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Physiological responsivity to venipuncture and speech giving in insulin-dependent diabetic adolsecents at two levels of diabetes control and their nondiabetic peers

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Title:
Physiological responsivity to venipuncture and speech giving in insulin-dependent diabetic adolsecents at two levels of diabetes control and their nondiabetic peers
Creator:
Gilbert, Brenda, 1947-
Publication Date:
Language:
English
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vii, 86 leaves : ill. ; 29 cm.

Subjects

Subjects / Keywords:
Adolescents ( jstor )
Anxiety ( jstor )
Diabetes ( jstor )
Diabetes complications ( jstor )
Galvanic skin response ( jstor )
Heart rate ( jstor )
Phlebotomy ( jstor )
Psychological stress ( jstor )
Type 1 diabetes mellitus ( jstor )
Type 2 diabetes mellitus ( jstor )
Adaptation, Physiological ( mesh )
Clinical and Health Psychology thesis Ph.D ( mesh )
Diabetes Mellitus, Type I -- Adolescent ( mesh )
Dissertations, Academic -- Clinical and Health Psychology -- UF ( mesh )
Stress, Psychological -- Adolescent ( mesh )
Genre:
bibliography ( marcgt )
non-fiction ( marcgt )

Notes

Thesis:
Thesis (Ph.D.)--University of Florida, 1985.
Bibliography:
Bibliography: leaves 81-85.
General Note:
Typescript.
General Note:
Vita.
Statement of Responsibility:
by Brenda Gilbert.

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University of Florida
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University of Florida
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Copyright [name of dissertation author]. Permission granted to the University of Florida to digitize, archive and distribute this item for non-profit research and educational purposes. Any reuse of this item in excess of fair use or other copyright exemptions requires permission of the copyright holder.
Resource Identifier:
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16878052 ( OCLC )
ACV8816 ( NOTIS )
AA00004874_00001 ( sobekcm )

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PHYSIOLOGICAL RESPONSIVITY TO
VENIPUNCTURE AND SPEECH GIVING IN
INSULIN-DEPENDENT DIABETIC ADOLESCENTS AT TWO LEVELS
OF DIABETES CONTROL AND THEIR NONDIABETIC PEERS






BY






BRENDA GILBERT


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


UNIVERSITY OF FLORIDA


1985




PHYSIOLOGICAL RESPONSIVITY TO
VENIPUNCTURE AND SPEECH GIVING IN
INSULIN-DEPENDENT DIABETIC ADOLESCENTS AT TWO LEVELS
OF DIABETES CONTROL AND THEIR NONDIABETIC PEERS
BY
BRENDA GILBERT
A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN
PARTIAL FULFILLMENT OF THE REQUIREMENTS
FOR THE DEGREE OF DOCTOR OF PHILOSOPHY
UNIVERSITY OF FLORIDA
1985














ACKNOWLEDGMENTS


Special thanks are given to all my committee members

which include Hugh Davis, Ph.D., Randy Carter, Ph.D., James

Johnson, Ph.D., and Barbara Melamed, Ph.D., who have given

steady support and excellent consultation. Barbara

Melamed, Ph.D., and Peter Lang, Ph.D., provided me with

much needed direction in the design of this research and

the selection and analyses of the physiological data.

Janet Silverstein, M.D., Michael Kappy, M.D., and their

coworkers were indispensable in helping me understand

diabetes and select and analyze the metabolic data

collected. The study could not have been accomplished

without the great assistance of my fellow students and

coworkers who helped collect the data. These include Gary

Geffken, Ph.D., Marika Spevack, M.S., Carol Lewis, M.A.,

and Barbara Walker.

Extra special thanks are given to Suzanne B. Johnson,

Ph.D., my "wonderful" chairperson. Her excellent direction

and support were essential to the completion of this

dissertation. In addition, extra special thanks are given

to my husband, David G. Gilbert, Ph.D., who paid my bills

while I worked on my degree and provided steady,

unflinching support.


iii
















TABLE OF CONTENTS


Page

ACKNOWLEDGMENTS................. ........................ iii

ABSTRACT ... ..... ................ ....... ............ vi

CHAPTERS

1 INTRODUCTION ...... ........................... I

Major Hypothees.................................7
Exploratory Investigations......................9

2 METHODOLOGY...................... .. .... ..... ....15

Participants. .... ..................... ... ...... 15
Stress Manipulation Task.....................17
Speeches .............................. ......... 17
Major Dependent Measures ...................... 18
Additional Dependent Measures..................24
Procedure.................. ....... .... ..... 26

3 RESULTS ............................ .......... .... 29

Description of Sample...........................29
Duration of Diabetes and HA1 Values.............29
Time of Day and Location of Data Collection....30
Reliability of Observation Measurement..........30
Subject-Parent LEC Correlations and T-Tests....30
Inter-relationship Between Measures............ 31
Control Variables................................32
Analyses of Major Hypotheese ...................34

4 DISCUSSION AND SUMMARY......................... 46

Reported and Observed Anxiety of Tasks..........47
Physiological Response to Tasks................47
Metabolic Reactivity..............................52
Life Stress and Diabetes Control..............54
Personality Findings .......................... 57
Future Research................................58
Implications. .... ................ ......... ....60










APPENDICES

A SPEECH TOPICS. .............................. 62

B HEART FUNCTIONING...... ............ .............63

C BRIEF NOTE ON SKIN CONDUCTANCE.................66

D VENIPUNCTURE QUESTIONNAIRE............ ........ 67

E VENIPUNCTURE OBSERVATION CHECKLIST.............68

F MANUAL FOR SCORING VENIPUNCTURE OBSERVATION
CHECKLIST AND TIMED BEHAVIOR CHECKLIST-
MODIFIED FORM........................ ........... 69

G RANK ORDER OF TASK FORM......................74

H TIMED BEHAVIOR CHECKLIST-MODIFIED FORM.........75

I PEARSON CORRELATIONS FOR SELECTED MEASURES
IN VENIPUNCTURE, SPEECH I AND SPEECH II
CONTROLLING FOR SEX (PARTIALLED OUT)...........77

J PEARSON PRODUCT MOMENT CORRELATIONS
CONTROLLING FOR SEX BETWEEN EXTRAVERSION
AND NEUROTICISM AND PHYSIOLOGICAL VARIABLES....80

BIBLIOGRAPHY... .............. ...... ......... .. ........ .81

BIOGRAPHICAL SKETCH... ............... ................... 86
















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

PHYSIOLOGICAL RESPONSIVITY TO
VENIPUNCTURE AND SPEECH GIVING IN
INSULIN-DEPENDENT DIABETIC ADOLESCENTS AT TWO LEVELS
OF DIABETES CONTROL AND THEIR NONDIABETIC PEERS

BY

BRENDA GILBERT

August, 1985


Chairperson: Suzanne B. Johnson, Ph.D.
Major Department: Clinical Psychology


Fifteen adolescents with insulin-dependent diabetes in

good diabetes control were yoked with 15 insulin-dependent

adolescents in poor control matched for age, sex, duration

of diabetes, and race. The same number of nondiabetic

adolescents matched for age and sex were included.

Participants were involved in three stressful tasks

(venipuncture and two speeches). Each task was preceded by

a rest period and followed by a recovery period. Both

speeches were preceded by a plan period. Observational,

physiological (heart rate, skin conductance, blood and

urine measures), and self-report data were collected. Life

stress and personality information were collected.

Diabetic adolescents in poor control had higher heart rates










across all conditions but no differences in skin

conductance were found. Diabetic adolescents had less

desirable blood and urine outcomes compared to the

nondiabetic youth with the adolescents with poor diabetes

control having the least desirable outcomes. No

differences in life stress between groups were found.

Adolescents with well-controlled diabetes were less

neurotic than the nondiabetic adolescents.


vii
















CHAPTER I
INTRODUCTION



A substantial number of people with insulin-dependent

diabetes have difficulty adequately controlling this

disease. They feel sick, miss school or work and have

serious problems carrying out normal activities. One very

serious, even life threatening, consequence of poor control

is ketoacidosis (Cahil, Etzwiler & Freinkel, 1976).

Repeated episodes of ketoacidosis are associated with

retinopathy and kidney failure. The increased incidence of

poor control and ketoacidosis in 12-18 year olds is well-

documented (Fallstrom, 1974; Koski & Kumento, 1975). The

relationship between the psychosocial and physiological

changes of adolescence and poor control in youngsters with

insulin-dependent diabetes is not entirely clear. The

question of what contributes to the onset and maintenance

of poor control and associated ketoacidotic symptoms in

some adolescents while others remain healthy is important

in our efforts to successfully manage this chronic illness.

Stress has been frequently implicated in cases of poor

diabetic control. Patients with insulin-dependent diabetes

may be particularly susceptible to stressful events because

they lack insulin, a hormone that counters other "stress"






2



hormones. More specifically, in both diabetic and

nondiabetic persons, stress results in increased levels of

catecholamines (epinephrine and norepinephrine). When

catecholamines are released into the blood a complex series

of events occurs. First, gluconeogenesis is stimulated

which increases blood glucose. Second, catecholamines act

directly on fat cells to increase lipolysis (fat breakdown

and mobilization of free fatty acids (FFA)).

Catecholamines also result in increased glucagon, which, in

turn, stimulates gluconeogenesis and ketogenesis in the

liver (Tarnow & Silverman, 1981-82).

Once the stress is over, there is typically an

increase in insulin production which "counters" the stress

hormones and permits the body to return to a normal

metabolic state. However, the youngster with diabetes does

not produce his own insulin and may not be able to counter

the effects of the stress hormones. Although exogenous

insulin replacement is helpful, the youngster is still left

with a system insensitive to rapidly changing stress

related blood glucose or ketone levels. When this system

is unable to effectively counteract the stress hormones,

ketoacidosis may result. Ketones (B-hydroxybutyric acid

and acetone) are produced in the liver from fatty acids

(fatty acids -> acetyl-Co A -> acetoacetyl-Co A -> B-

hydroxybutyric acid and acetone). Ketones provide a source

of energy, but in excessive amounts produce a low plasma










eventually the problems with diabetic control returned

(Minuchin, Rosman & Baker, 1978).

Only a few studies have compared the effects of stress

in diabetic and nondiabetic subjects. Hinkle and Wolf

(1952) assessed nondiabetic and diabetic adult and

adolescent responses to a stressful interview and a

nonstressful control period. Both groups showed similar

responses in blood ketone production and urine output.

However, diabetics with elevated ketone levels in the

nonstressful control period exhibited a particularly

exaggerated increase in ketones when stressed.

Vandenbergh, Sussman, and Titus (1966) performed a similar

study comparing diabetic and nondiabetic adults' reactions

to an unpredictable shock. Both groups responded with

increases in FFA levels and urine volume, although the

increases were not significantly different between stress

and nonstress periods. However, this lack of difference

may have been a result of their small sample size (i.e.,

n = 6 in each group).

The work of Hinkle and Wolf (1952) and Vandenburgh et

al. (1966) suggest that increased free fatty acid

production is a likely result of stress. However, a number

of questions remain. First, it is unclear whether the

responses of insulin-dependent patients are different from

subjects having adult-onset diabetes. Most of the subjects

studied were adults, not adolescents, and the effects of




4
eventually the problems with diabetic control returned
(Minuchin, Rosman & Baker, 1973).
Only a few studies have compared the effects of stress
in diabetic and nondiabetic subjects. Hinkle and Wolf
(1952) assessed nondiabetic and diabetic adult and
adolescent responses to a stressful interview and a
nonstressful control period. Both groups showed similar
responses in blood ketone production and urine output.
However, diabetics with elevated ketone levels in the
nonstressful control period exhibited a particularly
exaggerated increase in ketones when stressed.
Vandenbergh, Sussman, and Titus (1966) performed a similar
study comparing diabetic and nondiabetic adults reactions
to an unpredictable shock. Both groups responded with
increases in FFA levels and urine volume, although the
increases were not significantly different between stress
and nonstress periods. However, this lack of difference
may have been a result of their small sample size (i.e.,
n = 6 in each group).
The work of Hinkle and Wolf (1952) and Vandenburgh et
al. (1966) suggest that increased free fatty acid
production is a likely result of stress. However, a number
of questions remain. First, it is unclear whether the
responses of insulin-dependent patients are different from
subjects having adult-onset diabetes. Most of the subjects
studied were adults, not adolescents, and the effects of








problems). Each group observed their parents discussing

unresolved family problems and later joined their parents

in this discussion. A major finding in this research

endeavor was that in the psychosomatic group the

adolescents with diabetes produced higher levels of FFA

which took longer to return to baseline when compared to

youngsters in the other groups. The psychosomatic

adolescents also produced higher FFA levels than their

parents which remained elevated after their parents' FFA

levels had returned to the baseline level (Minuchin et al.,

1978). No similar difference was found for the normal or

behavior problem diabetic groups.

The findings of Minuchin et al. (1978) support the

notion that a subgroup of insulin-dependent diabetic youth

have exaggerated response patterns to stress. Their

findings suggest that there are no major metabolic response

differences between well-controlled insulin-dependent

diabetic youngsters and their parents. However, only a

small number of patients were studied and the criteria for

placement in study groups (psychosomatic, normal, behavior

problem) was not clearly specified. Consequently, it is

unclear how many youngsters in poor diabetic control have

the "psychosomatic" or heightened stress reactivity that

Minuchin et al. postulate.

To summarize the main points made thus far, stress

exposure leads to metabolic changes associated with insulin




6
problems). Each group observed their parents discussing
unresolved family problems and later joined their parents
in this discussion. A major finding in this research
endeavor was that in the psychosomatic group the
adolescents with diabetes produced higher levels of FFA
which took longer to return to baseline when compared to
youngsters in the other groups. The psychosomatic
adolescents also produced higher FFA levels than their
parents which remained elevated after their parents' FFA
levels had returned to the baseline level (Minuchin et al.,
1978). No similar difference was found for the normal or
behavior problem diabetic groups.
The findings of Minuchin et al. (1978) support the
notion that a subgroup of insulin-dependent diabetic youth
have exaggerated response patterns to stress. Their
findings suggest that there are no major metabolic response
differences between well-controlled insulin-dependent
diabetic youngsters and their parents. However, only a
small number of patients were studied and the criteria for
placement in study groups (psychosomatic, normal, behavior
problem) was not clearly specified. Consequently, it is
unclear how many youngsters in poor diabetic control have
the "psychosomatic" or heightened stress reactivity that
Minuchin et al. postulate.
To summarize the main points made thus far, stress
exposure leads to metabolic changes associated with insulin


7
efficiency in both nondiabetic and diabetic persons. These
metabolic changes are related to sympathetic increases of
epinephrine and norepinephrine production although other
body hormones and transmitter substances are involved. The
normal person has finely-tuned metabolic processes which
act to keep their metabolic responses within normal
limits. However, due to the insulin-dependent diabetic
individual's inefficient insulin response capability, more
extreme metabolic responses may become more likely.
Evidence to date suggests that at least some subgroups of
diabetics may be more metabolically reactive than other
groups, although the relationship between metabolic
responsivity and control level has not been clearly
specified. There is less evidence to suggest clear-cut
response differences between diabetics as a group and
nondiabetics, although this hypothesis has received little
research attention.
Major Hypotheses
The primary purpose of the present investigation was
to study the effects of stress on youngsters with insulin-
dependent diabetes. The stress responses of youngsters
with well-controlled diabetes were compared to youngsters
in poor control and both diabetic groups were compared to
nondiabetic adolescents. Self-report, behavioral,
psychophysiological, and metabolic effects of stress were
assessed. Few differences on any of the measures were


8
expected between the well-controlled diabetic youngsters
and their nondiabetic counterparts. In contrast, those
youngsters in poor control were expected to show greater
psychophysiological and metabolic reactivity to stress than
either of the two other groups.
The study's hypotheses were as follows:
1. Compared to well controlled diabetics or
nondiabetics, insulin-dependent diabetic
adolescents in poor control who are stressed in a
laboratory setting will exhibit (a) heightened
metabolic reactivity, (b) heightened
psychophysiological reactivity, and (c) slower
rates of psychophysiological recovery subsequent to
the stressful experience.
2. Well controlled diabetics will show increased
metabolic effects to stress compared to nondiabetic
normals.
3. Few differences between groups are expected on the
self and behavioral measures of stress and
anxiety. However, should differences exist they
should be between the poorly controlled diabetic
youngsters and the other two groups. If youngsters
in poor diabetic control are more stress-reactive,
they may acknowledge greater stress and appear more
anxious to an observer.


9
The present investigation differs from past attempts
to study the effects of stress on persons with diabetes in
a number of important respects. First, only insulin-
dependent adolescents were studied. Second, distinctions
between those in good versus poor control were made.
Third, in both groups of youngsters with diabetes the
youngster and parent confirmed that the prescribed insulin
dose was given the night before and morning of the
experiment. Fourth, self-report, behavioral, and
psychophysiological effects of the stress were measured.
In past research efforts, no attempt has been made to
quantify the stress experienced by the subject either
through subjective ratings or by more objective behavioral
or psychophysiological measurement. And finally, a sample
size of fifteen subjects per group was obtained.
Exploratory Investigations
In addition to the major purposes and hypotheses
outlined previously, this study explored two other
variables potentially related to diabetes control. These
are life stress and the personality dimensions of
extraversin and neuroticism.
Life Stress
Evidence has accumulated suggesting that diabetic
adolescents with high scores on a life stress/change scale
or who have lost a parent show increased ketoacidosis and
related symptoms (Chase & Jackson, 1981; Koski & Kumento,


10
1975). Bradley (1979) found that the number of stressful
life events was associated with diabetes control in
adults. Furthermore, the insulin treated group had higher
levels of diabetes disturbance (glycosuria, prescription
changes, and clinic visits) compared to the tablet treated
group, although there was little difference between
reported levels of life stress in the two groups.
These findings support the hypothesis that life stress
is associated with diabetes control particularly in
insulin-dependent diabetics.
Introversion-Neuroticism
Hans Eysenck (1967) has postulated two basic
dimensions of personality (introversion-extraversion and
stability-neuroticism) based on biological inheritance and
its interaction with environmental learning (Eysenck,
1967). His neuroticism dimension measures emotional
responsivity and reactivity and he suggests that this
dimension may be involved in psychosomatic disorders
(Eysenck, 1967). Persons high on neuroticism have low
tolerance for stress, whether physical or psychological,
tend to avoid stressful stimuli, and are "overly emotional,
reacting too strongly to all sorts of stimuli, and find it
difficult to get back on an even keel after each
emotionally arousing experience" (Eysenck & Eysenck, 1975,
p. 5). Furthermore, Eysenck (1967) suggests that whereas
introversion-extraversion is associated with cortical








men, both agree introversion should predispose an

individual toward increased emotional responding; Eysenck

via increased cortical arousal leading to earlier awareness

of more subtle threatening cues, and Gray via a

biologically increased sensitivity to aversive and

frustrative-nonreward cues. Gray's issue is not with the

validity of Eysenck's scales, but with the choice of factor

rotation and the nature of the underlying biological

predisposition.

In summary, high introversion and neuroticism may

predispose insulin-dependent diabetics toward higher

autonomic arousal and slower return to baseline. This

autonomic over-reactivity may predispose them toward more

diabetic control problems. It is interesting to note that

the two personality descriptions (from parental ratings)

that Simonds (1977) found to differentiate well controlled

from poorly controlled diabetic youth were anxious and

depressed. These are the same personality trait terms that

Eysenck (1967) uses to describe an introverted neurotic or

dysthymic personality. Due to the strong association

between sympathetic reactivity and neuroticism hypothesized

by Eysenck, it is reasonable to expect that if this

relationship exists it would show up in a diabetic

population where sympathetic influences may be magnified by

an easily disrupted metabolic system.




12
men, both agree introversion should predispose an
individual toward increased emotional responding; Eysenck
via increased cortical arousal leading to earlier awareness
of more subtle threatening cues, and Gray via a
biologically increased sensitivity to aversive and
frustrative-nonreward cues. Gray's issue is not with the
validity of Eysenck's scales, but with the choice of factor
rotation and the nature of the underlying biological
predisposition.
In summary, high introversion and neuroticism may
predispose insulin-dependent diabetics toward higher
autonomic arousal and slower return to baseline. This
autonomic over-reactivity may predispose them toward more
diabetic control problems. It is interesting to note that
the two personality descriptions (from parental ratings)
that Simonds (1977) found to differentiate well controlled
from poorly controlled diabetic youth were anxious and
depressed. These are the same personality trait terms that
Eysenck (1967) uses to describe an introverted neurotic or
dysthymic personality. Due to the strong association
between sympathetic reactivity and neuroticism hypothesized
by Eysenck, it is reasonable to expect that if this
relationship exists it would show up in a diabetic
population where sympathetic influences may be magnified by
an easily disrupted metabolic system.


13
Although Eysenck's personality theory has not been
applied to problems of diabetic control in insulin-
dependent youth, there is extensive literature assessing
psychophysiological reactivity in introverts and neurotics
compared to other control groups. For example, Stelmack
(1981) concluded that differences in electrodermal activity
between introverts and extroverts has support with
electrodermal activity generally greater for introverts and
electrodermal habituation faster for extroverts. In a
sample of college women, Harvey and Hirshmann (1980) found
significant heart rate differences for introverted-neurotic
and extraverted-stable groups who viewed slides of violent
death. The introverted-neurotic groups exhibited heart
rate increase whereas their counterparts showed heart rate
deceleration.
Some additional evidence exists suggesting a
relationship between neuroticism and reported illness.
Denny and Frisch (1981) found neuroticism to be a predictor
of self-reported illness in two samples of college
students. Akerstedt and Theorell (1976) found increased
physical complaints from neurotic vs. stable railway
workers (utilizing Eysenck's personality scale) who were
switched from day to night shifts. (Eysenck's scale was
administered prior to the shift change.) Less direct
evidence for a relationship between neuroticism and illness
comes from a study by Mehrabian and Ross (1977). These














CHAPTER 2
METHODOLOGY



Participants

Participants consisted of adolescents with insulin-

dependent diabetes and nondiabetic adolescents aged

11-18. Diabetic participants were obtained from lists of

patients treated through the North Florida Regional

Diabetes Program located at the J. Hillis Miller Health

Center, Gainesville, Florida; the University of South

Florida Diabetes Program located in Tampa, Florida; and

lists of campers attending a summer camp for diabetic

youngsters run by these two programs. The nondiabetic

youth were recruited from aged 12-18 students at the P.K.

Yonge School associated with the University of Florida and

through staff at the J. Hillis Miller Health Center.

Subjects were contacted based on their hemoglobin Al

(HA1) values, a physiological measure used to assess

diabetes control over several weeks time (Tarnow and

Silverman, 1981-82). The HA1 is a measure of the amount of

glucose adhering to hemoglobin in the blood and reflects

amount of blood glucose over a period of time. In this

study, adolescents in good diabetic control had HA1 values










of 12 or less and those in poor control had values 15 or

over. These cutoff scores are based on Harkavy's (1981)

study in which similar scores discriminated good and poor

control as defined by diabetologists' ratings. The HA1

value obtained at the time of the study served as the final

criterion and in three cases a participant whose HA1 was

slightly above 12 was kept as a good control subject if

his/her match had a value above 16.

All adolescents having diabetes at least one year and

meeting the HA1 criteria for good control were asked to

participate if a potential poor control match could be

identified. Participants were matched on sex, age, race,

and duration of diabetes. Matched subjects had to be of

the same sex, within 2 years of age, and of the same ethnic

group (except in one case where a white male was

substituted for a black male). Poor control subjects could

not have had diabetes more than 1 year longer than their

counterparts.

Each potential subject and his/her parent indicated

that the recommended insulin dose was regularly

administered and specifically acknowledged that the

required dose was administered at the regular time the

night before and the morning of the experimental session.

If the subject or parent indicated that this was not the

case, the adolescent was not used as a subject. This

occurred with two potential poor control subjects.




16
of 12 or lass and those in poor control had valas 15 or
over. These cutoff scores are based on Harkavy's (1981)
study in which similar scores discriminated good and poor
control as defined by diabetologists' ratings. The HA1
value obtained at the time of the study served as the final
criterion and in three cases a participant whose HA1 was
slightly above 12 was kept as a good control subject if
his/her match had a value above 16.
All adolescents having diabetes at least one year and
meeting the HA1 criteria for good control were asked to
participate if a potential poor control match could be
identified. Participants were matched on sex, age, race,
and duration of diabetes. Matched subjects had to be of
the same sex, within 2 years of age, and of the same ethnic
group (except in one case where a white male was
substituted for a black male). Poor control subjects could
not have had diabetes more than 1 year longer than their
counterparts.
Each potential subject and his/her parent indicated
that the recommended insulin dose was regularly
administered and specifically acknowledged that the
required dose was administered at the regular time the
night before and the morning of the experimental session.
If the subject or parent indicated that this was not the
case, the adolescent was not used as a subject. This
occurred with two potential poor control subjects.








paper was available for notetaking in the plan period. The

topics were "the last big argument I had or my most recent

big disappointment" and "a recent fun or pleasant time I

had or something very nice that happened to me." See

Appendix A for the instructions that accompanied each

topic. Each subject was told that the speech would be

videotaped and a small audience would listen. At least one

male and female were present during speech giving. Matched

subjects were yoked to the same speech order and the order

of the two speeches was alternated between sets of matched

subjects. If a subject "froze" in his speech, one of the

audience would say a phrase designed to keep the talk

going. Examples included "tell us some more about that,"

"keep going," "what else." Generally the audience was

supportive and friendly and listened to the subject with an

interested affect.


Major Dependent Measures

Heart Rate

One sympathetic response to emotional stress is

increased heart rate. Increased heart rate has been used

as an indicant of emotional arousal and remains sensitive

across several consecutive stressors punctuated by brief

rest periods (Harvey & Hirschmann, 1980; Shipman, Heath &

Oken, 1979).

Whether or not heart rate accelerates or decelerates

is greatly dependent on the nature of the task or




18
paper was available for notetaking in the plan period. The
topics were "the last big argument I had or my most recent
big disappointment" and "a recent fun or pleasant time I
had or something very nice that happened to me." See
Appendix A for the instructions that accompanied each
topic. Each subject was told that the speech would be
videotaped and a small audience would listen. At least one
male and female were present during speech giving. Matched
subjects were yoked to the same speech order and the order
of the two speeches was alternated between sets of matched
subjects. If a subject "froze" in his speech, one of the
audience would say a phrase designed to keep the talk
going. Examples included "tell us some more about that,"
"keep going," "what else." Generally the audience was
supportive and friendly and listened to the subject with an
interested affect.
Major Dependent Measures
Heart Rate
One sympathetic response to emotional stress is
increased heart rate. Increased heart rate has been used
as an indicant of emotional arousal and remains sensitive
across several consecutive stressors punctuated by brief
rest periods (Harvey & Hirschmann, 1980; Shipman, Heath &
Oken, 1979).
Whether or not heart rate accelerates or decelerates
is greatly dependent on the nature of the task or


stimulus. Siddle and Turpin (1980) point out that heart
rate decelerates in response to simple stimuli and
accelerates to intense or threatening stimuli, during
periods of word association tasks, and during mental
arithmetic tasks. Heart rate increases in both the
anticipatory and performance phases of public speaking
(Borkovec & O'Brien, 1977; Knight & Borden, 1979; Levenson
Jaffee & McFall, 1978). Please refer to Appendix B for a
brief discussion of the heart and primary theories
regarding its regulation.
Heart rate data were collected on a Lafayette four-
channel datagraph. Paper speed was 10 mm/sec. Heart rate
was obtained by counting the systolic spikes associated
with the cardiac contraction of the recorded pulses of the
photoplethysmographic transducer. The photoplethysmo-
grapnic transducer was attached to the thumb of the left
hand unless this arm held the heparin lock, in which case
it was attached to the thumb of the right hand.
Heart rate in beats per minute (bpm) was tabulated fo
each 1-minute segment of each period. Each period except
blood withdrawal (rest, plan, speech, recovery) lasted 3
minutes. Blood withdrawal lasted 2 minutes. The mean
heart rate of each period served as the respective period
score (rest, blood withdrawal, recovery, plan, and speech)








each period the mean of the skin conductance levels was

calculated and served as the score for each period. The

number of spontaneous conductance fluctuations equaling or

exceeding 0.1 micromhos was counted for each 5-minute

phase.

Blood Measures (FFA and Glucose)

Free fatty acids (FFA) and blood glucose increase in

response to stressful stimuli and are related to metabolic

disruption in diabetes (Tarnow & Silverman, 1981-82).

These blood measures were analyzed from blood samples drawn

at the beginning and end of the experimental session.

Urine Measures (Ketones, Glucose, and Volume)

Ketones increase in response to stress (Tarnow &

Silverman, 1981-82) and urine volume and urine sugar have

been shown to increase in response to stress exposure

(Hinkle & Wolf, 1952; Vandenbergh et al., 1966). These

urine measures were analyzed from urine samples taken at

the beginning and end of the experimental session-task

manipulations.

Venipuncture Questionnaire (VQ)

The VQ is a two-item Likert scale developed by the

researcher to allow the participant to rate venipuncture

(see Appendix D). The participant rated the task on two 5-

point scales asking how bothered by and painful the

venipuncture procedure was for them.










State Trait Inventory for Children (STAIC)

The state portion of the STAIC was administered to all

adolescents after each of the three tasks. The STAIC is

designed to measure both transitory anxiety specific to

stressful events (state anxiety) and stable anxiety with

consistency and permanence across time and events (trait

anxiety). Only the 20-item state anxiety portion of the

instrument was used in this study. The state portion of

the STAIC has good split-half reliability, r = .89 (Finch,

Montgomery & Deardorff, 1974), and has shown changes as a

function of stress (Bedell & Roitzch, 1976; Finch, Kendall,

Montgomery & Morris, 1975). The STAIC has been used

predominantly with children aged 8 and over. The STAIC was

orally administered and the subject responded to the task

portion of the procedure (blood withdrawal, speech).

Venipuncture Observation Scale (VOS)

The VOS was developed by the researcher to assess

observed anxiety in the venipuncture situation.

Appropriate items were selected from the Self-Injection

Behavior Profile Rating Scale (previously developed by the

researcher and S. Johnson, 1982). Other items were

developed from observed signs of nervousness noted by

medical staff involved in venipuncture. Ratings were

obtained from videotaped venipuncture session and

interrater reliabilities were obtained. Presence or

absence of each item was assessed for each 20 second










interval. Please see Appendices E and F for the VOS and

scoring procedure.

Rank Order of Task Form (ROTF)

The ROTF is a form developed by the researcher to

allow the participant to rank order the tasks from most

stressful to least stressful (Appendix G).

Personal Report of Confidence as Speaker
Short Form (PRCS)

The PRCS is a 50-item questionnaire revised by Paul

(1966) from an earlier and longer version in order to

improve the form's psychometric properties and make its

completion easier and quicker for the informant. The

instrument is designed to assess self-reported public

speaking anxiety.

Time Behavioral Checklist for Performance
Anxiety (TBCL) Modified Form

The TBCL was developed by Paul (1966) to assess

performance anxiety exhibited during a public speaking

exercise. The instrument lists 20 observable

manifestations of anxiety and is scored for their presence

or absence during consecutive 20-second observation

periods. The TBCL assesses behaviors reflecting

interference with performance (e.g., stammering) and

observable effects of arousal on behavior (e.g., heavy

breathing). The TBCL was modified by deleting items that

were inappropriate for videotaped speeches by seated

persons (e.g., pacing). Several items were added from










other facial rating protocols by Ekman and Friesen (1975)

including miserable smile and facial emblem negative. Paul

(1966) reports the average interobserver reliability after

training exceeded r = .95. Other investigators using the

TBCL have reported interrater reliabilities after training

between .71 to .96 (Ciminero, Calhoun & Adams, 1977).

Ratings were obtained from videotaped performances and

interrater reliabilities computed. Raters were trained

prior to scoring. See Appendices F and H for TBCL-M form

and scoring procedures.


Additional Dependent Measures

Junior Eysenck Personality Questionnaire (JEPQ)

The JEPQ is a personality inventory designed to

measure extraversion, neuroticism, psychoticism, and

conventionality for children aged 7-15 (Eysenck & Eysenck,

1978). Only the neuroticism, extraversion, and

conventionality scales were used. Six month test-retest

reliabilities for each scale by age and sex are as

follows: extraversion range--.38-.82, with all remaining

coefficients in the .60's and .70's; neuroticism range--.66

to .77, the conventionality scale range--.59 to .83; with

all remaining coefficients in the .60's and .70's. One

month test-retest reliabilities were considerably higher

with a range across scales by age and sex of .59 to .89,

with most coefficients in the .70's and .80's.










The JEPQ is an extension for children of the EPQ with

normative and reliability data available, but lacking

extensive validational studies. A manual to help interpret

scores is available.

Eysenck Personality Questionnaire (EPQ)

The EPQ is a personality inventory designed to measure

the same personality factors as the JEPQ in adults aged 16

and older. The extraversion, neuroticism, and

conventionality scales of the EPQ were administered to the

16-18 year-old subjects. One month test-retest

reliabilities by group and scale are primarily in the

.80's, with a range of .72 to .92; overall reliability

coefficients were as follows: extraversion was .90 and

.86; neuroticism was .89 and .80; and conventionality was

.86 and .86, for men and women, respectively. The

extraversion and neuroticism scale were produced through

factor analytic procedures and are orthogonal factors.

Eysenck and Eysenck (1975) report that others have

reproduced this factor pattern and they report validity

data using twin and other experimental studies (Eysenck &

Eysenck, 1975). A manual to help interpret scores is

available.

Life Events Checklist (LEC)

The LEC is a 46-item (plus four blank spaces for

individual responses) inventory of significant life events

for adolescents (Johnson & McCutcheon, 1980). The




25
The JEPQ is an extension for children of the EPQ with
normative and reliability data available, but lacking
extensive validational studies. A manual to help interpret
scores is available.
Eysenck Personality Questionnaire (EPQ)
The EPQ is a personality inventory designed to measure
the same personality factors as the JEPQ in adults aged 16
and older. The extraversin, neuroticism, and
conventionality scales of the EPQ were administered to the
16-18 year-old subjects. One month test-retest
reliabilities by group and scale are primarily in the
,80s, with a range of .72 to .92; overall reliability
coefficients were as follows: extraversin was .90 and
.86; neuroticism was .89 and .80; and conventionality was
.86 and .86, for men and women, respectively. The
extraversin and neuroticism scale were produced through
factor analytic procedures and are orthogonal factors.
Eysenck and Eysenck (1975) report that others have
reproduced this factor pattern and they report validity
data using twin and other experimental studies (Eysenck &
Eysenck, 1975). A manual to help interpret scores is
available.
Life Events Checklist (LEC)
The LEC is a 46-item (plus four blank spaces for
individual responses) inventory of significant life events
for adolescents (Johnson & McCutcheon, 1980). The








electrodes were avoided and attempts were made to use

nonthreatening and understandable words to explain the

different pieces of equipment (videorecorder and camera,

physiograph, leads). Although visible, the tray with

venipuncture equipment was placed somewhat behind the

youngster. The adolescent was seated in a comfortable

chair and the heart rate and skin conductance electrodes

were attached to the hand. Then the participant was asked

to close his/her eyes and rest for 3 minutes. Afterward

the videorecorder was turned on and the heparin lock

inserted. When the venipuncture procedure was completed,

the recorder was turned off and the adolescent asked to

rest with closed eyes for 3 minutes. After the recovery

period, the following questionnaires were administered (by

the researcher reading the items outloud): STAIC (applied

to blood withdrawal), VQ, JEPQ or EPQ, LEC, and PRCS.

After completion of the questionnaires which took about 30

minutes, the 3-minute baseline rest for the first speech

took place, followed by presenting the topic to the subject

and giving him/her 3 minutes to plan the speech. Then the

audience came in the room, the videorecorder was turned on,

and the adolescent gave the speech. This was followed by

the 3-minute recovery period. The STAIC (for the speech)

was administered a second time. Then the same procedure

was followed for the second speech. After the recovery

period for the second speech, the STAIC (for the second






28



speech) was readministered and the final blood withdrawal

done and heparin lock discontinued. The ROTF was

administered, the electrodes were removed from the

youngster's hand, and the Peabody Picture Vocabulary Test

was given. The participant was debriefed and paid.
















CHAPTER 3
RESULTS



Description of Sample

Forty-five adolescents participated including 18

females, 27 males, 8 black and 37 nonblack subjects. Each

good control diabetic subject (GCDS) was yoked to a same

sex, same race subject with the exception of one black GCDS

whose poor control diabetic subject (PCDS) match was

nonblack.

An ANOVA was performed for age and no significant

difference' between groups was found (F(2,42) = .616, p =

.54). Mean ages by group were GCDS--14.75 years, PCDS--

13.92 years, and nondiabetic subjects (NDS)--14.33 years.

The range of age was 11 to 18.8 years.


Duration of Diabetes and HA1 Values

A t-test was computed to determine differences between

GCDS and PCDS in duration of diabetes. No significant

differences were found (t(28) = .82, p = .421). The mean

number of years for duration of diabetes for the GCDS was

5.62 and for the PCDS 4.47.

A t-test showed significant difference for HA1 values

between the GCDS and PCDS (T = -9.77, P < .001). The mean










value for the GCDS was equal to 11.26 with a range of 8.5

to 13. The mean value for the PCDS was equal to 16.23 with

a range of 15 to 18.5.


Time of Day and Location of Data Collection

A 3 X 3 chi-square statistic was computed and no

evidence emerged suggesting differences between groups in

time of day subjects were run (chi-square = 3.6, p = .50).

An equivalent number of GCDS and PCDS were run in

Gainesville and in clinics outside Gainesville. Eight GCDS

and eight PCDS were run in Gainesville and the remaining

seven in each group outside Gainesville. All NDS were run

in Gainesville.


Reliability of Observation Measurement

Pearson product moment correlations were computed for

interscorer reliability of observed anxiety (VOC, TBCL).

The following reliability coefficients were obtained: for

the VOC, r = .79, p < .001; for the first speech (TBCL), r

= .75, P < .001; and for the second speech (TBCL), r = .71,

p < .001. No significant differences were found between

scorers with t values and probabilities as follows: VOC (t

= .94, P = .36); first speech TBCL (t = .66, p = .52); and

second speech TBCL (t = 1.6, p = .13).


Subject-Parent LEC Correlations and T-Tests

Pearson product moment correlations were computed

between the subject and parent forms of the LEC. Pearson




30
value for the GCDS was equal to 11.26 with a range of 8.5
to 13* The mean value for the PCDS was equal to 16.23 with
a range of 15 to 18.5.
Time of Day and Location of Data Collection
A 3 X 3 chi-square statistic was computed and no
evidence emerged suggesting differences between groups in
time of day subjects were run (chi-square = 3.6, p = .50).
An equivalent number of GCDS and PCDS were run in
Gainesville and in clinics outside Gainesville. Eight GCDS
and eight PCDS were run in Gainesville and the remaining
seven in each group outside Gainesville. All NDS were run
in Gainesville.
Reliability of Observation Measurement
Pearson product moment correlations were computed for
interscorer reliability of observed anxiety (VOC, TBCL).
The following reliability coefficients were obtained: for
the VOC, _r_ = .79 p < .001; for the first speech (TBCL), _r_
= .75, P < .001; and for the second speech (TBCL), _r_ = .71,
p < .001. No significant differences were found between
scorers with t values and probabilities as follows: VOC (_t_
= .94, p = .36); first speech TBCL (t_ = .66, p = .52); and
second speech TBCL (_t_ = 1.6, p = .13).
Subject-Parent LEC Correlations and T-Tests
Pearson product moment correlations were computed
between the subject and parent forms of the LEC. Pearson








ranged from no relationship to .52 (observed video anxiety

for venipuncture with rated venipuncture pain).


Control Variables

Speech Fear (PRCS)

No significant differences were found between the

three groups on reported speech fear (PRCS) using a oneway

ANOVA (F(2,42) = .51, p < .60). The following mean scores

by experimental group were found: GCDS = 11.47, PCDS =

10.67, NDS = 13.20; where the higher the score, the more

fear indicated.

Venipuncture Fear (VQ)

An ANOVA was computed between all groups for rated

venipuncture fear (VQ) and no statistically significant

differences emerged (F(2,42) = 1.58, p < .22). The

following mean ratings by experimental group were found:

GCDS = 4.33, PCDS = 3.93, NDS = 3.60; where the lower the

score, the more fear indicated.

Venipuncture Pain (VQ)

An ANOVA was computed between all groups for

venipuncture pain and no statistically significant

difference occurred (F(2,42) = .16, p = .85). The mean

ratings by experimental group were as follows: GCDS =

4.13, PCDS = 4.00, NDS = 3.93; where the lower the score,

the more pain indicated.










Venipuncture Observation Scale (VOS)

An ANOVA was computed for observed venipuncture

anxiety for all groups and no statistically significant

differences were found (F(2,28) = 1.60, p = .22).

Observed Speech Anxiety (TBCL)

An ANOVA was computed between all groups for observed

speech anxiety for both speeches. No statistically

significant differences were found for either speech [first

speech--(F(2,34) = .327, p = .72), second speech--(F(2,33)

= .03, p = .97)].

Reported Anxiety (STAIC) for Venipuncture and Speeches

An ANOVA was computed between all groups for the STAIC

for venipuncture and no statistically significant results

emerged (F(2,42) = .44, P = .65). ANOVAs were performed on

the STAIC administered for each of the speeches. No

significant differences were found for the second speech

(F(2,42) = .28, p = .76) but a tendency toward significance

occurred on the first speech (F(2,42) = 2.96, p = .06). A

Duncan's Range Test at the .05 level of significance showed

the PCDS reported more anxiety than the GCDS. Means for

the three groups are as follows: GCDS = 33.73, PCDS =

40.13, NDC = 35.67.

Rank Order of Task Form (ROTF)

Two 3 X 3 chi-square statistics were computed for the

rank order of tasks by subjects. The first chi-square

analysis found no difference between groups in rank










ordering venipuncture, first speech, and second speech

(chi-square = 5.4, P < .50). The second analysis found no

difference between groups in rank ordering venipuncture,

the speech on a pleasant topic, or the speech on an

unpleasant topic (chi-square = 6.0, p < .20).

Speech Order and Heart Rate

A 5 X 2 X 4 repeated measures ANOVA was computed for

experimental group, speech order and period (rest, plan,

speech, recovery) for both speeches. No main or

interaction effects were found for speech order in either

speech (F(1,37) = 1.17, p = .29) and (F(1,39) = .59, P =

.45), respectively.

Speech Order and Skin Conductance

A 3 X. 2 X 4 repeated measures ANOVA was performed for

experimental group, speech order, and period (rest, plan,

speech, recovery) for both speeches. No significant

differences were found for speech order in either speech

(F(1.38) = 1.76, p = .19) and (F(1,37) = 2.87, p = .10),

respectively.


Analyses of Major Hypotheses

Heart Rate for Venipuncture

A 5 X 2 X 3 repeated measures ANOVA was computed for

experimental group, sex, and venipuncture period (rest,

blood withdrawal, recovery). Significant main effects were

found for experimental group (F(2,39) = 6.25, p = .004),

sex (F(1,59) = 9.63, p = .004), and period (F(2,78)




34
ordering venipuncture, first speech, and second speech
(chi-square = 3.4, P < -50). The second analysis found no
difference between groups in rank ordering venipuncture,
the speech on a pleasant topic, or the speech on an
unpleasant topic (chi-square = 6.0, p < .20).
Speech Order and Heart Rate
A 3 X 2 X 4 repeated measures ANOVA was computed for
experimental group, speech order and period (rest, plan,
speech, recovery) for both speeches. No main or
interaction effects were found for speech order in either
speech (£(1,37) = 1.17 P = .29) and (£(1,39) = .59, p =
.45), respectively.
Speech Order and Skin Conductance
A 3 X. 2 X 4 repeated measures ANOVA was performed for
experimental group, speech order, and period (rest, plan,
speech, recovery) for both speeches. No significant
differences were found for speech order in either speech
(£(1.38) = 1.76, p = .19) and (£(1,37) = 2.87, P = .10),
respectively.
Analyses of Major Hypotheses
Heart Rate for Venipuncture
A 3 X 2 X 3 repeated measures ANOVA was computed for
experimental group, sex, and venipuncture period (rest,
blood withdrawal, recovery). Significant main effects were
found for experimental group (£(2,39) = 6.25, p = .004),
sex (£(1,39) = 9.63, p = .004), and period (£(2,78)
































































































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Heart Rate for First Speech

A 3 X 2 X 4 repeated measures ANOVA was computed

between experimental group, sex, and period. Significant

main effects were found for experimental group (F(2,39) =

5.65, p = .007), sex (F(1,39) = 9.51, p = .004), and period

(F(3,117) = 32.35, p = .000). In each case the PCDS had

significantly higher HRs than the NDS and, with the

exception of the speech period higher than the GCDS. See

Figure 2 for the comparison of HR by experimental group and

period.

Overall females had higher HRs with a mean HR of 89.54

BPM compared to an 80.13 mean for males. Paired t-tests

were computed between all possible combinations of periods

in the first speech and the rest and recovery periods

significantly differed (were less) from the plan (t(44) =

-3.17, p = .003 and t(44) = 40.57, p = .000, respectively),

and speech periods (t(44) = -7.32, p = .000 and t(44) =

8.39, p = .000). Heart rate during the plan period

likewise was less than the speech period (t(43) = 39.17, P

< .001).

Heart Rate for Second Speech

A 3 X 2 X 4 repeated measures ANOVA was computed for

experimental group, sex, and period. Significant main

effects were found for sex (F(1,37) = 4.19, p = .05) and

period (F(3,111) = 31.65, p < .001). A tendency for

experimental group to be significant was found





















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39
(_F(2,37) = 2.54, p < .09) with PCDS having higher HRs that
GCDS and NDS. Female subjects had higher heart rates
(86.83 BPM compared to the 80.6 BPM of their male
counterparts.
Paired t-tests showed that the rest and recovery-
periods had lower HRs than the plan (_t_(44) = -3.53, p =
.001 and _t_(42) = 1.87, P = .07) and speech periods (_t(44) =
-7.84, p < .001 and _t(42) = 8.89, P < .001). The planning
period had a lower HR than the speech period (_t(44) =
-8.00, p < .001).
Skin Conductance for Venipuncture
A 3 X 2 X 3 repeated measures ANOVA was computed for
experimental group, sex, and period. A significant main
effect was found for period (_F(2,78) = 44*76, p < .001).
Paired t-tests showed each period significantly different
from the others with the highest level of skin conductance
in the blood withdrawal period and lowest level in the rest
period. The T values were as follows: rest-blood
withdrawal (_t_(44) = -7.99, P < .001); rest-recovery (_t(44)
= -6.23, p < .001); and blood withdrawal-recovery (_t_(44) =
3.10, p = .003).
Skin Conductance for First Speech
A 3 X 2 X 4 repeated measures ANOVA for experimental
group, sex, and period was computed which found a
significant effect for period (_F(3,114) = 17.35, p <
.001). Paired t-tests were computed and skin conductance


40
levels were less in the rest and recovery periods when
compared with the plan (t_(43) = -2.77, P < .008) and (_t_(43)
= 2.4, p < .02) and speech (_t_(43) = -5.74, p < .001) and
(_t_(43) = 5*78, p < .001) periods. The speech period had
higher levels of skin conductance when compared with the
plan period (_t(43) = -3.16, p < .003).
Skin Conductance for Second Speech
A 3 X 2 X 4 repeated measures ANOVA was computed. A
significant main effect was found for period. Subsequent
paired t-tests were computed and found speech skin
conductance differed significantly (was higher) from all
other speech periods with t values as follows: from rest
(_t_(44) = -3.88, p < .001); from plan (_t(43) = -2.0, p <
.05); and from recovery (_t(42) = 4.95, p < .001). Skin
conductance in the planning period was higher than in the
rest period (_t(43) = -4.29, p < .001).
Skin Conductance Fluctations-Venipuncture
A 3 X 2 X 3 repeated measures ANOVA was computed
between experimental group, sex and period. A significant
main effect was found for period (F_(2,76) = 26.53, P <
.001). Paired t-tests were utilized to compare each period
with the other periods. The blood withdrawal period had a
higher number of skin conductance fluctuations than the
rest or recovery period (_t_(44) = -7.02, p < .001 and jt(44)
= -1.85, p < .07, respectively).


41
Skin Conductance Fluctuations for First Speech
A 3 X 2 X 4 repeated measures ANOVA was computed for
experimental group, sex, and period. A significant main
effect for period (F_(3,114) = 76.89, P < .001) and an
interaction between period and experimental group (jF(6,114)
= 2.38, p < .04) were found. The rest and recovery periods
had fewer SC fluctuations than the plan (_t_(43) = -8.4, p <
.001 and t_(43) = 7.29, P < .001, respectively) and speech
periods (t_(43) = -10.71, p < .001 and _t(43) = 9-91, P <
.001, respectively). The plan period had fewer
fluctuations than the speech period (_t_(43) = -4.72, p <
.001). Experimental group was significant only in the
speech period (_F(2,41) = 3.08, p < .06) with a subsequent
Duncan's Multiple Range Test showing that the GODS had more
fluctuations than the PCDS with the following means: GCDS
= 14.53, PCDS = 9-57, and NDS = 10.87.
Skin Conductance Fluctuations for Second Speech
A 3 X 2 X 4 repeated measures ANOVA was computed for
experimental group, sex, and period. A significant main
effect was found for period (_F(3,111) = 41.64, p < .001).
Each period was compared with the remaining three periods
utilizing paired t-tests. The rest and recovery periods
had the lowest number of fluctuations compared to the plan
(t_(43) = -6.59, p < .001 and _t(42) = 6.29, p < .001,
respectively) and speech periods (_t(44) = -9.11, p < .001
and t_(42) = 8.41, p < .001, respectively). The speech


42
period had the highest number of SC fluctuations (_t_(43) =
-4.44, P < .001).
Life Events Checklist (LEC)
A oneway ANOVA was computed using the LEC completed by
the adolescent for each of several methods of scoring the
LEC and none reached statistical significance. The F
values and probabilities for each scoring method are as
follows: total events rated good (F_(2,41) = .43, p = .65);
total events rated bad (F_(2,41) = .40, p = .68); total
events rated good and weighted by impact on life (_F(2,41) =
.08, p = .92); total events rated bad and weighted by
impact on life (F_(2,41) = .70, p = .50); sum of total good
and bad events (F_(2,41) = .31, p = .74); and sum of total
good and bad life events weighted for impact on life
(F_(2,41) = .17, p = .85).
Eysenck Personality Questionnaire (EPQ, JEPQ)
A oneway ANOVA was computed for experimental group for
each dimension of the EPQ (extraversin, neuroticism,
psychoticism, conventionality). All EPQ and JEPQ scores
were converted to t scores with mean = 50, SD = 10 (based
on age and sex norms in Eysenck & Eysenck, 1975, 1978)
before analyses. No significant differences were found for
extraversin (F_(2,42) = 1.00, p = .38) or psychoticism
(_F_(2,42) = .38, p = .69). A significant _F value was
obtained for neuroticism (_F(2,42) = 5.9, p < .005) and a
subsequent Duncan's Multiple Range Test (at the .05 level








statistically significant, the same pattern of mean values

was found for the post FFA sample, i.e., GCDS = .49, PCDS =

.55, and NDS = .36.

Blood Sugars

A 3 X 2 X 2 repeated measures ANOVA was computed for

experimental group, sex and trial (pre- and post-blood

withdrawal). A significant main effect for experimental

group (F(2,28) = 14.12, p < .001) and a trial by sex

interaction (F(1,28) = 9.82, p < .004) were found. A

oneway ANOVA and subsequent Duncan Multiple Range Test were

computed for both pre- and post-blood withdrawals. The

overall model was significant for both blood withdrawals

(F(2,35) = 15.38, p < .001 and F(2,32) = 15.89, p < .001,

respectively). At the .05 level of significance the Duncan

Multiple Range Test found all three experimental groups

differed significantly from each other at the initial

withdrawal but only the NDS differed from both diabetic

groups at the second withdrawal. Mean blood sugar values

for the first and second blood withdrawals, respectively,

were as follows: GCDS = 210.73, 215.17; PCDS = 294.5,

275.84; and NDS = 59.8, 65.64. Although at the first blood

withdrawal females had significantly higher levels of blood

sugar, no significant difference was found at the second

blood withdrawal.










Urine Volume

A oneway ANOVA was computed for experimental group

with urine volume. Overall significance for the model was

found at (F(2,42) = 5.67, p = .007). A Duncan's Multiple

Range Test showed that the NDS differed from the two

diabetic groups with a mean volume of 69.67 cc compared to

183.8 for the GCDS and 256.67 for the PCDS.

Pre- and Post-Urine Sugar

A Wilcoxin rank sum test (equivalent to the Mann-

Whitney U test) was computed for GCDS and PCDS urine sugar

levels for pre- and post-experimental session. No

significant differences were found between groups at the

beginning of the experimental session (z = .41, p = .66)

but the PCDS had larger values at the end of the session (z

= 1.85, p = .04). All NDS had 0 percent urine sugar.

Pre- and Post-Urine Ketones

A Wilcoxin Rank Sum Test was computed for urine

ketones before and after the experimental session. No

significant differences were found pre-session (z = .39, p

= .35) although a tendency for PCDS to have higher levels

of urine ketones was found at post-experiment (z = 1.29, p

= .10). No traces of urine ketones were found for any NDS.

Pre- and Post-Plasma Ketones

No evidence of plasma ketones was found in any

experimental group at pre- or post-blood withdrawals.
















CHAPTER 4
DISCUSSION AND SUMMARY



The major contribution of this study was to clarify

where and how insulin-dependent diabetic and noninsulin-

dependent diabetic youth differ in their physiological and

metabolic responsivity to a psychological stress.

Furthermore, differences between the responsiveness to the

stress by the level of diabetes control was addressed.

Basically the findings suggested that the insulin dependent

diabetic adolescent responds similarly to psychological

stress as his nondiabetic peer but generally with higher

and less desirable levels of response. However, little

evidence of excessive physiological responsivity or slower

return to baselines accrued. This study generally

replicated the directions of the findings of Hinkle and

Wolf (1952) and Vandenbergh et al. (1966). However, the

outcomes of this study failed to support the findings of

Minuchin et al. (1978). Specifically, no group responded

with a comparatively extreme increase in FFAs and slower

return to baseline FFA levels. In fact, in this study the

PCDS actually had a slightly lower FFA level after the

stressful task compared to pre-experimentally. This does

not support the notion that ketoacidosis and other serious










illness in insulin dependent diabetes are the result of an

extreme physiological response to stess.

What this study has not done is to definitively tell

us the reasons for the physiological and metabolic

differences found between groups. Possible explanations

and their merits are more fully discussed in the following

sections. Likewise, the exploratory hypotheses regarding

life stress and personality traits are discussed.


Reported and Observed Anxiety of Tasks

Overall there were few differences between the GCDS,

PCDS, and NDS in self-reports of anxiety, task rank

ordering, or observed anxiety on any of the tasks

(venipuncture or speeches). The one exception, in the

predicted 'direction, was that the PCDS tended to report a

higher level of anxiety during the first speech but this

tendency was lost during the second speech.


Physiological Response to Tasks

Heart rate, but not skin conductance, significantly

differentiated the PCDS from the GCDS and NDS. Heart rate

in PCDS was consistently about 10 BPM higher than the GCDS

or NDS which were highly similar. However, no differences

between groups were found for skin conductance. In fact, a

tendency of higher skin conductance fluctuations in the

GCDS was found compared to the PCDS and NDS. Furthermore,

no evidence of heightened reactivity and slower return to










baseline emerged. Instead, a consistent pattern of higher

HR level for poor control adolescents across all conditions

whether rest, blood withdrawal, speech, or recovery was

found.

Heart Rate

The finding of higher heart rate in the PCDS is

consistent with the hypothesis that this group had higher

levels of catecholamines. This hypothesis is further

supported by the finding that PCDS had higher FFA, blood

sugars, urine sugars, urine volume, and urine ketones. In

effect, stress triggers the introduction of catecholamines

and other stress hormones which set off the stress response

of increased HR, FFA and blood sugar. This is the normal

physiological process stimulated by stress. In the PCDS

these stress responses were higher and less desirable than

in the good control group or nondiabetic group. In the

normal stress response insulin counters the effects of the

stress hormones and operates to reduce FFA and blood

sugars. By reducing the influence of the catecholamines

and stress hormones insulin contributes to the recovery of

heart rate to pre-stress levels. The skin conductance

findings and failure to find differences between groups on

self-reported and observation measures of anxiety do not

support this explanation.










Other Explanations of Higher Heart Rate in PCDS

The PCDS may have more morphologic damage to

circulatory organs (veins, arteries, heart) which reduces

the overall efficiency and intactness of the circulatory

system. One well-known risk of insulin-dependent diabetes

is heart disease. The retinal damage that is a serious

complication of IDDM is contributed to by vascular

hemorrhages, aneurysms, and neovascularizations. To make

up for the inefficiency resulting from these morphologic

abnormalities/damage the heart rate may be increased to

provide the blood flow required for normal body function.

Another potential explanation is that our PCDS had

higher rates of autonomic neuropathy. Naliboff (1985)

reports that estimates have been made that 40% of persons

with diabetes have at least mild symptoms of autonomic

neuropathy. He found a higher resting heart rate in a

group of adult subjects with both insulin-dependent and

noninsulin-dependent diabetes. Upon further examination of

these individuals some evidence of autonomic neuropathy was

found in almost all diabetics.

Autonomic neuropathy tends to be manifested earlier in

the parasympathetic nervous system as opposed to the

sympathetic nervous system. This fact may help explain the

desynchrony between heart rate and skin conductance which

is primarily innervated by the sympathetic nervous

system. Since heart rate is heavily influenced by










parasympathetic processes as well as sympathetic processes,

autonomic neuropathy may show heart rate effects before

skin conductance effects. That is, a relatively greater

deterioration of parasympathetic inhibition of heart rate

in the PCDS would lead to an increased heart rate. If this

explanation is supported, it suggests that children with

insulin-dependent diabetes should be monitored for

autonomic neuropathy symptoms earlier than currently is

done.

Skin Conductance

The failure to find differences between experimental

groups in skin conductance levels is interesting. This in

conjunction with the failure to find differences between

groups in self-report or observed anxiety supports the

hypothesis that the groups were not differentially

stressed. As a result support for an alternate explanation

to increased catecholamine levels to account for the heart

rate finding is suggested.

Other Explanations for Skin Conductance Findings

Skin temperature is positively associated with skin

conductance response (Haroian, Lykken & Huser, 1984;

Venables & Christie, 1980). If vasoconstriction or poor

circulation was more pronounced in the PCDS, finger

temperature would have been reduced in the PCDS. Such

reductions of skin temperature in the PCDS may have acted

to mask any heightened sympathetic input to the sweat










glands that are responsible for skin conductance

activity. Since we did not measure vasoconstriction,

finger temperature, or epinephrine, we cannot rule out this

possibility.

Also, heart rate and skin conductance do not always

jointly distinguish between groups although they may

function similarly in both groups. For instance in our

study, both skin conductance and heart rate levels

increased in the plan, speech, and blood withdrawal periods

and decreased in the rest and recovery periods. However,

only heart rate distinguished between experimental

groups. This type of finding in the literature is not

unusual. Defining the mechanisms that underlie the

discrepancies in physiological response systems is very

difficult. For example, until recently the measurement of

epinephrine was both difficult and lacked reliability.

Currently, the measurement of epinephrine is improved but

remains difficult and very expensive.

Skin Conductance Fluctuations

The tendency of the GCDS to have higher numbers of

skin conductance fluctuations suggests that this group had

a higher propensity to notice and respond to nuances in the

environment whether the nuance consisted of physiograph

noises, movements inside or outside the room, etc. Skin

conductance level is an indication of more than anxiety.

Like heart rate, skin conductance responds to new or novel










stimuli. Instead of decreasing in the orienting situation

as heart rate does, skin conductance increases (Lacey,

1967). The GCDS low heart rate level, lower FFAs, lower

urine volume, lower blood and urine sugars, and similar

self-report, ratings, and behavioral measures of anxiety

provide consistent data to rule out that this group was

more anxious or aroused by the tasks. This supports the

hypothesis that the GCDS are more alert to environmental

changes. If so, this finding leads to the question of

whether or not such a propensity might make the GCDS more

alert to both internal and external changes in the

environment which aid them in better decision making in the

care of their diabetes. Since persons with

insulin-dependent diabetes must make daily decisions

directly influencing the management of their disorder such

as when a snack is needed, when their insulin dose requires

adjustment, or when exercise is needed, this extra

awareness may benefit them.


Metabolic Reactivity

Clear metabolic differences emerged between at least

one of the diabetic and the nondiabetic groups on all

dependent measures. The nondiabetic group had a lower

level of FFA, lower urine volume, and lower blood and urine

sugars. In addition, although not always statistically

significant, in every case the PCDS had the highest values




52
stimuli. Instead of decreasing in the orienting situation
as heart rate does, skin conductance increases (Lacey,
1967). The GCDS low heart rate level, lower FFAs, lower
urine volume, lower blood and urine sugars, and similar
self-report, ratings, and behavioral measures of anxiety
provide consistent data to rule out that this group was
more anxious or aroused by the tasks. This supports the
hypothesis that the GCDS are more alert to environmental
changes. If so, this finding leads to the question of
whether or not such a propensity might make the GCDS more
alert to both internal and external changes in the
environment which aid them in better decision making in the
care of their diabetes. Since persons with
insulin-dependent diabetes must make daily decisions
directly influencing the management of their disorder such
as when a snack is needed, when their insulin dose requires
adjustment, or when exercise is needed, this extra
awareness may benefit them.
Metabolic Reactivity
Clear metabolic differences emerged between at least
one of the diabetic and the nondiabetic groups on all
dependent measures. The nondiabetic group had a lower
level of FFA, lower urine volume, and lower blood and urine
sugars. In addition, although not always statistically
significant, in every case the PCDS had the highest values


53
for FFA, urine volume, urine ketones and blood and urine
sugars with the GCDS having the middle values.
Only minimal support for the hypothesis that PCDS
would show heightened reactivity emerged. Instead, a
picture of sustained higher levels of HR, FFA, and blood
sugars was found. In fact, in the case of FFAs and blood
sugars, the post-experimental values were reduced enough
for statistical significance to be lost when it was found
pre-experimentally. One possible exception to this
generalization is that although no significant differences
were found pre-experimentally in urine sugars and urine
ketones between the GCDS and PCDS, differences were found
post-experimentally with the PCDS having higher levels.
Both Hinkle and Wolf (1952) and Vandenbergh et al.
(1966) found that their diabetic participants tended to
have a blood glucose decrease following stress. The drop
in the diabetic group tended to be higher while in the
nondiabetic group the level tended to stay the same or
increase slightly (as occurred in our GCDS and NDS). Both
researchers point out that increased urine sugars did not
help account for the blood sugar drop in the poorly
controlled group. In our case, urine sugars and ketones
were higher post-experimentally in the PCDS and may help
explain the reduction in blood sugar and FFAs. That is,
sugar and ketones were filtered from the blood into the
urine. Hinkle and Wolf and Vandenbergh et al. had small








between groups in stressfulness of blood withdrawal and

speech giving even though physiological responses differed

between groups.

Brand, Johnson and Johnson (1983) report a finding

similar to that of this study. They found no relationship

between Hemoglobin Al and the LEC in diabetic youth aged 10

to 17.8 years attending a summer camp. The only

correlation that they found which approached significance

was between negative life change and urine ketones.

In the two studies that found a relationship between

diabetes health variables, in particular Hemoglobin Al, and

reported life stress, several differences emerge.

Bradley's (1979) study differed from ours in several

ways. First, she included British adult subjects with

insulin-dependent diabetes and adult onset diabetes.

Secondly, she used another life events change instrument

than the LEC. Chase and Jackson (1981) also used another

life stress questionnaire and measured life stress over the

preceding 3 months instead of year as in the current

study. As in this study, they looked at adolescents with

insulin-dependent diabetes. They found a high correlation

between amount of reported life stress and Hemoglobin Al

values (r = .41). In contrast, the current study found a

nonsignificant Pearson correlation between negative life

events and Hemoglobin Al of .16 and total life events of

.02. The participants in this study were matched for










duration of diabetes, sex, age, and race while those in

Chase and Jackson's were not. It was also confirmed from

both parents and adolescent that the prescribed insulin

dosage was administered at the same time generally and

specifically the night before and morning of the

experiment. As a result the sample was different.

Perhaps an instrument more sensitive to everyday

stresses would show a stronger relationship. Kanner,

Coyne, Schaefer and Lazarus (1981) suggest that a life

stress scale designed to measure smaller, more frequent

daily stressors might yield better results in predicting

psychological and health outcomes than the major life event

scales such as the LEC. Such scales are now available.

Although more refined techniques to assess stress

might yield higher predictive power, other factors need

assessment to account for significant amounts of the

variance. For instance, in our study we found for the most

part that the experimental groups reported and behaved in

ways suggesting that they viewed the tasks with similar

levels of stress/anxiety. Yet the PCDS were in much poorer

control of their disorder and physiologically dealt less

efficiently and effectively with the stresses. It is

reasonable to expect that the physiological

predispositions/states, behavioral tendencies, as well as

cognitive traits of the individual, must be considered to




56
duration of diabetes, sex, age, and race while those in
Chase and Jackson's were not. It was also confirmed from
both parents and adolescent that the prescribed insulin
dosage was administered at the same time generally and
specifically the night before and morning of the
experiment. As a result the sample was different.
Perhaps an instrument more sensitive to everyday
stresses would show a stronger relationship. Kanner,
Coyne, Schaefer and Lazarus (1931) suggest that a life
stress scale designed to measure smaller, more frequent
daily stressors might yield better results in predicting
psychological and health outcomes than the major life event
scales such as the LEC. Such scales are now available.
Although more refined techniques to assess stress
might yield higher predictive power, other factors need
assessment to account for significant amounts of the
variance. For instance, in our study we found for the most
part that the experimental groups reported and behaved in
ways suggesting that they viewed the tasks with similar
levels of stress/anxiety. Yet the PCDS were in much poorer
control of their disorder and physiologically dealt less
efficiently and effectively with the stresses. It is
reasonable to expect that the physiological
predispositions/states, behavioral tendencies, as well as
cognitive traits of the individual, must be considered to


57
make the best predictions of the effect of stress on
health.
Personality Findings
On the JEPQ/EPQ the GCDS were less neurotic than both
other groups and more conventional than the NDS. This
finding is similar to Simonds (1977) who found (using
parental reports) that the poorly controlled group was more
likely to be anxious and depressed, the same terms Eysenck
uses to describe an introverted neurotic personality.
Likewise Simonds reported that his good control group
reported fewer conflicts than the nondiabetic group and had
an unusually low incidence of parental divorce. Our
findings in addition to Simonds suggest that adolescents
with insul-in-dependent diabetes in good control may be
unusually well-adjusted and conventional or socially rule
oriented. Also in accord with Simonds, they suggest that
in general poorly controlled diabetic adolescents have
average or normal psychological adjustment.
No evidence emerged supporting differential
physiological or metabolic responsiveness due to
neuroticism. This suggests that neuroticism is not related
to poor control through a clearly identifiable
physiological or metabolic mechanism. (See Appendix J for
the correlation coefficients between neuroticism and
physiological and metabolic variables.) It appears more
reasonable to postulate that the more conventional,








still may not know the degree to which the damage

contributes to our findings of increased heart rate.

Another approach to this question is to see if the

increased heart rate and metabolic responses can be

reversed. That is, can a poor control diabetic group be

treated by some method and as a result respond

physiologically and metabolically like the good control

group. To the extent that circulatory or autonomic

neuropathy is resistant to intervention, reversal of heart

rate findings would not be expected.

Another line of investigation relates to the question

of whether or not the PCDS is more stress sensitive but,

due to their initial high level of being stressed,

differential rates of response were lost. More stress

sensitive persons might become more physiologically aroused

about participating in the experiment and their heightened

initial arousal may not be generalizable to other

situations. Measurement of heart rate and some metabolic

measures (perhaps FFA and urine volume) in ordinary and

nonintrusive ways would be very informative. Heart

monitoring devices could be attached and worn over time so

that the participant "forgets" about the device. Blood

sample would be more difficult to accomplish. However, as

metabolic measures such as glycosolated hemoglobin become

available, indicants of the metabolic state over time will

help address this question.










Several other questions were raised by the findings.

One was whether or not the GCDS were more sensitive to

novel or changing stimuli in the environment as was

suggested by their increased skin conductance

fluctuations. Likewise, are they more aware of internal

states and changes in the body. As suggested by Simonds

(1977) and our personality findings, are the GCDS more

psychologically well-adjusted compared to both their

diabetic and nondiabetic peers? Furthermore, are they more

rule-oriented and likely to follow medical advice and live

more health-oriented life styles?


Implications

This study has several practical implications. First,

the high heart rate in the PCDS may be indicative of

serious medical problems in this group that to date have

not been expected to be manifested at so young an age.

Generally, adolescents of this age group are not closely

monitored for symptoms of autonomic neuropathy or

circulatory disease. These findings suggest that regular

monitoring should be taking place for these youngsters.

A second implication is that the PCDS do not build up

excessive FFAs or blood sugars in response to a stress but

return to their pre-stress baseline as their GCDS and NDS

counterparts. This does not provide support for a

"psychosomatic" hypothesis, for example as suggested by

Minuchin et al. (1978), in which predisposed




60
Several other questions were raised by the findings.
One was whether or not the GCDS were more sensitive to
novel or changing stimuli in the environment as was
suggested by their increased skin conductance
fluctuations. Likewise, are they more aware of internal
states and changes in the body. As suggested by Simonds
(1977) and our personality findings, are the GCDS more
psychologically well-adjusted compared to both their
diabetic and nondiabetic peers? Furthermore, are they more
rule-oriented and likely to follow medical advice and live
more health-oriented life styles?
Implications
This study has several practical implications. First,
the high heart rate in the PCDS may be indicative of
serious medical problems in this group that to date have
not been expected to be manifested at so young an age.
Generally, adolescents of this age group are not closely
monitored for symptoms of autonomic neuropathy or
circulatory disease. These findings suggest that regular
monitoring should be taking place for these youngsters.
A second implication is that the PCDS do not build up
excessive FFAs or blood sugars in response to a stress but
return to their pre-stress baseline as their GCDS and NDS
counterparts. This does not provide support for a
"psychosomatic" hypothesis, for example as suggested by
Minuchin et al. (1978), in which predisposed


61
insulin-dependent diabetic youngsters become sick when
exposed to a stress (for Minuchin et al., the family stress
of a "psychosomatic family").
A final implication is that the GCDS are more
psychologically healthy and may be behaviorally oriented
toward better caretaking of their disease. This requires
much more investigation and can only be hypothesized about
at this time. It fits nicely with the current finding of
other researchers (Simonds, 1977).


APPENDIX A
SPEECH TOPIC
Speech Topic 1
Hello. Your speech will be on the topic of "a recent
fun or pleasant time I had or something very nice that
happened to me." You are free to pick any event or angle
you wish. Some ideas include a grade you especially like;
a good time with your friend, parent, brother, sister,
etc.; special equipment that you got like a bike or record
player; an event you got to go to, etc. You can talk about
when it occurred, how it came about, what it was like for
you, how you still feel, what happened later, etc.
Speech Topic 2
Hello. Your speech will be on the topic of "the last
big argument I had or my most recent big disappointment."
You are free to pick any event or angle you wish. Some
ideas include a grade you did not like; an argument with
your friend, parent, brother, sister, etc.; equipment that
broke like a bike or record player; an event you had to
miss, etc. You can talk about when it occurred, how it
came about, what it was like for you, how you still feel,
what happened later, etc.
62








environmental rejection. Obrist (1976) introduces a new

principle in HR activity. He uses the term cardiac-somatic

coupling to describe the principle that HR changes in

accordance with somatic need. In other words, as somatic

activity increases HR increases and as somatic activity

decreases HR decreases. However, Obrist points out that

cardiac-somatic coupling breaks down in those situations

related to active avoidance of aversive stimuli. These

situations result in substantial HR increase that is

unrelated to somatic activity.

The heart is neurally innervated by two interactive

inputs from the sympathetic and parasympathetic branches of

the autonomic nervous system (ANS). The sympathetic input

consists of adrenergic fibers originating in the spinal

cord via the stellate and caudal cervicle ganglia. The

neural transmitter substances are epinephrine and

norepinephrine. Excitation of these fibers increases HR

and blood pressure and is associated with myocardiac

contractile force. Parasympathetic fibers (cholinergic)

emanate from the vagus nerve. Excitation of these fibers

reduces HR and contractile force and, in general, is

antagonistic (opposite in effect) to sympathetic

excitation. In general, the higher the sympathetic input,

the higher the parasympathetic input. Heart activity

influences baroreceptors in the vagal nerve which respond

according to the level of heart activity by either






65


inhibiting HR when HR is high and reducing parasympathetic

inhibition when HR is low.
















APPENDIX C
BRIEF NOTE ON SKIN CONDUCTANCE



The eccrine sweat glands are of particular importance

to the psychophysiologist and are sympathetically

innervated. These glands appear to play a role in thermal

regulation only for very hot temperatures. Eccrine sweat

glands are widespread over the body but are particularly

dense on the palmar and plantar surfaces. Martin and

Venables (1980, p. 10) point out that it is realistic to

think of the principle effector mechanism in SC measurement

as sweat glands arranged as resistors in parallel. The

eccrine sweating produces SC changes which are related to

orienting or signal responses. At the skin surface sweat

is both discharged and reabsorbed.
















APPENDIX D
VENIPUNCTURE QUESTIONNAIRE


Please rate how
drawn.


bothered you are in general by having blood


1
extremely
bothered


3
moderately
bothered


5
not bothered
at all


Please rate how painful the venipuncture procedure was for
you.


1
extremely
painful


3
moderately
painful


5
not painful
at all




APPENDIX D
VENIPUNCTURE QUESTIONNAIRE
Please rate how bothered you are in general by having blood
drawn.
1 2 3 4 5
extremely moderately not bothered
bothered bothered at all
Please rate how painful the venipuncture procedure was for
you.
1
2
3
4
5
extremely
moderately
not painful
painful
painful
at all
67


APPENDIX E
VENIPUNCTURE OBSERVATION CHECKLIST
Subject Name Number
Rater Name Rating Date
BEHAVIOR TIME PERIOD
1 2 3 4 5 6 SUM
Time:
*
X
X
X
X
X
Verbalized Pain
*
X
X
X
X
X
Verbalized Anxiety
*
*
X
*
X
*
Verbal Delay
*
X
X
*
*
X
Looks Away
X
*
*
*
*
Â¥
Facial Grimaces
*
*
X
*
X
X
Moisten Lips
*
X
*
*
*
X
Swallow
*
*
*
*
*
*
Heavy Breathing
x
V-
X
X
Â¥
Â¥
Smile Miserable
*
X
X
*
X
X
Tearing/Crying
*
*
X
X
X
*
Behavioral Delay
*
*
X
*
X
*
Facial Emblem Negative
X
*
X
X
*
X
*Facial Emblem Neutral
*
X
X
X
*
X
Smile False
X
X
*
*
X
X
*Smile Spontaneous
*
X
X
X
X
X
Laughs
*
X
X
X
X
X
Talks Other
*
*
X
X
*
*
Blink Number
X
X
X
*
*
*
None
*Anxiety General 0 1
Activity General 0 1
Positive General 0 1
Moderate
2 3 4 5
2 3 4 5
2 3 4 5
Extreme
6 7 8 9
6 7 8 9
6 7 8 9
*
not scored or analyzed
68


APPENDIX F
MANUAL FOR SCORING VENIPUNCTURE OBSERVATION CHECKLIST
AND TIMED BEHAVIOR CHECKLIST-MODIFIED FORM
General Procedure
Both the Venipuncture Observation Checklist (VOC) and
the Timed Behavior Checklist-Modified Form (TBCL-M) have
similar formats for scoring. First of all the videotapes
are readied for display on the Betamax videorecorder set.
The viewer(s) arrange themselves in comfortable seats
placed in a position maximizing their view of the tapes.
If two or more viewers are present, each is situated so
that no one can observe another scoring. This is done to
prevent inflation of the reliability measures by influences
other than the videotapes. Each scorer should have a
clipboard, pen or pencil, and scoring sheet. Before
viewing the videotape, scoring sheets should be completed
for subject's name or initials, ID number, scorer's name,
date, and whether the scorer is a reliablity checker. On
the TBCL-M the speech number should be recorded (either 1
or 2) depending on whether the first or second speech is
being scored. The time settings delineating each 20 second
period should be filled in at the top of the form. The
initial time setting is obtained from the videorecorder
69


70
clock and subsequent times figured by adding 20 seconds to
the preceding time period.
Scoring Forms
Both forms have similar layouts. Each has a list of
specific behaviors going down the left hand column. To the
right of the list of behaviors, time period columns appear
with a separate box for each specific behavior. Each time
period accounts for 20 seconds for behavior.
Scoring
Scoring consists of checking behaviors that appear
during each time segment. Behaviors are scored for their
presence or absence. If a behavior occurs during a time
segment, the corresponding box is checked. If it does not
occur, a zero is placed in the corresponding box. For both
forms (VOC, TBCL-M) the videotape is viewed for 20
seconds. The videotape is stopped by pressing the stop
button. The scorer then marks the appropriate box for the
behavior(s) that occurred during that 20 second period.
Each segment will require viewing several times to maximize
adequate scoring.
Venipuncture Observation Checklist
Two minutes of the venipuncture procedure will be
scored. This accounts for six time periods. The 60
seconds immediately before and after the needle insertion
will be scored. If needle insertion occurs before 60








Tearing/crying: tearing or crying; noticable welling or

tears in the eyes is scored.

Behavioral delay: involves a behavioral gesture that

delays venipuncture; examples include withdrawal of

arm, failure to extend arm when appropriate, or

covering site of injection.

Facial emblem negative: involves the coordinated tensing

and movement of facial muscles to provide a facial

expression that communicates negative affect to the

viewer; exclude if a smile is present; example includes

a snarled upper lip and nose or gritted teeth with

forehead frown.


The Time Behavior Checklist-Modified Form

The TBCL-M is scored in the same manner as the VOC

except that there are nine 20 second periods to be

scored. Many of the categories of behavior are the same

and the same definitions and descriptions apply in both

scales. Both include the following behavioral

categories: facial grimaces, moistens or bites lips,

swallows, smile miserable, heavy or uneven breathing, and

facial emblem negative. The distinct categories for the

TBCL-M are as follows:

No eye contact: fewer than three contacts with total

duration of all contacts less than two seconds.




72
Tearing/crying: tearing or crying; noticable welling or
tears in the eyes is scored.
Behavioral delay: involves a behavioral gesture that
delays venipuncture; examples include withdrawal of
arm, failure to extend arm when appropriate, or
covering site of injection.
Facial emblem negative: involves the coordinated tensing
and movement of facial muscles to provide a facial
expression that communicates negative affect to the
viewer; exclude if a smile is present; example includes
a snarled upper lip and nose or gritted teeth with
forehead frown.
The Time Behavior Checklist-Modified Form
The TBCL-M is scored in the same manner as the VOC
except that there are nine 20 second periods to be
scored. Many of the categories of behavior are the same
and the same definitions and descriptions apply in both
scales. Both include the following behavioral
categories: facial grimaces, moistens or bites lips,
swallows, smile miserable, heavy or uneven breathing, and
facial emblem negative. The distinct categories for the
TBCL-M are as follows:
No eye contact: fewer than three contacts with total
duration of all contacts less than two seconds.


Face deadpan: face looks bland, emotionless, flat for
entire 20 second period; associated with minimal eye
and head movement.
Vocal quivering: voice noticably quivers, breaks, or has
obvious pitch changes; includes noticable speech flow
or rhythm changes.
Speech blocks: includes evidence of speech blocks where
speaker cannot continue; examples include asking
researcher how much time left to speak, 3 seconds of
silence, having to repeat speech, saying have run out
of things to say.
Stammer/stutter: includes stammering or stuttering in
which at least two unnecessary sounds occur
consecutively; examples include "a a" or "f-f-friend"
excludes insertion of unnecessary words such as "you
know," unless phrase is repeated twice consecutively;
score if 5 or more breaks in flow occur in the 20
second period.














APPENDIX H
TIMED BEHAVIOR CHECKLIST-MODIFIED FORM


Subject Nan
Rater Name

BEHAVE


Number


Rating Date Speech #

IOR TIME PERIOD
1 2 3 4 5 6 7 8 9 SUM
Time: *


No Eye Contact *
Facial Grimaces *
Face Deadpan ?
Moisten Lips *
Swallows *
Smile Miserable *
Vocal Quivering *
Speech Blocks *
Stammer/Stutter *
Heavy Breathing *
Facial Emblem Neg. *
*Facial Emblem Neut. *
*Smile False *
*Smile Spontaneous *
*Laughs *
*Blink Number *


None
*Anxiety General 0 1 2
*Activity General 0 1 2
*Positive General 0 1 2


* not scored or analyzed


Moderate Extreme
3 4 5 6 7 8 9
3 4 5 6 7 8 9
3 4 5 6 7 8 9


ne



























APPENDIX I
PEARSON CORRELATIONS FOR SELECTED MEASURES IN
VENIPUNCTURE, SPEECH I AND SPEECH II
CONTROLLING FOR SEX (PARTIALLED OUT)




APPENDIX I
PEARSON CORRELATIONS FOR SELECTED MEASURES IN
VENIPUNCTURE, SPEECH I AND SPEECH II
CONTROLLING FOR SEX (PARTIALLED OUT)














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PC
Self-Reported Measure
STAIC 1.0*
VQ
Item I: fear** -.59* 1 .0*
Item II: pain**
JEPQ
-.44*
.37*
1 .0
Extraversin
-.28*
.23
.28* 1.0
Neuroticism
.44*
.25*
-.32* -.13
1 .0
Conventionality
-.22
.26*
.17 .10
-.19
1 .0
LEC
-.02
- .06
-.22 .08
.36*
.01
1 .0
Observed Measure
VOS
.14
-.14
-.52* -.32*
.29*
.21
.37* 1
.0
Metabolic Physiological Measure
Post 31ood Sugar
.13
-.004
-.14 -.09
-.17
.19
.01
.48* 1
.0
Post Urine Volume
.10
-.09
-.13 .08
-.13
.24*
-.08
.16
.72*
1 .0
Post FFA
.25
-.24
-.09 -.19
.12
.13
-.004
.06
.33*
.32*
1 .0
Rest HR
.23
-.19
.07 .02
-.05
-.003
-.30* -
.11
.33*
.23
.23 1
I .0
Blood Withdrawal HR
.39*
-.33*
-.11 -.12
.04
-.06
-.14
.20 -
.39*
.27*
.36*
.85*1 .0
Rest SC
.23*
-.25*
-.13 -.14
-.11
-.08
-.30* -
.14
.18
.10
.23
.22 .15 1.0
Blood Withdrawal SC
32*
-.37*
-.16 -.07
-.17
-.04
-.22 -
.07
.28*
.35*
.22
.28* .21 .85*
* Significant at the
.05
level.
** Note: for the VQ,
both
items
I and II were scored in
the dir
ection
of
the lower the
score, the
higher the fear or pain reported.













BIBLIOGRAPHY


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Bedell, J., & Roitzch, J. (1976). The effects of stress on
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Bradley, C. (1979). Life events and the control of
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Brand, A., Johnson, J., & Johnson, S. (1983). Life stress
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Chase, H., & Jackson, G. (1981). Stress and sugar control
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Ciminero, R., Calhoun, K., & Adams, H. (1977). Handbook of
behavioral assessment. New York: John Wiley and Sons.

Denny, D., & Frisch, M. (1981). The role of neuroticism in
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Ekman, P., & Friesen, W. (1975). Unmasking the face: A
guide to recognizing emotions from facial clues.
Princeton, New Jersey: Prentice Hall.

Ekman, P., & Friesen, W. (1982). Felt, false, and
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Eysenck, H. (1967). The biological basis of personality.
Springfield, IL: Charles C. Thomas.

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Personality Questionnaire: Junior and adult. San
Diego: Education and Industrial Testing Services.

Fallstrom, K. (1974). On the personality structure in
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Finch, A., Kendall, P., Montgomery, L., & Morris, T.
(1975). Effects of two types failure on anxiety.
Journal of Abnormal Psychology, 84, 583-585.

Finch, A., Montgomery, L., & Deardorff, P. (1974).
Reliability of state-trait anxiety with emotionally
disturbed children. Journal of Abnormal Child
Psychology, 2, 67-69.

Gad, M., & Johnson, J. (1980). Correlates of adolescent
life stress as related to race, SES, and levels of
perceived social support. Journal of Clinical Child
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Ganong, W. (1971). Review of medical physiology (6th
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Gilbert, B., & Johnson, S. (1982). Effects of a peer-
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Gray, J. (1975). Elements of a two-process of learning.
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Harkavy, J. (1981). A study of the relationship of
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diabetes. Unpublished master's thesis, University of
Florida, Gainesville, Florida.




82
Ekraan, P., & Friesen, W. (1975). Unmasking the face: A
guide to recognizing emotions from facial clues.
Princeton, New Jersey: Prentice Hall.
Ekman, P., & Friesen, W. (1982). Felt, false, and
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238-251.
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Eysenck, H., & Eysenck, S. (1975). Manual: Eysenck
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Fallstrom, K. (1974). On the personality structure in
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Finch, A., Kendall, P., Montgomery, L., & Morris, T.
(1975). Effects of two types failure on anxiety.
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Finch, A., Montgomery, L., & Deardorff, P. (1974).
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Gad, M., & Johnson, J. (1980). Correlates of adolescent
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33
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85


Tarnow, J., & Silverman, S. (1981-82). The
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85
Tarnow, J., & Silverman, S. (1981-82). The
psychophysiologic aspects of stress in juvenile
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John Wiley and Sons.








I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.




Suzanne B/. Johnson, Chairman
Associate Professor of Clinical
Psychology



I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.




Hugh Davy
Professor of Clinical Psychology



I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.




Barbara Melamed
Professor of Clinical Psychology



I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.




James Johnson
Associate Professor of Clinical
Psychology











I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.




Randy Cart'r
Associate Professor of
Statistics



This dissertation was submitted to the Graduate Faculty of
the College of Health Related Professions and to the
Graduate School and was accepted as partial fulfillment of
the requirements for the degree of Doctor of Philosophy.



August, 1985 _0 __ _A......_
Dean, College of Health Related
Professions


Dean, Graduate School





























UNIVERSITY OF FLORIDA
11111111111 1111111111111111111111i 1 11 lllll 111111111
3 1262 08554 3790




Full Text
HEART RATE (BPM)
110
PODS
GCDS
NDS
100
90
70
T
res t
plan
speech
recovery
PERIOD
Figure 2. Mean heart rate in beats per minute for first speech rest, plan, speech,
and recovery by experimental group.
00


APPENDIX E
VENIPUNCTURE OBSERVATION CHECKLIST
Subject Name Number
Rater Name Rating Date
BEHAVIOR TIME PERIOD
1 2 3 4 5 6 SUM
Time:
*
#
*
*
*
*
Verbalized Pain
*
*
*
*
*
Â¥
Verbalized Anxiety
*
*
*
*
*
Verbal Delay
*
*
*
*
*
*
Looks Away
*
*
*
%
Â¥
Facial Grimaces
*
*
*
*
*
Â¥
Moisten Lips
*
*
*
*
*
Swallow
*
*
*
*
*
*
Heavy Breathing
*
*
Â¥
#
*
*
Smile Miserable
*
*
*
*
Tearing/Crying
*
*
*
*
*
*
Behavioral Delay
*
#
*
*
*
*
Facial Emblem Negative
*
*
*
*
*
*
Facial Emblem Neutral
*
*
*
*
*
#
Smile False
*
*
*
*
*
*
Smile Spontaneous
*
*
*
*
*
Laughs
*
*
*
*
*
*
Talks Other
*
*
*
*
*
*
Blink Number
*
*
*
*
*
*
None
Anxiety General 012
Activity General 012
Positive General 012
Moderate Extreme
3 4 5 6 7 8 9
3 4 5 6 7 8 9
3 4 5 6 7 8 9
* not scored or analyzed
68


APPENDICES
A SPEECH TOPICS 62
B HEART FUNCTIONING 63
C BRIEF NOTE ON SKIN CONDUCTANCE 66
D VENIPUNCTURE QUESTIONNAIRE 67
E VENIPUNCTURE OBSERVATION CHECKLIST 68
F MANUAL FOR SCORING VENIPUNCTURE OBSERVATION
CHECKLIST AND TIMED BEHAVIOR CHECKLIST-
MODIFIED FORM 69
G RANK ORDER OF TASK FORM 74
H TIMED BEHAVIOR CHECKLIST-MODIFIED FORM 75
I PEARSON CORRELATIONS FOR SELECTED MEASURES
IN VENIPUNCTURE, SPEECH I AND SPEECH II
CONTROLLING FOR SEX (PARTIALLED OUT) 77
J PEARSON PRODUCT MOMENT CORRELATIONS
CONTROLLING FOR SEX BETWEEN EXTRAVERSION
AND NEUROTICISM AND PHYSIOLOGICAL VARIABLES....80
BIBLIOGRAPHY 81
BIOGRAPHICAL SKETCH 86
v


TABLE OF CONTENTS
ACKNOWLEDGMENTS iii
ABSTRACT vi
CHAPTERS
1 INTRODUCTION 1
Major Hypotheses 7
Exploratory Investigations 9
2 METHODOLOGY 15
Participants 15
Stress Manipulation Task 17
Speeches 17
Major Dependent Measures 18
Additional Dependent Measures 24
Procedure 26
3 RESULTS 29
Description of Sample 29
Duration of Diabetes and HA1 Values 29
Time of Day and Location of Data Collection....30
Reliability of Observation Measurement 30
Subject-Parent LEC Correlations and T-Tests....30
Inter-relationship Between Measures 31
Control Variables 32
Analyses of Major Hypotheses 34
4 DISCUSSION AND SUMMARY 46
Reported and Observed Anxiety of Tasks 47
Physiological Response to Tasks 47
Metabolic Reactivity 52
Life Stress and Diabetes Control 54
Personality Findings 57
Future Research 58
Implications 60
iv


APPENDIX F
MANUAL FOR SCORING VENIPUNCTURE OBSERVATION CHECKLIST
AND TIMED BEHAVIOR CHECKLIST-MODIFIED FORM
General Procedure
Both the Venipuncture Observation Checklist (VOC) and
the Timed Behavior Checklist-Modified Form (TBCL-M) have
similar formats for scoring. First of all the videotapes
are readied for display on the Betamax videorecorder set.
The viewer(s) arrange themselves in comfortable seats
placed in a position maximizing their view of the tapes.
If two or more viewers are present, each is situated so
that no one can observe another scoring. This is done to
prevent inflation of the reliability measures by influences
other than the videotapes. Each scorer should have a
clipboard, pen or pencil, and scoring sheet. Before
viewing the videotape, scoring sheets should be completed
for subject's name or initials, ID number, scorer's name,
date, and whether the scorer is a reliablity checker. On
the TBCL-M the speech number should be recorded (either 1
or 2) depending on whether the first or second speech is
being scored. The time settings delineating each 20 second
period should be filled in at the top of the form. The
initial time setting is obtained from the videorecorder
69


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Self-Reoort Measures
STAIC 3
1 .0
PROS
.43*
1 .0
JEPQ
Extraversin
-.04
-.09
1 .0
Neuroticism
.18
.50*
-.13
1 .0
Conventionality
.03
-.13
.10
-.19
LEC
.05
.27*
-.08
.36
Observed Measures
TBCL-Modified for
Speech II
.12
.11
-.27*
.12
Metabolic-Physiological
Measures
Post Blood Sugar
-.06
-.12
-.09
-.17
Post Urine Volume
-.00
-.07
.08
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PAGE 96

81,9(56,7< 2) )/25,'$


35
= 14.26, p < .001). A significant period X sex interaction
occurred (1(2,78) = 3.40, p = .04). Subsequent ANOVAs for
experimental group accompanied by Duncan's Multiple Range
Tests (at the .05 level of significance) found the heart
rate for PCDS was significantly higher than the two
remaining groups at each period of the venipuncture
procedure [rest (1(2,42) = 4.17, p =.02); blood withdrawal
(1(2,42) = 6.58, p = .003); recovery (1(2,42) = 4.37, p =
.02)]. Figure 1 illustrates the magnitude of the HR
differences.
Overall females had a higher heart rate in beats per
minute (BPM) with a mean equal to 90.19 BPM compared to
80.35 BPM for males.
Utilizing paired t-tests it was found that HR during
blood withdrawal was significantly higher than HR during
the rest or recovery period (_t_(44) = -5.14 p < .001) and
(_t_(44) = 3.76, p = .001), respectively. ANOVAs were
computed for sex by period with subsequent Duncan's
Multiple Range Tests performed. Whereas males had
significantly lower HRs in the rest and blood withdrawal
periods of the venipuncture procedure (1(1,43) = 10.11, p =
.003 and 1(1,43) = 3.77, p = .005, respectively), no such
sex difference was found in the recovery period (1(1,43) =
1.43, P = .24).


APPENDIX H
TIMED BEHAVIOR CHECKLIST-MODIFIED FORM
Subject Name
Number
Rater Name
Rating Date
Speech
#
BEHAVIOR
TIME PERIOD
1
ro
CM
4 5
6
7 8
9
SUM
Time:
*
*
*
*
*
*
*
*
*
No Eye Contact
*
*
*
*
*
*
*
*
*
Facial Grimaces
*
*
*
*
*
*
*
*
*
Face Deadpan
Â¥
*
*
*
*
Â¥
*
Moisten Lips
*
*
*
*
*
*
*
*
7
Swallows
*
*
*
*
*
*
*
*
*
Smile Miserable
*
*
*
*
*
*
*
*
*
Vocal Quivering
*
*
*
*
*
*
*
*
*
Speech Blocks
*
*
*
*
*
*
#
*
*
Stammer/Stutter
*
*
*
*
*
*
*
*
*
Heavy Breathing
*
*
*
*
*
*
*
*
*
Facial Emblem Neg.
*
*
*
*
*
*
*
*
*
Facial Emblem Neut.
*
*
*
*
*
*
*
*
*
Smile False
*
*
*
*
*
*
*
*
*
Smile Spontaneous
*
*
*
*
*
*
*
*
*
Laughs
*
*
*
*
*
*
*
*
*
Blink Number
*
*
*
*
*
*
*
*
*
Anxiety General
None
0
1
2
3
Moderate
4 5
6
7
Extreme
8 9
Activity General
0
1
2
3
4
5
6
7
8 9
Positive General
0
1
2
3
4
5
6
7
8 9
* not scored or analyzed
75


7
efficiency in both nondiabetic and diabetic persons. These
metabolic changes are related to sympathetic increases of
epinephrine and norepinephrine production although other
body hormones and transmitter substances are involved. The
normal person has finely-tuned metabolic processes which
act to keep their metabolic responses within normal
limits. However, due to the insulin-dependent diabetic
individual's inefficient insulin response capability, more
extreme metabolic responses may become more likely.
Evidence to date suggests that at least some subgroups of
diabetics may be more metabolically reactive than other
groups, although the relationship between metabolic
responsivity and control level has not been clearly
specified. There is less evidence to suggest clear-cut
response differences between diabetics as a group and
nondiabetics, although this hypothesis has received little
research attention.
Major Hypotheses
The primary purpose of the present investigation was
to study the effects of stress on youngsters with insulin-
dependent diabetes. The stress responses of youngsters
with well-controlled diabetes were compared to youngsters
in poor control and both diabetic groups were compared to
nondiabetic adolescents. Self-report, behavioral,
psychophysiological, and metabolic effects of stress were
assessed. Few differences on any of the measures were


BIOGRAPHICAL SKETCH
Brenda Gilbert was born in Knoxville, Tennessee, in
January of 1947* She obtained her M.S.W. degree from
Florida State University in 1972 and worked 5 years as a
social worker. She returned to the University of Florida
and earned an M.A. and Ph.D. in clinical psychology. Her
research interests are in the areas of medical psychology
and her focus has been on coping with chronic illness in
children and adolescents. She is married and the mother of
two beautiful girls. Currently, she is the coordinator of
an adolescent inpatient program.
86


53
for FFA, urine volume, urine ketones and blood and urine
sugars with the GCDS having the middle values.
Only minimal support for the hypothesis that PCDS
would show heightened reactivity emerged. Instead, a
picture of sustained higher levels of HR, FFA, and blood
sugars was found. In fact, in the case of FFAs and blood
sugars, the post-experimental values were reduced enough
for statistical significance to be lost when it was found
pre-experimentally. One possible exception to this
generalization is that although no significant differences
were found pre-experimentally in urine sugars and urine
ketones between the GCDS and PCDS, differences were found
post-experiraentally with the PCDS having higher levels.
Both Hinkle and Wolf (1952) and Vandenbergh et al.
(1966) found that their diabetic participants tended to
have a blood glucose decrease following stress. The drop
in the diabetic group tended to be higher while in the
nondiabetic group the level tended to stay the same or
increase slightly (as occurred in our GCDS and NDS). Both
researchers point out that increased urine sugars did not
help account for the blood sugar drop in the poorly
controlled group. In our case, urine sugars and ketones
were higher post-experimentally in the PCDS and may help
explain the reduction in blood sugar and FFAs. That is,
sugar and ketones were filtered from the blood into the
urine. Hinkle and Wolf and Vandenbergh et al. had small


BIBLIOGRAPHY
Akerstedt, T., & Theorell, T. (1976). Exposure to night
work serum gastrin reaction, psychosomatic complaints
personality variables. Journal of Psychosomatic
Research, 20, 479-434.
Baker, L., Barcai, A., Kay, R., & Hague, N. (1969). Beta
adrenergic blockade and juvenile diabetes. Journal of
Pediatrics, 75, 19-29.
Bedell, J., & Roitzch, J. (1976). The effects of stress on
state and trait anxiety in emotionally disturbed,
normal, and delinquent children. Journal of Abnormal
Child Psychology, 4_, 173-177.
Borkovec, T., & O'Brien, G. (1977). Relation of autonomic
perception and its manipulation to the maintenance and
reduction of fear. Journal of Abnormal Psychology, 86,
163-171.
Bradley, C. (1979). Life events and the control of
diabetes mellitus. Journal of Psychosomatic Research,
23, 159-162.
Brand, A., Johnson, J., & Johnson, S. (1983). Life stress
and diabetic control in children and adolescents with
insulin-dependent diabetes. Unpublished manuscript.
Cahill, G., Etzwiler, D., & Freinkel, N. (1976). Control
and diabetes. New England Journal of Medicine, 294,
1004.
Chase, H., & Jackson, G. (1981). Stress and sugar control
in children with insulin-dependent diabetes mellitus.
Brief Clinical and Laboratory Observations, 6, 1011-
1013.
Ciminero, R., Calhoun, K., & Adams, H. (1977). Handbook of
behavioral assessment. New York: John Wiley and Sons.
Denny, D., & Frisch, M. (1981). The role of neuroticism in
relation to life stress and illness. Journal of
Psychosomatic Research, 25, 303-307.
81


APPENDIX B
HEART FUNCTIONING
The heart in humans and higher mammals is a complexly
innervated organ whose activity frequently is used as an
indicator of a psychological process. Heart rate (HR)
acceleration and deceleration in response to various
stimuli have long been noted by psychologists. Heart rate
decelerates in response to simple stimuli and accelerates
to intense or threatening stimuli, during periods of word
association, and during mental arithmetic. Sokolov
referred to a HR increase in response to a stimulus as a
defense response whereas HR deceleration was called an
orienting response. Lacey (Siddle & Turpin, 1980)
hypothesized that this 'directional fractionation' could be
explained by the nature of the stimuli. Stimuli requiring
environmental intake and consequent sensory integration
would lead to HR deceleration. Lacey further suggested
that the HR deceleration was due to an indirect effect of
HR on cortical activity. Another explanation that has been
offered is that lowered body activity in general
facilitates sensory intake by reducing distraction. The
second part of the 'directional fractionation' is that HR
accelerates in response to stimuli requiring spurring
63


27
electrodes were avoided and attempts were made to use
nonthreatening and understandable words to explain the
different pieces of equipment (videorecorder and camera,
physiograph, leads). Although visible, the tray with
venipuncture equipment was placed somewhat behind the
youngster. The adolescent was seated in a comfortable
chair and the heart rate and skin conductance electrodes
were attached to the hand. Then the participant was asked
to close his/her eyes and rest for 3 minutes. Afterward
the videorecorder was turned on and the heparin lock
inserted. When the venipuncture procedure was completed,
the recorder was turned off and the adolescent asked to
rest with closed eyes for 3 minutes. After the recovery
period, the following questionnaires were administered (by
the researcher reading the items outloud): STAIC (applied
to blood withdrawal), VQ, JEPQ or EPQ, LEC, and PRCS.
After completion of the questionnaires which took about 30
minutes, the 3-minute baseline rest for the first speech
took place, followed by presenting the topic to the subject
and giving him/her 3 minutes to plan the speech. Then the
audience came in the room, the videorecorder was turned on,
and the adolescent gave the speech. This was followed by
the 3-minute recovery period. The STAIC (for the speech)
was administered a second time. Then the same procedure
was followed for the second speech. After the recovery
period for the second speech, the STAIC (for the second


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Self-Reoorted Measure
STAIC
1 .0*
VQ
Item I: fear**
-.59*
1 .0*
Item II: pain**
-.44*
.37*
JEPQ
Extraversin
-.28*
.23
Neuroticism
.44*
.25*
Conventionality
-.22
.26*
LEC
-.02
-.06
Observed Measure
VOS
.14
-.14
1 .0
28*
1 .0
32*
-.13
1 .0
17
.10
-.19
1 .0
22
.08
.36*
.01
1 .0
52*
-.32*
.29*
.21
.37* 1.0
Metabolic Physiological Measure
Post 31ood Sugar
.13
-.004 -.14
-.09 -
.17
.19
.01
.48* 1
.0
Post Urine Volume
.10
-.09 -.13
.08 -
.13
.24*
-.03
.16
.72*
1.0
Post FFA
.25
-.24 -.09
-.19
.12
.13
-.004
.06
.33*
.32*
1 .0
Rest HR
.23
-.19 .07
.02 -
.05
-.003
-.30* -
.11
.33*
.23
.23 '
I .0
Blood Withdrawal HR
.39*
-.33* -.11
-.12
.04
-.06
-.14
.20 -
.39*
.27*
.36*
.85*1 .0
Rest SC
.23*
-.25* -.13
-.14 -
.11
-.08
-.30* -
.14
.18
.10
.23
.22 .15 1.0
Blood Withdrawal SC
32*
-.37* -.16
-.07 -
.17
-.04
-.22 -
.07
.23*
.35*
.22
.28* .21 .85*
* Significant at the
.05
level.
** Note: for the VQ,
both
items I and
II were
scored in
the dir
action
of
the lower the
score, the
higher the fear or pain reported.


11
functioning/arousal, neuroticism is associated with
autonomic arousal which is mediated by the limbic-
hypothalamic brain area (Eysenck, 1967)
Eysenck's personality theory and related research
suggest that introversion also may be associated with
psychosomatic proneness. The unstable introvert, due to
his introverted propensities, is more aware of subtle
stimuli earlier and the stimuli are more "amplified in the
sense that the introvert is more cortically aroused by
it. One may think of the introvert as "geared to inspect"
stimuli. This earlier greater awareness of a threatening
stimulus should increase autonomic responsivity.
Furthermore, Gray (1975) has modified Eysenck's model of
extraversion-introversion by suggesting that introverts are
more sensitive to particular aversive stimulation, i.e.,
punishment and frustrative-nonreward and thus more
conditionable to situations involving punishment or
frustration-nonreward. Both Eysenck and Gray agree that
trait anxiety as measured by the Taylor Manifest Anxiety
Scale and the Spielberger Trait Anxiety Scale are
correlated with Eysenck's neuroticism and introversion
scales. In fact, Gray (1975) suggests that a 45 degree
rotation of Eysenck's factors would provide more relevant
dimensions although not independent factors. The new
factors could be labeled trait anxiety and impulsivity.
Regardless of the theoretical differences between these


12
men, both agree introversion should predispose an
individual toward increased emotional responding; Eysenck
via increased cortical arousal leading to earlier awareness
of more subtle threatening cues, and Gray via a
biologically increased sensitivity to aversive and
frustrative-nonreward cues. Grays issue is not with the
validity of Eysenck's scales, but with the choice of factor
rotation and the nature of the underlying biological
predisposition.
In summary, high introversion and neuroticism may
predispose insulin-dependent diabetics toward higher
autonomic arousal and slower return to baseline. This
autonomic over-reactivity may predispose them toward more
diabetic control problems. It is interesting to note that
the two personality descriptions (from parental ratings)
that Simonds (1977) found to differentiate well controlled
from poorly controlled diabetic youth were anxious and
depressed. These are the same personality trait terms that
Eysenck (1967) uses to describe an introverted neurotic or
dysthymic personality. Due to the strong association
between sympathetic reactivity and neuroticism hypothesized
by Eysenck, it is reasonable to expect that if this
relationship exists it would show up in a diabetic
population where sympathetic influences may be magnified by
an easily disrupted metabolic system.


65
inhibiting HR when HR is high and reducing parasympathetic
inhibition when HR is low.


8
expected between the well-controlled diabetic youngsters
and their nondiabetic counterparts. In contrast, those
youngsters in poor control were expected to show greater
psychophysiological and metabolic reactivity to stress than
either of the two other groups.
The studys hypotheses were as follows:
1. Compared to well controlled diabetics or
nondiabetics, insulin-dependent diabetic
adolescents in poor control who are stressed in a
laboratory setting will exhibit (a) heightened
metabolic reactivity, (b) heightened
psychophysiological reactivity, and (c) slower
rates of psychophysiological recovery subsequent to
the stressful experience.
2. Well controlled diabetics will show increased
metabolic effects to stress compared to nondiabetic
normals.
3. Few differences between groups are expected on the
self and behavioral measures of stress and
anxiety. However, should differences exist they
should be between the poorly controlled diabetic
youngsters and the other two groups. If youngsters
in poor diabetic control are more stress-reactive,
they may acknowledge greater stress and appear more
anxious to an observer.


APPENDIX C
BRIEF NOTE ON SKIN CONDUCTANCE
The eccrine sweat glands are of particular importance
to the psychophysiologist and are sympathetically
innervated. These glands appear to play a role in thermal
regulation only for very hot temperatures. Eccrine sweat
glands are widespread over the body but are particuarly
dense on the palmar and plantar surfaces. Martin and
Venables (1980, p. 10) point out that it is realistic to
think of the principle effector mechanism in SC measurement
as sweat glands arranged as resistors in parallel. The
eccrine sweating produces SC changes which are related to
orienting or signal responses. At the skin surface sweat
is both discharged and reabsorbed.
66


CHAPTER 2
METHODOLOGY
Participants
Participants consisted of adolescents with insulin-
dependent diabetes and nondiabetic adolescents aged
11-18. Diabetic participants were obtained from lists of
patients treated through the North Florida Regional
Diabetes Program located at the J. Hillis Miller Health
Center, Gainesville, Florida; the University of South
Florida Diabetes Program located in Tampa, Florida; and
lists of campers attending a summer camp for diabetic
youngsters run by these two programs. The nondiabetic
youth were recruited from aged 12-18 students at the P.K.
Yonge School associated with the University of Florida and
through staff at the J. Hillis Miller Health Center.
Subjects were contacted based on their hemoglobin A1
(HA1) values, a physiological measure used to assess
diabetes control over several weeks time (Tarnow and
Silverman, 1931-82). The HA1 is a measure of the amount of
glucose adhering to hemoglobin in the blood and reflects
amount of blood glucose over a period of time. In this
study, adolescents in good diabetic control had HA1 values
15


I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.
Suzanne BK Johnson, Chairman
Associate Professor of Clinical
Psychology
I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.
Hugh Dav
Professor of Clinical Psychology
I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.
Barbara Melamed
Professor of Clinical Psychology
I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.
Janies Johnson \
Associate Professor of Clinical
Psychology


41
Skin Conductancs Fluctuations for First Speech
A 3 X 2 X 4 repeated measures ANOVA was computed for
experimental group, sex, and period. A significant main
effect for period (F_(3,114) = 76.89 P < .001) and an
interaction between period and experimental group (_F(6,114)
= 2.38, p < .04) were found. The rest and recovery periods
had fewer SC fluctuations than the plan (j^(43) = -8.4 p <
.001 and _t_(43) = 7.29 P < .001, respectively) and speech
periods (t_(43) = -10.71, p < .001 and _t^(43) = 9*91, P <
.001, respectively). The plan period had fewer
fluctuations than the speech period ^t_(43) = -4.72, p <
.001). Experimental group was significant only in the
speech period (F_(2,41) = 3.08, p < .06) with a subsequent
Duncan's Multiple Range Test showing that the GCDS had more
fluctuations than the PCDS with the following means: GCDS
= 14.53, PCDS = 9.57, and NDS = 10.87.
Skin Conductance Fluctuations for Second Speech
A 3 X 2 X 4 repeated measures ANOVA was computed for
experimental group, sex, and period. A significant main
effect was found for period (_F(3,111) = 41.64, p < .001).
Each period was compared with the remaining three periods
utilizing paired t-tests. The rest and recovery periods
had the lowest number of fluctuations compared to the plan
(_t_(43) = -6.59, p < .001 and _t(42) = 6.29, p < .001,
respectively) and speech periods (_t^(44) = -9.11, p < .001
and t_(42) = 8.41, p < .001, respectively). The speech


APPENDIX J
PEARSON PRODUCT MOMENT CORRELATIONS
CONTROLLING FOR SEX BETWEEN EXTRAVERSION
AND NEUROTICISM AND PHYSIOLOGICAL VARIABLES
Physiological
Variables
Extraversin
Neuroticism
Post Blood Sugar
.09
(S=.31)
-.17
03
II
*
^3
Post Urine Volume
.08
C/3
II

04
O
-.13
O
CO
II
CO
Post FFA
-.19
03
It
f\3
.12
ro
CO
ii
CO
Task Venipuncture
Hr
-.12
(S=.22)
.04
(S=.40)
SC
-.07
(S=.31)
-.17
(S=.13)
HR Change
-.26
(S=.04)
.16
(S=.15)
SC Change
.07
(S=.33)
.17
(S.13)
Task Speech I
HR
.04
(S=.39)
-.09
(S=.28)
SC
. 06
(S=.35)
-.15
(S=.6)
HR Change
.26
(S=.04)
.04
(S=.39)
SC Change
.20
(S=.10)
1.0
(S=.25)


10
1975). Bradley (1979) found that the number of stressful
life events was associated with diabetes control in
adults. Furthermore, the insulin treated group had higher
levels of diabetes disturbance (glycosuria, prescription
changes, and clinic visits) compared to the tablet treated
group, although there was little difference between
reported levels of life stress in the two groups.
These findings support the hypothesis that life stress
is associated with diabetes control particularly in
insulin-dependent diabetics.
Introversion-Neuroticism
Hans Eysenck (1967) has postulated two basic
dimensions of personality (introversion-extraversion and
stability-neuroticism) based on biological inheritance and
its interaction with environmental learning (Eysenck,
1967). His neuroticism dimension measures emotional
responsivity and reactivity and he suggests that this
dimension may be involved in psychosomatic disorders
(Eysenck, 1967). Persons high on neuroticism have low
tolerance for stress, whether physical or psychological,
tend to avoid stressful stimuli, and are "overly emotional,
reacting too strongly to all sorts of stimuli, and find it
difficult to get back on an even keel after each
emotionally arousing experience" (Eysenck & Eysenck, 1975,
p. 5). Furthermore, Eysenck (1967) suggests that whereas
introversion-extraversion is associated with cortical


59
still may not know the degree to which the damage
contributes to our findings of increased heart rate.
Another approach to this question is to see if the
increased heart rate and metabolic responses can be
reversed. That is, can a poor control diabetic group be
treated by some method and as a result respond
physiologically and metabolically like the good control
group. To the extent that circulatory or autonomic
neuropathy is resistant to intervention, reversal of heart
rate findings would not be expected.
Another line of investigation relates to the question
of whether or not the PCDS is more stress sensitive but,
due to their initial high level of being stressed,
differential rates of response were lost. More stress
sensitive persons might become more physiologically aroused
about participating in the experiment and their heightened
initial arousal may not be generalizable to other
situations. Measurement of heart rate and some metabolic
measures (perhaps FFA and urine volume) in ordinary and
nonintrusive ways would be very informative. Heart
monitoring devices could be attached and worn over time so
that the participant "forgets" about the device. Blood
sample would be more difficult to accomplish. However, as
metabolic measures such as glycosolated hemoglobin become
available, indicants of the metabolic state over time will
help address this question.


50
parasympathetic processes as well as sympathetic processes,
autonomic neuropathy may show heart rate effects before
skin conductance effects. That is, a relatively greater
deterioration of parasympathetic inhibition of heart rate
in the PCDS would lead to an increased heart rate. If this
explanation is supported, it suggests that children with
insulin-dependent diabetes should be monitored for
autonomic neuropathy symptoms earlier than currently is
done.
Skin Conductance
The failure to find differences between experimental
groups in skin conductance levels is interesting. This in
conjunction with the failure to find differences between
groups in self-report or observed anxiety supports the
hypothesis that the groups were not differentially
stressed. As a result support for an alternate explanation
to increased catecholamine levels to account for the heart
rate finding is suggested.
Other Explanations for Skin Conductance Findings
Skin temperature is positively associated with skin
conductance response (Haroian, Lykken & Huser, 1984;
Venables & Christie, 1980). If vasoconstriction or poor
circulation was more pronounced in the PCDS, finger
temperature would have been reduced in the PCDS. Such
reductions of skin temperature in the PCDS may have acted
to mask any heightened sympathetic input to the sweat


22
State Trait Inventory for Children (STAIC)
The state portion of the STAIC was administered to all
adolescents after each of the three tasks. The STAIC is
designed to measure both transitory anxiety specific to
stressful events (state anxiety) and stable anxiety with
consistency and permanence across time and events (trait
anxiety). Only the 20-item state anxiety portion of the
instrument was used in this study. The state portion of
the STAIC has good split-half reliability, r_ = .89 (Finch,
Montgomery & Deardorff, 1974) and has shown changes as a
function of stress (Bedell & Roitzch, 1976; Finch, Kendall,
Montgomery & Morris, 1975). The STAIC has been used
predominantly with children aged 8 and over. The STAIC was
orally administered and the subject responded to the task
portion of the procedure (blood withdrawal, speech).
Venipuncture Observation Scale (VOS)
The VOS was developed by the researcher to assess
observed anxiety in the venipuncture situation.
Appropriate items were selected from the Self-Injection
Behavior Profile Rating Scale (previously developed by the
researcher and S. Johnson, 1982). Other items were
developed from observed signs of nervousness noted by
medical staff involved in venipuncture. Ratings were
obtained from videotaped venipuncture session and
interrater reliabilities were obtained. Presence or
absence of each item was assessed for each 20 second


48
baseline emerged. Instead, a consistent pattern of higher
HR level for poor control adolescents across all conditions
whether rest, blood withdrawal, speech, or recovery was
found.
Heart Rate
The finding of higher heart rate in the PCDS is
consistent with the hypothesis that this group had higher
levels of catecholamines. This hypothesis is further
supported by the finding that PCDS had higher FFA, blood
sugars, urine sugars, urine volume, and urine ketones. In
effect, stress triggers the introduction of catecholamines
and other stress hormones which set off the stress response
of increased HR, FFA and blood sugar. This is the normal
physiological process stimulated by stress. In the PCDS
these stress responses were higher and less desirable than
in the good control group or nondiabetic group. In the
normal stress response insulin counters the effects of the
stress hormones and operates to reduce FFA and blood
sugars. By reducing the influence of the catecholamines
and stress hormones insulin contributes to the recovery of
heart rate to pre-stress levels. The skin conductance
findings and failure to find differences between groups on
self-reported and observation measures of anxiety do not
support this explanation.


55
between groups in stressfulness of blood withdrawal and
speech giving even though physiological responses differed
between groups.
Brand, Johnson and Johnson (1983) report a finding
similar to that of this study. They found no relationship
between Hemoglobin A1 and the LEC in diabetic youth aged 10
to 17.8 years attending a summer camp. The only
correlation that they found which approached significance
was between negative life change and urine ketones.
In the two studies that found a relationship between
diabetes health variables, in particular Hemoglobin A1, and
reported life stress, several differences emerge.
Bradleys (1979) study differed from ours in several
ways. First, she included British adult subjects with
insulin-dependent diabetes and adult onset diabetes.
Secondly, she used another life events change instrument
than the LEC. Chase and Jackson (1981) also used another
life stress questionnaire and measured life stress over the
preceding 3 months instead of year as in the current
study. As in this study, they looked at adolescents with
insulin-dependent diabetes. They found a high correlation
between amount of reported life stress and Hemoglobin A1
values (r = .41). In contrast, the current study found a
nonsignificant Pearson correlation between negative life
events and Hemoglobin A1 of .16 and total life events of
.02. The participants in this study were matched for


13
Although Eysenck's personality theory has not been
applied to problems of diabetic control in insulin-
dependent youth, there is extensive literature assessing
psychophysiological reactivity in introverts and neurotics
compared to other control groups. For example, Stelmack
(1981) concluded that differences in electrodermal activity
between introverts and extroverts has support with
electrodermal activity generally greater for introverts and
electrodermal habituation faster for extroverts. In a
sample of college women, Harvey and Hirshmann (1980) found
significant heart rate differences for introverted-neurotic
and extraverted-stable groups who viewed slides of violent
death. The introverted-neurotic groups exhibited heart
rate increase whereas their counterparts showed heart rate
deceleration.
Some additional evidence exists suggesting a
relationship between neuroticism and reported illness.
Denny and Frisch (1981) found neuroticism to be a predictor
of self-reported illness in two samples of college
students. Akerstedt and Theorell (1976) found increased
physical complaints from neurotic vs. stable railway
workers (utilizing Eysenck's personality scale) who were
switched from day to night shifts. (Eysenck's scale was
administered prior to the shift change.) Less direct
evidence for a relationship between neuroticism and illness
comes from a study by Mehrabian and Ross (1977). These


16
of 12 or less and those in poor control had values 15 or
over. These cutoff scores are based on Harkavys (1981)
study in which similar scores discriminated good and poor
control as defined by diabetologists' ratings. The HA1
value obtained at the time of the study served as the final
criterion and in three cases a participant whose HA1 was
slightly above 12 was kept as a good control subject if
his/her match had a value above 16.
All adolescents having diabetes at least one year and
meeting the HA1 criteria for good control were asked to
participate if a potential poor control match could be
identified. Participants were matched on sex, age, race,
and duration of diabetes. Matched subjects had to be of
the same sex, within 2 years of age, and of the same ethnic
group (except in one case where a white male was
substituted for a black male). Poor control subjects could
not have had diabetes more than 1 year longer than their
counterparts.
Each potential subject and his/her parent indicated
that the recommended insulin dose was regularly
administered and specifically acknowledged that the
required dose was administered at the regular time the
night before and the morning of the experimental session.
If the subject or parent indicated that this was not the
case, the adolescent was not used as a subject. This
occurred with two potential poor control subjects.


34
ordering venipuncture, first speech, and second speech
(chi-square = 3-4, p < .50). The second analysis found no
difference between groups in rank ordering venipuncture,
the speech on a pleasant topic, or the speech on an
unpleasant topic (chi-square = 6.0, p < .20).
Speech Order and Heart Rate
A 3 X 2 X 4 repeated measures ANOVA was computed for
experimental group, speech order and period (rest, plan,
speech, recovery) for both speeches. No main or
interaction effects were found for speech order in either
speech (£(1,37) = 1.17, P = .29) and (£(1,39) = .59, P =
45), respectively.
Speech Order and Skin Conductance
A 3 X. 2 X 4 repeated measures ANOVA was performed for
experimental group, speech order, and period (rest, plan,
speech, recovery) for both speeches. No significant
differences were found for speech order in either speech
(£(1.38) = 1.76, p = .19) and (£(1,37) = 2.87, p = .10),
respectively.
Analyses of Major Hypotheses
Heart Rate for Venipuncture
A 3 X 2 X 3 repeated measures ANOVA was computed for
experimental group, sex, and venipuncture period (rest,
blood withdrawal, recovery). Significant main effects were
found for experimental group (£(2,39) = 6.25, p = .004),
sex (£(1,39) = 9.63, P = .004), and period (£(2,78)


CHAPTER 4
DISCUSSION AND SUMMARY
The major contribution of this study was to clarify
where and how insulin-dependent diabetic and noninsulin-
dependent diabetic youth differ in their physiological and
metabolic responsivity to a psychological stress.
Furthermore, differences between the responsiveness to the
stress by the level of diabetes control was addressed.
Basically the findings suggested that the insulin dependent
diabetic adolescent responds similarly to psychological
stress as -his nondiabetic peer but generally with higher
and less desirable levels of response. However, little
evidence of excessive physiological responsivity or slower
return to baselines accrued. This study generally
replicated the directions of the findings of Hinkle and
Wolf (1952) and Vandenbergh et al. (1966). However, the
outcomes of this study failed to support the findings of
Minuchin et al. (1978). Specifically, no group responded
with a comparatively extreme increase in FFAs and slower
return to baseline FFA levels. In fact, in this study the
PCDS actually had a slightly lower FFA level after the
stressful task compared to pre-experimentally. This does
not support the notion that ketoacidosis and other serious
46


82
Ekman, P., & Friesen, W. (1975) Unmasking the face: A
guide to recognizing emotions from facial clues.
Princeton, New Jersey: Prentice Hall.
Ekman, P., & Friesen, W. (1982). Felt, false, and
miserable smiles. Journal of Nonverbal Behavior, 6(4).
238-251.
Eysenck, H. (1967). The biological basis of personality.
Springfield, IL: Charles C. Thomas.
Eysenck, H., & Eysenck, S. (1975). Manual: Eysenck
Personality Questionnaire. San Diego: Educational and
Industrial Testing Service.
Eysenck, H., & Eysenck, S. (1978). Manual of the Eysenck
Personality Questionnaire: Junior and adult. San
Diego: Education and Industrial Testing Services.
Fallstrom, K. (1974). On the personality structure in
diabetic school children. Acta Paediatrica, 254, 5-71.
Finch, A., Kendall, P., Montgomery, L., & Morris, T.
(1975). Effects of two types failure on anxiety.
Journal of Abnormal Psychology, 84. 583-585.
Finch, A., Montgomery, L., & Deardorff, P. (1974).
Reliability of state-trait anxiety with emotionally
disturbed children. Journal of Abnormal Child
Psychology, 2_, 67-69.
Gad, M., & Johnson, J. (1980). Correlates of adolescent
life stress as related to race, SES, and levels of
perceived social support. Journal of Clinical Child
Psychology, 9., 13-16.
Ganong, W. (1971). Review of medical physiology (6th
ed.). Los Angeles: Lange Medical Publications.
Gilbert, B., & Johnson, S. (1982). Effects of a peer
modeling film in anxiety-reduction and skill
acquisition in children learning self-injection of
insulin. Behavior Therapy, 13. 186-193.
Gray, J. (1975). Elements of a two-process of learning.
London: Academic Press.
Harkavy, J. (1981). A study of the relationship of
knowledge, behavior, and control in juvenile
diabetes. Unpublished master's thesis, University of
Florida, Gainesville, Florida.


58
socially appropriate self-report response tendencies of the
GCDS may be related to behavioral tendencies to follow
prescribed instructions and advice regarding care. This
may reach into the general living style of the
respondent. She may be more inclined to eat properly,
exercise as directed, and avoid less healthful life styles.
Future Research
Several lines of research are suggested by the present
findings. The finding of desynchrony of heart rate and
skin conductance levels raises several questions. One is
whether the differences between PCDS and GCDS were due to
different levels of catecholamine response. Measurement of
plasma catecholamine would help answer this question. If
the PCDS had higher levels of catecholamine, that group
would be more physiologically stressed. If no differences
in catecholamines were found, our skin conductance findings
would be expected. We would not have to consider other
explanations of why no skin conductance differences
emerged, e.g., increased circulatory damage and/or
autonomic neuropathy.
Another research question relates to the presence of
increased circulatory system damage or autonomic damage.
Several avenues of research are available to explore these
hypotheses including medical examination and tests to
assess circulatory and autonomic neuropathy damage.
However, whether or not increased damage is identified, we


UNIVERSITY OF FLORIDA
3 1262 08554 3790


14
authors utilized a stimulus screening questionnaire (high
stimulus screening theoretically was related to low
arousability) devised by Mehrabian and Ross (1977), which
correlated negatively (r = -.54) with Eysenck's measure of
neuroticism. The high arousability group reported more
psychosomatic health complaints and nonrecurring illness.
In summary, the following exploratory hypotheses were
tested:
1. Adolescents in poor diabetic control will have
higher self-reported levels of life stress than
diabetic adolescents in good control or normal
nondiabetic youth.
2. Adolescents in poor diabetic control will have
higher scores on Eysenck's Neuroticism and
Introversion Scales than diabetic youngsters in
good control or nondiabatic normals.
3. Subjects scoring high on Eysenck's Neuroticism and
Introversion Scales will show heightened
psychophysiological reactivity to the laboratory
stresses and slower habituation than subjects
scoring low on these scales.


This is dedicated to my husband, David Gilbert,
and our two beautiful daughters,
Aline Marie, aged 11, and Elizabeth Ann, aged 3.


APPENDIX G
RANK ORDER OF TASK FORM
Please rank the three tasks according to how
stressful/anxious each one was for you. Place a J_ beside
the most stressful task for you and a 3_ beside the least
stressful task. Place a 2 beside the task that fell
between these tasks in stressfulness for you.
Speaking on a recent pleasant time
Speaking on a recent argument or disappointment
The venipuncture procedure
74


PHYSIOLOGICAL RESPONSIVITY TO
VENIPUNCTURE AND SPEECH GIVING IN
INSULIN-DEPENDENT DIABETIC ADOLESCENTS AT TWO LEVELS
OF DIABETES CONTROL AND THEIR NONDIABETIC PEERS
BY
BRENDA GILBERT
A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN
PARTIAL FULFILLMENT OF THE REQUIREMENTS
FOR THE DEGREE OF DOCTOR OF PHILOSOPHY
UNIVERSITY OF FLORIDA
1985

This is dedicated to my husband, David Gilbert,
and our two beautiful daughters,
Aline Marie, aged 11, and Elizabeth Ann, aged 3.

ACKNOWLEDGMENTS
Special thanks are given to all ray committee members
which include Hugh Davis, Ph.D., Randy Carter, Ph.D., James
Johnson, Ph.D., and Barbara Melamed, Ph.D., who have given
steady support and excellent consultation. Barbara
Melamed, Ph.D., and Peter Lang, Ph.D., provided me with
much needed direction in the design of this research and
the selection and analyses of the physiological data.
Janet Silverstein, M.D., Michael Kappy, M.D., and their
coworkers were indispensable in helping me understand
diabetes and select and analyze the metabolic data
collected. The study could not have been accomplished
without the great assistance of my fellow students and
coworkers who helped collect the data. These include Gary
Geffken, Ph.D., Marika Spevack, M.S., Carol Lewis, M.A.,
and Barbara Walker.
Extra special thanks are given to Suzanne B. Johnson,
Ph.D., my "wonderful" chairperson. Her excellent direction
and support were essential to the completion of this
dissertation. In addition, extra special thanks are given
to my husband, David G. Gilbert, Ph.D., who paid my bills
while I worked on my degree and provided steady,
unflinching support.
iii

TABLE OF CONTENTS
Page
ACKNOWLEDGMENTS iii
ABSTRACT vi
CHAPTERS
1 INTRODUCTION 1
Major Hypotheses 7
Exploratory Investigations 9
2 METHODOLOGY 15
Participants 15
Stress Manipulation Task 17
Speeches 17
Major Dependent Measures 18
Additional Dependent Measures 24
Procedure 26
3 RESULTS 29
Description of Sample 29
Duration of Diabetes and HA1 Values 29
Time of Day and Location of Data Collection.... 30
Reliability of Observation Measurement 30
Subject-Parent LEC Correlations and T-Tests....30
Inter-relationship Between Measures 31
Control Variables 32
Analyses of Major Hypotheses 34
4 DISCUSSION AND SUMMARY 46
Reported and Observed Anxiety of Tasks 47
Physiological Response to Tasks 47
Metabolic Reactivity 52
Life Stress and Diabetes Control 54
Personality Findings 57
Future Research 58
Implications 60
iv

APPENDICES
A SPEECH TOPICS 62
B HEART FUNCTIONING 63
C BRIEF NOTE ON SKIN CONDUCTANCE 66
D VENIPUNCTURE QUESTIONNAIRE 67
E VENIPUNCTURE OBSERVATION CHECKLIST 68
F MANUAL FOR SCORING VENIPUNCTURE OBSERVATION
CHECKLIST AND TIMED BEHAVIOR CHECKLIST-
MODIFIED FORM 69
G RANK ORDER OF TASK FORM 74
H TIMED BEHAVIOR CHECKLIST-MODIFIED FORM 75
I PEARSON CORRELATIONS FOR SELECTED MEASURES
IN VENIPUNCTURE, SPEECH I AND SPEECH II
CONTROLLING FOR SEX (PARTIALLED OUT) 77
J PEARSON PRODUCT MOMENT CORRELATIONS
CONTROLLING FOR SEX BETWEEN EXTRAVERSION
AND NEUROTICISM AND PHYSIOLOGICAL VARIABLES....80
BIBLIOGRAPHY 81
BIOGRAPHICAL SKETCH 86
v

Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy
PHYSIOLOGICAL RESPONSIVITY TO
VENIPUNCTURE AND SPEECH GIVING IN
INSULIN-DEPENDENT DIABETIC ADOLESCENTS AT TWO LEVELS
OF DIABETES CONTROL AND THEIR NONDIABETIC PEERS
BY
BRENDA GILBERT
August, 1985
Chairperson: Suzanne B. Johnson, Ph.D.
Major Department: Clinical Psychology
Fifteen adolescents with insulin-dependent diabetes in
good diabetes control were yoked with 15 insulin-dependent
adolescents in poor control matched for age, sex, duration
of diabetes, and race. The same number of nondiabetic
adolescents matched for age and sex were included.
Participants were involved in three stressful tasks
(venipuncture and two speeches). Each task was preceded by
a rest period and followed by a recovery period. Both
speeches were preceded by a plan period. Observational,
physiological (heart rate, skin conductance, blood and
urine measures), and self-report data were collected. Life
stress and personality information were collected.
Diabetic adolescents in poor control had higher heart rates
vi

across all conditions but no differences in skin
conductance were found. Diabetic adolescents had less
desirable blood and urine outcomes compared to the
nondiabetic youth with the adolescents with poor diabetes
control having the least desirable outcomes. No
differences in life stress between groups were found.
Adolescents with well-controlled diabetes were less
neurotic than the nondiabetic adolescents.
vii

CHAPTER I
INTRODUCTION
A substantial number of people with insulin-dependent
diabetes have difficulty adequately controlling this
disease. They feel sick, miss school or work and have
serious problems carrying out normal activities. One very
serious, even life threatening, consequence of poor control
is ketoacidosis (Cahil, Etzwiler & Freinkel, 1976).
Repeated episodes of ketoacidosis are associated with
retinopathy and kidney failure. The increased incidence of
poor control and ketoacidosis in 12-18 year olds is well-
documented (Fallstrom, 1974; Koski & Kumento, 1975). The
relationship between the psychosocial and physiological
changes of adolescence and poor control in youngsters with
insulin-dependent diabetes is not entirely clear. The
question of what contributes to the onset and maintenance
of poor control and associated ketoacidotic symptoms in
some adolescents while others remain healthy is important
in our efforts to successfully manage this chronic illness.
Stress has been frequently implicated in cases of poor
diabetic control. Patients with insulin-dependent diabetes
may be particularly susceptible to stressful events because
they lack insulin, a hormone that counters other "stress"
1

2
hormones. More specifically, in both diabetic and
nondiabetic persons, stress results in increased levels of
catecholamines (epinephrine and norepinephrine). When
catecholamines are released into the blood a complex series
of events occurs. First, gluconeogenesis is stimulated
which increases blood glucose. Second, catecholamines act
directly on fat cells to increase lipolysis (fat breakdown
and mobilization of free fatty acids (FFA)).
Catecholamines also result in increased glucagon, which, in
turn, stimulates gluconeogenesis and ketogenesis in the
liver (Tarnow & Silverman, 1981-82).
Once the stress is over, there is typically an
increase in insulin production which "counters" the stress
hormones and permits the body to return to a normal
metabolic state. However, the youngster with diabetes does
not produce his own insulin and may not be able to counter
the effects of the stress hormones. Although exogenous
insulin replacement is helpful, the youngster is still left
with a system insensitive to rapidly changing stress
related blood glucose or ketone levels. When this system
is unable to effectively counteract the stress hormones,
ketoacidosis may result. Ketones (6-hydroxybutyric acid
and acetone) are produced in the liver from fatty acids
(fatty acids -> acetyl-Co A -> acetoacety1-Co A -> 8-
hydroxybutyric acid and acetone). Ketones provide a source
of energy, but in excessive amounts produce a low plasma

3
pH, acidosis. This results in rapid deep breathing,
hypotension, and ultimately coma. Ketoacidosis is also
associated with hyperglycemia, osmotic diuresis, with
electrolyte and fluid loss, vomiting and dehydration.
Sodium is markedly depleted in circulation along with a
lowered total body potassium (Ganong, 1971).
The role of epinephrine and norepinephrine in
stimulating free fatty acid production is supported by the
work of Baker, Barcai, Kay, and Hague (1969) and Pinter,
Peterfy, Cleghorn, and Pattee (1967). Pinter et al. (1967)
demonstrated that FFA levels may be increased by both
exposure to stress (i.e., an anxiety-provoking suggestion
to hypnotized subjects and spontaneous speeches produced by
subjects) and exogenous epinephrine administration. Using
a single case design, Baker et al. (1969) found increased
FFAs during a stressful interview compared to a nonstress
period in an adolescent with insulin-dependent diabetes.
The above two studies by Pinter et al. and Baker et al.
report that the administration of propranolol (a e-
adrenergic blocking agent) in the stressful situtation
blocked the bulk of the increase in FFAs. However, Baker
et al. noted that the therapeutic effects of adrenergic
blocking agents with poorly controlled insulin-dependent
diabetic adolescents appear to be short lived. Although
this treatment was helpful for a temporary period of time,

4
eventually the problems with diabetic control returned
(Minuchin, Rosman & Baker, 1973).
Only a few studies have compared the effects of stress
in diabetic and nondiabetic subjects. Hinkle and Wolf
(1952) assessed nondiabetic and diabetic adult and
adolescent responses to a stressful interview and a
nonstressful control period. Both groups showed similar
responses in blood ketone production and urine output.
However, diabetics with elevated ketone levels in the
nonstressful control period exhibited a particularly
exaggerated increase in ketones when stressed.
Vandenbergh, Sussman, and Titus (1966) performed a similar
study comparing diabetic and nondiabetic adults’ reactions
to an unpredictable shock. Both groups responded with
increases in FFA levels and urine volume, although the
increases were not significantly different between stress
and nonstress periods. However, this lack of difference
may have been a result of their small sample size (i.e.,
n = 6 in each group).
The work of Hinkle and Wolf (1952) and Vandenburgh et
al. (1966) suggest that increased free fatty acid
production is a likely result of stress. However, a number
of questions remain. First, it is unclear whether the
responses of insulin-dependent patients are different from
subjects having adult-onset diabetes. Most of the subjects
studied were adults, not adolescents, and the effects of

5
diabetes type were not analyzed. Second, although there
was some suggestion that patients in poor control may be
more stress sensitive, this was not explicitly studied.
Consequently, it is unclear whether adolescents with
insulin-dependent diabetes differ from normals in their
metabolic response to stressful stimuli and whether
adolescents in good versus poor diabetic control differ as
well. Finally, no objective or subjective measure of
stress was collected in either study. Since an external
stressor may have different effects on different subjects,
it is difficult to assess how many subjects felt stressed
and to what extent.
Within the diabetes literature, there is repeated
mention of youngsters who have "brittle" diabetes. These
patients' (who are often adolescents) diabetes is very
difficult to manage, and they have numerous episodes of
ketosis. Minuchin et al. (1978) have suggested that there
is a subgroup of youngsters who have "psychosomatic"
insulin-dependent diabetes. These youngsters show
excessive reactivity to stress which results in a "brittle"
condition. Support for this position is found in a study
by Minuchin et al. (1978) in which psychosomatic insulin-
dependent diabetic adolescents were compared to two groups
of good control insulin-dependent diabetic adolescents (one
composed of normal adolescents and the other of adolescents
referred for psychiatric treatment of behavioral

6
problems). Each group observed their parents discussing
unresolved family problems and later joined their parents
in this discussion. A major finding in this research
endeavor was that in the psychosomatic group the
adolescents with diabetes produced higher levels of FFA
which took longer to return to baseline when compared to
youngsters in the other groups. The psychosomatic
adolescents also produced higher FFA levels than their
parents which remained elevated after their parents' FFA
levels had returned to the baseline level (Minuchin et al.,
1978). No similar difference was found for the normal or
behavior problem diabetic groups.
The findings of Minuchin et al. (1978) support the
notion that a subgroup of insulin-dependent diabetic youth
have exaggerated response patterns to stress. Their
findings suggest that there are no major metabolic response
differences between well-controlled insulin-dependent
diabetic youngsters and their parents. However, only a
small number of patients were studied and the criteria for
placement in study groups (psychosomatic, normal, behavior
problem) was not clearly specified. Consequently, it is
unclear how many youngsters in poor diabetic control have
the "psychosomatic" or heightened stress reactivity that
Minuchin et al. postulate.
To summarize the main points made thus far, stress
exposure leads to metabolic changes associated with insulin

7
efficiency in both nondiabetic and diabetic persons. These
metabolic changes are related to sympathetic increases of
epinephrine and norepinephrine production although other
body hormones and transmitter substances are involved. The
normal person has finely-tuned metabolic processes which
act to keep their metabolic responses within normal
limits. However, due to the insulin-dependent diabetic
individual's inefficient insulin response capability, more
extreme metabolic responses may become more likely.
Evidence to date suggests that at least some subgroups of
diabetics may be more metabolically reactive than other
groups, although the relationship between metabolic
responsivity and control level has not been clearly
specified. There is less evidence to suggest clear-cut
response differences between diabetics as a group and
nondiabetics, although this hypothesis has received little
research attention.
Major Hypotheses
The primary purpose of the present investigation was
to study the effects of stress on youngsters with insulin-
dependent diabetes. The stress responses of youngsters
with well-controlled diabetes were compared to youngsters
in poor control and both diabetic groups were compared to
nondiabetic adolescents. Self-report, behavioral,
psychophysiological, and metabolic effects of stress were
assessed. Few differences on any of the measures were

8
expected between the well-controlled diabetic youngsters
and their nondiabetic counterparts. In contrast, those
youngsters in poor control were expected to show greater
psychophysiological and metabolic reactivity to stress than
either of the two other groups.
The study's hypotheses were as follows:
1. Compared to well controlled diabetics or
nondiabetics, insulin-dependent diabetic
adolescents in poor control who are stressed in a
laboratory setting will exhibit (a) heightened
metabolic reactivity, (b) heightened
psychophysiological reactivity, and (c) slower
rates of psychophysiological recovery subsequent to
the stressful experience.
2. Well controlled diabetics will show increased
metabolic effects to stress compared to nondiabetic
normals.
3. Few differences between groups are expected on the
self and behavioral measures of stress and
anxiety. However, should differences exist they
should be between the poorly controlled diabetic
youngsters and the other two groups. If youngsters
in poor diabetic control are more stress-reactive,
they may acknowledge greater stress and appear more
anxious to an observer.

9
The present investigation differs from past attempts
to study the effects of stress on persons with diabetes in
a number of important respects. First, only insulin-
dependent adolescents were studied. Second, distinctions
between those in good versus poor control were made.
Third, in both groups of youngsters with diabetes the
youngster and parent confirmed that the prescribed insulin
dose was given the night before and morning of the
experiment. Fourth, self-report, behavioral, and
psychophysiological effects of the stress were measured.
In past research efforts, no attempt has been made to
quantify the stress experienced by the subject either
through subjective ratings or by more objective behavioral
or psychophysiological measurement. And finally, a sample
size of fifteen subjects per group was obtained.
Exploratory Investigations
In addition to the major purposes and hypotheses
outlined previously, this study explored two other
variables potentially related to diabetes control. These
are life stress and the personality dimensions of
extraversión and neuroticism.
Life Stress
Evidence has accumulated suggesting that diabetic
adolescents with high scores on a life stress/change scale
or who have lost a parent show increased ketoacidosis and
related symptoms (Chase & Jackson, 1981; Koski & Kumento,

10
1975). Bradley (1979) found that the number of stressful
life events was associated with diabetes control in
adults. Furthermore, the insulin treated group had higher
levels of diabetes disturbance (glycosuria, prescription
changes, and clinic visits) compared to the tablet treated
group, although there was little difference between
reported levels of life stress in the two groups.
These findings support the hypothesis that life stress
is associated with diabetes control particularly in
insulin-dependent diabetics.
Introversion-Neuroticism
Hans Eysenck (1967) has postulated two basic
dimensions of personality (introversion-extraversion and
stability-neuroticism) based on biological inheritance and
its interaction with environmental learning (Eysenck,
1967). His neuroticism dimension measures emotional
responsivity and reactivity and he suggests that this
dimension may be involved in psychosomatic disorders
(Eysenck, 1967). Persons high on neuroticism have low
tolerance for stress, whether physical or psychological,
tend to avoid stressful stimuli, and are "overly emotional,
reacting too strongly to all sorts of stimuli, and find it
difficult to get back on an even keel after each
emotionally arousing experience" (Eysenck & Eysenck, 1975,
p. 5). Furthermore, Eysenck (1967) suggests that whereas
introversion-extraversion is associated with cortical

11
functioning/arousal, neuroticism is associated with
autonomic arousal which is mediated by the limbic-
hypothalamic brain area (Eysenck, 1967).
Eysenck's personality theory and related research
suggest that introversion also may be associated with
psychosomatic proneness. The unstable introvert, due to
his introverted propensities, is more aware of subtle
stimuli earlier and the stimuli are more "amplified" in the
sense that the introvert is more cortically aroused by
it. One may think of the introvert as "geared to inspect"
stimuli. This earlier greater awareness of a threatening
stimulus should increase autonomic responsivity.
Furthermore, Gray (1975) has modified Eysenck's model of
extraversion-introversion by suggesting that introverts are
more sensitive to particular aversive stimulation, i.e.,
punishment and frustrative-nonreward and thus more
conditionable to situations involving punishment or
frustration-nonreward. Both Eysenck and Gray agree that
trait anxiety as measured by the Taylor Manifest Anxiety
Scale and the Spielberger Trait Anxiety Scale are
correlated with Eysenck's neuroticism and introversion
scales. In fact, Gray (1975) suggests that a 45 degree
rotation of Eysenck's factors would provide more relevant
dimensions although not independent factors. The new
factors could be labeled trait anxiety and impulsivity.
Regardless of the theoretical differences between these

12
men, both agree introversion should predispose an
individual toward increased emotional responding; Eysenck
via increased cortical arousal leading to earlier awareness
of more subtle threatening cues, and Gray via a
biologically increased sensitivity to aversive and
frustrative-nonreward cues. Gray's issue is not with the
validity of Eysenck's scales, but with the choice of factor
rotation and the nature of the underlying biological
predisposition.
In summary, high introversion and neuroticism may
predispose insulin-dependent diabetics toward higher
autonomic arousal and slower return to baseline. This
autonomic over-reactivity may predispose them toward more
diabetic control problems. It is interesting to note that
the two personality descriptions (from parental ratings)
that Simonds (1977) found to differentiate well controlled
from poorly controlled diabetic youth were anxious and
depressed. These are the same personality trait terms that
Eysenck (1967) uses to describe an introverted neurotic or
dysthymic personality. Due to the strong association
between sympathetic reactivity and neuroticism hypothesized
by Eysenck, it is reasonable to expect that if this
relationship exists it would show up in a diabetic
population where sympathetic influences may be magnified by
an easily disrupted metabolic system.

13
Although Eysenck's personality theory has not been
applied to problems of diabetic control in insulin-
dependent youth, there is extensive literature assessing
psychophysiological reactivity in introverts and neurotics
compared to other control groups. For example, Stelmack
(1981) concluded that differences in electrodermal activity
between introverts and extroverts has support with
electrodermal activity generally greater for introverts and
electrodermal habituation faster for extroverts. In a
sample of college women, Harvey and Hirshmann (1980) found
significant heart rate differences for introverted-neurotic
and extraverted-stable groups who viewed slides of violent
death. The introverted-neurotic groups exhibited heart
rate increase whereas their counterparts showed heart rate
deceleration.
Some additional evidence exists suggesting a
relationship between neuroticism and reported illness.
Denny and Frisch (1981) found neuroticism to be a predictor
of self-reported illness in two samples of college
students. Akerstedt and Theorell (1976) found increased
physical complaints from neurotic vs. stable railway
workers (utilizing Eysenck's personality scale) who were
switched from day to night shifts. (Eysenck's scale was
administered prior to the shift change.) Less direct
evidence for a relationship between neuroticism and illness
comes from a study by Mehrabian and Ross (1977). These

14
authors utilized a stimulus screening questionnaire (high
stimulus screening theoretically was related to low
arousability) devised by Mehrabian and Ross (1977), which
correlated negatively (r = -.54) with Eysenck's measure of
neuroticism. The high arousability group reported more
psychosomatic health complaints and nonrecurring illness.
In summary, the following exploratory hypotheses were
tested:
1. Adolescents in poor diabetic control will have
higher self-reported levels of life stress than
diabetic adolescents in good control or normal
nondiabetic youth.
2. Adolescents in poor diabetic control will have
higher scores on Eysenck's Neuroticism and
Introversion Scales than diabetic youngsters in
good control or nondiabetic normals.
3. Subjects scoring high on Eysenck's Neuroticism and
Introversion Scales will show heightened
psychophysiological reactivity to the laboratory
stresses and slower habituation than subjects
scoring low on these scales.

CHAPTER 2
METHODOLOGY
Participants
Participants consisted of adolescents with insulin-
dependent diabetes and nondiabetic adolescents aged
11-18. Diabetic participants were obtained from lists of
patients treated through the North Florida Regional
Diabetes Program located at the J. Hillis Miller Health
Center, Gainesville, Florida; the University of South
Florida Diabetes Program located in Tampa, Florida; and
lists of campers attending a summer camp for diabetic
youngsters run by these two programs. The nondiabetic
youth were recruited from aged 12-18 students at the P.K.
Yonge School associated with the University of Florida and
through staff at the J. Hillis Miller Health Center.
Subjects were contacted based on their hemoglobin A1
(HA1) values, a physiological measure used to assess
diabetes control over several weeks time (Tarnow and
Silverman, 1931-82). The HA1 is a measure of the amount of
glucose adhering to hemoglobin in the blood and reflects
amount of blood glucose over a period of time. In this
study, adolescents in good diabetic control had HA1 values
15

16
of 12 or lass and those in poor control had valúas 15 or
over. These cutoff scores are based on Harkavy's (1981)
study in which similar scores discriminated good and poor
control as defined by diabetologists' ratings. The HA1
value obtained at the time of the study served as the final
criterion and in three cases a participant whose HA1 was
slightly above 12 was kept as a good control subject if
his/her match had a value above 16.
All adolescents having diabetes at least one year and
meeting the HA1 criteria for good control were asked to
participate if a potential poor control match could be
identified. Participants were matched on sex, age, race,
and duration of diabetes. Matched subjects had to be of
the same sex, within 2 years of age, and of the same ethnic
group (except in one case where a white male was
substituted for a black male). Poor control subjects could
not have had diabetes more than 1 year longer than their
counterparts.
Each potential subject and his/her parent indicated
that the recommended insulin dose was regularly
administered and specifically acknowledged that the
required dose was administered at the regular time the
night before and the morning of the experimental session.
If the subject or parent indicated that this was not the
case, the adolescent was not used as a subject. This
occurred with two potential poor control subjects.

17
The nondiabetic group was obtained by advertising at
the P.K. Yonge School and through staff at the J. Hillis
Miller Health Center. They were of the same sex, race, and
within 2 years in age of both their diabetic matches. All
study participants were paid money; $15 the first year data
were collected and $25 the second year.
Stress Manipulation Task
Each youngster participated in three potentially
stressful tasks. First a heparin lock was inserted in the
participant's arm or hand for the initial blood
withdrawal. The needle insertion was preceded by a 3
minute rest period and followed by a 3 minute recovery
period. Secondly, each participant was asked to give two 3
minute speeches. Each speech was preceded by a 3 minute
rest period and planning period. Both speeches were
followed by a 3 minute recovery period. Participants
remained seated for both blood withdrawal and speech
giving. All three events were videotaped. Each rest and
recovery period was preceded with the request to close
their eyes and rest and relax as completely as possible "as
if they were going to sleep."
Speeches
Each subject was asked to give two speeches. She was
told that she would have 3 minutes to plan the speech and a
clock was pointed out to time the planning. No pencils or

18
paper was available for notetaking in the plan period. The
topics were "the last big argument I had or my most recent
big disappointment" and "a recent fun or pleasant time I
had or something very nice that happened to me." See
Appendix A for the instructions that accompanied each
topic. Each subject was told that the speech would be
videotaped and a small audience would listen. At least one
male and female were present during speech giving. Matched
subjects were yoked to the same speech order and the order
of the two speeches was alternated between sets of matched
subjects. If a subject "froze" in his speech, one of the
audience would say a phrase designed to keep the talk
going. Examples included "tell us some more about that,"
"keep going," "what else." Generally the audience was
supportive and friendly and listened to the subject with an
interested affect.
Major Dependent Measures
Heart Rate
One sympathetic response to emotional stress is
increased heart rate. Increased heart rate has been used
as an indicant of emotional arousal and remains sensitive
across several consecutive stressors punctuated by brief
rest periods (Harvey & Hirschmann, 1980; Shipman, Heath &
Oken, 1979).
Whether or not heart rate accelerates or decelerates
is greatly dependent on the nature of the task or

stimulus. Siddle and Turpin (1980) point out that heart
rate decelerates in response to simple stimuli and
accelerates to intense or threatening stimuli, during
periods of word association tasks, and during mental
arithmetic tasks. Heart rate increases in both the
anticipatory and performance phases of public speaking
(Borkovec & O'Brien, 1977; Knight & Borden, 1979; Levenson
Jaffee & McFall, 1978). Please refer to Appendix B for a
brief discussion of the heart and primary theories
regarding its regulation.
Heart rate data were collected on a Lafayette four-
channel datagraph. Paper speed was 10 mm/sec. Heart rate
was obtained by counting the systolic spikes associated
with the cardiac contraction of the recorded pulses of the
photoplethysmographic transducer. The photoplethysmo-
grapnic transducer was attached to the thumb of the left
hand unless this arm held the heparin lock, in which case
it was attached to the thumb of the right hand.
Heart rate in beats per minute (bpm) was tabulated fo
each 1-minute segment of each period. Each period except
blood withdrawal (rest, plan, speech, recovery) lasted 3
minutes. Blood withdrawal lasted 2 minutes. The mean
heart rate of each period served as the respective period
score (rest, blood withdrawal, recovery, plan, and speech)

20
Skin Conductance
Measurement of the conductance of an electrical
current through skin tissue is often used as a
physiological indicant of arousal (Martin & Venables,
1980). Due to the high density of eccrine sweat glands
(which are innervated by the sympathetic nervous system) on
palmar and plantar skin surfaces, these sites are typically
used to obtain electrodermal information. Between group
differences in skin conductance activity on stress-inducing
tasks have been found (Knight & Borden, 1979; Levenson,
Jaffee & McFall, 1978). Please see Appendix C for a brief
note on skin conductance.
Skin conductance data were collected on a Lafayette
four-channel datagraph with paper speed of 10 mm/sec. Skin
conductance level and responses were recorded via bipolar
leads from the middle phalanges of the first and second
fingers of the left hand (unless this arm held the heparin
lock in which case the right hand was used) using Beckman
silver/si1ver chloride miniature electrodes with K-Y
Lubricating Jelly (Johnson & Johnson) as an electrode
medium.
Skin conductance was measured in micromhos. Skin
conductance levels were measured at each 20 second point
for each 1-minute segment during the 3-minute rest period,
the 3-minute plan period, the 3-minute task period (or 2-
minute blood withdrawal), and the recovery period. For

21
each period the mean of the skin conductance levels was
calculated and served as the score for each period. The
number of spontaneous conductance fluctuations equaling or
exceeding 0.1 micromhos was counted for each 3-minute
phase.
Blood Measures (FFA and Glucose)
Free fatty acids (FFA) and blood glucose increase in
response to stressful stimuli and are related to metabolic
disruption in diabetes (Tarnow & Silverman, 1981-82).
These blood measures were analyzed from blood samples drawn
at the beginning and end of the experimental session.
Urine Measures (Ketones, Glucose, and Volume)
Ketones increase in response to stress (Tarnow &
Silverman, 1981-82) and urine volume and urine sugar have
been shown to increase in response to stress exposure
(Hinkle & Wolf, 1952; Vandenbergh et al., 1966). These
urine measures were analyzed from urine samples taken at
the beginning and end of the experimental session-task
manipulations.
Venipuncture Questionnaire (VQ)
The VQ is a two-item Likert scale developed by the
researcher to allow the participant to rate venipuncture
(see Appendix D). The participant rated the task on two 5-
point scales asking how bothered by and painful the
venipuncture procedure was for them.

22
State Trait Inventory for Children (STAIC)
The state portion of the STAIC was administered to all
adolescents after each of the three tasks. The STAIC is
designed to measure both transitory anxiety specific to
stressful events (state anxiety) and stable anxiety with
consistency and permanence across time and events (trait
anxiety). Only the 20-item state anxiety portion of the
instrument was used in this study. The state portion of
the STAIC has good split-half reliability, r_ = .89 (Finch,
Montgomery & Deardorff, 1974)» and has shown changes as a
function of stress (Bedell & Roitzch, 1976; Finch, Kendall,
Montgomery & Morris, 1975). The STAIC has been used
predominantly with children aged 8 and over. The STAIC was
orally administered and the subject responded to the task
portion of the procedure (blood withdrawal, speech).
Venipuncture Observation Scale (VOS)
The VOS was developed by the researcher to assess
observed anxiety in the venipuncture situation.
Appropriate items were selected from the Self-Injection
Behavior Profile Rating Scale (previously developed by the
researcher and S. Johnson, 1982). Other items were
developed from observed signs of nervousness noted by
medical staff involved in venipuncture. Ratings were
obtained from videotaped venipuncture session and
interrater reliabilities were obtained. Presence or
absence of each item was assessed for each 20 second

23
interval. Please see Appendices E and F for the VOS and
scoring procedure.
Rank Order of Task Form (ROTF)
The ROTF is a form developed by the researcher to
allow the participant to rank order the tasks from most
stressful to least stressful (Appendix G).
Personal Report of Confidence as Speaker
Short Form (PROS)
The PROS is a 30-item questionnaire revised by Paul
(1966) from an earlier and longer version in order to
improve the form's psychometric properties and make its
completion easier and quicker for the informant. The
instrument is designed to assess self-reported public
speaking anxiety.
Time Behavioral Checklist for Performance
Anxiety (TBCL) Modified Form
The TBCL was developed by Paul (1966) to assess
performance anxiety exhibited during a public speaking
exercise. The instrument lists 20 observable
manifestations of anxiety and is scored for their presence
or absence during consecutive 20-second observation
periods. The TBCL assesses behaviors reflecting
interference with performance (e.g., stammering) and
observable effects of arousal on behavior (e.g., heavy
breathing). The TBCL was modified by deleting items that
were inappropriate for videotaped speeches by seated
persons (e.g., pacing). Several items were added from

24
other facial rating protocols by Ekman and Friesen (1975)
including miserable smile and facial emblem negative. Paul
(1966) reports the average interobserver reliability after
training exceeded r_ = .95* Other investigators using the
TBCL have reported interrater reliabilities after training
between .71 to .96 (Ciminero, Calhoun & Adams, 1977).
Ratings were obtained from videotaped performances and
interrater reliabilities computed. Raters were trained
prior to scoring. See Appendices F and H for TBCL-M form
and scoring procedures.
Additional Dependent Measures
Junior Eysenck Personality Questionnaire (JEPQ)
The JEPQ is a personality inventory designed to
measure extraversión, neuroticism, psychoticism, and
conventionality for children aged 7-15 (Eysenck & Eysenck,
1978). Only the neuroticism, extraversión, and
conventionality scales were used. Six month test-retest
reliabilities for each scale by age and sex are as
follows: extraversión range--.38-.82, with all remaining
coefficients in the ,60's and .70's; neuroticism range--.66
to .77, the conventionality scale range—.59 to .83; with
all remaining coefficients in the .60's and ,70's. One
month test-retest reliabilities were considerably higher
with a range across scales by age and sex of .59 to .89,
with most coefficients in the ,70's and .80's.

25
The JEPQ is an extension for children of the EPQ with
normative and reliability data available, but lacking
extensive validational studies. A manual to help interpret
scores is available.
Eysenck Personality Questionnaire (EPQ)
The EPQ is a personality inventory designed to measure
the same personality factors as the JEPQ in adults aged 16
and older. The extraversión, neuroticism, and
conventionality scales of the EPQ were administered to the
16-18 year-old subjects. One month test-retest
reliabilities by group and scale are primarily in the
,80’s, with a range of .72 to .92; overall reliability
coefficients were as follows: extraversión was .90 and
.86; neuroticism was .89 and .80; and conventionality was
.86 and .86, for men and women, respectively. The
extraversión and neuroticism scale were produced through
factor analytic procedures and are orthogonal factors.
Eysenck and Eysenck (1975) report that others have
reproduced this factor pattern and they report validity
data using twin and other experimental studies (Eysenck &
Eysenck, 1975). A manual to help interpret scores is
available.
Life Events Checklist (LEC)
The LEC is a 46-item (plus four blank spaces for
individual responses) inventory of significant life events
for adolescents (Johnson & McCutcheon, 1980). The

26
respondent is requested to check those events (s)he
experienced during the preceding year, rate the event as
good or bad, and rate the degree of impact the event on
his/her life on a 4-point scale from no effect = 0 to great
effect = 3. This instrument developed by Gad and Johnson
(1980) is relatively new and was developed to overcome
specific deficiencies in the existing life change/stress
inventories. Specific items were selected from existing
life change/stress inventories and nominations by an
adolescent sample. It has been administered to adolescents
aged 12 to 17 and found to correlate with indices of
physical and emotional health.
Procedure
The families were asked to participate either by
telephone or in a letter. A letter was used only when
there was no telephone in the home. If both parents and
adolescent agreed to participate, an appointment time was
scheduled. Parents were asked to observe the insulin
injection of their child the night before and morning of
the experiment. In all cases, an informed consent was
obtained from both the adolescent and parent. The parent
was given an LEC form to complete while the youngster was
taken to the study area.
First the participant voided urine into a container.
Then she was taken to the room where the experiment was to
transpire and the equipment was explained. Words like

27
electrodes were avoided and attempts were made to use
nonthreatening and understandable words to explain the
different pieces of equipment (videorecorder and camera,
physiograph, leads). Although visible, the tray with
venipuncture equipment was placed somewhat behind the
youngster. The adolescent was seated in a comfortable
chair and the heart rate and skin conductance electrodes
were attached to the hand. Then the participant was asked
to close his/her eyes and rest for 3 minutes. Afterward
the videorecorder was turned on and the heparin lock
inserted. When the venipuncture procedure was completed,
the recorder was turned off and the adolescent asked to
rest with closed eyes for 3 minutes. After the recovery
period, the following questionnaires were administered (by
the researcher reading the items outloud): STAIC (applied
to blood withdrawal), VQ, JEPQ or EPQ, LEC, and PRCS.
After completion of the questionnaires which took about 30
minutes, the 3-minute baseline rest for the first speech
took place, followed by presenting the topic to the subject
and giving him/her 3 minutes to plan the speech. Then the
audience came in the room, the videorecorder was turned on,
and the adolescent gave the speech. This was followed by
the 3-minute recovery period. The STAIC (for the speech)
was administered a second time. Then the same procedure
was followed for the second speech. After the recovery
period for the second speech, the STAIC (for the second

28
speech) was readministered and the final blood withdrawal
done and heparin lock discontinued. The ROTF was
administered, the electrodes were removed from the
youngster's hand, and the Peabody Picture Vocabulary Test
was given. The participant was debriefed and paid.

CHAPTER 3
RESULTS
Description of Sample
Forty-five adolescents participated including 18
females, 27 males, 8 black and 37 nonblack subjects. Each
good control diabetic subject (GCDS) was yoked to a same
sex, same race subject with the exception of one black GCDS
whose poor control diabetic subject (PCDS) match was
nonblack.
An ANOVA was performed for age and no significant
difference' between groups was found (_F(2,42) = .616, p =
•54). Mean ages by group were GCDS--14.75 years, PCDS--
13.92 years, and nondiabetic subjects (NDS)--14.33 years.
The range of age was 11 to 18.8 years.
Duration of Diabetes and HA1 Values
A t-test was computed to determine differences between
GCDS and PCDS in duration of diabetes. No significant
differences were found (t(28) = .82, p = .421). The mean
number of years for duration of diabetes for the GCDS was
5.62 and for the PCDS 4-47*
A t-test showed significant difference for HA1 values
between the GCDS and PCDS (T_ = -9-77, p < .001). The mean
29

30
value for the GCDS was equal to 11.26 with a range of 8.5
to 13* The mean value for the PCDS was equal to 16.23 with
a range of 15 to 18.5.
Time of Day and Location of Data Collection
A 3 X 3 chi-square statistic was computed and no
evidence emerged suggesting differences between groups in
time of day subjects were run (chi-square = 3.6, p = .50).
An equivalent number of GCDS and PCDS were run in
Gainesville and in clinics outside Gainesville. Eight GCDS
and eight PCDS were run in Gainesville and the remaining
seven in each group outside Gainesville. All NDS were run
in Gainesville.
Reliability of Observation Measurement
Pearson product moment correlations were computed for
interscorer reliability of observed anxiety (VOC, TBCL).
The following reliability coefficients were obtained: for
the VOC, _r_ = .79» p < .001; for the first speech (TBCL), _r_
= .75, P < .001; and for the second speech (TBCL), _r_ = .71,
p < .001. No significant differences were found between
scorers with t values and probabilities as follows: VOC (jt_
= .94, p = .36); first speech TBCL (_t = .66, p = .52); and
second speech TBCL (_t_ = 1.6, p = .13).
Subject-Parent LEC Correlations and T-Tests
Pearson product moment correlations were computed
between the subject and parent forms of the LEC. Pearson

31
product moment correlations were obtained for various
possible scoring methods and the following validity
coefficients were obtained: total events rated good—-_r_ =
.40, p = .05; total events rated bad--r_ = .54, p = .004;
total events rated good and weighted for impact on life--_r_
= .43, p = .01; total events rated bad and weighted for
impact on life--r_ = .60, p = .001, sum of total number of
events--j?_ = .35, p = .08; and sum of total number of events
weighted for impact on life—r_ = .50, p = .009. Paired t-
tests were computed between the subjects' and parents' LEC
scores. There was a significant difference between all
scores from the various possible methods; youngsters,
compared to the parents, reporting more events and having
higher weighted score.
Inter-relationships Between Measures
Pearson product moment correlations were completed
between the physiological, self-report, and observation
data. Appendix I is a compilation of a selection of these
Pearson coefficients. Physiological variables had
coefficients ranging from .04 to .72 (post-blood sugar and
urine volume) with the majority between .20 and .40 (HRs
with FFA and blood sugars). Self-report measures had
coefficients between .02 and .59 (the first STAIC with
rated venipuncture fear) with most higher than .25 (STAIC,
JEPQ, Speech Fear Questionnaire). Validity coefficients
between self-report, physiological, and observation data

32
ranged from no relationship to .52 (observed video anxiety
for venipuncture with rated venipuncture pain).
Control Variables
Speech Fear (PRCS)
No significant differences were found between the
three groups on reported speech fear (PRCS) using a oneway
ANOVA (F_(2,42) = .51 , p < .60). The following mean scores
by experimental group were found: GCDS = 11.47, PCDS =
10.67, NDS = 13-20; where the higher the score, the more
fear indicated.
Venipuncture Fear (VQ)
An ANOVA was computed between all groups for rated
venipuncture fear (VQ) and no statistically significant
difference's emerged (_F(2,42) = 1.58, p < .22). The
following mean ratings by experimental group were found:
GCDS = 4-33, PCDS = 3-93, NDS = 3.60; where the lower the
score, the more fear indicated.
Venipuncture Pain (VQ)
An ANOVA was computed between all groups for
venipuncture pain and no statistically significant
difference occurred (F_(2,42) = .16, p = .85). The mean
ratings by experimental group were as follows: GCDS =
4.13, PCDS = 4.00, NDS = 3.93; where the lower the score,
the more pain indicated.

33
Venipuncture Observation Scale (VOS)
An ANOVA was computed for observed venipuncture
anxiety for all groups and no statistically significant
differences were found (_F(2,28) = 1.60, p = .22).
Observed Speech Anxiety (TBCL)
An ANOVA was computed between all groups for observed
speech anxiety for both speeches. No statistically
significant differences were found for either speech [first
speech—(J?(2,34) = .327, p = .72), second speech—(F_(2,33)
= .03, P = .97)].
Reported Anxiety (S'TAIC) for Venipuncture and Speeches
An ANOVA was computed between all groups for the STAIC
for venipuncture and no statistically significant results
emerged (_F(2,42) = .44, P = .65). ANOVAs were performed on
the STAIC administered for each of the speeches. No
significant differences were found for the second speech
(_F(2,42) = .28, p = .76) but a tendency toward significance
occurred on the first speech (_F(2,42) = 2.96, p = .06). A
Duncan's Range Test at the .05 level of significance showed
the PCDS reported more anxiety than the GODS. Means for
the three groups are as follows: GCDS = 33.73, PCDS =
40.13, NDC = 35.67.
Rank Order of Task Form (ROTF)
Two 3X3 chi-square statistics were computed for the
rank order of tasks by subjects. The first chi-square
analysis found no difference between groups in rank

34
ordering venipuncture, first speech, and second speech
(chi-square = 3.4, P < -50). The second analysis found no
difference between groups in rank ordering venipuncture,
the speech on a pleasant topic, or the speech on an
unpleasant topic (chi-square = 6.0, p < .20).
Speech Order and Heart Rate
A 3 X 2 X 4 repeated measures ANOVA was computed for
experimental group, speech order and period (rest, plan,
speech, recovery) for both speeches. No main or
interaction effects were found for speech order in either
speech (£(1,37) = 1.17» P = .29) and (£(1,39) = .59, p =
.45), respectively.
Speech Order and Skin Conductance
A 3 X. 2 X 4 repeated measures ANOVA was performed for
experimental group, speech order, and period (rest, plan,
speech, recovery) for both speeches. No significant
differences were found for speech order in either speech
(£(1.38) = 1.76, p = .19) and (£(1,37) = 2.87, P = .10),
respectively.
Analyses of Major Hypotheses
Heart Rate for Venipuncture
A 3 X 2 X 3 repeated measures ANOVA was computed for
experimental group, sex, and venipuncture period (rest,
blood withdrawal, recovery). Significant main effects were
found for experimental group (£(2,39) = 6.25, p = .004),
sex (£(1,39) = 9.63, p = .004), and period (£(2,78)

35
= 14.26, p < .001). A significant period X sex interaction
occurred (F_(2,78) = 3.40, p = .04). Subsequent ANOVAs for
experimental group accompanied by Duncan's Multiple Range
Tests (at the .05 level of significance) found the heart
rate for PODS was significantly higher than the two
remaining groups at each period of the venipuncture
procedure [rest (F_(2,42) = 4.17, P =.02); blood withdrawal
(F_(2,42) = 6.58, p = .003); recovery (F_(2,42) = 4.37, p =
.02)]. Figure 1 illustrates the magnitude of the HR
differences.
Overall females had a higher heart rate in beats per
minute (BPM) with a mean equal to 90.19 BPM compared to
80.35 BPM for males.
Utilizing paired t-tests it was found that HR during
blood withdrawal was significantly higher than HR during
the rest or recovery period (_t_(44) = -5.14, p < .001) and
(_t_(44) = 3.76, p = .001), respectively. ANOVAs were
computed for sex by period with subsequent Duncan's
Multiple Range Tests performed. Whereas males had
significantly lower HRs in the rest and blood withdrawal
periods of the venipuncture procedure (F_(1,43) = 10.11, p =
.003 and _F(1,43) = 8.77, p = .005, respectively), no such
sex difference vías found in the recovery period (_F(1,43) =
1.43, P = .24).

HEART RATE (BPM)
110-T
100-
90_
80-
70-
Figure 1 .
PCDS
GCDS
NDS
rest blood withdrawal recovery
PERIOD
Mean heart rate in beats per minute for venipuncture rest, blood withdrawal
and recovery by experimental group. ^
O'-

37
Heart Rate for First Speech
A 3 X 2 X 4 repeated measures ANOVA was computed
between experimental group, sex, and period. Significant
main effects were found for experimental group (_F(2,39) =
5.65, p = .007), sex (_F(1,39) = 9.51, P = .004), and period
(F_(3,117) = 32.35, p = .000). In each case the PODS had
significantly higher HRs than the NDS and, with the
exception of the speech period higher than the GODS. See
Figure 2 for the comparison of HR by experimental group and
period.
Overall females had higher HRs with a mean HR of 89*54
BPM compared to an 80.13 mean for males. Paired t-tests
were computed between all possible combinations of periods
in the first speech and the rest and recovery periods
significantly differed (were less) from the plan (t_(44) =
-3.17, p = .003 and t_(44) = 40.57, p = .000, respectively),
and speech periods (t_(44) = -7.32, p = .000 and _t(44) =
8.39, P = .000). Heart rate during the plan period
likewise was less than the speech period (t_(43) = 39*17, p
< .001).
Heart Rate for Second Speech
A 3 X 2 X 4 repeated measures ANOVA was computed for
experimental group, sex, and period. Significant main
effects were found for sex (_F (1,37) = 4*19, P = *05) and
period (_F(3,111) = 31.65, p < .001). A tendency for
experimental group to be significant was found

HEART RATE (BPM)
110
PCDS
GCDS
NDS
100
90
70
T
rest
plan
speech
recovery
PERIOD
Figure 2. Mean heart rate in beats per minute for first speech rest, plan, speech,
and recovery by experimental group.
CO

39
(_F(2,37) = 2.54, p < .09) with PCDS having higher HRs that
GCDS and NDS. Female subjects had higher heart rates
(86.83 BPM compared to the 80.6 BPM of their male
counterparts.
Paired t-tests showed that the rest and recovery-
periods had lower HRs than the plan (_t_(44) = -3.53, p =
.001 and _t_(42) = 1.87, P = .07) and speech periods (_t(44) =
-7.84, p < .001 and _t(42) = 8.89, P < .001). The planning
period had a lower HR than the speech period (_t(44) =
-8.00, p < .001).
Skin Conductance for Venipuncture
A 3 X 2 X 3 repeated measures ANOVA was computed for
experimental group, sex, and period. A significant main
effect was found for period (_F(2,78) = 44*76, p < .001).
Paired t-tests showed each period significantly different
from the others with the highest level of skin conductance
in the blood withdrawal period and lowest level in the rest
period. The T values were as follows: rest-blood
withdrawal (_t_(44) = -7.99, P < .001); rest-recovery (_t(44)
= -6.23, p < .001); and blood withdrawal-recovery (_t_(44) =
3.10, p = .003).
Skin Conductance for First Speech
A 3 X 2 X 4 repeated measures ANOVA for experimental
group, sex, and period was computed which found a
significant effect for period (_F(3,114) = 17.35, p <
.001). Paired t-tests were computed and skin conductance

40
levels were less in the rest and recovery periods when
compared with the plan (t_(43) = -2.77, P < .008) and (_t_(43)
= 2.4, p < .02) and speech (_t_(43) = -5.74, p < .001) and
(_t_(43) = 5*78, p < .001) periods. The speech period had
higher levels of skin conductance when compared with the
plan period (_t(43) = -3.16, p < .003).
Skin Conductance for Second Speech
A 3 X 2 X 4 repeated measures ANOVA was computed. A
significant main effect was found for period. Subsequent
paired t-tests were computed and found speech skin
conductance differed significantly (was higher) from all
other speech periods with t values as follows: from rest
(_t_(44) = -3.88, p < .001); from plan (_t(43) = -2.0, p <
.05); and from recovery (_t(42) = 4.95, p < .001). Skin
conductance in the planning period was higher than in the
rest period (_t(43) = -4.29, p < .001).
Skin Conductance Fluctations-Venipuncture
A 3 X 2 X 3 repeated measures ANOVA was computed
between experimental group, sex and period. A significant
main effect was found for period (F_(2,76) = 26.53, P <
.001). Paired t-tests were utilized to compare each period
with the other periods. The blood withdrawal period had a
higher number of skin conductance fluctuations than the
rest or recovery period (_t_(44) = -7.02, p < .001 and jt(44)
= -1.85, p < .07, respectively).

41
Skin Conductance Fluctuations for First Speech
A 3 X 2 X 4 repeated measures ANOVA was computed for
experimental group, sex, and period. A significant main
effect for period (F_(3,114) = 76.89, P < .001) and an
interaction between period and experimental group (jF(6,114)
= 2.38, p < .04) were found. The rest and recovery periods
had fewer SC fluctuations than the plan (_t_(43) = -8.4, p <
.001 and t_(43) = 7.29, P < .001, respectively) and speech
periods (t_(43) = -10.71, p < .001 and jt(43) = 9-91, P <
.001, respectively). The plan period had fewer
fluctuations than the speech period (_t_(43) = -4.72, p <
.001). Experimental group was significant only in the
speech period (_F(2,41) = 3.08, p < .06) with a subsequent
Duncan's Multiple Range Test showing that the GODS had more
fluctuations than the PCDS with the following means: GCDS
= 14.53, PCDS = 9-57, and NDS = 10.87.
Skin Conductance Fluctuations for Second Speech
A 3 X 2 X 4 repeated measures ANOVA was computed for
experimental group, sex, and period. A significant main
effect was found for period (_F_(3,111 ) = 41.64, p < .001).
Each period was compared with the remaining three periods
utilizing paired t-tests. The rest and recovery periods
had the lowest number of fluctuations compared to the plan
(t_(43) = -6.59, p < .001 and _t(42) = 6.29, p < .001,
respectively) and speech periods (_t(44) = -9.11, p < .001
and t_(42) = 8.41, p < .001, respectively). The speech

42
period had the highest number of SC fluctuations (_t_(43) =
-4.44, P < .001).
Life Events Checklist (LEC)
A oneway ANOVA was computed using the LEC completed by
the adolescent for each of several methods of scoring the
LEC and none reached statistical significance. The F
values and probabilities for each scoring method are as
follows: total events rated good (F_(2,41) = .43, p = .65);
total events rated bad (F_(2,41) = .40, p = .68); total
events rated good and weighted by impact on life (_F(2,41) =
.08, p = .92); total events rated bad and weighted by
impact on life (F_(2,41) = .70, p = .50); sum of total good
and bad events (F_(2,41) = .31, P = .74); and sum of total
good and bad life events weighted for impact on life
(F_(2,41) = .17, p = .85).
Eysenck Personality Questionnaire (EPQ, JEPQ)
A oneway ANOVA was computed for experimental group for
each dimension of the EPQ (extraversión, neuroticism,
psychoticism, conventionality). All EPQ and JEPQ scores
were converted to t scores with mean = 50, SD = 10 (based
on age and sex norms in Eysenck & Eysenck, 1975, 1978)
before analyses. No significant differences were found for
extraversión (F_(2,42) = 1.00, p = .38) or psychoticism
(_F_(2,42) = .38, p = .69). A significant _F value was
obtained for neuroticism (_F(2,42) = 5.9, p < .005) and a
subsequent Duncan's Multiple Range Test (at the .05 level

43
of significance) was performed and found the good control
diabetic group differed significantly (less neurotic) from
the remaining two groups. The mean t score for the GCDS
was 45.13 compared to 52.87 and 55.73 for the PCDS and NDS,
respectively. An ANOVA was performed for conventionality
which showed a tendency (_F(2,42) = 2.48, p = .10) for GCDS
to positively endorse conventional items more frequently
than the NDS utilizing Duncan's Multiple Range Test. The
mean t score for the GCDS was 58.47 compared to 55.20 and
50.80 by the PCDS and NDS, respectively.
A series of Pearson product moment correlations were
computed between extraversión and neuroticism and HR and
skin conductance for all the individual periods in the
venipuncture procedure and the speeches. No significant
correlations for HR or skin conductance were found. As a
result, no further analyses of extraversión or neuroticism
and psychophysiological arousal were done.
Free Fatty Acid (FFA)
A 3 X 2 X 2 repeated measures analysis was computed
for experimental group, sex and time of measurement (pre-
post blood withdrawal). A tendency toward significance for
experimental group was found (_F(2,34) = 2.8, p = .07). A
Duncan's Multiple Range Test at the .05 level of
significance found that the PCDS differed from the NDS at
the first blood withdrawal. Mean values were as follows:
GCDS = .44; PCDS = .59; NDS = .31. Although not

44
statistically significant, the same pattern of mean values
was found for the post FFA sample, i.e., GCDS = .49, PCDS =
.55, and NDS = .36.
Blood Sugars
A 3 X 2 X 2 repeated measures ANOVA was computed for
experimental group, sex and trial (pre- and post-blood
withdrawal). A significant main effect for experimental
group (F_(2,28) = 14.12, p < .001) and a trial by sex
interaction (F_(1,2S) = 9.82, p < .004) were found. A
oneway ANOVA and subsequent Duncan Multiple Range Test were
computed for both pre- and post-blood withdrawals. The
overall model was significant for both blood withdrawals
(F_(2,35) = 15.38, p < .001 and _F(2,32) = 15.89, p < .001,
respectively). At the .05 level of significance the Duncan
Multiple Range Test found all three experimental groups
differed significantly from each other at the initial
withdrawal but only the NDS differed from both diabetic
groups at the second withdrawal. Mean blood sugar values
for the first and second blood withdrawals, respectively,
were as follows: GCDS = 210.73, 215.17; PCDS = 294.5,
275.84; and NDS = 59.8, 65.64. Although at the first blood
withdrawal females had significantly higher levels of blood
sugar, no significant difference was found at the second
blood withdrawal.

45
Urine Volume
A oneway ANOVA was computed for experimental group
with urine volume. Overall significance for the model was
found at (_F(2,42) = 5.67, p = .007). A Duncan's Multiple
Range Test showed that the NDS differed from the two
diabetic groups with a mean volume of 69.67 cc compared to
183.8 for the GODS and 256.67 for the PODS.
Pre- and Post-Urine Sugar
A Wilcoxin rank sum test (equivalent to the Mann-
Whitney U test) was computed for GODS and PODS urine sugar
levels for pre- and post-experimental session. No
significant differences were found between groups at the
beginning of the experimental session (z = .41, P = .66)
but the PODS had larger values at the end of the session (z
= 1.85, P = .04). All NDS had 0 percent urine sugar.
Pre- and Post-Urine Ketones
A Wilcoxin Rank Sum Test was computed for urine
ketones before and after the experimental session. No
significant differences were found pre-session (z = .39, p
= .35) although a tendency for PODS to have higher levels
of urine ketones was found at post-experiment (z = 1.29, P
= .10). No traces of urine ketones were found for any NDS.
Pre- and Post-Plasma Ketones
No evidence of plasma ketones was found in any
experimental group at pre- or post-blood withdrawals.

CHAPTER 4
DISCUSSION AND SUMMARY
The major contribution of this study was to clarify
where and how insulin-dependent diabetic and noninsulin-
dependent diabetic youth differ in their physiological and
metabolic responsivity to a psychological stress.
Furthermore, differences between the responsiveness to the
stress by the level of diabetes control was addressed.
Basically the findings suggested that the insulin dependent
diabetic adolescent responds similarly to psychological
stress as his nondiabetic peer but generally with higher
and less desirable levels of response. However, little
evidence of excessive physiological responsivity or slower
return to baselines accrued. This study generally
replicated the directions of the findings of Hinkle and
Wolf (1952) and Vandenbergh et al. (1966). However, the
outcomes of this study failed to support the findings of
Minuchin et al. (1978). Specifically, no group responded
with a comparatively extreme increase in FFAs and slower
return to baseline FFA levels. In fact, in this study the
PCDS actually had a slightly lower FFA level after the
stressful task compared to pre-experimentally. This does
not support the notion that ketoacidosis and other serious
46

47
illness in insulin dependent diabetes are the result of an
extreme physiological response to stess.
What this study has not done is to definitively tell
us the reasons for the physiological and metabolic
differences found between groups. Possible explanations
and their merits are more fully discussed in the following
sections. Likewise, the exploratory hypotheses regarding
life stress and personality traits are discussed.
Reported and Observed Anxiety of Tasks
Overall there were few differences between the GCDS,
PCDS, and NDS in self-reports of anxiety, task rank
ordering, or observed anxiety on any of the tasks
(venipuncture or speeches). The one exception, in the
predicted direction, was that the PCDS tended to report a
higher level of anxiety during the first speech but this
tendency was lost during the second speech.
Physiological Response to Tasks
Heart rate, but not skin conductance, significantly
differentiated the PCDS from the GCDS and NDS. Heart rate
in PCDS was consistently about 10 BPM higher than the GCDS
or NDS which were highly similar. However, no differences
between groups were found for skin conductance. In fact, a
tendency of higher skin conductance fluctuations in the
GCDS was found compared to the PCDS and NDS. Furthermore,
no evidence of heightened reactivity and slower return to

48
baseline emerged. Instead, a consistent pattern of higher
HR level for poor control adolescents across all conditions
whether rest, blood withdrawal, speech, or recovery was
found.
Heart Rate
The finding of higher heart rate in the PCDS is
consistent with the hypothesis that this group had higher
levels of catecholamines. This hypothesis is further
supported by the finding that PCDS had higher FFA, blood
sugars, urine sugars, urine volume, and urine ketones. In
effect, stress triggers the introduction of catecholamines
and other stress hormones which set off the stress response
of increased HR, FFA and blood sugar. This is the normal
physiological process stimulated by stress. In the PCDS
these stress responses were higher and less desirable than
in the good control group or nondiabetic group. In the
normal stress response insulin counters the effects of the
stress hormones and operates to reduce FFA and blood
sugars. By reducing the influence of the catecholamines
and stress hormones insulin contributes to the recovery of
heart rate to pre-stress levels. The skin conductance
findings and failure to find differences between groups on
self-reported and observation measures of anxiety do not
support this explanation.

49
Other Explanations of Higher Heart Rate in PCDS
The PCDS may have more morphologic damage to
circulatory organs (veins, arteries, heart) which reduces
the overall efficiency and intactness of the circulatory
system. One well-known risk of insulin-dependent diabetes
is heart disease. The retinal damage that is a serious
complication of IDDM is contributed to by vascular
hemorrhages, aneurysms, and neovascularizations. To make
up for the inefficiency resulting from these morphologic
abnormalities/daraage the heart rate may be increased to
provide the blood flow required for normal body function.
Another potential explanation is that our PCDS had
higher rates of autonomic neuropathy. Naliboff (1985)
reports that estimates have been made that 40$ of persons
with diabetes have at least mild symptoms of autonomic
neuropathy. He found a higher resting heart rate in a
group of adult subjects with both insulin-dependent and
noninsulin-dependent diabetes. Upon further examination of
these individuals some evidence of autonomic neuropathy was
found in almost all diabetics.
Autonomic neuropathy tends to be manifested earlier in
the parasympathetic nervous system as opposed to the
sympathetic nervous system. This fact may help explain the
desynchrony between heart rate and skin conductance which
is primarily innervated by the sympathetic nervous
system. Since heart rate is heavily influenced by

50
parasympathetic processes as well as sympathetic processes,
autonomic neuropathy may show heart rate effects before
skin conductance effects. That is, a relatively greater
deterioration of parasympathetic inhibition of heart rate
in the PCDS would lead to an increased heart rate. If this
explanation is supported, it suggests that children with
insulin-dependent diabetes should be monitored for
autonomic neuropathy symptoms earlier than currently is
done.
Skin Conductance
The failure to find differences between experimental
groups in skin conductance levels is interesting. This in
conjunction with the failure to find differences between
groups in self-report or observed anxiety supports the
hypothesis that the groups were not differentially
stressed. As a result support for an alternate explanation
to increased catecholamine levels to account for the heart
rate finding is suggested.
Other Explanations for Skin Conductance Findings
Skin temperature is positively associated with skin
conductance response (Haroian, Lykken & Huser, 1984;
Venables & Christie, 1980). If vasoconstriction or poor
circulation was more pronounced in the PCDS, finger
temperature would have been reduced in the PCDS. Such
reductions of skin temperature in the PCDS may have acted
to mask any heightened sympathetic input to the sweat

51
glands that are responsible for skin conductance
activity. Since we did not measure vasoconstriction,
finger temperature, or epinephrine, we cannot rule out this
possibility.
Also, heart rate and skin conductance do not always
jointly distinguish between groups although they may
function similarly in both groups. For instance in our
study, both skin conductance and heart rate levels
increased in the plan, speech, and blood withdrawal periods
and decreased in the rest and recovery periods. However,
only heart rate distinguished between experimental
groups. This type of finding in the literature is not
unusual. Defining the mechanisms that underlie the
discrepancies in physiological response systems is very
difficult. For example, until recently the measurement of
epinephrine was both difficult and lacked reliability.
Currently, the measurement of epinephrine is improved but
remains difficult and very expensive.
Skin Conductance Fluctuations
The tendency of the GCDS to have higher numbers of
skin conductance fluctuations suggests that this group had
a higher propensity to notice and respond to nuances in the
environment whether the nuance consisted of physiograph
noises, movements inside or outside the room, etc. Skin
conductance level is an indication of more than anxiety.
Like heart rate, skin conductance responds to new or novel

52
stimuli. Instead of decreasing in the orienting situation
as heart rate does, skin conductance increases (Lacey,
1967). The GCDS low heart rate level, lower FFAs, lower
urine volume, lower blood and urine sugars, and similar
self-report, ratings, and behavioral measures of anxiety
provide consistent data to rule out that this group was
more anxious or aroused by the tasks. This supports the
hypothesis that the GCDS are more alert to environmental
changes. If so, this finding leads to the question of
whether or not such a propensity might make the GCDS more
alert to both internal and external changes in the
environment which aid them in better decision making in the
care of their diabetes. Since persons with
insulin-dependent diabetes must make daily decisions
directly influencing the management of their disorder such
as when a snack is needed, when their insulin dose requires
adjustment, or when exercise is needed, this extra
awareness may benefit them.
Metabolic Reactivity
Clear metabolic differences emerged between at least
one of the diabetic and the nondiabetic groups on all
dependent measures. The nondiabetic group had a lower
level of FFA, lower urine volume, and lower blood and urine
sugars. In addition, although not always statistically
significant, in every case the PCDS had the highest values

53
for FFA, urine volume, urine ketones and blood and urine
sugars with the GCDS having the middle values.
Only minimal support for the hypothesis that PCDS
would show heightened reactivity emerged. Instead, a
picture of sustained higher levels of HR, FFA, and blood
sugars was found. In fact, in the case of FFAs and blood
sugars, the post-experimental values were reduced enough
for statistical significance to be lost when it was found
pre-experimentally. One possible exception to this
generalization is that although no significant differences
were found pre-experimentally in urine sugars and urine
ketones between the GCDS and PCDS, differences were found
post-experimentally with the PCDS having higher levels.
Both Hinkle and Wolf (1952) and Vandenbergh et al.
(1966) found that their diabetic participants tended to
have a blood glucose decrease following stress. The drop
in the diabetic group tended to be higher while in the
nondiabetic group the level tended to stay the same or
increase slightly (as occurred in our GCDS and NDS). Both
researchers point out that increased urine sugars did not
help account for the blood sugar drop in the poorly
controlled group. In our case, urine sugars and ketones
were higher post-experimentally in the PCDS and may help
explain the reduction in blood sugar and FFAs. That is,
sugar and ketones were filtered from the blood into the
urine. Hinkle and Wolf and Vandenbergh et al. had small

54
and more hetareoganeous samples which may have prevented a
similar finding. It should be noted that our findings did
not parallel the findings of Minuchin et al. (1978).
Whereas the PCDS FFA level post-experimentally was lower
than pre-experimentally and the NDS and GCDS slightly
higher, the psychosomatic diabetic group in the Minuchin et
al. study showed higher FFA levels post-experimentally and
the other diabetic and nondiabetic groups lower FFA levels.
Another explanation of the decreased final blood sugar
and FFA level in our sample is that the PCDS had a higher
metabolic need for energy to sustain normal body
functions. The increased HR across tasks provides support
for this notion. That is, the body must burn more energy
(FFA, blood sugar) to deal with a higher heart rate.
Life Stress and Diabetes Control
The hypothesis that number of reported life stress
events would be related to level of diabetes control was
not confirmed. No relationship between diabetes control,
determined in this study by Hemoglobin A1 value, and amount
of positive, negative, or combined positive and negative
life events was found. Likewise no differences emerged
between the diabetic and nondiabetic groups. The failure
to find differences between groups on the LEC suggests that
it is not the amount of reported life stress per se that
influences level of diabetes control. This conclusion is
supported further by the lack of reported differences

55
between groups in stressfulness of blood withdrawal and
speech giving even though physiological responses differed
between groups.
Brand, Johnson and Johnson (1983) report a finding
similar to that of this study. They found no relationship
between Hemoglobin A1 and the LEC in diabetic youth aged 10
to 17.8 years attending a summer camp. The only
correlation that they found which approached significance
was between negative life change and urine ketones.
In the two studies that found a relationship between
diabetes health variables, in particular Hemoglobin A1, and
reported life stress, several differences emerge.
Bradley's (1979) study differed from ours in several
ways. First, she included British adult subjects with
insulin-dependent diabetes and adult onset diabetes.
Secondly, she used another life events change instrument
than the LEC. Chase and Jackson (1981) also used another
life stress questionnaire and measured life stress over the
preceding 3 months instead of year as in the current
study. As in this study, they looked at adolescents with
insulin-dependent diabetes. They found a high correlation
between amount of reported life stress and Hemoglobin A1
values (r = .41). In contrast, the current study found a
nonsignificant Pearson correlation between negative life
events and Hemoglobin A1 of .16 and total life events of
.02. The participants in this study were matched for

56
duration of diabetes, sex, age, and race while those in
Chase and Jackson's were not. It was also confirmed from
both parents and adolescent that the prescribed insulin
dosage was administered at the same time generally and
specifically the night before and morning of the
experiment. As a result the sample was different.
Perhaps an instrument more sensitive to everyday
stresses would show a stronger relationship. Kanner,
Coyne, Schaefer and Lazarus (1931) suggest that a life
stress scale designed to measure smaller, more frequent
daily stressors might yield better results in predicting
psychological and health outcomes than the major life event
scales such as the LEC. Such scales are now available.
Although more refined techniques to assess stress
might yield higher predictive power, other factors need
assessment to account for significant amounts of the
variance. For instance, in our study we found for the most
part that the experimental groups reported and behaved in
ways suggesting that they viewed the tasks with similar
levels of stress/anxiety. Yet the PCDS were in much poorer
control of their disorder and physiologically dealt less
efficiently and effectively with the stresses. It is
reasonable to expect that the physiological
predispositions/states, behavioral tendencies, as well as
cognitive traits of the individual, must be considered to

57
make the best predictions of the effect of stress on
health.
Personality Findings
On the JEPQ/EPQ the GCDS were less neurotic than both
other groups and more conventional than the NDS. This
finding is similar to Simonds (1977) who found (using
parental reports) that the poorly controlled group was more
likely to be anxious and depressed, the same terms Eysenck
uses to describe an introverted neurotic personality.
Likewise Simonds reported that his good control group
reported fewer conflicts than the nondiabetic group and had
an unusually low incidence of parental divorce. Our
findings in addition to Simonds suggest that adolescents
with insul.in-dependent diabetes in good control may be
unusually well-adjusted and conventional or socially rule
oriented. Also in accord with Simonds, they suggest that
in general poorly controlled diabetic adolescents have
average or normal psychological adjustment.
No evidence emerged supporting differential
physiological or metabolic responsiveness due to
neuroticism. This suggests that neuroticism is not related
to poor control through a clearly identifiable
physiological or metabolic mechanism. (See Appendix J for
the correlation coefficients between neuroticism and
physiological and metabolic variables.) It appears more
reasonable to postulate that the more conventional,

58
socially appropriate self-report response tendencies of the
GCDS may be related to behavioral tendencies to follow
prescribed instructions and advice regarding care. This
may reach into the general living style of the
respondent. She may be more inclined to eat properly,
exercise as directed, and avoid less healthful life styles.
Future Research
Several lines of research are suggested by the present
findings. The finding of desynchrony of heart rate and
skin conductance levels raises several questions. One is
whether the differences between PCDS and GCDS were due to
different levels of catecholamine response. Measurement of
plasma catecholamine would help answer this question. If
the PCDS had higher levels of catecholamine, that group
would be more physiologically stressed. If no differences
in catecholamines were found, our skin conductance findings
would be expected. We would not have to consider other
explanations of why no skin conductance differences
emerged, e.g., increased circulatory damage and/or
autonomic neuropathy.
Another research question relates to the presence of
increased circulatory system damage or autonomic damage.
Several avenues of research are available to explore these
hypotheses including medical examination and tests to
assess circulatory and autonomic neuropathy damage.
However, whether or not increased damage is identified, we

59
still may not know the degree to which the damage
contributes to our findings of increased heart rate.
Another approach to this question is to see if the
increased heart rate and metabolic responses can be
reversed. That is, can a poor control diabetic group be
treated by some method and as a result respond
physiologically and metabolically like the good control
group. To the extent that circulatory or autonomic
neuropathy is resistant to intervention, reversal of heart
rate findings would not be expected.
Another line of investigation relates to the question
of whether or not the PCDS is more stress sensitive but,
due to their initial high level of being stressed,
differential rates of response were lost. More stress
sensitive persons might become more physiologically aroused
about participating in the experiment and their heightened
initial arousal may not be generalizable to other
situations. Measurement of heart rate and some metabolic
measures (perhaps FFA and urine volume) in ordinary and
nonintrusive ways would be very informative. Heart
monitoring devices could be attached and worn over time so
that the participant "forgets" about the device. Blood
sample would be more difficult to accomplish. However, as
metabolic measures such as glycosolated hemoglobin become
available, indicants of the metabolic state over time will
help address this question.

60
Several other questions were raised by the findings.
One was whether or not the GCDS were more sensitive to
novel or changing stimuli in the environment as was
suggested by their increased skin conductance
fluctuations. Likewise, are they more aware of internal
states and changes in the body. As suggested by Simonds
(1977) and our personality findings, are the GCDS more
psychologically well-adjusted compared to both their
diabetic and nondiabetic peers? Furthermore, are they more
rule-oriented and likely to follow medical advice and live
more health-oriented life styles?
Implications
This study has several practical implications. First,
the high heart rate in the PCDS may be indicative of
serious medical problems in this group that to date have
not been expected to be manifested at so young an age.
Generally, adolescents of this age group are not closely
monitored for symptoms of autonomic neuropathy or
circulatory disease. These findings suggest that regular
monitoring should be taking place for these youngsters.
A second implication is that the PCDS do not build up
excessive FFAs or blood sugars in response to a stress but
return to their pre-stress baseline as their GCDS and NDS
counterparts. This does not provide support for a
"psychosomatic" hypothesis, for example as suggested by
Minuchin et al. (1978), in which predisposed

61
insulin-dependent diabetic youngsters become sick when
exposed to a stress (for Minuchin et al., the family stress
of a "psychosomatic family").
A final implication is that the GCDS are more
psychologically healthy and may be behaviorally oriented
toward better caretaking of their disease. This requires
much more investigation and can only be hypothesized about
at this time. It fits nicely with the current finding of
other researchers (Simonds, 1977).

APPENDIX A
SPEECH TOPIC
Speech Topic 1
Hello. Your speech will be on the topic of "a recent
fun or pleasant time I had or something very nice that
happened to me." You are free to pick any event or angle
you wish. Some ideas include a grade you especially like;
a good time with your friend, parent, brother, sister,
etc. ; special equipment that you got like a bike or record
player; an event you got to go to, etc. You can talk about
when it occurred, how it came about, what it was like for
you, how you still feel, what happened later, etc.
Speech Topic 2
Hello. Your speech will be on the topic of "the last
big argument I had or my most recent big disappointment."
You are free to pick any event or angle you wish. Some
ideas include a grade you did not like; an argument with
your friend, parent, brother, sister, etc.; equipment that
broke like a bike or record player; an event you had to
miss, etc. You can talk about when it occurred, how it
came about, what it was like for you, how you still feel,
what happened later, etc.
62

APPENDIX B
HEART FUNCTIONING
The heart in humans and higher mammals is a complexly
innervated organ whose activity frequently is used as an
indicator of a psychological process. Heart rate (HR)
acceleration and deceleration in response to various
stimuli have long been noted by psychologists. Heart rate
decelerates in response to simple stimuli and accelerates
to intense or threatening stimuli, during periods of word
association, and during mental arithmetic. Sokolov
referred to a HR increase in response to a stimulus as a
defense response whereas HR deceleration was called an
orienting response. Lacey (Siddle & Turpin, 1980)
hypothesized that this 'directional fractionation' could be
explained by the nature of the stimuli. Stimuli requiring
environmental intake and consequent sensory integration
would lead to HR deceleration. Lacey further suggested
that the HR deceleration was due to an indirect effect of
HR on cortical activity. Another explanation that has been
offered is that lowered body activity in general
facilitates sensory intake by reducing distraction. The
second part of the 'directional fractionation' is that HR
accelerates in response to stimuli requiring spurring
63

64
environmental rejection. Obrist (1976) introduces a new
principle in HR activity. He uses the term cardiac-somatic
coupling to describe the principle that HR changes in
accordance with somatic need. In other words, as somatic
activity increases HR increases and as somatic activity
decreases HR decreases. However, Obrist points out that
cardiac-somatic coupling breaks down in those situations
related to active avoidance of aversive stimuli. These
situations result in substantial HR increase that is
unrelated to somatic activity.
The heart is neurally innervated by two interactive
inputs from the sympathetic and parasympathetic branches of
the autonomic nervous system (ANS). The sympathetic input
consists of adrenergic fibers originating in the spinal
cord via the stellate and caudal cervicle ganglia. The
neural transmitter substances are epinephrine and
norepinephrine. Excitation of these fibers increases HR
and blood pressure and is associated with myocardiac
contractile force. Parasympathetic fibers (cholinergic)
emanate from the vagus nerve. Excitation of these fibers
reduces HR and contractile force and, in general, is
antagonistic (opposite in effect) to sympathetic
excitation. In general, the higher the sympathetic input,
the higher the parasympathetic input. Heart activity
influences baroreceptors in the vagal nerve which respond
according to the level of heart activity by either

65
inhibiting HR when HR
inhibition when HR is
is high and reducing parasympathetic
low.

APPENDIX C
BRIEF NOTE ON SKIN CONDUCTANCE
The eccrine sweat glands are of particular importance
to the psychophysiologist and are sympathetically
innervated. These glands appear to play a role in thermal
regulation only for very hot temperatures. Eccrine sweat
glands are widespread over the body but are particuarly
dense on the palmar and plantar surfaces. Martin and
Venables (1980, p. 10) point out that it is realistic to
think of the principle effector mechanism in SC measurement
as sweat glands arranged as resistors in parallel. The
eccrine sweating produces SC changes which are related to
orienting or signal responses. At the skin surface sweat
is both discharged and reabsorbed.
66

APPENDIX D
VENIPUNCTURE QUESTIONNAIRE
Please rate how bothered you are in general by having blood
drawn.
1 2 3 4 5
extremely moderately not bothered
bothered bothered at all
Please rate how painful the venipuncture procedure was for
you.
1
2
3
4
5
extremely
moderately
not painful
painful
painful
at all
67

APPENDIX E
VENIPUNCTURE OBSERVATION CHECKLIST
Subject Name Number
Rater Name Rating Date
BEHAVIOR TIME PERIOD
1 2 3 4 5 6 SUM
Time:
*
X
X
X
X
X
Verbalized Pain
*
X
X
X
X
X
Verbalized Anxiety
*
*
X
*
X
*
Verbal Delay
*
X
X
*
*
X
Looks Away
X
*
*
*
*
Â¥
Facial Grimaces
*
*
X
*
X
X
Moisten Lips
X
X
*
*
*
X
Swallow
*
*
*
*
*
*
Heavy Breathing
X
V-
X
X
—¥—
—5P
Smile Miserable
*
X
X
*
X
X
Tearing/Crying
*
*
X
X
X
*
Behavioral Delay
*
*
X
*
X
*
Facial Emblem Negative
X
*
X
X
*
X
*Facial Emblem Neutral
*
X
X
X
*
X
♦Smile False
X
X
*
*
X
X
*Smile Spontaneous
*
X
X
X
X
X
♦Laughs
*
X
X
X
X
X
♦Talks Other
*
*
X
X
*
*
♦Blink Number
X
X
X
*
*
*
None
*Anxiety General 0 1
♦Activity General 0 1
♦Positive General 0 1
Moderate
2 3 4 5
2 3 4 5
2 3 4 5
Extreme
6 7 8 9
6 7 8 9
6 7 8 9
*
not scored or analyzed
68

APPENDIX F
MANUAL FOR SCORING VENIPUNCTURE OBSERVATION CHECKLIST
AND TIMED BEHAVIOR CHECKLIST-MODIFIED FORM
General Procedure
Both the Venipuncture Observation Checklist (VOC) and
the Timed Behavior Checklist-Modified Form (TBCL-M) have
similar formats for scoring. First of all the videotapes
are readied for display on the Betamax videorecorder set.
The viewer(s) arrange themselves in comfortable seats
placed in a position maximizing their view of the tapes.
If two or more viewers are present, each is situated so
that no one can observe another scoring. This is done to
prevent inflation of the reliability measures by influences
other than the videotapes. Each scorer should have a
clipboard, pen or pencil, and scoring sheet. Before
viewing the videotape, scoring sheets should be completed
for subject's name or initials, ID number, scorer's name,
date, and whether the scorer is a reliablity checker. On
the TBCL-M the speech number should be recorded (either 1
or 2) depending on whether the first or second speech is
being scored. The time settings delineating each 20 second
period should be filled in at the top of the form. The
initial time setting is obtained from the videorecorder
69

70
clock and subsequent times figured by adding 20 seconds to
the preceding time period.
Scoring Forms
Both forms have similar layouts. Each has a list of
specific behaviors going down the left hand column. To the
right of the list of behaviors, time period columns appear
with a separate box for each specific behavior. Each time
period accounts for 20 seconds for behavior.
Scoring
Scoring consists of checking behaviors that appear
during each time segment. Behaviors are scored for their
presence or absence. If a behavior occurs during a time
segment, the corresponding box is checked. If it does not
occur, a zero is placed in the corresponding box. For both
forms (VOC, TBCL-M) the videotape is viewed for 20
seconds. The videotape is stopped by pressing the stop
button. The scorer then marks the appropriate box for the
behavior(s) that occurred during that 20 second period.
Each segment will require viewing several times to maximize
adequate scoring.
Venipuncture Observation Checklist
Two minutes of the venipuncture procedure will be
scored. This accounts for six time periods. The 60
seconds immediately before and after the needle insertion
will be scored. If needle insertion occurs before 60

71
seconds has lapsed continue to score after needle insertion
until six time periods have been scored.
Definitions and Descriptions of Behavioral Categories
Verbalized pain: says hurts, painful, ouch, ohhh, or other
verbal indication of pain/discomfort.
Verbalized anxiety: says scary, afraid, anxious, doesn't
like, or asked if it will hurt; exclude painful.
Verbal delay: makes excuses to delay venipuncture; example
includes asking phlebotomist to "wait a second."
Looks away at time of injection: this is scored only at
the time of needle insertion.
Facial grimaces: includes noncommunicative facial
movements such as tics and other uncoordinated muscle
movements; includes involuntary flinches.
Moistens or bites lips: licks or bites lips.
Swallows: swallows (note closed mouth and throat
movement).
Heavy and/or uneven breathing: involves obvious and clear
heavy and/or uneven breathing; include heavy and uneven
breathing associated with crying.
Smile miserable: involves a smile combined with clear
negative affect; usually a smile with a contracted
upper lip and may involve other facial expressions
indicative of negative affect; it is differentiated
from facial emblem negative by the smile which is
absent in the facial emblem negative.

72
Tearing/crying: tearing or crying; noticable welling or
tears in the eyes is scored.
Behavioral delay: involves a behavioral gesture that
delays venipuncture; examples include withdrawal of
arm, failure to extend arm when appropriate, or
covering site of injection.
Facial emblem negative: involves the coordinated tensing
and movement of facial muscles to provide a facial
expression that communicates negative affect to the
viewer; exclude if a smile is present; example includes
a snarled upper lip and nose or gritted teeth with
forehead frown.
The Time Behavior Checklist-Modified Form
The TBCL-M is scored in the same manner as the VOC
except that there are nine 20 second periods to be
scored. Many of the categories of behavior are the same
and the same definitions and descriptions apply in both
scales. Both include the following behavioral
categories: facial grimaces, moistens or bites lips,
swallows, smile miserable, heavy or uneven breathing, and
facial emblem negative. The distinct categories for the
TBCL-M are as follows:
No eye contact: fewer than three contacts with total
duration of all contacts less than two seconds.

Face deadpan: face looks bland, emotionless, flat for
entire 20 second period; associated with minimal eye
and head movement.
Vocal quivering: voice noticably quivers, breaks, or has
obvious pitch changes; includes noticable speech flow
or rhythm changes.
Speech blocks: includes evidence of speech blocks where
speaker cannot continue; examples include asking
researcher how much time left to speak, 3 seconds of
silence, having to repeat speech, saying have run out
of things to say.
Stammer/stutter: includes stammering or stuttering in
which at least two unnecessary sounds occur
consecutively; examples include "a a" or "f-f-friend"
excludes insertion of unnecessary words such as "you
know," unless phrase is repeated twice consecutively;
score if 5 or more breaks in flow occur in the 20
second period.

APPENDIX G
RANK ORDER OF TASK FORM
Please rank the three tasks according to how
stressful/anxious each one was for you. Place a J_ beside
the most stressful task for you and a 3_ beside the least
stressful task. Place a 2 beside the task that fell
between these tasks in stressfulness for you.
Speaking on a recent pleasant time
Speaking on a recent argument or disappointment
The venipuncture procedure
74

APPENDIX H
TIMED BEHAVIOR CHECKLIST-MODIFIED FORM
Subject Name
N
umbe
r
Rater Name
F
lating Da
> 3 4
* *
te
Speech #
RIOD
8 9
* *
BEHAVIOR
Time
1
r
*
TIME PE
5 6 7
* * *
SUM
*
No Eye Contact
*
*
*
*
*
*
*
*
*
Facial Grimaces
*
*
*
*
*
*
*
*
*
Face Deadpan
*
*
*
*
*
*
*
*
*
Moisten Lips
*
*
*
*
*
*
*
*
*
Swallows
*
*
*
*
*
*
*
*
*
Smile Miserable
*
*
*
*
*
*
*
*
*
Vocal Quivering
*
*
*
*
*
*
*
*
*
Speech Blocks
*
*
*
*
*
*
*
*
*
Stammer/Stutter
*
*
*
*
*
*
*
*
*
Heavy Breathing
*
*
*
*
*
*
*
*
*
Facial Emblem Neg.
*
*
*
*
*
*
*
*
*
♦Facial Emblem Neut
•
*
*
*
*
*
*
*
*
*
♦Smile False
*
*
*
*
*
*
*
*
*
♦Smile Spontaneous
*
*
*
*
*
*
*
*
*
♦Laughs
*
*
*
*
*
*
*
*
*
♦Blink Number
*
*
*
*
*
*
*
*
*
None
Moderate
Extreme
*Anxiety General
0
1
2
3
4
5
6
7
8
9
♦Activity General
0
1
2
3
4
5
6
7
8
9
♦Positive General
0
1
2
3
4
5
6
7
8
9
* not scored or analyzed
75

APPENDIX I
PEARSON CORRELATIONS FOR SELECTED MEASURES IN
VENIPUNCTURE, SPEECH I AND SPEECH II
CONTROLLING FOR SEX (PARTIALLED OUT)

SPEECH I
CN
u
CO
<
u
H
PS
CO
P-.
Self-Reported Measures
STAIC 2 1 .0
PRCS
.49*
1 .0
JEPQ
Extraversión
-.29*
-.09
Neuroticism
.55*
.50
Conventionality
-.06
-.13
LEC
.19
.27
Observed Measures
TBCL-Modified
for Speech I
.21
.14
Metabolie-Physiological
Measures
Post Blood Sugar
.11
.12
Post Urine Volume
-.02
-.07
Post FFA
.20
.14
Rest HR
.11
-.17
Speech I HR
.01
-.19
Rest SC
-.11
-.14
Speech I SC
-.12
-.14
•H
T9
c
r-H
(0
o
E
eg
•H
•M
CO
c
Cm
co
•H
o
•H
U
'O
•rH
T9
0)
•H
4-1
O
>
4-)
c
s:
03
o
i
U
Q
>
-4
M
D
c
CJ
u
X
o
w
CQ
w
2
o
H
1 .0
-.13
1 .0
.10
-.19
1 .0
-.08
.36*
.01 1.0
-.34*
.004
-.02
-.06
1 .0
-.09
-.17
.19
.01
.07
.08
-.13
.24*
-.08
-.10
-.19
.12
.13
-.004
-.00
-.07
-.10
-.01
-.31*
.07
-.04
-.03
-.02
-.37*
-.13
-.13
-.19
.03
-.27*
-.03
-.06
-.15
.10
-.22
-.11
U E
CO 3
00 I-H
3 O
CO >
T3 0)
O
C
PC
o
•iH
<
2
rM
u
Cl4
PC
a
CQ
x
X
CO
Ü
M
M
M
M
M
CO
co
CO
CO
CD
CO
O
o
o
a
(D
CQ
fQ
CQ
PC
CO
pc
.0
72*
1 .0
33*
.32*
1 .0
39*
• 32*
.28*
1 .0
30*
.23
.27*
.90*
1 .0
12
.16
.19
.28*
.22
1 .0
13
.20
.21
.26*
.22
.94*
* Significant at the .05 level

SPEECH II:
CD
Vh
E
CO
3
4-J
00
r—H
•rH
3
o
c
r—(
CO
>
pp
o
E
CO
•rH
32
•rH
CO
C
V4-l
X)
QJ
CO
•H
o
•H
o
G
h-1
>-<
O '
•H
X
o
•H
<
hH
CO
•H
4-»
O
r—H
u
OP
CJ
>
4->
C
2:
CQ
35
U-t
nn
X
CO
CJ
03
o
i
O
»—I
CO
Vj
Vh
>
rJ
4-1
4-J
4-J
4—1
4->
<
a
4-)
G
a
O
CO
CO
CO
CO
d)
CO
H
os
X
a)
O
w
CQ
o
O
o
O.
0)
uo
p-i
w
z
CJ
-i
H
PU
PU
cu
CO
X
Self-Reoort Measures
STAIC 3
1 .0
PRCS
.43*
1 .0
JEPQ
Extraversión
-.04
-.09
1 .0
Neuroticism
.18
.50*
-.13
1 .0
Conventionality
.03
-.13
.10
-.19
1 .0
LEC
.05
.27*
-.08
.36*
.01
1 .0
Observed Measures
TBCL-Modified for
Speech II
.12
.11
-.27*
.12
-.26
i
b
ro
b
Metabolic-Physiological
Measures
Post Blood Sugar
-.06
-.12
-.09
-.17
.19
.01 -.06
Post Urine Volume
-.00
-.07
.08
-.13
.24*
-.08 -.06
Post FFA
-.02
.14
-.19
.12
.13
-.004 -.21
Rest HR
-.14
-.18
-.08
-.10
.03
-.31* -.12
Speech II HR
-.07
-.19
-.09
-.10
-.04
-.25* .04
Rest SC
.02
-.12
-.11
-.14
.04
-.22 -.22
Speech II SC
.16
-.16
-.13
-.04
.14
-.20 -.15
1 .0
.72*
1 .0
.33*
.32*
1 .0
.37*
.30*
.31*
1 .0
.33*
.30*
.38*
.89*
1 .0
.04
.07
.19
.20
.12
.15
.18
.24
.23
.16
1 .0
.84*
* Significant at the .05 level.
oo

VENIPUNCTURE:
J-l
E
r-(
eg
3
CO
4-)
00
rH
•H
a
o
eg
P
rH
CO
>
u
I—(
o
E
CC3
h-l
hH
•H
C/5
C
T)
o
rP
C/3
•H
o
O
p
4-J
E
E
Lj
o
•H
O
•H
<
•H
tH
•H
4_)
rH
Li
lu
02 3
CJ
4-J
4-J
>
4-J
c
CQ
ID
CO
o
t—I
HH
eg
o
T3
hH
J-i
LJ
>
4J
4J
â– U
â– H O
4-J
<
4-J
3
P
o
in
CO
CO
CO
CO O
CO
H
O'
o
X
O
O
w
o
o
o
o
0J rH
0)
in
>
>
w
z
a
-J
>
CL,
CL,
cu
pc CQ
PC
Self-Reported Measure
STAIC 1.0*
VQ
Item I: fear** -.59* 1 .0*
Item II: pain**
JEPQ
-.44*
.37*
1 .0
Extraversión
-.28*
.23
.28* 1.0
Neuroticism
.44*
.25*
-.32* -.13
1 .0
Conventionality
-.22
.26*
.17 .10
-.19
1 .0
LEC
-.02
- .06
-.22 .08
.36*
.01
1 .0
Observed Measure
VOS
.14
-.14
-.52* -.32*
.29*
.21
.37* 1
.0
Metabolic Physiological Measure
Post 31ood Sugar
.13
-.004
-.14 -.09
-.17
.19
.01
.48* 1
.0
Post Urine Volume
.10
-.09
-.13 .08
-.13
.24*
-.08
.16
.72*
1 .0
Post FFA
.25
-.24
-.09 -.19
.12
.13
-.004
.06
.33*
.32*
1 .0
Rest HR
.23
-.19
.07 .02
-.05
-.003
-.30* -
.11
.33*
.23
.23 1
I .0
Blood Withdrawal HR
.39*
-.33*
-.11 -.12
.04
-.06
-.14
.20 -
.39*
.27*
.36*
.85*1 .0
Rest SC
.23*
-.25*
-.13 -.14
-.11
-.08
-.30* -
.14
.18
.10
.23
.22 .15 1.0
Blood Withdrawal SC
• 32*
-.37*
-.16 -.07
-.17
-.04
-.22 -
.07
.28*
.35*
.22
.28* .21 .85*
* Significant at the
.05
level.
** Note: for the VQ,
both
items
I and II were scored in
the dir
ection
of
the lower the
score, the
higher the fear or pain reported.

APPENDIX J
PEARSON PRODUCT MOMENT CORRELATIONS
CONTROLLING FOR SEX BETWEEN EXTRAVERSION
AND NEUROTICISM AND PHYSIOLOGICAL VARIABLES
Physiological
Variables
Extraversión
Neuroticism
Post Blood Sugar
.09
(S=.31)
-.17
(s=
.17)
Post Urine Volume
•
o
CO
o
l-O
•
ii
CO
-.13
(s=
.20)
Post FFA
-.19
(S=.12)
.12
(S=
.23)
Task Venipuncture
Hr
-.12
(S=.22)
.04
(S=
.40)
SC
-.07
(S=.31)
-.17
(S=
• 13)
HR Change
-.26
(S=.04)
.16
(S=
• 15)
SC Change
.07
(S=.33)
.17
(S=
.13)
Task Speech I
HR
.04
(S=.39)
-.09
(s=
.28)
SC
.06
(S=.35)
-.15
(S=
.6)
HR Change
.26
(S=.04)
.04
(s=
.39)
SC Change
.20
(S=.10)
1.0
(S=
.25)

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33
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85
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BIOGRAPHICAL SKETCH
Brenda Gilbert was born in Knoxville, Tennessee, in
January of 1947. She obtained her M.S.W. degree from
Florida State University in 1972 and worked 5 years as a
social worker. She returned to the University of Florida
and earned an M.A. and Ph.D. in clinical psychology. Her
research interests are in the areas of medical psychology
and her focus has been on coping with chronic illness in
children and adolescents. She is married and the mother of
two beautiful girls. Currently, she is the coordinator of
an adolescent inpatient program.
86

I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.
Suzanne B/. Johnson,
Associate Professor
Psychology
Chairman
of Clinical
I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.
Hugh DavM
Professor of Clinical Psychology
I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.
Barbara Melamed
Professor of Clinical Psychology
I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.
V (K 11 -
James Johnson \
Associate Profes'sor of Clinical
Psychology

I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.
Randy Carter
Associate Professor of
Statistics
This dissertation was submitted to the Graduate Faculty of
the College of Health Related Professions and to the
Graduate School and was accepted as partial fulfillment of
the requirements for the degree of Doctor of Philosophy.
August, 1985
Dean, College of Health Related
Professions
Dean, Graduate School

UNIVERSITY OF FLORIDA
3 1262 08554 3790



UNIVERSITY OF FLORIDA
3 1262 08554 3790


64
environmental rejection. Obrist (1976) introduces a new
principle in HR activity. He uses the term cardiac-somatic
coupling to describe the principle that HR changes in
accordance with somatic need. In other words, as somatic
activity increases HR increases and as somatic activity
decreases HR decreases. However, Obrist points out that
cardiac-somatic coupling breaks down in those situations
related to active avoidance of aversive stimuli. These
situations result in substantial HR increase that is
unrelated to somatic activity.
The heart is neurally innervated by two interactive
inputs from the sympathetic and parasympathetic branches of
the autonomic nervous system (ANS). The sympathetic input
consists of adrenergic fibers originating in the spinal
cord via the stellate and caudal cervicle ganglia. The
neural transmitter substances are epinephrine and
norepinephrine. Excitation of these fibers increases HR
and blood pressure and is associated with myocardiac
contractile force. Parasympathetic fibers (cholinergic)
emanate from the vagus nerve. Excitation of these fibers
reduces HR and contractile force and, in general, is
antagonistic (opposite in effect) to sympathetic
excitation. In general, the higher the sympathetic input,
the higher the parasympathetic input. Heart activity
influences baroreceptors in the vagal nerve which respond
according to the level of heart activity by either


83
Haroian, K., Lykken, D., & Huser, R. (1984). SPR
Abstracts: The effect of hand temperature on
electrodermal measurement. Psychophysiology, 21(5),
580.
Harvey, F., & Hirschmann, R. (1980). The influence of
extraversin and neuroticism on heart rate responses to
aversive visual stimuli. Personality and Individual
Differences, J_, 97-100.
Hinkle, L., & Wolf, S. (1952). Importance of life stress
in course and management of diabetes mellitus. Journal
of American Medical Association, 148, 513-525.
Johnson, J., & McCutcheon, S. (1980). Assessing life
stress in older children and adolescents: Preliminary
findings with the life events checklist. In I. Sarason
& C. Spielberger (Eds.), Stress and anxiety (Vol. 7,
pp. 111-126). Washington, DC: Hemisphere.
Johnson, J., & Sarason, I. (1982). Life stress research:
Where we have beenwhere we are going. Unpublished
manuscript.
Johnson, S. (1980). Psychosocial factors in juvenile
diabetes: A review. Journal of Behavioral Medicine,
1, 95-116.
Kanner, A., Coyne, J., Schaefer, C., & Lazarus, R.
(1981). Comparison of two modes of stress measurement
daily hassles and uplifts versus major life events.
Journal of Behavioral Medicine, 4_, 1-39.
Knight, M., & Borden, R. (1979). Autonomic and affective
reactions of high and low socially-anxious individuals
awaiting public performance. Psychophysiology, 16,
209-213.
Koski, M., & Kumento, A. (1975). Adolescent development
and behavior: A psychosomatic followup study of
childhood diabetes. In Z. Laron (Ed.), Diabetes in
juveniles: Medical and rehabilitation aspects. Modern
problems in paediatrics (Vol. T2~, pp. 348-353).
Basel: Karger.
Lacey, J. (1967). Somatic response patterning and
stress: Some revisions of activation theory. In M. H.
Appley & R. Trumbull (Eds.), Psychological stress:
Issues in research (pp. 14-36). New York: Appleton-
Century-Crofts.


71
seconds has lapsed continue to score after needle insertion
until six time periods have been scored.
Definitions and Descriptions of Behavioral Categories
Verbalized pain: says hurts, painful, ouch, ohhh, or other
verbal indication of pain/discomfort.
Verbalized anxiety: says scary, afraid, anxious, doesnt
like, or asked if it will hurt; exclude painful.
Verbal delay: makes excuses to delay venipuncture; example
includes asking phlebotomist to "wait a second."
Looks away at time of injection: this is scored only at
the time of needle insertion.
Facial grimaces: includes noncommunicative facial
movements such as tics and other uncoordinated muscle
movements; includes involuntary flinches.
Moistens or bites lips: licks or bites lips.
Swallows: swallows (note closed mouth and throat
movement).
Heavy and/or uneven breathing: involves obvious and clear
heavy and/or uneven breathing; include heavy and uneven
breathing associated with crying.
Smile miserable: involves a smile combined with clear
negative affect; usually a smile with a contracted
upper lip and may involve other facial expressions
indicative of negative affect; it is differentiated
from facial emblem negative by the smile which is
absent in the facial emblem negative.


APPENDIX A
SPEECH TOPIC
Speech Topic 1
Hello. Your speech will be on the topic of "a recent
fun or pleasant time I had or something very nice that
happened to me." You are free to pick any event or angle
you wish. Some ideas include a grade you especially like;
a good time with your friend, parent, brother, sister,
etc. ; special equipment that you got like a bike or record
player; an event you got to go to, etc. You can talk about
when it occurred, how it came about, what it was like for
you, how you still feel, what happened later, etc.
Speech Topic 2
Hello. Your speech will be on the topic of "the last
big argument I had or my most recent big disappointment."
You are free to pick any event or angle you wish. Some
ideas include a grade you did not like; an argument with
your friend, parent, brother, sister, etc.; equipment that
broke like a bike or record player; an event you had to
miss, etc. You can talk about when it occurred, how it
came about, what it was like for you, how you still feel,
what happened later, etc.
62


51
glands that are responsible for skin conductance
activity. Since we did not measure vasoconstriction,
finger temperature, or epinephrine, we cannot rule out this
possibility.
Also, heart rate and skin conductance do not always
jointly distinguish between groups although they may
function similarly in both groups. For instance in our
study, both skin conductance and heart rate levels
increased in the plan, speech, and blood withdrawal periods
and decreased in the rest and recovery periods. However,
only heart rate distinguished between experimental
groups. This type of finding in the literature is not
unusual. Defining the mechanisms that underlie the
discrepancies in physiological response systems is very
difficult. For example, until recently the measurement of
epinephrine was both difficult and lacked reliability.
Currently, the measurement of epinephrine is improved but
remains difficult and very expensive.
Skin Conductance Fluctuations
The tendency of the GCDS to have higher numbers of
skin conductance fluctuations suggests that this group had
a higher propensity to notice and respond to nuances in the
environment whether the nuance consisted of physiograph
noises, movements inside or outside the room, etc. Skin
conductance level is an indication of more than anxiety.
Like heart rate, skin conductance responds to new or novel


across all conditions but no differences in skin
conductance were found. Diabetic adolescents had less
desirable blood and urine outcomes compared to the
nondiabetic youth with the adolescents with poor diabetes
control having the least desirable outcomes. No
differences in life stress between groups were found.
Adolescents with well-controlled diabetes were less
neurotic than the nondiabetic adolescents.
vii


73
Face deadpan: face looks bland, emotionless, flat for
entire 20 second period; associated with minimal eye
and head movement.
Vocal quivering: voice noticably quivers, breaks, or has
obvious pitch changes; includes noticable speech flow
or rhythm changes.
Speech blocks: includes evidence of speech blocks where
speaker cannot continue; examples include asking
researcher how much time left to speak, 3 seconds of
silence, having to repeat speech, saying have run out
of things to say.
Stammer/stutter: includes stammering or stuttering in
which at least two unnecessary sounds occur
consecutively; examples include "a a" or "f-f-friend";
excludes insertion of unnecessary words such as "you
know," unless phrase is repeated twice consecutively;
score if 5 or more breaks in flow occur in the 20
second period.


84
Levenson, R., Jaffee, L., & McFall, R. (1978, April).
Heightened responsibility to stress in nonassertive,
low self-confident subjects. Presented at Society of
Psychophysiological Research, Vancouver, BC.
Martin, I., & Venables, P. (1980). Techniques in
psychophysiology. New York: John Wiley and Sons.
Mehrabian, A., & Ross, M. (1977). Quality of life change
and individual differences in stimulus screening in
relation to incidence of illness. Psychological
Reports, 41, 267-278.
Minuchin, S., Rosman, B., & Baker, L. (1978).
Psychosomatic families. Cambridge, MA: Harvard
University Press.
Naliboff, B. (1985). Biobehavioral studies of stress and
stress management in diabetes. Unpublished manuscript.
Obrist, P. (1976). The cardiovascular behavioral
interaction--as it appears today. Psychophysiology, 3
95-107.
Paul, G. (1966). Insight vs. desensitization in
psychotherapy. Palo Alto, CA: Stanford University
Press.
Pinter, E., Peterfy, G., Cleghorn, J., & Pattee, C.
(1967). The influence of emotional stress on fat
mobilization: The role of endogenous catecholamines
and B adrenergic receptors. American Journal of
Medical Science, 234, 634-651.
Shipman, W., Heath, H., & Oken, D. (1979). Response
specificity among muscular and autonomic variables.
Archives of General Psychiatry, 23 369-374.
Siddle, D., & Turpin, G. (1980). Measurement,
quantification, and analysis of cardiac activity. In
I. Martin & P. Venables (Eds.), Techniques in
psychotherapy (pp. 139-246). New York: John Wiley and
Sons.
Simonds, J. (1977). Psychiatric status of diabetic youth
matched with a control group. Diabetes, 26, 921-925.
Stelmack, R. (1981). The psychophysiology of extraversin
and neuroticism. In H. Eysenck (Ed.), A model for
personality. New York: Springer-Verlag.


47
illness in insulin dependent diabetes are the result of an
extreme physiological response to stess.
What this study has not done is to definitively tell
us the reasons for the physiological and metabolic
differences found between groups. Possible explanations
and their merits are more fully discussed in the following
sections. Likewise, the exploratory hypotheses regarding
life stress and personality traits are discussed.
Reported and Observed Anxiety of Tasks
Overall there were few differences between the GCDS,
PCDS, and NDS in self-reports of anxiety, task rank
ordering, or observed anxiety on any of the tasks
(venipuncture or speeches). The one exception, in the
predicted direction, was that the PCDS tended to report a
higher level of anxiety during the first speech but this
tendency was lost during the second speech.
Physiological Response to Tasks
Heart rate, but not skin conductance, significantly
differentiated the PCDS from the GCDS and NDS. Heart rate
in PCDS was consistently about 10 BPM higher than the GCDS
or NDS which were highly similar. However, no differences
between groups were found for skin conductance. In fact, a
tendency of higher skin conductance fluctuations in the
GCDS was found compared to the PCDS and NDS. Furthermore,
no evidence of heightened reactivity and slower return to


3
pH, acidosis. This results in rapid deep breathing,
hypotension, and ultimately coma. Ketoacidosis is also
associated with hyperglycemia, osmotic diuresis, with
electrolyte and fluid loss, vomiting and dehydration.
Sodium is markedly depleted in circulation along with a
lowered total body potassium (Ganong, 1971)
The role of epinephrine and norepinephrine in
stimulating free fatty acid production is supported by the
work of Baker, Barcai, Kay, and Hague (1969) and Pinter,
Peterfy, Cleghorn, and Pattee (1967). Pinter et al. (1967)
demonstrated that FFA levels may be increased by both
exposure to stress (i.e., an anxiety-provoking suggestion
to hypnotized subjects and spontaneous speeches produced by
subjects) and exogenous epinephrine administration. Using
a single case design, Baker et al. (1969) found increased
FFAs during a stressful interview compared to a nonstress
period in an adolescent with insulin-dependent diabetes.
The above two studies by Pinter et al. and Baker et al.
report that the administration of propranolol (a e-
adrenergic blocking agent) in the stressful situtation
blocked the bulk of the increase in FFAs. However, Baker
et al. noted that the therapeutic effects of adrenergic
blocking agents with poorly controlled insulin-dependent
diabetic adolescents appear to be short lived. Although
this treatment was helpful for a temporary period of time,


PHYSIOLOGICAL RESPONSIVITY TO
VENIPUNCTURE AND SPEECH GIVING IN
INSULIN-DEPENDENT DIABETIC ADOLESCENTS AT TWO LEVELS
OF DIABETES CONTROL AND THEIR NONDIABETIC PEERS
BY
BRENDA GILBERT
A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN
PARTIAL FULFILLMENT OF THE REQUIREMENTS
FOR THE DEGREE OF DOCTOR OF PHILOSOPHY
UNIVERSITY OF FLORIDA
1985


61
insulin-dependent diabetic youngsters become sick when
exposed to a stress (for Minuchin et al., the family stress
of a "psychosomatic family").
A final implication is that the GCDS are more
psychologically healthy and may be behaviorally oriented
toward better caretaking of their disease. This requires
much more investigation and can only be hypothesized about
at this time. It fits nicely with the current finding of
other researchers (Simonds, 1977).


30
value for the GCDS was equal to 11.26 with a range of 8.5
to 13. The mean value for the PCDS was equal to 16.23 with
a range of 15 to 18.5.
Time of Day and Location of Data Collection
A 3 X 3 chi-square statistic was computed and no
evidence emerged suggesting differences between groups in
time of day subjects were run (chi-square = 3.6, p = .50).
An equivalent number of GCDS and PCDS were run in
Gainesville and in clinics outside Gainesville. Eight GCDS
and eight PCDS were run in Gainesville and the remaining
seven in each group outside Gainesville. All NDS were run
in Gainesville.
Reliability of Observation Measurement
Pearson product moment correlations were computed for
interscorer reliability of observed anxiety (VOC, TBCL).
The following reliability coefficients were obtained: for
the VOC, v_ = .79, P < .001; for the first speech (TBCL), _r_
= .75, p < .001; and for the second speech (TBCL), _r_ = .71,
p < .001. No significant differences were found between
scorers with t values and probabilities as follows: VOC (_t_
= 94, p = .36); first speech TBCL (jt = .66, p = .52); and
second speech TBCL (_t = 1.6, p = .13).
Subject-Parent LEC Correlations and T-Tests
Pearson product moment correlations were computed
between the subject and parent forms of the LEC. Pearson


60
Several other questions were raised by the findings.
One was whether or not the GCDS were more sensitive to
novel or changing stimuli in the environment as was
suggested by their increased skin conductance
fluctuations. Likewise, are they more aware of internal
states and changes in the body. As suggested by Simonds
(1977) and our personality findings, are the GCDS more
psychologically well-adjusted compared to both their
diabetic and nondiabetic peers? Furthermore, are they more
rule-oriented and likely to follow medical advice and live
more health-oriented life styles?
Implications
This study has several practical implications. First,
the high heart rate in the PCDS may be indicative of
serious medical problems in this group that to date have
not been expected to be manifested at so young an age.
Generally, adolescents of this age group are not closely
monitored for symptoms of autonomic neuropathy or
circulatory disease. These findings suggest that regular
monitoring should be taking place for these youngsters.
A second implication is that the PCDS do not build up
excessive FFAs or blood sugars in response to a stress but
return to their pre-stress baseline as their GCDS and NDS
counterparts. This does not provide support for a
"psychosomatic" hypothesis, for example as suggested by
Minuchin et al. (1978), in which predisposed


4
eventually the problems with diabetic control returned
(Minuchin, Rosman & Baker, 1973).
Only a few studies have compared the effects of stress
in diabetic and nondiabetic subjects. Hinkle and Wolf
(1952) assessed nondiabetic and diabetic adult and
adolescent responses to a stressful interview and a
nonstressful control period. Both groups showed similar
responses in blood ketone production and urine output.
However, diabetics with elevated ketone levels in the
nonstressful control period exhibited a particularly
exaggerated increase in ketones when stressed.
Vandenbergh, Sussman, and Titus (1966) performed a similar
study comparing diabetic and nondiabetic adults' reactions
to an unpredictable shock. Both groups responded with
increases in FFA levels and urine volume, although the
increases were not significantly different between stress
and nonstress periods. However, this lack of difference
may have been a result of their small sample size (i.e.,
n = 6 in each group).
The work of Hinkle and Wolf (1952) and Vandenburgh et
al. (1966) suggest that increased free fatty acid
production is a likely result of stress. However, a number
of questions remain. First, it is unclear whether the
responses of insulin-dependent patients are different from
subjects having adult-onset diabetes. Most of the subjects
studied were adults, not adolescents, and the effects of


24
other facial rating protocols by Ekman and Friesen (1975)
including miserable smile and facial emblem negative. Paul
(1966) reports the average interobserver reliability after
training exceeded r_ = .95. Other investigators using the
TBCL have reported interrater reliabilities after training
between .71 to .96 (Cirainero, Calhoun & Adams, 1977).
Ratings were obtained from videotaped performances and
interrater reliabilities computed. Raters were trained
prior to scoring. See Appendices F and H for TBCL-M form
and scoring procedures.
Additional Dependent Measures
Junior Eysenck Personality Questionnaire (JEPQ)
The JEPQ is a personality inventory designed to
measure extraversin, neuroticism, psychoticism, and
conventionality for children aged 7-15 (Eysenck & Eysenck,
1978). Only the neuroticism, extraversin, and
conventionality scales were used. Six month test-retest
reliabilities for each scale by age and sex are as
follows: extraversin range.38-.82, with all remaining
coefficients in the .60's and .70's; neuroticism range.66
to .77, the conventionality scale range.59 to .83; with
all remaining coefficients in the ,60's and .70's. One
month test-retest reliabilities were considerably higher
with a range across scales by age and sex of .59 to .89,
with most coefficients in the ,70's and ,80's.


6
problems). Each group observed their parents discussing
unresolved family problems and later joined their parents
in this discussion. A major finding in this research
endeavor was that in the psychosomatic group the
adolescents with diabetes produced higher levels of FFA
which took longer to return to baseline when compared to
youngsters in the other groups. The psychosomatic
adolescents also produced higher FFA levels than their
parents which remained elevated after their parents' FFA
levels had returned to the baseline level (Minuchin et al.,
1978). No similar difference was found for the normal or
behavior problem diabetic groups.
The findings of Minuchin et al. (1978) support the
notion that a subgroup of insulin-dependent diabetic youth
have exaggerated response patterns to stress. Their
findings suggest that there are no major metabolic response
differences between well-controlled insulin-dependent
diabetic youngsters and their parents. However, only a
small number of patients were studied and the criteria for
placement in study groups (psychosomatic, normal, behavior
problem) was not clearly specified. Consequently, it is
unclear how many youngsters in poor diabetic control have
the "psychosomatic or heightened stress reactivity that
Minuchin et al. postulate.
To summarize the main points made thus far, stress
exposure leads to metabolic changes associated with insulin


56
duration of diabetes, sex, age, and race while those in
Chase and Jackson's were not. It was also confirmed from
both parents and adolescent that the prescribed insulin
dosage was administered at the same time generally and
specifically the night before and morning of the
experiment. As a result the sample was different.
Perhaps an instrument more sensitive to everyday
stresses would show a stronger relationship. Kanner,
Coyne, Schaefer and Lazarus (1981) suggest that a life
stress scale designed to measure smaller, more frequent
daily stressors might yield better results in predicting
psychological and health outcomes than the major life event
scales such as the LEC. Such scales are now available.
Although more refined techniques to assess stress
might yield higher predictive power, other factors need
assessment to account for significant amounts of the
variance. For instance, in our study we found for the most
part that the experimental groups reported and behaved in
ways suggesting that they viewed the tasks with similar
levels of stress/anxiety. Yet the PCDS were in much poorer
control of their disorder and physiologically dealt less
efficiently and effectively with the stresses. It is
reasonable to expect that the physiological
predispositions/states, behavioral tendencies, as well as
cognitive traits of the individual, must be considered to


45
Urine Volume
A oneway ANOVA was computed for experimental group
with urine volume. Overall significance for the model was
found at (F^(2,42) = 5.67, P = .007). A Duncan's Multiple
Range Test showed that the NDS differed from the two
diabetic groups with a mean volume of 69.67 cc compared to
183.8 for the GODS and 256.67 for the PODS.
Pre- and Post-Urine Sugar
A Wilcoxin rank sum test (equivalent to the Mann-
Whitney U test) was computed for GODS and PODS urine sugar
levels for pre- and post-experimental session. No
significant differences were found between groups at the
beginning of the experimental session (z = .41, P = .66)
but the PODS had larger values at the end of the session (z
= 1.85 P = .04). All NDS had 0 percent urine sugar.
Pre- and Post-Urine Ketones
A Wilcoxin Rank Sum Test was computed for urine
ketones before and after the experimental session. No
significant differences were found pre-session (z = .39, P
= .35) although a tendency for PODS to have higher levels
of urine ketones was found at post-experiment (z = 1.29, p
= .10). No traces of urine ketones were found for any NDS.
Pre- and Post-Plasma Ketones
No evidence of plasma ketones was found in any
experimental group at pre- or post-blood withdrawals.


Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy
PHYSIOLOGICAL RESPONSIVITY TO
VENIPUNCTURE AND SPEECH GIVING IN
INSULIN-DEPENDENT DIABETIC ADOLESCENTS AT TWO LEVELS
OF DIABETES CONTROL AND THEIR NONDIABETIC PEERS
BY
BRENDA GILBERT
August, 1985
Chairperson: Suzanne B. Johnson, Ph.D.
Major Department: Clinical Psychology
Fifteen adolescents with insulin-dependent diabetes in
good diabetes control were yoked with 15 insulin-dependent
adolescents in poor control matched for age, sex, duration
of diabetes, and race. The same number of nondiabetic
adolescents matched for age and sex were included.
Participants were involved in three stressful tasks
(venipuncture and two speeches). Each task was preceded by
a rest period and followed by a recovery period. Both
speeches were preceded by a plan period. Observational,
physiological (heart rate, skin conductance, blood and
urine measures), and self-report data were collected. Life
stress and personality information were collected.
Diabetic adolescents in poor control had higher heart rates
vi


57
make the best predictions of the effect of stress on
health.
Personality Findings
On the JEPQ/EPQ the GCDS were less neurotic than both
other groups and more conventional than the NDS. This
finding is similar to Simonds (1977) who found (using
parental reports) that the poorly controlled group was more
likely to be anxious and depressed, the same terras Eysenck
uses to describe an introverted neurotic personality.
Likewise Simonds reported that his good control group
reported fewer conflicts than the nondiabetic group and had
an unusually low incidence of parental divorce. Our
findings in addition to Simonds suggest that adolescents
with insul.in-dependent diabetes in good control may be
unusually well-adjusted and conventional or socially rule
oriented. Also in accord with Simonds, they suggest that
in general poorly controlled diabetic adolescents have
average or normal psychological adjustment.
No evidence emerged supporting differential
physiological or metabolic responsiveness due to
neuroticism. This suggests that neuroticism is not related
to poor control through a clearly identifiable
physiological or metabolic mechanism. (See Appendix J for
the correlation coefficients between neuroticism and
physiological and metabolic variables.) It appears more
reasonable to postulate that the more conventional,


23
interval. Please see Appendices E and F for the VOS and
scoring procedure.
Rank Order of Task Form (ROTF)
The ROTF is a form developed by the researcher to
allow the participant to rank order the tasks from most
stressful to least stressful (Appendix G).
Personal Report of Confidence as Speaker
Short Form (PROS)
The PRCS is a 30-item questionnaire revised by Paul
(1966) from an earlier and longer version in order to
improve the form's psychometric properties and make its
completion easier and quicker for the informant. The
instrument is designed to assess self-reported public
speaking anxiety.
Time Behavioral Checklist for Performance
Anxiety (TBCL) Modified FornT
The TBCL was developed by Paul (1966) to assess
performance anxiety exhibited during a public speaking
exercise. The instrument lists 20 observable
manifestations of anxiety and is scored for their presence
or absence during consecutive 20-second observation
periods. The TBCL assesses behaviors reflecting
interference with performance (e.g., stammering) and
observable effects of arousal on behavior (e.g., heavy
breathing). The TBCL was modified by deleting items that
were inappropriate for videotaped speeches by seated
persons (e.g., pacing). Several items were added from


44
statistically significant, the same pattern of mean values
was found for the post FFA sample, i.e., GCDS = .49, PCDS =
.55, and NDS = .36.
Blood Sugars
A 3 X 2 X 2 repeated measures ANOVA was computed for
experimental group, sex and trial (pre- and post-blood
withdrawal). A significant main effect for experimental
group (F_(2,28) = 14.12, p < .001) and a trial by sex
interaction (JT(1,29) = 9.82, p < .004) were found. A
oneway ANOVA and subsequent Duncan Multiple Range Test were
computed for both pre- and post-blood withdrawals. The
overall model was significant for both blood withdrawals
(F_(2,35) = 15.38, p < .001 and .F(2,32) = 15.89, p < .001,
respectively). At the .05 level of significance the Duncan
Multiple Range Test found all three experimental groups
differed significantly from each other at the initial
withdrawal but only the NDS differed from both diabetic
groups at the second withdrawal. Mean blood sugar values
for the first and second blood withdrawals, respectively,
were as follows: GCDS = 210.73, 215.17; PCDS = 294.5,
275.84; and NDS = 59.8, 65.64. Although at the first blood
withdrawal females had significantly higher levels of blood
sugar, no significant difference was found at the second
blood withdrawal.


26
respondent is requested to check those events (s)he
experienced during the preceding year, rate the event as
good or bad, and rate the degree of impact the event on
his/her life on a 4-point scale from no effect = 0 to great
effect = 3. This instrument developed by Gad and Johnson
(1980) is relatively new and was developed to overcome
specific deficiencies in the existing life change/stress
inventories. Specific items were selected from existing
life change/stress inventories and nominations by an
adolescent sample. It has been administered to adolescents
aged 12 to 17 and found to correlate with indices of
physical and emotional health.
Procedure
The families were asked to participate either by
telephone or in a letter. A letter was used only when
there was no telephone in the home. If both parents and
adolescent agreed to participate, an appointment time was
scheduled. Parents were asked to observe the insulin
injection of their child the night before and morning of
the experiment. In all cases, an informed consent was
obtained from both the adolescent and parent. The parent
was given an LEC form to complete while the youngster was
taken to the study area.
First the participant voided urine into a container.
Then she was taken to the room where the experiment was to
transpire and the equipment was explained. Words like


21
each period the mean of the skin conductance levels was
calculated and served as the score for each period. The
number of spontaneous conductance fluctuations equaling or
exceeding 0.1 micromhos was counted for each 3-minute
phase.
Blood Measures (FFA and Glucose)
Free fatty acids (FFA) and blood glucose increase in
response to stressful stimuli and are related to metabolic
disruption in diabetes (Tarnow & Silverman, 1981-82).
These blood measures were analyzed from blood samples drawn
at the beginning and end of the experimental session.
Urine Measures (Ketones, Glucose, and Volume)
Ketones increase in response to stress (Tarnow &
Silverman, 1981-82) and urine volume and urine sugar have
been shown to increase in response to stress exposure
(Hinkle & Wolf, 1952; Vandenbergh et al., 1966). These
urine measures were analyzed from urine samples taken at
the beginning and end of the experimental session-task
manipulations.
Venipuncture Questionnaire (VQ)
The VQ is a two-item Likert scale developed by the
researcher to allow the participant to rate venipuncture
(see Appendix D). The participant rated the task on two 5-
point scales asking how bothered by and painful the
venipuncture procedure was for them.


2
hormones. More specifically, in both diabetic and
nondiabetic persons, stress results in increased levels of
catecholamines (epinephrine and norepinephrine). When
catecholamines are released into the blood a complex series
of events occurs. First, gluconeogenesis is stimulated
which increases blood glucose. Second, catecholamines act
directly on fat cells to increase lipolysis (fat breakdown
and mobilization of free fatty acids (FFA)).
Catecholamines also result in increased glucagon, which, in
turn, stimulates gluconeogenesis and ketogenesis in the
liver (Tarnow & Silverman, 1981-82).
Once the stress is over, there is typically an
increase in insulin production which "counters" the stress
hormones and permits the body to return to a normal
metabolic state. However, the youngster with diabetes does
not produce his own insulin and may not be able to counter
the effects of the stress hormones. Although exogenous
insulin replacement is helpful, the youngster is still left
with a system insensitive to rapidly changing stress
related blood glucose or ketone levels. When this system
is unable to effectively counteract the stress hormones,
ketoacidosis may result. Ketones (6-hydroxybutyric acid
and acetone) are produced in the liver from fatty acids
(fatty acids -> acetyl-Co A -> acetoacetyl-Co A -> 8-
hydroxybutyric acid and acetone). Ketones provide a source
of energy, but in excessive amounts produce a low plasma


I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.
Randy Cartr
Associate Professor of
Statistics
This dissertation was submitted to the Graduate Faculty of
the College of Health Related Professions and to the
Graduate School and was accepted as partial fulfillment of
the requirements for the degree of Doctor of Philosophy.
August, 1985
Q. &
Dean, College of Health Related
Professions
Dean, Graduate School


32
ranged from no relationship to .52 (observed video anxiety
for venipuncture with rated venipuncture pain).
Control Variables
Speech Fear (PRCS)
No significant differences were found between the
three groups on reported speech fear (PRC3) using a oneway
ANOVA (F_(2,42) = .51 P < .60). The following mean scores
by experimental group were found: GCDS = 11.47, PCDS =
10.67 NDS = 13.20; where the higher the score, the more
fear indicated.
Venipuncture Fear (VQ)
An ANOVA was computed between all groups for rated
venipuncture fear (VQ) and no statistically significant
difference's emerged (F_(2,42) = 1.58, p < .22). The
following mean ratings by experimental group were found:
GCDS = 4.33, PCDS = 3-93, NDS = 3.60; where the lower the
score, the more fear indicated.
Venipuncture Pain (VQ)
An ANOVA was computed between all groups for
venipuncture pain and no statistically significant
difference occurred (F^(2,42) = .16, p = .85). The mean
ratings by experimental group were as follows: GCDS =
4.13, PCDS = 4.00, NDS = 3-93; where the lower the score,
the more pain indicated.


5
diabetes type were not analyzed. Second, although there
was some suggestion that patients in poor control may be
more stress sensitive, this was not explicitly studied.
Consequently, it is unclear whether adolescents with
insulin-dependent diabetes differ from normals in their
metabolic response to stressful stimuli and whether
adolescents in good versus poor diabetic control differ as
well. Finally, no objective or subjective measure of
stress was collected in either study. Since an external
stressor may have different effects on different subjects,
it is difficult to assess how many subjects felt stressed
and to what extent.
Within the diabetes literature, there is repeated
mention of youngsters who have "brittle" diabetes. These
patients' (who are often adolescents) diabetes is very
difficult to manage, and they have numerous episodes of
ketosis. Minuchin et al. (1978) have suggested that there
is a subgroup of youngsters who have "psychosomatic"
insulin-dependent diabetes. These youngsters show
excessive reactivity to stress which results in a "brittle"
condition. Support for this position is found in a study
by Minuchin et al. (1978) in which psychosomatic insulin-
dependent diabetic adolescents were compared to two groups
of good control insulin-dependent diabetic adolescents (one
composed of normal adolescents and the other of adolescents
referred for psychiatric treatment of behavioral


39
(F/2,37) = 2.54, p < .09) with PCDS having higher HRs that
GCDS and NDS. Female subjects had higher heart rates
(86.83 BPM compared to the 80.6 BPM of their male
counterparts.
Paired t-tests showed that the rest and recovery
periods had lower HRs than the plan (_t_(44) = -3.53, P =
.001 and _t_(42) = 1.87, P = .07) and speech periods (_fc_(44) =
-7.84, p < .001 and _t_(42) = 8.89, P < .001). The planning
period had a lower HR than the speech period (_t_(44) =
-8.00, p < .001).
Skin Conductance for Venipuncture
A 3 X 2 X 3 repeated measures ANOVA was computed for
experimental group, sex, and period. A significant main
effect was found for period (F_(2,78) = 44.76, p < .001).
Paired t-tests showed each period significantly different
from the others with the highest level of skin conductance
in the blood withdrawal period and lowest level in the rest
period. The T values were as follows: rest-blood
withdrawal (_t_(44) = -7.99, P < .001); rest-recovery (_t_(44)
= -6.23, p < .001); and blood withdrawal-recovery (_t_(44) =
3.10, p = .003).
Skin Conductance for First Speech
A 3 X 2 X 4 repeated measures ANOVA for experimental
group, sex, and period was computed which found a
significant effect for period (F_(3,114) = 17.35, P <
.001). Paired t-tests were computed and skin conductance


APPENDIX D
VENIPUNCTURE QUESTIONNAIRE
Please rate how bothered you are in general by having blood
drawn.
1 2 3 4 5
extremely moderately not bothered
bothered bothered at all
Please rate how painful the venipuncture procedure was for
you.
1
2
3
4
5
extremely
moderately
not painful
painful
painful
at all
67


ACKNOWLEDGMENTS
Special thanks are given to all my committee members
which include Hugh Davis, Ph.D., Randy Carter, Ph.D., James
Johnson, Ph.D., and Barbara Melamed, Ph.D., who have given
steady support and excellent consultation. Barbara
Melamed, Ph.D., and Peter Lang, Ph.D., provided me with
much needed direction in the design of this research and
the selection and analyses of the physiological data.
Janet Silverstein, M.D., Michael Kappy, M.D., and their
coworkers were indispensable in helping me understand
diabetes and select and analyze the metabolic data
collected. The study could not have been accomplished
without the great assistance of my fellow students and
coworkers who helped collect the data. These include Gary
Geffken, Ph.D., Marika Spevack, M.S., Carol Lewis, M.A.,
and Barbara Walker.
Extra special thanks are given to Suzanne B. Johnson,
Ph.D., my "wonderful" chairperson. Her excellent direction
and support were essential to the completion of this
dissertation. In addition, extra special thanks are given
to my husband, David G. Gilbert, Ph.D., who paid my bills
while I worked on my degree and provided steady,
unflinching support.
iii


9
The present investigation differs from past attempts
to study the effects of stress on persons with diabetes in
a number of important respects. First, only insulin-
dependent adolescents were studied. Second, distinctions
between those in good versus poor control were made.
Third, in both groups of youngsters with diabetes the
youngster and parent confirmed that the prescribed insulin
dose was given the night before and morning of the
experiment. Fourth, self-report, behavioral, and
psychophysiological effects of the stress were measured.
In past research efforts, no attempt has been made to
quantify the stress experienced by the subject either
through subjective ratings or by more objective behavioral
or psychophysiological measurement. And finally, a sample
size of fifteen subjects per group was obtained.
Exploratory Investigations
In addition to the major purposes and hypotheses
outlined previously, this study explored two other
variables potentially related to diabetes control. These
are life stress and the personality dimensions of
extraversin and neuroticism.
Life Stress
Evidence has accumulated suggesting that diabetic
adolescents with high scores on a life stress/change scale
or who have lost a parent show increased ketoacidosis and
related symptoms (Chase & Jackson, 1981; Koski & Kumento,


APPENDIX I
PEARSON CORRELATIONS FOR SELECTED MEASURES IN
VENIPUNCTURE, SPEECH I AND SPEECH II
CONTROLLING FOR SEX (PARTIALLED OUT)


43
of significance) was performed and found the good control
diabetic group differed significantly (less neurotic) from
the remaining two groups. The mean t score for the GCDS
was 45.13 compared to 52.87 and 55-73 for the PCDS and NDS,
respectively. An ANOVA was performed for conventionality
which showed a tendency (_F(2,42) = 2.48, p = .10) for GCDS
to positively endorse conventional items more frequently
than the NDS utilizing Duncan's Multiple Range Test. The
mean t score for the GCDS was 58.47 compared to 55.20 and
50.80 by the PCDS and NDS, respectively.
A series of Pearson product moment correlations were
computed between extraversin and neuroticism and HR and
skin conductance for all the individual periods in the
venipuncture procedure and the speeches. No significant
correlations for HR or skin conductance were found. As a
result, no further analyses of extraversin or neuroticism
and psychophysiological arousal were done.
Free Fatty Acid (FFA)
A 3 X 2 X 2 repeated measures analysis was computed
for experimental group, sex and time of measurement (pre
post blood withdrawal). A tendency toward significance for
experimental group was found (J?(2,34) = 2.8, p = .07). A
Duncan's Multiple Range Test at the .05 level of
significance found that the PCDS differed from the NDS at
the first blood withdrawal. Mean values were as follows:
GCDS = .44; PCDS = .59; NDS = .31. Although not


52
stimuli. Instead of decreasing in the orienting situation
as heart rate does, skin conductance increases (Lacey,
1967). The GCDS low heart rate level, lower FFAs, lower
urine volume, lower blood and urine sugars, and similar
self-report, ratings, and behavioral measures of anxiety
provide consistent data to rule out that this group was
more anxious or aroused by the tasks. This supports the
hypothesis that the GCDS are more alert to environmental
changes. If so, this finding leads to the question of
whether or not such a propensity might make the GCDS more
alert to both internal and external changes in the
environment which aid them in better decision making in the
care of their diabetes. Since persons with
insulin-dependent diabetes must make daily decisions
directly influencing the management of their disorder such
as when a snack is needed, when their insulin dose requires
adjustment, or when exercise is needed, this extra
awareness may benefit them.
Metabolic Reactivity
Clear metabolic differences emerged between at least
one of the diabetic and the nondiabetic groups on all
dependent measures. The nondiabetic group had a lower
level of FFA, lower urine volume, and lower blood and urine
sugars. In addition, although not always statistically
significant, in every case the PCDS had the highest values


85
Tarnow, J. & Silverman, S. (1981-82). The
psychophysiologic aspects of stress in juvenile
diabetes. International Journal of Psychiatry in
Medicine, 11, 25-44.
Vandenbergh, R., Sussman, K., & Titus, C. (1966). Effects
of hypnotically induced acute emotional stress on
carbohydrate and lipid metabolism in patients with
diabetes mellitus. Stress and Metabolism in Diabetes,
28, 382-389.
Venables, P., & Christie, M. (1980). Electrodermal
activity. In I. Martin & P. Venables (Eds.),
Techniques of psychophysiology (pp. 3-62). New York:
John Wiley and Sons.


19
stimulus. Siddle and Turpin (1980) point out that heart
rate decelerates in response to simple stimuli and
accelerates to intense or threatening stimuli, during
periods of word association tasks, and during mental
arithmetic tasks. Heart rate increases in both the
anticipatory and performance phases of public speaking
(Borkovec & O'Brien, 1977; Knight & Borden, 1979; Levenson,
Jaffee & McFall, 1978). Please refer to Appendix B for a
brief discussion of the heart and primary theories
regarding its regulation.
Heart rate data were collected on a Lafayette four-
channel datagraph. Paper speed was 10 mm/sec. Heart rate
was obtained by counting the systolic spikes associated
with the cardiac contraction of the recorded pulses of the
photoplethysraographic transducer. The photoplethysrao-
grapnic transducer was attached to the thumb of the left
hand unless this arm held the heparin lock, in which case
it was attached to the thumb of the right hand.
Heart rate in beats per minute (bpm) was tabulated for
each 1-minute segment of each period. Each period except
blood withdrawal (rest, plan, speech, recovery) lasted 3
minutes. Blood withdrawal lasted 2 minutes. The mean
heart rate of each period served as the respective period
score (rest, blood withdrawal, recovery, plan, and speech).


37
Heart Rate for First Speech
A 3 X 2 X 4 repeated measures ANOVA was computed
between experimental group, sex, and period. Significant
main effects were found for experimental group (F_(2,39) =
5.65, p = .007), sex (FO,39) = 9.51, p = .004), and period
(F_(3,117) = 32.35, p = .000). In each case the PCDS had
significantly higher HRs than the NDS and, with the
exception of the speech period higher than the GCDS. See
Figure 2 for the comparison of HR by experimental group and
period.
Overall females had higher HRs with a mean HR of 89*54
BPM compared to an 80.13 mean for males. Paired t-tests
were computed between all possible combinations of periods
in the first speech and the rest and recovery periods
significantly differed (were less) from the plan (_t_(44) =
-3.17, p = .003 and _t(44) = 40.57, p = .000, respectively),
and speech periods (_t_(44) = -7.32, p = .000 and _t_(44) =
8.39, P = .000). Heart rate during the plan period
likewise was less than the speech period (_t_(43) = 39.17, p
< .001).
Heart Rate for Second Speech
A 3 X 2 X 4 repeated measures ANOVA was computed for
experimental group, sex, and period. Significant main
effects were found for sex (_F(1,37) = 4.19, P = .05) and
period (F_(3,111) = 31.65, p < .001). A tendency for
experimental group to be significant was found


20
Skin Conductance
Measurement of the conductance of an electrical
current through skin tissue is often used as a
physiological indicant of arousal (Martin & Venables,
1980). Due to the high density of eccrine sweat glands
(which are innervated by the sympathetic nervous system) on
palmar and plantar skin surfaces, these sites are typically
used to obtain electrodermal information. Between group
differences in skin conductance activity on stress-inducing
tasks have been found (Knight & Borden, 1979; Levenson,
Jaffee & McFall, 1978). Please see Appendix C for a brief
note on skin conductance.
Skin conductance data were collected on a Lafayette
four-channel datagraph with paper speed of 10 mm/sec. Skin
conductance level and responses were recorded via bipolar
leads from the middle phalanges of the first and second
fingers of the left hand (unless this arm held the heparin
lock in which case the right hand was used) using Beckman
silver/silver chloride miniature electrodes with K-Y
Lubricating Jelly (Johnson & Johnson) as an electrode
medium.
Skin conductance was measured in micromhos. Skin
conductance levels were measured at each 20 second point
for each 1-minute segment during the 3-minute rest period,
the 3-minute plan period, the 3-minute task period (or 2-
minute blood withdrawal), and the recovery period. For


49
Other Explanations of Higher Heart Rate in PCDS
The PCDS may have more morphologic damage to
circulatory organs (veins, arteries, heart) which reduces
the overall efficiency and intactness of the circulatory
system. One well-known risk of insulin-dependent diabetes
is heart disease. The retinal damage that is a serious
complication of IDDM is contributed to by vascular
hemorrhages, aneurysms, and neovascularizations. To make
up for the inefficiency resulting from these morphologic
abnormalities/daraage the heart rate may be increased to
provide the blood flow required for normal body function.
Another potential explanation is that our PCDS had
higher rates of autonomic neuropathy. Naliboff (1985)
reports that estimates have been made that 40% of persons
with diabetes have at least mild symptoms of autonomic
neuropathy. He found a higher resting heart rate in a
group of adult subjects with both insulin-dependent and
noninsulin-dependent diabetes. Upon further examination of
these individuals some evidence of autonomic neuropathy was
found in almost all diabetics.
Autonomic neuropathy tends to be manifested earlier in
the parasympathetic nervous system as opposed to the
sympathetic nervous system. This fact may help explain the
desynchrony between heart rate and skin conductance which
is primarily innervated by the sympathetic nervous
system. Since heart rate is heavily influenced by


31
product moment correlations were obtained for various
possible scoring methods and the following validity
coefficients were obtained: total events rated good_r_ =
.40, p = .05; total events rated bad_r_ = .54, p = .004;
total events rated good and weighted for impact on life v_
= .43, p = .01; total events rated bad and weighted for
impact on life--r_ = .60, p = .001, sum of total number of
events-_r_ = .35, p = .08; and sum of total number of events
weighted for impact on life--£_ = .50, p = .009 Paired t-
tests were computed between the subjects' and parents' LEC
scores. There was a significant difference between all
scores from the various possible methods; youngsters,
compared to the parents, reporting more events and having
higher weighted score.
Inter-relationships Between Measures
Pearson product moment correlations were completed
between the physiological, self-report, and observation
data. Appendix I is a compilation of a selection of these
Pearson coefficients. Physiological variables had
coefficients ranging from .04 to .72 (post-blood sugar and
urine volume) with the majority between .20 and .40 (HRs
with FFA and blood sugars). Self-report measures had
coefficients between .02 and .59 (the first STAIC with
rated venipuncture fear) with most higher than .25 (STAIC,
JEPQ, Speech Fear Questionnaire). Validity coefficients
between self-report, physiological, and observation data


72
Tearing/crying: tearing or crying; noticable welling or
tears in the eyes is scored.
Behavioral delay: involves a behavioral gesture that
delays venipuncture; examples include withdrawal of
arm, failure to extend arm when appropriate, or
covering site of injection.
Facial emblem negative: involves the coordinated tensing
and movement of facial muscles to provide a facial
expression that communicates negative affect to the
viewer; exclude if a smile is present; example includes
a snarled upper lip and nose or gritted teeth with
forehead frown.
The Time Behavior Checklist-Modified Form
The TBCL-M is scored in the same manner as the VOC
except that there are nine 20 second periods to be
scored. Many of the categories of behavior are the same
and the same definitions and descriptions apply in both
scales. Both include the following behavioral
categories: facial grimaces, moistens or bites lips,
swallows, smile miserable, heavy or uneven breathing, and
facial emblem negative. The distinct categories for the
TBCL-M are as follows:
No eye contact: fewer than three contacts with total
duration of all contacts less than two seconds.


40
levels were less in the rest and recovery periods when
compared with the plan (jt_(43) = -2.77, p < .008) and (_t_(43)
= 2.4, p < .02) and speech (_t_(43) = -5.74, p < .001) and
(_t.(43) = 5.78, p < .001) periods. The speech period had
higher levels of skin conductance when compared with the
plan period (_t(43) = -3.16, p < .003).
Skin Conductance for Second Speech
A 3 X 2 X 4 repeated measures ANOVA was computed. A
significant main effect was found for period. Subsequent
paired t-tests were computed and found speech skin
conductance differed significantly (was higher) from all
other speech periods with t values as follows: from rest
(_t_(44) = -3.88, p < .001); from plan (jt_(43) = -2.0, p <
.05); and from recovery (_t_(42) = 4.95, p < .001). Skin
conductance in the planning period was higher than in the
rest period (Jt^(43) = -4.29, P < .001).
Skin Conductance Fluctations-Venipuncture
A 3 X 2 X 3 repeated measures ANOVA was computed
between experimental group, sex and period. A significant
main effect was found for period (F_(2,76) = 26.53, P <
.001). Paired t-tests were utilized to compare each period
with the other periods. The blood withdrawal period had a
higher number of skin conductance fluctuations than the
rest or recovery period (_t_(44) = -7.02, p < .001 and J^(44)
= -1.85, P < .07, respectively).


42
period had the highest number of SC fluctuations (_t_(43) =
-4.44, P < .001).
Life Events Checklist (LEC)
A oneway ANOVA was computed using the LEC completed by
the adolescent for each of several methods of scoring the
LEC and none reached statistical significance. The F
values and probabilities for each scoring method are as
follows: total events rated good (_F(2,41) = .43, P = .65);
total events rated bad (F_(2,41) = .40, p = .68); total
events rated good and weighted by impact on life (F_(2,41) =
.08, p = .92); total events rated bad and weighted by
impact on life (F_(2,41) = .70, p = .50); sum of total good
and bad events (F_(2,41) = .31, P = .74); and sum of total
good and bad life events weighted for impact on life
(F_(2,41) = .17, p = .85).
Eysenck Personality Questionnaire (EPQ, JEPQ)
A oneway ANOVA was computed for experimental group for
each dimension of the EPQ (extraversin, neuroticism,
psychoticism, conventionality). All EPQ and JEPQ scores
were converted to t scores with mean = 50, SD = 10 (based
on age and sex norms in Eysenck & Eysenck, 1975, 1978)
before analyses. No significant differences were found for
extraversin (F_(2,42) = 1.00, p = .38) or psychoticism
(F^(2,42) = .38, p = .69). A significant _F value was
obtained for neuroticism (j^(2,42) = 5.9, P < .005) and a
subsequent Duncan's Multiple Range Test (at the .05 level


HEART RATE (BPM)
110r
100-
90-
80-
70-
Figure 1 .
PODS
GCDS
NDS
rest blood withdrawal recovery
PERIOD
Mean heart rate in beats per minute for venipuncture rest, blood withdrawal
and recovery by experimental group.
04
O'.


54
and more hetareogeneous samples which may have prevented a
similar finding. It should be noted that our findings did
not parallel the findings of Minuchin et al. (1978).
Whereas the PCDS FFA level post-experimentally was lower
than pre-experimentally and the NDS and GCDS slightly
higher, the psychosomatic diabetic group in the Minuchin et
al. study showed higher FFA levels post-experimentally and
the other diabetic and nondiabetic groups lower FFA levels.
Another explanation of the decreased final blood sugar
and FFA level in our sample is that the PCDS had a higher
metabolic need for energy to sustain normal body
functions. The increased HR across tasks provides support
for this notion. That is, the body must burn more energy
(FFA, blood sugar) to deal with a higher heart rate.
Life Stress and Diabetes Control
The hypothesis that number of reported life stress
events would be related to level of diabetes control was
not confirmed. No relationship between diabetes control,
determined in this study by Hemoglobin A1 value, and amount
of positive, negative, or combined positive and negative
life events was found. Likewise no differences emerged
between the diabetic and nondiabetic groups. The failure
to find differences between groups on the LEC suggests that
it is not the amount of reported life stress per se that
influences level of diabetes control. This conclusion is
supported further by the lack of reported differences


70
clock and subsequent times figured by adding 20 seconds to
the preceding time period.
Scoring Forms
Both forms have similar layouts. Each has a list of
specific behaviors going down the left hand column. To the
right of the list of behaviors, time period columns appear
with a separate box for each specific behavior. Each time
period accounts for 20 seconds for behavior.
Scoring
Scoring consists of checking behaviors that appear
during each time segment. Behaviors are scored for their
presence or absence. If a behavior occurs during a time
segment, the corresponding box is checked. If it does not
occur, a zero is placed in the corresponding box. For both
forms (VOC, TBCL-M) the videotape is viewed for 20
seconds. The videotape is stopped by pressing the stop
button. The scorer then marks the appropriate box for the
behavior(s) that occurred during that 20 second period.
Each segment will require viewing several times to maximize
adequate scoring.
Venipuncture Observation Checklist
Two minutes of the venipuncture procedure will be
scored. This accounts for six time periods. The 60
seconds immediately before and after the needle insertion
will be scored. If needle insertion occurs before 60


28
speech) was readministered and the final blood withdrawal
done and heparin lock discontinued. The ROTF was
administered, the electrodes were removed from the
youngster's hand, and the Peabody Picture Vocabulary Test
was given. The participant was debriefed and paid.


SPEECH I:
H
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2:
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i
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00 H
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0)
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(X,
PU
Pu
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Self-Reported Measures
STAIC 2
1 .0
PROS
.49*
1 .0
JEPQ
Extraversin
-.29*
-.09
1.0
Neuroticism
.55*
.50*
-.13
1 .0
Conventionality
-.06
-.13
.10
-.19
LEC
.19
.27*
-.08
.36*
Observed Measures
TBCL-Modified
for Speech I
.21
.14
-.34*
.004
Metabolic-Physiolo
eical Measures
Post Blood Sugar
.11
.12
-.09
-.17
Post Urine Volume
-.02
-.07
.08
-.13
Post FFA
.20
.14
-.19
.12
Rest HR
.11
-.17
-.07
-.10
Speech I HR
.01
-.19
-.04
-.08
Rest SC
-.11
-.14
-.13
-.19
Speech I SC
-.12
-.14
-.06
-.15
1 .0
01 1 .0
-.02 -.06 1.0
.19
.01
.07
1.0
.24*
-.08
-.10
.72*
1 .0
.13
-.004
-.00
.33*
.32*
1 .0
-.01
-.31*
.07
.39*
.32*
.28*
1 .0
-.02
-.37*
-.13
.30*
.23
.27*
.90*
1 .0
.03
-.27*
-.03
.12
.16
.19
.28*
.22
.10
-.22
-.11
.13
.20
.21
.26*
.22
1 .0
.94*
*
Significant at the .05 level


CHAPTER 3
RESULTS
Description of Sample
Forty-five adolescents participated including 18
females, 27 males, 8 black and 37 nonblack subjects. Each
good control diabetic subject (GCDS) was yoked to a same
sex, same race subject with the exception of one black GCDS
whose poor control diabetic subject (PCDS) match was
nonblack.
An ANOVA was performed for age and no significant
difference" between groups was found (F^(2,42) = .616, p =
.54). Mean ages by group were GCDS14.75 years, PCDS
13.92 years, and nondiabetic subjects (NDS)--14.33 years.
The range of age was 11 to 18.8 years.
Duration of Diabetes and HA1 Values
A t-test was computed to determine differences between
GCDS and PCDS in duration of diabetes. No significant
differences were found (t(28) = .82, p = .421). The mean
number of years for duration of diabetes for the GCDS was
5.62 and for the PCDS 4-47*
A t-test showed significant difference for HA1 values
between the GCDS and PCDS (_T = -9*77, p < .001). The mean
29


CHAPTER I
INTRODUCTION
A substantial number of people with insulin-dependent
diabetes have difficulty adequately controlling this
disease. They feel sick, miss school or work and have
serious problems carrying out normal activities. One very
serious, even life threatening, consequence of poor control
is ketoacidosis (Cahil, Etzwiler & Freinkel, 1976).
Repeated episodes of ketoacidosis are associated with
retinopathy and kidney failure. The increased incidence of
poor control and ketoacidosis in 12-18 year olds is well-
documented (Fallstrom, 1974; Koski & Kumento, 1975). The
relationship between the psychosocial and physiological
changes of adolescence and poor control in youngsters with
insulin-dependent diabetes is not entirely clear. The
question of what contributes to the onset and maintenance
of poor control and associated ketoacidotic symptoms in
some adolescents while others remain healthy is important
in our efforts to successfully manage this chronic illness.
Stress has been frequently implicated in cases of poor
diabetic control. Patients with insulin-dependent diabetes
may be particularly susceptible to stressful events because
they lack insulin, a hormone that counters other "stress"
1


18
paper was available for notetaking in the plan period. The
topics were "the last big argument I had or my most recent
big disappointment" and "a recent fun or pleasant time I
had or something very nice that happened to me." See
Appendix A for the instructions that accompanied each
topic. Each subject was told that the speech would be
videotaped and a small audience would listen. At least one
male and female were present during speech giving. Matched
subjects were yoked to the same speech order and the order
of the two speeches was alternated between sets of matched
subjects. If a subject "froze" in his speech, one of the
audience would say a phrase designed to keep the talk
going. Examples included "tell us some more about that,"
"keep going," "what else." Generally the audience was
supportive and friendly and listened to the subject with an
interested affect.
Major Dependent Measures
Heart Rate
One sympathetic response to emotional stress is
increased heart rate. Increased heart rate has been used
as an indicant of emotional arousal and remains sensitive
across several consecutive stressors punctuated by brief
rest periods (Harvey & Hirschmann, 1980; Shipman, Heath &
Oken, 1979).
Whether or not heart rate accelerates or decelerates
is greatly dependent on the nature of the task or


17
The nondiabetic group was obtained by advertising at
the P.K. Yonge School and through staff at the J. Hillis
Miller Health Center. They were of the same sex, race, and
within 2 years in age of both their diabetic matches. All
study participants were paid money; $15 the first year data
were collected and $25 the second year.
Stress Manipulation Task
Each youngster participated in three potentially
stressful tasks. First a heparin lock was inserted in the
participant's arm or hand for the initial blood
withdrawal. The needle insertion was preceded by a 3
minute rest period and followed by a 3 minute recovery
period. Secondly, each participant was asked to give two 3
minute speeches. Each speech was preceded by a 3 minute
rest period and planning period. Both speeches were
followed by a 3 minute recovery period. Participants
remained seated for both blood withdrawal and speech
giving. All three events were videotaped. Each rest and
recovery period was preceded with the request to close
their eyes and rest and relax as completely as possible "as
if they were going to sleep."
Speeches
Each subject was asked to give two speeches. She was
told that she would have 3 minutes to plan the speech and a
clock was pointed out to time the planning. No pencils or


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33
Venipuncture Observation Scale (VOS)
An ANOVA was computed for observed venipuncture
anxiety for all groups and no statistically significant
differences were found (j?(2,28) = 1.60, p = .22).
Observed Speech Anxiety (TBCL)
An ANOVA was computed between all groups for observed
speech anxiety for both speeches. No statistically
significant differences were found for either speech [first
speechCF(2,34) = .327, P = .72), second speech(F_(2,33)
= .03, p = .97)].
Reported Anxiety (S'TAIC) for Venipuncture and Speeches
An ANOVA was computed between all groups for the STAIC
for venipuncture and no statistically significant results
emerged (F_(2,42) = .44, p = .65). ANOVAs were performed on
the STAIC administered for each of the speeches. No
significant differences were found for the second speech
(JT(2,42) = .28, p = .76) but a tendency toward significance
occurred on the first speech (F^(2,42) = 2.96, p = .06). A
Duncan's Range Test at the .05 level of significance showed
the PCDS reported more anxiety than the GCDS. Means for
the three groups are as follows: GCDS = 33.73, PCDS =
40.13, NDC = 35.67.
Rank Order of Task Form (ROTF)
Two 3X3 chi-square statistics were computed for the
rank order of tasks by subjects. The first chi-square
analysis found no difference between groups in rank


25
The JEPQ is an extension for children of the EPQ with
normative and reliability data available, but lacking
extensive validational studies. A manual to help interpret
scores is available.
Eysenck Personality Questionnaire (EPQ)
The EPQ is a personality inventory designed to measure
the same personality factors as the JEPQ in adults aged 16
and older. The extraversin, neuroticism, and
conventionality scales of the EPQ were administered to the
16-18 year-old subjects. One month test-retest
reliabilities by group and scale are primarily in the
.80's, with a range of .72 to .92; overall reliability
coefficients were as follows: extraversin was .90 and
.86; neuroticism was .89 and .80; and conventionality was
.86 and .86, for men and women, respectively. The
extraversin and neuroticism scale were produced through
factor analytic procedures and are orthogonal factors.
Eysenck and Eysenck (1975) report that others have
reproduced this factor pattern and they report validity
data using twin and other experimental studies (Eysenck &
Eysenck, 1975). A manual to help interpret scores is
available.
Life Events Checklist (LEC)
The LEC is a 46-item (plus four blank spaces for
individual responses) inventory of significant life events
for adolescents (Johnson & McCutcheon, 1980). The