of untreated controls. The outcome improve- ments found might be due to changes caused by factors other than the intervention pro- grams, such as seasonal changes, general changes in workload and stress, or there may simply be a regression towards the mean (since the participants who volunteered for the study had high levels of perceived stress). However, a general decrease in workload and stress does not seem likely in the present case. During the period of the intervention pro- grams, time pressure and workload in Sweden increased considerably, as did work absentee- ism due to stress-related disorders (Wennberg, 2001). In addition, during the study a reorganization was performed at the com- pany, details of which were announced only a few weeks before the post-treatment mea- surements were taken. This reorganization

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involved changes in work tasks, colleagues, leaders and work environment for the study participants, factors that are known to con- tribute to stress (European Agency for Safety and Health at Work, 2000).

Another disadvantage of considering 2 active treatments in general, and the treat- ments in this study in particular, lies in the risk of inter-treatment contamination. Although efforts were made to avoid con- tamination, one explanation for the lack of difference in outcome between the treatments is that they did not differ sufficiently in content. In line with the Jones and Johnston recommendation (2000) for most effective treatment, the cognitive behaviour therapy groups included a reference to physical inter- vention, e.g. ‘‘applied relaxation’’, whereas the yoga groups, although having a main focus on physical exercise, also talked about stress-related issues.

One risk of assigning participants at ran- dom to 2 different treatment groups is always that some might be disappointed with their assigned group. Although no participant refused to participate in their group, and all participants completed their treatment, a few stated on their post-treatment evaluation form that they would have preferred the other treatment. These objections were divided equally between the 2 groups That is, there were both yoga participants who would rather been trained in cognitive behaviour therapy and cognitive behaviour therapy participants who would have preferred training in yoga. Despite their comments, there was still a significant reduction in stress-related pro- blems among them, which may provide evidence that the treatments would be even more effective if participants were able to choose between them.

The largest shortcoming of the current study is probably the lack of follow-up data to assess long-term change. With only 1 post- treatment assessment, no conclusions could be drawn about the process of change.

Despite the methodological shortcomings of the study, the consistent pattern in the outcome variables and the medium-to-large effect sizes indicates that both cognitive behaviour therapy and yoga are promising stress management techniques. Future studies are needed to replicate the results, and methodological issues need to be resolved.

Since both methods are multimodal, and in light of the recent development in cognitive behaviour therapy, there is a need to generate further data on the effects of the different models.

Acknowledgements

The authors are indebted to Maj-Lis Bäckström and Laura Ikäheimo Lundberg at SEB for providing facilities and encouraging employees to participate in the study, to Marie Öfvergård for running the yoga train- ing program, to Dr Gunilla Burell for instructions regarding the cognitive beha- vioural therapy program, and to Ann- Christine Sjöbeck for performing the hor- mone assays. Financial support was obtained from the Bank of Sweden Tercentenary Foundation (UL). All authors share equal responsibility for this manuscript. JG, SI and UvT also served as instructors for the cognitive behaviour therapy intervention program.

References Appels, A., Höppener, P., & Mulder, P. (1987). A

questionnaire to assess premonitory symptoms of myocardial infarction. International Journal of Cardiology, 17, 15–24.

Burell, G. (1996). Group psychotherapy project new life: treatment of coronary-prone beha- viours for patients who have had coronary artery bypass graft surgery. I. R. Allan & S. Schidt (Eds), Heart and Mind. The Practice of Cardiac Psychology. Washington DC: American Psychological Association.

Cohen, J. (1988). Statistical Power Analysis for the Behavioural Science (2nd edn). Hillsdale, NJ: Erlbaum.

Cohen, J. (1992). A power primer. Psychological Bulletin, 112, 151–159.

Cohen, S., Kamarck, T., & Mermelstein, R. (1983). A global measure of perceived stress. Journal of Health and Social Behaviour, 24, 385–396.

Cummins, S. E., & Gevirtz, R. N. (1993). The relationship between daily stress and urinary cortisol in a normal population: an emphasis on individual differences. Behavioral Medicine, 19, 129–134.

Eskin, M., & Parr, D. (1996). Introducing a Swedish Version of an Instrument Measuring Mental Stress. Stockholm: Stockholms Universitet. Reports from the Department of Psychology.

European Agency for Safety and Health at Work (2000). Research on Work-Related Stress. Luxembourg: Office for Official Publications of the European Communities.

VOL 35, NO 1, 2006 Stress management through CBT and yoga 9

D ow

nl oa

de d

by [

E as

te rn

M ic

hi ga

n U

ni ve

rs it

y] a

t 17

:2 5

25 J

un e

20 16

European Commission (2000). Guidance on Work- Related Stress. Spice of Life or Kiss of Death?. Luxembourg: Office for Official Publications of the European Communities. Employment and Social Affairs, Health and Safety at Work.

Feldman, B., Wang, E., Willan, A., & Szalai, J. P. (2003). The randomized placebo-phase design for clinical trials. Physical Therapy in Sport, 4, 129–136.

Fersling, P. (1997). Naturligt övernaturligt. [Natural Supernatural]. Köpenhamn: Politikens Forlag.

Frisch, M. B., Cornell, J., Villanueva, M., & Retzlaff, P. J. (1992). Clinical validation of the Quality of Life Inventory: a measure of life satisfaction for use in treatment planning and outcome assessment. Psychological Assessment, 4, 92–101.

Graham, J. R. (1990). MMPI-2: Assessing Personality and Psychopathology. New York: Oxford University Press.

Jones, M. C., & Johnston, D. W. (2000). Reducing distress in first level and student nurses: a review of the applied stress management literature. Journal of Advanced Nursing, 32, 66–74.

Kurina, L., Schneider, B., & Waite, B. (2004). Stress, symptoms of depression and anxiety, and cortisol patterns in working parents. Stress and Health, 20, 53–64.

Lundberg, U. (2000). Catecholamines. In G. Fink (Ed.), Encyclopedia of Stress. San Diego: Academic Press.

Maes, M., Mommen, K., Hendrickx, D., Peeters, D., D’Hondt, P., & Ranjan, R., et al. (1997). Components of biological variation, including seasonality, in blood concentrations of TSH, TT3, FT4, PRL, cortisol and testosterone in health volunteers. Clinical Endocrinology, 46, 587–598.

Malathi, A., Damodaran, A., Shah, N., Patil, N., & Maratha, S. (2000). Effect of yogic practices on

subjective well being. Indian Journal of Physiological Pharmacology, 44, 202–206.

Murphy, L. R. (1996). Stress management in work settings: a critical review of the health effects. American Journal of Health Promotion, 11, 112–35.

Murugesan, R., Govindarajulu, N., & Bera, T. K. (2000). Effect of selected yogic practices on the management of hypertension. Indian Journal of Physiological Pharmacology, 44, 207–210.

Öst, L. -G. (1987). Applied relaxation: Description of a coping technique and review of controlled studies. Behaviour Research and Therapy, 25, 397–409.

Riggin, R. M., & Kissinger, P. T. (1977). Determination of catecholamines in urine by reverse-phase liquid chromatography with elec- trochemical detection. Analytical Chemistry, 49, 2109–2111.

Sackett, D., Haynes, R., Tugwell, P., & Guyatt, G. (1991). Clinical Epidemiology: A Basic Science for Clinical Medicine. Philadelphia, PA: Lippincott, Williams & Wilkins.

Schafer, A. (1982). The ethics of the randomized clinical trial. New England Journal of Medicine. 307, 719–724.

Singh-Khalsa, D. (1998). Hjärnans långa liv [The Long Life of the Brain.]. Stockholm: Svenska Förlaget.

van der Klink, J. J., Blonk, R. W., Schene, A. H., & van Dijk, F. J. (2001). The benefits of interven- tions for work-related stress. American Journal of Public Health, 91, 270–276.

Wennberg, A. (Ed.) (2001). Work Life 2000. Quality in Work. Scientific Reports from the Workshops. Stockholm: National Institute for Working Life.

Yehuda, R., Teicher, M. H., Trestman, R. L., Levengood, R. A., & Siever, L. J. (1996). Cortisol regulation in posttraumatic stress disorder and major depression: a chronobiolo- gical analysis. Biological Psychiatry, 40, 79–88.

10 Granath, Ingvarsson, von Thiele and Lundberg COGNITIVE BEHAVIOUR THERAPY

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