German Journal of Psychiatry
1Johann Wolfgang Goethe Universität, Frankfurt; 2Justus-Liebig-Universität,
Dr. Sonja Rohrmann, Johann Wolfgang Goethe-Universität Frankfurt, Institut für
Psychologie, Kettenhofweg 128, D-60054 Frankfurt/Main, Germany, e-mail: Rohrmann@psych.uni-frankfurt.de
Secretory immunoglobulin A
(sIgA) in saliva has been suggested to play an important role in protecting the
mucosa of the upper respiratory tract and the oral cavity against viral
infections and bacterial adherence. Low concentrations of sIgA are associated
with certain diseases, like e.g. caries and repeated infections of the upper
respiratory tract. It is known that subjects scoring high on neuroticism and
anxiety scales are characterized by lower sIgA baseline levels than low scorers
and by a more pronounced reduction of sIgA in certain stress conditions. As
shown in many studies, relaxation consistently leads to highly significant
increases in sIgA concentrations.
these findings together, the questions emerge whether subjects high in anxiety
report higher frequencies of diseases related to low sIgA baseline levels than
low anxiety subjects, whether these groups differ with respect to changes in
sIgA after relaxation training and with respect to subjective effects of this
Secretory immunoglobulin A (sIgA) in saliva has
been suggested to play an important role in protecting the mucosa of the upper
respiratory tract and the oral cavity against viral infections and bacterial adherence
(Tomasi, 1970). It is therefore one of the most important factors within the
so-called "local immune system".
It could be demonstrated that patients suffering
from caries have lower sIgA concentrations than healthy subjects (Lehner et al.,
1967). The same is true for patients suffering from infections of the upper
respiratory tract (McClelland et al., 1982; Calvo et al., 1988; Tenovuo et al.,
1986; Norrby, 1993). On the other hand, high levels of sIgA were clearly related
to a low prevalence of caries (Gregory et al., 1986; Camling et al., 1987).
Subjects high in neuroticism and anxiety are
characterized by lower basal levels of sIgA (Graham et al., 1988; Hennig, 1994)
and by more pronounced decreases in sIgA in certain stress conditions (Hennig,
1994; Hennig et al., 1996) than subjects with low scores.
Several studies demonstrate that relaxation
leads to highly significant increases in sIgA concentrations. Dillon et al.
(1985) have shown that a humorous movie leads to increases in sIgA suggesting
(but not proving) that increases in well-being are accompanied by increases in
sIgA-concentrations. Another study by Jasnoski and Kugler (1987) demonstrated
that relaxation and relaxation in combination with imagery led to highly
significant increases in sIgA. Green & Green (1987) investigated the
question whether relaxation-induced responses in sIgA were specific to a certain
type of relaxation. Therefore they used four groups, one exercising relaxation,
another one with the instruction of imagery, a third receiving a massage, and a
fourth group who had to lie down on the floor and received no further treatment.
In the first three groups highly significant increases in sIgA could be
observed, while the untreated group did not show any changes in sIgA. As
concluded in the meta-analysis by van Rood and coworkers (1993) sIgA
concentrations can be significantly enhanced by relaxation, which is a stable
and reliable phenomenon.
(1) Do high anxiety
subjects report higher frequencies of diseases associated with low sIgA levels
than low anxiety subjects?
(2) Do high and low
anxiety subjects show differences with respect to their relaxation induced
changes in sIgA as well as with respect to subjective ratings on the effects of
the relaxation training?
In order to answer the first
question, 232 subjects (118 females, 114 males) between 20 and 73 years of age
(mean 47.5 ± 10) had to answer selected
items of a health questionnaire (Janke et al., unpublished) related to infectious diseases and
health problems. Since the question whether short term changes in sIgA in saliva
reflect changes in the immunocompetence or a changed “leakage” –
phenomenon (see Cripps et al.
1991), items were chosen which can be directly related to diseases restricted to the mouth and related areas.
Following this logic, a low concentration of sIgA in saliva may be associated
with higher incidence of these diseases, no matter whether immunological or
transport-processes are involved. Therefore, five items are related to those
diseases (sIgA – related), three of them are not. The sIgA- related diseases
were defined as: common cold, tonsillitis, bronchitis, gingivitis, and
stomatitis, whereas gastritis, dermatitis, and infections of the urinary tract
were considered as control items of a comparable pathogenesis (infection) and
comparable prevalence in the population. Each subject had to rate the frequency
of these diseases personally experienced on a Likert scale ranging from 0 = not
at all, 1 = once per year, 2 = two to four times per year, 3 = five times or
more often per year. Furthermore, subjects filled in the trait anxiety scale of
the State-Trait-Anxiety-Inventory (STAI, Laux et al., 1981). Subjects obtained
STAI scores between 21 and 71 (mean 38.85 ± 10.43).
Pearson correlations were
computed between the frequency of the diseases and the STAI-score. The influence
of gender was partialled out.
In order to answer the second question, 28 males and 28 females between 20 and 35 years of age (mean 24 ± 3.23) took part in a relaxation training. Before and after a ten minutes progressive muscle relaxation task according to Jacobson (1938), saliva was sampled by salivettes (Sarstedt, Nuembrecht, FRG) for exactly five minutes to control for saliva flow rate. Saliva was centrifuged and stored at -20°C until assayed. The concentration of secretory immunoglobulin A was measured by nephelometry as described by Hennig & Netter (1996), and Hennig, Poessel, and Netter (1996). SIgA secretion rate was computed as concentration (mg/dl) multiplied by saliva volume (ml) per minute resulting in µg/min. Furthermore, after the relaxation training subjects filled in a questionnaire on five statements like "I was able to suppress thoughts" or "I felt relaxed" using a Likert scale ranging from 0 = "not at all" to 6 = "very pronounced" as well as the trait anxiety scale of the State-Trait-Anxiety-Inventory (STAI, Laux et al., 1981). Subjects obtained STAI scores between 22 and 75 (mean 38.17 ± 9.53).
A t-test for
dependent groups was computed in order to compare the sIgA secretion rate before
and after relaxation. Furthermore, Pearson correlations were computed between
changes in sIgA and trait anxiety. The influences of gender and sIgA baseline
levels were partialled out. Furthermore, Pearson correlations were computed
between subjective ratings on the relaxation training and the STAI score. The
influence of gender was partialled out, again.
correlations between the number of related diseases and trait anxiety were
found: Subjects scoring high on the STAI reported to suffer more frequently from
common cold, tonsillitis, bronchitis, gingivitis, and stomatitis than low
scorers (see Table 1). However, no association was found between diseases not
related to sIgA and trait anxiety: High anxiety subjects did not differ from low
anxiety ones with respect to frequencies reported for gastritis, dermatitis, and
infections of the urinary tract (see Table 1). Considering that the number of
computed correlations requires an adjustment of the a-level, the level of
significance (.05) was divided by the number of correlations
(p < .01)*
(p < .01) *
(p < .01) *
(p < .01) *
(p < .01) *
(p = n.s.)
(p = n.s.)
of the urinary tract
(p = n.s.)
still significant after Bonferroni correction
As also shown by partial
correlations, subjects high in anxiety reported to have liked the relaxation
task less well (rxy.gender = -.36, p < .05), were less able to
suppress thoughts or somatic sensations during the training (rxy.gender =
-.37, p < .05; rxy.gender = .49, p < .01), and felt less
relaxed (rxy.gender = -.37, p < .05) than subjects low in anxiety.
No relationship between being able to ignore noise (rxy.gender =
-.12, p = n.s.), or judging the training as stressful and anxiety (rxy.gender
= .25, p = n.s.) was observed.
The two studies showed that
high anxiety subjects
(1) more frequently
report to suffer from sIgA-related diseases than low anxiety ones,
(2) show more
pronounced relaxation induced increases in sIgA, and feel less relaxed by the
Given the results from the
literature that high scores in anxiety are, on the one hand, associated with low
baseline levels of sIgA and, on the other hand, with marked decreases of sIgA in
certain stress conditions, our study nicely matches these observations by the
finding that high anxiety subjects report higher frequencies of diseases
referring to low sIgA levels, like common cold, bronchitis, gingivitis,
tonsillitis, and stomatitis than low anxiety subjects. High anxiety scores go
along with high scores in neuroticism, so that one can assume that subjects with
high anxiety scores are perhaps more willing to report complaints about health
than low scorers or that they tend to complain a lot more. Therefore, subjective
reports about diseases related to sIgA have to be compared to reports on
non-sIgA-related diseases and diseases of approximately the same prevalence.
Interestingly, no signifcant correlations with non-sIgA-related diseases
(gastritis, dermatitis, infections of the urinary tract) were found, so that
probably no response styles are responsible for the correlations between trait
anxiety and sIgA-related diseases. It is well known that the sIgA secretion rate
can be enhanced by relaxation, which was replicated in our study. More
interestingly, high anxiety subjects showed more pronounced increases in sIgA
than low anxiety subjects.
The physiological mechanism
underlying the strong and rapid response of the local antibody production in
saliva is still unsolved. Contrary to all expectations, the relationship between
anxiety and physiological responses to stress are inconsistent in the literature
(e.g. Born et al., 1980; Deffenbacher, 1986; Hinton, 1991). However, since
subjects high in anxiety feel chronically stressed, probably the tonic autonomic
arousal is enhanced because of a shift in output and chronically enhanced
catecholamine release. So if high anxiety subjects show particularly high
relaxation induced increases of sIgA, this could support the hypothesis that the
autonomic nervous system is involved in this process. Possibly there is an
increase of plasma cell activity in the lamina propria of the oral mucosa, which
is induced by direct sympathetic innervation or hormonal influences. One could
assume that the sympathetic activity protects the organism from an
over-production of dimer sIgA in plasma cells. A reduction of sympathetic
activity would then lead to an increase of sIgA production. The concept of
reduced inhibition as a source for promoting immunological processes is quite
well accepted. Also results indicating an inverse relationship between sIgA and
sympathetically induced physiological changes upon stress, like increases in
body temperature or neuromuscular activity, are suitable to confirm this concept
In general, relaxation
training is also supposed to influence the immune system in a positive way. The
present knowledge about the clinical meaning of stimulation of special immune
parameters has to be understood purely as an increase and not in the sense of
favouring the organism. Therefore a possible clinical impact of these results
can only be carefully suggested, particularly, since the correlations are
significant but not very powerful so that they explain only a small part of the
variance. Relaxation induced increases of sIgA are not only a consistent finding
in the literature (see the meta-analysis by van Rood et al., 1993), but also an
intraindividually stable phenomenon (Hennig, 1998). Furthermore, Green et al.
(1988) have shown that repeated relaxation training leads to an enduring
increase of sIgA. Also in this study there was a significant positive
correlation between relaxation induced changes in sIgA and the amount of
experience subjects reported to have with relaxation training (rxy =
.45; p < .45). Therefore, one could assume that high anxiety subjects are
able to increase their sIgA secretion rate by repeated relaxation training,
which possibly leads to a reduction of health problems associated with low sIgA
secretion rates. So Andrews and Hall (1990) e.g. reported a reduction of ulcera
in the oral cavity by relaxation training in subjects suffering from repeated
viral infections of the mucous membrane of the mouth.
But high anxiety subjects are
often not ready to take part in relaxation training, since they feel they are
unable to relax. Also in this study high anxiety subjects reported to have less
fun, not to be able to suppress thoughts and somatic sensations, and to have
felt less relaxed than low anxiety subjects. As shown by partial correlations
(controlling for gender), there are significant negative relationships between
changes in sIgA and subjective ratings concerning the relaxation training, like
being able ignore disturbing noise (rxy.gender = -.29; p < .05), feeling
relaxed (rxy.gender = -.28; p < .05), and liking this relaxation
tasks (rxy.gender = -.36; p < .01) in the total group. After
dividing subjects into high (n = 20) and low anxiety subjects (n = 19) according
to the median of the STAI, no significant partial correlations were found
between changes of sIgA and ratings on the training in low anxiety subjects, but
some significant relations for high anxiety subjects: The variables of being
able to ignore disturbing noise (rxy.gender = -.42; p < .10),
rating the training as stressful (rxy.gender = .49; p < .05), and
liking this relaxation tasks (rxy.gender = -.59; p < .01) were
related to relaxation induced changes in sIgA. In order to reduce the
discrepancy between objective (sIgA increase) and subjective (e.g. feeling
relaxed) relaxation responses, biofeedback of sIgA increases by relaxation may
A possible prophylactic and
therapeutic consequence of these studies could be to convince high anxiety
subjects that they can possibly benefit from relaxation training. However, more
clinical studies are needed to supply evidence for the validity, the mechanism,
and the positive effects for patients with specific immunological deficits.
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Because of a mistake in the
experimental procedure, 19 subjects did not fill in the STAI, so that
correlations refer to only 39 instead of to 58 cases.