Running title: grip strength, depression and anxiety

Degree, but not direction of grip strength asymmetries, is related to depression and
anxiety in an elderly population

Junhong YU*1, Iris RAWTAER1 , Rathi MAHENDRAN1, 2, Ee-Heok KUA1,2, Lei FENG*2

Department of Psychological Medicine, National University Hospital, Singapore

Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of
Singapore

*Correspondence to be directed to:

Mr. Junhong Yu, Institute of Clinical Neuropsychology, Room 309, 3/F, The Hong Kong Jockey Club
Building for Interdisciplinary Research, 5 Sassoon Road, Pokfulam, Hong Kong. Email:
gerardyu87@gmail.com
Or
Dr. Lei Feng, Department of Psychological Medicine, National University of Singapore, NUHS
Tower Block, 1E Kent Ridge Road, Singapore 119228, Singapore.
Email: pcmfl@nus.edu.sg

The present research was conducted at the Department of Psychological Medicine, National
University Hospital. The authors have no conflicts of interest to declare. The authors would like to
thank Fadzillah Nur d/o Mohd Abdullah for her kind assistance in preparing the data. This research
was supported by the Virtual Institute for the Study of Aging, National University of Singapore (grant
number VG-8); the Alice Lim Memorial Fund, Singapore (Alice Lim Award 2010); the Lee Kim Tah
Holdings Ltd., Singapore; the Kwan Im Thong Hood Cho Temple, Singapore; and the Presbyterian
Community Services, Singapore

Accepted for publication in Laterality: Asymmetries of Body, Brain and Cognition

on 26th April 2016

ABSTRACT
Despite the abundance of studies on asymmetries in manual laterality, a marker for atypical
brain lateralization in depression and anxiety, findings in this area are mixed. Traditionally,
research have looked at individual differences in depression and anxiety as a function of the
direction of asymmetry. However, recent research has emphasized on studying the degree of
asymmetry in addition to its direction. To these ends, the present study aims to unravel the
associations between the degree and direction of manual lateralization, and,
depression/anxiety. Cognitively healthy elderlies (N=326, 91 males, Mage=68) were
administered grip strength assessments on both hands and self-report measures of depression
and anxiety. Partial correlation analyses controlling for age, education and sex revealed
significant positive associations between degree of lateralization and anxietyin the overall
sample and among right-dominant participants, as well as a significant positive relationship
between degree of lateralization and depression among right-dominant participants. None of
the correlations involving direction of lateralization yielded significance, neither was there
significant differences between left and right-dominant participants on depression and anxiety
scores. These findings suggest degree of manual lateralization, but not direction, is related to
depression and anxiety at least among right-dominant individuals.

INTRODUCTION
Manual laterality refers to the lateralization of various hand related abilities and
preferences(Fagot & Vauclair, 1991). It can be assessed via a wide variety of objective and
subjective measures. Grip strength asymmetry is one such objective measure that has been
used in studying manual laterality. While grip strength asymmetries may not correlate
strongly with other manual performance asymmetries- suggesting the partial independence in
the lateralization of various manual abilities, grip strength asymmetries nevertheless did
correlate strongly with scores from questionnaires assessing hand preferences (Triggs,
Calvanio, Levine, Heaton, & Heilman, 2000). Grip strength asymmetries, together with other
motor-related asymmetries and hand preferences, have been used to investigate several
laterality related phenomenon.
Affective disorders, such as depression and anxiety, is one area in which manual
lateralization has been implicated in. Cerebral lateralization in depression and anxiety have
been observed in many electrophysiological (Thibodeau, Jorgensen, & Kim, 2006) and
neuroimaging studies (Briceo et al., 2013; Eden et al., 2015). This, taken together with the
fact that manual lateralization does reflect hemispheric asymmetries in a number of brain
regions (Rentera, 2012) and brain activity during affective processing (Costanzo et al., 2015),
have perhaps led to a growing interest in using manual lateralization as a proxy of cerebral
lateralization to study these affective disorders. Over the past four decades, research in this
area using grip strength asymmetries and other manual laterality measures have generally
associate non-right-dominance (i.e. being left-handed or mixed-handed) with depression
(Beiderman et al., 1994; Crews, Harrison, Rhodes, & Demaree, 1995; Denny, 2009; Emerson,
Harrison, Everhart, & Williamson, 2001) and anxiety (Everhart, Harrison, Shenal,
Williamson, & Wuensch, 2002; Hicks & Pellegrini, 1978; Orme, 1970; Wright & Hardie,

2012). This non-right dominance can be framed in terms of the direction of lateralization- the
more right-lateralized one is, the less likely he/she will experience depression and anxiety
symptoms. It should be noted, there were also many reports of negative findings on the
relationship between this direction of lateralization and depression (Moscovitch, Strauss, &
Olds, 1981; Shan-Ming et al., 1985; Webb et al., 2013) , and anxiety (Beaton & Moseley,
1984; French & Richards, 1990; Merckelbach, de Ruiter, & Olff, 1989).
Perhaps as an attempt to resolve such mixed findings, recent research (Lyle, Chapman,
& Hatton, 2012; Prichard, Propper, & Christman, 2013) have emphasized the importance of
looking at the degree of lateralization, that is, the tendency of exhibiting superior
performance in one hand relative to the other (regardless of right or left), rather than simply
the direction of lateralization (i.e., right vs left). For instance, as reviewed by Prichard et al.
(2013), many studies have showed that individual differences in many personality
characteristics and cognitive abilities occur partly as a function of the degree of manual
lateralization. Lyle et al. (2012) reported a degree by direction interaction effect on anxiety
outcomes. They found that consistent right-handers reported higher levels of anxiety relative
to inconsistent right-handers whereas, among left-handers, consistency was unrelated to
anxiety. Apart from this, there are no other studies that looked at the degree of lateralization
in depression or anxiety; more research is certainly needed to confirm the effect of degree of
lateralization in depression and anxiety.
In addition to this issue of degree of lateralization, there are two other areas in the
literature that have not been adequately addressed. Firstly, most of the studies were
conducted using the young to middle-aged populations; the elderly was rarely studied. Given
that dextrality (i.e., right-dominance) increases with age (Porac, Coren, & Duncan, 1980), it
would be interesting to know if such associations between manual lateralization, depression

and anxiety can be generalized to elderly populations. Another issue relates to the use of selfreport measures of handedness in most of the previous research. These measures rely largely
on subjective recall that may be influenced by extraneous variables such as ones cognitive
status and societal norms. The latter is an even more important consideration in Asian
cultures where there are strong societal pressures for right-handedness (Asai & Tanno, 2009).
Hence, in such cultures, it may be useful to utilize performance-based measures to avoid
possible social conformity biases in reporting hand preferences. With this in mind, we
decided on using grip strength asymmetries as an objective index of manual laterality in the
current study. This form of manual lateralization was previously successful in picking up
significant relationships between laterality, depression and anxiety (Emerson et al., 2001;
Everhart et al., 2002).
In view of these shortcomings in the literature, the present study sought to investigate
the relationship between the degree and direction of manual laterality, as indicated by grip
strength asymmetries, and, depression and anxiety in an elderly population. Based on
previous findings, we hypothesized that depression and anxiety symptoms are positively
related to the degree of lateralization, at least among participants who are right-dominant.
Additionally, we also hypothesize that these symptoms are negatively related to the direction
of lateralization (i.e. right-dominance). Of note, the focus of the present study is restricted to
subsyndromal depression and anxiety, that is, the participants in this study were not
previously diagnosed with any depressive and anxiety disorders.

METHODS
Measures

We used the 15-item version (Sheikh & Yesavage, 1986) of the Geriatric Depression Scale
(GDS) to assess the level of depression. This version of the GDS consists of 15 yes/no
questions each worth a point, giving a maximum possible total score of 15. This measure
has been validated and has demonstrated good psychometric properties in the local context
(Nyunt, Fones, Niti, & Ng, 2009). The Geriatric Anxiety Inventory (GAI; Pachana et al.,
2007) was used to index the level of anxiety. There are 20 agree/disagree items in the GAI,
each worth a point, giving a maximum possible total score of 20. The GAI was validated and
has shown good psychometric properties in a similar Asian population (Yan, Xin, Wang, &
Tang, 2014). In both of these geriatric measures, higher scores correspond to greater severity
of symptoms.
Grip strength was assessed via on a dynamometer. Such a measure of hand dominance has
been found to highly correlate with scores of traditional questionnaires that assessed hand
preferences (Triggs, Calvanio, Levine, Heaton, & Heilman, 2000). Upon instruction,
participants used an overhand grip to exert their maximum grip strength on the dynamometer
within a period of 5 seconds. They were given at least two attempts per hand; a third attempt
was given only if the participant reported that he/she had not exerted his/her maximum
strength in the previous two attempts. The starting hands were counter-balanced across
participants; half of the participants did the hand grip test first with their right hands, and the
other half did it with their left hands. A rest period of 15 seconds was given in between each
attempt. However, longer rest periods would also be given if the participant indicated that
he/she needed more time to rest. The grip strength was recorded in Newtons across multiple
attempts, and for each participant, only the largest value is taken amongst the attempts per
hand (i.e. Maximum left grip and Maximum right grip) for calculating the lateralization
measures. The direction of lateralization (Ldirection) was calculated as Ldirection =

Right grip Left grip

Right grip+ Left grip

(Geuze et al., 2012). A larger value of Ldirection corresponds to a more right-

dominant individual. Participants who had a negative Ldirection value (i.e. Right grip < Left
grip) were classified as left-dominant and those with positive values (i.e. Right grip > Left
grip) were classified as right-dominant for the purpose of the categorical analyses. The degree
of lateralization (Ldegree) was obtained by taking the absolute value of Ldirection (i.e., Ldegree =
|Ldirection|)
Participants and procedures
These participants were part of the Aging in a Community Environment Study (ACES). In
the ACES, elderly participants were recruited (aged 60 years) from geographically defined
residential districts in Jurong (a western part of Singapore) via door to door visits by nurses.
Subsequently, participants who expressed interest were invited to a community research
center. At the center, written informed consent was obtained from them. Following which,
trained nurses administered the above questionnaires, hand grip strength assessments and a
demographics questionnaire to the participants. During the administration of the
questionnaires, these nurses were also present for the entire duration to provide clarification
to the participants if they had problems understanding any of the items. These questionnaires
would also be administered verbally by the nurses in cases where participants are illiterate.
The ACES was approved by the National University of Singapore Institutional Review Board.
Each participant was assigned a unique code number for identification; no personal identifiers
were used in the data entry.
A total of 326 (91 males and 235 females) participants from the ACES cohort were
included in the current studys sample, after excluding participants who were diagnosed with
Mild Cognitive Impairment and dementia (N = 57), and incomplete responses (N= 12). This

sample was predominantly of Chinese ethnicity (318 Chinese, five of other Asian ethnicities
and three prefer not to disclose their ethnicity). The mean age of the participants was 68 years
(SD = 5.6; range= 60-89) and on average, participants had approximately six years of
education (SD = 4.2). It should be noted that this level of education is typical of older adults
in Singapore (Collinson, Fang, Lim, Feng, & Ng, 2014). A medical screening was conducted
as part of the recruitment process, and it did not identify anyone who had a physical injury or
condition that may influence grip strength in an asymmetrical manner.
Statistical Analysis
All analyses were carried out using the Statistical Package for the Social Sciences (SPSS
version 20) software. Shapiro-Wilk tests suggested that the data violated assumptions of
normality; ps < .05, as such, non-parametric tests were used for the analyses. Mann-Whitney
U and Chi-square tests were used to analyze for group differences in GDS and GAI scores,
and demographic variables between the left and right-handers. Partial Spearmans Rho ()
was used to examine correlations between the lateralization measures and, GDS and GAI
scores, controlling for age, sex and years of education. Statistical significance was set at p
< .05 for all analyses, and all tests of statistical significance were two-tailed.

RESULTS
The participants had a mean GDS score of 1.7 (SD= 1.7), and mean GAI score of 1.3
(SD=2.5). Based upon their Ldirection values, 241 and 85 participants were classified as right
and left-handers respectively. Mann-Whitney U and Chi-square tests showed that these two
groups were not significantly different in terms of age, years of education and distribution of
genders (ps > .05). Both groups also did not differ significantly in their GDS and GAI scores
(ps > .05; see Table 1). GDS scores were significantly correlated with GAI ( = .49, p < .001).

The correlation statistics relating to lateralization and GAI/GDS is shown in Table 2.

In the overall sample, the correlation analyses yielded a significant correlation between GAI
scores and Ldegree ( = .11, p = .04). None of the lateralization measures was significantly
correlated with GDS scores in the overall sample (ps > .05). Additionally, a marginally
significant correlation between GAI scores and Ldirection ( = .10, p = .06) was observed.
Among right-dominant participants, Ldegree was significantly correlated with GAI scores (
= .16, p = .01) and GDS scores ( = .13, p = .045). None of these correlations were
significant among left-dominant participants (ps > .05).

DISCUSSION
The current report investigated the relationship between manual lateralization via grip
strength asymmetries and, depression and anxiety. The results revealed significant, albeit
modest, associations between degree of lateralization and anxiety levels, in the overall sample
and among right-dominant participants. Essentially, we have managed to replicate Lyle et al.
(2012) findings relating to group differences between consistent and inconsistent rightdominant participants on anxiety outcomes, using correlational analyses, objective measures
of manual lateralization and a bigger sample. Taken together, the accumulated evidence thus
far consistently show that, at least among right-dominant individuals, higher degree of
lateralization is related to worse anxiety outcomes.
Like Lyle et al., we also did not find a significant association between degree of
lateralization and anxiety levels among left-dominant individuals in the present study.
Nevertheless, given the small effect sizes typically associated with such relationships, the
current sample of left-dominant individuals may not be large enough to detect such weak
associations. Neither was it likely in Lyle et al.s small sample of left-handers. In light of

10

such methodological issues, the findings relating to these relationships among left-dominant
individuals remain somewhat inconclusive. Future studies may want to clarify on such
associations using a larger sample of left-dominant individuals.
In addition to replicating previous findings, the current report also showed that
depression scores were also related to degree of lateralization among the right-dominant but
not left-dominant in a similar manner. This has yet to be documented in the literature.
Nevertheless, such a relationship is not surprising. Since anxiety was related to degree of
lateralization (at least among right-dominant individuals), we would also expect similar
findings in depression, given the strong intercorrelation between GDS and GAI scores in the
current report and the large diagnostic overlap between depression and anxiety disorders in
general (Zbozinek et al., 2012).
The correlational and categorical analyses both showed direction of lateralization was
not significantly related to depression or anxiety. Nevertheless, we did find a marginally
significant relationship between anxiety levels and direction of lateralization. We believe that
this was likely to be largely driven by the significant correlation between degree of
lateralization and anxiety levels, instead of an inherent relationship between anxiety and
direction of lateralization. The correlations of anxiety with degree and direction of
lateralization would be expected to be similar when right-dominant individuals greatly
outnumber their left-dominant counterparts in the sample; with a greater proportion of rightdominant individuals, the meaning of the relationships of direction-anxiety and degreeanxiety becomes more indistinguishable from each other. Hence, the marginally significant
association was likely to be a statistical artifact and not an accurate characterization of the
relationship between direction and anxiety. Additionally, this interpretation is also supported
by the fact that there was not a significant group difference in anxiety levels between left and

11

right-dominant groups. Essentially, the categorical analyses have complemented the nonsignificant associations between direction and depression/anxiety.
The null findings relating to the direction of lateralization is inconsistent with
previous reports of left-hand dominance being associated with depression (e.g., Denny (2009))
and anxiety (e.g. Everhart et al., (2002)). Given that Dennys (2009) study had similarly used
an older adult sample (i.e. age 50 years), and Everhart et al. (2002) had similarly employed
a grip strength paradigm to assess manual lateralization, this inconsistency is unlikely to be
related to the age of the participants or the type of manual laterality measures used. On the
other hand, this is perhaps the first such study in this area that was conducted on an Asian
sample, and this might point to the possibility of such inconsistent findings attributing to
cultural differences. There is some evidence to support such a hypothesis. It was previously
reported that East Asians, relative to westerners showed a more lateralized pattern of brain
activation in processing social stimuli (Goh et al., 2010). Therefore, the direction of
lateralization, which is a proxy for hemispheric specialization, may also be subjected to such
confounding effects across cultures. To this end, future studies may want to use a crosscultural paradigm to clarify on lateralization-depression/anxiety associations across cultures.
The findings of the current research contribute to a better theoretical understanding of
the pathophysiology associated with depression and anxiety. These findings suggest that the
pathophysiological mechanisms associated with degree of manual lateralization, such as the
lack of interhemispheric interaction (Prichard et al., 2013), may be more crucially implicated
in depression and anxiety than that of cerebral lateralization that is linked to the direction of
manual lateralization (Rentera, 2012). Furthermore, unlike other manual laterality measures
such as hand preference and those that require fine motor skills, grip strength asymmetries
are thought to be independent of asymmetry in the corticospinal tract (Triggs et al., 2000).

12

This suggests that corticospinal tract asymmetries alone may not account for the atypical
manual lateralization in depression and anxiety symptoms. Future studies may consider
exploring where exactly such manual lateralization in affective disorders is localized in the
brain.
One notable strength of the study relates to the use of objective measures of manual
lateralization which effectively avoids biases relating to memory and social conformity that
may be implicated in handedness preference questionnaires. The current report was, however,
limited by the relatively small sample of left-handers. In conclusion, the current report has
showed that, at least among right-dominant participants, degree, but not direction of
lateralization, was related to anxiety and depression symptoms.

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TABLE 1
Descriptive statistics and differences between the right and left dominant groups

Dominant hand group

Between-group comparison
Mann-Whitney
U

Right (N = 241)

Left (N = 85)

Mean Age (SD)

67.8 (5.4)

68.7 (6.1)

9461

.30

Mean Years of education

(SD)

6.1 (4.3)

6.0 (4.2)

101300

.88

Males

64

27

Females

177

58

Mean GDS score (SD)

1.61 (1.64)

1.70 (1.83)

10148

.90

Mean GAI score (SD)

1.36 (2.60)

1.13 (2.13)

9891

.58

Gender

.85

.36

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TABLE 2
Partial Rho () correlation between lateralization measures and, GDS and GAI scores,
controlling for age, sex and years of education
Overall sample (N= 336)

Right-dominant (N=241)

Left-dominant (N=85)

GDS

GDS

GDS

GAI

GAI

GAI

Degree

.05

.38

.11

.04

.13

.05

.16

.01

.05

.63

-.11

.33

Direction

.07

.21

.10

.06