The relationship between sensory processing difficulties and anxiety level of healthy adults

210 British Journal of Occupational Therapy May 2011 74(5)

Research

IntroductionPeople experience life through their senses Sensory processing refers tothe ability to register and modulate sensory information and to organisethis sensory input to respond to situational demands (Humphry 2002)Although most people have balanced sensory processing abilities 15of the total population has more intense sensory processing patterns(Simeonsson et al 2003 Miller et al 2007) These intense patterns areexpressed by either sensory hypersensitivity resulting from a low neuro-logical threshold to sensory stimuli (requiring very little stimulation foractivation) or sensory hyposensitivity resulting from a high neurologicalthreshold to sensory stimuli (requiring much stimulation for activation)These extreme patterns affect onersquos behaviour and quality of life (Parham andMailloux 2001) The literature refers mainly to sensory hypersensitivity andemphasises its possible impacts on functional abilities behaviour emotionsand mental health The coping strategies that people develop to deal withsensory hypersensitivity add to the negative impact on their quality of life(Abernethy 2010)

Dunn (1997) developed a model about the relationship between thepersonrsquos neurological thresholds and behavioural self-regulation strategycontinua (Dunn 1997 Brown et al 2001) In this model Dunn claimed thatindividuals who use a passive behaviour strategy allow stimuli to occur andthen respond to them whereas individuals who use an active behaviour strategyact to control the amount and type of sensory input they receive (Dunn 2007)According to this model four sensory processing patterns exist1 Low Registration ndash individuals with high neurological thresholds and a

passive behaviour strategy who fail to detect stimuli that others noticeand are often described as either easy going or withdrawn inattentiveunmotivated or self-absorbed

The relationship between sensory processingdifficulties and anxiety level of healthy adultsBatya Engel-Yeger1 and Winnie Dunn2

Key wordsSensory mental health

Purpose The purpose of the study was to examine the relationship betweenextreme sensory reactivity as expressed in daily living situations and trait andstate anxiety among healthy individuals

Procedures One hundred and thirty-five healthy individuals filled in theAdolescent Adult Sensory Profile regarding their responses to daily sensoryexperiences Anxiety was assessed by Spielbergerrsquos State-Trait Anxiety Inventory

Findings Participants with sensory hypersensitivity as well as those withLow Registration of sensory input showed elevated trait anxiety and state anxietyMen with lower registration had more elevated trait anxiety than womenSensation Avoiding was found to be the significant predictor for state anxiety

Conclusion Trait anxiety and state anxiety might be related to extremesensory processing patterns Occupational therapy intervention with people whoexpress enhanced anxiety level should refer to their sensory reactivity as a meansto optimise intervention outcomes increase their self-confidence improve theirfunctioning and participation in daily living and enhance their wellbeing

copyThe College of Occupational Therapists LtdSubmitted 25 August 2010Accepted 13 April 2011

1Senior Lecturer Department of OccupationalTherapy Faculty of Social Welfare andHealth Sciences University of HaifaMount Carmel Israel

2Professor Department of OccupationalTherapy Education University of KansasMedical Centre Kansas City Kansas USA

Corresponding authorDr Batya Engel-Yeger Senior LecturerDepartment of Occupational TherapyFaculty of Social Welfare and Health SciencesUniversity of HaifaMount Carmel Haifa 31950Email batyaresearchhaifaacil

Reference Engel-Yeger B DunnW (2011)The relationship between sensory processingdifficulties and anxiety level of healthy adultsBritish Journal of Occupational Therapy74(5) 210-216

DOI 104276030802211X13046730116407

211British Journal of Occupational Therapy May 2011 74(5)

Batya Engel-Yeger and Winnie Dunn

2 Sensation Seeking ndash individuals with high neurologicalthresholds and an active behaviour strategy who experiencepleasure from a rich sensory environment and behavioursthat create sensation they can be considered exuberantor easily distracted

3 Sensation Avoiding ndash individuals with low neurologicalthresholds and an active behaviour strategy who engagein behaviours that limit exposure to stimuli and can beconsidered introspective or reclusive

4 Sensory Sensitivity ndash individuals with low neurologicalthresholds and a passive behaviour strategy who experiencediscomfort with sensation and may be seen as preciseor picky (Dunn 1997)

Based on theoretical frameworks (for example Dunn 2001Miller et al 2007) as well as on clinical evidence and pre-vious studies (for example Kinnealey et al 1995 Hofmannand Bitran 2007) people with low neurological thresholdsoften show fear negative affect and neuroticism as well asrigid and controlling behaviours including negative oraggressive responses or sensation avoidance

Previous reports suggested that sensory processing relatedmainly to low neurological thresholds might share commonbehavioural and physiological traits with anxiety and mightbe a possible risk factor for enhanced anxiety level (Kinnealeyand Fuiek 1999 Pfeiffer et al 2005 Tsuji et al 2009)

Anxiety is considered normal when it occurs in responseto a lsquorealisticrsquo threat and dissipates when the danger is nolonger present (Beck et al 1985) Even though a certainlevel of anxiety can motivate individuals to participate in lifeand complete tasks anxiety can also be debilitating andparalysing (Beck et al 1985) and can cause irritability andmake people feel lsquoon edgersquo (American Psychiatric Association1994) The concept of state anxiety refers to a transitoryemotional response to a stressful situation that involvedunpleasant feelings of tension and apprehensive thoughtsThis condition is subject to continual fluctuation as a resultof temporal changes in the environment In contrast traitanxiety refers to individual differences in anxiety pronenesswhich are relatively stable (Metzger 1976) This enduringpersonality characteristic could predispose people to stateanxiety in times of stress (Spielberger et al 1983)

For several decades associations were made in the lit-erature between sensory processing patterns related to lowthreshold and anxiety This relationship was described forexample by Ayres (1972) who noted that children withhypersensitivity to tactile sensations showed high anxietylevel during tactile experiences that were not self-initiatedTo express this relationship Royeen and Lane (1991) andWilbarger and Wilbarger (1991) also used the term lsquosensoryaffective disorderrsquo Heller (2003) emphasised that in severesensory hypersensitivitysensory defensiveness stress andanxiety can increase together with other psychologicalproblems even in emotionally healthy environments

The relationship between sensory processing patterns andanxiety has neurophysiological manifestations showinghyperarousal mechanisms and enhanced sympathetic nervoussystem reactivity mainly among individuals with sensory

hypersensitivity (Mefford and Potter 1989 Miller et al 1999Berridge and Waterhouse 2003) This hyperarousability wasmanifested in enhanced activity of the brain areas associatedwith hyperemotionality These areas include for examplethe limbic structures and components of the reticular systemhypothalamus and cortex Kisley et al (2004) found that indi-viduals with hypersensitivity had altered brain sensory gatingexpressed in evoked response potential (ERP) componentsand lsquoover-inclusionrsquo of irrelevant sounds into the focus ofattention Grossman (1978) found that animals with a lesionedlimbic system (one of the main elements involved in emotionalresponses) demonstrated exaggerated defensive reactionshyperresponsiveness to handling light touch and temperaturechanges Although this procedure cannot be tested on humansthe behaviours presented by these animals are similar tothose manifested among people with hypersensitivity

The negative impacts of extreme sensory processingpatterns and anxiety expressed in unbalanced physiologicalregulation and on behaviour might have a devastating influ-ence on quality of life Nonetheless only few studies examinedthe relationship between sensory processing patterns andanxiety The present study aimed to expand the knowledgein this area and to answer the specific question of whether asignificant relationship exists between sensory processingpatterns and anxiety level The answer to this question couldincrease occupational therapistsrsquo awareness of related outcomesof sensory processing patterns and enable implementation ofthis knowledge in evaluation and intervention processes

In the present study there is reference to both traitand state anxiety and to sensory processing abilities asexpressed in daily living situations It was hypothesisedthat adults with more intense sensory processing patternsrelated mainly to a low neurological threshold wouldshow a greater state trait anxiety level

MethodParticipantsOne hundred and thirty-five healthy individuals participatedin this study Participantsrsquo socioeconomic level ranged fromlow to high according to the criteria of the Central Bureauof Statistics in Israel (2010) Inclusion criteria were healthyparticipants aged 18-50 years Exclusion criteria were thepresence 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 wererecruited by an advertisement published in several neigh-bourhoods in northern Israel calling for participation in astudy about sensations and personal characteristics

InstrumentsA demographic questionnaire including information about par-ticipantsrsquo health status sociodemographic status medicationsand treatments was used

The Adolescent Adult Sensory Profile (AASP) (Brown andDunn 2002) based on Dunnrsquos model of sensory processing


The relationship between sensory processing difficulties and anxiety level of healthy adults

(Dunn 1997) In this self-measurement tool respondentsanswer questions about their behavioural responses to sensoryexperiences The questionnaire has 60 items includingquestions pertaining to each of the sensory systems Forscoring the 60 items are sorted equally into four quadrantsndash Low Registration Sensation Seeking Sensory Sensitivityand Sensation Avoiding (based on factor analysis) ndash reflectingdifferent sensory processing patterns Participants indicatehow often they respond to the sensory event in the mannerdescribed in the items using a five-point Likert scale(from 1 = almost never to 5 = almost always) The resultantscore for each quadrant ranges from 5 to 75

Using national samples of 950 adolescents and adults(ages 11-90 years) Brown and Dunn (2002) calculatedcut-off scores which indicate when scores are significantlydifferent from their peersrsquo responses Each age group(11-17 18-64 65 and older) has its own norms Thisquestionnaire has good internal consistency with coefficientalpha values of 0692 for Low Registration 0639 forSensation Seeking 0657 for Sensory Sensitivity and 0699for Sensation Avoiding (Pohl et al 2003)

The questionnaire was translated into Hebrew and trans-lated back into English by bilingual occupational therapiststo ensure the validity of the translated form (As measurementof psychometric properties of the Hebrew version is still inprocess this study used the American norms)

Anxiety level Anxiety score was assessed by SpielbergerrsquosState-Trait Anxiety Inventory (STAI) (Spielberger 1972)The STAI is designed to provide an empirical measure ofthe anxiety level of lsquonormalrsquo adults (Metzger 1976)

The first part of the questionnaire assesses the level ofstate anxiety and the second part assesses trait anxietyEach part includes 20 statements that describe the emotionalcondition (for example lsquoI feel upsetrsquo lsquoI feel comfortablersquolsquoI am worriedrsquo and lsquoI am jitteryrsquo) and individuals rate theirfeelings about each sentence on a four-point scale (from0 = not at all to 3 = very much so)

ProcedureAfter receiving ethical approval from the institutional reviewboard (IRB) advertisements for participation in this studywere published in several neighbourhoods Those inter-ested in taking part telephoned the research coordinatorreceived detailed information about the study and com-pleted a demographic questionnaire that included sociode-mographic data and information about health status Thisquestionnaire was used to determine participant eligibilityParticipants who satisfied the inclusion criteria met thedata collector in their home signed the consent form andfilled in the AASP and the STAI

Data analysisPearsonrsquos correlation test examined the relationship betweenAASP and STAI scores ANOVAs with Scheffe Post Hoctest examined whether significant differences in anxietyscore existed between the different ranges of each sensoryprocessing pattern

Table 1 Participantsrsquo sociodemographic informationGeneral sampleAge range (years)18-49Mean age plusmnSD2763plusmn584Years of education ndash range 10-23Mean years of education plusmnSD1463plusmn219Socioeconomic level () Low444

Average274High 281Men Women

Number49 86Age range (years) 18-4920-50Mean age plusmnSD2797plusmn5832953plusmn697Years of education ndash range10-2210-23Mean years of education plusmnSD145plusmn223148plusmn198

Table 2 The significant correlations between SpielbergerrsquosState-Trait Anxiety Inventory scores and the sensoryprocessing patterns

Anxiety Low Sensation Sensory Sensationscores Registration Seeking Sensitivity AvoidingStateNSNS026026Trait031NS045043Total score019NS039038NS = not significant ple005 ple0001

Stepwise Linear Regression examined whether STAI scoresmay be predicted by the sensory processing patterns

Probabilities at or below 005 were considered significant

ResultsTable 1 summarises the participantsrsquo sociodemographicinformation

The relationship between sensoryprocessing pattern and anxiety scoresAs presented in Table 2 higher trait anxiety state anxiety andtotal anxiety level were positively correlated with higher levelsof Low Registration Sensory Sensitivity and Sensation Avoiding

Differences in STAI scores between theperformance ranges of each sensoryprocessing patternIn the present study the five ranges for each sensory pro-cessing pattern as presented in the AASP manual (that islsquoMuch less than most peoplersquo lsquoLess than most peoplersquo lsquoSimilarto most peoplersquo lsquoMore than most peoplersquo and lsquoMuch morethan most peoplersquo) were merged into three as follows (1)lsquoMuch less than most peoplersquo and lsquoLess than most peoplersquo weremerged and defined as lsquoLess than most peoplersquo (representingapproximately 16 of the population or more than onestandard deviation (SD) below the mean) (2) lsquoSimilar tomost peoplersquo was not changed (representing approximately68 of the population between -1 SD and +1 SD) and (3)



lsquoMore than most peoplersquo and lsquoMuch more than most peoplersquowere merged and defined as lsquoMore than most peoplersquo(representing approximately 16 of the population or morethan 1 SD above the mean) This strategy yielded a highernumber of participants in each of the three categories

Fig 1 depicts the frequency (in percentage) of perfor-mance intervals in each sensory processing pattern

Low neurological threshold

Sensory Sensitivity patternState anxiety scores were significantly higher among par-ticipants in the lsquoMore than most peoplersquo range than those inthe lsquoLess than most peoplersquo range (F2134 = 456 p = 0012mean difference = 967 p = 002)

Gender was not found to have a significant effect onthese results

Trait anxiety scores were higher among participants inthe lsquoMore than most peoplersquo range than among participantsin the lsquoSimilar to most peoplersquo range (mean difference = 574p = 002) and the lsquoLess than most peoplersquo range (mean differ-ence = 1579 ple0001) People in the lsquoSimilar to most peoplersquorange had higher trait anxiety scores than those in the lsquoLessthan most peoplersquo range (mean difference = 1006 p = 0015)

Gender was not found to have a significant impact onthese results

The total STAI score was also significantly different amongparticipants in the three sensory processing performanceranges (F2134 = 1302 ple0001) Participants in the lsquoLessthan most peoplersquo range had a lower STAI score than thosein the lsquoSimilar to most peoplersquo range (mean difference = 1684p = 0025) and among participants in the lsquoMore than mostpeoplersquo range (mean difference = 2547 ple0001) Participantsin the lsquoMore than most peoplersquo range were significantly higheron the STAI than those in the lsquoSimilar to most peoplersquo range(mean difference = 863 p = 0012)

Sensation Avoiding patternState anxiety scores were significantly higher among partici-pants in the lsquoMore than most peoplersquo range than among thosein the lsquoSimilar to most peoplersquo range (F2134 = 626 p = 0003mean difference = 736 p = 003)


Trait anxiety score was significantly different amongparticipants in the three sensory processing performanceranges (F2134 = 1294 ple0001) The trait anxiety scorewas higher among participants in the lsquoSimilar to mostpeoplersquo range than those in the lsquoLess than most peoplersquorange (mean difference = 971 ple 0001) and higheramong participants in the lsquoMore than most peoplersquo rangethan those in the lsquoLess than most peoplersquo range (meandifference = 1526 ple0001)


The total STAI score was significantly different amongthe participants in the three sensory processing performanceranges (F2134 = 1073 ple0001) this score was lower amongparticipants in the lsquoLess than most peoplersquo range than thosein the lsquoSimilar to most peoplersquo range (mean difference = 1707ple0001) and higher among participants in the lsquoLess thanmost peoplersquo range than those in the lsquoMore than most peoplersquorange (mean difference = 2154 p = 003)

High neurological thresholdThe only significant difference was found in the trait anxietyscore (F2134 = 485 p = 009) participants in the lsquoMorethan most peoplersquo range for Low Registration had signifi-cantly higher trait anxiety scores than those in the lsquoSimilarto most peoplersquo range (mean difference = 536 p = 001)

Regarding the impact of gender in the Low Registrationpattern women had significantly higher trait anxiety scoresthan men (F2134 = 449 p = 003) A significant interactionbetween sensory processing range and gender was found(F2134 = 299 p = 005) in the lsquoSimilar to most peoplersquo rangewomen had higher trait anxiety scores (4008plusmn804) thanmen (3434plusmn906) whereas in the lsquoMore than most peoplersquorange men had higher trait anxiety scores (4261plusmn865)than women (4401plusmn1052)

Predicting STAI scores by sensoryprocessing patternsState anxiety A stepwise linear regression for STAI scoresyielded one model in which Sensation Avoiding was thesignificant predictor for state anxiety (β = 026 ple001)accounting for 7 of the variance (F1134 = 97 p = 0002)

Trait anxiety Sensory Sensitivity was found to be asignificant predictor for trait anxiety (β = 045 ple0001)predicting 20 of the score When adding Sensation Avoidingtwo models were found in the first trait anxiety was signi-ficantly predicted by Sensory Sensitivity (β = 028 p = 002)(F1134 = 3292 ple0001) and in the second by SensationAvoiding (β = 023 p = 004) accounting for an additional2 of the variance (F1134 = 403 p = 004)

Fig 1 Frequency (in percentage) of performance intervals in

each sensory processing pattern



In summary state and trait anxiety levels were higheramong individuals with sensory processing patterns relatedto a low neurological threshold (that is Sensory Sensitivityand Sensation Avoiding) These patterns were also found topredict state and or trait anxiety Higher trait anxiety scoreswere also presented among individuals with Low Registration

DiscussionThe present study examined the relationship betweensensory processing patterns and state and trait anxietylevel This aim was derived from previous literature onconsistent patterns of personality and sensory processingreported among children and adults which emphasisedthe need to improve understanding of how these con-structs interact (Dunn 2001)

In this study it was hypothesised that there would be asignificant relationship between anxiety and sensory pro-cessing the data support this hypothesis The strongestcorrelations were found between anxiety and SensorySensitivity and Sensation Avoiding which are both lowneurological threshold patterns Both patterns related notonly to state anxiety but also to trait anxiety The predictionof state and trait anxiety by these sensory processing patternsstrengthens these results where Sensation Avoiding wasfound to play a role in both state and trait anxiety This findingsupports previous reports claiming that anxiety is one of thepossible explanations for the exaggerated defence mechanismsand poor self-regulation of individuals with sensory hyper-sensitivity when meeting an unpleasant sensation

Previous reports mainly discussed the relationshipbetween sensory hypersensitivity and anxiety among pop-ulations with disorders such as post-traumatic stress disorder(PTSD) (Morgan and Grillon 1999) pervasive develop-mental disorders (PDD) and attention deficit hyperactivitydisorder (ADHD) Some of these reports even supported thisrelationship by physiological manifestations For exampleMangeot et al (2001) found that sensory sensitivity inchildren with ADHD was associated with enhanced sweat-gland activity following sensory stimulation measured bygreater magnitudes of electrodermal reactivity Amongindividuals with PTSD evoked response potentials (ERP)were used in order to understand the underlying neuralmechanism of hypersensitivity and exagerated emotionalresponses ERP studies in PTSD evaluated attentional andpreattentional processes The studies that refer to attentionalprocesses evaluated the P3 component This brain potentialis elicited in response to a significant stimulus McFarlaneet al (1993) used an auditory target discrimination taskparadigm and found that PTSD patients exhibited decreasedP3 evoked potential amplitudes that failed to distinguishtarget from distractor tones compared with normal controlsThese investigators hypothesised that diminished P3 ampli-tudes may be an index of disturbed concentration foundin individuals with PTSD They suggested that greaterreactivity to stimuli in participants with PTSD may be related

to their impaired perceptual evaluation of stimuli due to adefect in early stimulus gating

The results of the present study emphasise that similaremotional aspects might be found among healthy individualswith higher anxiety tendency Kinnealey and Fuiek (1999)claimed that sensory hypersensitivity might be an unrecog-nised contributing or confounding factor in some peoplewith anxiety Therapists should pay more attention to therole of sensory processing difficulties This is because ofthe emotional and cognitive burden endured by those whoexperience these difficulties and also because of the addi-tional common outcomes related to anxiety such as socialanxiety depression (Hofmann and Bitran 2007) social andphysical withdrawal and isolation (Oliver 1990 Kinnealeyet al 1995) In populations with specific disorders theseoutcomes might be even more extreme For example Tsujiet al (2009) found a higher anxiety and a higher depressionlevel among children with PDD and sensory hypersensitivitythan children with PDD who were not hypersensitiveThey concluded that children with PDD and hypersensitivityhave more serious psychopathologies These negativeoutcomes might lead to deterioration in functioning andparticipation and thus in health status and wellbeing(Kinnealey and Fuiek 1999)

The new aspect highlighted in this study was the findingthat individuals with a Low Registration pattern (that isa high neurological threshold) show relatively high traitanxiety as well Women in the lsquoSimilar to most peoplersquorange of this sensory processing pattern had higher traitanxiety than men According to previous reports lifetimeprevalence of one or more anxiety disorders is nearly two-fold higher in women than in men (Kessler et al 1994 Mageeet al 1996) In the present study however men with moreextreme behaviours related to this sensory processingpattern had higher trait anxiety than women As mentionedabove the existing literature manifests higher anxietylevels among women Data about the role of anxiety inmen with extreme Low Registration are scarce

In a recent study performed by Engel-Yeger and Dunn(2011) healthy individuals with an extreme Low Registrationpattern showed higher pain catastrophising levels Theauthors suggested that because these individuals fail to detectsensations and might overlook the warnings of imminentpain in their surroundings they experience the pain suddenlyand have an excessive catastrophising reaction Pain cata-strophising level is also known to be anxiety related (Sullivanet al 2001 Jerome and Liss 2005) Nevertheless gender wasnot found to have an impact on the results in the study ofEngel-Yeger and Dunn (2011) Thus further studies shouldexamine this point for a better understanding of whether menwith extreme Low Registration are prone to experiencinghigher anxiety levels These studies should also illuminatethe possible impacts of the anxiety on the individualrsquosperformance participation and quality of life

The findings of the study suggest that the emotional andcognitive energy as well as the time-consuming strategies thatpeople with low neurological thresholds experience (Oliver



1990 Kinnealey et al 1995) might be experienced alsoby people with Low Registration and might be affected bygender Adults with Low Registration might not notice cuesto which others are responsive and once they do noticethe cues are so intense that they might be overwhelmed bythe sensation as they become aware of the situation Inaddition to raising their anxiety level in a specific statethis might raise their trait anxiety level More studies areneeded to investigate the emotional outcomes that mightbe experienced by individuals with Low Registration Itmight also be important to take into account the sensoryprocessing patterns when planning interventions for theindividual

It should be noted that anxiety might be both a causativeand a resultant factor of extreme sensory processing patternsleading to emotional lability (Ayres 1972) On the one handanxiety might be impacted by perception of sensory stimuliresulting in increased attention and increased reactivity tothem On the other hand anxiety resulting from stress canamplify reactivity to sensory stimuli (Ayres 1972) Indeedindividuals with anxiety disorders such as agoraphobiamight show difficulties in processing sensory information

Based on previous reports Abernethy (2010) high-lighted that the treatment of a mental health problem canbe hampered by the existence of extreme sensory processingpatterns related mainly to hypersensitivity Thus studyingthe sensory profile of these individuals could help tounderstand the pathophysiology mechanisms of the disorderand implement beneficial intervention strategies (Viaud-Delmon et al 2000) for health services including occupationaltherapy Moreover early identification and treatment ofsensory processing difficulties is important based on reportsemphasising that individuals whose sensory processingdifficulties were not identified and treated in childhood havedifficulty growing out of them (Wilbarger 1995 Kinnealeyand Koenig 2004) The possible psychological effectsresulting from the need to cope with daily difficulties causedby extreme sensory processing patterns might elevateemotional burden in adults (Abernethy 2010) expressedalso by enhanced anxiety level

In occupational therapy intervention with people whoexpress enhanced anxiety levels should refer to their sensoryprofile for a better understanding of whether their sensoryprocessing abilities contribute to anxiety level Interventionshould employ a cognitive method to help the person developexpectations (Rothbart and Jones 1999) and to understandwhich sensory stimuli might trigger anxious reactions (Dunn2001) It should assist the person in constructing explicitenvironmental conditions routines and activities that willsupport his or her sensory needs and personality traits inorder to minimise anxiety and enhance self-regulationparticipation and involvement in various activities andthus elevate self-esteem and wellbeing (Dunn 2001)

In summary because anxiety as well as extreme sensoryprocessing patterns and the relation between them might havean impact on self-esteem (Royeen and Lane 1991) lead todepression (Kinnealey and Fuiek 1999) and have an impact

on performance additional studies should expand the knowl-edge about the relationship between sensory processing andanxiety-related disorders and other extreme personality traitsStudies should also focus on specific populations such asindividuals with psychiatric disorders and anxiety-relatedpathologies such as agoraphobia and examine the role ofsensory processing in their pathology It should be mentionedhowever that the relatively small number of participants inthis study affects the generalisation of the results

ConclusionHealthy individuals with sensory hypersensitivity and indi-viduals with low registration of sensory input might haveelevated anxiety levels Gender was found to play a role inLow Registration men with lower registration of sensoryinput might be more prone to elevated trait anxiety thanwomen Sensation Avoiding was found to be the significantpredictor for state and trait anxiety Therapists could provideintervention with people who express an enhanced anxietylevel by referring to their sensory profile and employingstrategies that consider their sensory needs this methodholds promise for modulating the individualrsquos anxietylevel and elevating the personrsquos wellbeing

Conflict of interest None declared

Key findings Elevated anxiety is related not only to sensory hypersensitivity butalso to low registration of sensory input

This relationship should receive attention in mental health settings

What the study has addedThis study enriched the limited literature about emotional aspectsrelated to sensory processing Occupational therapists should refer tothese aspects and implement them in practice and research

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Beck AT Emery G Greenberg RL (1985) Anxiety disorders and phobias acognitive perspective New York Basic Books

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Brown C DunnW (2002) The AdolescentAdult Sensory Profile userrsquos manualSan Antonio TX Psychological Corporation

Brown C Tollesfon N DunnW Cromwell R Filion D (2001) The Adult SensoryProfile measuring patterns of sensory processing American Journal ofOccupational Therapy 55(1) 75-82



Central Bureau of Statistics Israel (2010) Designing household survey samplespractical guidelines Available at httpwww1cbsgovilreader Accessed170411

Dunn W (1997) The impact of sensory processing abilities on the daily livesof young children and their families a conceptual model Infants andYoung Children 9(4) 23-35

Dunn W (2001) The sensations of everyday life empirical theoretical andpragmatic considerations American Journal of Occupational Therapy55(6) 608-20

DunnW (2007) Supporting children to participate successfully in everyday lifeby using sensory processing knowledge Infants and Young Children20(2) 84-101

Engel-Yeger B DunnW (2011) The relationship between sensory processingpatterns and pain catastrophizing level in healthy adults AmericanJournal of Occupational Therapy 65(1) 44 Full article available athttpajotaotapressnetcontent651e1fullpdf Accessed 040511

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Heller S (2003) Too loud too bright too fast too tight what to do if youare sensory defensive in an overstimulating world New York Quill

Hofmann SG Bitran S (2007) Sensory-processing sensitivity in social anxietydisorder relationship to harm avoidance and diagnostic subtypes Journalof Anxiety Disorders 21(7) 944-54

Humphry R (2002) Young childrenrsquos occupations explicating the dynamicsof developmental processes American Journal of Occupational Therapy56(2) 171-79

Jerome EM Liss M (2005) Relationships between sensory processing styleadult attachment and coping Personality and Individual Differences38(6) 1341-52

Kessler RC McGonagle KA Zhao S Nelson CB Hughes M Eshleman SWittchen HU Kendler KS (1994) Lifetime and 12-month prevalenceof DSM-III-R psychiatric disorders in the United States Results fromthe National Comorbidity Survey Archives of General Psychiatry51(1) 8-19

Kinnealey M Fuiek M (1999) The relationship between sensory defensivenessanxiety depression and perception of pain in adults Occupational TherapyInternational 6(3) 195-206

Kinnealey M Koenig K (2004) Impact of treatment for sensory defensivenessexamined in study Temple Times Available at httpwwwtempleedutemple_times Accessed 161204

Kinnealey M Oliver BWilbarger P (1995) A phenomenological study of sensorydefensiveness in adults American Journal of Occupational Therapy49(5) 444-51

Kisley MA Noecker TL Guinther PM (2004) Comparison of sensory gatingto mismatch negativity and self-reported perceptual phenomena inhealthy adults Psychophysiology 41(4) 604-12

Magee WJ Eaton WW Wittchen HU McGonagle KA Kessler RC (1996)Agoraphobia simple phobia and social phobia in the National ComorbiditySurvey Archives of General Psychiatry 53(2) 159-68

Mangeot SD Miller LJ McIntosh DN McGrath-Clarke J Simon J Hagerman RJGoldson E (2001) Sensory modulation dysfunction in children with attention-deficit-hyperactivity disorder Developmental Medicine and Child Neurology43(6) 399-406

McFarlane ACWeber DL Clark CR (1993) Abnormal stimulus processing inposttraumatic stress disorder Biological Psychiatry 34(5) 311-20

Mefford IN Potter WZ (1989) A neuroanatomical and biochemical basisfor attention deficit disorder with hyperactivity in children a defect intonic adrenaline mediated inhibition of locus coeruleus stimulationMedical Hypotheses 29(1) 33-42

Metzger RL (1976) A reliability and validity study of the State-Trait AnxietyInventory Journal of Clinical Psychology 32(2) 276-78

Miller LJ McIntosh DN McGrath J Shyu V Lampe M Taylor AK Tassone FNeitzel K Stackhouse T Hagerman RJ (1999) Electrodermal responsesto sensory stimuli in individuals with fragile X syndrome a preliminaryreport American Journal of Medical Genetics 83(4) 268-79

Miller LJAnzalone ME Lane SJ Cermak SA Osten ET (2007) Concept evolutionin sensory integration a proposed nosology for diagnosisAmerican Journalof Occupational Therapy 61(2) 135-40

Morgan CA Grillon C (1999) Abnormal mismatch negativity in womenwith sexual assault-related posttraumatic stress disorder BiologicalPsychiatry 45(7) 827-32

Oliver BF (1990) The social and emotional issues of adults with sensorydefensiveness American Occupational Therapy Association SensoryIntegration Special Interest Section Newsletter 13(3) 1-3

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Pohl PS DunnW Brown C (2003) The role of sensory processing in the everydaylives of older adultsOccupational Therapy Journal of Research 23(3) 99-106

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In AG Fisher EF Murray AC Bundy eds Sensory integration theory andpractice Philadelphia FA Davis

Simeonsson RJ Leonardi M Lollar D Bjorck-Akesson E Hollenweger JMartinuzzi A (2003) Applying the International Classification of FunctioningDisability and Health (ICF) to measure childhood disability Disability andRehabilitation 25(11-12) 602-10

Spielberger CD (1972) Anxiety as an emotional state In CD Spielbergered Anxiety current trends in theory and research (Vol 1) New YorkAcademic Press

Spielberger CD Gorsuch RL Lushene R Vagg PR Jacobs GA (1983) Manualfor the State-Trait Anxiety Inventory STAI Palo Alto CA ConsultingPsychologists Press

Sullivan MJL Thorn B Haythornthwaite JA Keefe FJ Martin M Bradley LALefebvre JC (2001) Theoretical perspectives on the relation betweencatastrophizing and pain Clinical Journal of Pain 17(1) 52-64

Tsuji H Miyawaki D Kawaguchi T Matsushima N Horino A Takahashi KSuzuki F Kiriike N (2009) Relationship of hypersensitivity to anxietyand depression in children with high-functioning pervasive developmentaldisorders Psychiatry and Clinical Neurosciences 63(2) 195-201

Viaud-Delmon I Ivanenko YP Berthoz A Jouvent R (2000) Adaptation as asensorial profile in trait anxiety a study with virtual reality Journal ofAnxiety Disorders 14(6) 583-601

Wilbarger P (1995)The sensory diet activity programs based on sensory processingtheory Sensory Integration Special Interest Section Newsletter 18(2) 1-4

Wilbarger P Wilbarger J (1991) Sensory defensiveness in children 2-12Santa Barbara CA Avanti Education Programs



2 Sensation Seeking ndash individuals with high neurologicalthresholds and an active behaviour strategy who experiencepleasure from a rich sensory environment and behavioursthat create sensation they can be considered exuberantor easily distracted

3 Sensation Avoiding ndash individuals with low neurologicalthresholds and an active behaviour strategy who engagein behaviours that limit exposure to stimuli and can beconsidered introspective or reclusive

4 Sensory Sensitivity ndash individuals with low neurologicalthresholds and a passive behaviour strategy who experiencediscomfort with sensation and may be seen as preciseor picky (Dunn 1997)

Based on theoretical frameworks (for example Dunn 2001Miller et al 2007) as well as on clinical evidence and pre-vious studies (for example Kinnealey et al 1995 Hofmannand Bitran 2007) people with low neurological thresholdsoften show fear negative affect and neuroticism as well asrigid and controlling behaviours including negative oraggressive responses or sensation avoidance

Previous reports suggested that sensory processing relatedmainly to low neurological thresholds might share commonbehavioural and physiological traits with anxiety and mightbe a possible risk factor for enhanced anxiety level (Kinnealeyand Fuiek 1999 Pfeiffer et al 2005 Tsuji et al 2009)

Anxiety is considered normal when it occurs in responseto a lsquorealisticrsquo threat and dissipates when the danger is nolonger present (Beck et al 1985) Even though a certainlevel of anxiety can motivate individuals to participate in lifeand complete tasks anxiety can also be debilitating andparalysing (Beck et al 1985) and can cause irritability andmake people feel lsquoon edgersquo (American Psychiatric Association1994) The concept of state anxiety refers to a transitoryemotional response to a stressful situation that involvedunpleasant feelings of tension and apprehensive thoughtsThis condition is subject to continual fluctuation as a resultof temporal changes in the environment In contrast traitanxiety refers to individual differences in anxiety pronenesswhich are relatively stable (Metzger 1976) This enduringpersonality characteristic could predispose people to stateanxiety in times of stress (Spielberger et al 1983)

For several decades associations were made in the lit-erature between sensory processing patterns related to lowthreshold and anxiety This relationship was described forexample by Ayres (1972) who noted that children withhypersensitivity to tactile sensations showed high anxietylevel during tactile experiences that were not self-initiatedTo express this relationship Royeen and Lane (1991) andWilbarger and Wilbarger (1991) also used the term lsquosensoryaffective disorderrsquo Heller (2003) emphasised that in severesensory hypersensitivitysensory defensiveness stress andanxiety can increase together with other psychologicalproblems even in emotionally healthy environments

The relationship between sensory processing patterns andanxiety has neurophysiological manifestations showinghyperarousal mechanisms and enhanced sympathetic nervoussystem reactivity mainly among individuals with sensory

hypersensitivity (Mefford and Potter 1989 Miller et al 1999Berridge and Waterhouse 2003) This hyperarousability wasmanifested in enhanced activity of the brain areas associatedwith hyperemotionality These areas include for examplethe limbic structures and components of the reticular systemhypothalamus and cortex Kisley et al (2004) found that indi-viduals with hypersensitivity had altered brain sensory gatingexpressed in evoked response potential (ERP) componentsand lsquoover-inclusionrsquo of irrelevant sounds into the focus ofattention Grossman (1978) found that animals with a lesionedlimbic system (one of the main elements involved in emotionalresponses) demonstrated exaggerated defensive reactionshyperresponsiveness to handling light touch and temperaturechanges Although this procedure cannot be tested on humansthe behaviours presented by these animals are similar tothose manifested among people with hypersensitivity

The negative impacts of extreme sensory processingpatterns and anxiety expressed in unbalanced physiologicalregulation and on behaviour might have a devastating influ-ence on quality of life Nonetheless only few studies examinedthe relationship between sensory processing patterns andanxiety The present study aimed to expand the knowledgein this area and to answer the specific question of whether asignificant relationship exists between sensory processingpatterns and anxiety level The answer to this question couldincrease occupational therapistsrsquo awareness of related outcomesof sensory processing patterns and enable implementation ofthis knowledge in evaluation and intervention processes

In the present study there is reference to both traitand state anxiety and to sensory processing abilities asexpressed in daily living situations It was hypothesisedthat adults with more intense sensory processing patternsrelated mainly to a low neurological threshold wouldshow a greater state trait anxiety level

MethodParticipantsOne hundred and thirty-five healthy individuals participatedin this study Participantsrsquo socioeconomic level ranged fromlow to high according to the criteria of the Central Bureauof Statistics in Israel (2010) Inclusion criteria were healthyparticipants aged 18-50 years Exclusion criteria were thepresence 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 wererecruited by an advertisement published in several neigh-bourhoods in northern Israel calling for participation in astudy about sensations and personal characteristics

InstrumentsA demographic questionnaire including information about par-ticipantsrsquo health status sociodemographic status medicationsand treatments was used

The Adolescent Adult Sensory Profile (AASP) (Brown andDunn 2002) based on Dunnrsquos model of sensory processing

















































































































The relationship between sensory processing difficulties and anxiety level of healthy adults

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