Vancampfort, D., De Hert, M., Knapen, J., Maurissen, K., Raepsaet, J., Deckx, S., & ... Probst, M.

(2011). Effects of progressive muscle relaxation on state anxiety and subjective well-being in
people with
schizophrenia:
a randomized controlled trial. Clinical Rehabilitation, 25(6), 567-575
Evaluative
study
9p. doi:10.1177/0269215510395633
Clinical Rehabilitation

Effects of progressive muscle

relaxation on state anxiety and
subjective well-being in people
with schizophrenia: a randomized
controlled trial

25(6) 567575
! The Author(s) 2011
Reprints and permissions:
sagepub.co.uk/journalsPermissions.nav
DOI: 10.1177/0269215510395633
cre.sagepub.com

Davy Vancampfort1,2, Marc De Hert1,3, Jan Knapen1,2,

Katrien Maurissen1,2, Julie Raepsaet1, Seppe Deckx1,2,
Sander Remans1 and Michel Probst1,2
Abstract
Objective: To examine the efficacy of a single progressive muscle relaxation session compared with
a control condition on state anxiety, psychological stress, fatigue and subjective well-being in patients with
schizophrenia.
Design: Randomized controlled trial.
Setting: An acute inpatient care unit of an University Psychiatric Centre.
Subjects: Sixty-four out of 88 eligible patients with schizophrenia.
Interventions: Patients were randomly assigned to either a single progressive muscle relaxation session
during 25 minutes or a resting control condition with the opportunity to read for an equal amount of time.
Main outcome measures: Before and after the single interventions the State anxiety inventory and the
Subjective exercise experiences scale were completed. Effect sizes were calculated.
Results: Only within progressive muscle relaxation, participants (n=27) showed decreased state anxiety,
psychological stress and fatigue and increased subjective well-being. Between-group differences in post
scores were found for state anxiety, subjective well-being and psychological stress, but not for fatigue. The
effect size favouring progressive muscle relaxation was 1.26 for subjective well-being and 1.25 and 1.02
for respectively state anxiety and psychological stress.
Conclusions: Progressive muscle relaxation is highly effective in reducing acute feelings of stress and
anxiety in patients with schizophrenia. A reduction in stress and state anxiety is associated with an
increase in subjective well-being.

Keywords
Psychiatric rehabilitation, stress, anxiety, physiotherapy
Received 22 March 2010; accepted 5 December 2010
1

University Psychiatric Centre Catholic University Leuven,

Campus Kortenberg, Kortenberg, Belgium
2
Faculty of Kinesiology and Rehabilitation Sciences, Catholic
University Leuven, Leuven, Belgium
3
Faculty of Medicine, Catholic University Leuven, Leuven,
Belgium

Corresponding author:
Davy Vancampfort, University Psychiatric Centre Catholic
University Leuven, Campus Kortenberg, Leuvensesteenweg
517, B-3070 Kortenberg, Belgium
Email: Davy.Vancampfort@uc-kortenberg.be

568

Introduction
Schizophrenia is one of the most debilitating
psychiatric
disorders.1
The
Diagnostic
Statistical Manual of Mental Disorders-IV
(DSM-IV) criteria for schizophrenia include
positive and negative symptomatology severe
enough to cause social and occupational dysfunction.2 Positive symptomatology reects an
excess or distortion of normal functions and
manifests itself in symptoms such as delusions,
hallucinations and disorganized speech and
behaviour. Negative symptoms reect a reduction or loss of normal functions, consisting of
symptoms such as aective attening, apathy,
avolition, social withdrawal and cognitive
impairments. The lifetime prevalence and incidence are 0.300.66% and 10.222.0 per
100 000 person-years, respectively.3
Increased sensitivity to anxiety and stress is
related to worsening of symptoms. People with
schizophrenia experience diculties in coping
with anxiety and stress and possess a relatively
limited repertoire of coping strategies.4,5
In schizophrenia, an increase in subjective anxiety and stress results in an increase in negative
aect and a decrease in positive well-being.6
Clinical rehabilitation strategies that aim to
enhance coping with feelings of stress, anxiety
and well-being should therefore be key.
Relaxation techniques including progressive
muscle relaxation have been considered as an
adjunctive therapy for dealing with stress, anxiety and depression and can provide patients with
self-maintenance coping skills to reduce these
symptoms.7,8 Studies of progressive muscle
relaxation as an intervention in treating trait
anxiety in people with chronic schizophrenia
have been performed since the early 1980s.
Hawkins et al. demonstrated that after 10 sessions of 40 minutes of progressive muscle relaxation (ve times a week) participants
demonstrated reduced trait anxiety compared
with a minimal treatment control.9 Recently,
Chen et al.10 conrmed that the degree of trait
anxiety improvement is signicantly higher in
a progressive muscle relaxation group receiving

Clinical Rehabilitation 25(6)

40 minutes of progressive muscle relaxation for

11 consecutive days than in a placebo control
group.
Previous studies only focused on trait anxiety.
When measuring a persons level of anxiety, one
must, however, consider both trait anxiety and
state anxiety. Trait anxiety is independent of
specic situations and measures a persons general level of anxiety that persists on a regular
basis. Trait anxiety can be dened as a predisposition to perceive a situation as threatening.
It inuences ones cognitive appraisal, which has
an impact on how individuals perceive stressful
situations. In contrast, state anxiety is dependent on very specic situations and changes on
a regular basis.11 It can be dened as the actually
experienced emotional status. Individuals with
higher trait anxiety (a greater disposition to
experience anxiety) show higher levels of state
anxiety in dierent situations than lower trait
anxious individuals.12
To the authors knowledge, the present study
is the rst to examine the eects of a single session of progressive muscle relaxation on state
anxiety, stress and subjective well-being in a
sample group of patients with schizophrenia.
The single-session format was utilized to facilitate evaluation of acute changes in state anxiety,
stress and subjective well-being following the
intervention.

Methods
Over a 12-month period, consecutive patients
with a DSM-IV2 diagnosis of schizophrenia
from an acute inpatient care unit were invited
to participate. Acute symptoms were at least
partially remitted in all patients. Participants
with the following characteristics were
excluded from the study: (a) having a psychiatric
co-morbidity (anxiety disorders and/or depressive disorders, substance dependence), (b)
exhibiting musculoskeletal problems that might
aect progressive muscle relaxation training, (c)
not being able to concentrate for 25 minutes
duration at a time, (d) not being able to complete the questionnaires within 510 minutes

Vancampfort et al.

without diculties and with minimal instructions, (e) having received previous progressive
muscle relaxation training.
The eects of 25 minutes of progressive
muscle training were compared with a resting
control condition. During two weeks participants undertook one weekly habituation session
in order to get used to the environment and the
protocol. Feedback was elicited during these sessions to allow participants to experience and
share the changes and sensations of relaxation.
In the third week participants were randomly
allocated to either the experimental progressive
muscle relaxation or the resting control condition. An independent statistician generated a
randomization list using a research randomizer
(www.randomizer.org). Questionnaires were
answered 5 minutes before and immediately
after the completion of the condition. During
the week of the test condition also psychiatric
symptoms were administered.
The study procedure was approved by the
Scientic and Ethical Committee of the
University Psychiatric Centre of the Catholic
University of Leuven in accordance with the
principles of the Declaration of Helsinki. All
participants gave their informed consent.

569

larger clinical physiotherapy programme consisting of aquatic sessions (once a week), walking (twice a week), yoga training (once a week),
tness training (twice a week), psycho-education
about an active lifestyle (once every two weeks)
and group-related movement sessions with
psychosocial and cognitive objectives (twice
a week). Progressive muscle relaxation was
oered once a week and lasted approximately
25 minutes.

Control condition
Participants in the resting control condition sat
quietly in a room for 25 minutes and were told
that they could read. Reading material was provided for participants who did not bring their
own material. The same physiotherapist was
also here present in the room and only left
during completion of the questionnaires. After
the resting control condition and after completing the questionnaires, participants still had the
opportunity to take part in another progressive
muscle relaxation session.

Questionnaires
State Anxiety Inventory. State anxiety was

Progressive muscle relaxation

Progressive muscle relaxation was originally
developed by Edmund Jacobson.13 The original
Jacobson method required dozens of sessions
where the participant was taught to relax 30 different muscle groups. Bernstein and Borkovec14
later shortened this technique to 16 muscle
groups and found it to be equally eective.15
The protocol for the progressive muscle relaxation in this study was administered by a trained
physiotherapist. Training consisted of successive
tensing and relaxing at least ve major muscle
groups, beginning with the upper body and proceeding to the lower parts. Tensing for about
8 seconds and relaxing for about 30 seconds of
each muscle group was practised twice prior to
proceeding to a subsequent muscle group.
Progressive muscle relaxation is part of a

assessed by the State Anxiety Inventory of

Spielberger.16 The range of possible total
scores is 2080. Higher scores indicate higher
levels of anxiety. The State Anxiety Inventory
has been extensively validated and is the most
widely used measure of anxiety in exercise
research.

Subjective Exercise Experiences Scale. Stress,

subjective well-being and fatigue were measured
using the Subjective Exercise Experiences
Scale.17 Each subscale contains four items,
which are scored on a scale from 0 (not at all)
to 7 (entirely). Higher scores on a subscale
indicate a higher perception for this factor.
The Subjective Exercise Experiences Scale represents one of the most reliable and valid instruments for assessing subjective well-being in
exercise settings.17

570

Clinical Rehabilitation 25(6)

Psychosis evaluation tool for common

use by caregivers

The signicance level was set at 0.05 (twotailed).

The psychosis evaluation tool for common use

by caregivers18 was used by an independent and
well-trained nurse to evaluate schizophrenia
symptoms. It evaluates 20 symptom items on a
7-point scale, resulting in an overall score ranging from 20 to 140. Symptoms are grouped in
ve factors: positive (hallucinations, delusions,
unusual thought content, grandiosity), negative
(poor rapport, passive/apathetic withdrawal,
blunted aect, motor retardation), depressive
(anxiety, depression, feelings of guilt, somatic
concerns), cognitive (poor attention, disorientation, diculties with abstract thinking, conceptual disorganization) and excitatory (poor
impulse control, lack of cooperation, hostility,
excitement) symptoms. The scores for each
factor range from 4 to 28. Validation results suggest that the psychosis evaluation tool for
common use by caregivers can be successfully
used for the evaluation of symptoms in
schizophrenia.19

Results

Statistical analysis
To assess the dierences in baseline characteristics between the progressive muscle relaxation
group and control condition groups an unpaired
Students t-test was used. For dierences in
gender distribution the Fisher exact test was
used.
A 2  2 (condition  time) MANOVA with
post-hoc Schee was conducted using Statistica
9 to test the signicance of the within prepost
and between-groups post scores dierences.
Eect size for a given variable was calculated
as the dierence after treatment between the
treatment and control condition divided by the
pooled standard deviation. The established criteria of the eect size, which reects the eect of
a treatment are small (0.200.49), medium
(0.500.79) and large (>80).20
Relationships between changes in measurement variables were assessed using Pearson
product moment correlations.

Out of 88 patients with schizophrenia, 64 met

the inclusion criteria. Reasons for exclusion are
presented in Figure 1. From the 32 patients who
where allocated to the progressive muscle relaxation, 27 (84%) completed the session and lled
out the questionnaires correctly. In the control
group, 26 patients (81%) lled out the questionnaires. One of these 26 reports contained incomplete data and was excluded from the nal
analysis. More details on drop-out data are
given in Figure 1.
The descriptive characteristics of the patients
who completed the intervention study are shown
in Table 1. Participants in the progressive muscle
relaxation and control condition were similar at
baseline related to age, gender, body mass index
and symptomatology.
The internal consistency assessed by
Cronbachs alpha coecients in the present
study was 0.90 for the State Anxiety Inventory,
and 0.78, 0.92 and 0.70 for respectively the subscales psychological stress, positive well-being
and fatigue on the Subjective Exercise
Experiences Scale. All Cronbachs alpha values
exceeded the commonly used criterion of 0.70,
which indicates acceptable internal consistency
of the measurements.
The results for all outcomes are presented in
Table 2. MANOVA showed a signicant time by
group interaction for the State Anxiety Inventory
and Subjective Exercise Experiences Scale (Wilks
 0.44, P < 0.001). Schee post-hoc analysis
revealed that within the progressive muscle relaxation group signicant decreased state anxiety,
psychological stress, fatigue and increased subjective well-being could be observed. There were no
signicant prepost changes within the control
group. Both groups diered signicantly from
each other for all the post measures.
Eect sizes for progressive muscle relaxation
were 1.25 (95% CI 1.83 to 0.63) for state
anxiety, 1.00 (95% CI 1.58 to 0.43) for

Vancampfort et al.

571

Assessed for eligibility

(n = 88)

Excluded
(n = 24)
Reasons: psychiatric comorbidity
(n = 6), previous experience with
progressive muscle relaxation
(n= 13), musculoskeletal problems
(n = 4), not able to concentrate for 25
minutes (n=1).

Allocated to progressive muscle

relaxation
(n= 32)
Received progressive muscle relaxation
(n= 27)
Did not receive allocated intervention
(n = 5)
Reasons: refused to participate (n = 1),
other appointment (n = 1), transfer to other
hospital (n = 1), not motivated to fill in the
questionnaires (n = 1), not motivated to
continue the session (n= 1)

Analysed
(n= 27)
Excluded from analysis
(n = 0)

Allocated to the control condition

(n = 32)
Received control condition
(n = 26)
Did not receive allocated intervention
(n = 6)
Reasons: refused to participate (n = 2),
other appointment (n= 2), transfer to
other hospital (n= 2)

Analysed
(n = 25)
Excluded from analysis
(n= 1)
Reason: incomplete data

Figure 1. Flowchart of the eligible patients.

psychological stress, +1.26 (95% CI 0.65 to

1.84) for subjective well-being and 0.46
(1.02 to 0.09) for fatigue.
Table 3 indicates that in the progressive
muscle relaxation group a reduction in state
anxiety was signicantly correlated with a psychological stress reduction and an increase in
subjective well-being.

Discussion
This is the rst study with a randomized controlled group design demonstrating signicant

eects of a single session of progressive muscle

relaxation on state anxiety, psychological stress
and subjective well-being in patients with schizophrenia. The ndings concur with previous progressive muscle relaxation studies investigating trait
anxiety reductions in schizophrenia9,10 and are consistent with prior reports in other populations.21,22
Results furthermore indicated that reduced
ratings of state anxiety are associated with
decreased psychological stress and increased
subjective well-being. This corresponds with earlier observed associations in schizophrenia
between subjective appraisals of anxiety, stress

572

Clinical Rehabilitation 25(6)

Table 1. Baseline characteristics of the participants who received progressive muscle relaxation or a control
condition

Gender
Male (%)
Female (%)
Age
Body mass index
Number of antipsychotics
PECC total score
Positive symptoms
Negative symptoms
Depressive symptoms
Excitement
Cognitive symptoms

Progressive muscle relaxation (n 27)

Control condition (n 25)

18 (66.67 %)
9 (33.33 %)
35.74  10.75
24.29  2.99
2.15  0.77
54.22  13.71
13.11  5.44
11.56  4.44
11.85  4.60
10.33  4.86
7.37  3.77

13 (52.00%)
12 (48.00%)
35.40  11.28
24.90  4.51
2.08  0.84
54.96  12.59
12.98  4.99
12.52  5.25
12.92  4.65
9.76  5.97
6.92  3.12

P-value
0.40

0.91
0.57
0.64
0.84
0.85
0.48
0.41
0.71
0.64

Values expressed as mean  standard deviation or as otherwise indicated.

PECC, Psychosis Evaluation tool for Common use by Caregivers.

Table 2. State anxiety, stress, well-being and fatigue scores before and after progressive muscle relation and control
condition

State anxiety (SAI)

Stress (SEES)
Well-being (SEES)
Fatigue (SEES)

Progressive muscle relaxation (n 27)

Control condition (n 25)

Pre

Post

Pre

Post

45.22  10.31
11.59  5.05
16.70  5.30
11.78  4.37

33.44  8.64a,b
7.48  3.57a,b
21.52  4.12a,b
8.58  3.74a,b

45.24  11.80
12.16  5.50
15.68  5.94
11.64  4.92

45.68  10.97
12.16  5.44
15.36  5.57
10.52  4.49

Values expressed as mean  standard deviation.

SAI, State Anxiety Inventory; SEES, Subjective Exercise Experiences Scale.
MANOVA with repeated measures, Sheffe test (P set at 0.05).
a
Pre versus post progressive muscle relaxation.
b
Post progressive muscle relaxation versus post control condition.

and concurrent mood (an increase in negative

and a decrease in positive aect).6
The present study provides support for the
utility of behavioural interventions such as progressive muscle relaxation in reducing state anxiety and increasing subjective well-being in
patients with schizophrenia. The ability to deal
with state anxiety, psychological stress and negative aect during progressive muscle relaxation
may of relevance for several other mental health
benets. The use of alcohol, nicotine or illegal

drugs is a common practice among individuals

with schizophrenia.2325 Although numerous
motivations exist to use these substances, it has
been suggested that the mentioned unhealthy
behaviours may partly be attempts to alleviate
or to cope with unpleasant aective states and
feelings of state anxiety.2628 The limited benet
of such eorts supports the need to provide
other more healthy methods to regulate the
variability of subjective well-being. This study
demonstrates that relaxation techniques may

Vancampfort et al.

573

Table 3. Pearson product moment correlation matrix

of the significant prepost difference effect sizes for State
Anxiety Inventory and Subjective Exercise Experiences
Scale in the progressive muscle relaxation group

State anxiety (SAI)

Stress (SEES)
Well-being (SEES)

merely as a diversion or as welcomed evidence

to patients that their psychosocial needs were
being acknowledged.

State
anxiety (SAI)

Stress
(SEES)

Well-being
(SEES)

Recommendations and implications

for future research

1.00
/
/

0.58*
1.00
/

0.47*
0.51*
1.00

Further studies need to replicate the present

ndings in a larger sample and with more
repeated measures.
Furthermore, future research needs to examine potential physiological (e.g. increased norepinephrine, serotonin and beta-endorphins,
increased parasympathetic activity)30 and/or
psychological mechanisms (e.g. increased selfecacy, distraction)31 that could be responsible
for the reduced state anxiety and psychological
stress and improved subjective well-being.
It also needs to be demonstrated if the benecial eects of progressive muscle relaxation can
be translated into behavioural outcomes, for
example through increasing rates of abstinence
from alcohol, nicotine or illegal drugs.
Specically, future studies should examine
whether implementing self-managed relaxation
techniques increases rates of abstinence from
substance abuse and whether any eects of progressive muscle relaxation on abstinence rates
are mediated by reductions in psychological
stress and state anxiety and increases in subjective well-being during or following these
activities.

*P < 0.05 (two-tailed).

SAI, State Anxiety Inventory; SEES, Subjective Exercise
Experiences Scale.

oer such an easy to learn healthy alternative for

subjective stress and state anxiety regulation.
The present results should be viewed in the
light of several methodological limitations.
No power analysis was completed prior to the
start of data collection. The sample size was
rather small and collected in a single hospital
which may aect the generalizability of the ndings. We also did not include parameters such as
illness duration or educational level in order to
increase the external validity. Secondly, the current study did not examine potential physiological and/or psychological mechanisms that are
responsible for the reduced state anxiety, psychological distress and improved subjective
well-being.
A third limitation was the lack of repeated
measures after the progressive muscle relaxation
session. Despite state anxiety reductions lasting
for 24 hours after cessation of the exercise,29
only the response immediately after the completion of the session was assessed. Fourth, state
anxiety and well-being responses only were measured with self-report questionnaires. Fifth, it
can be argued that the two habituation sessions
given before the intervention are actually part of
the intervention and their eects on the outcomes of the study need to be considered.
Even though these were habituation sessions,
the amount of time spent with a patient may
have been therapeutic in nature. Lastly, it is
not known whether the session of progressive
muscle relaxation may have exerted its eects

Recommendations and implications

for clinical practice
As progressive muscle relaxation has produced
very encouraging results in this study, it is suggested that progressive muscle relaxation should
be oered as routine care to patients with
schizophrenia experiencing state anxiety and
psychological stress. The present study indicates
that progressive muscle relaxation could already
be started in an acute inpatient care unit. This
echoes previous ndings suggesting that searching for a method of self-management is a powerful factor in the early stages of treatment.32

574

It may give the patients some increased sense of

self-control and autonomy during their stay in
hospital
Conclusively, progressive muscle relaxation is
highly eective in reducing state anxiety along
with reducing psychological stress and improving subjective well-being in patients with schizophrenia. Acute changes could be obtained
already after two habituation sessions.
Progressive muscle relaxation should therefore
be recommended as routine care to patients
with schizophrenia in acute inpatient units

Clinical messages
. Progressive muscle relaxation reduces
state anxiety and psychological stress
and improves subjective well-being in
patients with schizophrenia.
. Acute changes could already be obtained
after two habituation sessions.

Funding
This research received no specic grant from any
funding agency in the public, commercial, or notfor-prot sectors.

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