Title: Cognitive attention redirection preparatory techniques, coping style, and adults' adjustment to periodontal surgery
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Title: Cognitive attention redirection preparatory techniques, coping style, and adults' adjustment to periodontal surgery
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Language: English
Creator: Dearborn, Mitzi June, 1955-
Copyright Date: 1982
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COGNITIVE ATTENTION REDIRECTION PREPARATORY TECHNIQUES,
COPING STYLE, AND ADULTS' ADJUSTMENT TO PERIODONTAL SURGERY







BY

MITZI JUNE DEARBORN


A DISSERTATION PRESENTED TO THE GRADUATE COUNCIL
OF THE UNIVERSITY OF FLORIDA IN
PARTIAL FULFILLMENT OF THE REQUIREMENTS
FOR THE DEGREE OF DOCTOR OF PHILOSOPHY


UNIVERSITY OF FLORIDA


1982















ACKNOWLEDGEMENTS


I wish to extend my deep appreciation to each of the five members

of my committee. Dr. Barbara Melamed, Dr. Cynthia Belar, Dr. Wallace

Mealiea, Dr. Randy Carter, and Dr. Warren Rice each provided constructive

thought-provoking feedback and continuous support in the development,

implementation, and evaluation of this doctoral research. I am especially

grateful to my chairperson, Dr. Barbara Melamed, who provided endless

encouragement, enthusiasm, wisdom, and guidance.

I extend my gratitude to the members of the University of Florida

Periodontal Clinic. I wish to thank Dr. Samuel Low, whose cooperation

and dental expertise contributed substantially in the development of

materials and in the effective implementation of this study. Thanks

are extended to Dr. Frank Collins, Jerilynn Stillwell, and the entire

staff of the Periodontal Clinic for their cooperation and assistance.

In addition, I appreciate the time and effort provided by Steven

Karashik and Jeff Stenback, who served as undergraduate research

assistants and assisted with data collection. I am grateful to Dr. James

Hastings, who provided encouragement and assistance during my internship

year in Milwaukee, Wisconsin. Special thanks are extended to my fiance,

Rick Miller, who consistently showed patience, understanding and

helpfulness.
















TABLE OF CONTENTS

Page
ACKNOWLEDGEMENTS . . . . . . . . . . . ii

ABSTRACT . . . . . . . . . . . . . .

INTRODUCTION . . . . . . . . . ... ..... 1

Major Theoretical Paradigms . . . . . . . . 4
Applications of Cognitive Attention Redirection
Training with Surgical Patients . . . . . .. 10
Psychological Subject Variables . . . . . . .. 15
Statement of the Problem. . . . . . . . . 24

METHOD . . . . . . . . . . . . . . 30

Subjects. ... . . . . . .. ....... 30
Materials. . . . . . . .. . ... . 30
Procedure . . . . . . . . . . .. . 39

RESULTS ..... . . . . . . . . . 45

Group Equivalence and Manipulation Validity Check . . .. 45
Analyses . . . . . . . . . . . . .. 47
Physiological Measures . . . . . . . . .. 50
Self-Reported Anxiety . . . . . . . . . . 56
Behavioral Measures . . . . . . . . . . 61
Patients' Ratings of Surgery and Recovery Experiences . 65
Postoperative Recovery Measures . . . . . . .. 66

DISCUSSION . . . . . . . . . . . . .. 76

Effects of Treatment. . . . . . . .. . . 76
Effects of R-S . . . . . . . . . . 78
Effects of Previous Experience . . . . . . .. 80
Effects of Other Psychological Subject Variables . . .. 81
Methodological Issues and Implications for Future
Research . . . . . . . . . . . 83
Concluding Statement .... . . . . . . 86

APPENDICES

A--Cognitive Attention Redirection Taped Coping
Instructions . . . . . . . . . . .. 87









Page
B--Taped Practice Session for Cognitive Coping
Instructions . . . . . . . . ... ... .90
C--Patient's Consent Form . . . . . . . . 92
D--A-State State-Trait Anxiety Inventory . . . ... 93
E--Ten-Point Rating of Anxiety . . . . . . .. 95
F--Modified R-S Scale . . . . . . . ... . 96
G--Patient Questionnaire . . . . . . . .. . 98
H--Focus and Clarity of Images Scale . . . . . .. 101
I--Ease of Pleasant Imagery Practice Rating . . . .. 102
J--Operating Room Behavioral Measure . . . . .... 103
K--Postsurgery Patient Questionnaire . . . . .... 104
L--Patient's Daily Ratings . . . . . . . .. 106
M--Surgical Procedure Data Sheet . . . . . . .. 108
N--Surgeon's Ratings of Patient Behavior . . . ... 109
0--One Week Follow-Up Questions . . . . . . .. 110
P--Surgeon's Ratings of Healing and Swelling . . . .. 111
Q--Training Instruction Procedure . . . . . .... 112
R--Mean Square, F, and Significance Values Obtained From
Analyses of Variance and Covariance . . . . .. 115

REFERENCE NOTES . . . . . . . . ... .... .130

REFERENCES . . . . . . . . . . . . . 131

BIOGRAPHICAL SKETCH . . . . . . . .... .... 135















Abstract of Dissertation Presented to the Graduate Council
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy


COGNITIVE ATTENTION REDIRECTION PREPARATORY TECHNIQUES,
COPING STYLE, AND ADULTS' ADJUSTMENT TO PERIODONTAL SURGERY


By

Mitzi June Dearborn

December 1982


Chairperson: Barbara G. Melamed, Ph.D.
Major Department: Clinical Psychology


For the adult patient anticipating surgery, psychological pre-

operative preparations have been useful in reducing emotional distress

and facilitating recovery. This study investigated the effectiveness

of cognitive attention redirection preoperative preparatory training and

differential treatment effects for coping style. Hypotheses were

1) training facilitates patients' adjustment and recovery and 2) repressors

benefit more from training than sensitizers. The effects of previous

experience, pain expectation, activity interference expectation, and

perceived responsibility for health recovery were considered.

Subjects were 33 adults scheduled for periodontal surgery at the

University of Florida Dental Clinic. These premanipulation measures

were taken: heart rate, Palmar Sweat Index (PSI), A-State State-Trait

Anxiety Inventory, Epstein-Fenz Modified R-S Scale, and ratings of









expected pain, activity interference, and recovery responsibility.

Trained subjects received 15 minutes of cognitive attention redirection

training, which provided instructions and practice in thinking about

pleasant situations to reduce stress. Control group subjects were un-

instructed during a comparable 15 minute period. Several additional

measures of heart rate, PSI, and A-State anxiety were taken.

Other adjustment and recovery measures included patients' operator

behaviors, ratings of surgical/postsurgical experiences, daily recovery

ratings, and surgeon's ratings of patient behavior and healing/swelling.

Data were analyzed using analyses of variance and covariance.

Findings did support the hypothesis that training facilitates

adjustment and recovery. Trained subjects showed significantly lower

heart rates immediately before, during, and following surgery, as com-

pared with controls. When the effects of experience, pain expectation,

and recovery responsibility were considered, further effects of training

were found. For those with experience, trained subjects showed signifi-

cantly fewer repetitive movements than controls. For subjects with low

recovery responsibility or high pain expectation, training tended to

reduce postoperative sleeping and eating interference. Contrary to

predicted hypotheses, effects of treatment did not change with coping

style. Main effects of R-S and experience were obtained. Sensitizers

and experienced subjects showed poorer adjustment and recovery than

repressors and inexperienced subjects, with significant differences for

behavioral and self-reported anxiety measures. When subjects had both a

sensitizing style and experience, their recovery and adjustment were

impeded further.
















INTRODUCTION


For the adult patient anticipating elective surgical procedures,

upcoming surgery can be both threatening and stressful. In the presence

of such psychological stress preoperative psychological preparation

becomes particularly important. Adequate psychological preparation for

surgery may reduce emotional distress and facilitate postoperative

recovery. However, it is not accurate to assume that all psychological

preparations are equally effective. Therefore, it is important to

carefully determine what preparations are most effective in reducing

distress for surgical patients.

In a careful review of the literature, Dearborn (Note 1) evaluated

preparatory components of psychological preparation which facilitate

the reduction of adult patients' psychological distress associated with

surgery. A variety of psychological preparations have been used with

adult surgical patients, and these have been classified into three

major types/categories: preparatory information, supportive preparation,

and preparatory cognitive coping techniques. When the results of 35

studies of psychological surgical preparations were compared, findings

indicated that preparatory information and preparatory cognitive coping

techniques appeared most effective in reducing psychological distress

associated with surgery; results from research with supportive prepa-

rations were unclear and inconsistent, with numerous methodological

difficulties.







2


Although preparatory information and preparatory cognitive coping

techniques were found to be most effective, it is not the case that

every type of preparatory information and every type of preparatory

cognitive coping technique facilitated adjustment and postoperative

recovery. When the effectiveness of several types of preparatory

information given prior to both surgical and nonsurgical medical pro-

cedures was compared, findings strongly indicated that providing

information about sensations which will be experienced during the

procedure is significantly more effective in reducing distress than

providing procedural information (Fuller et al., 1978; Johnson, 1972;

Johnson & Leventhal, 1974; Johnson et al., 1978). Findings also con-

sistently indicated that providing frequent preexposure to visual or

verbal presentations of medical procedures without associated pain is

significantly more effective than no preexposure, such that physiologi-

cal,self-report, and behavioral measures of distress decreased as a

function of increased frequency of preexposure (Shipley et al., 1977,

1978, 1979; Vernon & Bigelow, 1974).

When research which investigated the effectiveness of relaxation

training, hypnotic techniques, and cognitive attention redirection as

cognitive coping preparation for surgical patients was reviewed, find-

ings supported the effectiveness of cognitive attention redirection as

compared with controls (Kendall et al., 1979; Langer, Janis, & Wolfer,

1975; Pickett & Clum, Note 2). Findings for the effectiveness of

relaxation training and hypnotic techniques were inconclusive, and many

studies were limited by methodological difficulties. It should be noted

that although the effectiveness of cognitive attention redirection









strategies was most clearly supported, two other studies (Cohen, 1976;

Lucas, 1976) indicated only limited effectiveness of cognitive attention

redirection preparation. The composite of these results suggests that

additional research which investigates the effectiveness of cognitive

attention redirection preparation for surgical patients will be par-

ticularly useful.

In addition to indicating that sensory descriptive information,

frequent informational preexposure, and cognitive attention redirection

techniques were most effective as preparations in facilitating adult

patients' adjustment to surgery and other nonsurgical stressful medical

procedures, Dearborn's (Note 1) review also found that psychological

subject variables influenced the effectiveness of preparation. Some-

times psychological subject variables, such as preoperative anxiety

level, locus of control, and coping style, interacted with the type of

psychological preparation to produce differential effectiveness in the

reduction of distress. Of these three variables, coping style has most

frequently been found to interact with type of surgery preparation.

For example, Shipley et al. (1978) reported a significant interaction

between an information preparation (frequency of informational pre-

exposure) and coping style. Shipley et al. (1978) reported that

sensitizers showed a monotonic decrease in heart rate as a function of

number of informational tape preexposures, whereas repressors showed an

inverted U-shaped function in which one viewing produced the highest

heart rate. These findings suggest that it will be important to con-

sider psychological subject variables in the search to identify effective

preparations for adult patients scheduled for surgical procedures.










In the present research it is of primary interest to further in-

vestigate the preparatory effectiveness of cognitive attention redirection

techniques in facilitating adjustment to surgery by studying adult

patients scheduled to undergo periodontal surgery. Psychological subject

variables, including preoperative anxiety, locus of control, and coping

style, will be considered, and the interaction effects between prepara-

tion and coping style will be of particular interest. First, it is

important to gain a better understanding of cognitive attention re-

direction coping strategies and the influence of psychological subject

variables in effectively preparing adult surgical patients. Therefore,

further examination of these three areas will be helpful: major

theoretical paradigms of surgical preparation, applications of cognitive

attention redirection training with surgical patients, and the role of

psychological subject variables.


Major Theoretical Paradigms


Two major theoretical paradigms have frequently been employed as

conceptual frameworks in the preparation of surgical patients. These

paradigms have been referred to as 1) the fear drive model and 2) the

parallel response model (Leventhal, 1970). Cognitive coping prepara-

tions, such as attention redirection, appear most consistent with the

second model.


Fear Drive Model

In the fear drive model an emotional fear reaction in a threatening

situation acts as a drive to perform instrumental behaviors which will









reduce the emotional activity. In this model attitude change and

behavior change is mediated by the fear response, such that instru-

mental changes occur as a direct result of the fear response. These

instrumental changes may include a wide variety of fear reducing

behaviors, which may either facilitate or disrupt effective adjustment

during a threatening situation.

Janis (1958) applied the fear drive model to the preparation of

surgical patients. According to Janis (1958) preoperative fear stimu-

lates psychological preparatory "work of worrying," which permits the

patient to adaptively reflect over the upcoming stressful situation.

Through preparatory "work of worrying" patients with a moderate level

of fear would have fewer postoperative emotional and behavioral problems,

as compared with low and high fear patients. Since a moderate level of

preoperative fear was considered most adaptive, Janis (1958) also pro-

posed that preparatory information and instructions would be most

effective with low or moderate preoperative fear prior to preparation.

On the other hand high fear patients would not benefit from preparatory

information because the high levels of fear would interfere with infor-

mation acceptance.

Janis' hypotheses were based upon findings of two research

projects: 1) a study of 22 surgical patients who were intensively inter-

viewed and observed pre-andpostoperatively and 2) a survey of 150 male

college students who remembered experiencing surgery within the previous

five years. Findings of his research identified a significant curvi-

linear relationship between preoperative fear and postoperative adjust-

ment. Patients with moderate fear showed better postoperative









adjustment, as compared with patients having high or low preoperative

fear. However, methodological difficulties may bias Janis' results.

First, his findings are based upon correlational data. Second, patients

with high fear were characterized by excessively high fear behavior,

which often included crying, insomnia, and requests to postpone

surgery. Third, in the survey of 150 students, surgical information

was provided retrospectively, and it was subject to errors of recall

(both intentional and unintentional distortions).

In recent research (Rinzler, 1978; Schuster, 1979; Sime, 1976;

Vernon & Bigelow, 1974; Wolfer & Davis, 1970) which has investigated

the relationship between fear/anxiety and postoperative adjustment, the

curvilinear relationship hypothesized by Janis (1958) has not been

supported. For Rinzler's (1978) cholecystectomy patients, Vernon and

Bigelow's (1974) herniorrhaphy patients, and Wolfer and Davis' (1970)

major abdominal surgery patients, preoperative state anxiety was

essentially unrelated to postoperative adjustment. Only Schuster (1979)

obtained a curvilinear relationship similar to Janis' for one measure

of postoperative recovery. When Schuster (1979) measured state anxiety

in 35 patients scheduled for cardiac surgery, he found that patients

with high or low anxiety levels had significantly more postoperative

psychological disturbance, as compared with moderately anxious patients.

But, for a different measure-postoperative hospitalization, Schuster

(1979) found a linear relationship between preoperative anxiety and

postoperative recovery. Patients with high anxiety spent significantly

more days hospitalized than low or moderately anxious patients.










Similarly, Sime (1976) also found a significant linear relation-

ship between preoperative fear and postoperative recovery. Again this

linear relationship is contrasted with Janis' (1958) hypothesized

curvilinear relationship. When Sime (1976) studied 57 women undergoing

abdominal surgery, she found that patients with high preoperative fear

had significantly longer recovery, more analgesics and sedatives, and

higher levels of preoperative negative affect. A linear relationship

between preoperative fear and postoperative adjustment was also reported

by Johnson et al. (1970). In sum, the composite of these findings has

not supported the fear drive model for conceptualizing adjustment to

surgery.


Parallel Response Model

Another model called the parallel response model has been derived

by Leventhal (1970). This model has received more consistent support

than the fear drive model, and it is of particular interest because

this model supports the usefulness of identifying new coping responses

(such as cognitive attention redirection strategies) for an individual

so that he/she may cope more effectively in a threatening situation.

In the parallel response model, adaptive instrumental behavior under

threatening conditions is not necessarily preceded by fearful emotional

responses, since emotional responses and adaptation do not cause one

another. Both emotional and adaptive behaviors are consequences of

environmental stimuli, and the nature of these emotional and adaptive

behaviors is mediated by cognitive processes, in which external stimuli,

internal cues, and the individual's coping repertoire are evaluated.

In a threatening situation instrumental actions may serve to reduce









emotional behavior (fear control), or they may serve to reduce objective

threat (danger control). In contrast to the fear drive model, emotional

fear responses are not required in order for adaptive instrumental

actions to occur. In a study of 62 female surgical patients, Johnson

et al. (1971) reported findings which are consistent with the parallel

response model; they found that measures of the patients' emotional

responses were uncorrelated with indices of danger controlling actions

related to their recovery. These findings support an independent

relationship between emotional fear responses and adaptive actions.

Similar to Leventhal (1970), Lazarus (1977) also opposes a view in

which emotions serve as drives or motives for adaptive behavior.

According to Lazarus (1966, 1975, 1977) cognitive appraisal mediates

both emotional reactions and coping actions by intervening between

stimulus and response. An individual's cognitive appraisal of a

threatening situation may be affected by environmental characteristics,

personality disposition, and beliefs about available coping abilities.

If a person's cognitive appraisal changes, then subsequent emotional

responses and coping actions also will change. This has important

implications in preparing individuals for stressful situations, since

facilitating changes in cognitive appraisal will influence his/her

emotional reactions and coping actions. Changes in cognitive appraisal

may develop 1) by providing new information which suggests that the

situation is less threatening or 2) by providing new coping strategies

with which to deal with the threatening situations. Studies which have

taught subjects cognitive attention redirection coping strategies with

which to deal with threatening situations are of particular interest here.









In laboratory studies (Chaves & Barber, 1974; Turk, Note 3)

cognitive attention redirection coping strategies, in which a subject

is trained to redirect his/her attention or reinterpret the stressful

situation, have been utilized effectively for reduction of pain.

Chaves and Barber (1974) instructed subjects to imagine pleasant events

or imagine insensitivity to reduce pain. The exact nature of these

pleasant events was determined by each subject individually. Subjects

who used these cognitive attention redirection strategies made signifi-

cantly lower pain ratings, as compared with the no treatment control

and the placebo treatment group, who were told to expect pain reduction

but not given coping strategy instruction. To reduce ischemic pain

Turk (Note 3) employed a stress innoculation procedure (Meichenbaum,

1977; Meichenbaum & Turk, 1976), in which each subject was taught

three cognitive attention redirection strategies. These three

strategies were focusing on other things in the room, focusing on

bodily processes, and focusing on more pleasant images. Each subject

was permitted to vary his use of these cognitive attention redirection

strategies according to his individual preference. Results showed

that all subjects were able to tolerate pain significantly longer after

training, as compared with pretreatment pain tolerance. Similar cognitive

attention redirection coping strategies have also been taught to surgical

patients in order to facilitate coping associated with better adjustment

and recovery.









Applications of Cognitive Attention Redirection
Training with Surgical Patients


Several researchers (Cohen, 1976; Kendall et al., 1979; Langer

et al., 1975; Lucas, 1976; Pickett & Clum, Note 2) have investigated

the usefulness of cognitive attention redirection coping strategies as

preparation for patients undergoing surgical procedures. Pickett and

Clum (Note 2) found that cholecystectomy patients who received attention

redirection training presented significantly less postoperative self-

reported anxiety, as compared with relaxation training patients or con-

trol group patients. In this study attention redirection training

consisted of training patients to imagine themselves avoiding the

situation of surgery and related events. Although attention redirection

significantly reduced anxiety, no significant differences between treat-

ment groups were reported for the McGill Pain Questionnaire pain rating

index taken four days postoperatively. Only one significant difference

in pain was reported: attention redirection treatment yielded signifi-

cantly lower "worst pain" measures, as compared with controls. A signi-

ficant interaction between treatment and locus of control was also

reported for measures of postoperative anxiety. For attention re-

direction subjects, those with an internal locus of control reported

significantly less postoperative anxiety as compared with those having

external locus of control.

Pickett and Clum's (Note 2) findings do indicate that cognitive

attention redirection is a useful strategy for reduction of postoperative

anxiety in cholecystectomy patients. However, it has been suggested that

measurement of postoperative pain at the fourth postoperative day may be









too long after surgery to find sufficient variation in pain levels.

Also, because an interaction between locus of control and treatment

(with attention redirection preparation internals having significantly

less anxiety than externals) was found and the sample population was

skewed toward an internal locus of control, the authors suggested that

the sample skew may have enhanced the effectiveness of attention re-

direction.

Further support for the effectiveness of cognitive attention re-

direction preparation with surgery patients was provided by Langer et al.

(1975) and Kendall et al. (1979), who compared cognitive attention

redirection with informative preparation. In the study by Langer et al.

(1975), 60 patients undergoing a variety of elective surgeries, in-

cluding hysterectomy, herniorrhaphy, cholecystectomy, tubal ligations,

transuretheral resections, and D & C's, were randomly assigned to one

of four groups: attention redirection coping device in which patients

were trained to distract themselves from negative aspects of surgery

and to focus on positive aspects instead, preparatory information only,

combination of preparatory information and attention redirection, or

a neutral control group in which the patient was interviewed but

questions were unrelated to the patient's fears about upcoming surgery.

Experimental groups were equated on type of operation, seriousness of

surgery, age, sex and religious affiliation. Significant main effects

for coping attention redirection communications were found with

measures of post-preparation stress/anxiety rated by the nurses and

postoperative recovery indicated by the number of pain relievers and

sedatives requested by the patient. Attention redirection patients










showed less anxiety/stress following preparation and requested fewer

medications postoperatively, as compared with patients receiving

preparatory information only or neutral interview. In addition, there

was a nonsignificant trend for coping attention redirection strategy

to reduce length of hospitalization.

In the study by Kendall et al. (1979) a cognitive attention re-

direction preparation, referred to as the cognitive-behavioral inter-

vention, consisted of training male veteran cardiac catheterization

patients to identify stress-related cues and to utilize stress-

reduction coping strategies which had been useful for the patient in

the past. The experimenter assisted the patient in identifying

strategies with which to relabel and reinterpret stressful experiences,

and the experimenter served as a coping model who related a personal

stressful experience in which a cognitive coping strategy was used

effectively. Kendall et al. (1979) included three additional treatment

groups: a patient education group which received information about the

heart and catheterization procedures, an attention placebo control

group which consisted of a nondirective general interview exclusive of

material related to patient education training or coping skills,-and

a current hospital conditions control group which received only a

standard description of the procedure with no special intervention.

Both the informative preparation group and the cognitive-behavioral

attention redirection group were significantly less anxious (A-State

STAI) post-preparation and postoperatively, and they received signifi-

cantly higher physician adjustment ratings during surgery as compared

with control groups. At the same time the cognitive redirection

preparation was superior to the informative preparation.









Although findings by Pickett and Clum (Note 2), Langer et al.

(1975), and Kendall et al. (1979) have supported the effectiveness of

cognitive attention redirection in reducing distress associated with

surgery, studies by Cohen (1976) and Lucas (1976) have indicated only

limited support for the usefulness of cognitive attention redirection

as preparation for surgical patients. Findings were mixed in one study

and negative in the other. In Cohen's (1976) study, cholecystectomy

and herniorrhaphy patients were given cognitive coping training (con-

sisting of redirection of attention to more pleasant things and

thinking positively), instruction in deep breathing and moving, or

reassurance about postoperative recovery (control group). Only weak

treatment effects were reported with control group subjects staying in

the hospital longer than attention redirection subjects; at the same

time more "negative psychological reactions" were reported for attention

redirection subjects. In Lucas' (1976) research with heart surgery

patients, medical measures of recovery for attention redirection sub-

jects were compared with attention placebo and no treatment controls.

No significant differences were reported, but attention redirection

subjects tended to show better recovery, as compared with controls.

In summary, findings from studies with cognitive attention re-

direction generally support the usefulness of cognitive attention

redirection preparations in reducing distress of surgical patients,

but positive findings were not consistently reported. Differences

between studies may have occurred because of different methodologies

between studies. Studies differed in the measurement instruments

which were employed. Various measures were used, including self-report










questionnaires of pain and anxiety, observer ratings of anxiety/

adjustment, heart rate, and medical recovery indices, such as length

of hospitalization, minor complications, and amount of medication.

Typically each study included only a few measures with only minimal

overlap between studies. For example, each study utilized a different

measure of anxiety, and only Kendall et al. (1979) utilized the A-State

Spielberger State-Trait Anxiety Inventory (STAI) which has frequently

been used in surgery research as a measure of self-reported situational

anxiety. Studies also differed in attention redirection instructions;

between studies instructions varied in content, which included thoughts

about generally pleasant things, making future plans, imaginary avoid-

ing of surgery, relabeling experiences and cognitive coping models.

Also, different studies used different populations of surgical patients,

and variables such as previous experience with the surgical procedure

were not adequately investigated. For example, the study by Kendall

et al. (1979) included many patients who had been previously hospitalized

for catheterization procedures. Important effects of previous experience

have been noted in studies of surgical preparation with children

(Melamed & Siegel, 1980), which may also be similar for adults.

Future studies are needed to further investigate the effectiveness

of cognitive attention redirection coping strategies in preparing

patients for surgery. Measurement instruments should be selected in

order to provide measures of three systems (Lang, 1968): behavioral,

self-report, and physiological. Furthermore, reliable and valid in-

struments which are frequently utilized in surgical preparation research

should be employed to facilitate comparison between studies. The effects









of previous experience should be assessed. Also, in future studies it

may be important to consider psychological variables, such as coping

style, locus of control, and anxiety level.


Psychological Subject Variables


George et al. (1980) showed that psychological variables were

significant predictors of postoperative pain, interference with usual

behaviors (sleeping, eating, and daily activities), and healing.

When the effect of physical trauma was controlled for, higher levels

of overall pain were significantly correlated with subjects' expecta-

tions of a greater amount of pain, higher levels of anxiety about

recovery, and more vigilant coping behaviors. These psychological

variables accounted for 27% of the variance in overall pain. When the

effect of physical trauma was again controlled for, greater overall

interference was significantly correlated with expectations about

amount of interference, anxiety, vigilant coping behaviors, and internal

locus of control. These variables accounted for 40% of the variance.

Controlling for the effect of trauma, slower overall healing was signi-

ficantly correlated with amount of pain expected, vigilant coping, and

internal locus of control, which accounted for 36% of the variance.

Findings indicated that both psychological variables and physical

trauma may assist in prediction of postoperative recovery. Expectations/

anxiety about recovery (physical trauma was second) most consistently

accounted for the greatest portion of the variance in recovery

measures, as compared with other psychological factors. George et al.

(1980) suggested that psychological measures of anxiety, locus of









control, and coping behaviors might be utilized to identify patients

who were high risk for poorer adjustment and therefore in greater need

of psychological preparation prior to surgery. High risk patients

appear to be those with high anxiety, vigilant coping behavior, or an

internal locus of control.


Relationships Between Psychological Variables and Recovery

Studies involving other types of surgery have also investigated

the relationship between patients' postoperative recovery and pre-

operative anxiety or coping style. Findings have generally supported

high positive correlations between recovery and nonvigilant coping

style but mixed findings have been reported for the relationship

between recovery and preoperative anxiety. As previously indicated,

high preoperative anxiety has been highly correlated with poor recovery

in some studies (Janis, 1958; Schuster, 1979; Sime, 1976) but no

significant relationship has been found in others (Rinzler, 1978;

Schuster, 1979; Vernon & Bigelow, 1974; Wolfer & Davis, 1970).

Several researchers (Abram & Gill, 1961; Boyd et al., 1973; Cohen,

1976; Cohen & Lazarus, 1973; Miller et al., Note 4) have investigated the

relationship between coping style and postoperative recovery. Types

of coping responses vary along a continuum, having avoidance and

vigilance as endpoints. Avoidance involves psychological retreat from

threat, whereas vigilance involves a preference to approach threat more

directly. Since the Byrne Repression-Sensitization Scale (Byrne, 1961;

Byrne et al., 1963) has often been utilized to measure coping style,

repressor (nonvigilant) and sensitizer (vigilant) labels shall be

employed here.









Results reported by Cohen (1976), Cohen and Lazarus (1973), and

Miller et al. (Note 4) indicated that sensitizers show poorer post-

operative adjustment and slower recovery. For 158 herniorrhaphy and

cholecystectomy patients with no preoperative intervention, Cohen

(1976) reported that sensitizers showed a more complicated recovery

postoperatively. In the study by Cohen and Lazarus (1973) coping style

was determined for herniorrhaphy, thyroidectomy, and cholecystectomy

patients. Cohen and Lazarus (1973) reported statistically significant

differences bewteen coping groups: sensitizers required significantly

longer hospitalization and showed significantly more minor complications,

as compared with repressors. For patients undergoing colposcopy, which

is a less stressful nonsurgical gynecological procedure, Miller et al.

(Note 4) found that sensitizers had significantly greater depression

before colposcopy and significantly greater muscular tension during

colposcopy.

On the other hand results obtained from research by Boyd et al.

(1973) and Abram and Gill (1961) indicated that repressors show poorer

postoperative adjustment and recovery. For 27 male patients undergoing

reconstructive vascular surgery, Boyd et al. (1973) found that patients

who utilized a repressive coping style had poorer adjustment six months

postoperatively, as compared with sensitizers; however, results of

statistical analyses were not provided. Abram and Gill (1961) findings

of increased postoperative disturbance for repressors, as compared with

sensitizers, approached significance (p<.07). However, these findings

do not provide strong support for the superiority of the sensitizing

coping style, particularly in view of methodological difficulties in









the Boyd et al. (1973) study. The composite results of all five

studies generally indicate that persons with repressive coping styles

show better adjustment to stressful medical procedures, as compared

with those with sensitizing coping style; this conclusion is con-

sistent with findings by George et al. (1980) with dental surgery

patients.


Interaction Between Psychological Variables and Preparation

George et al. (1980) have suggested that patients with high

anxiety, vigilant coping behaviors, and internal locus of control may

benefit most from psychological preparation prior to surgery. Since

all psychological preparations are not equally effective for every

patient, it is important to determine which preparations are most

effective for patients with particular preoperative psychological

characteristics. Interactions between these psychological subject

variables and informational preparation have been frequently reported;

however, little information is available about the interaction between

these variables and cognitive attention redirection coping preparations

in facilitating adjustment and recovery from surgery.

For the variable preoperative anxiety, Johnson et al. (1978) and

Sime (1976) found a significant interaction between preoperative fear/

anxiety and preparatory information for measures of postoperative

recovery. Johnson et al. (1978) reported that high fear cholecystectomy

patients who received preparatory information showed significantly

less postoperative anger, as compared with controls. No significant

mood differences between treatment groups were found for patients with

low fear. Sime (1976) also found a significant interaction between










preoperative fear and preparatory information for measures of post-

operative recovery. She reported that patients with high fear who

obtained a large amount of information had significantly fewer

analgesics, sedatives, and days to discharge, as compared with high

fear patients with little information. Whereas, moderate fear patients

with a larger amount of information required significantly longer

hospitalization, as compared with moderate fear patients with little

information. Findings from both studies suggest that providing

additional preparatory information to patients with high fear results

in significantly improved recovery. For patients with moderate fear,

providing very little preoperative information appears most beneficial.

For the variable locus of control, the interaction between locus

of control and two types of psychological preparation have been investi-

gated (Auerbach et al., 1976; Pickett & Clum, Note 2). Locus of con-

trol is a measure of the extent to which a person perceives personal

control over events. Based upon the scores obtained with the scale, a

person may be classified as being internally oriented or externally

oriented. A person with an internal locus of control would perceive

events primarily as a function of his own actions. On the other hand

a person with an external locus of control would perceive events as

being unrelated to his actions.

Auerbach et al. (1976) investigated the interaction between locus

of control and type of preparatory information for patients' adjustment

to dental extraction surgery. Half of the patients were given general

information about the dental clinic and equipment, and half were given

specific information about the upcoming surgical procedure. Locus of









control was determined by administering Rotter's Internal-External Locus

of Control Scale postoperatively. Auerbach et al. (1976) reported a

significant interaction between type of information and locus of con-

trol. Internal locus of control patients who received specific infor-

mation obtained significantly higher ratings of adjustment made by the

dentist, as compared with internals who received general information.

Whereas external locus of control subjects with specific information

showed significantly poorer adjustment than externals with general

information. These findings emphasize the importance of locus of

control as a psychological subject variable which may influence the

effectiveness of preparatory information.

Pickett and Clum (Note 2) investigated the interaction between

locus of control and type of cognitive preparation. Locus of control

was assessed for a group of predominantly female cholecystectomy

patients, and patients scores were grouped into internal, middle, and

external ranges. A significant interaction between locus of control

and cognitive coping preparation was reported for postoperative state

anxiety measured by the Present Affect Reactions Questionnaire. For

the attention redirection group a linear relationship was found between

I-E scores and anxiety, such that patients with an internal locus of

control reported the least postoperative anxiety and externals reported

the most postoperative anxiety. For the relaxation training group a

curvilinear relationship was found, such that patients with mid-range

I-E scores reported the highest postoperative anxiety. A trend for

significant interaction between locus of control and cognitive coping

preparation was also found for postoperative pain rating scores;









for pain ratings linear and curvilinear relationships,comparable to

those reported for postoperative anxiety, were found. To summarize

Pickett and Clum's (Note 2) findings, cognitive attention redirection

training appears most effective to patients with an internal locus of

control and least effective for externals; relaxation training appear

effective for both internals and externals but not for mid-range I-E

patients.

For the variable coping style, research findings (Andrew, 1970;

DeLong, 1971; Shipley et al., 1978, 1979; Miller et al., Note 4) have

indicated an interactive effect between coping style and preoperative

preparatory information. Andrew (1970) and Miller et al. (Note 4)

reported a significant interaction between coping style and pre-

operative preparatory information versus no preparatory information.

For 50 primarily herniorrhaphy patients, Andrew (1970) reported that

1) repressors with preparatory information required significantly more

medication than nonprepared repressors and 2) no significant differ-

ences between sensitizers with or without preparatory information.

For women undergoing colposcopy, a nonsurgical diagnostic procedure,

Miller et al. (Note 4) found that 1) sensitizers without preparatory

information showed significantly higher sustained pulse rate than pre-

pared sensitizers and 2) repressors with preparatory information showed

significantly higher sustained pulse rate than nonprepared repressors.

(Higher sustained pulse rate was interpreted as an indication of higher

anxiety.) DeLong (1971) investigated the interaction between coping

style and specific versus general information with female patients

undergoing either hysterectomy or cholecystectomy. She reported that










1) repressors who were given specific information had significantly

more complaints, as compared with repressors who were given general

information and 2) sensitizers who were given specific information

complained less than sensitizers who were given general information.

Findings from these three studies suggested that increased preparatory

information with specific details of surgery improves adjustment and

recovery for sensitizers, whereas the same preparatory information

retards adjustment and recovery for repressors.

Shipley and associates (1977, 1978, 1979) also investigated the

interaction between coping style and frequency of informational pre-

exposure for patients scheduled to undergo endoscopy. Several effects

were seen with different measures of adjustment. The clearest inter-

action of coping style with frequency of informative preexposure was

found for heart rate measures during the first five minutes of scoping.

In the study of subjects with no previous experience, Shipley et al.

(1978) reported that sensitizers showed a monotonic decrease in heart

rate as a function of number of taped exposures, whereas repressors

showed an inverted U-shaped function in which one viewing produced the

highest heart rate. In the second study (Shipley et al., 1979), which

included only subjects with previous experience, sensitizers again

showed a monotonic decrease in heart rate as a function of number of

taped exposures, whereas repressors showed a monotonic increase as a

function of number of taped exposures. For other measures of sensitizers'

adjustment, interaction results supported a monotonic increase in adjust-

ment as a function of number of taped exposures, which is consistent

with heart rate data. But, for other measures of repressors' adjustment,










findings did not support a consistent relationship between adjustment

and taped exposures. In sum, findings for sensitizers consistently

indicated that increased preexposure reduces distress; however, findings

for repressors have been less clear with greater inconsistencies.

Results of these five studies show the importance of investigating

interaction effects between coping style and preoperative preparatory

techniques. The composite of these findings suggests that increased

preparatory information with frequent preexposure and specific details

of surgery improves adjustment and recovery for sensitizers, whereas

the same preparatory information retards adjustment and recovery for

repressors. But, it must be remembered that findings regarding the

interaction between coping style and preparation are complex. These

complexities are not easily explained. They may be related to measure-

ment issues or to differences in previous experience. Also, to better

understand results, it sometimes may be useful to consider sensitizer-

repressor response differences reported by Lazarus and Alfert (1964).

Lazarus and Alfert (1964) have found that self-report and physio-

logical measures are inversely related as a function of coping style.

In response to threat repressors showed greater physiological arousal

with less self-reported arousal, whereas sensitizers showed less

physiological arousal with greater self-reported arousal. Most studies

which were reviewed by Dearborn (Note 5) reported similar findings,

except for a study by Early and Kleinknecht (1978) in which sensitizers

showed significantly greater increases in Palmar Sweat Index (PSI)

physiological activation response, as compared with repressors. It may

be useful to consider these response differences when interpreting com-

plex data.









To summarize, reviewed research has indicated that coping style

and preoperative preparation do interact and produce differential

effects on postoperative recovery. Egbert (1967) has suggested that

different preoperative preparation approaches might be selected for

different coping styles; this would facilitate postoperative recovery

in all patients. Some research has been directed toward the discovery

of maximally effective combinations of preoperative preparation with

coping style, but preoperative preparation which has been studied

primarily consisted of preparatory information. Providing preparatory

information has been most effective with sensitizers for whom adjust-

ment and recovery have been significantly improved; providing pre-

operative surgical information for repressors generally has not been

useful. On the other hand investigation of possible interactions

between coping style and cognitive coping preparatory techniques have

not been explored. Some cognitive preparatory techniques may be more

effective with repressors than sensitizers.


Statement of the Problem


In the present study the effectiveness of cognitive attention

redirection strategies in facilitating the patient's adjustment and

recovery from surgery was investigated. Adjustment and recovery were

assessed with physiological, behavioral, and self-report measures.

The effects of cognitive attention redirection coping preparation on

measures of adjustment and recovery for patients with different coping

styles were examined carefully. The effect of previous experience with

periodontal flap surgery was assessed for all measures. Other









psychological subject variables, such as preoperative anxiety, recovery

expectations, and recovery responsibility were considered in the evalua-

tion of treatment effectiveness for measures of postoperative recovery.

First, it was of interest to test the preparatory effectiveness of

cognitive attention redirection training in increasing surgical adjust-

ment and postsurgical recovery. Some research (Kendall et al., 1979;

Langer et al., 1975; Pickett & Clum, Note 2) has supported the effective-

ness of cognitive attention redirection training in preparing surgery

patients but a few studies (Cohen, 1976; Lucas, 1976) have indicated

only limited effectiveness. Therefore, the present study assists in

providing additional information about the effectiveness of cognitive

attention redirection training with surgical patients. It was

hypothesized that those patients who received preparatory training with

cognitive attention redirection coping strategies would show better

adjustment and recovery assessed with physiological, self-report, and

behavioral measures, as compared with control group patients.

Specifically, it was expected that compared to control group subjects,

trained treatment group subjects would show 1) a trend toward signifi-

cantly less increase in physiological arousal from pre-manipulation

measurement to post-manipulation measurement immediately before entering

the operating room, 2) a trend toward significantly less increase in

physiological arousal and fewer overt anxiety-related behaviors during

surgery, and 3) a trend toward significantly better recovery measured

by postoperative pain, healing, interference with activities, and medi-

cation consumption scales. These findings would be consistent with the

composite of results from previous research with both laboratory

subjects and surgical patients.










Second, it was expected that the nature of these findings could

be better understood when variations in subjects' Repression-

Sensitization (R-S) coping styles were examined. It was of interest

to determine whether cognitive attention redirection training differ-

entially improved adjustment and recovery for subjects with repressing

versus sensitizing coping styles. In general, those higher in

sensitization were not expected to benefit from cognitive attention

redirection coping training because it is inconsistent with their

natural coping style. Those subjects higher in repression were

expected to benefit due to greater consistency between experimental

training and their natural coping style. Since repressors generally

have not benefitted from receiving specific preparatory information

about surgery procedures (Andrew, 1970; DeLong, 1971; Shipley, et al.,

1978, 1979; Miller et al., Note 4), it seems especially important to

determine if training with cognitive attention redirection strategies

is more useful with repressors.

Several specific predictions were made regarding Treatment X R-S

interactions. Predictions for heart rate and self-reported anxiety

measures are based on previous findings, which are summarized in

Dearborn's (Note 5) paper; these findings indicated that sensitizers

show significantly greater subjective anxiety and significantly fewer

physiological responses during stress conditions as compared with

repressors. No specific predictions were made about PSI change, since

the relationship between R-S and PSI responses in stressful conditions

is not clear, with sensitizers showing greater increases in PSI

activation response than repressors in one study by Early and









Kleinknecht (1978). It was expected that the present study would

assist in examining the relationship between PSI response under stress

and repression-sensitization.

For measures of heart rate, it was expected that repressors in

the trained treatment group would show significantly less increase from

pre-manipulation measurement to post-manipulation measurement

immediately before entering the operating room, as compared with the

control group repressors. When compared with control group repressors,

trained treatment group repressors were also expected to show signifi-

cantly less heart rate increase at the following measurement points:

preinjection, placement of cutting instruments into the mouth, after

10 minutes of digging and loosening diseased tissue, at onset of

osseous recontouring (if applicable), and at initial suturing. No

differences between groups were expected for sensitizers, since 1) the

training strategy is not consistent with their natural coping style

and 2) sensitizers have shown fewer heart rate responses in stressful

situations.

For measures of self-reported anxiety, no significant differences

between trained treatment and control groups were predicted for

repressors or sensitizers. None were expected for sensitizers since

training is not consistent with their natural coping style. Although

the cognitive attention redirection training is more consistent with

repressors' coping style, repressors generally self-report low anxiety

in stressful situations; therefore, no differences between treatment

groups were expected for repressors. Sensitizers were expected to show

higher self-reported anxiety than repressors, regardless of treatment.










For recovery measures of postoperative pain, interference, medi-

cations, and healing, it was expected that repressors who were given

cognitive coping instruction would show significantly better recovery

than control group repressors. For sensitizers no significant

differences in recovery were expected between the trained treatment

group and control group. Trained repressors were expected to show

significantly better recovery than trained or control group sensitizers.

Similar findings were expected for measures of overt behavior in the

operating room during surgery, with trained treatment group repressors

showing fewer overt behaviors and better adjustment.

Third, the patients' preoperative anxiety level, expectations

about recovery, and beliefs about responsibility for health recovery

were considered in the evaluation of treatment effectiveness for

measures of postoperative recovery. Findings from studies by Johnson

et al. (1978) and Sime (1976) suggested that providing additional prepara-

tory information to patients with high fear results in significantly

improved recovery. Based on these results a significant interaction

between treatment and preoperative anxiety might be hypothesized.

For patients with high anxiety, it would be predicted that those re-

ceiving preparatory cognitive attention redirection training would show

significantly better recovery, as compared with controls. For patients

with low anxiety, no significant differences in recovery between

groups would be predicted. Findings by George et al. (1980) suggested

that patients with expectations of poor recovery need preoperative

preparation. It was predicted that those patients with expectations

for poor recovery would show significantly better recovery when given







29

cognitive attention redirection training as compared with controls.

For locus of control Pickett and Clum (Note 2) reported that internals

having cognitive attention redirection training showed significantly

better adjustment to surgery as compared with externals having the

same training. Therefore, it would be predicted that for those

periodontal surgery patients receiving preparatory cognitive attention

redirection training, those who take high responsibility for their

recovery would show significantly better recovery as compared with

those who take low responsibility for their health.
















METHOD


Subjects

The subjects were 33 adult dental patients scheduled for periodontal

surgery at the University of Florida College of Dentistry Dental Clinic

in Gainesville, Florida. Patients were selected from those scheduled

for periodontal flap surgery, in which tissue is surgically lifted

away from the teeth and inflamed tissues of the supporting structures

of the teeth are removed. Patients were not invited to participate in

the study if they were unable to read or if they were judged to be

disoriented or physically unable to complete the experimental pro-

cedures. Only those patients who gave written informed consent were

permitted to participate.


Materials

Cognitive Attention Redirection Taped Coping Instructions

Cognitive Attention Redirection Taped Coping Instructions

(Appendix A) are instructions taped on an audio cassette tape which

lasts approximately six minutes. At the beginning of the tape, con-

cepts introducing people's ability to control stress are provided

(Langer et al., 1975), and the subject is introduced to the idea that

a person's behavior can influence the amount of stress he/she experiences.










Then instructions are given for cognitive attention redirection away

from the surgical procedure by focusing on pleasant images/thoughts

about situations other than surgery. The tape provides an example of

how one might imagine a situation which is pleasant and calming.

The complete verbatim content of this tape is given in Appendix A.


Taped Practice Session for Cognitive Coping Instructions

The Taped Practice Session for Cognitive Coping Instructions

(Appendix B) consists of instructions taped on an audio cassette tape

which lasts approximately six minutes. These instructions provide the

subject with an opportunity to practice imagining pleasant situations.

Three examples are given on the tape, in which the subject is told to

visualize himself/herself in one of three settings: 1) at a theater

watching a movie with a traffic accident, 2) at the dentist's office

getting ready to have a tooth filled, and 3) at the periodontist's

getting ready to have an injection prior to periodontal surgery.

Immediately following each example the subject is told to "imagine

pleasant things" and shift his/her thoughts to one of the two pleasant

situations which the subject had described earlier. The complete ver-

batim content of this tape is given in Appendix B.


Patient's Consent Form

The Patient's Consent Form (Appendix C) was used to obtain written

informed consent from each subject participating in this study. This

form provides a description of the study and information about risks,

benefits, and confidentiality.










A-State State-Trait Anxiety Inventory

The A-State State-Trait Anxiety Inventory (Appendix D) was devised

by Spielberger et al. (1970) to measure current level of situational

anxiety. The A-State State-Trait Anxiety Inventory (STAI) is a 20 item

scale that asks people to indicate how they feel at a particular moment

in time. For each item the person selects one of the following four

alternatives to best describe how he/she feels: 1) not at all, 2) some-

what, 3) moderately so, and 4) very much so. As recommended by

Spielberger et al. (1970), the title "Self-Evaluation Questionnaire"

was utilized when the inventory was administered to subjects. The 20

item A-State STAI and the short form A-State STAI have been utilized

with medical patients in several studies (Auerbach & Kendall, 1978;

Auerbach et al., 1976; Kendall et al., 1979; Shipley et al., 1978,

1979).


Ten-Point Rating of Anxiety

The 10-Point Rating of Anxiety (Appendix E) is a 10-point rating

scale, which subjects used to rate feelings of tension and/or nervous-

ness. A rating of 1 indicates no feelings of tension or nervousness,

and a rating of 10 indicates high tension or nervousness.


Epstein-Fenz Modified R-S Scale

The Epstein-Fenz (1967) Modified R-S Scale (Appendix F), which

contains 30 Minnesota Multiphasic Personality Inventory items, is used

to measure coping style. Responses vary along a continuum from re-

pression to sensitization. High scores indicate a sensitizing coping

style with a preference to approach threat directly, whereas low scores









indicate a repressive coping style with a preference to avoid or retreat

from threat. The items of the Epstein-Fenz Modified R-S Scale are a

subset of those included in Byrne's Scale; Epstein-Fenz Modified R-S

Scale items were selected in an attempt to reduce the high correlation

(approximately .90) between Byrne's R-S Scale (1964) and measures of

trait anxiety. The Epstein-Fenz R-S Scale has been used as a measure

of coping style in research (Shipley et al., 1977, 1978, 1979) pre-

paring patients for endoscopy. Shipley et al. (1979) reported a

correlation of .44 between the Epstein-Fenz Modified R-S Scale and

Spielberger's Trait Anxiety Scale (1970).


Patient Questionnaire

The Patient Questionnaire (Appendix G) contains 13 questions each

with a ten-point rating scale. George et al. (1980) devised the first

nine rating scales included in the Patient Questionnaire. When George

et al. (1980) factor analyzed responses to these questions, they

identified four factors which corresponded to these concepts: a) amount

of suffering and pain expected (questions #1, #2, #3, and #5), b) anxiety

about recovery (question #4), c) trait anxiety (questions #6 and #7), and

d) coping behaviors (questions #8 and #9). The tenth rating scale was

included to provide a measurement of overall fear of dental procedures

in general. The last three rating scales were included to indicate

the extent to which a subject believes that an individual's behavior

affects health and rate of recovery and the extent to which the subject

takes responsibility for health care.









Palmar Sweat Index

The Palmar Sweat Index (PSI) is a measure of sweat gland activity,

which is administered by a simple finger print procedure. Palmar

sweating is measured by applying a special plastic solution to the

fingertip; after letting it dry for 15-30 seconds, the print is easily

removed from the finger with a piece of scotch tape (Johnson & Dabbs,

1967). The polyvinyl solution withdraws from moisture, leaving holes

in the print where there are active sweat glands. Then the number of

active sweat glands are counted by placing the print on a slide which

may be examined carefully using a slide projector. Dividing the number

of active sweat glands by the total number of sweat glands and multiply-

ing by 100 yields the PSI score.


Pulse Rate Monitor

The Sears Pulse Rate Monitor was used to measure heart rate. The

monitor provides a digital readout of pulse rate per minute at six beat

intervals. Pulse rate is measured from the index finger. This in-

strument is compact, portable, and easily utilized. When heart rate

readings were taken simultaneously with the Sears Pulse Rate Monitor

and a polygraph, readings were highly consistent. For each heart rate

measurement period, the average of three consecutive readings was

calculated for each subject.


Focus and Clarity of Images Scale

The Focus and Clarity of Images Scale (Appendix H) consists of two

questions about 1) the subject's ability to focus on a pleasant situa-

tion and 2) the clarity and vividness of the subject's image of the

situation. The first question.requires a 10-point rating, where a










rating of 1 indicates low ability to focus thoughts on the pleasant

situation and a rating of 10 indicates high ability to focus on the

situation. The second question provides seven alternatives which

reflect increasing clarity and vividness. A score of 1 indicates a

perfectly clear and vivid image, and a score of 7 indicates no image.


Ease of Pleasant Imagery Practice Rating

The Ease of Pleasant Imagery Practice Rating (Appendix I) is a

10-point rating scale, which subjects used to rate their ability to

shift their thoughts and imagine pleasant situations. A rating of 1

indicates low ability to shift thoughts and a rating of 10 indicates

high ability to shift thoughts.


Operating Room Behavioral Measure

The Operating Room Behavioral Measure (Appendix J) was used to

assess each subject's overt behavior during periodontal treatment in

the operator. With this measure the experimenter indicated the

frequency of occurrence for each of these behaviors: surgeon instructs

patient to hold still, patient jerks head, patient asks questions about

how the surgery procedure is progressing, patient nonverbally indicates

discomfort, patient verbalizes pain or discomfort, patient requests a

stop point, patient expresses apprehension or dislike about the pro-

cedure, patient asks to use the bathroom, patient shows repetitive

movements of hands and/or feet, and patient shows obvious stiffness of

body and/or limbs. Prior to beginning this study, each experimenter

was given two practice sessions for recording these behaviors, such

that the occurrence of each behavior could be accurately identified









without prompting from the trainer. Due to the difficulty in dis-

criminating among adults through overt behaviors (Kleinknecht &

Bernstein, Note 6), this Operating Room Behavioral Measure was devised

specifically for the periodontal surgery population of patients.

The 10 behaviors, which are listed above, were selected in advance

for this record from observations of a sample of 10 adults who had

periodontal surgery prior to the onset of this study. These behaviors

overlap with those included in the Dental Operatory Ratings Scale de-

vised by Kleinknecht and Bernstein (Note 6) to measure overt behavior

during dental treatment in the operator, although the two scales are

not identical. For each subject in this periodontal surgery study, a

score indicating the number of behaviors observed per minute of surgery

was calculated for each of the 10 behaviors.


Postsurgery Patient Questionnaire

The Postsurgery Patient Questionnaire (Appendix K) was devised

specifically for this study to provide a measure of 1) cognitive and

affective activity which occurred during the surgical procedure and

2) the patient's assessment of treatment credibility. The first four

questions assess the degree to which each subject utilized cognitive

attention redirection coping strategies during the procedure. The next

three questions were included to assess the amount of unpleasantness

perceived during the procedure. The last two questions provide a

measure of treatment credibility, in which the patient indicates 1) how

much he/she expected that being involved in the study would be helpful

and 2) how much he/she found that being involved in the study was help-

ful.










Patient's Daily Ratings

The Patient's Daily Ratings questionnaire (Appendix L) is similar

in form to the questionnaire devised by George et al. (1980) to measure

postoperative recovery. The questionnaire includes two measures of pain:

pain ratings and pain medication, which emerged as independent dimen-

sions of the pain experience with factor analyses performed by George

et al. (1980). The second group of rating scales measure three

independent dimensions of functional interference which also were

determined factor analytically by George et al. (1980): a) interference

with activities, b) interference with sleep, and c) interference with

eating. The Patient's Daily Ratings questionnaire includes one

additional rating scale which measures unpleasantness of postoperative

recovery. For each subject, a composite score was calculated for pain,

medication, activity interference, sleeping interference, eating inter-

ference, and unpleasantness. A composite score was calculated by

standardizing each of the daily ratings and then adding the standardized

scores together for each of the six measures.


Physical Trauma Measure

The Physical Trauma Measure was included in order to measure the

degree of physical trauma experienced during the surgical procedure.

It was devised by Dr. Samuel Low, a periodontal surgeon at the University

of Florida. The physical trauma measure is determined as a function of

pocket depths (which reflects extent of diseased tissue), degree of

difficulty of surgery, and length of time for the surgical procedure.

Information about physical trauma was obtained from the Surgical Pro-

cedure Data Sheet (Appendix M), which was completed by the surgeon.









One composite physical trauma measure was obtained for each subject by

standardizing the scores for pocket depths, degree of difficulty, and

length of time, and then adding the three standardized scores together.

A similar composite measure was also employed by George et al. (1980)

to assess the degree of physical trauma received during dental extraction

procedures.


Surgeon's Rating of Patient Behavior

The Surgeon's Rating of Patient Behavior (Appendix N) questionnaire

provides a measure of the patient's level of cooperation and anxiety

during the procedure, as judged by the surgeon performing periodontal

surgery. It consists of two rating scales of patient anxiety and

cooperation. The first scale measures the patient's anxiety rated on

a 10-point scale ranging from low to high anxiety. The second scale

measures the patient's cooperation rated on a 10-point scale ranging

from low to high cooperation.


One Week Follow-up Questions

One Week Follow-up Questions (Appendix 0) include four questions.

The first question requires a frequency count of how often patients

utilized the cognitive attention redirection coping strategy to shift

their thoughts to pleasant and calming situations. The second and third

questions are 10-point ratings to indicate the overall amount of dis-

comfort experienced during the postsurgery recovery period. The last

question is a 10-point rating to indicate the extent to which the patient is

believed to benefit from being in this research project.









Surgeon's Ratings of Healing and Swelling

The Surgeon's Ratings of Healing and Swelling questionnaire

(Appendix P) consists of three rating scales of healing and swelling

which are completed by the surgeon. This questionnaire was devised by

Dr. Samuel Low, a periodontist at the University of Florida. The first

scale provides a measure of healing rated on a 10-point scale ranging

from poor to excellent. The second scale provides a measure of facial

swelling rated on a 10-point scale ranging from none to severe. The

third scale provides a measure of unintentional denudation (bone exposed)

rated on a 10-point scale ranging from none to severe.


Procedure


Approximately one hour prior to surgery, the experimenter described

the project to each patient individually. This introduction was given

to each patient:

I want to tell you more about this project for periodontal sur-

gery patients. Your dentists want you to be in the project

because they believe it will be helpful for you. We want to

find out what the periodontal surgery experience is like for

you and what is helpful in preparing you for periodontal

surgery. I will ask you some questions and have you fill

out some questionnaires. I will be taking some measures of

heart rate and palmar sweating from your fingers. After the

surgery procedure you will take about five minutes to

answer a few questions. You will take home some daily

rating sheets, and each day you will answer some short









questions about your recovery. You will bring these with

you when you return for your follow-up appointment. I

will spend approximately five minutes talking with you

immediately before that appointment.

If the patient agreed to participate, written informed consent was

obtained. All subjects were seen individually in a comfortable inter-

viewing room. Measures of heart rate and PSI were obtained first,

followed by administration of the A-State STAI and a 10-point ratings

of anxiety. Then the subject completed the Epstein-Fenz Modified R-S

Scale and the Patient Questionnaire. Subjects were assigned to either

the trained treatment group or the control group, such that types of

R-S Scale coping styles were approximately equal for each group.

Then the trained treatment group subjects were given training in

cognitive attention redirection. (For an exact account of the training

instruction procedure, please see Appendix Q.) The subject was in-

structed to listen to a cassette tape, which provided instructions

about how to make the periodontal surgery experience more pleasant and

less stressful. The Cognitive Attention Redirection Taped Coping

Instructions then were played. When the tape ended and the recorder

was turned off, the experimenter helped the subject to identify and

imagine two different situations which are pleasant and calming. After

one situation which is pleasant and calming had been identified, the

subject was asked to describe the situation to the experimenter in such

a way that both the subject and the experimenter obtained a clear image

of the situation. The experimenter asked questions in order to help

the subject get a clear image. Then the experimenter helped the subject









identify and clearly imagine one additional situation which is pleasant

and calming for that subject. After the subject identified and

imagined each situation, the subject completed the Focus and Clarity of

Images Scale, which assessed the subject's ability to focus on the

pleasant situation and the clarity and vividness of the subject's

image of the situation. Then the experimenter turned on the cassette

player again and played the Taped Practice Session for Cognitive Coping

Instructions. This tape gave the subject a chance to practice imagin-

ing pleasant situations. Once the cassette player was turned off, the

subject rated his/her ability to shift thoughts and imagine pleasant

situations by using the Ease of Pleasant Imagery Practice Rating.

Control group subjects were left alone in the interviewing room

for 15 minutes, so that each was free to utilize his/her own natural

coping style. A variety of magazines were available for the patient to

read. Control group subjects were told that the experimenter would

return in approximately 15 minutes to ask a few additional questions

before seeing the periodontal surgeon.

After the completion of cognitive coping instruction for the trained

treatment group and the return of the experimenter to the interview room

for control group subjects, all remaining measurement procedures were

identical for each subject regardless of treatment group assignment.

The experimenter informed the subject that the periodontist was about

ready to see the patient for surgery. Then heart rate, PSI, A-State

STAI, and a 10-point anxiety rating were administered.

The subject was taken to the operating room, and the experimenter

recorded physiological measures and behavioral observations during surgery.









Whenever possible (88% of the cases in each treatment group), the

experimenter in the operating room was a different experimenter than

the one providing preoperative measurement and instruction, so that the

subject's treatment group assignment would not be known. In the

operating room a measure of heart rate was taken: a) when the patient

first laid down in the chair, b) as the surgeon examined the patient's

mouth, c) prior to the injection when the cotton stick was placed in the

mouth, d) when the cutting instruments were first placed in the patient's

mouth, e) after 10 minutes of digging and loosening diseased tissue,

f) after 25 minutes of digging and loosening of diseased tissue (if

applicable), g) at the first mouth rinse, h) at the second mouth rinse,

i) at the onset of osseous recontour drilling (if applicable), j) at the

onset of suturing, k) at the completion of the surgery procedure while

the subject remained lying down in the chair, and 1) postoperatively

once the subject sat up in the chair. Three of these heart rate

measures (b, g, and h listed above) were included as neutral points,

so that the subject would not expect measurements to occur only at

significant procedural points during surgery. Measures of PSI were

taken following heart rate at these measurement periods: a) when the

patient first laid down in the chair, b) prior to injection, c) at the

onset of suturing, and d) at the completion of the surgery procedure

once the subject sat up in the chair. During surgery the experimenter

also recorded the subject's overt behaviors specified by the Operating

Room Behavioral Measure.

Once surgery was completed and the subject was sitting up in the

chair, the subject was asked to complete a 10-point rating of anxiety









about how he/she felt at that moment, the A-State STAI according to how

he/she felt during surgery while the surgeon was working in the subject's

mouth, and the Postsurgery Patient Questionnaire. The subject was

given the Patient Daily Ratings to be completed at home on a daily

basis for the seven days following surgery. The patient was instructed

to return these ratings at the time of the suture removal appointment.

Before leaving the operator, all patients were given a written copy of

the Department of Periodontics standard home care instructions, which

are utilized with all periodontal surgery patients seen in the

Periodontal Clinic. The instructions included information about the

surgical dressing, brushing and flossing, using ice to control swelling,

and diet. Following surgery the surgeon completed the Surgical Pro-

cedure Data Sheet and the Surgeon's Ratings of Patient Behavior.

At the suture removal appointment the subject was seated in the

operator chair, and the experimenter interviewed the subject for five

to ten minutes before the periodontist began to work in the patient's

mouth. The Patient's Daily Ratings sheets were collected at that time.

The experimenter told the subject that prior to seeing the periodontist

and having stitches removed, physiological measures would be obtained

and a few questions would be completed. The experimenter then measured

heart rate and PSI. The subject completed the A-State STAI, a 10-point

rating of anxiety, and the One Week Follow-up Questions. The experi-

menter thanked the patient for participating in the project. Immediately

following the suture removal appointment, the surgeon completed the

Surgeon's Ratings of Healing and Swelling and the Surgeon's Ratings of

Patient Behavior. Table 1 summarizes the kinds of measures used with

all subjects and the time that they were assessed.








Table 1. Measures and time of assessment.
Pre-
Measure Manipulation

Heart Rate X

PSI X

A-State STAI X

10-Point Anxiety X

R-S Scale X

Patient Questionnaire X

Operating Room
Behavioral Measure

Postsurgery Patient
Questionnaire

Surgeon's Ratings of
Patient Behavior

Surgical Procedure
Data Sheet

Patient Daily Ratings

One-week Follow-up
Questions

Surgeon's Ratings of
Healing and Swelling


Post- At I-week


Post-
Manipulation

X

X

X

X


O.R.

X

X

X

X


During 1-week
Postsurqerv


At 1-week
Follow-up

X

X

X

X


__


--.---.-.-,-- ---^- - **- _____


---















RESULTS


Results of group equivalence and manipulation validity checks are

presented first, followed by a general description of the analyses per-

formed. Results are presented separately for each dependent measure,

with dependent measures organized into five major sections: physiological

measures, self-reported anxiety, behavioral measures, patients' ratings

of surgery and recovery experiences, and postoperative recovery measures.

Obtained results indicate that cognitive attention redirection training

does facilitate patients' adjustment and recovery. Strong treatment

effects were seen for heart rate measures, with trained subjects showing

significantly lower heart rates than control subjects. Additional

effects of training were seen when level of previous experience, pain

expectation, and recovery responsibility were considered. Main effects

of R-S coping style and previous experience and R-S X Experience inter-

actions were found, with sensitizers, experienced subjects, and experienced

sensitizers showing poorer adjustment and recovery.


Group Equivalence and Manipulation Validity Check


Several tests were conducted to determine the comparability of sub-

jects between treatment groups (trained and control) and to ascertain treat-

ment credibility and differential application of trained techniques. Sub-

ject characteristics for each treatment group are shown in Table 2.

T-test analyses showed no significant differences between groups for

subjects' age, physical trauma score, and Repression-Sensitization (R-S) score.











Table 2. Subject characteristics for each treatment group.

Treatment
Subject Characteristic Trained Control


Age


x

s.d.


R-S Score


s.d.
s.d.


Trauma Score





Sex

Male

Female



Experience

Experienced

No Experience


s.d.
s.d.


= 41.62

= 11.904



= 12.50

= 4.87


= .27

= 2.1


n =6

n = 10





n =4

n =12


x = 41.00

s.d. = 13.698



S= 12.88

s.d. = 4.14


s.d.
s.d.


= -.28

=1.7


n=7

n = 10





n =6

n = 11









Chi-square analyses showed no significant differences between groups with

respect to subjects' sex or previous experience with periodontal flap

surgery. Three t-tests indicated no significant differences between

trained and control groups for treatment credibility, measured by subjects'

ratings of 1) how helpful they expected the research project to be,

2) how helpful they found the project immediately following surgery, and

3) how helpful they found the project one week postsurgery. Two t-tests

were conducted to assess differential application of trained techniques

between treatment groups. For subjects' ratings of time spent thinking

about pleasant situations during surgery, the difference between groups

approached significance, t(31) = 1.91, p<.06. Subjects in the trained

group reported more time spent thinking about pleasant things during

surgery than control group subjects. For subjects' ratings of time spent

shifting thoughts to pleasant situations during the week following surgery,

there were no significant differences between treatment groups. Six

additional t-tests indicated that subjects in the trained group did not

differ significantly as a function of R-S or previous experience for

measures of their ability to focus on pleasant situations, clearly imagine

pleasant situations, and shift thoughts to pleasant situations.


Analyses


In order to evaluate the main hypotheses, factorial analyses of

variance and covariance were conducted using the same three grouping

factors in each analysis. Grouping factors were treatment, R-S, and

previous experience. For the treatment factor, subjects were categorized

as trained (n = 16) or control (n = 17). For the R-S factor, subjects









were categorized as repressors (n = 23) or sensitizers (n = 10). A

sensitizer was defined by a score greater than or equal to 16 on the

Epstein-Fenz Modified R-S Scale, and a repressor was defined by a score

under 16 on the Epstein-Fenz Modified R-S Scale. For the experience

factor, subjects were categorized as experienced (n = 10) which referred

to having one or more previous periodontal flap surgeries, or no

experience (n = 23) which referred to having no previous periodontal

flap surgeries. Treatment X R-S, Treatment X Experience, and R-S X

Experience interactions were examined but Treatment X R-S X Experience

higher order interactions were excluded due to severely restricted cell

size. The distribution of subjects for 2 X 2 grouping factor combinations

is shown in Tables 3, 4, and 5. For R-S X Experience interactions, find-

ings should be interpreted with caution since there were only two

sensitizers with previous experience.

In addition, for the postoperative recovery measures, correlations

between postoperative recovery and patients' expectation of pain ratings,

expectation of interference ratings, A-State anxiety scores prior to

treatment manipulation, and ratings of perceived responsibility for

recovery were calculated for each treatment group. For any of the post-

operative recovery-psychological subject variable correlations which

reached significance, 2 X 2 (Treatment X Psychological Subject Variable)

analyses of variance were conducted using that recovery measure as the

dependent variable. For the pain expectation factor, subjects were

categorized as low (n = 13) if their expectation of pain rating was in

the lower half of the scale (5 or below), and they were categorized as

high (n = 20) if their expectation of pain rating was 6 or above.









Table 3. Distribution of subjects for Treatment X R-S.

R-S
Treatment Repressors Sensitizers

Trained 11 5

Control 12 5





Table 4. Distribution of subjects for Treatment X Experience.

Experience
Treatment Experienced No Experience

Trained 4 12

Control 6 11


Table 5. Distribution of subjects for R-S X Experience.

Experience
R-S Experienced No Experience

Repressors 8 15

Sensitizers 2 8









For the interference expectation factor, subjects were categorized as

low (n = 14) if their expectation of interference rating was in the lower

half of the scale (5 or below), and they were categorized as high (n = 19)

if their expectation of interference rating was 6 or above. For the

A-State anxiety factor, a median split was utilized to categorize

subjects: a score below 36 indicated low anxiety (n = 16) and a score

above 36 indicated high anxiety (n = 16). For the recovery responsibility

factor, subjects were categorized as low (n = 8) if their responsibility

for recovery rating was in the upper half of the scale (6 or above) and

high (n = 25) if their responsibility for recovery rating was 5 or below.

This responsibility for recovery factor may be seen as comparable to a

locus of control measure specifically related to recovery from illness.

The distribution of subjects for 2 X 2 (Treatment X Psychological Subject

Variable) groupings is shown in Table 6.


Physiological Measures

Heart Rate

Analysis of heart rate data included measures taken prior to treat-

ment manipulation (PRE-M), following treatment manipulation (POST-M),

when the subject first laid down in the operating room chair (BEGIN),

immediately prior to the injection (PRE-INJ), after 10 minutes of digging

and loosening diseased tissue (DIG), at the completion of surgery while

the subject remained lying in the chair (END), and postsurgery once the

subject was sitting up in the chair (CHAIR-UP). The heart rate measure

taken when the cutting instruments were first placed in the subject's

mouth was excluded due to confounding physiological effects created by









Table 6. Distribution of subjects for Treatment X Psychological Subject
Variables.


Psychological Treatment
Subject Variable Trained Control

Pain Expectation

Low (n = 13) 7 6

High (n = 20) 9 11


Interference Expectation

Low (n = 14) 6 8

High (n = 19) 10 9


A-State Anxiety

Low (n = 16) 8 8

High (n = 16) 8 8


Recovery Responsibility

Low (n = 8) 3 5

High (n = 25) 13 12










the medication at that point in time. Heart rate measures taken after

25 minutes of digging and loosening diseased tissue, at the onset of

suturing, at the onset of osseous recontour drilling, and at the one

week postsurgery suture removal appointment were excluded from the

analysis due to missing data for these measurements. Significant positive

correlations were found between PRE-M and POST-M heart rates (r = .85,

p<.001), PRE-M and BEGIN heart rates (r = .77), p<.001), PRE-M and

PRE-INJ heart rates (r = .63, p<.001), PRE-M and DIG heart rates

(r = .60, p<.001), PRE-M and END heart rates (r = .49, p<.002), and

PRE-M and CHAIR-UP heart rates (r = .75, p<.001). In view of 1) the

noted significant correlations between pre-manipulation heart rate and

other heart rate measures specified above and 2) nonsignificant low

correlations between pre-manipulation heart rate and treatment grouping,

R-S grouping, and previous surgery experience grouping, heart rate data

was analyzed utilizing repeated measures analysis of covariance with

PRE-M heart rate as the covariate.

The 2 X 2 X 2 X 6 (Treatment X R-S X Experience X Measurement

Periods) repeated measures analysis of covariance produced a significant

main effect for treatment, F (1,23) = 4.39, p<.05, and a main effect for

measurement period which approached significance F (5,125) = 2.05, p<.08.

Trained subjects showed significantly lower adjusted mean heart rate than

control subjects. Heart rate responses then were analyzed separately

at each of the six measurement periods utilizing one-way analyses of

covariance with treatment as the between subjects factor and PRE-M heart

rate as the covariate. The one-way analyses of covariance showed signi-

ficantly lower adjusted mean heart rate in trained subjects as compared









with control subjects for POST-M measurement, F (1,30) = 12.94, p<.001,

PRE-INJ measurement, F (1,30) = 4.97, p<.04, and CHAIR-UP measurement,

F (1,30) = 5.66, p<.03. Results from the one-way analysis of covariance

for the BEGIN measurement period approached significance, F (1,30) = 2.85,

p<.10, with trained subjects showing lower adjusted mean heart rate than

control subjects. There were no significant adjusted mean heart rate

differences between trained and control groups at DIG and END measurement

periods. Figure 1 shows the nature of these differences. Although the

follow-up suture removal heart rate measurement was excluded from the

repeated measures analysis of variance due to missing data, findings of

lower heart rate in trained subjects prior to and during surgery would

suggest that trained subjects also may have lower heart rates at the

follow-up appointment. A one-tailed t-test was conducted comparing

absolute mean heart rates between trained and control groups. At follow-

up trained subjects continued to show lower heart rates than control

subjects, t (22) = 1.63, p<.06, despite the fact that subjects knew that

suture removal was to take place instead of periodontal surgery.

The main effect of measurement periods obtained from the 2 X 2 X 2 X 6

repeated measures analysis of covariance represents 1) a general increase

in heart rate over time up to and including heart rate measured after

10 minutes of digging and loosening diseased tissue and 2) a general

decrease in heart with the completion of surgery. To further clarify

the main effect of measurement periods, paired t-test (for related means)

were conducted using the unadjusted heart rate means for POST-M versus

BEGIN, POST-M versus PRE-INJ, POST-M versus DIG, POST-M versus END,

POST-M versus CHAIR-UP, BEGIN versus PRE-INJ, BEGIN versus DIG,

















































POST-M BEGIN PRE-INJ


END CHAIR-UP


MEASUREMENT PERIOD





T-- U Trained

S--- Control


Figure 1. Adjusted mean heart rates for the trained and control
groups across six measurement periods.


80 -


w






wT
wuJ
(/1
F-

LLJ
LLJ
L.L
F_


75 -







70


65-


I j I I









BEGIN versus END, BEGIN versus CHAIR-UP, PRE-INJ versus DIG, PRE-INJ

versus END, PRE-INJ versus CHAIR-UP, DIG versus END, DIG versus CHAIR-UP,

and END versus CHAIR-UP. Mean heart rate increased from BEGIN to PRE-INJ,

t (32) = 1.65, p<.10, BEGIN to DIG, t (32) = 2.91, p<.01, and POST-M to

DIG, t (32) = 2.34, p<.02. Mean heart rate decreased significantly from

DIG to END, t (32) = 3.2, p<.01 and DIG to CHAIR-UP, t (32) = 2.4, p<.02.


Palmar Sweat Index (PSI)

Analysis of PSI data included PSI measures taken prior to treatment

manipulation (PRE-M),following treatment manipulation (POST-M), when the

subject first laid down in the operating room chair (BEGIN), and immediately

following completion of surgery once the subject was sitting up in the

chair (CHAIR-UP). The PSI measure taken at the time of injection was

excluded due to confounding physiological effects created by the medication

at that point in time. PSI measures taken at the onset of suturing and

at the one week postsurgery suture removal appointment were excluded due

to missing data for those measurements.

A 2 X 2 X 2 X 4 (Treatment X R-S X Experience X Periods) repeated

measures analysis of variance with PRE-M, POST-M, BEGIN, and CHAIR-UP

periods yielded a main effect of experience which approached significance,

F (1,24) = 3.37, p<.08, and a significant main effect of periods, F (3,72) =

5.3, p<.01. The main effect of experience indicated that experienced

subjects had more open sweat pores across the four measurement periods

than subjects with no previous experience. When PSI scores were analyzed

separately at each of the four measurement periods using t-test com-

parisons between experience and no experience groups, no significant

differences were obtained.









The main effect of measurement periods obtained from the 2 X 2 X 2 X 4

repeated measures analysis of variance represents 1) generally stable

palmar sweating prior to surgery and 2) a decrease in palmar sweating

following completion of surgery. To further clarify the main effect of

measurement periods, paired t-test comparisons were conducted with PSI

means for PRE-M versus POST-M, PRE-M versus BEGIN, PRE-M versus CHAIR-UP,

POST-M versus BEGIN, POST-M versus CHAIR-UP, and BEGIN versus CHAIR-UP.

The mean percentage of open sweat pores decreased significantly from

BEGIN to CHAIR-UP, t (31) = 3.26, p<.01, POST-M to CHAIR-UP, t (31) = 4.0,

p<.01, and PRE-M to CHAIR-UP, t (31) = 3.21, p<.01. No significant

differences were obtained between mean PSI scores PRE-M to POST-M,

PRE-M to BEGIN, and POST-M to BEGIN.


Self-Reported Anxiety


A-State Anxiety

A 2 X 2 X 2 X 4 (Treatment X R-S X Experience X Periods) repeated

measures analysis of variance was conducted utilizing all four A-State

anxiety measurement periods: prior to treatment manipulation (PRE-M),

following treatment manipulation (POST-M), during surgery (SURGERY), and

at postoperative treatment for suture removal one week following surgery

(FOLLOW-UP). This analysis resulted with a significant main effect of

R-S, F (1,24) = 5.83, p<.03, a significant main effect of periods,

F (3,72) = 12.88, p<.O01, a significant Periods X Experience interaction,

F (3,72) = 4.05, p<.02, and a Periods X Treatment X Experience interaction

which approached significance F (3,72) = 2.69, p<.06.










The main effect of R-S indicated that repressors showed significantly

lower A-State anxiety across the four measurement periods than sensitizers.

A-State mean scores also were analyzed separately at each of the four

measurement periods using t-test comparisons between R-S groups.

Repressors obtained significantly lower mean A-State scores than

sensitizers at the PRE-M period, t (30) = 2.9, p<.Ol, POST-M period,

t (30) = 2.13, p<.05, and FOLLOW-UP period, t (30) = 2.19, p<.05.

No significant differences were found at the SURGERY period.

The main effect of measurement periods obtained from the 2 X 2 X 2 X 4

repeated measures analysis of variance represents 1) an increase in

A-State anxiety during surgery and 2) a decrease in A-State anxiety at

postoperative treatment for suture removal one week following surgery.

To further clarify the main effect of measurement periods, paired t-test

comparisons were conducted with the A-State means for PRE-M versus POST-M,

PRE-M versus SURGERY, PRE-M versus FOLLOW-UP, POST-M versus SURGERY,

POST-M versus FOLLOW-UP, and SURGERY versus FOLLOW-UP measurement periods.

No significant difference was obtained between mean A-State anxiety

PRE-M to POST-M. A-State anxiety increased from POST-M to SURGERY measure-

ment, t (31) = 2.34, p<.02, and PRE-M to SURGERY measurement, t (31) = 1.65,

p<.10. A-State anxiety decreased significantly from SURGERY to FOLLOW-UP

measurement, t (31) = 5.99, p<.01, POST-M to FOLLOW-UP measurement,

t (31) = 5.71, p<.Ol, and PRE-M to FOLLOW-UP measurement, t (31) = 5.9,

p<.01.

With the obtained interactions for A-State anxiety, the Periods X

Experience interaction indicates that subjects with previous experience

increase anxiety from POST-M to SURGERY, whereas subjects with no previous










experience show essentially no change in anxiety from POST-M to SURGERY.

This Period X Experience interaction is depicted in Figure 2. The

Periods X Treatment X Experience interaction indicates that 1) experienced

subjects show little change in anxiety from PRE-M to POST-M and a clear

anxiety increase from POST-M to SURGERY, regardless of treatment group

and 2) trained subjects without experience show a slight decrease in

anxiety PRE-M to POST-M and a clear increase in anxiety POST-M to SURGERY,

whereas control subjects without experience show essentially little

change in anxiety PRE-M to POST-M and a small decrease in anxiety from

POST-M to SURGERY. This Periods X Treatment X Experience interaction is

depicted in Figure 3.


10-Point Rating of Anxiety

A 2 X 2 X 2 X 4 (Treatment X R-S X Experience X Periods) repeated

measures analysis of variance was conducted utilizing all four 10-point

anxiety measurement periods: prior to treatment manipulation (PRE-M),

following treatment manipulation (POST-M), immediately following surgery

(CHAIR-UP), and at postoperative treatment for suture removal one week

following surgery (FOLLOW-UP). This analysis resulted with a significant

main effect of periods, F (3,75) = 7.38, p<.001. There were no other

significant main effects or interactions.

The main effect of measurement periods obtained with the 2 X 2 X 2 X 4

repeated measures analysis of variance represents a general decrease in

anxiety from the measurement following treatment manipulation to the

measurement at postoperative treatment one week following surgery. To

further clarify the main effect of measurement periods, paired t-test


































PRE-M POST-M SURGERY FOLLOW-UP


MEASUREMENT PERIOD




U- Experience

0 No Experience


Mean state anxiety scores for subjects with
experience or no experience across the four
measurement periods.


Figure 2.








80O-

8 0 E X P E R I E N C E
45


40 -


35 -


30 -


25


NO EXPERIENCE


I I I I
PRE-M POST-M SURGERY FOLLOW-UP


I I I I
PRE-M POST-M SURGERY FOLLOW-UP


MEASUREMENT PERIOD



U--- Trained

L--- Control


Mean state anxiety scores across the four measurement periods as effected by previous
experience and treatment.


Figure 3.









comparisons were conducted for mean anxiety at PRE-M versus POST-M,

PRE-M versus CHAIR-UP, PRE-M versus FOLLOW-UP, POST-M versus CHAIR-UP,

POST-M versus FOLLOW-UP, and CHAIR-UP versus FOLLOW-UP measurement

periods. Anxiety decreased significantly from POST-M to CHAIR-UP,

t (32) = 2.25, p<.05, CHAIR-UP to FOLLOW-UP, t (32) = 2.64, p<.01,

POST-M to FOLLOW-UP, t (32) = 5.6, p<.01, PRE-M to CHAIR-UP, t (32) = 2.4,

p<.02, and PRE-M to FOLLOW-UP, t (32) = 5.6, p<.01. No significant

difference was obtained between mean 10-point anxiety ratings PRE-M to

POST-M.


Behavioral Measures


Operating Room Behaviors

Analyses of operating room behavior utilized measures of nonverbal

discomfort, verbal discomfort, repetitive movements, and body stiffness.

Meaningful analyses could not be conducted for the other six behavioral

measures because there were no occurrences of the behaviors in over 60%

of the subjects. Nonverbal discomfort, verbal discomfort, repetitive

movements, and body stiffness scores each were analyzed with a 2 X 2 X 2

(Treatment X R-S X Experience) analysis of variance. The 2 X 2 X 2

analysis of variance for nonverbal discomfort resulted with a significant

main effect of Experience, F (1,26) = 6.00, p<.03, a main effect of R-S

which approached significance, F (1,26) = 3.11, p<.09, and a significant

R-S X Experience interaction, F (1,26) = 10.22, p<.01. With the main

effect of R-S, sensitizers showed more nonverbal discomfort behaviors per

hour than repressors. With the main effect of experience, experienced

subjects showed more nonverbal discomfort behaviors per hour than subjects










with no previous experience. For the R-S X Experience interaction, LSD

comparisons indicated that sensitizers with experience showed significantly

more nonverbal discomfort behaviors per hour than sensitizers without

experience (p<.05), repressors with experience (p<.05), and repressors

without experience (p<.05). This interaction is depicted in Figure 4.

The 2 X 2 X 2 analysis for repetitive movements resulted with a

significant main effect of R-S, F (1,25) = 5.38, p<.03, a significant

main effect of experience, F (1,25) = 6.23, p<.02, and a significant

Treatment X Experience interaction, F (1,25) = 13.05, p<.01. With the

main effect of R-S, sensitizers showed more repetitive movements per hour

than repressors. With the main effect of experience, experienced sub-

jects showed more repetitive movements per hour than subjects with no

previous experience. For the Treatment X Experience interaction, LSD

comparisons indicated that control subjects with experience had signifi-

cantly more repetitive movements than control subjects with no experience

(p<.05), trained subjects with experience (p<.05), and trained subjects

with no experience (p<.05). This interaction is depicted in Figure 5.

No significant main effects or interactions were obtained from analyses

of variance for verbal discomfort and body stiffness measures.


Surgeon's Ratings of Patient Behavior

Surgeon's ratings of patient cooperation during surgery, patient

anxiety during surgery, patient cooperation during one week postoperative

suture removal, and patient anxiety during one week postoperative suture

removal each were analyzed with a 2 X 2 X 2 (Treatment X R-S X Experience)

analysis of variance. These analyses of variance resulted with no signi-

ficant main effects or interactions.















































Repressor


Sensitizer


R-S


---- Experience

SD No Experience


Mean number of nonverbal discomfort behaviors
during time in the dental operator for
repressors and sensitizers with experience or
no experience.


7


6


5


4-


3


2-


1 -


V)
0





U--
w>
3:I









-J
Ll- l-


Figure 4.


r







64




12



10



8
I 8



6






LLJ
Cl




























Figure 5. Mean number of repetitive movements during
LU

















SExperience

*"--No Experience


Figure 5. Mean number of repetitive movements during
time in the dental operator for trained and
control groups with experience or no experience.










Patients' Ratings of Surgery and Recovery Experiences


Patients' Ratings of the Surgery Experience

Patients' ratings of surgery unpleasantness, desire to quit during

surgery, and satisfaction with surgery each were analyzed with a 2 X 2 X 2

(Treatment X R-S X Experience) analysis of variance. The 2 X 2 X 2

analysis of variance for surgery unpleasantness resulted with a R-S main

effect which approached significance, F (1,25) = 3.11, p<.09, and in-

dicated that sensitizers rated surgery as more unpleasant than repressors.

The 2 X 2 X 2 analysis of variance for surgery satisfaction resulted with

a main effect of experience which approached significance, F (1,24) = 3.36,

p<.08, and indicated that subjects with experience rated less satisfaction

than subjects with no previous experience. No significant main effects or

interactions were obtained from the analysis of variance for desire to

quit during surgery.


Patients' Ratings of the Postsurgery Recovery Experience

Separate 2 X 2 X 2 (Treatment X R-S X Experience) analyses of

variance were conducted for 1) the composite measure of patient's daily

ratings of postoperative unpleasantness, 2) patient's overall post-

operative unpleasantness rating, which was completed at the postoperative

suture removal appointment, and 3) patient's overall postoperative dis-

comfort rating, which also was completed at the postoperative suture

removal appointment. The 2 X 2 X 2 analysis of variance for the composite

measure of daily postoperative unpleasantness resulted with a main effect

of experience which approached significance, F (1,26) = 3.06, p<.09, and

indicated that subjects with previous experience reported greater









unpleasantness than subjects with no previous experience. The 2 X 2 X 2

analysis of variance for overall postoperative unpleasantness also re-

sulted with a main effect of experience which approached significance,

F (1,23) = 3.08, p<.09, and again indicated that subjects with previous

experience reported greater unpleasantness than subjects with no previous

experience. The 2 X 2 X 2 analysis of variance for overall postoperative

discomfort resulted with a main effect of experience which approached

significance, F (1,23) = 2.92, p<.10, and a R-S X Experience interaction

which approached significance, F (1,23) = 3.19, p<.09. With the main

effect of experience, experienced subjects reported more postoperative

discomfort than subjects with no previous experience. For the R-S X

Experience interaction, LSD comparisons indicated that sensitizers with

experience reported more discomfort than sensitizers without experience

(p<.05), repressors without experience (p<.05), and repressors with

experience (p<.10). This interaction is depicted in Figure 6.


Postoperative Recovery Measures


Surgeon's Ratings of Healing and Swelling

Separate 2 X 2 X 2 (Treatment X R-S X Experience) analyses of

variance were conducted for surgeon's ratings of healing, swelling, and

unintentional bone denudation. The 2 X 2 X 2 analysis of variance for

surgeon's rating of healing yielded a significant R-S X Experience inter-

action, F (1,25) = 4.19, p<.05. LSD comparisons showed that sensitizers

with experience had poorer healing than sensitizers with no previous

experience (p<.05), repressors with experience (p<.10), and repressors

with no experience (p<.10). The nature of this interaction is portrayed












10

Cn --


Repressor


Sensitizer


R-S



I I-- Experience

0 -- No Experience


Mean 10-point postoperative discomfort
ratings at the one-week follow-up appoint-
ment for repressors and sensitizers with
experience or no experience.


Figure 6.


I









in Figure 7. The 2 X 2 X 2 analysis of variance for surgeon's ratings

of bone denudation resulted with a significant main effect of R-S,

F (1,25) = 4.12, p<.05, which indicated that repressors had significantly

greater bone denudation than sensitizers. No significant main effects

or interactions were obtained from the analysis of variance for surgeon's

ratings of swelling.

When correlations between 1) measures of healing, swelling, and bone

denudation and 2) measures of pain expectation, interference expectation,

A-State anxiety, and recovery responsibility were calculated for each

treatment group, significant correlations were obtained between pain

expectation and measures of healing, swelling, and bone denudation. Pain

expectation was negatively correlated with good healing for the trained

(r = -.38, p<.07) and control (r = -.46, p<.04) groups. Pain expectation

was positively correlated with swelling for the trained group (r = .45,

p<.04) but not for the control group. Pain expectation was positively

correlated with bone denudation for both treatment groups, but only the

correlation for the trained group reached significance (r = .52, p<.02).

In view of these significant correlations, separate 2 X 2 (Treatment

X Pain Expectation) analyses of variance were conducted for surgeon's

ratings of healing, swelling, and bone denudation. The 2 X 2 analysis

of variance for surgeon's ratings of unintentional bone denudation re-

sulted with a significant main effect of pain expectation, F (1,28) = 4.03,

p<.05. Subjects with high pain expectation had significantly greater bone

denudation than subjects with low pain expectation. No significant main

effects or interactions were obtained from the analyses of variance for

the surgeon's ratings of healing and swelling.
































- .J
C j
Z






I-




ow


LU
I- U


Repressor Sensitizer

R-S





m Experience

No Experience


Figure 7.


Surgeon's mean 10-point postoperative healing
ratings at the one-week follow-up appointment
for repressors and sensitizers with experience
or no experience









Patient's Composite Ratings of Postoperative Pain, Medication, and
Interference

Separate 2 X 2 X 2 (Treatment X R-S X Experience) analyses of

variance were conducted for 1) the composite measure of patient's daily

pain ratings, 2) the composite measure of patient's daily medication

consumption, 3) the composite measure of patient's daily ratings of

interference with usual activities, 4) the composite measure of patient's

daily ratings of interference with eating, and 5) the composite measure

of patient's daily ratings of interference with sleeping. The 2 X 2 X 2

analysis of variance for the composite measure of patient's daily ratings

of eating interference resulted with a significant R-S X Experience

interaction, F (1,26) = 4.21, p<.05. LSD comparisons indicated that

sensitizers with previous experience reported more eating interference

than sensitizers with no previous experience (p<.05), repressors with

previous experience (p<.10), and repressors with no experience (p<.10).

This interaction is depicted in Figure 8. No significant main effects or

interactions were obtained from analyses of variance for composite

measures of pain, medication, activity interference, or sleeping inter-

ference.

Correlations between 1) the composite measures of daily pain, daily

medication consumption, daily activity interference, daily eating inter-

ference, and daily sleeping interference and 2) measures of pain expectation,

interference expectation, A-State anxiety, and recovery responsibility

were calculated for each treatment group. Significant correlations were

obtained for composite measures of daily pain, daily eating interference,

and daily sleeping interference.














































Sensitizer


R-S





---Experience

D-- No Experience


Mean composite scores of postoperative eating
interference for repressors and sensitizers
with experience or no experience.


iuJ


l-
ZQZ
0 L

L.J

QL-

S l


-r


Repressor


Figure 8.










Pain expectation was positively correlated with both the composite

measure of sleeping interference (r = .49, p<.03) and the composite

measure of eating interference (r = .48, p<.03) for the control group,

but not for the trained group. Separate 2 X 2 (Treatment X Pain Expecta-

tion) analyses of variance were conducted for the composite measure of

eating interference and the composite measure of sleeping interference.

The 2 X 2 analysis of variance for the composite measure of eating

interference resulted with a Treatment X Pain Expectation interaction,

which approached significance, F (1,29) = 3.08, p<.09. LSD comparisons

indicated that control group subjects with low pain expectation reported

significantly less eating interference than control group subjects with

high pain expectation (p<.05). This interaction is depicted in Figure 9.

No significant main effects or interactions were obtained from the

analysis of variance for the composite measure of sleeping interference.

Interference expectation was positively correlated with the composite

measure of daily eating interference for the control group (r = .58, p<.01),

but not for the trained group. In addition, interference expectation was

positively correlated with the composite measure of daily sleeping inter-

ference for the control group (r = .45, p<.04) and negatively correlated

with the composite measure of daily sleeping interference for the trained

group (r = -.42, p<.05). Separate 2 X 2 (Treatment X Interference

Expectation) analyses of variance were conducted for the composite measure

of eating interference and the composite measure of sleeping interference.

No significant main effects or interactions were obtained from these

analyses of variance.








73







+4 -





+2 -





-4
C-


LI =
00





w -2





-4



Trained Control

TREATMENT



SLow Pain Expectation

0 High Pain Expectation


Figure 9. Mean composite scores of postoperative eating
interference for trained and control groups
with low pain expectation or high pain
expectation.









Recovery responsibility was positively correlated with the composite

measure of daily pain for both treatment groups, but only the correlation

for the control group reached significance (r = .41, p<.05). In addition,

recovery responsibility was positively correlated with the composite

measure of sleeping interference for the control group (r = .43, p<.05),

but not for the trained group. Separate 2 X 2 (Treatment X Recovery

Responsibility) analyses of variance were conducted for the composite

measure of daily pain and the composite measure of daily sleeping inter-

ference. The 2 X 2 analysis of variance for the composite measure of

sleeping interference resulted in a significant Treatment X Recovery

Responsibility interaction, F (1,29) = 4.95, p<.04. LSD comparisons

indicated that control group subjects with low responsibility reported

more sleeping interference as compared with high responsibility control

group subjects (p<.05), low responsibility trained subjects (p<.10),

and high responsibility trained subjects (p<.10). This interaction is

depicted in Figure 10. No significant main effects or interactions

were obtained from the analysis of variance for the composite measure

of daily pain.






































-2 -


Trained


Control


TREATMENT





----U Low Responsibility

--High Responsibility


Figure 10.


Mean composite scores of postoperative
sleeping interference for trained and con-
trol groups with low recovery responsibility
or high recovery responsibility.


+8



+6




+4




+2 -




0


jL
O-c


V) L.
W LU




0















DISCUSSION


This study assisted in the evaluation of cognitive attention re-

direction training and subject factors which influence patients'

adjustment to elective surgery. Because the elective surgery experience

can be stressful for adult patients, it is important to identify stress-

reducing preparatory interventions which may improve adjustment and

recovery. Interventions which reduce patients' distress and promote

recovery may be particularly important for periodontal surgery patients,

because the complete treatment of periodontal disease may involve not one

but several successive surgeries. In general, findings from this study

do indicate that cognitive attention redirection training improves adjust-

ment and recovery for periodontal surgery patients. It was found that

having a sensitizing coping style and/or previous experience exerted

negative effects on adjustment and recovery. Effects of treatment, R-S,

previous experience, and other psychological subject variables are dis-

cussed below. Findings from this research also suggested some interesting

additional avenues of future research, which are discussed in conjunction

with methodological issues.


Effects of Treatment


Cognitive attention redirection training did improve adjustment and

recovery for periodontal surgery patients. The findings in this study

help to clarify the effects of cognitive attention redirection training









as a preparatory intervention for patients undergoing stressful medical

procedures. Findings are generally consistent with those previously

reported by Kendall et al. (1979), Langer et al. (1975), and Pickett and

Clum (Note 2).

We know from research by Beck and Weaver (1981) that typically

heart rate accelerates at high-stress dental appointments, but with

training periodontal surgery patients' heart rate acceleration was

diminished. As predicted, trained treatment group subjects showed signi-

ficantly lower heart rates following treatment manipulation, during

surgery, and following surgery, as compared with control group subjects.

Mean heart rate also tended to remain lower in trained subjects at the

one-week follow-up suture removal appointment, despite the fact that

subjects knew that suture removal was to take place instead of periodontal

flap surgery.

When the effects of previous experience, pain expectation, and

recovery responsibility were considered, further effects of training were

found. For subjects with previous experience, trained subjects showed

significantly fewer repetitive movements than control subjects. Training

did not reduce A-State anxiety increases from postmanipulation to surgery,

regardless of previous experience. Trained subjects with experience,

trained subjects with no experience, and control subjects with experience

showed a clear increase in anxiety from postmanipulation to surgery,

whereas control subjects with no experience showed a small decrease in

anxiety.

Treatment also tended to affect postoperative eating and sleeping

interference, when pain expectation and recovery responsibility were con-

sidered. Training tended to decrease postoperative sleeping interference










for subjects with low recovery responsibility. For pain expectation

significant positive correlations between pain expectation and post-

operative sleeping and eating interference were obtained for the

control group but not the trained group. These correlations suggested

that training tended to reduce postoperative eating and sleeping inter-

ference for subjects with high pain expectation.

Findings indicate that trained subjects show better surgical

adjustment and recovery for measures of heart rate, operating room

behaviors, and postoperative recovery. However, training did not

decrease self-reported A-State anxiety during surgery. These findings

of improved recovery with physiological and behavioral measures but not

with self-reported anxiety might be related to a delay in attitudinal

change which follows behind behavioral changes (Hodgson & Rachman, 1974).

According to Hodgson and Rachman (1974), after a treatment intervention

concordance between measures in different response systems will increase

during the follow-up period. It would be interesting to see if the

periodontal surgery patients who had received cognitive attention re-

direction training in this study would show both lower self-reported

anxiety and better behavioral adjustment at their next surgery appointment,

as compared with previously untrained patients.


Effects of R-S


The main effects of R-S identified in this study help to clarify the

relationship between coping style and adjustment/recovery for patients

undergoing stressful medical procedures. Previous research generally

supported better recovery and adjustment in repressors as compared with









sensitizers (Cohen, 1976; Cohen & Lazarus, 1973; Miller et al., Note 4),

but two studies (Abram & Gill, 1961; Boyd et al., 1973) suggested better

adjustment and recovery in sensitizers. Results from this periodontal

surgery study provide additional evidence that repressors show better

adjustment and recovery to stressful medical procedures than sensitizers.

As predicted, periodontal sensitizers reported significantly higher A-State

anxiety than repressors. Sensitizers also showed significantly more

repetitive movements, and they tended to make higher surgery unpleasant-

ness ratings and more nonverbal discomfort behaviors. Although repressors

received higher ratings of unintentional bone denudation at one-week

follow-up than sensitizers, this finding is best interpreted with caution.

Although greater bone denudation in repressors might reflect retarded

healing, periodontal surgeons recognize that there are several factors

related to the surgical procedure itself which may affect follow-up bone

denudation more strongly than the patient's rate of healing. In general,

it is concluded that findings from this study do indicate better adjust-

ment in repressors, thus providing additional support for results reported

by Cohen (1976), Cohen and Lazarus (1973), and Miller et al. (Note 4).

The obtained interactions between R-S and previous experience suggest

that for sensitizers, having previous experience further impedes their

recovery and adjustment. Periodontal surgery patients who had both a

sensitizing coping style and previous experience showed significantly

more nonverbal discomfort behaviors, more one-week postoperative dis-

comfort ratings, poorer one-week postoperative healing, and more daily

eating interference than sensitizers with no previous experience. It may

be that sensitizers' vigilant coping style increases their awareness of









pain and discomfort which was experienced at previous exposure to surgery,

thereby impeding adjustment and recovery. Certainly, these findings

should be interpreted cautiously since there were only two sensitizers

with previous experience in the sample of periodontal surgery patients.

Further investigation with a larger sample of experienced sensitizers

would help to clarify these effects.

Contrary to predicted hypotheses, there were no Treatment X R-S

interactions. It was expected that cognitive attention redirection

training would differentially improve adjustment and recovery for re-

pressors versus sensitizers. Since the cognitive training treatment is

more consistent with the repressing coping style, repressors were expected

to benefit from training but sensitizers were not expected to benefit.

Because only 10 subjects in the total sample were sensitizers, the number

of sensitizers may have been too small to result with a meaningful inter-

action. In general, the findings of this study suggest that cognitive

attention redirection training does improve adjustment and recovery,

regardless of coping style.


Effects of Previous Experience


We have seen that it is important to consider periodontal surgery

patients' previous experience when evaluating the effects of treatment

and coping style. Previous experience also emerged as an important

variable, regardless of treatment or coping style. Subjects with pre-

vious experience showed poorer adjustment and recovery than subjects with

no experience. The greatest differences between experienced and in-

experienced subjects were seen for behavioral and self-reported anxiety









measures during surgery. Previous experience also has emerged as an

important factor in determining children's surgical adjustment after

exposure to preparatory material (Melamed et al., 1978; Melamed &

Siegel, 1980). However, there has been little systematic investigation

of the previous experience variable with adults undergoing stressful

medical procedures. These findings with periodontal surgery patients

would suggest that the effects of previous experience should be con-

sidered more often.


Effects of Other Psychological Subject Variables


The findings suggest that it is important to consider the effects of

other psychological subject variables. Pain expectation and recovery

responsibility did affect postoperative recovery. Control subjects with

high pain expectation reported significantly more eating interference

than control subjects with low pain expectation. The significant positive

correlation between pain expectation and sleeping interference for control

subjects also suggested poorer recovery in untrained subjects with high

pain expectation. It is also noted that in both treatment groups high

pain expectation subjects had significantly more bone denudation than

low pain expectation subjects, but again it must be remembered that bone

denudation may more accurately reflect aspects of the surgical technique

rather than rate of healing. These main effects of pain expectation are

consistent with those reported by George et al. (1980). In discussing

their findings, George et al. (1980) suggested that presurgical psychologi-

cal intervention could modify pain expectation and subsequent recovery.

In fact, correlational findings in this periodontal surgery study suggest









that preoperative cognitive attention redirection training does diminish

the negative effects of high pain expectation on postoperative recovery.

The combined effects of recovery responsibility and treatment in-

fluenced postoperative sleeping interference. For control group subjects,

those with low responsibility showed significantly more sleeping inter-

ference than high responsibility subjects. But the effects of low

recovery responsibility were diminished with training. Among the low

responsibility subjects, subjects with training tended to show less post-

operative sleeping interference than control subjects. One interpretation

of these findings might be that subjects with low recovery responsibility

do not perform adequate self-care behaviors to promote good recovery,

unless they are given training which defines personal responsibility,

either implicitly or explicitly.

Although these recovery responsibility findings differ from those

reported by George et al. (1980) and Pickett and Clum (Note 2), it is

suspected that these differences may be related to different locus of

control instruments. Whereas Pickett and Clum (Note 2) utilized a

measure of general control over life events and George et al. (1978)

utilized a measure of general control over health-related events, this

present study utilized a rating of perceived responsibility specifically

related to health recovery following illness. Perhaps it may be impor-

tant to specifically assess beliefs about health responsibility when the

dependent measures are postoperative recovery and healing. On the other

hand the number of periodontal surgery subjects with low recovery responsi-

bility scores was small in each treatment group, which limits the generality

of findings. Further research will serve to clarify the effects of









general locus of control and recovery responsibility for measures of

postoperative recovery.


Methodological Issues and Implications for Future Research


Although findings indicated that the cognitive attention redirection

training treatment did facilitate patients' adjustment and recovery, as

compared with control group subjects, it is not known what components of

the training procedure were responsible for the difference between groups.

Both groups were given the expectation that involvement in the project

would be helpful and both completed the same questionnaires. However, it

may be that the 15 minutes of additional direct contact with the experi-

menter in the training group had a distress reducing effect. Or, the

training may have served to distract the subjects. It is noted that in

this study a distracting film was not used, so that untrained subjects

could utilize their own natural coping style. In the future it might be

useful to ascertain the effects of showing a distracting film or having

the experimenter spend 15 minutes just talking with the subjects about

general topics. Since the effect of training may have been to induce

general relaxation, it might have been useful to compare the effect of the

cognitive attention redirection training and relaxation training.

Furthermore, we know only a little about the changes in cognitive

appraisal that may have preceded the obtained differences between groups.

Although this study was not intended to test the theoretical conceptuali-

zation of surgery preparation, this type of cognitive attention redirection

training and obtained results would be consistent with the parallel

response model in which cognitive appraisal mediates emotional and









adaptive behaviors. A difference in adaptive behavior was seen between

trained and control groups, as indicated by trained subjects' more

frequent self-reported thoughts about pleasant things during surgery.

Trained subjects also showed decreased physiological arousal after

training, but they showed no significant changes in self-reported

anxiety. Although these differences in behavior and physiology may

reflect changes in cognitive appraisal, it would be interesting to know

what about the subject's cognitive appraisal changed. Did the subject

perceive greater personal control over recovery following training?

Did the subject's expectation of pain, interference, and unpleasantness

change as a result of training? Or, was the subject simply thinking

about more pleasant things to comply with external demands by the

experimenter? Also, it would be interesting to know to what extent

cognitive appraisal changes within 15 minutes. Future studies might

attempt to determine more specifically what changes in cognitive appraisal

occur in surgery patients following preparation.

The effects of practice and feedback may also be important. In the

training procedure used in this study, subjects were given practice in

shifting their attention to pleasant and relaxing situations. However,

they were not given feedback about their ability to shift to pleasant

thoughts, nor were they given suggestions about how to improve their

ability. Providing practice, feedback, and suggestions might produce

even greater improvements in adjustment and recovery. Also, training

provided more than once and/or several days prior to the surgery would

permit practice over time, and the training approach might be better

integrated into the subject's overall cognitive appraisal of the surgery

situation.









In view of the findings obtained in this study which indicated that

1) previous experience subjects show generally poorer adjustment and

recovery and 2) training improves adjustment for experienced subjects,

it would be interesting to have data about subjects' responses at a

subsequent surgery appointment. Several questions about generalization

of effects might be addressed. Do subjects who were inexperienced at the

time of training at the first surgery show better adjustment/recovery

at the second surgery, instead of showing poorer adjustment/recovery once

they had become experienced? At the next surgery do subjects who had

previously received training when they were experienced maintain their

gains of improved adjustment/recovery? Since periodontal flap surgery

is often performed at separate appointments for each quadrant of the

mouth, patients undergoing periodontal flap surgery would provide an

ideal population with which to explore these questions.

Findings of the present research have suggested several avenues for

further investigation, which were discussed above. Additional studies

are especially needed because of the small sample size and unequal cell

frequencies in this study. Even with significant differences, the

generality of findings are limited and require further exploration.

In sum, future research with larger sample sizes might further explore

the effects of cognitive attention redirection training, components of

training, changes in cognitive appraisal, and generalization of effects

over time. At the same time important effects of repression-sensitization

coping style, previous experience, and other psychological subject

variables should be assessed further.









Concluding Statement


The present research has provided important information about

psychological preparation and subject variables, which influence

periodontal surgery patients' adjustment and recovery. First, the

findings of this study suggest that cognitive attention redirection

training is an effective treatment. Second, findings help to identify

patients who are at high risk for poorer adjustment and recovery:

patients with a sensitizing coping style and/or previous periodontal

surgery experience. Since the periodontal surgeon may see one patient

for several surgeries within a two or three month period, it may be

especially important for the surgeon to be aware of high risk factors

and preparatory techniques which are available to reduce distress and

promote recovery. Furthermore, it may be that preparatory intervention

at that first surgical appointment will interrupt the negative effects

of previous experience at subsequent surgeries.















APPENDIX A
COGNITIVE ATTENTION REDIRECTION TAPED COPING INSTRUCTIONS


Sometimes people are a little anxious before beginning periodontal

surgery. But people can learn coping behaviors which prevent or reduce

stress. Events rarely cause stress by themselves but instead the views

that people take of events and the attention they give those views

determines the stress they experience. Your coping behavior can affect

the amount of stress you experience. For example, imagine that you are

making preparations for special friends to arrive at your home for a

party this evening. As their arrival draws near, you are still in the

middle of preparations when you receive a minor cut on your finger.

Because you are attending to your upcoming party preparations, it is

very unlikely you would notice the cut very much at all. On the other

hand, if you were sitting reading a boring newspaper and received a

paper cut, you might have nursed it attentively for a while. This

example illustrates that people's thoughts and behaviors can influence

the amount of stress they experience.

Today we would like to teach you something you can do to make

your periodontal surgery experience more pleasant and less stressful.

We want to teach you how to focus your attention on positive things,

which are pleasant and calming for you. You will learn to think about

positive things during the periodontal procedure, instead of focusing on

aspects of the surgery procedure which might make you feel nervous or tense.









You should think about pleasant things as much as possible. Thinking

about pleasant things will help you feel calm and relaxed.

Together we need to figure out what kinds of things are pleasant

and calming for you. In a few minutes we will ask you to name a situa-

tion which is pleasant and calming for you. Then you will close your

eyes and imagine the pleasant situation. You will try to get a clear

image of the situation by noticing what features best describe the

situation. The situation should make you feel pleasant and calm, and

your muscles should feel heavy and relaxed. As you imagine the situa-

tion, you should experience a warm and pleasant feeling.

Before we help you identify and imagine situations which are most

pleasant and calming for you, I want to give you an example of how I

imagine a situation which is pleasant and calming for me. For me,

sitting on the beach in the sunshine is very pleasant and calming.

Now I will close my eyes and try to get a clear image of what it is like

on the beach. It is a bright sunny day, and the sky is blue with puffy

white clouds scattered in the sky. I can see the ocean, which has a

deep blue color. I see the waves coming in, and I can hear them

splashing down. The sun is beating down intensely, and I feel warm and

comfortable. My muscles feel very relaxed, and my breathing is slow

and regular. Being on the beach in the sunshine is a very pleasant and

calming image for me.

But what is a pleasant and calming situation for you? Some people

would not find it to be pleasant and calming on the beach. It would

not be pleasant and calming for a person who was afraid of water or for

a person who found the beach to be a boring place. Soon we will turn









off this cassette player and talk with you about situations that are

pleasant and calming for you. You will get a clear image in your mind

of the whole situation.

Remember what we have talked about in the last few minutes. We

have looked at something which you can do to make your periodontal

surgery experience more pleasant and less stressful. By thinking

about pleasant things you will feel more calm and relaxed. Thinking

about pleasant and calming situations may be helpful at any time,

before periodontal surgery, during the surgery procedure, or during

your recovery period. Closing your eyes and forming images of

pleasant situations may be particularly helpful at some points while

you are sitting in the operating chair and the periodontist is working

on your mouth. By thinking of pleasant things you may help to reduce

the amount of stress you experience.















APPENDIX B
TAPED PRACTICE SESSION FOR COGNITIVE COPING INSTRUCTIONS


Now you will practice thinking about pleasant things which may

help you to feel more calm and relaxed. In order to practice this

I will ask you to imagine yourself in several different situations.

Then I will tell you to think about pleasant things, and you will

imagine one of the pleasant situations which you described previously.

I will ask you to visualize three different examples of situations.

After I describe each example, I will say "imagine pleasant things."

You should immediately shift your thoughts and imagine one of the two

pleasant situations which you described earlier.

Now we will start the first example. When I say "imagine pleasant

things," you will shift your thoughts to the first pleasant situation

which you described earlier.

Close your eyes, and visualize yourself at a movie theater. You

are watching a movie in which there is a car accident. A car crashes

into a concrete wall at high speed. Three people in the car are injured,

and you see blood. Now, imagine pleasant things. (A 20-second pause

follows.)

Now I will give you another example. When I say "imagine pleasant

things," you will shift your thoughts to the second pleasant situation

which you described before.









Make sure your eyes are closed, and visualize yourself at the

dentist's office. You are getting ready to have a tooth filled. You

are lying in the dentist's chair, and you can see the drill and hear

its sound as the dentist begins to work on your teeth. Now, imagine

pleasant things. (A 20-second pause follows.)

Now I will give you the last example. When I say "imagine pleasant

things," you will again shift your thoughts to the first pleasant

situation which you described earlier.

Make sure your eyes are closed and visualize that you are in the

periodontal clinic. You are sitting in the operating room chair

beginning periodontal surgery. The periodontist has put some cream

on your gum, so that he can start to give you an injection. Now,

imagine pleasant things. (A 20-second pause follows.)

Before we turn off the cassette player, I want to remind you to

think about pleasant things as much as you can in order to help you

feel relaxed and calm. Remember to shift your thoughts to pleasant and

calming situations. Thinking about pleasant and calming situations may

be helpful at any time before surgery, during the surgery procedure,

or during your recovery period. By thinking of pleasant things you may

help to reduce the amount of stress you experience.















APPENDIX C
PATIENT'S CONSENT FORM


University of Florida
Shands Teaching Hospital
Gainesville, Florida


Patient Consent for Investigational Study of
the Periodontal Surgery Experience


Description of Study:

I have been informed that this study will investigate character-
istics of periodontal patients and their responses to the surgery
experience. In order to determine what the surgery experience is like
for me, I will be asked to answer various questionnaires pre and post-
operatively. Several simple measures of heart rate and palmar sweating
will be taken from my fingers. I will also be asked to take seven
short questionnaires home with me and to complete one questionnaire
each day for seven days postoperatively. I agree to return these
questionnaires at the time of my suture removal appointment. At my
suture removal appointment I will be asked a few additional questions
about the periodontal surgery experience, and measures of heart rate
and palmar sweating will be taken again.

I was assured that there will be no additional discomfort re-
sulting from this experiment and that all data obtained will remain
confidential. Any inquiries I have concerning the procedures will be
answered at any time. I realize that there is no monetary compensation
for my participation in this project. I understand that I am free to
withdraw my consent and to discontinue participation in the project
or activity at any time without prejudice. In the event of my sus-
taining a physical injury which is proximately caused by this experi-
ment, no professional medical care will be provided me without charge.


"I have read and understand the described procedure in which I am to
participate and have received a copy of this description."


Patient's signature Date

Witnessed by Date
















APPENDIX D
A-STATE STATE-TRAIT ANXIETY INVENTORY


DIRECTIONS: A number of statements which people have used to describe
themselves are given below. Read each statement and circle the response
which indicates how you feel right now, that is, at this moment.
There are no right or wrong answers. Do not spend too much time on any
one statement but give the answer which seems to describe your present
feelings best.


A. I feel calm


F. I feel upset


Not at all
Somewhat
Moderately so
Very much so


B. I feel secure


Not at all
Somewhat
Moderately so
Very much so


C. I am tense


Not at all
Somewhat
Moderately so
Very much so


D. I am regretful


Not at all
Somewhat
Moderately so
Very much so


E. I feel at ease


Not at all
Somewhat
Moderately so
Very much so


1. Not at all
2. Somewhat
3. Moderately so
4. Very much so


G. I am presently worrying
over possible misfortunes


1. Not at all
2. Somewhat
3. Moderately so
4. Very much so

H. I feel rested

1. Not at all
2. Somewhat
3. Moderately so
4. Very much so

I. I feel anxious

1. Not at all
2. Somewhat
3. Moderately so
4. Very much so

J. I feel comfortable

1. Not at all
2. Somewhat
3. Moderately so
4. Very much so








K. I feel self-confident

1. Not at all
2. Somewhat
3. Moderately so
4. Very much so

L. I feel nervous

1. Not at all
2. Somewhat
3. Moderately so
4. Very much so

M. I am jittery

1. Not at all
2. Somewhat
3. Moderately so
4. Very much so

N. I feel "high strung"


R. I feel over-excited
and rattled

1. Not at all
2. Somewhat
3. Moderately so
4. Very much so

S. I feel joyful

1. Not at all
2. Somewhat
3. Moderately so
4. Very much so

T. I feel pleasant

1. Not at all
2. Somewhat
3. Moderately so
4. Very much so


1. Not at all
2. Somewhat
3. Moderately so
4. Very much so

0. I am relaxed

1. Not at all
2. Somewhat
3. Moderately so
4. Very much so

P. I feel content

1. Not at all
2. Somewhat
3. Moderately so
4. Very much so

Q. I am worried

1. Not at all
2. Somewhat
3. Moderately so
4. Very much so

*Reproduced by special permission of the Publisher, Consulting Psychologists
Press, Inc., Palo Alto, CA 94306, from The State Trait Anxiety Inventory by
Charles Spielberger, Richard Gorsuch, and Robert Lushene (1968). Further
reproduction is prohibited without the Publisher's consent.




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