Description
Full assignment instructions and information needed are attached as files. There are 2 parts to this assignment. Part 1 – Find the original article the press release is based on. Using psychology principles, find faults in the press release and answer questions listed in assignment instructions(not all questions are relevant to press release and article) Part 2 – Write a press release based on the article provided. Instructions for press release are under “PART 2”. Please no outside sources. There is no set page or word count for this assignment.Psychological and autonomic effects of art making
in college-aged students
David A. Sandmire, Nancy E. Rankin, Sarah R. Gorham, Daniel T. Eggleston,
Cecelia A. French, Emily E. Lodge, Gavin C. Kuns & David R. Grimm
To cite this article: David A. Sandmire, Nancy E. Rankin, Sarah R. Gorham, Daniel T. Eggleston,
Cecelia A. French, Emily E. Lodge, Gavin C. Kuns & David R. Grimm (2016) Psychological and
autonomic effects of art making in college-aged students, Anxiety, Stress, & Coping, 29:5, 561-569,
DOI: 10.1080/10615806.2015.1076798
To link to this article: http://dx.doi.org/10.1080/10615806.2015.1076798
Accepted author version posted online: 29
Jul 2015.
Published online: 28 Aug 2015.
Submit your article to this journal
Article views: 740
View related articles
View Crossmark data
Citing articles: 1 View citing articles
BRIEF REPORT
Psychological and autonomic effects of art making in college-aged
students
David A. Sandmirea, Nancy E. Rankinb, Sarah R. Gorhamc, Daniel T. Egglestona, Cecelia
A. Frencha, Emily E. Lodgea, Gavin C. Kunsa and David R. Grimma
aBiology Department, University of New England, 11 Hills Beach Road, Biddeford, ME 04005, USA; bPsychology
Department, University of New England, 11 Hills Beach Road, Biddeford, ME 04005, USA; cArts and Communications
Department, University of New England, 11 Hills Beach Road, Biddeford, ME 04005, USA
ABSTRACT
Background and objectives: Anxiety disorders comprise the most
common category of mental illness among US young adults. Art making
might be one method to help reduce anxiety, but the few studies
investigating this have used only subjective measures of anxiety.
Design: This study employed both subjective (self-reported state anxiety
from the State-Trait Anxiety Inventory) and objective (heart rate
variability) measures to assess whether 30-minute periods of art making
reduced anxiety in 47 first-year college students prior to their final
examinations. Methods: Students participated in free-form painting,
mandala coloring, clay modeling, and control sessions. Results:
Repeated-measures ANOVA with post hoc analysis revealed significantly
greater pre- to post-session reductions in anxiety for all three types of
art-making sessions than for the control session, as measured
objectively. Measured subjectively, only free-form painting yielded a
significant decrease in anxiety compared to the control session.
Conclusions: Given the health benefits of anxiety reduction, further
study is warranted to determine the duration of art making’s anxietyreducing
effect.
ARTICLE HISTORY
Received 6 November 2014
Revised 30 June 2015
Accepted 15 July 2015
KEYWORDS
Anxiety; State-Trait Anxiety
Inventory; heart rate
variability; autonomic
nervous system; art making
Introduction
Anxiety disorders are the most common mental illnesses in the USA, affecting nearly 40 million adults
(Kessler, Chiu, Demler, & Walters, 2005). Among the college population, anxiety continues to be the
predominant presenting concern (Reetz, Barr, & Krylowicz, 2013). Forty-two percent of college students
sought counseling services for anxiety, while 51% of students “felt overwhelming anxiety”
within the last 12 months (American College Health Association, 2013). In a recent report by the
National Survey of Counseling Center Directors (2010), the number of students requesting help for
severe psychological problems rose sharply from 16% to 44% between 2000 and 2010. This trend
toward increasing mental health issues among students on college campuses is cause for concern.
Anxiety also plays a role in academic performance. Students ranked stress and anxiety as the top
two factors that contributed to poor academic performance (Gallagher, 2012). Thus, it is important to
identify ways to reduce anxiety by, for example, exercise and athletics, relaxation therapies, and
leisure activities. An alternative modality might be art making. Indeed, art therapy has been shown
to decrease anxiety level among certain groups of hospitalized patients. Nainis et al. (2006) found
that a one-hour art therapy session significantly reduced anxiety in hospitalized cancer patients in
© 2015 Taylor & Francis
CONTACT David A. Sandmire dsandmire@une.edu
ANXIETY, STRESS, & COPING, 2016
VOL. 29, NO. 5, 561–569
http://dx.doi.org/10.1080/10615806.2015.1076798
Downloaded by [Ryerson University Library] at 09:30 22 September 2017
the short-term. Mercer, Warson, and Zhao (2010, p. 147) found that visual journaling tended to reduce
anxiety and negative affect among medical students, leading the authors to suggest that “the
drawing process helped the participants to better visualize their stressors, more easily focus upon
them, and more readily transform them into positive emotions.” De Morais et al. (2014) reported
that working with clay tended to reduce anxiety among psychiatric patients and suggested that
artwork could be a way to non-verbally express the emotional framework and context of the
anxiety. Julliard, Intilli, Ryan, Vollmann, and Seshadri (2002) blindly analyzed the art-making
product to identify positive and negative themes related to stress experienced by medical residents,
finding common negative themes (e.g. feeling overwhelmed, anxious, and depressed) among particular
demographic subgroups. Given the promising results from these studies, the investigators
herein questioned whether the benefits of art making might apply to the broader population (e.g.
individuals without anxiety disorder diagnoses). A recent study of college students without reported
anxiety disorders showed a significant reduction in anxiety after a 30-minute art-making session
(Sandmire, Gorham, Rankin, & Grimm, 2012), using the State-Trait Anxiety Inventory (STAI) Form Y
(Spielberger, Gorusch, Lushene, Vagg, & Jacobs, 1983). One limitation of that study and similar
ones, however, was that they only used subjective measures of anxiety (Curry & Kasser, 2005;
Walsh, Chang, Schmidt, & Yoepp, 2005). In fact, there is little objective physiologic data supporting
the belief that art making reduces anxiety. More generally, Fraser and Sayah (2011), in their systematic
review of arts-based methods in health research, note that the majority of studies use qualitative
measures. Given this, more studies designed to collect quantitative, objective data would be valuable
to art therapy professionals, providing physiologic evidence to contribute to the growing field of art
therapy research.
This study investigated whether art making can reduce anxiety as gauged by both subjective
psychological and objective physiological measures. Interestingly, earlier studies using subjective
measures found that the degree of anxiety reduction afforded by art making may be dependent
on the level of creativity and expression required of the art-making activity (Curry & Kasser, 2005).
Thus, the current investigation also sought to determine if the anxiety-reducing effects of
art making are dependent on the level of structure and direction required of each activity. It was
hypothesized that the subjective and objective measures would corroborate the findings of the
investigators’ previous study that art making reduces short-term anxiety. Furthermore, it was
thought that the level of anxiety reduction would be greatest for the art-making activity with the
most structure and direction (i.e. coloring mandala designs).
Methods
Fifty healthy, primarily Caucasian, first-year undergraduate students (39 female and 11 male), aged 18
and 19 years old, from a northeast US university participated in this study which took place during the
two-week period prior to final examinations of the fall and spring semesters. Participants attended
brief informational sessions, signing IRB-approved consent forms prior to participation. Each participant
attended four separate 65-minute sessions, three including 30 minutes of an art-making activity
(experimental sessions), and one entailing 30 minutes of non-art making (control session). Participants
engaged in art making of varying degrees of structure and direction: coloring mandalas
(greater degree), modeling with clay (medium degree), and free-form painting (lesser degree).
Those with panic, anxiety, or obsessive compulsive disorders or other mental illnesses were excluded
from this study, as were those taking medications that influence the central nervous system (e.g. to
treat depression or attention deficit disorder) and those with diabetes mellitus, cardiovascular
disease, autonomic nervous system dysfunction, or a smoking history.
The STAI Form Y was administered both immediately before and after the activity as a subjective
measure of anxiety (Spielberger et al., 1983), and data pertaining to state anxiety (one’s current level
of anxiety) was analyzed. Heart rate variability (HRV) was used as an objective indicator of anxiety,
specifically the vagal score, an indirect measure of parasympathetic nerve influence on heart rate
562 D. A. SANDMIRE ET AL.
Downloaded by [Ryerson University Library] at 09:30 22 September 2017
(Pagani et al., 1986). Participants began by resting for 15 minutes; HRV was then measured for five
minutes prior to and following art making using a lead II ECG electrode configuration. HRV entailed
quantification of the beat-to-beat fluctuations in the heart rate, as observed by changes in ECGderived
R-R intervals, using the BIOPAC Systems Inc., AcqKnowledge 4 program (Santa Barbara, CA).
Data were then transformed into frequency spectra using discrete Fourier algorithms (Colombo
et al., 1999; Smith, 1999), the high-frequency (HF) component (0.15–0.40 Hz) representing parasympathetic
influence on heart rate, and the low-frequency (LF) component (0.04–0.15 Hz) indicating
sympathetic and, to a lesser extent, parasympathetic influence on heart rate. The HF (parasympathetic)
component was presented in a normalized unit by dividing it by the difference between
the total power and the very LF component (Pagani et al., 1986; Task Force, 1996).
Groups of four participants each engaged in a 30-minute art making and control sessions. The artmaking
activities were (1) coloring in mandala designs, (2) modeling with clay, and (3) free-form
painting. Control sessions included identical tests, timelines and group sizes, with social interaction
but no art making. Data collection occurred over two fall semesters and one spring semester. Participation
occurred in sessions spread over four days for the first fall semester and over six days for the
second fall semester and the spring semester. Participants participated in sessions for only one of the
three semesters and took part in only one session on each day. Participants were randomized evenly
into six groups with regard to the order of art media used in the sessions.
For each of the four activity types, paired, one-tailed (or two-tailed when appropriate) Student’s ttests
were conducted to compare pre- vs. post-activity mean STAI state score and vagal score.
Repeated-measures ANOVA with the Greenhouse-Geisser correction was used to determine
whether the mean pre- to post-activity change in STAI state score and vagal score differed significantly
among the four activity types. Bonferroni adjustments allowed pairwise comparisons of
mean pre- vs. post-activity changes in scores for the four activity types. Analyses were performed
using SPSS software, version 20.0 (SPSS Inc., Chicago, IL, USA).
Results
Of the fifty participants enrolled in the study, three withdrew from the study after their first two sessions,
and one student neglected to fill out the STAI trait questionnaire prior to the mandala session.
Another participants’ HRV data could not be used for any of the four sessions due to frequent premature
ventricular contractions. Abnormal breathing patterns prevented the use of the HRV data
for the pre- and post-free form session measurements of three subjects, the pre-mandala session
measurements of four students, the post-mandala session measurements of three subjects, the
pre-clay session measurements of three students, and the post-clay session measurements of two
participants.
One-tailed or two-tailed paired Student’s t-tests were performed, where appropriate, to compare
participants’ pre- and post-activity mean scores for the two measures and all four activity types (free
form, mandala, clay, and control). The pre- to post-STAI state score decreased significantly for all three
art media (p < .001, t[48] = 6.16; p < .001, t[49] = 5.93; and p < .001, t[47] = 5.21, for free form, mandala,
and clay, respectively). However, the pre- to post-STAI state score also decreased significantly during
the control session (p = .005, t[46] = 2.97), though the degree of decrease was less pronounced (8.2%)
than that observed for the art-making sessions (17.2%, 16.0%, and 14.4% for free form, mandala, and
clay, respectively) (Figure 1, Table 1). Furthermore, the mean decrease in STAI state score of the combined
three art sessions (−5.42) was significantly greater than the decrease in STAI state score during
the control session (−2.76) (p < .01, t[47] = −2.77). The pre- to post-vagal score increased significantly
for all three art media (p < .001, t[44] = −5.57; p < .001, t[43] = −5.72; and p < .001, t[43] = −6.55, for
free form, mandala, and clay, respectively), but actually decreased significantly during the control
session (p = .017, t[45] = 2.49) (Figure 1, Table 2).
Repeated-measures ANOVA showed that mean change in STAI state score significantly
differed among the activity types (F(2.798, 128.701) = 3.875, p = .013, partial η2 effect size = 0.56). It
ANXIETY, STRESS, & COPING 563
Downloaded by [Ryerson University Library] at 09:30 22 September 2017
was −2.76 (±6.36) for the control group, but was −5.97 (±5.74), −5.54 (±5.90), and −4.76 (±6.26) for
the free form, mandala, and clay groups, respectively. Post hoc Bonferroni adjustments showed that
participation for 30 minutes in free form art making decreased STAI state score to a significantly
greater degree than did participation in the 30-minute control session (p = .038). Also, while the
mandala and clay sessions yielded greater decreases in STAI state scores than did the control
session, they were not significant.
The mean change in vagal score differed significantly among the activity types (F(2.77, 96.87) =
13.83, p < .001, partial η2 effect size = 0.54). It was −0.04 (±0.12) for the control group, but was
0.08 (±0.10), 0.10 (±0.11), and 0.09 (±0.09) for the free form, mandala, and clay groups, respectively.
Participation for 30 minutes in all three types of art making resulted in significantly greater increases
in vagal score than noted after the 30-minute control session (p < .001, p < .001, and p < .001, respectively,
for free form, mandala, and clay). Hence, engaging in art making for 30 minutes elicited a significantly
greater increase in vagal score than did participation in 30 minutes of non-art making.
Participants were randomized to six sequences of art media over their three art-making sessions
so that any potential order effect due to participant acclimation would influence the results for all
Figure 1. STAI state and vagal scores.
Note: The bar graphs depict results from the Student’s t-tests for the pre- to post-change in mean STAI state score (±standard
deviations) and vagal score (±standard deviations) for each art making activity and control session.
Table 1. One-tailed, paired-samples t-test for mean pre- to post-session change in STAI state score.
Paired differences
Mean SD SE mean Cohen’s d effect size
95% confidence
interval of the
difference
Lower Upper t df Sig.
Free form −5.48 6.23 0.89 −7.27 −3.69 6.16 48 <.001 0.80
Mandala −5.19 6.19 0.88 −6.95 −3.43 5.93 49 <.001 0.68
Clay −4.67 6.22 0.90 −6.48 −2.87 5.21 47 <.001 0.59
Control −2.76 6.36 0.93 −4.62 −0.89 2.97 46 .005 0.30
564 D. A. SANDMIRE ET AL.
Downloaded by [Ryerson University Library] at 09:30 22 September 2017
three art media equally if at all. Subsequent ANOVAs showed that there was no difference in mean
pre- to post-session change in vagal or STAI state scores among the three art session numbers. Finally,
Pearson correlation coefficients assessed whether the change in anxiety as measured subjectively
(STAI) correlated with the change in anxiety as measured objectively (HRV) across all four sessions.
The change in STAI state score was minimally correlated with the vagal score in the direction predicted
(r = −0.16, p = .04).
Discussion
This study was conducted on first-year college students during the last two weeks of the semesters,
prior to final examinations, when stress and pressure to succeed academically are heightened and the
need to find an outlet for maintaining both mental and physical well-being is critical. As hypothesized,
30 minutes of art making during this time was associated with a significant decrease in the
mean STAI state anxiety score for all three art media. While mean state anxiety also decreased significantly
for the control session, it did so to a significantly lesser extent. It is possible, therefore, that with
regard to one’s subjective feeling of anxiety, two relaxing effects were involved, that of art making
and that of merely sitting and socially interacting with peers for 30 minutes.
The anxiety-reducing effect of art making was also observed by the significant increase in the
mean vagal score (HF component of HRV) for all three art media. For the control session, however,
the reduction in the state anxiety score was in contrast to a significant decrease in mean vagal
score. This suggests that the control session was moderately relaxing from a subjective perspective,
but perhaps anxiety provoking from an objective standpoint, the latter indicated by a withdrawal of
parasympathetic nervous system control on cardiac function.
Clearly, STAI scores, compared to HRV data, have greater potential for response bias since participants
may have answered the STAI based on what they believed would be socially desirable or
expected rather than on their actual current level of anxiety. The first-year college students in this
study may have assumed that the researchers were predicting a pre- to post-activity anxiety
reduction and gave responses accordingly. Podsakoff, MacKenzie, Lee, and Podsakoff (2003)
argued that this “social desirability bias” might be lessened by using more than one instrument to
measure the dependent variable. Hence, our use of HRV as an objective measure. We believe therefore,
that the issue of responding in a socially desirable manner, as well as the potentially high degree
of response variance inherent in self-reporting scales (Podsakoff & Organ, 1986) such as the STAI, contributed
to the reduced state anxiety score for the control session. The three art-making sessions
yielded an additional 7% reduction in anxiety scores compared to the control session, suggesting
an independent effect of art making on subjective feelings of anxiety.
The autonomic nervous system’s control of cardiac function and heart rate illustrates the reciprocal
effect of parasympathetic and sympathetic innervation. In healthy humans during resting conditions,
both autonomic divisions are tonically active. However, parasympathetic control
predominates via the myelinated vagus efferent pathway (polyvagal theory, Porges, 1995; Porges,
2001). During exercise, physical and psychological distress, and certain disease states, the “vagal
Table 2. One-tailed, paired-samples t-test for mean pre- to post-session change in vagal score.
Paired differences
Mean SD SE mean Cohen’s d effect size
95% confidence
interval of the
difference
Lower Upper t df Sig.
Free form 0.08 0.10 0.01 0.05 0.11 −5.57 44 <.001 0.52
Mandala 0.10 0.11 0.02 0.06 0.13 −5.72 43 <.001 0.52
Clay 0.09 0.09 0.01 0.06 0.11 −6.55 43 <.001 0.52
Control −0.04 0.12 0.02 −0.08 −0.01 2.49 45 .017 0.24
ANXIETY, STRESS, & COPING 565
Downloaded by [Ryerson University Library] at 09:30 22 September 2017
brake,” as it applies to vagal inhibition of cardiac sympathetic activity (Porges, 2007), is removed,
resulting in a shift in the sympatho-vagal balance such that cardiac sympathetic control prevails
(Masi, Hawkley, Rickett, & Cacioppo, 2007). This increased cardiac sympathetic activity has been
well studied in healthy individuals as well as in diseased and aged populations (De Meersman &
Stein, 2007; Grimm, De Meersman, Almenoff, Spungen, & Bauman, 1997), and although it is important
acutely to engage the fight-or-flight system to meet metabolic demands, chronic sympathetic activation
is associated with increased morbidity and mortality (Tsuji et al., 1994). Our study was
based on the premise that during a stressful period in a college student’s life, cardiac sympathetic
activity would be heightened, and by engaging in 30 minutes of art making, anxiety would decrease,
demonstrated objectively by an increase in the cardiac vagal brake, and hence a decrease in cardiac
sympathetic activity.
In brief, the polyvagal theory posits that vagal efferent and afferent pathways mediate both visceral
homeostasis and affective and social engagement behaviors (Porges, 2001, 2007). Our study’s
findings support this concept, particularly if one considers art making as a type of social engagement
requiring a relative increase in vagal activity, compared to sympathetic activity, to promote a composed
and focused state necessary to perform the art-making activities. Furthermore, the study
setting was more akin to a drop-in art center than an individual studio, thus allowing participants
to interact and observe each other’s work.
More broadly, the amount of vagal activity appears to have implications in several important areas
of human function. In the psychosocial realm, investigators report an inverse relationship between
cardiac vagal control and acute stress (Sloan et al., 1994), social anxiety (De Meersman, Reisman,
Daum, & Zorowitz, 1996) and depression (Friedman & Thayer, 1998). More recently, Geisler, Kubiak,
Siewert, & Weber, 2013 observed that enhanced resting vagal activity predicts better self-control of
emotional and stress-related responses. Researchers have also shown anxiety to have a detrimental
effect on academic performance (King, Heinrich, Spielberger, & Stephenson, 1976) and grade point
average among first-year college students (Grinnell & Kyte, 1979) and to be directly correlated with
higher dropout rates (Culler & Holahan, 1980). At the physiologic level, reduced vagal control is associated
with obesity (Rabbia et al., 2003), impaired carbohydrate metabolism and type 2 diabetes mellitus
(Ewing, Neilson, Shapiro, Stewart, & Reid, 1991; Takayama, Sakura, Katsumori, Wasada, & Iwamoto,
2001), and cardiovascular disease (Bigger et al., 1995; Garet et al., 2005; Kleiger, Miller, & Bigger,
1987). In contrast, enhanced cardiac vagal control has a potentially protective effect against such diseases
(De Meersman, 1993; Hunt, Farquhar, & Taylor, 2001). Thus, if young adults can develop routines
such as art making to help cope with stress and anxiety, they may have better academic success as well
as an improved ability to maintain both psychological and physical well-being. Although not directly
examined in this study, the links between anxiety and academic performance suggest that it may be
beneficial for universities to invest in campus-based art centers for students as a way to reduce stress,
much like they invest in athletic facilities for a similar purpose. Formal opportunities for art therapy in
college counseling centers may also be warranted.
An additional goal of this study was to determine whether the anxiety-reducing effect of art
making (Sandmire et al., 2012) is dependent on the degree of free expression and creativity inherent
in the activity. Curry and Kasser (2005) reported that art making, more specifically coloring a mandala
design, significantly reduced self-reported anxiety compared with free-form coloring, and suggested
that the extent of anxiety reduction afforded was related to the level of structure and direction
required of each media. They inferred that the inherently structured mandala coloring exercise, as
compared to the more open-ended creation of art from a blank palette, allowed participants to
enter a meditative-like state and hence reduce their anxiety. We found no differential anxietyreducing
effect among the various art-making activities as gauged by changes in HRV parameters.
All three art media equally reduced anxiety. In contrast to Curry and Kasser, our findings suggest
art making is anxiety relieving, regardless of the medium used.
There was the potential for selection bias of our participants, all of whom received extra credit and
a $15 iTunes gift card for their participation in the study. The extra credit offering may have selected
566 D. A. SANDMIRE ET AL.
Downloaded by [Ryerson University Library] at 09:30 22 September 2017
for students doing more poorly in their college course who presumably were under greater stress
related to their academic performance. Furthermore, a large majority of our participants were
recruited from a freshman biology course that was part of the biology department’s required curriculum,
with many of these students interested in careers in highly competitive health care fields, thus
increasing the likelihood that participants experienced significant academic pressure. That said, the
participants’ pre-art making mean state anxiety score was comparable to the normative data for
female college students reported by Spielberger et al. (1983). Nonetheless, a cohort of 18- to 19-
year old college students is a unique group, and care should be taken when generalizing the findings
of this study.
Finally, the differences observed between the objective (HRV data) and subjective (STAI) measurements
for the control session are most likely the result of a combination of factors. In addition to the
response bias and the potentially high degree of score variance in self-reporting scales discussed previously,
the social interaction among the participants during the control session, from an observational
standpoint, was minimal in comparison to the art-making sessions, as was the case in the
De Morais et al. (2014) study as well, and thus the social engagement was limited, which may
partly account for the decrease in cardiac vagal score. Moreover, STAI data acquired from the
post-control session may have reflected a classically conditioned response of relaxation after
sitting relatively quietly during the combined 30-minute control session and final five-minute
period of HRV data collection. In other words, participants may have felt immediate relief that the
control session and post-session HRV data collection had concluded (with electrodes and wiring
removed), which was depicted by the reduction in state anxiety scores.
This study was not designed to determine the length of time that an anxiolytic effect of art making
lasts, and it is possible that the effect’s duration is an hour or less. Nonetheless, even an hour of targeted
relaxation might be a useful coping strategy for college students encountering the situational
stress of final examinations and other academic responsibilities. Future longitudinal studies might
examine the duration of the anxiety-reducing effect as well as the potential anxiety-relieving
effect of a long-term art-making program such as one might experience through an art class or an
extended art therapy intervention.
In conclusion, the objective physiologic HRV findings of this study corroborate the subjective findings
of our previous study that 30 minutes of art making in first-year college students is a useful
means for reducing stress, albeit briefly. With current studies reporting that anxiety disorders are
among the most common mental health concerns in college students, it is imperative that we identify
strategies to help mitigate stress. This study’s results suggest that there is a benefit to referring
those suffering from anxiety to art therapists as a way of reducing symptoms. The observation
that art making increases cardiac vagal control may also have important implications, since elevated
cardiac vagal control is associated with enhanced mental and social adaptability and provides cardiovascular
health benefits (Porges, 2001; Sloan et al., 1994; Sandercock, Bromley, & Brodie, 2005: Yoo,
Lee, Yi, Kim, & Kim, 2011). This is in stark contrast to the multitude of pathophysiologic states that may
result, in part, from removal of the “vagal brake” and subsequent chronically heightened states of
sympathetically triggered fight-or-flight phenomena (Stein, Kleiger, & Rottmann, 1997; Thayer &
Lane, 2007). Therefore, emphasizing activities that enhance cardiac vagal control may help to
buffer the stressors of college life as well as benefit one’s general state of health.
Acknowledgements
University of New England Vice President for Research Mini-grant.
Disclosure statement
No potential conflict of interest was reported by the authors.
ANXIETY, STRESS, & COPING 567
Downloaded