Abstract
Background:
Patients with anxiety disorder were showing severity of anxiety symptoms as well as poor quality of life. Guided imagery (GI) provides immediate relaxation, and improves the severity of anxiety symptoms and the quality of life of patients with anxiety disorder. Anxiety is a basic emotion that is required as a motivation for everyday work of life. Anxiety presents a complex cognitive, affective, physiological, and behavioral response that is related to future harm (real or perceived).
Aim:
To study the efficacy of GI intervention on patients with anxiety disorder and their quality of life.
Materials and Methods:
This longitudinal, interventional study was done in a state institute of mental health, psychiatric unit on 20 patients (outpatients) with anxiety disorder, diagnosed according to diagnostic criteria of research ICD-10 DCR. Patients were assessed using a sociodemographic and clinical data sheet, Hamilton anxiety scale, and World Health Organization QOL instrument, short-form (WHOQOL-BREF), Hindi version.
Results:
Patients with anxiety disorder in the experimental group improved as compared with the control group significantly. The mean QOL-BREF score was also improved after intervention in the intervention group.
Conclusion:
GI intervention helps reduce the severity of anxiety symptoms and improve the quality of life in patients with anxiety disorder.
Keywords: Anxiety disorder, guided imagery, quality of life, relaxation
Anxiety presents a complex cognitive, affective, physiological, and behavioral response that is related to potential harm (real or perceived).[1,2] It is associated with intense fear, which is characterized by a fight or flight response.
Relaxation therapy is an efficient technique for reducing symptoms of anxiety and provides complete calmness. Symptoms of anxiety disorder were significantly reduced after administering relaxation therapy.[3] Guided imagery (GI) is a relaxation technique that is based on the interactions of the brain, mind, body, and behavior. In it, all senses are activated through the imagination of pleasing objects, places, or events that produce pleasant feelings and relaxation. It can be applied self-directed, conducted by a professional, or by a recording.[4] Mind and body integration in GI can promote relaxation and help reduce stress, anxiety, and depression. It is also an effective regulator for high blood pressure,[5] cholesterol, heart rate,[6,7] pain, and blood sugar levels,[8] and improves the immune system and could be a potential anxiety countermeasure. It helps in learning to control functions of the autonomic nervous system by deep breathing associated with vivid pleasant visualizations.
It is successfully implemented in reducing anxiety and depressive symptoms associated with physical illness. Anxiety, stress, and depression secondary to cancer in females are successfully treated by relaxation along with medical treatment.[9] GI is a cost-effective method of therapy for anxiety and pain in patients with COVID-19.[10] Anxiety and depression associated with patients undergoing hemodialysis can also be intervened with GI. The severity of anxiety and depression was lower in the patients' group who were seeking GI intervention as compared with the control group. Their vital signs like respiratory rate and heart rate were also reduced significantly after intervention in the intervention group.[6] GI is effective if it is done regularly either assisted therapist or by audio files.[11] Listening to audio file of GI for 20 min per day for 1 week significantly decreased anxiety and depression in patients with cancer who were undergoing chemotherapy. Patients with cancer in the intervention group reported the greatest rate of improvement from pain, insomnia, appetite, and nausea than the control group.[11]
When guided imagery (GI) is combined with progressive muscle relaxation (PMR), the quality and credibility of the treatment increase in secondary anxiety, and depression in cancer patients undergoing chemotherapy treatment.[12] Nature-based GI interventions are more efficient in reducing state anxiety symptoms than traditional (non-nature-based) GI. Nature-based GI intervention is cost-effective and easily accessible.[13] Mental imagery-focused cognitive therapy can help in improving depression and anxiety symptoms in bipolar disorder.[14]
Very few Indian studies have evaluated the usefulness of this technique in anxiety disorders. Given the above, the present work was undertaken to study the efficacy of GI intervention on patients with anxiety disorder and its effects on their quality of life.
MATERIAL AND METHODS
This longitudinal, interventional study was undertaken in the Psychiatry unit of a State Institute of Mental Health after permission from the Institutional Ethical Committee. All the participants gave written informed consent.
Sample
The participants consisted of 20 patients with generalized anxiety disorder diagnosed according to the diagnostic criteria of research ICD-10 DCR. Patients who were educated up to 10th standard, age ranges of 20–60 years, and mild to moderate level of severity were included in the study, and comorbidity of other physical or mental disorders were excluded from the study.
Tools
Sociodemographic and clinical data sheet: It was a self-prepared performance designed to record the sociodemographic and clinical details of the patients.
Hamilton Anxiety Scale (HAM-A): It has 14 items that assess the various symptoms of anxiety along with severity.
WHOQOL-BREF: It is a self-reported questionnaire, which is the short version of WHOQOL100. It has 26 items and 4 QOL domains. It is a 5-point rating scale where a score of 1 indicates a low and 5 suggests a high score.
Intervention
Before starting the intervention, information and rationale of the goals and methods were provided to the participants. GI was done in a two-part process. They were asked to be comfortable, keep the phone silent and close their eyes, take a slow, long deep breath, and focus on the sensations of breathing. Deep breathing exercises were taught to relax the patient. The GI session started with pleasant nature-based imagery, which relaxes the mind as well as the body. A session lasts for 30–40 min. The patients were asked to perform this at home regularly, at least for 5 consecutive days. Ten sessions were conducted for better results.
Procedure
The patients included in the study were randomly divided into two groups: experimental and control groups. All patients gave written informed consent for the study. Sociodemographic and clinical data were recorded using self-prepared performa. Patients of both groups were assessed by the HAM-A and WHOQOL-BREF before and after the intervention. The experimental group was treated by usual pharmacotherapy with GI therapy, whereas the control group was treated only by usual pharmacotherapy.
Statistical analysis
Therapeutic management was an independent variable, dependent variable was the severity of anxiety symptoms and quality of life in these cases. Data analysis was performed using Statistical Package for the Social Sciences (SPSS) (IBM, Armonk, USA). In addition, the level of statistical significance was set at P < 0.05. Data were analyzed by SPSS using descriptive statistics, the Chi-square test, and the Mann–Whitney U test.
RESULTS
In this study, Table 1 suggests that an equal number of male and female patients were included in the study. The mean age of the patients was 32.5 years. Most of the patients in both the groups were educated up to intermediate level, married, Hindu by religion, unemployed, and hail from middle socioeconomic status of semiurban area of Haryana. They were not statistically significant to each other.
Table 1.
Sociodemographic characteristics of the intervention group and control group
| Variables | Intervention group | Control Group | Mann–Whitney U test/Chi-square Value |
|---|---|---|---|
| Age | |||
| M±SD | 33.00±11.89 | 32.00±11.00 | 0.48 NS |
| Sex | |||
| Male | 5 (50%) | 6 (60%) | 0.20 NS |
| Female | 5 (50%) | 4 (40%) | |
| Education | |||
| High School | 1 (10%) | 2 (20%) | 0.87 NS |
| Intermediate | 7 (70%) | 5 (50.0%) | |
| Graduation | 2 (20%) | 3 (30%) | |
| Marital Status | |||
| Married | 5 (50%) | 7 (70%) | 0.83 NS |
| Single | 5 (50%) | 3 (30%) | |
| Occupation | |||
| Unemployed | 5 (50%) | 7 (70%) | 0.87 NS |
| Employed | 3 (30%) | 2 (20%) | |
| Business | 2 (20%) | 1 (10%) | |
| Residence | |||
| Semiurban | 6 (60%) | 5 (50%) | 0.20 NS |
| Urban | 4 (40%) | 5 (50%) |
NS - Not significant
Table 2 shows the baseline assessment of both the groups on the HAM-A and quality of life scale. It suggests that most patients from both groups showed mild to moderate levels of severity when assessed on the HAM-A. Their scores on quality of life scale also indicate poor quality of life. Patients with anxiety disorder have poor quality of life in the context of physical health or psychological health. Patients usually experience exaggerated symptoms because they are afraid of potential harm. Anxiety is associated with poor physical and psychological health. Patients may have unhealthy relationships with others.
Table 2.
Comparison of severity of anxiety disorder and quality of life between intervention and control group at baseline
| Areas of Assessment | Intervention Group Mean±SD | Control Group Mean±SD | Mann–whitney U test |
|||
|---|---|---|---|---|---|---|
| Mean Rank |
U | Z-score | ||||
| Intervention Group | Control Group | |||||
| Hamilton Anxiety Scale | 21.30±3.09 | 19.30±3.53 | 11.55 | 9.45 | 39.5 | 0.80 NS |
| WHO Quality Of Life -BREF | ||||||
| Physical health | 16.80±4.76 | 16.80±4.62 | 10.60 | 10.40 | 49.00 | 0.08 NS |
| Psychological health | 13.80±3.79 | 13.40±3.24 | 10.85 | 10.15 | 46.50 | 0.70NS |
| Social relationship | 7.40±2.88 | 8.60±2.60 | 9.05 | 11.95 | 35.50 | 1.12NS |
| Environment | 20.70±2.71 | 20.20±2.25 | 10.90 | 10.10 | 46.00 | 0.31NS |
NS - Not significant
Table 3 depicts the differences between the intervention group and the control group after intervention in the severity of anxiety disorder and quality of life. The overall aim of the study is to identify whether GI is successful in palliating anxiety. The study assesses the effect of GI, as mean differences between the experimental group and control group were compared employing the Mann–Whitney U test. The result indicates that patients in the intervention group showed improvement (15.40 ± 2.45) as compared with the control group (5.70 ± 7.04) on HAM-A. They differ statistically significantly on U = 12.5, Z = 2.86, P < 0.01. The findings of the present study have aligned with the literature that GI effectively reduces anxiety.[6,14,15,16] Other studies on GI also suggest that it is a complementary and cost-effective medicine for palliating anxiety and pain.[10] It is effective in reducing anxiety as well as lowering the associated physical symptoms like heart rate, systolic blood pressure, and oxygen saturation.[10] Progressive Muscular Relaxation (PMR) combined with GI was found an effective treatment to improve patients' mood, anxiety, and depression as well as physical symptoms such as nausea, and vomiting and reduce heart rate, blood pressure, cortisol, and improving immunity of the patient with breast cancer patients.[12,11] The findings of the present study are similar to the previous study in that nature-based GI treatment effectively reduces anxiety, is cost-effective, and is easy to administer.[13]
Table 3.
Comparison of differences in severity of anxiety disorder and quality of life between intervention and control group due to intervention
| Areas of Assessment | Intervention Group (M±SD) |
Control Group (M±SD) |
Mann–Whitney U Test |
|||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Mean Rank |
U | Z-Score | ||||||||
| Pre | Post | Difference (Pre-Post) | Pre | Post | Difference (Pre-Post) | Intervention Group | Control Group | |||
| HAM-A | 21.30±3.09 | 5.90±1.85 | 15.40±2.45 | 19.30±3.53 | 13.60±7.31 | 5.70±7.04 | 14.25 | 6.75 | 12.5 | 2.86** |
| WHO Quality of Life -BREF | ||||||||||
| Physical health | 16.80±4.76 | 21.60±4.77 | 4.80±7.20 | 16.30±4.47 | 17.20±4.87 | 0.40±3.13 | 7.65 | 13.35 | 21.50 | 2.29* |
| Psychological health | 13.80±3.79 | 21.40±1.31 | 7.60±4.03 | 13.40±3.24 | 12.40±2.37 | 1.00±3.62 | 6.10 | 14.90 | 6.00 | 3.31** |
| Social relationship | 7.40±2.88 | 11.20±1.92 | 3.80±3.03 | 8.60±2.60 | 9.80±2.28 | 1.20±1.64 | 4.10 | 6.90 | 5.50 | 1.49 NS |
| Environment | 20.70±2.71 | 21.50±2.88 | 0.80±1.75 | 20.20±2.25 | 20.10±2.38 | 0.10±3.87 | 9.55 | 11.45 | 40.50 | 0.73 NS |
NS - Not significant; *P<0.05; **P<0.01
The scores on quality of life were statistically significant differing on physical health, Z = 2.29, P < 0.05, and psychological health Z = 3.31, P < 0.01, after the intervention. Quality of life when compared with the control group and experimental group after intervention, no statistically significant difference was found on social relationship and environment scale.
DISCUSSION
The findings of our study in agreement with many earlier studies suggest that physiological health is improved by the application of GI. It is a good treatment choice for treating physiological responses such as heart rate, blood pressure, respiratory rate, sleep quality, and oxygen saturation in different disorders.[10,11,12] Relaxation improves psychological health and also reduces anxiety, stress, and depression. GI helps patients overcome most of their anxiety symptoms, which makes them feel psychologically and physically healthy. The findings are consistent with other studies, which showed that quality of life is improved after GI and relaxation in elderly patients with cancer of breast or prostate.[17] Similar studies supported the present findings that the use of GI and relaxation techniques helps in the improvement of quality of life. GI and relaxation are recommended for a better quality of life.[18,19] Similar to this study, other studies suggested that quality of life significantly improved pre- to postintervention after relaxation exercise in lymphoma survivors.[20]
Limitation
The sample size was small and the sample was hospital based from one center. The results cannot therefore be generalized.
CONCLUSION
GI is a better and more effective treatment for moderating anxiety. It is easy and safe to apply, which provides immediate relief and help in dropping anxiety. Practicing it regularly helps in growing positive coping and improving the quality of life in patients with anxiety disorders.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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