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Applied Psychophysiology and Biofeedback [apb] pp383-apbi-367321 February 18, 2002 12:11 Style file version Nov. 19th, 1999

Applied Psychophysiology and Biofeedback, Vol. 27, No. 1, March 2002 (°


C 2002)

Autogenic Training: A Meta-Analysis of Clinical


Outcome Studies
Friedhelm Stetter1,2 and Sirko Kupper1

Autogenic training (AT) is a self-relaxation procedure by which a psychophysiological


determined relaxation response is elicited. A meta-analysis was performed to evaluate the
clinical effectiveness of AT. Seventy-three controlled outcome studies were found (published
1952–99). Sixty studies (35 randomized controlled trials [RCT]) qualified for inclusion in
the meta-analysis. Medium-to-large effect sizes (ES) occurred for pre–post comparisons
of disease-specific AT-effects, with the RCTs showing larger ES. When AT was compared
to real control conditions, medium ES were found. Comparisons of AT versus other psy-
chological treatment mostly resulted in no effects or small negative ES. This pattern of
results was stable at follow-up. Unspecific AT-effects (i.e., effects on mood, cognitive per-
formance, quality of life, and physiological variables) tended to be even larger than main
effects. Separate meta-analyses for different disorders revealed a significant reduction of
the heterogeneity of ES. Positive effects (medium range) of AT and of AT versus control in
the meta-analysis of at least 3 studies were found for tension headache/migraine, mild-to-
moderate essential hypertension, coronary heart disease, asthma bronchiale, somatoform
pain disorder (unspecified type), Raynaud’s disease, anxiety disorders, mild-to-moderate
depression/dysthymia, and functional sleep disorders.
KEY WORDS: autogenic training; relaxation; meta-analysis; controlled clinical studies; effectiveness.

Relaxation methods such as autogenic training (AT), progressive muscle relaxation,


relaxation–biofeedback, and relaxation–hypnosis are frequently used in many psychological
treatment approaches and settings for the therapy of a variety of disorders and in preventive
or rehabilitative programs (Stetter, 1998). AT is the relaxation method most frequently used
in German-speaking countries. AT was described in a monograph by I. H. Schultz in 1932.
It had been introduced to Anglo-American countries as well (e.g., by the work of Wolfgang
Luthe: Linden, 1990; Luthe, 1970a, 1970b, 1970c; Luthe & Schultz, 1969a, 1969b; Schultz
& Luthe, 1969). However AT does not have such a wide following in Anglo-American
countries compared to the German-speaking area (Linden, 1994; Sellers, 1974). AT is
based on passive concentration of bodily perceptions (e.g., heaviness and warmth of arms,
legs, and abdomen; rhythm of breath; and heartbeat) that are facilitated by self-suggestions.
1 OberbergklinikExtertal for Psychotherapy, Psychiatry, and Psychosomatic Medicine, Extertal, Germany.
2 Addressall correspondence to Friedhelm Stetter, MD, Oberbergklinik Extertal for Psychotherapy, Psychiatry,
and Psychosomatic Medicine, Brede 29, D 32699 Extertal, Germany; e-mail: stetter@oberbergkliniken.de.

45
1090-0586/02/0300-0045/0 °
C 2002 Plenum Publishing Corporation
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46 Stetter and Kupper

These self-suggestions can be regarded as psychophysiologically adapted subverbal stimuli


(Sellers, 1974). Practitioners who use AT suggest that it should be practiced regularly
and that the exercises should be “debriefed.” The learning process can be facilitated by
several techniques, for instance, evidence suggests that diaries are an effective component
of treatment (Krampen, 1991).
Within the therapeutic sessions the task of the therapist includes (1) to evaluate disease-
models of the participants and to introduce the psychophysiological model of the effects
of AT (or relaxation in general), (2) to reinforce positive relaxation responses reported by
the participants after the excercises, (3) to deal with possible negative initial relaxation-
responses, and (4) to enhance motivation for training.
AT can be introduced in individual sessions. However, AT is frequently applied in
group settings. Evidence from one controlled study suggests a slight superiority of indi-
vidual teaching (Sellers, 1974). However, clinical evidence and evidence from many other
controlled studies demonstrates that the group setting is as well appropriate (Stetter &
Kupper, 1998).
There exists quite a body of literature and empirical data concerning the psychophys-
iological model of change in AT (review by Hoffmann, Hoffmann, Derra, & Stetter, 2000;
Luthe, 1965, 1970a, 1970b, 1970c; Luthe & Schultz, 1969a, 1969b; Schultz & Luthe, 1969).
However, Linden (1994) pointed out that so far the empirical validation of clinical outcome
research has mainly been based on case reports or pre–post studies. Those practitioners
or clinicians who were familiar with AT seemed somewhat enthusiastic, and some mono-
graphs recommended AT for nearly all and every clinical symptom or disease. This was
even somehow true with Schultz (1932/1987) himself. In the field of psychotherapeutic re-
search, however, a lack of controlled clinical outcome research was assumed. As an example,
Grawe, Donati, and Bernauer (1994) conducted an extensive review on psychotherapeutic
outcome studies, published until 1983/84. Among more than thousand studies they found
only 14 controlled AT-studies and concluded that the effectiveness of AT had not been
validated as had of other relaxation methods (especially progressive muscle relaxation or
relaxation–hypnosis). A first qualitative and quantitative meta-analysis of clinical outcome
research concerning AT that had an appropriate database was published by Linden (1994) in
this journal. Linden found 30 controlled studies published until 1992. He included 24 studies
in the quantitative analysis. AT was as effective as other relaxation methods.
The purpose of this study was to enlarge the database regarding the effectiveness of AT
to include recently published studies. Also, a closer restriction to clinical populations was
used as compared to the study of Linden (1994) that focused on a variety of applications of
AT. The present meta-analysis sought to replicate the results of the study of Linden (1994)
and to test the following hypotheses:

1. Primary hypotheses
a. Therapy with AT results in significant pre–post effects concerning the key symp-
toms of several psychosomatic or psychological disorders or clinical syndromes.
b. Therapy with AT is superior to real control conditions.
c. The effectiveness of a therapy with AT is similar to that of other psychological
treatments.
2. Secondary hypothesis: AT will demonstrate significant secondary effects on out-
comes such as mood, cognitive performance, quality of life, and physiological
variables.
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Autogenic Training: A Meta-Analysis 47

METHODS

Sampling Method

Studies were sampled by means of the Medline electronic database (search terms:
“autogenic training,” “autogenic relaxation”) and by means of bibliographies of relevant
reviews (Grawe et al., 1994; Linden, 1994; Stetter, 1998) and monographs (Binder & Binder,
1998; Hoffmann, Hoffmann, & Derra, 1997; Luthe, 1965). Unpublished dissertations of AT
were not included in the review. Inclusion criteria were as follows:

1. The study was published in periodical journals or books between 1932 and 1999.
Schultz’s original monograph on AT was published in 1932; thus, no clinical AT
trials were published prior to 1932.
2. The study addresses a clinically defined group of patients suffering from a specific
disorder or at least a syndrome or clinically significant symptom (e.g., anxiety).
Some syndromes were included that may not completely be related to the op-
erationalized diagnostic systems as the DSM-IV or the ICD-10 (e.g., “vegetative
dystonia,” which now may be classified as “somatoform pain disorder, unspecified
type”). This guideline was used because some studies had been carried out long be-
fore these diagnostic systems were available, and it was not appropriate to exclude
these studies from the analysis for that single reason.
3. At least one control group or control phase had to be included in the studies. These
were either psychologically nontreated groups (“real control groups”: participants
were in waiting status or on medical basic therapy only or received a placebo ther-
apy) or treatment groups receiving another (psychological) therapy. If all treatment
groups in a study received a basic medical therapy (e.g., nonpsychiatric medication),
it was included in the review.
4. AT had to be applied for therapeutic purposes in at least one group.
5. AT had to be the only or at least the main therapeutic method in one group or had to
be added as therapeutic component to one group only. Studies were excluded if AT
played an inferior or not clearly discernible role within an extensive therapy plan or
if AT was not administered in a way that at least some excercises were practiced by
the participants themselves without therapeutic guidance. To judge studies on this
criterion, a restrictive methodology was used by both authors and each voted for
the inclusion of a “critical” study. Interrater reliability was not determined statisti-
cally. However, discussion about inclusion or exclusion arose only with very few
studies.
6. At least one outcome criterion relating directly to the disorder or syndrome had to
be evaluated in the studies (physiological and behavioral or psychological).
7. At least 5 participants had to be in each treatment or control group.
8. If there was more than one publication relating to the same sample of patients, only
the most detailed report was included.

Use of random sampling was not an inclusionary criterion. However, separate meta-
analyses for randomized and nonrandomized controlled studies are presented in this paper.
Moreover studies were included in the analyses even if not all six standard exercises of AT
were included for the study. However, at least the heaviness and warmth concentration and
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48 Stetter and Kupper

the rest presentation had to be administered, as positive effects of AT had been demonstrated
even with such a basic procedure (Langen, 1959; Sellers, 1974).

Definition of Main Effects and Unspecific Effects

As the main topic of this study was the clinical outcome of a therapy with AT, effect-
sizes (ES) were calculated on outcome variables related directly to the target symptoms of
the disorder or syndrome addressed in each study. Main outcome variables were grouped as
either “physiological” (e.g., blood pressure and other haemodynamic variables, skin tem-
perature, blood levels of hormones, etc.) or “behavioral and psychological” (Linden, 1994;
Smith & Glass, 1977). Examples for behavioral variables are frequency of attacks (panic,
asthma, seizures, etc.) drawn from protocols, duration of sleep, reduction in specific medi-
cation (e.g., pain medication). Examples for psychological variables are self-administered
questionnaires or structured investigations concerning key complaints or symptoms.
Unspecific effects do not relate directly to the target symptoms. In most cases they
concern mood (e.g., reduction of depressiveness and general feelings of tension), state
of mind (e.g., concentration, calmness), or quality of life. They deal for example with the
improvement of subjective feelings of being breathless and sleepless of patients with anxiety
(Ehlers, Stangier, & Gieler, 1995; Spiess et al., 1988) or with the improvement of feelings of
depressiveness of patients with headache (Van Dyck, Zitman, Linssen, & Spinhoven, 1991).
Moreover, some studies reported unspecific physiological effects, which were analyzed as
well (e.g., reduction of the heart rate in Raynaud patients (Keefe, Surwit, & Pilon, 1980;
Surwit, Pilon, & Fenton, 1978)).

Reconstruction of Statistical Information

It is a crucial problem of meta-analysis that in several studies some of the essential


data for meta-analysis are not reported. However, it is possible to reconstruct the missing
information in some cases. In this meta-analysis, by means of the following formulas

2t 2 F 2r
d=√ d=√ d=√
df d f (error) 1 − r2

some statistic informations were converted as proposed by Glass (1977); Glass, McGaw,
and Smith (1981); and Fricke and Treinies (1985):

t to d, F to d, and r to d

If only n E (experimental group), n c (control group), and the statement that the means
of both samples differed significantly at a given α-level were reported, the following re-
construction was used: The size tα;DF;two-tailed with DF = n E + n C − 2 was drawn from the
t-distribution table. In the same way the report of a nonsignificant result was transformed
using p = 1.00 as a conservative estimation as proposed by Kenny (1999).
If appropriate graphical illustrations of the results were presented and tables or other
presentations of the figures were missing, figures were reconstructed as far as possible
using a ruler. If means were presented without figures concerning the variance, any values
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Autogenic Training: A Meta-Analysis 49

of variance mentioned in the same study concerning the very group(s) were used. If even
that was not available, the variance of a similar population mentioned in other studies was
used as proposed by Linden (1994).

Calculation of Effect-Sizes and Additional Coefficents

With the (reconstructed) information reported in each study the ES (Hedges corrected
estimator of the population effect size) were calculated. For each different question sep-
arate meta-analyses were performed. All available ES formed the data pool. If only one
study with one ES was available, the Hedges-corrected estimator of population ES was
used (“d”). If more ES were available, either the ES weighted by its own variance (“D W+ ”;
weighted integration method) or the ES weighted by the sample size (“1”; random effects
model) was used according to the result of the test of homogeneity. D W+ was used if the
population effect sizes were homogeneous, 1 if they were heterogeneous. To determine
this, the coefficient “H ” was calculated, and a test for statistical significance was performed
subsequently (Hedges & Olkin, 1985). Heterogeneity was assumed if the level of signifi-
cance was lower than .01. The significance of each ES was tested by the normal distribution
Z and its corresponding probability. A significant result indicates an ES that differs from
zero. Subsequently the 95%-confidence-interval for each ES was determined.
The fail-safe N (Orwin, 1983) for ES was also calculated. This is a hypothetical
estimator dealing with the problem of an uncomplete retrieval of studies. The fail-safe N
demonstrates how many file-drawer studies with an assumed ES of zero are necessary to
reduce the ES of the meta-analysis to a given level (e.g., 0.2 or 0.5).
According to Glass (1976), effect sizes are labeled in the following way: “Small”:
0.2–0.49, “Medium”: 0.50–0.79, “Large”: ≥0.8.

Inferential Statistical Data Assessment

The Statistical Package for the Social Sciences, version 10.0.5 (SPSS for Windows;
SPSS, 1999) and the “Meta-Analysis Program” by Schwarzer (1995; http://www.fu-berlin.
de/gesund/)—checked by the meta-analysis program developed by Fricke and Kreft
(1986)—were used for the inferential statistics and meta-analyses. Furthermore the pro-
gram “META” by Kenny (1999) from the University of Connecticut (http://nw3.nai.net/
∼dakenny/) was used to calculate the single effects of each study.

RESULTS

Description of Studies Included in the Review

Bibliographic features, the number of treatment and control groups, the number of
participants in the different groups, the duration of treatment and follow-up, and the key
results are presented for each study separately in Table I. The methodological comments
of Table I consider several details of the design of each study, describe the experimental
and control conditions, and put emphasis on the sample sizes .The terms “small” or “large”
sample size are defined as samples sizes of n ≤ 12 and n > 12 respectively. If sample sizes
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Table I. Controlled Clinical Studies Concerning Effects of Autogenic Training (AT) Published Between 1932 and 1999
50

1. Total no. of groups (AT/other


treatment/real control) Total sample 1. Length of
2. Description of comparisons of Variables size [N ] (sizes treatment
different treatment (or real Possible included pre: AT/other (N post)
control) conditions quantitative in quantitative treatment/real 2. Follow-up Descriptive assessment
Disease/studies 3. Methodical comments analyses analyses control) (N follow-up) (clinical main symptoms)
Applied Psychophysiology and Biofeedback [apb]

Tension headache and migraine


Hutchings & 1. N = 3 (2/1/0) Study not EMG. N = 18 12 weeks The reduction of headache was most
Reinking 2. “Jacobson-Wolpe included in Headache-score (12/6/0) (N = 18) pronounced in both groups with
(1976) autogenic-relaxation” (“verbal”) quantitative derived from EMG biofeedback. A third group
plus EMG biofeedback vs. EMG analyses (no diaries with relaxation and behavioral
biofeedback as control group in clear therapy showed a somewhat
patients with severe tension AT-condition) poorer outcome. This result was
headache. Third group: “Verbal” significant concerning the
therapy plus components of headache score
pp383-apbi-367321

progressive relaxation (PR) and


behavioral therapy (BT). Basic
medical treatment all. No clear
AT-condition, as tapes had
components of PR and BT
additionally
3. Randomized study. Small sample
sizes
February 18, 2002

Kröner & Heiß 1. N = 6 (1/1/2) 2 groups with Pre–post and Intensity and N = 73 1. 6 weeks Significant reduction of headache
(1982) mixed therapy pre–follow-up duration of (11/10/30) 22 (11/10/25) intensity at post only in the
2. AT vs. progressive relaxation (PR) for AT. AT vs. headache derived (mixed) 2. 4 months (no groups with PR and AT plus PR
vs. AT plus PR (self-control other from diaries. information without self-control training.
12:11

therapy in all three groups) vs. AT psychological Analgetic and about dropouts) Pre–follow-up significant
plus PR (without self-control treatment (post migraine reductions in all three groups who
therapy) vs. placebo relaxation and follow-up). medication received PR (two groups had AT
(false biofeedback) vs. waiting AT vs. real additionally). Nearly similiar
control in a mixed population of control (post results concerning headache
tension headache and migraine and follow-up) frequency, analgetic and migraine
patients (65% had both diagnosis). medication
The two mixed groups (AT + PR)
were not suitable for comparisions
(mixed therapy). Basic medical
Stetter and Kupper

treatment all
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3. Sample sizes differ. Large


standard deviations observed.
Multitude of comparisons is not
adequate in the light of the sample
sizes (no alpha-correction!)
Collet, Cottraux, 1. N = 2 (1/1/0) Pre–post for AT. Intensity and N = 31 10 sessions Significant reduction of headache
& Juenet 2. AT vs. galvanic skin response AT vs. other duration of (15/16/0) (duration of intensity and frequency in the
(1986) biofeedback in patients with psychological headache derived therapy phase biofeedback group only.
tension headache treatment (post from diaries. unclear) Reduction in the AT group not
3. Randomized study. Poor and follow-up) Medication. N = 25 (12/13) significant. AT follow-up
administration of AT which was Unspecific 2. 1 year, significantly more dropouts in the
Applied Psychophysiology and Biofeedback [apb]

taught via tape recordings effect: anxiety. N = 20 (7/13) AT group. Improvement in 10/13
Dropouts patients in the biofeedback group
(follow-up) and 5/12 patients in the AT group.
Autogenic Training: A Meta-Analysis

Authors discussed the possible


negative impact of taperecorded
AT application
Janssen & 1. N = 5 (3/3/0) Pre–post and Intensity, N = 41, 1. 12 weeks Significant ( p = .052) reduction of
Neutgens 2. AT vs. PR in three populations: pre–follow-up frequency, and Tension (N = 41) headache score in the combined
pp383-apbi-367321

(1986) patients with tension headache; for AT in three duration of headache: 2. 25 weeks (no group (tension headache and
patients with migraine; patients different headache (5/5/0), information migraine) only. AT seems to have
with both diseases. Basic medical samples. AT (headache-score/ Migraine: about dropouts) a little superiority. In patients
treatment both. Three independent vs. other Janssen-Scale). (6/6/0), with tension headache PR was
samples were analyzed in this one psychological Unspecific Combined: significantly superior to AT,
study treatment in effects: (9/10/0) which showed no effect. No
3. Randomized study. Multitude of three different neuroticism and marked effects in the migraine
comparisons is not adequate in samples (post somatization group. Stable at follow-up for
light of the sample sizes (no and follow-up) both treatments in the migraine
February 18, 2002

alpha-correction!) and the combined group. No


further effects in the tension
headache group. Positive
unspecific effects for all groups
12:11

and treatments
Sargent, Solbach, 1. N = 4 (1/2/1) Pre–post and Intensity and N = 193 1. 8 weeks (no Significant reduction of intensity
Coyne, Spohn, 2. AT vs. thermal biofeedback vs. pre–follow-up frequency of No information and frequency in all four groups.
& Segerson EMG biofeedback vs. real control for AT. AT vs. headache information about dropouts) Reductions less pronounced in the
(1986) in patients with migraine (some real control about the 2. 24 weeks control group. Significant effects
suffered from tension headache (post and initial sample (N = 136) in favor for treatment groups
(Continued )
51
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Table I. (Continued )
52

1. Total no. of groups (AT/other


treatment/real control) Total sample 1. Length of
2. Description of comparisons of Variables size [N ] (sizes treatment
different treatment (or real Possible included pre: AT/other (N post)
control) conditions quantitative in quantitative treatment/real 2. Follow-up Descriptive assessment
Disease/studies 3. Methodical comments analyses analyses control) (N follow-up) (clinical main symptoms)
Applied Psychophysiology and Biofeedback [apb]

too). Basic medical treatment and follow-up). AT sizes of the only if all three treatment groups
daily records in all groups vs. other groups were combined and compared
3. Randomized study. Sophisticated psychological At follow-up: with the control group
study protocol. Poor objectivity of treatments (34/34 +
presentation (post and 34/34)
follow-up)
Reich (1989) 1. N = 8 (2/6/0) Pre–post and Weekly hours of N = 1,015, 1. 15 weeks (no Significant pre–post and
2. AT combined in same cases with pre–follow-up headache. Degree No information pre–follow-up reduction of
cognitive therapy, PR or hypnosis for AT in two of headache pain information about dropouts) symptoms and the use of
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vs. biofeedback (thermal or EMG different about the 2. 36 months prescribed and “over-the-counter”
or photopletysmograph) vs. samples. AT vs. initial sample (N = 703) medication in all four treatment
microelectrical therapy (TENS or two other sizes of the groups (including the “autogenic
electrical-neurotransmitter psychological groups training” group). Biofeedback was
modulation) vs. multimodal treatments At follow-up: most effective in reducing
treatment (combinations of any of (post and Tension duration and degree of headache
the treatments mentioned above) follow-up) headache: in both populations
in two populations: patients with (78/152/0),
February 18, 2002

tension headache; patients with combined


migraine. Basic medical treatment group: 81
all. Multimodal group not suitable Migraine:
for conclusions concerning AT (95/187/0),
12:11

3. Randomized study. Even in the combined


so-called “autogenic training” group: 110
group different components were
combined. Sample sizes differ
Spinhoven, 1. N = 3 (1/1/1) Pre–post and Headache index, N = 56, 1. 8 weeks, During treatment in both groups
Linssen, Van 2. AT vs. self-hypnosis vs. waiting pre–follow-up pain rating. 7 dropouts N = 46 head activity reduced significantly
Dyck, & control (two premeasures of later for AT. AT vs. Unspecific during (23/23) in contrast to the waiting-list
Zitman treated patients) in patients with real control effects: waiting 2. 6 months, period. Results stable at
(1992) tension headache. Basic medical (post). AT vs. psychological period. N = 40 follow-up. There were no
treatment in all groups other distress (derived 3 dropouts (20/20) differences between groups. The
Stetter and Kupper

3. Randomized study psychological from SCL 90) same results were obtained
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treatment (post during concerning unspecific effects


and follow-up) therapy (“psychological distress”).
At post: Long-term pain reduction was
(23/23/2 × most pronounced in patients who
23) attributed the positive outcome to
their own efforts
Zitman, Van 1. N = 3 (1/2/0) Pre–post and Headache index N = 96, 1. 8 weeks, Significant pain reduction in all
Dyck, 2. AT vs. future oriented hypnotic pre–follow-up derived from a 17 dropouts N = 79 groups. After treatment (post) no
Spinhoven, imagery (one group with and one for AT. AT vs. diary At post: (28/51) differences between the groups
& Linssen group without hypnotic induction) other (Budzynski- N = 79 (28/ 2. 6 months, were observed. At follow-up one
(1992) and in patients with tension headache. psychological index) and a 51/0) N = 66 of the hypnotic procedures (future
Van Dyck Basic medical treatment in all treatment (post pre–post (21/45/0) oriented hypnotic imagery with
Applied Psychophysiology and Biofeedback [apb]

et al. (1991) groups and follow-up) questionnaire. hypnotic induction) was superior
3. Sophisticated study protocol and Medication. to AT. As unspecific effect a
Autogenic Training: A Meta-Analysis

report Unspecific significant reduction of anxiety


effects: anxiety and depression was observed
(STAI-X1) and
depression
(Zung-scale)
Cott, 1. N = 3 (1/2/0) Pre–post and Duration, intensity,N = 62, 1. 8 weeks, Significant reduction of all outcome
pp383-apbi-367321

Parkinson, 2. AT vs. AT plus EMG-biofeedback pre–follow-up and density of 22 dropouts N = 35 variables in all groups. The
Fobich, vs. AT plus thermal-biofeedback. for AT. headache. before 2. 12 months, combination of AT plus
Bedard, & Basic medical treatment in all Conclusions Analgetic treatment; 5 N = 34 EMG-biofeedback showed a
Marlin groups AT vs. other medication dropouts (12/22/0) significant better outcome than AT
(1992) 3. Sophisticated study protocol psychological during alone or the combination of AT
treatment only treatment, plus thermal biofeedback (post
descriptive, as 1 dropout up and follow-up) except for the
all groups to follow-up, variable “medication” in which AT
received AT N = 34, plus EMG-biofeedback showed a
February 18, 2002

(12/22/0) significant smaller effect (post)


Ter Kuile, 1. N = 3 (1/1/1) Pre–post and Headache index N = 157 1. 8 weeks, Significant reduction of headache
Spinhoven, 2. AT vs. self-hypnosis vs. pre–follow-up (Holroy-index). (48/52/57) N = 134 index and medication in both
12:11

Linssen, waiting-list control in patients for AT. AT vs. Analgetic (41/40/53) treatment groups, not in control
Zitman, & with chronic headaches recruited real control medication. 2. 6 months, group. Significant difference of
Van Dyck from a neurological outpatient (post). AT vs. Responders/ N = 72 both treatments compared with
(1994) and facility and via newspaper and via other nonresponders at (37/35/0) waiting-list control. No
Ter Kuile, advertisment in a student facility. psychological follow-up. differences between treatments
Spinhoven, Basic medical treatment in all treatment (post Unspecific (post). Results stable at follow-up.
& Linssen groups and follow-up) effects: Intention-to-treat analysis: 29%
(1995) psychological responders in AT
53

(Continued )
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Table I. (Continued )
54

1. Total no. of groups (AT/other


treatment/real control) Total sample 1. Length of
2. Description of comparisons of Variables size [N ] (sizes treatment
different treatment (or real Possible included pre: AT/other (N post)
control) conditions quantitative in quantitative treatment/real 2. Follow-up Descriptive assessment
Disease/studies 3. Methodical comments analyses analyses control) (N follow-up) (clinical main symptoms)
Applied Psychophysiology and Biofeedback [apb]

3. Randomized study. distress vs. 26% responders in


Sophisticated study protocol (derived from self-hypnosis.The same results
and report SCL 90) were obtained concerning
unspecific effects. The high
hypnotizable patients showed a
greater improvement than the low
hypnotizable patients
Labbé (1995) 1. N = 3 (1/1/0) Pre–post and Headache N = 30 (10/10/10) 1. 8 weeks (N = 30) Significant reduction of headache
pp383-apbi-367321

2. AT vs. AT plus thermal pre–follow-up frequency, 2. 6 months (N = 30) frequency and duration in both
biofeedback vs. waiting-list for AT. AT vs. duration, and treatment groups. Significantly
control in children suffering real control headache index more improvement in treatment
from migraine headache (post and groups compared to control
3. Randomized study follow-up). group. Results stable at follow-up.
Conclusions AT plus biofeedback showed in
AT vs. other some outcome variables better
psychological results than AT alone (e.g., 80%
treatment only symptom-free in combined group,
February 18, 2002

descriptive, as 50% symptom-free in AT, no


all groups patient symptom-free in
received AT waiting-control group)
Hypertension
12:11

Katzenstein, 1. N = 1 (1/0/0); N = 2 (1/0/1) Pre–post for AT. Systolic and N = 33 (33/0/0) 1. In both pilot After one initial session of AT there
Kriegel, & 2. AT pre–post; AT vs. AT vs. real diastolic blood N = 20 (10/0/10) studies evaluation was a significant reduction in
Gaefke unassissted self-relaxation control (post) pressure (SBP, after the first SBP and DBP in both studies. In
(1974) (placebo) DBP) session (N = 33) the second study, there was a
3. Two pilot-studies followed by 2. N = 20 reduction in the control group as
the study mentioned next in well, however not a significant
this table. First pilot study: one. Both groups differed highly
pre–post for AT; second pilot significantly in SBP and DBP in
study At vs. real control. Only favor for the AT group
short-term effects of AT were
Stetter and Kupper

evaluated
Style file version Nov. 19th, 1999
P1: GCQ

Katzenstein 1. N = 6 (4/0/2) Pre–post and SBP and DBP N = 150 1. 25 sessions Reduction of SBP and DBP in all
et al. (1974) 2. AT plus antihypertensive drugs pre–follow-up Group 1–4: (40 + probably weekly groups. Reduction less
vs. antihypertensive drugs. AT for AT. AT vs. 21/0/14 + 14) (no information pronounced in the AT plus
plus antihypertensive drugs real control Group 5: n = 46 about dropouts) psychopharmaka group.
plus psychopharmacological (post and Group 6: n = 15 2. 2 years Reduction still proved at
drugs vs. antihypertensive and follow-up) follow-up. AT plus psychotherapy
psychopharmacological drugs. most effective. AT additional to
(AT plus psychotherapy and two different pharmacological
AT plus psychopharmaka treatments revealed only small
without control conditions) advantages
Applied Psychophysiology and Biofeedback [apb]

3. Sample sizes of groups differ.


Statistical analyses reported
only for comparisons of AT
Autogenic Training: A Meta-Analysis

plus psychotherapy group. AT


vs. control of the first four
groups were reanalyzed for
the meta-analysis
Luborsky, 1. N = 3 (2/1/0) Pre–post for AT. SBP and DBP N = 15 (10/5/0) 1. 9 weeks (N = 15) Mean decrease in SBP and DBP
Ancona, 2. AT vs. antihypertensive drugs. AT vs. real 2. 2 weeks (N = 15) most pronounced for
pp383-apbi-367321

Masoni, AT vs. AT plus control (post antihypertensive drug treatment


Scolari, & antihypertensive drugs vs. and (the only significant result). AT
Longoni antihypertensive drugs follow-up). AT has a positive effect. Combined
(1980) 3. Randomized study. Very small vs. medical group showed the smallest effects.
sample sizes (Type II error!) treatment (post Results stable at follow-up
and follow-up)
Charlesworth, 1. N = 2 (1/0/1) Pre–post and SBP and DBP N = 40 (22/0/18) 1. 10 weeks Significant reduction of SBP and
Williams, & 2. AT vs. waiting-control group pre–follow-up (N = 40) DBP in the AT group compared to
February 18, 2002

Baer (1984) 3. Randomized study. for AT. AT vs. 2. 3 years (N = 32) the waiting group. After
Sophisticated study protocol. real control introduction of AT to the waiting
AT as essential component of (post) group: significant positive
a stress management program outcome in this group as well.
12:11

Results stable at follow-up


Aivazyan, 1. N = 5 (1/0/1) Pre–follow-up SBP and DBP N = 90 (44/0/46) 1. 6 months Patient in the AT group showed a
Zaitsev, & 2. AT vs. psychologically for AT. AT vs. 2. 5 years significant reduction of SBP and
Yurenev untreated controls. Basic real control DBP compared to real control. In
(1988) medical treatment in both (follow-up) the AT patients a smaller increase
groups in left-ventricular myocardial
(Continued )
55
Style file version Nov. 19th, 1999
P1: GCQ

Table I. (Continued )
56

1. Total no. of groups (AT/other


treatment/real control) Total sample 1. Length of
2. Description of comparisons of Variables size [N ] (sizes treatment
different treatment (or real Possible included pre: AT/other (N post)
control) conditions quantitative in quantitative treatment/real 2. Follow-up Descriptive assessment
Disease/studies 3. Methodical comments analyses analyses control) (N follow-up) (clinical main symptoms)
Applied Psychophysiology and Biofeedback [apb]

3. Randomized study. mass, improved psychological


Sophisticated study protocol. indices (MMPI), and a decrease
Mild hypertension and in the number of sick days of
moderate hypertension leave was observed. AT was
investigated separately more effective in mild than in
moderate hypertension
Aivazyan, 1. N = 5 (1/2/2) Pre–post and SBP and DBP N = 117 1. 6 weeks (no Greatest reduction of SBP and
Zaitsev, 2. AT vs. biofeedback vs. pre–follow-up (23/47/47) information DBP in the biofeedback and
Salenko, breathing-relaxation vs. for AT. AT vs. about dropouts) breathing-relaxation groups. AT
pp383-apbi-367321

Yurenev, & untreated control vs. real control 2. 1 year (N = 82) had a smaller positive effect.
Patrusheva “psychological placebo.” (post and Results stable at follow-up.
(1988) Discontinuation of medication follow-up). AT Decrease of SBP and DBP in
4 weeks before study vs. other psychological placebo group,
3. Randomized study. psychological but less than in AT group. At
Unsophisticated study protocol. treatment (post follow-up high dropout rate in
Treatment groups were pooled and follow-up) placebo group (65%) and return
in some analysis of the study to initial levels of BP. At
February 18, 2002

follow-up significant reduction


for all treatments vs. control
groups in BP
Blanchard et al. 1. N = 3 (1/1/1) Pre–post and SBP and DBP N = 59 (21/20/18) 1. 10 weeks Significant decrease of DBP for
12:11

(1988) and 2. AT vs. thermal biofeedback vs. pre–follow-up (6 dropouts both treatments in all.
McCoy et al. “self-relaxation controls” (real for AT. AT vs. were replaced) Significant decrease of SBP in
(1988) placebo); unmedicated male real control 2. 12 months Soviets only. AT superior to
patients with mild hypertension (post). AT vs. (N = 59) biofeedback in Americans. At
3. Randomized study. other follow-up results stable for
Sophisticated study protocol. psychological Soviets not for Americans (who
Small sample sizes. American treatment (post practiced relaxation less)
vs. Soviet patients and follow-up)
Yurenev et al. 1. N = 5 (1/3/1) Study not N = 134 1. 12 weeks Reduction of SBP and DBP
(1988) 2. AT plus breathing-relaxation included in (40/74/20) (dropout rates: significant for all treatments
plus biofeedback “called quantitative physical 86%; (physical training > acupuncture
Stetter and Kupper

psychological treatment” vs. analyses as acupunture 37%; > medical > psychological
Style file version Nov. 19th, 1999
P1: GCQ

acupunture vs. physical data for AT psychological treatment). No effects for


training vs. psychopharmaka effects were 34%) untreated group. At follow-up
(β-blocker, sedativa) vs. not available. 2. 1 year results stable. No significant
untreated control Data was differences between treatments
3. Randomized study. Poor reported for
presentation objectivity; no “psychological
data for pure AT group; sample treatment”
sizes differ only
Loesch, 1. N = 3 (2/0/1) Pre–post for Amount of N = 185 1. 12 weeks (no In 29% of the AT patients
Seefeldt, & 2. AT vs. real control AT-subgroup antihypertensive (115/0/70) information (respectively 1% in controls)
Hecht 3. Sample sizes differ with medication about dropouts) normotony was achieved
(1989) unchanged and necessary for although medication was
Applied Psychophysiology and Biofeedback [apb]

without normotony. discontinued. In 2% of the AT


medication. DBP and SBP patients (respectively 63% in the
AT vs. real (AT-subgroups) controls) medication had to be
Autogenic Training: A Meta-Analysis

control (post) increased. Significant reduction


of DBP and SBP for both AT
groups with unchanged or
without medication
Tsikulin, 1. N = 4 (1/3/0) Pre–post for AT. SBP and DBP N = 162 1. 12 weeks (no Reduction of SBP and DBP most
Zinkovskiy, 2. AT plus additional unspecific AT vs. medical (66/96/0) information pronounced in the
pp383-apbi-367321

& Volkov relaxation vs. antihypertensive treatment about dropouts) antihypertensive drug group
(1989) drugs vs. antihypertensive (post) ( p < .001). Other drug
drugs plus treatments and AT also effective
psychopharmacological drugs ( p < .05) (AT >
vs. psychopharmacological psychopharmaka >
drugs psychopharmaka plus
3. Additional relaxation antihypertensives).
components in AT group not Recommendation: AT most
February 18, 2002

described effective in patients with


borderline or mild hypertension
Coronary heart disease/secondary prevention of cardiac infarction
Laberke 1. N = 2 (1/0/1) AT vs. real Number of cardiac N = 61 1. Not reported (up Before treatment angina pectoris
12:11

(1952a, 2. AT plus psychotherapy vs. control infarctions (31/0/30) to 1 year of of equal degree in both groups.
1952b) psychologically untreated (follow-up) treatment) Within 4 years no cardiac
control in patients suffering 2. 4 years infarction in the AT group. 4
from angina pectoris. Basic patients with cardiac infarction
medical treatment in both in the control group
groups
3. Unsophisticated outcome
measures
57

(Continued )
Style file version Nov. 19th, 1999
P1: GCQ

Table I. (Continued )
58

1. Total no. of groups (AT/other


treatment/real control) Total sample 1. Length of
2. Description of comparisons of Variables size [N ] (sizes treatment
different treatment (or real Possible included pre: AT/other (N post)
control) conditions quantitative in quantitative treatment/real 2. Follow-up Descriptive assessment
Disease/studies 3. Methodical comments analyses analyses control) (N follow-up) (clinical main symptoms)
Applied Psychophysiology and Biofeedback [apb]

Polácková, 1. N = 2 (1/0/1) Pre–post for AT. Anxiety, N = 189 1. 4 months (no Anxiety, depression, neuroticism,
Bocková, & 2. AT vs. no psychological AT vs. real depression, (131/0/48) information about and heart rate were highly
Sedivec treatment in patients 2 months control (post) neuroticism as dropouts) significantly reduced in the AT
(1982) after myocardial infarction. Basic psychological only, compared to the control
medical treatment in both groups risk factors for a group without significant
3. Poor objectivity of presentation reinfarction (EPI, changes (post). No significant
MAS, MHQ). reduction of blood pressure in
Heart rate, blood any group
pressure
pp383-apbi-367321

Simma & 1. N = 2 (1/0/1) Study not N = 19 1. 32 weeks, Different effects of the two
Benzer 2. AT vs. no psychological included in the (11/8) N = 12 (8/4) treatment modalities not
(1985) treatment in patients after cardiac quantitative reported. It was reported that
infarction. Basic medical analysis both groups showed a reduction
treatment and physical in both because the of type A behavior (Bortner
groups control group Scale). AT facilitated the
3. Very small and varying sample was too small practice of physical training,
sizes. At the end of treatment the (n < 5) at post which resulted in a lower
February 18, 2002

physical training group falls short (many dropout rate. Positive


of the critical value of n = 5. dropouts) personality changes (FPI) more
Poor objectivity of the report pronounced in the AT group
Winterfeld 1. N = 2 (1/0/1) Pre–post for AT. Microcirculation, N = 30 1. 12–26 weeks (no Significantly better
12:11

et al. (1993) 2. AT vs. real control in patients’ AT vs. real left ventricular (16/0/14) information about microcirculation and higer
coronary heart disease and control (post) ejection fraction dropouts) LVEF in the AT group. In
hypertonia. Basic medical (LVEF), muscle controls microcirculation
treatment in both groups circulation, SBP decreased. Significant reduction
3. Very sophisticated study protocol and DBP, heart of SBP in the AT group only.
and outcome measures rate Significant decrease in blood
pressure, increase of muscle
circulation and LVEF.
Significant mean differences of
all outcome variables
Stetter and Kupper

significantly in favor for AT


Style file version Nov. 19th, 1999
P1: GCQ

Stetter, 1. N = 2 (2/0/0) Study not N = 27 1. 9 weeks AT results in a reduction of


Günthner, 2. AT in patients with coronary included in the (27/0/0) (N = 27) possible psychological risk
Mann, & heart disease after cardiac quantitative factors (e.g., aggressiveness,
Bartels infarction vs. healthy controls analyses (no depressiveness, nervousness;
(1994) 3. Comparisons don’t allow a conclusion FPI, EWL-K). Patients were
conclusion concerning the concerning able to learn AT as well as
efficacy of AT efficacy of AT) controls (e.g., increases of skin
temperature not different
between groups)
Rakov, 1. N = 2 (1/0/1) Pre–post for AT. Heart rhythm, N = 115 1. 4 weeks Significant reduction of
Mandrykin, 2. AT vs. real control in patients AT vs. real peroxide (70/0/45) (5 sessions per dysrhythmic heart actions and
& Zamotaev with severe coronary heart control (post) oxidation of week) improvement of lipid
Applied Psychophysiology and Biofeedback [apb]

(1997) disease after aortocoronary lipids, bicycle 2. 4 months metabolism in the AT group
bypass operation. Basic medical ergometry. compared to the control group
Autogenic Training: A Meta-Analysis

treatment in both groups Unspecific ( p < .01– p < .001). Reduction


3. Randomized study. Sophisticated effects: anxiety of state and trait anxiety in the
outcome measures. Sample sizes (STAI-X1/X2) AT group much more
differ pronounced than in the control
group. Result stable at
follow-up
pp383-apbi-367321

Asthma bronchiale
Sauer & 1. N = 2 (1/0/1) Study not N = 30 (7/0/16), 1. 4 weeks Reduction of nervousness and
Schnetzer 2. AT vs. real control. Basic included in the 7 dropouts (N = 23) psychosomatic complaints (FPI)
(1978) medical treatment in both groups quantitative more pronounced in the AT
3. Small sample sizes. Only analyses as no group vs. control group
possible psychological assessment of
correlations of asthma focussed. target
Poor statistical analyses symptoms
available
February 18, 2002

Deter & Allert 1. N = 3 (1/1/1) Study not N = 31 (9/10/12) 1. 1 year (40 The use of sympathomimetic
(1983) 2. AT plus 9 months of group included in the sessions) drugs in the treatment groups
psychotherapy vs. functional quantitative 2. 1 year (N = 23) was significantly reduced
12:11

relaxation plus 12 months of analyses ( p < .05); however, not in


group psychotherpy vs. waiting because of control. The same result was
control. Basic medical treatment extreme observed concerning steroids.
in both groups methodological Functional relaxations seemed
3. Randomized study. Small sample shortcomings to facilitate attendence of the
sizes. No data for comparisons group psychotherapy more than
AT vs. waiting control reported. AT (no exact data reported)
Amount of additional group
59

(Continued )
Style file version Nov. 19th, 1999
P1: GCQ

Table I. (Continued )
60

1. Total no. of groups (AT/other


treatment/real control) Total sample 1. Length of
2. Description of comparisons of Variables size [N ] (sizes treatment
different treatment (or real Possible included pre: AT/other (N post)
control) conditions quantitative in quantitative treatment/real 2. Follow-up Descriptive assessment
Disease/studies 3. Methodical comments analyses analyses control) (N follow-up) (clinical main symptoms)
Applied Psychophysiology and Biofeedback [apb]

psychotherapy different in the


treatment groups. Comparison
between treatments: n < 5 in
relaxation group
Spiess et al. (1988) 1. N = 2 (1/0/1) Pre–post for AT.Objective lung N = 38 1. 15 weeks (no Objective lung function variables
2. AT vs. real control. Basic AT vs. real variables (e.g., (15/0/23) information about did not change in the AT group.
medical treatment in both control (post) vital capacity, dropouts) Increase of total capacity in the
groups. A second control group flow variables), control group. Significant
with medical treatment only behavioral improvement of asthma-related
pp383-apbi-367321

could not be analyzed in variables behavioral variables in the AT


quantitative analyses (breathlesness, group only. Unspecific effects
3. Randomized study. coughing urge, concerning anxiety (STAI) and
Sophisticated study protocol asthma attacks). depressiveness more
Unspecific pronounced in the AT group
effects: anxiety compared with control group
(STAI),
depressiveness
February 18, 2002

Henry, de Rivera, 1. N = 2 (1/1/0) Pre–post for AT. Objective lung N = 24 1. 8 months (no Relevant clinical improvement of
Gonzalez-Martin, 2. AT vs. support group therapy. AT vs. other variables (e.g., (12/12/0) information about objective lung function variables
& Abreu (1993) Basic medical treatment in both psychological vital capacity, dropouts) (>15%) in the AT group only
groups treatment (post) different flow
12:11

3. Randomized study. variables)


Sophisticated study protocol
Haber, Moser, 1. N = 2 (1/0/1) Pre–post for AT. Objective lung N = 101 1. 12 weeks No significant changes in the
Sachs, & Spiess 2. AT vs. real control. Basic AT vs. real variables (e.g., (53/0/48) (N = 71, objective lung variables.
(1993) medical treatment in both control (post) vital capacity, 49/0/37) Significant improvement in
groups. AT included some different flow coping behavior, asthma-related
“functional breathing exercises” variables); complaints, asthma attacks, and
3. Very sophisticated study coping behavior, aerosol dosage in the AT group
protocol. Objective and clinical disease-related compared to control group.
relevant outcome measures diary (e.g., Unspecific effects concerning
Stetter and Kupper

medication) anxiety (STAI) and


Style file version Nov. 19th, 1999
P1: GCQ

complaints (e.g., depressiveness more


breathlessness, pronounced in the AT group
coughing urge, compared with control group
asthma attacks)
Somatoform pain disorder, unspecified type
Beitel & Kröner 1. N = 2 (1/0/1) Pre–post and Improvement in N = 147 1. 6 months Significant improvement in
(1982) and 2. AT vs. waiting-list control in pre–follow-up self-concept (112/0/35) (N = 100, self-concept in 57% in the AT
Kröner & Beitel participants in an outpatient for AT. AT vs. (Q-Sort-Test). 65/0/35) group vs. 20% in the waiting-list
(1980) prevention program. Many real control Anxiety (MAS 2. 6 months control group (post and
participants are referred to such (post) Taylor). (N = 58, 58/0/0) follow-up). Same results in all
programs by their physicians Nervousness, other outcome variables (post).
and are patients with various depressiveness, participants who practiced AT
Applied Psychophysiology and Biofeedback [apb]

psychosomatic complaints (FPI). Subjective daily improved significantly


3. Sample sizes differ. rating of somatic more (62%) than participants
Autogenic Training: A Meta-Analysis

Sophisticated application of AT and psychic who practiced less frequently


well-being (48%)
Schulte (1983) 1. N = 3 (1/1/1) Data suitable for Trait-personality N = 107 1. 3 weeks The general effect of the whole
2. AT vs. behavioral group therapy the quantitative (FPI) ratings of (14/77/16) 2. 12 weeks (no rehabilitation program is
vs. real control (no analyses is only physicians information about demonstrated by improvement
psychological therapy) in reported for the dropouts) in all variables for the whole
pp383-apbi-367321

patients in an inpatient behavioral sample. The behavioral therapy


rehabilitation group therapy. improved more than the AT or
3. Sample sizes differ extremely. Study not the control group
Very poor objectivity in the included in the
report, which focuses on the quantitative
effects of behavioral therapy analysis
Schrapper & Mann 1. N = 2 (1/0/1) Pre–post for AT. Trait-personality N = 152 1. 10 weeks Significant improvement of the AT
(1985) 2. AT in participants in an AT vs. real (EWL): general (112/0/40) (N = 110, group compared with the control
outpatient prevention program control (post) well-being, 70/0/40) group concerning the variables:
February 18, 2002

vs. real control (participants of passive and tired, general well-being, passive and
an educational program) open to others, tired, open to others, anxious
3. Sample sizes differ emotional and depressive. Improvement in
12:11

irritable, anxious both groups concerning the


and depressive variable “emotional irritable”
Farné & Corallo 1. N = 2 (1/0/1) Pre–post for AT. Emotional and N = 79 1. 3 months Significant reduction of emotional
(1992) 2. AT vs. waiting-list control AT vs. real somatic distress (40/0/39) (N = 79, and somatic distress in the AT
(included in thorough diagnostic control (post) index (ESDS) 47/0/32) group (pre–post). Improvement
process) in an outpatient in the AT group is significantly
psychotherapeutic setting more pronounced than in the
control group
61

(Continued )
Style file version Nov. 19th, 1999
P1: GCQ

62

Table I. (Continued )
1. Total no. of groups (AT/other
treatment/real control) Total sample 1. Length of
2. Description of comparisons of Variables size [N ] (sizes treatment
different treatment (or real Possible included pre: AT/other (N post)
control) conditions quantitative in quantitative treatment/real 2. Follow-up Descriptive assessment
Disease/studies 3. Methodical comments analyses analyses control) (N follow-up) (clinical main symptoms)
Applied Psychophysiology and Biofeedback [apb]

3. Randomized study.
7 participants of waiting-list
obviously put on AT during the
study
Carruthers 1. N = 3 (1/1/1) Pre–post for AT. SBP and DBP. Heart beat N = 48 1. 6 weeks In the AT group significant
(1984, 1988) 2. AT vs. physical training vs. no AT vs. real frequency (BPM). Cholesterol, (16/16/16) (N = 45, improvement of all
psychological treatment in control (post). triglycerides, free fatty acids, 16/13/16) outcome variables except
managers in an extraordinary AT vs. medical HDL, glucose, uric acid for uric acid and HDL. In
pp383-apbi-367321

stressful situation treatment the group with physical


(quasi-experimental stress test) (post) exercises significant
3. Randomized study improvement of all
outcome variables except
for SBP and
triglycerides. No
significant improvement
in the real control group.
February 18, 2002

In the AT group the


improvement in cardiac
variables was more
pronounced and in blood
12:11

lipids less pronounced


compared with the
physical training group
Carruthers 1. N = 2 (1/1/0) Pre–post for AT. SBP and DBP. Heart beat N = 100 1. 8 weeks; Significant improvement of
(1984) and 2. AT vs. physical training in an AT vs. medical frequency (BPM). Cholesterol, (50/50/0) 1 dropout in all outcome variables in
Carruthers outpatient prevention program treatment triglycerides, free fatty acids. the AT and the AT group. Significant
& Stetter 3. Randomized study (post) Anxiety (STAI-X1), depression more than improvement of all
(1992) (HAMD), global feelings of 2 dropouts outcome variables in the
disease in the physical training group
(General-Health-Questionniare) physical except for anxiety and
training group global feelings of disease
Stetter and Kupper
Style file version Nov. 19th, 1999
P1: GCQ

Raynaud’s disease
Surwit et al. 1. N = 2 (1/0/1) Pre–post for AT. Skin temperature during cold N = 30 1. 4 weeks In all AT groups a
(1978) 2. AT and AT plus thermal AT vs. real stress test (dramatic decrease of (15/0/15) (N = 30) significant improved
biofeedback vs. waiting-list control (post) room temperature). Frequency ability to maintain digital
control in patients with and intensity of Raynaud skin temperature in the
idiopathic Raynaud’s disease. attacks (diaries). Unspecific presence of cold stress
Both treatments were either effects: heart rate challenge was observed
applied in laboratory or home (post). Highly significant
sessions. Both treatment groups improvement in AT
were combined in most analyses groups compared to
of the study as there were no waiting-list control
differences between AT and AT concerning stress test.
Applied Psychophysiology and Biofeedback [apb]

plus biofeedback with a Similiar tendencies were


tendency for AT plus found for frequency and
Autogenic Training: A Meta-Analysis

biofeedback to be inferior intensity of attacks


3. Randomized Study. Poor
objectivity of presentation
concerning pure AT effects
Keefe et al. 1. N = 3 (1/2/0) Pre–post and Skin temperature during cold N = 21 1. 3 sessions Significant improvement in
(1980) 2. AT vs. AT plus thermal pre–follow-up stress test. Frequency of (7/7 + 7/0) during about cold stress test in all
pp383-apbi-367321

biofeedback vs. progressive for AT. AT vs. Raynaud attacks. Unspecific 4 weeks treatment conditions
relaxation (PR) in patients with real control effects: heart rate 2. About compared to 4-week
idiopathic Raynaud’s disease. (baseline as 5 weeks baseline. Significant
Baseline was evaluated for all control: of home improvement in
groups during 4 weeks and, baseline was training frequency of attacks in
treatment effects were reported evaluated in (N = 20) the AT and the PR group
for 4 and 9 weeks of training. the same after 4 weeks and even
For quantitative meta-analyses manner during more pronounced
the AT and PR groups were used the same time improvement after
February 18, 2002

3. Randomized study. Small period as 9 weeks of training.


sample sizes. Sophisticated treatment No significant effects in
study protocol effects). AT vs. the AT plus biofeedback
12:11

other group
psychological
treatment (post
and follow-up)
Surwit, Allen, 1. N = 4 (2/1/1), 2 dependent Pre–post for AT. Skin temperature during cold N = 20 1. 4 weeks (no Neither prazosin nor AT
Gilgor, & groups AT vs. real stress test (20/10/10), information alone were effective in
Duvic 2. Baseline was evaluated. In the control 2 dependent about improving the reaction to
(1982) first 4 weeks of treatment (placebo groups dropouts) the cold stress test.
63

(Continued )
Style file version Nov. 19th, 1999
P1: GCQ

Table I. (Continued )
64

1. Total no. of groups (AT/other


treatment/real control) Total sample 1. Length of
2. Description of comparisons of Variables size [N ] (sizes treatment
different treatment (or real Possible included pre: AT/other (N post)
control) conditions quantitative in quantitative treatment/real 2. Follow-up Descriptive assessment
Disease/studies 3. Methodical comments analyses analyses control) (N follow-up) (clinical main symptoms)
Applied Psychophysiology and Biofeedback [apb]

prazosin medication or placebo group). AT vs. However the combination of


was given. In the following 4 medical both was significantly superior
weeks AT was applied to verum treatment to AT alone
and placebo group in patients (prazosin
with idiopathic Raynaud’s group)
disease. Comparisons were
possible for baseline vs.
prazosin vs. prazosin plus AT.
The same was possible for
pp383-apbi-367321

placebo
3. Randomized study. Small
sample sizes. Conclusions
concerning effects of AT were
only possible using intragroup
comparisons
Freedman, Ianni, 1. N = 4 (1/3/0) Pre–post and Skin temperature N = 32 1. 5 weeks Significant improvement in the
& Wenig (1983) 2. AT vs. EMG-biofeedback vs. pre–follow-up during cold stress (8/24/0) (N = 32) cold stress test and frequency of
February 18, 2002

thermal biofeedback vs. thermal for AT. AT vs. test. Vasospastic 2. 1 year attacks in both thermal
biofeedback with cold stress other attacks. (N = 30) biofeedback groups only with
training in patients with psychological Unspecific the group with additional cold
idiopathic Raynaud’s disease. treatment (post) effects: stress training being superior.
12:11

Cognitive stress management in EMG-levels, Results stable at follow-up.


half of the patients in all groups stress ratings Unspecific effects: Reductions
3. Randomized study of EMG-level and stress ratings
were significant in the AT and
EMG group only
Haustein, 1. N = 2 (1/0/1) Pre–post for AT. Skin temperature N = 12 1. 4 months The initial hypnosis session
Seikowski, & 2. AT vs. no (further) AT vs. real during cold stress (6/0/6) (N = 12) resulted in a significant increase
Weber (1995) psychological treatment. One to control (post) test (fingers put of skin temperature during the
two sessions of relaxation in cold water). session in all patients. The aim
hypnosis in both groups at the Vasospastic was to give the patients an initial
Stetter and Kupper

beginning of treatment in attacks. Clinical impression of “warmth.” After


Style file version Nov. 19th, 1999
P1: GCQ

patients with sklerodermia and investigation of AT was introduced to 6 patients


vasospastic attacks. 4-weeks the hands. the increase in skin temperature
baseline evaluation before the Unspecific was significantly higher than in
initial hypnosis in both groups effects: the 6 patients without any
3. Randomized study. Small neurotizism, further treatment. Long-term
sample sizes coping effects in the cold stress test, the
frequency of attacks, and the
investigations of the hands were
not observed in any group.
Improvement in neurotizism in
the control group only. No
changes concerning coping in
Applied Psychophysiology and Biofeedback [apb]

any group
Freedman (1989) 1. N = 2 (1/1/0) Pre–post for AT. Finger blood flow N = 16 1. 5 weeks Significant improvement of blood
Autogenic Training: A Meta-Analysis

2. AT vs. thermal biofeedback in AT vs. other (venous (8/8/0) (N = 16) flow and skin temperature in the
patients with idiopathic psychological occlusion biofeedback group only.
Raynaud’s disease treatment (post) plethysmogra- Baseline blood flow and skin
3. Randomized study. Small phy), skin temperature (long-term effects
sample sizes temperature of treatment) did not improve
before and during from beginning to end of the
pp383-apbi-367321

the sessions. treatment period in any group.


Unspecific Unspecific effects: significant
effects: heart rate, increase in skin conductance in
blood pressure, the biofeedback group only
skin conductance during the sessions. No effects
for heart rate or SBP in any
group. Significant reduction in
DBP in both groups
Preparation for childbirth
February 18, 2002

Prill (1965) 1. N = 2 (1/0/1) Pre–post for AT. Duration of N = 404 1. 6–8 weeks Duration of opening phase was
2. AT vs. no psychological AT vs. real dilatation period (104/0/300) (N = 404) 3 hr in the mean shorter in
treatment. Basic medical care in control (post) of delivery. women who had learned AT
12:11

all groups Number of compared with control. Number


3. Poor objectivity of presentation. labours. Behavior of labours was reduced, and the
Sample sizes differ during delivery frequency (labours/hour) was
(Clinical rating 1 increased in the AT group. 8.6%
(very well in the AT group vs. 16–19% in
adapted) to 4 the control group showed a very
(very worse problematic behavior during
adapted)) delivery (rating 4)
65

(Continued )
Style file version Nov. 19th, 1999
P1: GCQ

Table I. (Continued )
66

1. Total no. of groups (AT/other


treatment/real control) Total sample 1. Length of
2. Description of comparisons of Variables size [N ] (sizes treatment
different treatment (or real Possible included pre: AT/other (N post)
control) conditions quantitative in quantitative treatment/real 2. Follow-up Descriptive assessment
Disease/studies 3. Methodical comments analyses analyses control) (N follow-up) (clinical main symptoms)
Applied Psychophysiology and Biofeedback [apb]

Zimmermann-Tansella 1. N = 2 (1/1/0) Study not N = 90, only 34 1. 9 weeks The RAT patients tended to
et al. (1979) 2. Respiratory AT (“RAT”) vs. included in women could (N = 34, report less pain during
preparation for childbirth quantitative be follow-up 14/20/0) delivery and showed
according to Lamaze. Basic analyses until delivery significantly less anxiety
medical care in both groups before labour compared to
3. Randomized study. As RAT control. The duration of
combines components of AT, dilatation tended to be shorter
progressive relaxation, and and the duration of expulsion
respiratory relaxation, this period was significantly
pp383-apbi-367321

study is not suitable shorter in the RAT group


concerning conclusions compared to control group.
concerning effects of AT No differences were observed
between both groups
concerning body weight and
APGAR-index of the babies
Bianchi et al. (1994) 1. N = 2 (1/0/1) Study not N = 28 1. 8 weeks No significant differences
2. Respiratory AT (“RAT”) vs. no included in (14/0/14) (N = 28, occurred between both
February 18, 2002

other psychological treatment. quantitative 14/0/14) groups with the exception of


Basic medical care in both analyses plasma levels of endorphins
groups during delivery: During
3. Randomized study. As RAT delivery the levels increased
12:11

combines components of AT, highly significantly more in


progressive relaxation, and the control group compared
respiratory relaxation, this to the RAT group. The same
study is not suitable was true for plasma levels of
concerning conclusions endorphins in the cord blood
concerning effects of AT
Bowel diseases
Berndt & Maercker 1. N = 2 (1/0/1) Pre–follow-up for Reduction of N = 34 1. 14 weeks 10 patients (77%) in the AT
(1985) 2. AT vs. no psychological AT. AT vs. real clinical main (17/0/17) (N = 26, 13/013) group vs. 6 patients (46%) in
treatment in patients with control symptoms 2. 12 months the control group were free of
Stetter and Kupper

irritable bowel syndrome. (follow-up) (abdominal pain, (N = 26) symptoms or much improved
Style file version Nov. 19th, 1999
P1: GCQ

Basic medical treatment and diarrhoea, (follow-up). No patient in the


diet counselling in both constipation, AT vs. 2 patients in the
groups (clinical rating). control group showed a
3. Randomized study. Unspecific deterioration (not
Unsophisticated outcome effects: sleep significant). All of 9 patients
measure disorders, in the AT group diagnosed as
nervousness, “neurotic” showed an
nausea, headache, improvement. 3 of 8 patients
vertigo in the AT group diagnosed as
“neurotic” showed an
improvement (significant
difference). Improvement of
Applied Psychophysiology and Biofeedback [apb]

unspecific effects
significantly more
Autogenic Training: A Meta-Analysis

pronounced in the AT group


vs. control group
Milne, Joachim, & 1. N = 2 (1/0/1) Pre–post and Crohn’s Disease N = 80 1. 4 months Significant reduction of CDAI
Niedhardt (1986) 2. AT combined with some pre–follow-up Activity Index (40/0/40) (N = 77, in the AT group (post and
components of coping skill for AT. AT vs. (CDAI). 40/0/37) follow-up). The control
training vs. no psychological real control Inflammatory 2. 12 months group deteriorated slightly
pp383-apbi-367321

treatment in patient (post and Bowel Disease (N = 69, over the study year.
inflammatory bowel disease follow-up) (IBD) Stress 37/0/32) Significant reduction in IBD
(M. Crohn and Colitis Index in the AT group only
ulcerosa). Basic medical
treatment in both groups
3. Randomized study.
Sophisticated study protocol
Epilepsy
De Rivera, De Pre–post for AT. Frequency of 1. 9 months Patients with a low frequency of
February 18, 2002

1. N = 2 (1/1/0) N = 21
Montigny, & 2. AT vs. support type of AT vs. other seizures drawn (11/10/0) (N = 20, seizures (1 seizure/week or
Remillard (1977) psychotherapy in patients with psychological from a diary. 10/10/0) less; n = 15) in both groups
temporal lobe epilepsy. Basic treatment Unspecific showed a small decrease (not
12:11

medical treatment in both (post) effects: significant). Patients with a


groups including antiepileptic psychological high frequency of seizures
medication symptoms (n = 5) showed a significant
3. Randomized study (BPRS, Cornell) decrease in the AT group
only. There was no decrease
in intensity of seizures in the
control group, whereas most
of the patients in the AT
67

(Continued )
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P1: GCQ

68

Table I. (Continued )
1. Total no. of groups (AT/other
treatment/real control) Total sample 1. Length of
2. Description of comparisons of Variables size [N ] (sizes treatment
different treatment (or real Possible included pre: AT/other (N post)
control) conditions quantitative in quantitative treatment/real 2. Follow-up Descriptive assessment
Disease/studies 3. Methodical comments analyses analyses control) (N follow-up) (clinical main symptoms)
Applied Psychophysiology and Biofeedback [apb]

group reported such a


decrease. Both groups showed
a significant reduction of the
total psychopathology score
(BPRS) that was significantly
more pronounced in the AT
group. Concerning the
self-reported symptoms
pp383-apbi-367321

(Cornell Index) the reduction


was significant in the AT
group only
Akimenko & 1. N = 2 (1/0/1) Study not included in N = ? (53/0/?) 1. 12 weeks During and after the training
Gromov 2. AT plus biofeedback training to the quantitative 19 patients 2. 1–3 years (data 31% of the patients showed no
(1995) identify precursers of seizures analyses: A with about dropouts seizures. In 50% of the
vs. no psychological treatment comparison with tonic–clonic were not reported) patients seizures occurred less
in patients with generalized, psychologically seizures, 26 frequently, and 19% were
February 18, 2002

fokal, and atypical seizures. untreated patients patients with unchanged. The treated group
Basic medical treatment in was only mentioned fokal seizures, was superior to a not defined
both groups including in the discussion 8 patients with group of epileptic patients
antiepileptic medication and data were not atypical without psychological
12:11

3. Poor objectivity of reported seizures treatment (basic medical


presentation in which data of (“?” data was treatment in both groups). 2 of
psychologically untreated not reported) 26 patients were still free of
patients is not reported in detail seizures at follow-up
Fibromyalgia
Keel et al. 1. N = 2 (1/1/0) Study not included in N = 32 1. 15 weeks There was no significant
(1998) 2. AT (as control group) vs. pain quantitative (N = 27, 13/14/0) improvement in either group
control training including AT analyses: AT effects 2. 3 months (post); however, at follow-up
in outpatients suffering from could not be (N = 27) pain intensity decreased in the
fibromyalgia (ACR criteria) analyzed (both combined group whereas
without psychiatric disorder groups received AT) there was an opposite
Stetter and Kupper
Style file version Nov. 19th, 1999
P1: GCQ

3. Amount of therapy differed tendency in the AT only group


extremely between both (significant). At post 7
groups, with the combined patients of the combined
group receiving twice as much group vs. 2 patients of the AT
therapy as the AT group group improved in general. At
follow-up this held true only
for 5 patients of the combined
group
Rucco Feruglio, 1. N = 2 (1/1/0) Pre–post for AT. AT Spontaneous pain N = 53 1. 6 months There were much more dropouts
Genco, & 2. AT vs. an hypnotic procedure vs. other (visual analoque (27/26/0) (N = 35, 11/24/0) in the AT group compared to
Mosanghini oriented on Erickson’s psychological scale), pain trigger the hypnosis group. AT
Applied Psychophysiology and Biofeedback [apb]

(1995) technique in patients with treatment (post) points, quality of proved difficult to apply in
fibromyalgia sleep, dropouts this setting. While there was a
3. Randomized study clear improvement in all
Autogenic Training: A Meta-Analysis

outcome measures in the


hypnosis group, there was
only poor improvement in the
AT group. The superiority of
hypnosis was significant or
highly significant
pp383-apbi-367321

Atopic eczema
Ehlers et al. 1. N = 5 (1/3/1) Pre–post and Severity of skin N = 149; 1. 12 weeks Significant improvement in all
(1995) 2. AT vs. cognitive behavioral Pre–follow-up for lesions. Topical 12 patients (N = 126, four treatment groups
therapy (BT) vs. AT. AT vs. real steroids. Different droped out 23/81/22) concerning all outcome
dermatological education (DE) control (post and measures of before 2. 12 months variables. No significant
vs. combination of BT and DE follow-up). AT vs. itching and treatment (N = 120, differences were observed
vs. no psychological treatment. other psychological scratching. (N = 137, 22/77/21) between the treatment groups.
Basic medical treatment in all and Measures of 28/85/24) All treatments were superior
February 18, 2002

groups psychoeducative illness-related to the control group


3. Randomized study. treatments (post and distress. concerning all variables
Sophisticated study protocol follow-up) Unspecific effects: except for “coping cognitions
and outcome measures. AT depression, related to itching” for the DE
12:11

was initially introduced as anxiety group (post). Concerning


“psychological placebo unspecific effects AT and
treatment” BT + DE showed a greater
improvement than the control
group. Results stable at
follow-up with the DE group
showing the smallest effects
69

(Continued )
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P1: GCQ

70

Table I. (Continued )
1. Total no. of groups (AT/other
treatment/real control) Total sample 1. Length of
2. Description of comparisons of Variables size [N ] (sizes treatment
different treatment (or real Possible included pre: AT/other (N post)
control) conditions quantitative in quantitative treatment/real 2. Follow-up Descriptive assessment
Disease/studies 3. Methodical comments analyses analyses control) (N follow-up) (clinical main symptoms)
Applied Psychophysiology and Biofeedback [apb]

Infertility
O’Moore, 1. N = 2 (1/0/1) Pre–follow-up Number of N = 23 couples 1. 8 weeks (N = 23) In the AT group one woman got
O’Moore, 2. AT vs. no psychological for AT. AT vs. pregnancies. (13/0/10) 2. 2 months pregnant during follow-up (and
Harrison, treatment in couples with real control Plasma levels of (N = 22, 12/010) delivered a healthy female child
Murphy, & idiopathic infertility. Basic (follow-up) prolactin in the later) and two women had
Carruthers medical treatment in both women. unusually prolonged periods, but
(1983) groups Unspecific didn’t allow to test for pregnancy
3. Follow-up period probably too effects: anxiety (not rated as success). No woman
pp383-apbi-367321

short (STAI) got pregnant in the control group.


Prolactin levels decreased
significantly in women in the AT
group. State anxiety decreased in
women and men of the AT group
(pre–post for AT only)
Glaucoma
Kaluza & 1. N = 2 (1/0/1) Pre–post and Intraocular pressure N = 23 1. 2 months Highly significant reduction of
February 18, 2002

Strempel 2. AT vs. waiting-list control pre–follow-up (IOP). Long-term (11/0/12) (N = 23, 11/0/12) long-term IOP in the AT group as
(1995) group in patients with for AT. AT vs. changes 2. 10 months basic AT was administered. An
open-angle glaucoma. Basic real control measured by IOP (N = 23, 23/0/0) additional significant reduction of
medical treatment in both (post) before each IOP was observed, when 4 months
12:11

groups single AT session. later eight sessions of advanced


3. Randomized study. Reduction of AT were applied. The same was
Sophisticated study protocol medication true when AT was applied to the
(pre–follow-up) waiting-list control patients
subsequently in the study.
Difference of IOP reduction
between the AT group and the
control group during waiting
phase was not significant.
Medication was reduced in 10/23
patients after the application of AT
Stetter and Kupper
Style file version Nov. 19th, 1999
P1: GCQ

Health-related quality of life (HQL) in cancer patients


Mantovani et al. 1. N = 3 (1/1/1) Pre–post for AT. Psychological N = 74 1. 6 months Both psychological/psychosocial
(1996) 2. AT plus social support vs. AT vs. real variables: (N = 72, treatments proved to be
social support only vs. no control (post) depression (BDI), 24/23/25) significantly more effective
psychosocial treatment in anxiety (STAI). concerning a multitude of
patients with solid tumors Multidimensional outcome variables (all related to
(various locations) or measurements of HQL) than the basic medical
haematological malignancies HQL: Quality of treatment combined with
aged over 65 and showing Life Index (QLI, psychopharmacotherapy alone.
clinical symptoms of Spitzer), There were no clear differences
depression or anxiety. Basic Functional Index between both psychological/
Applied Psychophysiology and Biofeedback [apb]

medical treatment Living-Cancer psychosocial treatments. AT


(antineoplastic therapy) in all (FLIC), subj. seemed to have no additional
Autogenic Training: A Meta-Analysis

groups including chemotherapy effect to social support


psychopharmako therapy with impact (SCI).
alprazolam and sulpirid Functional status
3. Randomized study. Aim of the and physical
study was not the improvement symptoms: KPPS
concerning the cancer itself (Kanofsky),
pp383-apbi-367321

Morrow
Assessment of
Nausea and
Emesis (MANE),
pain
Infection with HIV
Fukunishi, 1. N = 3 (1/1/1) Study not N = 19 1. 3 months A significant improvement after the
Hosaka, 2. AT plus progressive relaxation included in (6/6/7) (N = 19) relaxation training was observed
Matsumoto, & (PR) vs. supportive quantitative concerning anxiety, fatigue,
February 18, 2002

Hayashi psychotherapy vs. no analyses: AT depression, and confusion.


(1997) psychological treatment in and PR were Concerning the comparison of the
patients with an HIV infection mixed and no three groups, the patients in the
12:11

without symptoms of AIDS. clinical main relaxation group showed


Basic medical treatment in all symptom significantly higher anger scores
groups related compared to the other two groups
3. Very small sample sizes. directly to (post). Comparisons concerning
Patients were told AT and PR HIV was the other variables were not
and could use one of each or investigated significant
both for stress management
(Continued )
71
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P1: GCQ

Table I. (Continued )
72

1. Total no. of groups (AT/other


treatment/real control) Total sample 1. Length of
2. Description of comparisons of Variables size [N ] (sizes treatment
different treatment (or real Possible included pre: AT/other (N post)
control) conditions quantitative in quantitative treatment/real 2. Follow-up Descriptive assessment
Disease/studies 3. Methodical comments analyses analyses control) (N follow-up) (clinical main symptoms)
Applied Psychophysiology and Biofeedback [apb]

Anxiety disorders, test anxiety, tensiona


Lehrer, Atthowe, 1. N = 4 (1/1/2) Pre–post for AT. Anxiety (IPAT). N = 55 (no. of 1. 4 sessions Significant reduction of anxiety in
& Weber 2. AT vs. progressive relaxation AT vs. real Anxiety self-ratings groups not during 4 weeks the AT and PR group, however, not
(1980) (PR) vs. false biofeedback control (post). (diary). Unspecific reported) (no report about in the control groups (post). AT
(placebo) vs. waiting-list AT vs. other effect: heart rate, dropouts) and PR were highly significantly
control in anxious participants psychological finger temperature, superior to the control groups
(striking scores in a treatment respiration during the (post). Both treatment groups did
self-questionnaire for anxiety (post) sessions not differ significantly (IPAT and
IPAT) self-ratings). Unspecific effects:
pp383-apbi-367321

3. Sophisticated study protocol. The only significant result was a


Poor objectivity of presentation reduction of the heart rate in the
AT group
Herbert & 1. N = 2 (1/0/1) Pre–post and Trait and state anxiety N = 72 1. 6 weeks State and trait anxiety decreased
Gutman (1980, 2. AT vs. waiting-list control pre–follow-up (STAI). (62/0/10) 2. 6 weeks (no significantly in the AT group.
1983) group in patients with for AT. AT vs. Stress-related report about Stress-related physical and
stress-related disorders in the real control symptoms dropouts) psychological symptoms
setting of a family physician (post) decreased in 80% of the patients
February 18, 2002

3. Sample sizes differ of the AT group. Results stable at


follow-up. There were no such
effects observed in the control
group
12:11

Banner & 1. N = 6 (1/3/2) Pre–post and Tension rating scale, N = 63 1. 9 weeks There was a significant decrease in
Meadows 2. AT vs. EMG biofeedback vs. pre–follow-up duration, severity, (9/11 + 12 + (N = 63) tension on all cognitive measures
(1983) thermal biofeedback vs. EMG for AT. AT vs. and frequency of 12/9 + 10) 2. 3 months except for the tension rating scale
plus thermal biofeedback vs. real control problems, ability to (N = 57, 8/11 + in all groups, even the control
unspecific music (placebo) vs. (post, relax, Fear of 9 + 11/9 + 8) groups (post and follow-up).
waiting-list control in follow-up). Negative evaluation There were no significant
participants suffering from AT vs. other Scale, social distress, differences between the six groups
“tension” without severe psychological anxiety (STAI-X1,
organic diseases or psychosis treatment X2)
3. Randomized study (post,
Stetter and Kupper

follow-up)
Style file version Nov. 19th, 1999
P1: GCQ

Bailey (1984) 1. N = 2 (1/0/1) AT vs. real Sickness absence N = 45 1. 6 weeks (no The AT group had significantly fewer
2. AT vs. no psychological control records (total days (25/0/20) report about total days off and certificated days
treatment in student nurses (follow-up) off, certificated and dropouts). off compared to the control group.
supposed to be under a high uncertificated days Results were The result concerning
risk of stress. Stress off) taken after the uncertificated days off was not
information sessions in both first two school significant. The control group had
groups blocks and nearly twice as much average time
3. Sophisticated and “realistic” wards sick compared to the AT group
outcome measures
Stetter, Walter, 1. N = 2 (1/1/0) Pre–post and Trait-Anxiety N = 27 1. 6 weeks A significant reduction of trait
Zimmermann, 2. AT vs. group hypnosis in pre–follow-up (STAI-X2), (14/13/0) (N = 26, anxiety and the frequency of panic
Applied Psychophysiology and Biofeedback [apb]

Zähres, & outpatients with anxiety for AT. AT vs. frequency of panic 13/13/0) attacks was observed in both
Straube (1994) disorders (ICD 10) without other attacks. Unspecific 2. 12 weeks treatment groups. Both treatment
other psychiatric disorders and psychological effects: (N = 26) groups did not differ significantly
Autogenic Training: A Meta-Analysis

without other therapy treatment psychosomatic (post). Results were stable at


3. “Moderate random” (post, complaints (BL) follow-up. The same results were
assignment (according to the follow-up) obtained concerning the decrease
availability of the of psychosomatic complaints with
treatments)—not rated as a continued decrease up to
“randomized study” for this follow-up
pp383-apbi-367321

meta-analysis
Reed & Meyer 1. N = 2 (2/0/0) Study not N = 21 1. 3 weeks There was a significant reduction in
(1974) 2. Active instructions of AT vs. included in (N = 18, test anxiety in both groups at the
passive instructions of AT in the 8 active/10 end of treatment with a tendency
self-referred students with quantitative passive toward a greater improvement in
some degree of test anxiety analyses: No instructions) the active group. 14 of 16
3. Randomized study. No real or proper control participants who completed the
other treatment control. Small condition self-report forms reported
February 18, 2002

sample sizes increased positive performance


Kröner, Frieg, & 1. N = 5 (1/3/1) Pre–post for AT. Anxiety (STAI X1, N = 80 1. 10 weeks Significant improvement in anxiety
Niewendiek 2. AT vs. AT plus self-control AT vs. real X2), test anxiety (16/16 + (N = 63, (STAI) in groups with S; however
(1982) training (“S”) vs. AT plus control (post) (TAQ), experimental 16 + 16/16) 14/13 + 12 + not for the AT only group, the AT
12:11

systematic desensitization (neuropsychological) 12/12) plus systematic desensitisation


(“D”) vs. AT plus S plus D vs. test situation group, and the control group
no psychological treatment in (including tests of (“factor S” significant).
students screened for test concentration, Significant improvement in test
anxiety intelligence, etc.) anxiety in all groups, except for
3. Sample sizes differ. the AT only group and the control
Sophisticated study protocol group (“factor D” significant).
73

(Continued )
Style file version Nov. 19th, 1999
P1: GCQ

Table I. (Continued )
74

1. Total no. of groups (AT/other


treatment/real control) Total sample 1. Length of
2. Description of comparisons of Variables size [N ] (sizes treatment
different treatment (or real Possible included pre: AT/other (N post)
control) conditions quantitative in quantitative treatment/real 2. Follow-up Descriptive assessment
Disease/studies 3. Methodical comments analyses analyses control) (N follow-up) (clinical main symptoms)
Applied Psychophysiology and Biofeedback [apb]

Concerning the experimental


test situation there was an
improvement in the
performance of all groups
(test-retest effect?). Main
result: AT only did not improve
anxiety or specific test anxiety
Depression/dysthymia
Haward (1965) Pre–post for AT. Stress reactivity 1. 12 weeks Significant reduction of stress
pp383-apbi-367321

1. N = 3 (1/1/1) N = 30
2. AT plus behavior therapy AT vs. real (respiratory stress (10/10/10) (N = 30) reactivity as physiological
(BT) vs. BT only vs. control (post) reactivity) measure concerning
medication plus “unspecific (concerning “dysthmic-neurotic” states in
psychotherapy” in dysthymic both groups the AT group ( p = .01) and in
patients receiving BT). the unspecific psychotherapy
3. Outcome measure indirectly AT vs. medical group ( p = .05), however, not
related to dysthymia treatment (post) significant concerning the BT
only group. At the end of
February 18, 2002

treatment the difference


between the groups was
significant ( p = .005)
Jessup & Neufeld 1. N = 3 (1/1/2) Pre–post for AT. Anxiety (mood N = 20 (not 1. 4 days (N = 20) The AT group and the tone only
12:11

(1977) 2. AT vs. frontalis biofeedback AT vs. real adjective list). reported) group (placebo 1) were
vs. placebo 1 (tone only) vs. (placebo) Unspecific superior concerning the
placebo 2 (unassisted control. effects: Egotism reduction of anxiety compared
self-relaxation) Because of (mood adjective to the biofeedback group and
3. Very small sample sizes. Only shortcomings of list) the self-relaxation group
15/20 “psychiatric” inpatients the protocol and (placebo 1). Concerning the
received a diagnosis of of the reduction of egotism there was
depression. The diagnosis of presentation the a tendency for a superiority of
5 patients was not reported. study is at the the tone only group (placebo 1)
Basic psychiatric treatment in threshold for over all other groups. Because
Stetter and Kupper

all groups. Very poor inclusion in of the heterogeneity and the


Style file version Nov. 19th, 1999
P1: GCQ

objectivity of presentation. quantitative small size of the sample and


Only one outcome measure analyses the inappropriate AT-procedure
relating directly to one has to be very cautious in
depression. AT was applied interpreting the results.
very inappropriate (four Moreover, the authors
sessions on four consecutive discussed if possibly “listening
days; tapes only) to pleasant tone” in the placebo
1 group was really a
control—especially regarding
the very short time of “real”
Applied Psychophysiology and Biofeedback [apb]

relaxation treatment
Krampen (1997, 1. N = 3 (1/1/1) Pre–post for AT Symptoms of N = 55 1. 10 weeks In the first 10 weeks all outcome
1999) 2. AT vs. psychotherapy (after 10 depression (BDI, (19/18/18) (N = 48, variables improved in the AT
Autogenic Training: A Meta-Analysis

(cognitive behavioral therapy weeks). AT vs. H-Scale 19/15/14) and group. In the waiting-list
and client centered therapy real control [hopelessness], another 10 weeks control there was a tendency
PT) vs. waiting-list control in (waiting list, ICD-10 criteria), of treatment toward a deterioration. PT was
outpatients with ICD-10 post 10 weeks). control beliefs, (N = 48) significantly superior to AT (20
diagnosed depression. After AT vs. control self-efficacy. 2. Follow-up 1: 8 sessions PT vs. 10 sessions
10 weeks the AT group (post 20 weeks Unspecific months (N = 48) AT) concerning symptoms of
pp383-apbi-367321

received PT additionally to and follow-up 1 effects: follow-up 2: depression (BDI, H-Scale).


AT and the waiting control and 2: one psychosomatic 3 years (N = 48) Both treatments were equally
received a combination of PT group received complaints. effective concerning the
and AT for another 10 weeks psychotherapy Relapse rate improvement in control beliefs
3. Randomized study. only, the other and self-efficacy. AT was
Sophisticated study protocol two groups significantly superior to PT
and outcome measures received AT concerning complaints. After
plus 20 weeks all three groups
February 18, 2002

psychotherapy). improved significantly on all


AT vs. other outcome measures. Both
psychological groups with AT plus PT were
treatment (post significantly superior to PT
12:11

10 weeks) only. This result was stable at


both follow-ups. After 3 years
there was a significantly lower
relapse rate in the AT group (3
of 33) compared to the PT only
group (6 of 15)
(Continued )
75
Style file version Nov. 19th, 1999
P1: GCQ

Table I. (Continued )
76

1. Total no. of groups (AT/other


treatment/real control) Total sample 1. Length of
2. Description of comparisons of Variables size [N ] (sizes treatment
different treatment (or real Possible included pre: AT/other (N post)
control) conditions quantitative in quantitative treatment/real 2. Follow-up Descriptive assessment
Disease/studies 3. Methodical comments analyses analyses control) (N follow-up) (clinical main symptoms)
Applied Psychophysiology and Biofeedback [apb]

Functional sleep disorders


Nicassio & 1. N = 4 (1/1/2) Pre–post and Daily time to fall N = 32 1. 4 weeks A significant reduction of the
Bootzin (1974) 2. AT vs. progressive relaxation pre–follow-up asleep (drawn (N = 30, time to fall asleep was
vs. placebo control (unassisted for AT. AT vs. from diaries) 7/7/16) observed in the AT and the
self-relaxation) vs. no real control 2. 6 months PR group. Both relaxation
psychological treatment (post, (N = 17, patients groups were equally
control in patients with follow-up). AT without treatment effective and superior to
evaluated functional sleep vs. other were not both control groups. Results
onset insomnia (<30 min). psychological followed-up) were stable at follow-up.
pp383-apbi-367321

Any psychotropic medication treatment (post, Global improvement


was discontinued before the follow-up) (self-questionnaire) was
study started analysed for both treatments
3. Randomized study. Small combined. At follow-up
sample sizes there was a small decrease
of the improvement
observed in both relaxation
groups at the end of
February 18, 2002

treatment
Engel-Sittenfeld, 1. N = 3 (1/2/0) Pre–post and Time to fall asleep, N = 35 (including 1. 14 weeks In the client centered therapy
Engel, Huber, 2. AT vs. EMG and EEG (theta) follow-up for use of sleeping a waiting-list Dropouts: AT: 2, group significantly more
& Zangl biofeedback vs. client centered AT. AT vs. other medication, time control, which biofeedback:1, patients droped out than in
12:11

(1980) therapy in patients with psychological and periods was not analyzed client centered: 6 both relaxation groups.
functional chronic sleep treatment (post, awake during the any further) (N = 22, Concerning all other
disorders (<3 years) without follow-up) night, duration of 8/8 + 6/0) outcome variables there
psychiatric disorders and sleep, feelings of 2. 40 weeks were no significant
organic disorders that may recreation in the (N = 22) differences between the
cause sleep disorders morning drawn three groups. Concerning
3. Small sample sizes, large from diaries. the use of medication, time
standard deviations. Poor Dropouts and periods awake during
objectivity of presentation the night, and feelings of
recreation all groups showed
Stetter and Kupper

a significant improvement
Style file version Nov. 19th, 1999
P1: GCQ

Coursey, Frankel, 1. N = 3 (1/2/0) Pre–post for AT. General success N = 22 1. 6 weeks In the AT group 2/6, in the BF
Gaarder, & 2. AT vs. EMG biofeedback (BF) AT vs. other index derived (6/6 + 10/0) (N = 22) group 3/6, and in the EL
Mott (1980) vs. electrosleep (EL) in psychological from polygraph group 0/10 patients
patients with functional treatment recordings (e.g., succeeded in achieving a
chronic sleep onset insomnia (EMG sleep latency, meaningful improvement in
(<35 min) without psychiatric biofeedback, total sleep, their sleep difficulties based
disorders and organic disorders post). AT vs. percentage of on the different variables.
that may cause sleep disorders. medical REM and Delta This result was significant
Any sleep medication was treatment sleep) and diaries for BF vs. EL ( p = .036)
discontinued before the study (electrosleep, and not significant for AT
started post) vs. EL ( p = .125)
Applied Psychophysiology and Biofeedback [apb]

3. Small sample sizes.


Poor objectivity of
presentation
Autogenic Training: A Meta-Analysis

Alcoholism
Sharp, Hurford, 1. N = 2 (1/0/1) Pre–post for AT. Drinking-related N = 25 1. 4 weeks A significant improvement in
Allison, 2. Thermal biofeedback assisted AT vs. real locus of control (12/0/13) (N = 25) the drinking-related locus of
Sparks, & AT vs. no additional control (post) (DRIE). control was observed in
Comeron psychological treatment in Unspecific effect: the AT group only. AT
(1997) alcohol dependent adolescents finger was significantly superior
pp383-apbi-367321

(18–21) years. Basic temperature to the control group. A


alcoholism treatment in both significant increase in
groups finger temperature after a
3. Randomized study. Outcome training session (post) was
measure was “drinking related observed in the AT group
locus of control,” however, not only. The AT group was
abstinence or alcohol significantly superior to the
consumption. No “pure” AT control group. In
February 18, 2002

procedure interpreting the results one


has to consider that AT
was presented by audiotape
and was assisted by
12:11

biofeedback
(Continued )
77
Style file version Nov. 19th, 1999
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78

Table I. (Continued )
1. Total no. of groups (AT/other
treatment/real control) Total sample 1. Length of
Applied Psychophysiology and Biofeedback [apb]

2. Description of comparisons of Variables size [N ] (sizes treatment


different treatment (or real Possible included pre: AT/other (N post)
control) conditions quantitative in quantitative treatment/real 2. Follow-up Descriptive assessment
Disease/studies 3. Methodical comments analyses analyses control) (N follow-up) (clinical main symptoms)

Stutter
Alarcia, Pinard, 1. N = 4 (1/2/1) Pre–post and Objective measures N = 48 1. 12 weeks Concerning objective measures
Serrano, & 2. AT vs. behavioral therapy (BT) pre–follow-up of stutter (e.g., (12/24/12) (N = 44, of stutter significant
Tetreault vs. reeducation of language vs. for AT. AT vs. reading aloud, 12/23/9) improvement compared with
pp383-apbi-367321

(1982) no treatment at all. Patient real control conversation). 2. 36 weeks (no the control group is observed
were excluded if they received (post). AT vs. Rating of information about in the reeducation group only.
any psychiatric or neurological other patient’s relatives dropouts) However effects reversed at
diagnosis or were on any psychological concerning follow-up. Concerning
psychiatric or neurological treatment (post improvement. relative’s ratings significant
medication and follow-up) Unspecific improvement compared with
3. Sophisticated study protocol effects: anxiety the control group is observed
and outcome measures (IPAT), in the behavioral and AT group
February 18, 2002

neurotizism only. These effects continued


(Willoughby) up to follow-up (highly
significant). Unspecific effects:
Concerning anxiety all
12:11

treatment groups were superior


to the control group.
Concerning neurotizism this
was true only for the
behavioral and AT group
a Investigation of anxiety partly as symptom and partly as disorder.
Stetter and Kupper
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Autogenic Training: A Meta-Analysis 79

within one study differed in more than 5 participants, the term “varying sample sizes” is
used ([Ni 6= Ni+1 ] > 5). As demonstrated by Linden (1994), the descriptive review regards
some studies that were not included in the subsequent meta-analysis. Reasons are mentioned
in Table I. This relates to studies comparing different modalities of the AT application (e.g.,
active vs. passive learning, single vs. group stetting, patients vs. healthy controls), studies in
which only unspecific effects were analyzed in a controlled design (e.g., patients with HIV
infection) and studies in which AT did not play a clearly discernible role and in which not
enough statistical material was reported to conduct a meta-analysis. A total of 73 controlled
clinical studies were found. Fourty-one of the studies were randomized trials (Table I).
Thirteen of the 73 studies described in Table I were excluded from the meta-analysis:
In two studies one of the groups had a sample size smaller than five. Two studies provided no
proper control condition as revealed by careful analysis. In four studies AT was combined
with other therapy modalities in such a way that effects for AT itself could not be analyzed. In
five studies no data for AT effects were reported. Sixty controlled clinical studies remained.
Thirty-five of the remaining studies were randomized controlled trials (RCT).

Overall Results for AT

Most of the meta-analytic results are presented in tables (Tables II–XI). Within each part
of the tables from left to right the following results are presented: pre–post (pre–follow-up)
effects for AT, comparisons of the outcome between the AT group and real control groups,
and comparisons between AT and other psychological treatment groups. Results concerning
clinical main symptoms and unspecific effects are presented separately in Tables II–V to
deal with the primary and with the secondary hypotheses. Moreover, results of the two
domains of outcome (behavioral/psychological or physiological) and results of all outcome
variables together are presented separately (from left to right) in all tables. For each row of
all tables a separate meta-analysis was performed.
For methodological reasons the presentation of all ES is supported by the presentation
of the number of participants (N ) and of studies (Nstudies ) on which they are based and by an
indicator of the number of single ES derived from these studies (NES ) that were aggregated
to the ES. Additionally other significant indicators necessary for the interpretation of meta-
analytic results are presented.

Randomized Controlled Studies

Overall meta-analytic results of the therapy with AT derived from 33 RCTs are pre-
sented in Table II (In two of the 35 RCTs follow-up data is presented only).
Pre–Post for AT. Disease specific (main) pre–post effects for AT (0.68–0.75) were in
the range of medium ES. Unspecific effects were somewhat larger (0.73–0.78; Table II).
AT Versus Real Control Treatments (Posttreatment). For this group of analysis medium
ES in favour for AT were observed for all main effects (0.59–0.63). Unspecific effects were
at the borderline of large ES in favour for AT (0.65–0.88; Table II).
AT Versus Other Psychological Treatments (Posttreatment). Small disease specific
(main) effects in favour for other psychological treatments were found (−0.25 to 0.46).
Outcomes based on unspecific effects varied considerably (0.14 to −1.23): The psycho-
logical variables showed a small positive ES in favour for AT. The physiological variables
resulted in a large negative ES (Table II).
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80 Stetter and Kupper

Table II. Results of the Meta-Analysis of 35 Randomized Controlled AT-Studies, Post (Total of 33 Studies)
Main effects Unspecific effects
Phys. Psy. Total Phys. Psy. Total

Pre–post for AT
N 546 1232 1530 100 366 450
NStudies 17 23 33 5 9 13
NES 45 72 117 3 19 22
H 14.28 41.87∗∗ 47.76∗ 1.42 25.46∗∗ 27.15∗∗∗
D W+ 0.68∗∗∗ — 0.75∗∗∗ 0.78∗∗∗ — —
1 — 0.68∗∗∗ — — 0.74∗∗ 0.73∗∗∗
95%-confid. 0.52–0.87 0.54–0.82 0.65–0.85 0.38–1.19 0.23–1.25 0.37–1.08
VESE (%) 100 89.78 100 100 24.50 40.21
Fail N 0.2/0.5 42/7 55/8 91/16 15/3 24/4 34/6
AT vs. real control
N 458 729 1039 25 347 372
NStudies 13 17 25 1 7 8
NES 34 54 88 1 17 18
H 27.46∗∗∗ 11.87 35.26† — 32.96∗∗∗ 33.97∗∗∗
D W+ — 0.59∗∗∗ 0.61∗∗∗ 0.88 — —
1 0.63∗∗∗ — — — 0.65∗ 0.67∗
95%-confid. 0.24–1.02 0.44–0.74 0.49–0.74 — −0.09 to 1.39 0.02–1.31
VESE (%) 34.44 35.17 53.72 — 13.78 16.58
Fail N 0.2/0.5 28/3 33/3 49/5 — 16/2 19/3
AT vs. other psychological treatment
N 166 1057 1207 16 225 241
NStudies 4 15 18 1 6 7
NES 10 52 62 2 7 9
H 5.19 24.84 ∗ 29.96∗ — 16.75 ∗ 25.00∗∗∗
D W+ −0.46 ∗∗ −0.25 ∗∗∗ −0.28∗∗∗ −1.23 — —
1 — — — — 0.38† 0.14
95%-confid. −0.77 to −0.15 −0.38 to −0.12 −0.40 to −0.16 — −0.18 to 0.95 −0.53 to 0.34
VESE (%) 64.29 96.52 74.54 — 29.86 21.37
Fail N 0.2/0.5 6/0 1/−8 1/−10 — 5/−1 −2/−5

Note. Phys. = physiological outcome variables; Psy. = behavioral/psychological outcome variables; Total =
combination of all outcome variables (physiological and behavioral/psychological); N = sample size of all pa-
tients of all groups; NStudies = number of studies; NES = number of effect sizes; H = coefficient indicating
the result of the test of homogeneity; level of significance of H : † p < .10, ∗ p < .05, ∗∗ p < .01, ∗∗∗ p < .001;
homogeneity is assumed if p ≥ .01; D W+ = effect size (ES) d weighted by its own variance; 1 = ES d
weighted by the sample size; significance of ES-coefficients tested by the normal distribution Z : † p < .10,
∗ p < .05, ∗∗ p < .01, ∗∗∗ p < .001; 95%-confid. = 95%-confidence interval of population ES; VESE (%) =
amount of variance explained by sampling error in percent; Fail N 0.2/0.5 = fail-safe N for critical delta of
0.20/0.50.

AT Versus Medical Treatments. Only four RCTs were found, in which AT was com-
pared to effects of medical (nonpsychological) treatment. The results are not presented in
tables: Postcomparisons showed no effects (physiological: D W+ = −0.04, psychological/
behavioral: D W+ = +0.04, combined: D W+ = −0.03). One single ES from one single
study related to a follow-up comparison and revealed a strong negative effect (D W+ =
−1.12).
Pre-Follow-Up for AT. Main effects were at the borderline of strong ES (0.74–0.89).
Unspecific effects were in the medium range (0.53: Table III).
AT Versus Real Control Treatments (Follow-Up). For this group of analysis medium
ES in favour for AT were observed for all main effects (0.51–0.56). Large unspecific effects
in favour for AT were found (1.09; Table III).
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Autogenic Training: A Meta-Analysis 81

Table III. Results of the Meta-Analysis of 35 Randomized Controlled AT-Studies, Follow-Up (Total of 19 Studies)
Main effects Unspecific effects
Phys. Psy. Total Phys. Psy. Total

Pre–follow-up for AT
N 400 860 1138 — 224 224
NStudies 8 14 19 — 5 5
NES 18 43 61 — 14 14
H 34.62∗∗∗ 15.73 43.71∗∗∗ — 6.28 6.28
D W+ — 0.74 ∗∗∗ — — 0.53∗∗∗ 0.53∗∗∗
1 0.88∗∗ — 0.89∗∗∗ — — —
95%-confid. 0.18–1.58 0.60–0.88 0.60–1.19 — 0.26–0.80 0.26–0.80
VESE (%) 19.25 64.67 40.44 — 65.45 65.45
Fail N 0.2/0.5 27/6 41/8 66/15 — 9/1 9/1
AT vs. real control
N 326 334 617 — 106 106
NStudies 4 9 12 — 3 3
NES 11 34 45 — 5 5
H 11.18∗ 14.06† 24.37∗ — 15.42∗∗∗ 15.42∗∗∗
D W+ 0.56∗∗∗ 0.51∗∗∗ 0.52∗∗∗ — — —
1 — — — — 1.09∗ 1.09∗
95%-confid. 0.34–0.78 0.29–0.74 0.36–0.69 — −0.03 to 2.22 −0.03 to 2.22
VESE (%) 11.72 32.17 18.08 — 15.56 15.56
Fail N 0.2/0.5 −2/−3 19/2 18/0 — 13/4 13/4
AT vs. other psychological treatment
N 233 945 1079 — 272 272
NStudies 3 10 12 — 5 5
NES 11 58 69 — 15 15
H 5.71† 10.75 11.49 — 5.24 5.24
D W+ 0.03 −0.21∗∗ −0.21∗∗∗ — 0.05 0.05
1 — — — — — —
95%-confid. −0.25 to 0.30 −0.35 to −0.07 −0.33 to −0.08 — −0.21 to 0.30 −0.21 to 0.30
VESE (%) 42.43 100 100 — 48.20 48.20
Fail N 0.2/0.5 −2/−3 1/−6 1/−7 — −5/−5 −5/−5

Note. Phys. = physiological outcome variables; Psy. = behavioral/psychological outcome variables; Total =
combination of all outcome variables (physiological and behavioral/psychological); N = sample size of all pa-
tients of all groups; NStudies = number of studies; NES = number of effect sizes; H = coefficient indicating the
result of the test of homogeneity; level of significance of H : † p < .10, ∗ p < .05, ∗∗ p < .01, ∗∗∗ p < .001; homo-
geneity is assumed if p ≥ .01; D W+ = effect size (ES) d weighted by its own variance; 1 = ES d weighted by the
sample size; significance of ES-coefficients tested by the normal distribution Z : † p < .10, ∗ p < .05, ∗∗ p < .01,
∗∗∗ p < .001; 95%-confid. = 95%-confidence interval of population ES; VESE (%) = amount of variance ex-
plained by sampling error in percent; Fail N 0.2/0.5 = fail-safe N for critical delta of 0.20/0.50.

AT Versus Other Psychological Treatments (Follow-Up). Disease specific (main) ef-


fects for AT versus other psychological treatments were at the borderline of small (negative)
ES (−0.21 to 0.03). Unspecific effects were even smaller (0.05; Table III).

Nonrandomized Controlled Studies

Pre–Post for AT. Disease specific (main) pre–post effects for AT were in the range
of small ES (0.36–0.43). Unspecific effects were generally larger; however, they varied
significantly (0.25–0.81; Table IV).
AT Versus Real Control Treatments (Post). For this group of analysis medium ES in
favour for AT were observed for all main effects (0.62–0.74). Unspecific effects were large
in general; however, they varied widely (0.00–1.10; Table IV).
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82 Stetter and Kupper

Table IV. Results of the Meta-Analysis of 25 Nonrandomized Controlled AT-Studies, Post (Total of 22 Studies)
Main effects Unspecific effects
Phys. Psy. Total Phys. Psy. Total

Pre–post for AT
N 874 1206 1720 28 326 354
NStudies 8 16 22 1 5 6
NES 17 57 74 7 10 17
H 13.16† 7.32 14.90 — 17.07∗∗ 19.29∗∗
D W+ 0.36∗∗∗ 0.41∗∗∗ 0.43∗∗∗ 0.25 — —
1 — — — — 0.81∗∗∗ 0.73∗∗∗
95%-confid. 0.22–0.49 0.30–0.52 0.33–0.53 — 0.42–1.19 0.37–1.09
VESE (%) 74.31 100 100 — 49.85 51.09
Fail N 0.2/0.5 7/−2 17/−3 25/−3 — 15/3 16/3
AT vs. real control
N 850 1063 1423 35 189 224
NStudies 7 11 16 1 4 5
NES 21 44 65 3 5 9
H 14.30∗ 57.20∗∗∗ 56.18∗∗∗ — 51.30∗∗∗ 56.33∗∗∗
D W+ 0.62∗∗∗ — — 0.00 — —
1 — 0.74∗∗ 0.71∗∗∗ — 1.10 0.88
95%-confid. 0.47–0.77 0.20–1.29 0.33–1.09 — −0.90 to 3.10 −0.73 to 2.49
VESE (%) 61.13 16.94 22.46 — 6.23 6.90
Fail N 0.2/0.5 12/1 30/5 41/7 — 18/5 17/4
AT vs. other psychological treatment
N — 306 306 27 139 166
NStudies — 9 9 1 3 4
NES — 42 42 3 9 12
H — 3.08 3.08 — 0.59 0.59
D W+ — — — 0.33 0.34∗ 0.34∗
1 — −0.09 −0.09 — — —
95%-confid. — −0.33 to 0.14 −0.33 to 0.14 — −0.008 to 0.69 0.02–0.65
VESE (%) — 100 100 — 100 100
Fail N 0.2/0.5 — −5/−7 −5/−7 — 2/−1 3/−1

Note. N = sample size of all patients of all groups; NStudies = number of studies; NES = number of effect sizes;
H = coefficient indicating the result of the test of homogeneity; level of significance of H : † p < .10, ∗ p < .05,
∗∗ p < .01, ∗∗∗ p < .001; homogeneity is assumed if p ≥ .01; d = Hedges corrected effect size (ES); D W+ = ES
d weighted by its own variance; 1 = ES d weighted by the sample size; significance of ES-coefficients tested by
the normal distribution Z : † p < .10, ∗ p < .05, ∗∗ p < .01, ∗∗∗ p < .001; 95%-confid. = 95%-confidence interval
of population ES; VESE (%) = amount of variance explained by sampling error in percent; Fail N 0.2/0.5 =
fail-safe N for critical delta of 0.20/0.50.

AT Versus Other Psychological Treatments (Post). Disease specific (main) effects ES


were close to zero (−0.09). Unspecific effects were small, although in favour for AT (0.33–
0.34: Table IV).
AT Versus Medical Treatments. Only three nonrandomized controlled trials were found
in which AT was compared to effects of medical (nonpsychological) treatment. The results
are not presented in a table: Postcomparisons showed no effects concerning physiological
variables (D W+ = −0.04). In the field of psychological/behavioral outcome variables a
strong positive effect in favour for AT occurred (d = +0.82; both effects combined: D W+ =
0.02). Concerning follow-up data, no study was found.
Pre–Follow-Up for AT. Main effects (0.30–0.58) and unspecific effects (0.61) at the
borderline of medium ES in favour for AT were obtained (Table V).
AT Versus Real Control Treatments (Follow-Up). For this group of analysis small ES
in favour for AT were observed for all main effects (0.31). No study was found that provided
outcomes for unspecific effects (Table V).
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Autogenic Training: A Meta-Analysis 83

Table V. Results of the Meta-Analysis of 25 Nonrandomized Controlled AT-Studies, Follow-Up (Total of


12 Studies)
Main effects Unspecific effects
Phys. Psy. Total Phys. Psy. Total

Pre–follow-up for AT
N 122 416 538 — 238 238
NStudies 1 9 10 — 5 5
NES 4 29 33 — 2 2
H — 6.94 8.82 — 5.03 5.03
D W+ 0.30 0.58∗∗∗ 0.52∗∗∗ — 0.61∗∗∗ 0.61∗∗∗
1 — — — — — —
95%-confid. — 0.39–0.78 0.34–0.69 — 0.34–0.87 0.34–0.87
VESE (%) — 100 100 — 62.71 62.71
Fail N 0.2/0.5 — 17/1 16/0 — 10/1 10/1
AT vs. real control
N 89 184 273 — — —
NStudies 1 5 6 — — —
NES 4 12 16 — — —
H — 1.66 1.65 — — —
D W+ 0.31 0.31∗ 0.31∗∗ — — —
1 — — — — — —
95%-confid. — 0.01–0.61 0.06–0.56 — — —
VESE (%) — 100 100 — — —
Fail N 0.2/0.5 — 3/−2 3/−2 — — —
AT vs. other psychological treatment
N — 193 193 — 92 92
NStudies — 6 6 — 2 2
NES — 43 43 — 5 5
H — 0.37 0.37 — 0.76 0.76
D W+ — −0.18 −0.18 — 0.33† 0.33†
1 — — — — — —
95%-confid. — −0.48 to 0.11 −0.48 to 0.11 — −0.10 to 0.77 −0.10 to 0.77
VESE (%) — 100 100 — 100 100
Fail N 0.2/0.5 — 0/−4 0/−4 — 1/0 1/0

Note. Phys. = physiological outcome variables; Psy. = behavioral/psychological outcome variables; Total =
combination of all outcome variables (physiological and behavioral/psychological); N = sample size of all patients
of all groups; NStudies = number of studies; NES = number of effect sizes; H = coefficient indicating the result of
the test of homogeneity; level of significance of H: † p < .10, ∗ p < .05, ∗∗ p < .01, ∗∗∗ p < .001; homogeneity is
assumed if p ≥ .01; D W + = effect size (ES) d weighted by its own variance; 1 = ES d weighted by the sample size;
significance of ES-coefficients tested by the normal distribution Z: † p < .10, ∗ p < .05, ∗∗ p < .01, ∗∗∗ p < .001;
95%-confid. = 95%-confidence interval of population ES; VESE (%) = amount of variance explained by sampling
error in percent; Fail N 0.2/0.5 = fail-safe N for critical delta of 0.20/0.50.

AT Versus Other Psychological Treatments (Follow-Up). Disease specific (main) ef-


fects were at the borderline of small ES (−0.18). Unspecific effects were small, however,
in favour for AT (0.33; Table V).

Results of AT for Specific Psychosomatic and Psychological Disorders

Linden (1994) presented results for psychosomatic and psychological disorders sep-
arately. Following his example, overall results for psychosomatic disorders (randomized,
n = 31, and nonrandomized studies, n = 15) and for psychological disorders (random-
ized, n = 4, and nonrandomized studies, n = 10) are presented separately. In the following
sections and Tables (VI–XI) the results of each disorder are presented in detail, as this led
to more homogeneous ES.
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Table VI. Results of the Meta-Analysis (Total of Clinical Main Effect Sizes) Concerning Randomized Controlled AT-Studies Dealing With Different Psychosomatic Disorders
Post Follow-up
84

Pre–post AT AT vs. real control AT vs. other psych. treatment Pre–follow-up AT AT vs. real control AT vs. other psych. treatment
(D,D W+ resp. 1) (d, D W+ resp. 1) (d, D W+ resp. 1) (d, D W+ resp. 1) (d, D W+ resp. 1) (d, D W+ resp. 1)
Disorders N NSTUD. NES N NSTUD. NES N NSTUD. NES N NSTUD. NES N NSTUD. NES N NSTUD. NES
Tension headache/migraine 626 7 20 251 4 13 827 7 29 588 6 17 88 2 7 793 6 26
1 = 0.84∗∗∗ D W+ = 0.59∗∗∗ D W+ = −0.28∗∗∗ D W+ = 0.75∗∗∗ 1 = 1.53∗ D W+ = −0.27∗∗∗
Hypertension 12 4 10 182 4 12 134 2 8 318 5 14 283 3 11 134 2 8
Applied Psychophysiology and Biofeedback [apb]

D W+ = 0.87∗∗∗ DW+ = 0.93∗∗∗ D W+ = −0.34∗ D W+ = 1.24∗∗∗ 1 = −0.21 D W+ = −0.21

Coronary heart disease 64 1 1 52 1 1 — — — 64 1 2 — — — — — —


d = 0.64 d = 0.56 — d = 0.56 — —
Asthma bronchiale 54 2 10 62 2 10 — — — — — — — — — — — —
D W+ = 0.58∗ D W + = 0.98∗∗∗ — — — —
Somatoform pain disorder, 226 3 19 111 2 10 — — — — — — — — — — — —
unspecified type D W+ = 0.56∗∗∗ D W+ = 0.46∗∗ D W+ = −0.02 — — —
pp383-apbi-367321

Raynaud’s disease 108 6 12 76 4 7 46 3 5 30 2 3 — — — 14 1 1


D W+ = 0.47∗∗ D W+ = 0.31 D W+ = −0.53∗ D W+ = 0.25 — d = 0.00
Preparation for childbirth — — — — — — — — — — — — — — — — — —
— — — — — —
Bowel diseases 80 1 2 77 1 1 — — — 103 2 3 103 2 2 — — —
d = 0.59 d = 0.53 — 1 = 1.32 D W+ = 0.36∗ —
Epilepsy 20 1 1 — — — 20 1 1 — — — — — — — — —
— — — —
February 18, 2002

d = 0.55 d = 0.60
Fibromyalgia 22 1 3 — — — 35 1 4 — — — — — — — — —
d = 1.54 — d = −1.11 — — —
Atopic eczema 46 1 12 45 1 4 50 1 1 44 1 12 43 1 8 99 1 24
12:11

d = 0.86 d = 0.90 d = 0.50 d = 0.82 d = 0.38 d = 0.28

Infertility — — — — — — — — — — — — — — — — — —
— — — — — —
Glaucoma 22 1 4 23 1 2 — — — — — — 23 1 1 — — —
d = 1.05 d = 0.43 — — d = 0.36 —

HQL in cancer patients 48 1 8 47 1 8 — — — — — — — — — — — —


d = −0.06 d = 0.13 — — — —

Note. N = sample size of all patients of all groups; NStudies = number of studies; NES = number of effect sizes; H = coefficient indicating the result of the test of homogeneity;
level of significance of H : † p < .10, ∗ p < .05, ∗∗ p < .01, ∗∗∗ p < .001; homogeneity is assumed if p ≥ .01; d = Hedges corrected effect size (ES); D W+ = ES d weighted
Stetter and Kupper

by its own variance; 1 = ES d weighted by the sample size; significance of ES-coefficients tested by the normal distribution Z : † p < .10, ∗ p < .05, ∗∗ p < .01, ∗∗∗ p < .001;
95%-confid. = 95%-confidence interval of population ES; VESE (%) = amount of variance explained by sampling error in percent; Fail N 0.2/0.5 = fail-safe N for critical
delta of 0.20/0.50.
Style file version Nov. 19th, 1999
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Autogenic Training: A Meta-Analysis 85

Psychosomatic Disorders

Randomized Controlled Studies (Psychosomatic Disorders). Concerning a meta-


analysis of all RCTs (n = 31) dealing with psychosomatic disorders the analyses
demonstrated

–medium main ES (0.74) and medium unspecific ES (0.52) for pre–post comparisons,
–medium main ES (0.62) and small unspecific ES (0.27) for AT versus real control
comparisons,
–small main ES (−0.32) in favour for other treatments and no unspecific ES (0.008)
concerning AT versus other psychological treatments,
–large main ES (0.89) and medium unspecific ES (0.53) for pre–follow-up compar-
isons,
–borderline medium ES (0.46–0.49) for main and unspecific effects concerning AT
versus real control comparisons (follow-up), and
–small main ES (−0.22) in favour for other treatments and no unspecific ES (0.05)
concerning AT versus other psychological treatments (follow-up).

Separate results for each disorder are presented in Table VI.


Nonrandomized Controlled Studies (Psychosomatic Disorders). Concerning a meta-
analysis of all nonrandomized studies (n = 15) dealing with psychosomatic disorders the
analyses showed

–small main ES (0.38) and small unspecific ES (0.45) for pre–post comparisons,
–medium main ES (0.56) and small unspecific ES (0.35) for AT versus real control
comparisons,
–no main ES (−0.03) and small unspecific ES (0.30) in favour for AT concerning AT
versus other psychological treatments,
–small main ES (0.36) and medium unspecific ES (0.52) for pre–follow-up compar-
isons,
–small main ES (0.25) concerning AT versus real control comparisons (follow-up),
and
–small main ES (−0.22) in favour for other treatments and a small unspecific ES (0.21)
in favour for AT concerning AT versus other psychological treatments (follow-up).

Separate results for each disorder are presented in Table VII.


Combined Analyses (Randomized and Nonrandomized Studies; Psychosomatic
Disorders). In this section results of each disorder will be presented as shown in Table VIII.
Medium-to-large ES for pre–post effects of AT and AT versus real control were found for
tension headache/migraine, mild-to-moderate essential hypertension, inflamatory bowel
disease, atopic eczema, and glaucoma. For the latter three disorders, however, only one
study of each qualified for meta-analysis. Small-to-medium ES were found for coronary
heart disease, asthma bronchiale, somatoform pain disorder (unspecified type), Raynaud’s
disease, frontal lobe epilepsy, and preparation for childbirth. Again the interpretation of the
results for the latter two disorders is limited as the ES were based on one study only. Quality
of life in cancer patients was not positively influenced by AT in one study. The application
of AT in one study concerning Fibromyalgia resulted in a positive effect, whereas com-
pared to another psychological treatment (hypnosis) a strong negative effect occured. This
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86 Stetter and Kupper

suggests that patients suffering from fibromyalgia benefit more from hypnosis. With the
exception of atopic eczema (medium positive ES) the other direct comparisons of AT with
other psychological treatments resulted in small-to-medium negative ES (headache, hyper-
tension, Raynaud’s disease). Other techniques as symptom-biofeedback (all), progressive
relaxation (tension headache), or hypnosis (migraine) turned out to be more effective. The
pattern of results at follow-up was similar to that mentioned before. Most of the positive
effects of AT were stable until follow-up; some proved to be even larger. One study dealing
with infertility revealed a positive effect for AT at follow-up.

Psychological Disorders

Randomized Controlled Studies (Psychological Disorders). Concerning a meta-


analysis of all RCTs (n = 4) dealing with psychological disorders, the analyses showed
–large main ES (0.87) and large unspecific ES (1.73) for pre–post comparisons,
–medium main ES (0.58) for AT versus real control comparisons,
–small main ES (−0.24) in favour for other treatments and large unspecific ES (1.81)
in favour for AT concerning AT versus other psychological treatments,
–large main ES (1.12) for pre–follow-up comparisons,
–small main ES (0.33) concerning AT versus real control comparisons (follow-up),
and
–no main ES (0.00) concerning AT versus other psychological treatments (follow-up).
Separate results for each disorder are presented in Table IX.
Nonrandomized Controlled Studies (Psychological Disorders). Concerning a meta-
analysis of all nonrandomized studies (n = 10) dealing with psychological disorders, the
analyses found
–medium main ES (0.67) and large unspecific ES (1.08) for pre–post comparisons,
–large main ES (1.03) and large unspecific ES (1.01) for AT versus real control com-
parisons,
–no main ES (−0.15) and small unspecific ES (0.37) in favour for AT concerning AT
versus other psychological treatments,
–large main ES (0.83) and medium unspecific ES (0.64) for pre–follow-up compar-
isons,
–medium main ES (0.50) concerning AT versus real control comparisons (follow-up),
and
–no main ES (−0.15) and small unspecific ES (0.65) in favour for AT concerning AT
versus other psychological treatments (follow-up).
Separate results for each disorder are presented in Table X.
Combined Analyses (Randomized and Nonrandomized Studies; Psychological
Disorders). In this section results of each psychological disorder will be presented as is
shown in Table XI. Evidence for the effects of AT derived from three to five studies was
found for anxiety, mild-to-moderate depression, and functional sleep disorders: Pre–post
for AT and AT versus other psychological treatment showed medium-to-large ES in favour
for AT. For alcohol dependent patients and patients suffering from stutter, one study was in-
cluded. AT showed medium-to-large benefitial effects in alcoholism and small-to-medium
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Table VII. Results of the Meta-Analysis (Total of Clinical Main Effect Sizes) Concerning Nonrandomized Controlled AT-Studies Dealing With Different Psychosomatic
Disorders
Post Follow-up
Pre–post AT AT vs. real control AT vs. other psych. treatment Pre–follow-up AT AT vs. real control AT vs. other psych. treatment
(D, D W+ resp. 1) (d, D W+ resp. 1) (d, D W+ resp. 1) (d, D W+ resp. 1) (d, D W+ resp. 1) (d, D W+ resp. 1)
Disorders N NSTUD. NES N NSTUD. NES N NSTUD. NES N NSTUD. NES N NSTUD. NES N NSTUD. NES
Tension headache/migraine 102 3 11 36 1 8 134 3 18 88 3 11 36 1 4 111 3 18
D W+ = 0.45∗ d = 0.14 D W+ = −0.02 D W+ = 0.41∗ d = 0.14 D W+ = −0.22

Hypertension 462 4 8 294 3 6 — — — 122 1 4 89 1 4 — — —


D W+ = 0.55∗∗∗ D W+ = 0.56∗∗∗ — d = 0.64 d = 0.31 —

Coronary heart disease 294 2 10 209 2 8 — — — — — — 61 1 1 — — —


Applied Psychophysiology and Biofeedback [apb]

D W+ = 0.34∗∗ D W+ = 0.87∗∗∗ — — d = 0.25 —

Asthma bronchiale 98 1 12 86 1 16 — — — — — — — — — — — —
d = 0.24 d = 0.28 — — — —
Autogenic Training: A Meta-Analysis

Somatoform pain Disorder, 270 2 11 210 2 11 — — — 116 1 5 — — — — — —


unspecified type D W+ = 0.32∗∗ D W+ = 0.33∗ — d = 0.31 — —
Raynaud’s disease — — — — — — — — — — — — — — — — — —
— — — — — —
pp383-apbi-367321

Preparation for childbirth 208 1 1 404 1 3 — — — — — — — — — — — —


d = 0.37 d = 0.66 — — — —
Bowel diseases — — — — — — — — — — — — — — — — — —
— — — — — —

Epilepsy — — — — — — — — — — — — — — — — — —
— — — — — —
Fibromyalgia
February 18, 2002

Atopic eczema — — — — — — — — — — — — — — — — — —
— — — — — —
Infertility — — — — — — — — — 22 1 1 32 1 1 — — —
— — — d = 0.80 d = 0.15 —
12:11

Glaucoma — — — — — — — — — — — — — — — — — —
— — — — — —

HQL in cancer patients — — — — — — — — — — — — — — — — — —


— — — — — —

Note. N = sample size of all patients of all groups; NStudies = number of studies; NES = number of effect sizes; H = coefficient indicating the result of the test of homogeneity;
level of significance of H : † p < .10, ∗ p < .05, ∗∗ p < .01, ∗∗∗ p < .001; homogeneity is assumed if p ≥ .01; d = Hedges corrected effect size (ES); D W+ = ES d weighted
87

by its own variance; 1 = ES d weighted by the sample size; significance of ES-coefficients tested by the normal distribution Z : † p < .10, ∗ p < .05, ∗∗ p < .01, ∗∗∗ p < .001;
95%-confid. = 95%-confidence interval of population ES; VESE (%) = amount of variance explained by sampling error in percent; Fail N 0.2/0.5 = fail-safe N for critical
delta of 0.20/0.50.
Style file version Nov. 19th, 1999
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Table VIII. Results of the Meta-Analysis (Total of Clinical Main Effect Sizes) Concerning All Controlled AT-Studies (Randomised and Nonrandomized) Dealing With Different
Psychosomatic Disorders
Post Follow-up
88

Pre–post AT AT vs. real control AT vs. other psych. treatment Pre–follow-up AT AT vs. real control AT vs. other psych. treatment
(D, D W+ resp. 1) (d, D W+ resp. 1) (d, D W+ resp. 1) (d, D W+ resp. 1) (d, D W+ resp. 1) (d, D W+ resp. 1)
Disorders N NSTUD. NES N NSTUD. NES N NSTUD. NES N NSTUD. NES N NSTUD. NES N NSTUD. NES

Tension headache/migraine 728 10 31 287 5 21 961 10 47 676 9 28 124 3 11 904 9 44


1 = 0.85∗∗∗ D W+ = 0.54∗∗∗ D W+ = −0.25∗∗∗ D W+ = 0.71∗∗∗ 1 = 1.04† D W+ = −0.26∗∗∗
Hypertension 582 8 18 476 7 18 134 2 8 440 6 18 372 4 15 134 2 8
Applied Psychophysiology and Biofeedback [apb]

D W+ = 0.61∗∗∗ D W+ = 0.70∗∗∗ D W+ = −0.34∗ 1 = 1.12∗∗∗ 1 = −0.02 D W+ = −0.21

Coronary heart disease 358 3 11 261 3 9 — — — 64 1 2 61 1 1 — — —


D W+ = 0.39∗∗∗ D W+ = 0.80∗∗∗ — d = 0.56 d = 0.25 —

Asthma bronchiale 152 3 22 148 3 26 — — — — — — — — — — — —


D W+ = 0.35∗ D W+ = 0.55∗∗∗ — — — —
Somatoform pain disorder, 496 5 30 321 4 21 — — — 116 1 5 — — — — — —
unspecified type D W+ = 0.43∗∗∗ D W+ = 0.38∗∗∗ — d = 0.31 — —
pp383-apbi-367321

Raynaud’s disease 108 6 12 76 4 7 46 3 5 30 2 3 — — — 14 1 1


D W+ = 0.47∗∗ D W+ = 0.31 D W+ = −0.53∗ D W+ = 0.25 — D W+ = 0.00
Preparation for childbirth 208 1 1 404 1 3 — — — — — — — — — — — —
d = 0.37 d = 0.66 — — — —
Bowel diseases 80 1 2 77 1 1 — — — 103 2 3 103 2 2 — — —
d = 0.59 d = 0.53 — D W+ = 1.32† D W+ = 0.36∗ —
Epilepsy 20 1 1 — — — 20 1 1 — — — — — — — — —
February 18, 2002

d = 0.55 — d = 0.00 — — —
Fibromyalgia 22 1 3 — — — 35 1 4 — — — — — — — — —
d = 1.54 — d = −1.11 — — —
Atopic eczema 46 1 12 45 1 4 50 1 1 44 1 12 43 1 8 99 1 24
12:11

d = 0.86 d = 0.90 d = 0.50 d = 0.82 d = 0.38 d = 0.28


Infertility — — — — — — — — — 22 1 1 32 1 1 — — —
— — — d = 0.80 d = 0.15 —

Glaucoma 22 1 4 23 1 2 — — — — — — 23 1 1 — — —
d = 1.05 d = 0.43 — — d = 0.36 —

HQL in cancer patients 48 1 8 47 1 8 — — — — — — — — — — — —


d = −0.06 d = 0.13 — — — —

Note. N = sample size of all patients of all groups; NStudies = number of studies; NES = number of effect sizes; H = coefficient indicating the result of the test of homogeneity;
Stetter and Kupper

level of significance of H : † p < .10, ∗ p < .05, ∗∗ p < .01, ∗∗∗ p < .001; homogeneity is assumed if p ≥ .01; d = Hedges corrected effect size (ES); D W+ = ES d weighted
by its own variance; 1 = ES d weighted by the sample size; significance of ES-coefficients tested by the normal distribution Z : † p < .10, ∗ p < .05, ∗∗ p < .01, ∗∗∗ p < .001;
95%-confid. = 95%-confidence interval of population ES; VESE (%) = amount of variance explained by sampling error in percent; Fail N 0.2/0.5 = fail-safe N for critical
delta of 0.20/0.50.
Style file version Nov. 19th, 1999
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Table IX. Results of the Meta-Analysis (Total of Clinical Main Effect Sizes) Concerning Randomized Controlled AT-Studies Dealing With Different Psychological Disorders
Post Follow-up
Applied Psychophysiology and Biofeedback [apb]

Pre–post AT AT vs. real control AT vs. other psych. treatment Pre–follow-up AT AT vs. real control AT vs. other psych. treatment
(D, D W+ resp. 1) (d, D W+ resp. 1) (d, D W+ resp. 1) (d, D W+ resp. 1) (d, D W+ resp. 1) (d, D W+ resp. 1)
Autogenic Training: A Meta-Analysis

Disorders N NSTUD. NES N NSTUD. NES N NSTUD. NES N NSTUD. NES N NSTUD. NES N NSTUD. NES

Anxiety disorders, 18 1 9 28 1 9 44 1 9 16 1 9 25 1 9 25 1 9
test anxiety d = 1.05 d = 0.00 d = 0.00 d = 1.15 d = 0.00 d = 0.00
Depression/dysthymia 38 1 4 37 1 8 37 1 4 — — — 37 1 5 — — —
d = 0.72 d = 0.65 d = −0.60 — d = 0.54 —
pp383-apbi-367321

Functional sleep disorders 14 1 1 23 1 2 14 1 1 14 1 1 16 1 2 14 1 1


d = 1.58 d = 0.75 d = 0.12 d = 1.24 d = 0.96 d = 0.00
Alcoholism 24 1 1 25 1 1 — — — — — — — — — — — —
d = 0.77 d = 0.99 — — — —
Stutter — — — — — — — — — — — — — — — — — —
— — — — — —

Note. N = sample size of all patients of all groups; NStudies = number of studies; NES = number of effect sizes; H = coefficient indicating the result of the test of homogeneity;
February 18, 2002

level of significance of H : † p < .10, ∗ p < .05, ∗∗ p < .01, ∗∗∗ p < .001; homogeneity is assumed if p ≥ .01; d = Hedges corrected effect size (ES); D W+ = ES d weighted
by its own variance; 1 = ES d weighted by the sample size; significance of ES-coefficients tested by the normal distribution Z : † p < .10, ∗ p < .05, ∗∗ p < .01, ∗∗∗ p < .001;
95%-confid. = 95%-confidence interval of population ES; VESE (%) = amount of variance explained by sampling error in percent; Fail N 0.2/0.5 = fail-safe N for critical
delta of 0.20/0.50.
12:11

89
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90
Applied Psychophysiology and Biofeedback [apb]

Table X. Results of the Meta-Analysis (Total of Clinical Main Effect Sizes) Concerning Nonrandomized Controlled AT-Studies Dealing With Different Psychological Disorders
Post Follow-up
Pre–post AT AT vs. real control AT vs. other psych. treatment Pre–follow-up AT AT vs. real control AT vs. other psych. treatment
(D, D W+ resp. 1) (d, D W+ resp. 1) (d, D W+ resp. 1) (d, D W+ resp. 1) (d, D W+ resp. 1) (d, D W+ resp. 1)
Disorders N NSTUD. NES N NSTUD. NES N NSTUD. NES N NSTUD. NES N NSTUD. NES N NSTUD. NES

Anxiety disorders, 204 4 10 133 3 8 102 3 6 148 2 4 45 1 3 24 1 4


pp383-apbi-367321

test anxiety D W+ = 0.62∗∗∗ 1 = 1.27 D W+ = −0.18 D W+ = 0.89∗∗∗ d = 0.66 d = −0.06


Depression/dysthymia 30 2 2 30 2 2 — — — — — — — — — — — —
D W+ = 1.12∗∗ D W+ = 1.11∗ — — — —
Functional sleep disorders 28 2 7 — — — 34 2 15 16 1 6 — — — 22 1 12
D W+ = 0.63† — D W+ = 0.16 d = 0.56 — d = −0.005
Alcoholism — — — — — — — — — — — — — — — — — —
— — — — — —
Stutter 24 1 2 21 1 3 36 1 4 24 1 2 21 1 3 36 1 6
February 18, 2002

d = 0.57 d = 0.21 d = −0.38 d = 0.65 d = 0.20 d = −0.28

Note. N = sample size of all patients of all groups; NStudies = number of studies; NES = number of effect sizes; H = coefficient indicating the result of the test of homogeneity;
level of significance of H : † p < .10, ∗ p < .05, ∗∗ p < .01, ∗∗∗ p < .001; homogeneity is assumed if p ≥ .01; d = Hedges corrected effect size (ES); D W+ = ES d weighted
12:11

by its own variance; 1 = ES d weighted by the sample size; significance of ES-coefficients tested by the normal distribution Z : † p < .10, ∗ p < .05, ∗∗ p < .01, ∗∗∗ p < .001;
95%-confid. = 95%-confidence interval of population ES; VESE (%) = amount of variance explained by sampling error in percent; Fail N 0.2/0.5 = fail-safe N for critical
delta of 0.20/0.50.
Stetter and Kupper
Style file version Nov. 19th, 1999
P1: GCQ

Table XI. Results of the Meta-Analysis (Total of Clinical Main Effect Sizes) Concerning All Controlled AT-Studies (Randomised and Nonrandomized) Dealing With Different
Psychological Disorders
Applied Psychophysiology and Biofeedback [apb]

Post Follow-up
Pre–post AT AT vs. real control AT vs. other psych. treatment Pre–follow-up AT AT vs. real control AT vs. other psych. treatment
(D, D W+ resp. 1) (d, D W+ resp. 1) (d, D W+ resp. 1) (d, D W+ resp. 1) (d, D W+ resp. 1) (d, D W+ resp. 1)
Autogenic Training: A Meta-Analysis

Disorders N NSTUD. NES N NSTUD. NES N NSTUD. NES N NSTUD. NES N NSTUD. NES N NSTUD. NES

Anxiety disorders, 222 5 19 161 4 17 146 4 15 164 3 13 70 2 12 49 2 13


test anxiety D W+ = 0.65∗∗∗ 1 = 0.95 D W+ = −0.13 D W+ = 0.90∗∗∗ D W+ = 0.43∗ D W+ = −0.03
Depression/dysthymia 68 3 6 67 3 10 37 1 4 — — — 37 1 5 — — —
pp383-apbi-367321

D W+ = 0.87∗∗∗ D W+ = 0.83∗∗∗ d = −0.59 — d = 0.54 —


Functional sleep disorders 42 3 8 23 1 2 48 3 16 30 2 7 16 1 2 36 2 13
D W+ = 0.86∗∗ d = 0.75 D W+ = 0.14 D W+ = 0.79∗ d = 0.96 D W+ = −0.003
Alcoholism 24 1 1 25 1 1 — — — — — — — — — — — —
d = 0.77 d = 0.99 — — — —
Stutter 24 1 2 21 1 3 36 1 4 24 1 2 21 1 3 36 1 6
d = 0.57 d = 0.21 d = −0.38 d = 0.65 d = 0.20 d = −0.28

Note. N = sample size of all patients of all groups; NStudies = number of studies; NES = number of effect sizes; H = coefficient indicating the result of the test of homogeneity;
February 18, 2002

level of significance of H : † p < .10, ∗ p < .05, ∗∗ p < .01, ∗∗∗ p < .001; homogeneity is assumed if p ≥ .01; d = unbiased estimator of population effect size (ES); D W+ =
ES d weighted by its own variance; 1 = ES d weighted by the sample size; significance of ES-coefficients tested by the normal distribution Z : † p < .10, ∗ p < .05, ∗∗ p < .01,
∗∗∗ p < .001; 95%-confid. = 95%-confidence interval of population ES; VESE (%) = amount of variance explained by sampling error in percent; Fail N 0.2/0.5 = fail-safe N
for critical delta of 0.20/0.50.
12:11

91
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92 Stetter and Kupper

positive effects in stutter. Compared to a training of speech abilites, AT was less effective.
However, in this study the training of speech and the test of the main outcome variable were
very much the same, and the positive results of the training of speech were not stable at
follow-up. Concerning the outcome variable of the rating of speech ability in everyday life
given by the patients’ relatives, AT was clearly superior. With the exception of depression
for which a medium negative ES (in favour for cognitive therapy in one study) occurred,
direct comparisons to other psychological treatment resulted in very small or no relevant
ES. This pattern of results was stable at follow-up.

DISCUSSION

In this study 73 controlled trials concerning effects of the therapy with AT are quan-
titatively reviewed. The number of 35 RCTs included in the quantitative analysis is about
50% greater than that in the Linden (1994) paper. The main reason for this is the period of
time, as additional studies that had been published between 1992 and 1999 were included.
However another minor reason is that some studies were included that were either difficult
to retrieve or had to be translated (e.g., from Russian language). Therefore it was possible
to include studies from many countries and from different continents. This quite represen-
tative cross-section of different therapeutic applications of AT is presented in a descriptive
manner for all studies. On the one hand, this allows a structured and comprehensive insight
into what is known about controlled outcome of AT applications in various settings. On the
other hand, the methodological comments and the reported figures demonstrate the large
variety of the methodological quality in AT outcome research.
Some of the studies, especially the older ones, suffer from more or less severe
shortcomings concerning either the study protocol (only a little more than a half of the
studies were RCTs) or the objectivity of the presentation. Other studies are of limited
validity concerning the AT procedures. As a result of this descriptive part of the review,
two major points should be discussed to stimulate further research so as to overcome such
shortcomings:

1. In some studies “autogenic phrases” were presented by tape recordings. From a


methodological point of view the positive aspect of such a procedure is to minimize
the influence of the impact of different presentations of different therapists on
outcome. However, it may be a shift from the “autogenic” aspect of this relaxation
method to a tape induced or (if a therapist spoke the formulae aloud) to a voice
induced more or less hypnotic procedure. Study protocols should include at least
one real autogenic exercise in each therapeutic session.
2. Some studies suffer from small or very small sample sizes. This may result in
inadequate statistical power (beta-error) to detect clinically important outcomes.
In this meta-analysis at least 5 participants had to be in each group, as the usual
inferential statistics should not be applied in samples smaller than 10 (Clauß &
Ebner, 1989) if two groups are to be compared. However, a sample size of just
5 participants per group does not rule out objections concerning statistical power.
As proposed by Linden (1994), it was the purpose of this review to include as many
studies as possible. It should be noted that the inclusion criteria were followed strictly and
all analysis of the text and the figures of all studies were carried out in a conservative manner
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Autogenic Training: A Meta-Analysis 93

to provide as much objectivity as possible. Instead of determining an interrater reliability


concerning the in- or exclusion of each study, a consensus procedure was chosen. However,
even those studies that were not included in the subsequent analyses were presented in
Table I. This encourages a considerable degree of objectivity of presentation. This should
be mentioned especially, as one of the authors (F. S.) is supposed to be a member of the
German scientific-oriented “AT community.”
Following this line, 60 studies of which 35 were RCTs could be included in the
subsequent quantitative analysis. The results of randomized and nonrandomized controlled
studies are presented separately, as RCTs are assumed to fit for higher methodical standards.
Concerning the first hypothesis the analyses showed that pre–post and pre–follow-up
clinical main effects of AT are in a medium-to-large range of ES with the RCTs demon-
strating higher ES compared to nonrandomized studies. In psychological disorders large
ES are observed, whereas in psychosomatic disorders small-to-medium ES are to be found.
This result indicates somewhat stronger AT effects compared to the results of the study of
Linden (1994) who reported ES of 0.43–0.58 for pre–post effects of AT.
On behalf of the second hypothesis it can be noted that the AT-treated groups of
patients generally do better than patients in control condition concerning clinical outcome.
This group of comparisons shows medium ES in general. This result again indicates about
the same or somewhat stronger AT effects compared to the results of the study of Linden
(1994) who reported ES of 0.24–0.67 in favour for AT compared to control conditions.
Concerning the third hypothesis, the meta-analyses demonstrated very small effects in
general. If ES were greater than the lower borderline of small effects, they pointed toward a
superiority of other psychological treatments in improving clinical outcome. However, the
superiority was not very impressive. This result indicates the same or somewhat weaker AT
effects compared to the results of the study of Linden (1994) who reported ES of 0.00 to
−0.06 in favour for other treatments compared to AT.
To sum up the results of the meta-analyses on behalf of the three primary hypotheses,
one can assume that a therapy with AT results in medium-to-large clinical main effects that
are stable at follow-up and that exceed placebo effects (control conditions). Compared to
other psychological treatments, AT seems to be nearly equal or a little less effective. The
comparisons with medical treatments are rare and the meta-analytic results varying. One
should be very cautious with any interpretation.
Moreover it could be demonstrated that AT results in mostly medium-to-large ES con-
cerning unspecific therapeutic effects (secondary hypothesis). Especially in psychological
disorders such unspecific effects even exceeded the considerable amount of improvement
in clinical main effects.
Study ES turned out to be more homogeneous as the meta-analyses disaggregated to
the level of each of the disorders separately. In the field of psychosomatic disorders AT
proved its effectiveness in more than one study in mild-to-moderate hypertension, tension
headache and migraine, coronary heart disease, asthma bronchiale, Raynaud’s disease, and
an unspecified type of somatoform pain disorder. In the rare direct comparisons other psy-
chological therapies as progressive relaxation, hypnosis, or symptom-biofeedback turned
out to be equally or a little superior effective. Although AT had a positive effect on frontal
lobe epilepsy, the more specific biofeedback training of slow cortical potentials seems to
be more promising (Rockstroh et al., 1993). As there are promising results from one study
each concerning AT therapy for inflamatory bowel disease, atopic eczema, glaucoma, and
preparation for childbirth, further research may prove (or disprove) the properties of AT
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94 Stetter and Kupper

in these disorders. For the interpretation of the results it is crucial to keep in mind that in
nearly all of the studies a basic medical treatment was applied for all patients in all groups.
However, the results indicate that AT can play a serious role as one part of “psycho-somatic”
therapy.
In the field of psychological disorders AT turned out to be effective in anxiety, mild-
to-moderate depression, and functional sleep disorders. Concerning anxiety disorders, one
has to keep in mind that AT was not compared with cognitive or exposure therapy. As AT
had not been compared with psychopharmacological treatment (especially for depression
and anxiety disorders), one should not conclude from the results that AT is an alternative
to such a treatment at least for moderate and surely for severe forms of the disorders. One
study (Krampen, 1999) showed that in moderate depression cognitive therapy was more
effective than AT (medium ES). However, in the same study those patients receiving AT and
cognitve therapy showed the best outcome at follow-up. This result can stimulate further
clinical research: Study protocols in which one group receives AT whereas the other group is
treated otherwise and in which afterwards both treatments are switched between groups may
answer questions, if AT may play a role as a “preparation-therapy” or an “add-on-therapy.”
As a result of this meta-analysis, AT proved to be an effective relaxation method
being about as effective as other relaxation methods. This replicates the general findings
of Linden (1994) and contradicts the results of Grawe et al. (1994). However, perhaps all
relaxation methods should not be considered as stand-alone therapies especially in severe
forms of the disorders. In the psychosomatic area, relaxation, of course, should be an add-on
therapy to medical treatment. Its combination with behavioral and cognitive as well as with
psychotherapeutic components should be worth further investigation.

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