O R I G I N A L A R T I C L E Relaxation Training for NIPPM Predicting who may benefit JAMES D. L\NE, PHD CYNTHIA C. MCCASKILL, RN SUZANNE L. ROSS, PHD MARK N. FEINGLOS, MD RICHARD S. SURWIT, PHD OBJECTIVE— To examine the benefits of relaxation training for patients with NIDDM and to investigate individual differences that could predict a positive re- sponse to relaxation training. RESEARCH DESIGN AND METHODS— Thirty-eight subjects with NIDDM were treated with intensive conventional diabetes therapy after an initial metabolic evaluation and psychological and pharmacological testing. Half were assigned to also receive biofeedback-assisted relaxation training. Treatment effects on GHb levels and glucose tolerance were evaluated after 8 wk. RESULTS — Subjects demonstrated significant improvements in GHb level, but not in glucose tolerance, after 8 wk of intensive conventional treatment. These improve- ments persisted throughout the follow-up period. However, the group provided with relaxation training did not experience greater improvements on either measure than the group given conventional diabetes treatment only. Within the group that received relaxation training, correlations occurred between the improvements in glucose tolerance after treatment and individual differences in trait anxiety and in the effect of alprazolam on glucose tolerance. Differences in the effects of EPI on glucose tolerance and personality measures of neuroticism and perceived locus of control also appeared to be related to improvements in glucose tolerance after training. CONCLUSIONS— Relaxation training did not confer added benefit over and above that provided by conventional diabetes treatment for patients with NIDDM. Additional research is needed to determine whether the administration of relaxation training to selected patients, especially those who are most responsive to stress, would provide benefits for glucose control that are not achieved by conventional treatment. FROM THE DEPARTMENTS OF PSYCHIATRY AND MEDICINE, DUKE UNIVERSITY MEDICAL CENTER, DURHAM, NORTH CAROLINA. ADDRESS CORRESPONDENCE AND REPRINT REQUESTS TO RICHARD S. SURWIT, PHD, BOX 3842, DUKE UNIVERSITY MEDICAL CENTER, DURHAM, NC 27710. RECEIVED FOR PUBLICATION 23 JUNE 1992 AND ACCEPTED IN REVISED FORM 22 APRIL 1993. NIDDM, NON-INSULIN-DEPENDENT DIABETES MELL1TUS; 1 D D M , INSULIN-DEPENDENT DIABETES MELL1- TUS; OGTT, ORAL GLUCOSE TOLERANCE TEST; EPI, EPINEPHRINE; EMG, ELECTROMYOGRAM; BP, BLOOD PRESSURE; SBP, SYSTOLIC BLOOD PRESSURE; dBP, DIASTOLIC BLOOD PRESSURE; FPG, FASTING PLASMA GLUCOSE; R1A, RADIOIMMUNOASSAY; ANOVA, ANALYSIS OF VARIANCE; STA1, STATE TRAIT ANXIETY INVENTORY. O ver the last 30 yr, relaxation tech- niques have been applied to the treatment of various autonomically mediated illnesses. Relaxation training has been used in the treatment of hyper- tension, cardiac arrhythmias, Raynaud's disease, and migraine headache (1). Re- laxation techniques can reduce or pre- vent stress-induced increases in adreno- cortical activity (2,3) and circulating levels of catecholamines (4,5). Thus, re- laxation therapy might serve to moderate the negative effects of stress-induced changes in counterregulatory hormones on metabolic control in some patients with NIDDM. Moreover, relaxation ther- apy would not be associated with the undue adverse effects often caused by adrenergic blockade. There is a long history of the use of behavioral anxiolytic techniques in the treatment of diabetes. Before the discov- ery of insulin, it was common to treat "diabetes of obesity," which probably corresponds to what is now designated as NIDDM, with prescriptions of rest and opiates (6). Over the past 10 yr, a growing body of literature reporting the results of experimental applications of relaxation training in NIDDM has emerged. Rosenbaum (7) introduced 4 IDDM patients and 2 NIDDM patients, who were all being managed with insu- lin, to the use of a comprehensive stress management program. Biofeedback training proceeded sequentially from frontal EMG for the reduction of muscle tension, to digital skin temperature, and to skin conductance. A family therapy component of the treatment package in- cluded the recognition of life events as potential stressors. Five of six subjects showed improvement in at least one of the following areas: decreased average plasma glucose, decreased insulin dos- age, or improved glucose stability. Un- fortunately, because at least four different therapeutic interventions were used si- multaneously in these patients, it is dif- ficult to estimate the therapeutic effect of relaxation per se. DIABETES CARE, VOLUME 16, NUMBER 8, AUGUST 1993 1087