Autogenic training reduces anxiety after coronary

angioplasty: A randomized clinical trial

N. Kanji, PhD, BEd(Hons), RGN, RNT, A. R. White, MA, BM, BCh, and E. Ernst, MD, PhD, FRCP, FRCPEd Exeter,
United Kingdom

Objectives Autogenic training (AT) is a method of autosuggestion with some potential for reducing anxiety. This
study tests whether AT lowers anxiety levels experienced by patients undergoing coronary angioplasty.
Methods Fifty-nine patients were randomly assigned to receive regular AT or no such therapy as an adjunct to stan-
dard care for 5 months. The primary outcome measure was State Anxiety at 2 months. Qualitative information was gener-
ated by face-to-face interviews.
Results State Anxiety showed a significant intergroup difference both at 2 and 5 months. This finding was corrobo-
rated by secondary outcome measures, for example, quality of life, and by qualitative information about patients’ experi-
ences. The results do not allow us to determine whether the observed effects are specific to AT or of a nonspecific nature.
Conclusions Our results suggest that AT may have a role in reducing anxiety of patients undergoing coronary an-
gioplasty. (Am Heart J 2004;147:e10.)

Autogenic training (AT) was developed about 100
years ago by the German neurologist Johannes Schultz.
It is a hypnosis-based, autosuggestive healing method
that consists of 6 mental exercises aimed at relieving
anger, tension, and stress. The exercises are initially
taught in small groups in which patients control the
feeling of warmth and heaviness, eventually gaining
more and more control over autonomic functions.1
Subsequently, patients are encouraged to perform
these exercises at home on a regular basis.
Autogenic training is now a popular method, particu-
larly in Europe, advocated for controlling stress, anxi-
ety, phobias, depression, sleep disorders, headache,
premenstrual problems, pain, asthma, hypertension,
and other conditions.2 Encouraging trial evidence ex-
ists for a range of diverse indications: asthma, intesti-
nal diseases, glaucoma, eczema,3 hypertension,4 and
anxiety.5
The possibility that AT has anxiolytic effects renders
it a promising adjunct to interventions associated with
a high degree of anxiety such as angioplasty. This
study was therefore aimed at testing whether AT low-
From Complementary Medicine, Peninsula Medical School, Universities of Exeter and
Plymouth, Exeter, United Kingdom.
Submitted September 15, 2003; accepted October 14, 2003.
Reprint requests: E. Ernst, MD, Complementary Medicine, Peninsula Medical School,
Universities of Exeter and Plymouth, 25 Victoria Park Road, Exeter EX2 4NT United
Kingdom.
E-mail: Edzard.Ernst@pms.ac.uk
0002-8703/$ - see front matter
© 2004, Elsevier Inc. All rights reserved.
doi:10.1016/j.ahj.2003.10.011
ers the anxiety levels experienced by patients undergo-
ing coronary angioplasty.
Methods
Patients who had undergone elective angioplasty for coro-
nary heart disease the previous day at one leading UK center
(Harefield Hospital), who were older than 18 years of age
and willing to give written, informed consent were consid-
ered for inclusion. They were excluded if, within the preced-
ing 6 weeks, they had a myocardial infarction, were already
practicing a form of stress management, or were known to
have psychiatric disorders. Patients were recruited consecu-
tively during a period of 42 weeks.
All patients received standard care as practiced in this cen-
ter at that time. They were randomly assigned into two paral-
lel groups by means of the sealed, opaque envelope method
and ensuring concealment at allocation. The intervention
group received adjunctive AT, whereas the control group
received standard care only. Autogenic training was taught in
small groups, usually of 8 patients. They had supervised ses-
sions of 60 minutes each by one experienced, qualified AT
instructor. Subsequently, they were told to exercise AT inde-
pendently on a daily basis. Measurements were taken at base-
line as well as two and 5 months’ follow-up.
The primary outcome measure was the State Anxiety at 2
months. Secondary variables were Powers Quality of Life In-
dex, Cardiac Version III (QLI), blood pressure, heart rate, and
subjective experiences recorded in a diary. Patients were also
individually interviewed to generate qualitative information
about their experience. All measurements were taken after
introductory discussion, with the use of the Digital Blood
Pressure Monitor, Model DS-115. Thus the study followed an
open, randomized design with two parallel arms.
 American Heart Journal
K2 Kanji, White, and Ernst
March 2004

Table I. Demographic data: Groups A and B Figure 1

Group A Group B
(n ⴝ 30) (n ⴝ 29)

Sex (%)
Female 11 (36.7) 9 (31)
Male 19 (63.3) 20 (69)
Age (y) (%)
⬍49 3 (10) 0
50–59 5 (16.7) 13 (44.8)
60–69 13 (43.3) 8 (27.6)
70–79 9 (30) 8 (27.6)
Intervention (%)
PTCA 10 (33.3) 8 (27.6)
PTCA with Stent 20 (66.7) 21 (72.4)

PTCA, Percutaneous transluminal coronary angioplasty.

A power calculation was conducted to estimate an ade-

quate sample size for this study.6 This was based on a previ-
ously published trial that used the same primary outcome
measure.7 The use of these data and setting the power at
80% and the level of statistical significance at 5% resulted in a
total sample size of 32 patients. Allowing for a high dropout
rate, we decided to recruit 59 patients. The data were evalu-
ated as intergroup differences, using 2-sided t tests. They
were expressed as means ⫾ 1 SD. All analyses were accord-
ing to the intention-to-treat principle. Qualitative data were
analyzed by means of the constant comparative method, with
the use of the QSR NUD*IST program, and were validated by
an independent assessor.8 Ethical approval was obtained
from our local ethics committee.
Results
The demographic data of both groups are summa-
rized in Table I. There were no relevant differences
between baseline characteristics. Of the 59 patients,
23 dropped out (9 in the experimental and 14 in the
control group). Figure 1 depicts a flow chart of this
situation.
The primary outcome measure (State Anxiety at 2
months) shows a significant difference between
groups (31.2 ⫾ 9.8 vs 37.0 ⫾ 14.5). Compared with
baseline, the readings decreased in the experimental
group and increased in the control group. At 5-month
follow-up, the situation was strikingly similar (Table
II). These findings are corroborated by the secondary
variables (Table II). Blood pressure and heart rate,
however, were largely unaltered throughout the study,
except for a trend of diastolic blood pressure to de-
crease in the experimental group (Table III).
Table IV summarizes the themes that emerged on
interviewing patients. They indicate that subjective
experience was one of relaxation, improved wellness,
and empowerment.
Flow chart: Patient population.
Discussion
These results imply that regular AT can reduce anxi-
ety in patients undergoing coronary angioplasty. This
notion is supported both by quantitative (Table II) and
qualitative (Table IV) data. To the best of our knowl-
edge, this is the first randomized clinical trial to test
whether AT benefits such patients. As anxiety levels of
these individuals tend to be high and are likely to af-
fect objective outcomes as well as subjective quality of
life, the relevance of our results could be considerable.
The study is burdened with several flaws that limit
its conclusiveness. The sample size, albeit estimated
through a power calculation, was not large, and the
dropout rate was considerable. However, this would
tend to lessen rather than artificially increase our ef-
fect size. The more important limitation, therefore,
seems to lie elsewhere: The design of our study does
not allow us to differentiate between specific and non-
specific effects of AT. In other words, we cannot be
sure whether the noted group differences were due to
the extra attention being given to patients or to the
intrinsic effects of AT. The decision to design the
study as we did was taken after much deliberation. We
thought that at this early stage of knowledge, our de-
sign was justified. A further drawback of our study is
the fact that the AT teacher and evaluator of results
American Heart Journal
Kanji, White, and Ernst K3
Volume 147, Number 3

Table II. State and trait anxiety and quality of life index scores

State anxiety Trait anxiety Quality of life index

After 2 After 5 After 2 After 5 After 2 After 5

months months months months months months

Baseline P < .001 P < .001 Baseline P < .001 P < .04 Baseline P ⴝ ns P ⴝ ns

x SD x SD x SD x SD x SD x SD x SD x SD x SD

Experimental 38.5 10.3 31.2 9.8 30.4 8.8 41.3 9.5 36.4 8.9 37.6 10.3 20.6 4.7 22.3 3.7 22.0 3.8
group
Control 34.3 11.3 37.0 14.5 38.6 15.5 38.9 10.2 36.7 10.7 37.4 9.6 22.3 3.3 21.6 4.1 21.9 4.9
group

X, Mean; P values, inter-group differences; ns, no significant inter-group differences.

Table III. Systolic and diastolic blood pressure and pulse

Systolic BP Diastolic BP Pulse

After 2 After 5 After 2 After 5 After 2 After 5

Baseline months months Baseline months months Baseline months months

x SD x SD x SD x SD x SD x SD x SD x SD x SD

Experimental 120.8 17.9 121.1 17.2 126.0 7.3 80.1 11.2 73.6 12.1 75.2 4.6 62.2 14.3 57.9 9.3 54.0 9.9
group
Control 136.5 15.0 135.5 22.3 N/A N/A 81.3 8.4 80.5 9.9 N/A N/A 70.1 12.2 70.5 11.6 N/A N/A
group

BP, Blood pressure; X, mean; N/A, not available.

Table IV. Qualitative analysis: Themes emerging

Physiological category Psychological category Spiritual category

Bodily relaxation Relief of anger Strengthening of spiritual belief

Heaviness of limbs & body Relief of anxiety Experiencing altered states of consciousness
Warmth of limbs & body Burgeoning of assertiveness Development of a peaceful persona
Coolness of brow Achieving of calmness
Sensations of tingling or pins & needles Improvement of personal organisation
Relief of headaches, back pain & chest pain Mellowing of the persona
Cessation of dizzy spells Development of positivity and sensitivity
Improved hearing Improvement of thought processes
Facilitation of slower & deeper breathing Heightening of self-awareness
Awareness of heartbeat Minimisation of irritability and intolerance
Improved quality of sleep Acquiring the “content with oneself” feeling
Stabilisation of diabetes
Improved physical & mental energy
Improved posture
Improved sexual life

was the same person, who was unmasked to the relaxation methods or through studies incorporating
group allocation of the patients. an “attention control group.” It should be noted what
Future independent replications of our results should Stetter and Kupper recently showed: When AT was
try to overcome these limitations, for example, compared with real control conditions, the effect size
through noninferiority trials comparing AT with other was smaller compared with studies with no interven-

K4 Kanji, White, and Ernst
tion controls, and when AT was compared with other
psychological treatments, the results indicated no su-
periority of AT.9 It seems possible, therefore, that AT
is effective but not more so than other relaxation tech-
niques.
Autogenic training is certainly a safe intervention
when performed appropriately.2 It is furthermore an
inexpensive (self) treatment. Thus, AT might contrib-
ute to lowering healthcare costs for a range of condi-
tions. In addition, it seems to yield numerous potential
health benefits other than the reduction of anxi-
ety.3,4,5,9 In our opinion, it therefore deserves further
rigorous studies to establish its evidence base and its
role in health care.
In conclusion, patients undergoing coronary angio-
plasty who receive the adjunctive therapy reduce anxi-
ety levels significantly more effectively than similar
patients who do not receive this adjunctive therapy.
The question whether this is a specific or nonspecific
effect of AT merits further research.
American Heart Journal
March 2004
References
1. Segen JC. Dictionary of alternative medicine. Stamford (Conn):
Appleton and Lange; 1998.
2. Ernst E, Pittler MH, Stevinson C, et al. Desktop guide to complemen-
tary and alternative medicine. Edinburgh (UK): Mosby; 2001.
3. Stetter F, Kupper S. Autogenes training: qualitative Meta-Analyse
kontrollierter klinischer Studien und Beziehungen zur Naturhei-
lkunde. Forsch Komplemntärmed 1998;5:211–23.
4. Kanji M, White AR, Ernst E. Anti-hypertensive effects of autogenic
training: a systematic review. Perfusion 1999;12:279 – 82.
5. Kanji N, Ernst E. Autogenic training for stress and anxiety: a sys-
tematic review. Complement Ther Med 2000;8:106 –10.
6. Altman DG. Practical statistics for medical research. London (UK):
Chapman & Hall; 1997.
7. Desanti L. Training Autogeno Eansia Pre-Agonistica Nel Tiro Con
L’Arco (autogenic training and pre-competition anxiety in archery)).
Movimento 1981;5:120 –3.
8. Chenitz WC, Swanson JM. From practice to grounded theory.
Menlo Park (Calif): Addison-Wesley Publishing; 1986.
9. Stetter F, Kupper S. Autogenic training: a meta-analysis of clinical
outcome studies. Appl Psychophysiol Biofeedback 2002;27:45–98.
Reproduced with permission of the copyright owner. Further reproduction prohibited without
permission.