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The relationship between sensory processing difficulties and anxiety level of healthy adults
Batya Engel-Yeger 1 and Winnie Dunn 2 Key words:
Sensory, mental health. Purpose: The purpose of the study was to examine the relationship between extreme sensory reactivity as expressed in daily living situations, and trait and state anxiety, among healthy individuals. Procedures: One hundred and thirty-five healthy individuals filled in the Adolescent/Adult Sensory Profile regarding their responses to daily sensory experiences. Anxiety was assessed by Spielbergers State-Trait Anxiety Inventory. Findings: Participants with sensory hypersensitivity, as well as those with Low Registration of sensory input, showed elevated trait anxiety and state anxiety. Men with lower registration had more elevated trait anxiety than women. Sensation Avoiding was found to be the significant predictor for state anxiety. Conclusion: Trait anxiety and state anxiety might be related to extreme sensory processing patterns. Occupational therapy intervention with people who express enhanced anxiety level should refer to their sensory reactivity as a means to optimise intervention outcomes, increase their self-confidence, improve their functioning and participation in daily living, and enhance their wellbeing.

Introduction
People experience life through their senses. Sensory processing refers to the ability to register and modulate sensory information and to organise this sensory input to respond to situational demands (Humphry 2002). Although most people have balanced sensory processing abilities, 15% of the total population has more intense sensory processing patterns (Simeonsson et al 2003, Miller et al 2007). These intense patterns are expressed by either sensory hypersensitivity, resulting from a low neurological threshold to sensory stimuli (requiring very little stimulation for activation), or sensory hyposensitivity, resulting from a high neurological threshold to sensory stimuli (requiring much stimulation for activation). These extreme patterns affect ones behaviour and quality of life (Parham and Mailloux 2001). The literature refers mainly to sensory hypersensitivity and emphasises its possible impacts on functional abilities, behaviour, emotions and mental health. The coping strategies that people develop to deal with sensory hypersensitivity add to the negative impact on their quality of life (Abernethy 2010). Dunn (1997) developed a model about the relationship between the persons neurological thresholds and behavioural self-regulation strategy continua (Dunn 1997, Brown et al 2001). In this model, Dunn claimed that individuals who use a passive behaviour strategy allow stimuli to occur and then respond to them, whereas individuals who use an active behaviour strategy act to control the amount and type of sensory input they receive (Dunn 2007). According to this model, four sensory processing patterns exist: 1. Low Registration individuals with high neurological thresholds and a passive behaviour strategy, who fail to detect stimuli that others notice and are often described as either easy going or withdrawn, inattentive, unmotivated or self-absorbed

1 Senior Lecturer, Department of Occupational

Therapy, Faculty of Social Welfare and Health Sciences, University of Haifa, Mount Carmel, Israel. 2 Professor, Department of Occupational Therapy Education, University of Kansas Medical Centre, Kansas City, Kansas, USA. Corresponding author: Dr Batya Engel-Yeger, Senior Lecturer, Department of Occupational Therapy, Faculty of Social Welfare and Health Sciences, University of Haifa, Mount Carmel, Haifa 31950. Email: batya@research.haifa.ac.il Reference: Engel-Yeger B, Dunn W (2011) The relationship between sensory processing difficulties and anxiety level of healthy adults.
British Journal of Occupational Therapy, 74(5), 210-216.

DOI: 10.4276/030802211X13046730116407 The College of Occupational Therapists Ltd. Submitted: 25 August 2010. Accepted: 13 April 2011.

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2. Sensation Seeking individuals with high neurological thresholds and an active behaviour strategy, who experience pleasure from a rich sensory environment and behaviours that create sensation; they can be considered exuberant or easily distracted 3. Sensation Avoiding individuals with low neurological thresholds and an active behaviour strategy, who engage in behaviours that limit exposure to stimuli and can be considered introspective or reclusive 4. Sensory Sensitivity individuals with low neurological thresholds and a passive behaviour strategy, who experience discomfort with sensation, and may be seen as precise or picky (Dunn 1997). Based on theoretical frameworks (for example, Dunn 2001, Miller et al 2007) as well as on clinical evidence and previous studies (for example, Kinnealey et al 1995, Hofmann and Bitran 2007), people with low neurological thresholds often show fear, negative affect and neuroticism, as well as rigid and controlling behaviours including negative or aggressive responses or sensation avoidance. Previous reports suggested that sensory processing, related mainly to low neurological thresholds, might share common behavioural and physiological traits with anxiety and might be a possible risk factor for enhanced anxiety level (Kinnealey and Fuiek 1999, Pfeiffer et al 2005, Tsuji et al 2009). Anxiety is considered normal when it occurs in response to a realistic threat and dissipates when the danger is no longer present (Beck et al 1985). Even though a certain level of anxiety can motivate individuals to participate in life and complete tasks, anxiety can also be debilitating and paralysing (Beck et al 1985), and can cause irritability and make people feel on edge (American Psychiatric Association 1994). The concept of state anxiety refers to a transitory emotional response to a stressful situation that involved unpleasant feelings of tension and apprehensive thoughts. This condition is subject to continual fluctuation as a result of temporal changes in the environment. In contrast, trait anxiety refers to individual differences in anxiety proneness which are relatively stable (Metzger 1976). This enduring personality characteristic could predispose people to state anxiety in times of stress (Spielberger et al 1983). For several decades, associations were made in the literature between sensory processing patterns related to low threshold and anxiety. This relationship was described, for example, by Ayres (1972), who noted that children with hypersensitivity to tactile sensations showed high anxiety level during tactile experiences that were not self-initiated. To express this relationship, Royeen and Lane (1991) and Wilbarger and Wilbarger (1991) also used the term sensory affective disorder. Heller (2003) emphasised that in severe sensory hypersensitivity/sensory defensiveness, stress and anxiety can increase together with other psychological problems, even in emotionally healthy environments. The relationship between sensory processing patterns and anxiety has neurophysiological manifestations, showing hyperarousal mechanisms and enhanced sympathetic nervous system reactivity, mainly among individuals with sensory

hypersensitivity (Mefford and Potter 1989, Miller et al 1999, Berridge and Waterhouse 2003). This hyperarousability was manifested in enhanced activity of the brain areas associated with hyperemotionality. These areas include, for example, the limbic structures and components of the reticular system, hypothalamus and cortex. Kisley et al (2004) found that individuals with hypersensitivity had altered brain sensory gating expressed in evoked response potential (ERP) components and over-inclusion of irrelevant sounds into the focus of attention. Grossman (1978) found that animals with a lesioned limbic system (one of the main elements involved in emotional responses) demonstrated exaggerated defensive reactions, hyperresponsiveness to handling, light touch and temperature changes. Although this procedure cannot be tested on humans, the behaviours presented by these animals are similar to those manifested among people with hypersensitivity. The negative impacts of extreme sensory processing patterns and anxiety expressed in unbalanced physiological regulation, and on behaviour, might have a devastating influence on quality of life. Nonetheless, only few studies examined the relationship between sensory processing patterns and anxiety. The present study aimed to expand the knowledge in this area and to answer the specific question of whether a significant relationship exists between sensory processing patterns and anxiety level. The answer to this question could increase occupational therapists awareness of related outcomes of sensory processing patterns and enable implementation of this knowledge in evaluation and intervention processes. In the present study, there is reference to both trait and state anxiety and to sensory processing abilities as expressed in daily living situations. It was hypothesised that adults with more intense sensory processing patterns, related mainly to a low neurological threshold, would show a greater state /trait anxiety level.

Method
Participants
One hundred and thirty-five healthy individuals participated in this study. Participants socioeconomic level ranged from low to high, according to the criteria of the Central Bureau of Statistics in Israel (2010). Inclusion criteria were healthy participants, aged 18-50 years. Exclusion criteria were the presence of severe systemic chronic diseases (such as cancer), nervous system impairments (such as stroke or epilepsy) and medication use on a daily basis. All participants were recruited by an advertisement published in several neighbourhoods in northern Israel, calling for participation in a study about sensations and personal characteristics.

Instruments
A demographic questionnaire, including information about participants health status, sociodemographic status, medications and treatments, was used. The Adolescent /Adult Sensory Profile (AASP) (Brown and Dunn 2002), based on Dunns model of sensory processing

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(Dunn 1997). In this self-measurement tool, respondents answer questions about their behavioural responses to sensory experiences. The questionnaire has 60 items, including questions pertaining to each of the sensory systems. For scoring, the 60 items are sorted equally into four quadrants Low Registration, Sensation Seeking, Sensory Sensitivity and Sensation Avoiding (based on factor analysis) reflecting different sensory processing patterns. Participants indicate how often they respond to the sensory event in the manner described in the items, using a five-point Likert scale (from 1 = almost never to 5 = almost always). The resultant score for each quadrant ranges from 5 to 75. Using national samples of 950 adolescents and adults (ages 11- 90 years), Brown and Dunn (2002) calculated cut-off scores, which indicate when scores are significantly different from their peers responses. Each age group (11-17, 18 -64, 65 and older) has its own norms. This questionnaire has good internal consistency, with coefficient alpha values of 0.692 for Low Registration, 0.639 for Sensation Seeking, 0.657 for Sensory Sensitivity and 0.699 for Sensation Avoiding (Pohl et al 2003). The questionnaire was translated into Hebrew and translated back into English by bilingual occupational therapists, to ensure the validity of the translated form. (As measurement of psychometric properties of the Hebrew version is still in process, this study used the American norms.) Anxiety level: Anxiety score was assessed by Spielbergers State-Trait Anxiety Inventory (STAI) (Spielberger 1972). The STAI is designed to provide an empirical measure of the anxiety level of normal adults (Metzger 1976). The first part of the questionnaire assesses the level of state anxiety and the second part assesses trait anxiety. Each part includes 20 statements that describe the emotional condition (for example, I feel upset, I feel comfortable, I am worried and I am jittery) and individuals rate their feelings about each sentence on a four-point scale (from 0 = not at all to 3 = very much so).

Stepwise Linear Regression examined whether STAI scores may be predicted by the sensory processing patterns. Probabilities at or below 0.05 were considered significant.

Results
Table 1 summarises the participants sociodemographic information.

The relationship between sensory processing pattern and anxiety scores

As presented in Table 2, higher trait anxiety, state anxiety and total anxiety level were positively correlated with higher levels of Low Registration, Sensory Sensitivity and Sensation Avoiding.
Table 1. Participants sociodemographic information General sample Age range (years)...............................18-49.................................................... Mean age SD.................................27.635.84..................................... Years of education range ................10-23.................................................... Mean years of education SD...........14.632.19..................................... Socioeconomic level (%) ...................Low.........................44.4.................. Average...................27.4.................. High ........................28.1.................. Men Women Number............................................49 ...........................86..................... Age range (years) ..............................18-49......................20-50............... Mean age SD.................................27.975.83............29.536.97...... Years of education range................10-22......................10-23............... Mean years of education SD...........14.52.23..............14.81.98........ Table 2. The significant correlations between Spielbergers State-Trait Anxiety Inventory scores and the sensory processing patterns Anxiety Low Sensation Sensory Sensation scores Registration Seeking Sensitivity Avoiding State...................NS....................NS................0.26*...............0.26*......... Trait..................0.31***..............NS................0.45***..........0.43***..... Total score........0.19*..................NS................0.39***..........0.38***..... NS = not significant; *p 0.05; ***p 0.001.

Procedure
After receiving ethical approval from the institutional review board (IRB), advertisements for participation in this study were published in several neighbourhoods. Those interested in taking part telephoned the research coordinator, received detailed information about the study and completed a demographic questionnaire that included sociodemographic data and information about health status. This questionnaire was used to determine participant eligibility. Participants who satisfied the inclusion criteria met the data collector in their home, signed the consent form and filled in the AASP and the STAI.

Differences in STAI scores between the performance ranges of each sensory processing pattern
In the present study, the five ranges for each sensory processing pattern, as presented in the AASP manual (that is, Much less than most people, Less than most people, Similar to most people, More than most people and Much more than most people), were merged into three, as follows: (1) Much less than most people and Less than most people were merged and defined as Less than most people (representing approximately 16% of the population, or more than one standard deviation (SD) below the mean); (2) Similar to most people was not changed (representing approximately 68% of the population between -1 SD and +1 SD); and (3)

Data analysis
Pearsons correlation test examined the relationship between AASP and STAI scores. ANOVAs with Scheffe Post Hoc test examined whether significant differences in anxiety score existed between the different ranges of each sensory processing pattern.

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Fig. 1. Frequency (in percentage) of performance intervals in each sensory processing pattern.

More than most people and Much more than most people were merged and defined as More than most people (representing approximately 16% of the population, or more than 1 SD above the mean). This strategy yielded a higher number of participants in each of the three categories. Fig. 1 depicts the frequency (in percentage) of performance intervals in each sensory processing pattern.

Sensation Avoiding pattern State anxiety scores were significantly higher among participants in the More than most people range than among those in the Similar to most people range (F2,134 = 6.26, p = 0.003, mean difference = 7.36, p = 0.03). Gender was not found to have a significant effect on these results. Trait anxiety score was significantly different among participants in the three sensory processing performance ranges (F2,134 = 12.94, p 0.001). The trait anxiety score was higher among participants in the Similar to most people range than those in the Less than most people range (mean difference = 9.71, p 0.001) and higher among participants in the More than most people range than those in the Less than most people range (mean difference = 15.26, p 0.001). Gender was not found to have a significant impact on these results. The total STAI score was significantly different among the participants in the three sensory processing performance ranges (F2,134 = 10.73, p 0.001): this score was lower among participants in the Less than most people range than those in the Similar to most people range (mean difference = 17.07, p 0.001) and higher among participants in the Less than most people range than those in the More than most people range (mean difference = 21.54, p = 0.03).

High neurological threshold

The only significant difference was found in the trait anxiety score (F2,134 = 4.85, p = 0.09): participants in the More than most people range for Low Registration had significantly higher trait anxiety scores than those in the Similar to most people range (mean difference = 5.36, p = 0.01). Regarding the impact of gender, in the Low Registration pattern, women had significantly higher trait anxiety scores than men (F2,134 = 4.49, p = 0.03). A significant interaction between sensory processing range and gender was found (F2,134 = 2.99, p = 0.05): in the Similar to most people range, women had higher trait anxiety scores (40.08 8.04) than men (34.349.06), whereas in the More than most people range, men had higher trait anxiety scores (42.61 8.65) than women (44.01 10.52).

Low neurological threshold

Sensory Sensitivity pattern State anxiety scores were significantly higher among participants in the More than most people range than those in the Less than most people range (F2,134 = 4.56, p = 0.012, mean difference = 9.67, p = 0.02). Gender was not found to have a significant effect on these results. Trait anxiety scores were higher among participants in the More than most people range than among participants in the Similar to most people range (mean difference = 5.74, p = 0.02) and the Less than most people range (mean difference = 15.79, p 0.001). People in the Similar to most people range had higher trait anxiety scores than those in the Less than most people range (mean difference = 10.06, p = 0.015). Gender was not found to have a significant impact on these results. The total STAI score was also significantly different among participants in the three sensory processing performance ranges (F2,134 = 13.02, p 0.001). Participants in the Less than most people range had a lower STAI score than those in the Similar to most people range (mean difference = 16.84, p = 0.025), and among participants in the More than most people range (mean difference = 25.47, p 0.001). Participants in the More than most people range were significantly higher on the STAI than those in the Similar to most people range (mean difference = 8.63, p = 0.012).

Predicting STAI scores by sensory processing patterns

State anxiety: A stepwise linear regression for STAI scores yielded one model, in which Sensation Avoiding was the significant predictor for state anxiety ( = 0.26, p 0.01), accounting for 7% of the variance (F1,134 = 9.7, p = 0.002). Trait anxiety: Sensory Sensitivity was found to be a significant predictor for trait anxiety ( = 0.45, p 0.001), predicting 20% of the score. When adding Sensation Avoiding, two models were found: in the first, trait anxiety was significantly predicted by Sensory Sensitivity ( = 0.28, p = 0.02) (F1,134 = 32.92, p 0.001) and, in the second, by Sensation Avoiding ( = 0.23, p = 0.04), accounting for an additional 2% of the variance (F1,134 = 4.03, p = 0.04).

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In summary, state and trait anxiety levels were higher among individuals with sensory processing patterns related to a low neurological threshold (that is, Sensory Sensitivity and Sensation Avoiding). These patterns were also found to predict state and /or trait anxiety. Higher trait anxiety scores were also presented among individuals with Low Registration.

Discussion
The present study examined the relationship between sensory processing patterns and state and trait anxiety level. This aim was derived from previous literature on consistent patterns of personality and sensory processing reported among children and adults, which emphasised the need to improve understanding of how these constructs interact (Dunn 2001). In this study, it was hypothesised that there would be a significant relationship between anxiety and sensory processing; the data support this hypothesis. The strongest correlations were found between anxiety and Sensory Sensitivity and Sensation Avoiding, which are both low neurological threshold patterns. Both patterns related not only to state anxiety but also to trait anxiety. The prediction of state and trait anxiety by these sensory processing patterns strengthens these results, where Sensation Avoiding was found to play a role in both state and trait anxiety. This finding supports previous reports claiming that anxiety is one of the possible explanations for the exaggerated defence mechanisms and poor self-regulation of individuals with sensory hypersensitivity when meeting an unpleasant sensation. Previous reports mainly discussed the relationship between sensory hypersensitivity and anxiety among populations with disorders, such as post-traumatic stress disorder (PTSD) (Morgan and Grillon 1999), pervasive developmental disorders (PDD) and attention deficit hyperactivity disorder (ADHD). Some of these reports even supported this relationship by physiological manifestations. For example, Mangeot et al (2001) found that sensory sensitivity in children with ADHD was associated with enhanced sweatgland activity following sensory stimulation, measured by greater magnitudes of electrodermal reactivity. Among individuals with PTSD, evoked response potentials (ERP) were used in order to understand the underlying neural mechanism of hypersensitivity and exagerated emotional responses. ERP studies in PTSD evaluated attentional and preattentional processes. The studies that refer to attentional processes evaluated the P3 component. This brain potential is elicited in response to a significant stimulus. McFarlane et al (1993) used an auditory target discrimination task paradigm and found that PTSD patients exhibited decreased P3 evoked potential amplitudes that failed to distinguish target from distractor tones compared with normal controls. These investigators hypothesised that diminished P3 amplitudes may be an index of disturbed concentration found in individuals with PTSD. They suggested that greater reactivity to stimuli in participants with PTSD may be related

to their impaired perceptual evaluation of stimuli due to a defect in early stimulus gating. The results of the present study emphasise that similar emotional aspects might be found among healthy individuals with higher anxiety tendency. Kinnealey and Fuiek (1999) claimed that sensory hypersensitivity might be an unrecognised contributing or confounding factor in some people with anxiety. Therapists should pay more attention to the role of sensory processing difficulties. This is because of the emotional and cognitive burden endured by those who experience these difficulties, and also because of the additional common outcomes related to anxiety, such as social anxiety, depression (Hofmann and Bitran 2007), social and physical withdrawal and isolation (Oliver 1990, Kinnealey et al 1995). In populations with specific disorders, these outcomes might be even more extreme. For example, Tsuji et al (2009) found a higher anxiety and a higher depression level among children with PDD and sensory hypersensitivity than children with PDD who were not hypersensitive. They concluded that children with PDD and hypersensitivity have more serious psychopathologies. These negative outcomes might lead to deterioration in functioning and participation, and thus in health status and wellbeing (Kinnealey and Fuiek 1999). The new aspect highlighted in this study was the finding that individuals with a Low Registration pattern (that is, a high neurological threshold) show relatively high trait anxiety as well. Women in the Similar to most people range of this sensory processing pattern had higher trait anxiety than men. According to previous reports, lifetime prevalence of one or more anxiety disorders is nearly twofold higher in women than in men (Kessler et al 1994, Magee et al 1996). In the present study, however, men with more extreme behaviours related to this sensory processing pattern had higher trait anxiety than women. As mentioned above, the existing literature manifests higher anxiety levels among women. Data about the role of anxiety in men with extreme Low Registration are scarce. In a recent study performed by Engel-Yeger and Dunn (2011), healthy individuals with an extreme Low Registration pattern showed higher pain catastrophising levels. The authors suggested that because these individuals fail to detect sensations, and might overlook the warnings of imminent pain in their surroundings, they experience the pain suddenly and have an excessive catastrophising reaction. Pain catastrophising level is also known to be anxiety related (Sullivan et al 2001, Jerome and Liss 2005). Nevertheless, gender was not found to have an impact on the results in the study of Engel-Yeger and Dunn (2011). Thus, further studies should examine this point for a better understanding of whether men with extreme Low Registration are prone to experiencing higher anxiety levels. These studies should also illuminate the possible impacts of the anxiety on the individuals performance, participation and quality of life. The findings of the study suggest that the emotional and cognitive energy, as well as the time-consuming strategies that people with low neurological thresholds experience (Oliver

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1990, Kinnealey et al 1995), might be experienced also by people with Low Registration and might be affected by gender. Adults with Low Registration might not notice cues to which others are responsive and, once they do notice, the cues are so intense that they might be overwhelmed by the sensation as they become aware of the situation. In addition to raising their anxiety level in a specific state, this might raise their trait anxiety level. More studies are needed to investigate the emotional outcomes that might be experienced by individuals with Low Registration. It might also be important to take into account the sensory processing patterns when planning interventions for the individual. It should be noted that anxiety might be both a causative and a resultant factor of extreme sensory processing patterns leading to emotional lability (Ayres 1972). On the one hand, anxiety might be impacted by perception of sensory stimuli resulting in increased attention and increased reactivity to them. On the other hand, anxiety resulting from stress can amplify reactivity to sensory stimuli (Ayres 1972). Indeed, individuals with anxiety disorders, such as agoraphobia, might show difficulties in processing sensory information. Based on previous reports, Abernethy (2010) highlighted that the treatment of a mental health problem can be hampered by the existence of extreme sensory processing patterns related mainly to hypersensitivity. Thus, studying the sensory profile of these individuals could help to understand the pathophysiology mechanisms of the disorder and implement beneficial intervention strategies (ViaudDelmon et al 2000) for health services, including occupational therapy. Moreover, early identification and treatment of sensory processing difficulties is important, based on reports emphasising that individuals whose sensory processing difficulties were not identified and treated in childhood have difficulty growing out of them (Wilbarger 1995, Kinnealey and Koenig 2004). The possible psychological effects resulting from the need to cope with daily difficulties caused by extreme sensory processing patterns might elevate emotional burden in adults (Abernethy 2010), expressed also by enhanced anxiety level. In occupational therapy, intervention with people who express enhanced anxiety levels should refer to their sensory profile for a better understanding of whether their sensory processing abilities contribute to anxiety level. Intervention should employ a cognitive method to help the person develop expectations (Rothbart and Jones 1999) and to understand which sensory stimuli might trigger anxious reactions (Dunn 2001). It should assist the person in constructing explicit environmental conditions, routines and activities that will support his or her sensory needs and personality traits, in order to minimise anxiety and enhance self-regulation, participation and involvement in various activities and, thus, elevate self-esteem and wellbeing (Dunn 2001). In summary, because anxiety, as well as extreme sensory processing patterns and the relation between them, might have an impact on self-esteem (Royeen and Lane 1991), lead to depression (Kinnealey and Fuiek 1999) and have an impact

on performance, additional studies should expand the knowledge about the relationship between sensory processing and anxiety-related disorders and other extreme personality traits. Studies should also focus on specific populations, such as individuals with psychiatric disorders, and anxiety-related pathologies, such as agoraphobia, and examine the role of sensory processing in their pathology. It should be mentioned, however, that the relatively small number of participants in this study affects the generalisation of the results.

Conclusion
Healthy individuals with sensory hypersensitivity and individuals with low registration of sensory input might have elevated anxiety levels. Gender was found to play a role in Low Registration: men with lower registration of sensory input might be more prone to elevated trait anxiety than women. Sensation Avoiding was found to be the significant predictor for state and trait anxiety. Therapists could provide intervention with people who express an enhanced anxiety level by referring to their sensory profile and employing strategies that consider their sensory needs; this method holds promise for modulating the individuals anxiety level and elevating the persons wellbeing.
Conflict of interest: None declared.

Key findings Elevated anxiety is related not only to sensory hypersensitivity but also to low registration of sensory input. This relationship should receive attention in mental health settings.

What the study has added This study enriched the limited literature about emotional aspects related to sensory processing. Occupational therapists should refer to these aspects and implement them in practice and research.

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