Archives of Psychiatric Nursing 32 (2018) 278–284

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Archives of Psychiatric Nursing

journal homepage: www.elsevier.com/locate/apnu

Effects of Relaxation Therapy on Anxiety Disorders: A Systematic Review T

and Meta-analysis☆
⁎
Hyeun-sil Kim, Eun Joo Kim
Department of Nursing, Daejeon University, Daejeon, Republic of Korea

A R T I C L E I N F O A B S T R A C T

KEYWORDS: AIM: To explore the effect of relaxation therapy applied to people with anxiety disorders.
Anxiety disorder METHODS: Systematic review with meta-analysis.
Relaxation RESULTS: Sixteen Randomized Control Trials (RCTs) were included for meta-analysis to determine the effect of
Meta-analysis relaxation therapy. The overall effect of relaxation therapy on symptom of anxiety was significant with Hedges'
g = 0.62 (95% CI: 0.42–0.81), which indicates a medium-high effect; heterogeneity was statistically significant
with I2 = 48.84. Subgroup analysis exploring the possible causes of heterogeneity found that types of com-
parison of TAU and CBT was significant (Q = 4.20, p = 0.04). The effect of relaxation therapy on symptoms of
depression, phobia, and worry was significant; Hedges' g = 0.44 (95% CI: 0.30–0.59), 0.40 (95% CI: 0.06–0.75),
0.54 (95% CI: 0.28–0.79), respectively.
CONCLUSION: The results of this study provide evidence for the effectiveness of relaxation therapy for people
with anxiety disorders. Therefore, relaxation therapy can be selected as a useful intervention for reducing ne-
gative emotions in people with anxiety disorders.

Anxiety disorders and their correlated symptoms are common in
community settings and health care settings (Baldwin et al., 2014).
Most people with anxiety disorders suffer from its chronicity and life-
time comorbidity with other disorders (Hofmeijer-Sevink et al., 2012).
The global prevalence of anxiety disorders is up to 28. 3%, although the
prevalence varies by region and culture (Baxter, Scott, Vos, &
Whiteford, 2013). Moreover, prevalence rates have increased over time
(Kessler, Petukhova, Sampson, Zaslavsky, & Wittchen, 2012).
Pharmacological treatments and psychological interventions are
common clinical treatment strategies for anxiety disorders.
Pharmacological treatments are effective, but may be limited due to
adverse effects, such as sexual dysfunction, excessive perspiration,
drowsiness, and weight gain. Pharmacological treatments are also not
considered to be definitive, but are merely a symptomatic treatment
(Baldwin et al., 2014). Moreover, treatment guidelines by The National
Institute for Health and Care Excellence (NICE) in the United Kingdom
recommend psychological interventions as first-line treatments in ad-
vance of pharmacological treatment (NICE, 2014). Of psychological
interventions, relaxation based therapy has been widely studied and is
considered a valid treatment option for anxiety disorders. Previous
studies have reported that relaxation therapy has a numerically higher
effect size than that of Cognitive Behavior Therapy (CBT) in pre to post
treatment comparisons, though the efficacy of CBT has been the most
widely studied (Bandelow et al., 2015).
Relaxation response can be attained through Progressive Muscular
Relaxation (PMR), Applied Relaxation (AR), Autogenic Training (AT),
Mindfulness-Based Therapy (MBT) and meditation (Pagnini, Manzoni,
Castelnuovo, & Molinari, 2013). Although relaxation therapies vary in
techniques and the settings in which they are administrated, they share
the common treatment goal of using relaxation to decrease stress or
anxiety, which originated in Jacobson's muscle relaxation theory
(Pagnini et al., 2013).
There is much clinical evidence for the efficacy of relaxation
therapy applied to anxiety disorders, the efficacy of Mindfulness-Based
Stress Reduction (MBSR) on generalized anxiety disorders (Hoge et al.,
2013), and the efficacy of MBSR on social anxiety disorders (Jazaieri,
Goldin, Werner, Ziv, & Gross, 2012). Compared to CBT, there is evi-
dence that MBSR for anxiety disorders resulted in a greater reduction of
worry and comorbid emotional problems (Arch et al., 2013). A recent
randomized controlled study reported that AR for patients with Gen-
eralized Anxiety Disorder was more effective for decreasing muscle
tension than a pharmacological treatment was (Zullino et al., 2015).
However, despite the increasing number of clinical trials for relaxation,
as yet there have not been any consistent conclusions about relaxation's

☆
The authors have no conflict of interest to declare.
⁎
Corresponding author at: Department of Nursing, Daejeon University, 2 Daehakro, Dong-ku, Daejoen 34519, Republic of Korea.
E-mail address: ejkim@dju.kr (E.J. Kim).

https://doi.org/10.1016/j.apnu.2017.11.015
Received 2 October 2017; Accepted 18 November 2017
0883-9417/ © 2017 Elsevier Inc. All rights reserved.
H.-s. Kim, E.J. Kim
effectiveness for anxiety disorders, as proven in previous studies.
Therefore, the aim of our systematic review is to explore the best
available evidence on the effectiveness of relaxation therapy applied to
people with anxiety disorders.
METHODS
We follow the Cochrane Handbook for Systematic Reviews of
Interventions (Higgins & Thompson, 2002) to conduct this systematic
review of Randomized Control Trials (RCTs) to explore the effect of
relaxation therapy on anxiety disorders. The Preferred Reporting Items
for Systematic Reviews and Meta-analyses group (PRISMA) (Moher,
Liberati, Tetzlaff, & Altman, 2009) was used as a basis for the reporting
of our review.
SEARCH STRATEGY
Articles included in the systematic review were published before
April 2016, and found through a search of the computer-based
Cochrane Library, Pubmed, Cumulative Index to Nursing and Allied
Health Literature (CINAHL), PsycINFo, KoreaMed, and Research
Information Sharing Service (RISS). We conducted the search using the
following medical subject heading (MeSH) and text words: ((‘anxiety
disorders’[MeSH] OR ‘anxi*’ OR ‘GAD’ OR ‘generalized anxiety dis-
order’ OR ‘panic disorder’ OR ‘phobia’ OR ‘social phobia’ OR ‘social
anxiety disorder’ OR ‘PTSD’ OR ‘post traumatic stress disorder’ OR
‘OCD’ OR ‘obsessive compulsive’)) AND ((‘Relaxation Therapy’[Mesh])
OR ‘relax*’ OR ‘relaxation method’ OR ‘relaxation training’ OR ‘re-
laxation exercise(s)’ OR ‘autogenic training’ OR ‘applied relaxation’ OR
‘PMR’ OR ‘progressive relaxation’ OR ‘relaxation desensitization’ OR
‘Meditation’ OR ‘MBSR’ OR ‘Mindfulness meditation’ OR ‘imagery’)).
SELECTION CRITERIA
The selection criteria were as follows: (a) enrolled subjects with a
diagnosis of anxiety disorders aged 18 and older (b) relaxation inter-
vention (c) comparisons of placebo, usual care, wait listing, alternative
treatment or no treatment groups (d) outcome measures including an-
xiety (e) study designed in RCTs, and (f) study reported in Korean or
English. Exclusion criteria were as follows: (a) study was not original (e.
g., editorials, opinion pieces, reviews, and notes) (b) study used re-
laxation therapy in combination with other treatments, (c) study used
the comparison of pharmacological treatments, and (d) study used re-
laxation therapy as a comparison.
QUALITY ASSESSMENT
Two reviewers independently assessed the methodological quality
of included studies using the Scottish Intercollegiate Guidelines
Network, 2011 (SIGN) checklist. SIGN consists of 10 domains that
evaluate a study's internal validity. Potential responses are ‘yes’, ‘no’,
‘can't say’ and ‘does not apply’. Based on this checklist, the reviewers
appraised each study's methodological quality and finally evaluated
each one as follows: ‘high quality (++)’, ‘acceptable (+)’ or ‘un-
acceptable – reject (0)’.
DATA EXTRACTION AND ANALYSIS
Effect sizes were analyzed for each outcome in differences between
experimental and control groups and the change from pre- to post-
testing. Data were extracted by two persons in each selected study in-
dependently. Comprehensive Meta-Analysis (CMA 2. 1) was used to
calculate effect sizes and test the homogeneity among studies, and
moderate variable analyses.
Hedges' g, corrected standardized mean difference and 95%
Confidence Intervals (CI) were calculated. The average effect size
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Archives of Psychiatric Nursing 32 (2018) 278–284
(summary effect) was calculated using a random-effects model con-
sidering the variety of each sample, intervention, and the intervention
duration of each study (Borenstein, Hedges, Higgins, & Rothstein,
2009). The Q and the I2 statistics were used to identify between-study
heterogeneity. Here, Q value with p < 0.10 in x2 distribution may
indicate a problem with heterogeneity. A value of I2 between 0% and
40% may not be important, while a value over 50% may be considered
substantial heterogeneity (Higgins & Green, 2011). In order to explore
possible courses of heterogeneity, moderator analyses were performed
by subgrouping with types of intervention and types of comparison
using meta-ANOVA. Meta-regression was also performed to explore the
effect of the number of intervention sessions. In order to assess a po-
tential threat to the internal validity of our meta-analyses, publication
bias was analyzed using funnel plots.
RESULTS
STUDY CHARACTERISTICS
Initially, a total 16,173 studies were retrieved. After removing du-
plicates, the titles and abstracts of the remaining 7571 studies were
reviewed by two researchers. According to the selection criteria 166
studies were selected. The researchers independently evaluated the
eligibility of these 166 studies and selected 39. Of these studies, twenty
two were excluded based on selection criteria, and one study was ex-
cluded due to improper quality. Finally, 16 studies were included in our
review and meta-analysis (Fig. 1).
The characteristics of the selected papers are shown in Table 1.
Studies were published between 1988 and 2014. The pooled sample
was composed of 856 subjects, of which 431 were allocated to experi-
mental training groups, while 425 were in control groups. For the
treatment group we found that only two types of relaxation were uti-
lized in all the selected studies: AR was used in 9 studies, and MBSR was
used in 7 studies. Regarding the comparison group, 12 studies utilized
Treatment-As-Usual (TAU), while 4 studies utilized CBT. The number of
intervention sessions ranged from 8 to 48, and the duration of each
session ranged from 20 to 150 min.
Six studies examined the effect of relaxation on subjects with gen-
eral anxiety disorder; 4 with panic disorder; 2 with social anxiety dis-
order. In 4 studies subjects were not separated by subtypes of diagnosis,
instead administrating relaxation to subjects with all types of anxiety
disorders. Anxiety symptoms were measured using valid and reliable
instruments in all selected studies. The most commonly used instru-
ments were the Beck Anxiety Inventory (BAI) and the Hamilton Rating
Scale for Anxiety (HAMA).
QUALITY ASSESSMENT
All studies clearly described the research topics, concepts and ob-
jectives. Ten studies reported concealment; 14 studies reported
blinding; and 11 studies conducted intention-to-treat analyses. Mean
drop-out rate ranged from 0% to 24.5%. Ten studies were evaluated as
having high methodological quality (++), and 6 as acceptable (+)
(Table 1).
EFFECTS of RELAXATION THERAPY for ANXIETY
The overall effect of relaxation therapy on symptom of anxiety was
significant, and the effect size was Hedges' g = 0.62 (95% CI:
0.42–0.81) (Fig. 2), which indicates a medium-high effect according to
Cohen's criterion. The heterogeneity was statistically significant with
I2 = 48.84 (Q = 29.32, p = 0.02) indicating a medium-low hetero-
geneity according to Higgins and Green's (2011) criterion. The effect
sizes of AR and MBSR were mostly medium and statistically significant,
Hedges' g = 0.63 (95% CI: 0.38–0.88) and Hedges' g = 0.62 (95% CI:
0.31–0.93) respectively. The effect sizes on subtypes of diagnosis
H.-s. Kim, E.J. Kim
without 4 studies for overall anxiety disorders were significant and
ranged from small to medium. The effect size on panic disorder was
Hedges' g = 0.69 (95% CI: 0.32–1.05), on general anxiety disorder was
Hedges' g = 0.57(95% CI: 0.28–0.87), and on social anxiety disorder
was Hedges' g = 0.34 (95% CI: -0.03-0.72). The effect size of relaxation
therapy compared to the TAU group was large, Hedges' g = 0.72 (95%
CI: 0.47–0.96); and the effect size of relaxation therapy compared to the
CBT group was slightly below medium, Hedges' g = 0.35 (95% CI:
0.09–0.61).
MODERATOR EFFECTS
The results of subgroup analysis showed that the effect of relaxation
therapy on symptoms of anxiety was not moderated by intervention
type (Q = 0.01, p = 0.95). Moderator effect by types of comparison of
TAU and CBT was significant (Q = 4.20, p = 0.04). Meta regression
analysis for moderator effect of the number of treatment sessions
showed that the greater the number of intervention sessions, the greater
the effect size, but this was not statistically significant (b = 0.05,
p = 0.64).
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Fig. 1. Flow chart of study selection.
EFFECTS of RELAXATION THERAPY on SYMPTOM of DEPRESSION,
PHOBIA or WORRY
The effect of relaxation therapy on symptoms of depression was
medium low and statistically significant (Hedges' g = 0.44, 95% CI:
0.30–0.59). The effect of relaxation therapy on symptoms of phobia was
medium low and statistically significant (Hedges' g = 0.40, 95% CI:
0.06–0.75). The effect of relaxation therapy on symptoms of worry was
medium and statistically significant (Hedges' g = 0.54, 95% CI:
0.28–0.79) (Fig. 3).
PUBLICATION BIAS
Visual inspection of the funnel plot was performed to detect any
publication bias of the selected 16 studies, while additional statistical
analysis was conducted. Begg and Mazumdars rank correlation (Begg &
Mazumdar, 1994) was non-significant (Kendall's tau: 0.04, p = 0.14).
Egger's regression intercept test (Egger, Smith, Schneider, & Minder,
1997) showed a trend (p = 0.16) for no publication bias (inter-
cept = 2.27, standard deviation = 1.51). In addition, the trim and fill
procedure pointed at some possible publication bias. After adjusting for
publication bias, the mean effect size was reduced from Hedges'
g = 0.62 to Hedges' g = 0.59, but this did not affect the study results
(Fig. 4).
H.-s. Kim, E.J. Kim Archives of Psychiatric Nursing 32 (2018) 278–284

Table 1
Characteristics of included studies in meta-analysis.

Author (year) Diagnosis Sample size Age Intervention type Number of session ∗ min ∗ duration Outcome measures QA

Total Exp Cont

Arch et al. (2013) AD 105 45 60 18–75 MBSR 10 ∗ 90 ∗ 10wks MASQ-AA, BDI-II, ++

PSWQ
Boettcher et al. (2014) AD 91 45 46 18 < MBSR 48 ∗ 20 ∗ 8wks BAI, BDI-II ++
Borkovec and Costellol (1993) GAD 37 17 20 adult AR 12 ∗ 60–90 ∗ 6wks HAMA, BDI, PSWQ +
Clark et al. (1994) PD 32 16 16 18–60 AR 12*60*12wks PACS, BDI ++
Conrad, Isaac, and Roth (2008) GAD 50 29 21 adult AR 12 ∗ 60 ∗ 12wks BAI, BDI, PSWQ ++
Dugas et al. (2010) GAD 42 22 20 18–64 AR 12 ∗ 60 ∗ 12wks STAI-T, BDI-II, PSWQ ++
Hoge et al. (2013) GAD 89 48 41 18 < MBSR 8 ∗ 120 ∗ 8wks BAI ++
Hoyer et al. (2009) GAD 57 28 29 18–70 AR 15 ∗ 60 ∗ 15wks HAMA, BDI, PSWQ ++
Jazaieri et al. (2012) SAD 56 31 25 adult MBSR 8 ∗ 150 ∗ 8wks LSAS, BDI-II ++
Koszycki, Benger, Shlik, and Bradwejn SAD 53 26 27 adult MBSR 8 ∗ 150 ∗ 8wks SIS, BDI, SPS +
(2007)
Lee et al. (2007) AD 46 24 22 20–60 MBSR 8 ∗ 60 ∗ 8wks HAMA, BDI, SCL-90-R ++
Öst (1988) PD 18 9 9 20–60 AR 14 ∗ 60 ∗ 14wks HAMA, BDI +
Öst, Westling, and Hellström (1993) PD 30 15 15 20–60 AR 12 ∗ 60 ∗ wks STAI-S, BDI, FQ ++
Öst and Westling (1995) PD 38 19 19 18–60 AR 12 ∗ 60 ∗ 12 HAMA, BDI +
Öst and Breitholtz (2000) GAD 36 18 18 18–60 AR 12 ∗ 60 ∗ 12wks BAI, BDI, PSWQ +
Vøllestad, Sivertsen, and Nielsen (2011) AD 76 39 37 18–65 MBIs 8 ∗ 150 ∗ 8wks BAI, BDI, PSWQ +

Exp = experimental group; Cont = control group; QA = quality assessment; AD = anxiety disorder; GAD = generalized anxiety disorder; PD = panic disorder; SAD = social anxiety
disorder; MBSR = mindfulness based stress reduction; AR = applied relaxation; BAI = Beck's anxiety inventory; BDI = Beck's depression inventory; HAMA = Hamilton anxiety scale;
PSWQ = penn state worry questionnaire; PACS = panic/anxiety composite score; LSAS = Liebowitz social anxiety scale; MASQ-AA = mini mood and anxiety symptom questionnaire;
CSR = clinician's severity rating; SIS = social interaction scale; SPS = social phobia scale; SCL-90-R = symptom checklist-90-R; FQ = fear questionnaire; STAI-S = state-trait anxiety
inventory-state.

DISCUSSION meta-analysis, the effect size of relaxation when using a comparison of a

The goal of the present study was to determine the effectiveness of
relaxation therapy for anxiety disorders. The results of the present
meta-analysis provide evidence that relaxation therapy reduces symp-
toms of anxiety, depression, phobia or worry in patients with anxiety
disorders. The effect size of relaxation therapy on symptom of anxiety
for overall anxiety disorders was medium (Hedges'g = 0.62) and sta-
tistically significant (95% CI: 0.42–0.81). This result is somewhat
comparable to those of previous meta-analysis for the efficacy of psy-
chological treatment for anxiety disorders (Bandelow et al., 2015).
Although the effect sizes of relaxation therapy reported by Bandelow
et al. (2015) are higher than those of our results, this is most likely
because of different comparison conditions. In Bandelow et al.'s (2015)
wait-listed group was large (Cohen's d = 1.31); the effect size of re-
laxation when using pre to post experiment comparison was large
(Cohen's d = 1.36). The result of the current study showed that the
effect of relaxation therapy when compared to CBT was Hedges'
g = 0.35, indicating relaxation therapy is more effective than CBT for
reducing anxiety. This result was similar to the results of a previous
meta-analysis in which it was reported that the effect size of relaxation
therapy was higher than that of CBT in pre-post comparison (Bandelow
et al., 2015). This result also supports Boettcher's (2014) argument that
CBT is most widely studied but not all individuals respond to CBT ef-
fectively in clinic. For those individuals, relaxation therapy is more
effective than CBT.
Although there are several types of relaxation therapy, the present

Fig. 2. Forest plots of the effects on anxiety.

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H.-s. Kim, E.J. Kim
study found that only AR and MBSR had been studied using RCTs; there
were 9 studies for AR and 7 studies for MBSR. The effects of AR and
MBSR were significant (Hedges' g = 0.63 and 0.62 respectively). These
results provide evidence that AR or MBSR can be considered as a
treatment option in clinic to reduce anxiety in a person with anxiety
disorders. Strauss, Cavanagh, Oliver, and Pettman (2014) reported that
the effect of mindful based interventions was not significant on severity
of anxiety for people with anxiety disorders, which appears to be in
contrast to our findings of a significant medium effect of MBSR. This is
because the eligibility criteria for our study differed from Strauss et al.
(2014); we excluded cognition combined therapy, while Strauss et al.
(2014) included Mindfulness Based Cognitive Therapy (MBCT). This is
meaningful, as our restricted criteria produced the effect for relaxation
therapy only, rather than the combination of relaxation and cognitive
therapy.
In the current study we explored primarily whether relaxation based
therapy reduced symptoms of anxiety. However, we also found a sig-
nificant effect of relaxation therapy on depression, phobia, and worry.
In particular, depression is a comorbid symptom of anxiety (Starr,
Hammen, Connolly, & Brennan, 2014). Fifteen studies measured the
effect of relaxation therapy for symptoms of depression, and a
Fig. 3. Effects of Relaxation Therapy on: (A) Symptoms of depression. (B) Symptoms of phobia. (C) Symptoms of worry.
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significant reduction of depressive symptoms was found with medium
effect size. Our finding corresponds with the previous meta-analysis for
anxiety or depressive disorder (Strauss et al., 2014), where mindful
based interventions had significant effects on depressive disorder.
The overall effect of relaxation therapy on symptoms of anxiety was
significant; however, there was a significant heterogeneity of effect
sizes. To explore the possible source of heterogeneity, we conducted a
moderator analysis. We found heterogeneity in neither the effect sizes
between AR and MBSR, nor did we find it across the number of treat-
ment sessions. However, we found heterogeneity in effects between
comparisons of TAU and CBT. This might be a potential source of
heterogeneity.
It is not easy to select a cost effective and valid treatment modality
for anxiety disorders. Relaxation based therapy, regardless of its tech-
nique, could be used as a form of non-pharmacologic treatment for
reducing the severity of symptoms in people with anxiety disorders
(Pagnini et al., 2013). However, the current review of relaxation
therapy for anxiety disorders was limited to AR and MBSR. Therefore,
on the basis of the current findings, we suggest that AR and MBSR can
be selected as evidence based interventions when caring for people
suffering from anxiety disorders.
H.-s. Kim, E.J. Kim
Fig. 3. (continued)
LIMITATION
The present study has the following limitations. Our meta-analysis
reviewed the effectiveness of relaxation therapy for DSM-III-R or DSM-
IV anxiety disorders. Additionally, only AR and MBSR were reviewed
because of the restrictive inclusion criteria of RCTs. These limitations
may hinder generalizability. It is important to have an optimal treat-
ment duration when applying psychological interventions (NICE,
2014). However, the present meta-analysis could not determine the
adequate amount of time for the implementation of the therapy, nor
any lasting effect of the therapy, because of disparate data related to the
duration of the intervention and measurement times. Therefore, we
pooled data measured from the last measurement point following the
cessation of treatment. Follow-up data existed in only a few studies.
Thus, we could not determine any lasting effect after the completion of
the intervention.
Medications such as TCAs, MAOIs, or benzodiazepines are no longer
first line treatments for anxiety disorders (Bandelow et al., 2015).
Zullino et al. (2015) examined Venlafaxine versus AR for GAD using
Fig. 4. Funnel plot of standard error by Hedge's g.
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RCTs, and suggested a combination of the medication and AR in case of
failure of the first line treatment. According to our review, subjects
taking medication were included in most studies as experimental or
controlled trials. However, studies comparing groups applying relaxa-
tion with groups taking medications were few. The current review ex-
cluded studies that used the comparison of a medication group, because
this would increase heterogeneity. This study therefore cannot provide
information on the combination of relaxation therapy with medication,
nor on the effect of relaxation therapy compared to medication.
CONCLUSION
Relaxation therapy is a cost effective and useful psychological in-
tervention that nurses can apply to clients with anxiety disorders in
community and clinical settings. Of all the various types, 9 RCTs for AR
and 7 RCTs for MBSR met our inclusion criteria for meta-analysis. AR
and MBSR have medium-high effect sizes compared to TAU, with
homogeneity between two types. Besides symptoms of anxiety, the
current study presents evidence that the use of relaxation therapy can
H.-s. Kim, E.J. Kim Archives of Psychiatric Nursing 32 (2018) 278–284

reduce symptoms of depression, phobia, and worry in people with an- anxiety disorder: Effects on anxiety and stress reactivity. The Journal of Clinical
xiety disorders. Psychiatry, 74(8), 786. http://dx.doi.org/10.4088/JCP.12m08083.
Hoyer, J., Beesdo, K., Gloster, A. T., Runge, J., Höfler, M., & Becker, E. S. (2009). Worry
exposure versus applied relaxation in the treatment of generalized anxiety disorder.
REFERENCES Psychotherapy and Psychosomatics, 78(2), 106–115. http://dx.doi.org/10.1159/
000201936.
Jazaieri, H., Goldin, P. R., Werner, K., Ziv, M., & Gross, J. J. (2012). A randomized trial of
Arch, J. J., Ayers, C. R., Baker, A., Almklov, E., Dean, D. J., & Craske, M. G. (2013).
MBSR versus aerobic exercise for social anxiety disorder. J. Clin. Psychol. 68(7),
Randomized clinical trial of adapted mindfulness-based stress reduction versus group
715–731. http://dx.doi.org/10.1002/jclp.21863.
cognitive behavioral therapy for heterogeneous anxiety disorders. Behav. Res. Ther.
Kessler, R. C., Petukhova, M., Sampson, N. A., Zaslavsky, A. M., & Wittchen, H. U. (2012).
51(4), 185–196. http://dx.doi.org/10.1016/j.brat.2013.01.003.
Twelve-month and lifetime prevalence and lifetime morbid risk of anxiety and mood
Baldwin, D. S., Anderson, I. M., Nutt, D. J., Allgulander, C., Bandelow, B., den Boer, J. A.,
disorders in the United States. Int. J. Methods Psychiatr. Res. 21(3), 169–184. http://
... Malizia, A. (2014). Evidence-based pharmacological treatment of anxiety dis-
dx.doi.org/10.1002/mpr.1359.
orders, post-traumatic stress disorder and obsessive-compulsive disorder: A revision
Koszycki, D., Benger, M., Shlik, J., & Bradwejn, J. (2007). Randomized trial of a medi-
of the 2005 guidelines from the British Association for Psychopharmacology. J.
tation-based stress reduction program and cognitive behavior therapy in generalized
Psychopharmacol. 28(5), 403–439. http://dx.doi.org/10.1177/0269881114525674.
social anxiety disorder. Behaviour Research and Therapy, 45(10), 2518–2526. http://
Bandelow, B., Reitt, M., Röver, C., Michaelis, S., Görlich, Y., & Wedekind, D. (2015).
dx.doi.org/10.1016/j.brat.2007.04.011.
Efficacy of treatments for anxiety disorders: A meta-analysis. Int. Clin.
Lee, S. H., Ahn, S. C., Lee, Y. J., Choi, T. K., Yook, K. H., & Suh, S. Y. (2007). Effectiveness
Psychopharmacol. 30(4), 183–192. http://dx.doi.org/10.1097/YIC.
of a meditation-based stress management program as an adjunct to pharmacotherapy
0000000000000078.
in patients with anxiety disorder. Journal of Psychosomatic Research, 62(2), 189–195.
Baxter, A. J., Scott, K. M., Vos, T., & Whiteford, H. A. (2013). Global prevalence of anxiety
http://dx.doi.org/10.1016/j.jpsychores.2006.09.009.
disorders: A systematic review and meta-regression. Psychol. Med. 43(05), 897–910.
Moher, D., Liberati, A., Tetzlaff, J., & Altman, D. G. (2009). Preferred reporting items for
http://dx.doi.org/10.1017/s003329171200147x.
systematic reviews and meta-analyses: The PRISMA statement. Ann. Intern. Med.
Begg, C. B., & Mazumdar, M. (1994). Operating characteristics of a rank correlation test
151(4), 264–269. http://dx.doi.org/10.7326/0003-4819-151-4-200908180-00135.
for publication bias. Biometrics, 1088–1101. http://dx.doi.org/10.2307/2533446.
NICE (2014). Anxiety disorders. Quality standardLondon: National Institute for Health and
Boettcher, J., Åström, V., Påhlsson, D., Schenström, O., Andersson, G., & Carlbring, P.
Care Excellence. Retrieved from https://www.nice.org.uk.
(2014). Internet-based mindfulness treatment for anxiety disorders: A randomized
Öst, L. G. (1988). Applied relaxation vs progressive relaxation in the treatment of panic
controlled trial. Behav. Ther. 45(2), 241–253. http://dx.doi.org/10.1016/j.beth.2013.
disorder. Behaviour Research and Therapy, 26(1), 13–22. http://dx.doi.org/10.1016/
11.003.
0005-7967(88)90029-0.
Borenstein, M., Hedges, L. V., Higgins, J., & Rothstein, H. R. (2009). Introduction to Meta-
Öst, L. G., & Breitholtz, E. (2000). Applied relaxation vs. cognitive therapy in the treat-
analysis. 2009, Chichester, UK: John Wiley & Sons, Ltd1–452. http://dx.doi.org/10.
ment of generalized anxiety disorder. Behaviour Research and Therapy, 38(8),
1002/9780470743386.
777–790. http://dx.doi.org/10.1016/S0005-7967(99)00095-9.
Borkovec, T. D., & Costello, E. (1993). Efficacy of applied relaxation and cognitive-be-
Öst, L. G., & Westling, B. E. (1995). Applied relaxation vs cognitive behavior therapy in
havioral therapy in the treatment of generalized anxiety disorder. Journal of
the treatment of panic disorder. Behaviour Research and Therapy, 33(2), 145–158.
Consulting and Clinical Psychology, 61(4), 611. http://dx.doi.org/10.1037/0022-006X.
http://dx.doi.org/10.1016/0005-7967(94)E0026-F.
61.4.611.
Öst, L. G., Westling, B. E., & Hellström, K. (1993). Applied relaxation, exposure in vivo
Clark, D. M., Salkovskis, P. M., Hackmann, A., Middleton, H., Anastasiades, P., & Gelder,
and cognitive methods in the treatment of panic disorder with agoraphobia.
M. I. C. H. A. E. L. (1994). A comparison of cognitive therapy, applied relaxation and
Behaviour Research and Therapy, 31(4), 383–394. http://dx.doi.org/10.1016/0005-
imipramine in the treatment of panic disorder. The British Journal of Psychiatry,
7967(93)90095-C.
164(6), 759–769. http://dx.doi.org/10.1192/bjp.164.6.759.
Pagnini, F., Manzoni, G. M., Castelnuovo, G., & Molinari, E. (2013). A brief literature
Conrad, A., Isaac, L., & Roth, W. T. (2008). The psychophysiology of generalized anxiety
review about relaxation therapy and anxiety. Body, Movement and Dance in
disorder: 2. Effects of applied relaxation. Psychophysiology, 45(3), 377–388. http://
Psychotherapy, 8(2), 71–81. http://dx.doi.org/10.1080/17432979.2012.750248.
dx.doi.org/10.1111/j.1469-8986.2007.00644.x.
SIGN (2011). SIGN 50 (2011): A guideline developers' handbook (Revised ed.). Scottish
Dugas, M. J., Brillon, P., Savard, P., Turcotte, J., Gaudet, A., Ladouceur, R., ... Gervais, N.
Intercollegiate Guidelines Network. Available at: http://www.sign.ac.uk/guidelines/
J. (2010). A randomized clinical trial of cognitive-behavioral therapy and applied
fulltext/50/.
relaxation for adults with generalized anxiety disorder. Behavior Therapy, 41(1),
Starr, L. R., Hammen, C., Connolly, N. P., & Brennan, P. A. (2014). Does relational dys-
46–58. http://dx.doi.org/10.1016/j.beth.2008.12.004.
function mediate the association between anxiety disorders and later depression?
Egger, M., Smith, G. D., Schneider, M., & Minder, C. (1997). Bias in meta-analysis de-
Testing an interpersonal model of comorbidity. Depression and Anxiety, 31(1), 77–86.
tected by a simple, graphical test. Br. Med. J. 315(7109), 629–634. http://dx.doi.org/
http://dx.doi.org/10.1002/da.22172.
10.1136/bmj.315.7109.629.
Strauss, C., Cavanagh, K., Oliver, A., & Pettman, D. (2014). Mindfulness-based inter-
Higgins, J., & Thompson, S. G. (2002). Quantifying heterogeneity in a meta‐analysis.
ventions for people diagnosed with a current episode of an anxiety or depressive
Statistics in Medicine, 21(11), 1539–1558. http://dx.doi.org/10.1002/sim.1186.
disorder: A meta-analysis of randomised controlled trials. PLoS One, 9(4), e96110.
Higgins, J. P., & Green, S. (Eds.). (2011). Cochrane handbook for systematic reviews of
http://dx.doi.org/10.1371/journal.pone.0096110.
interventions version 5.1.0 [updated March 2011]The Cochrane Collaborationhttp://
Vøllestad, J., Sivertsen, B., & Nielsen, G. H. (2011). Mindfulness-based stress reduction for
handbook.cochrane.org.
patients with anxiety disorders: Evaluation in a randomized controlled trial.
Hofmeijer-Sevink, M. K., Batelaan, N. M., van Megen, H. J., Penninx, B. W., Cath, D. C.,
Behaviour Research and Therapy, 49(4), 281–288. http://dx.doi.org/10.1016/j.brat.
van den Hout, M. A., & van Balkom, A. J. (2012). Clinical relevance of comorbidity in
2011.01.007.
anxiety disorders: A report from the Netherlands Study of Depression and Anxiety
Zullino, D., Chatton, A., Fresard, E., Stankovic, M., Bondolfi, G., Borgeat, F., & Khazaal, Y.
(NESDA). J. Affect. Disord. 137(1), 106–112. http://dx.doi.org/10.1016/j.jad.2011.
(2015). Venlafaxine versus applied relaxation for generalized anxiety disorder: A
12.008.
randomized controlled study on clinical and electrophysiological outcomes.
Hoge, E. A., Bui, E., Marques, L., Metcalf, C. A., Morris, L. K., Robinaugh, D. J., ... Simon,
Psychiatry Q. 86(1), 69–82. http://dx.doi.org/10.1007/s11126-014-9334-2.
N. M. (2013). Randomized controlled trial of mindfulness meditation for generalized

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