Efficacy of art therapy on anxiety symptoms in adults

Anxiety disorders are several disorders with an "abnormal" experience fear,
which fear gives rise to sustained subjective distress and / or an obstacle to
social functioning. Among these disorders are panic disorder, social phobia,
agoraphobia, specific phobia, obsessive-compulsive disorder (OCD), post
traumatic stress disorder (PTSD) and generalized anxiety disorder (NHG standard
anxiety 2012 (Hassink-Franke, Terluin, Heest, of, Hekman, Marwijk, van &
Avendonk, of, 2012)). The prevalence of anxiety disorders in the population is
high (7.7% of men and 12.5% **of women).
Anxiety disorders lead to reduced quality of life and functional impairment,
also at work (Kouzis, 1994; Kessler, 1997; Deura, 2000). Anxiety disorders are
also associated with substantial personal and societal costs. Although there
are effective methods of treatment, for example, for PTSD and OCD, in some
anxiety disorders, including generalized anxiety disorder and social phobia,
these methods have less successful treatment results (Newman, Llera, Erickson,
Przeworski & Castonguay, 2013). It is therefore of interest to look at other,
new treatment options.
One of these options is art therapy (AT). The multidisciplinary guideline for
anxiety disorders of the Trimbos Institute (2013), visual art therapeutic
interventions are described as potentially effective treatments. This includes
anthroposophic Art Therapy (AT). AT uses color and form as 'impressions' that
are supposed to act on the health of the client, which is designed to exert a
rebalancing effect on the physical, psychological and individual-biographical
aspects of the patient. AT is applied already since the beginning of the last
century in various disorders. There is much experience in the treatment of
anxiety disorders. However, there has been little research on the effects and
operation of AT in anxiety disorders. To understand the potential value of AT
and its possible place in the existing treatment services, thorough empirical
research is needed.

The primary objective of the study is to determine what changes with regard to
anxiety level and perceived quality of life occur in patients with anxiety
treated with art therapy (AT) for three months.

Secondary objective is to explore mechanisms (stress respons, emotion
regulation and executive functioning) that can substantiate the possible
effects of AT on anxiety symptoms and quality of life.

The research questions of the study are:
1) What are the effects of AT on anxiety levels and quality of life?
2) What possible working mechanisms can contribute to a possible effect of AT?

It is expected that AT through stress reduction has a positive effect on
anxiety levels and the quality of life and that there can be small improvements
in the areas of executive functioning and emotion regulation.

Exploration within a single-blind randomized controlled trial (RCT) with
repeated measurements, combined with research aimed at identifying predictive
factors in the treatment group. Enrolled participants are divided into four
strata: whether or not using psychiatric drugs, and whether or not having
moderate to severe depression symptoms (4DKL: depression score> 6), and
subsequently assigned by means of block randomisation to treatment or control
group (3 months wait list). After three months, the control group will also
recieve the treatment.

Art therapy (AT),10-12 sessions (treatment period: 3 months). The therapist
makes an individual treatment plan after an intake and 1-3 free artistic works.
The therapists offer various visual art methods and techniques that are
intended to reduce anxiety symptoms. The following AT techniques are given to
the patients (Tit-Chris Marker & Mees 2009): drawing from
observation,light-dark exercises with charcoal, dynamic drawing and solid body
clay modeling (series of cube to octahedron (Geuskens, 2014)).

All participants will continue treatment as usual. AT is used as additional
therapy. Half of the participants is on a waiting list for three months. All
participants follow initial screening (T0) with the 4DKL: 10 minutes. The
measurements regard a psychodiagnostic interview (MINI-plus, 30 min), cognition
(ANT: BS (alertness), SAD (sustained attention), SSV (inhibition and mental
flexibility): a total of 30 min), questionnaires (LWASQ, MANSA, DERS, BRIEF)
and physiological measurements (heart rate and skin conductance). These
measurements take a maximum of 2 hours to complete, including a break.

Posttest after 3 months consists of the same elements, without the
psychodiagnostic interview. This measurement therefore takes up to 1.5 hours.
The delayed post-test after 6 months only consist of questionnaires (4DKL,
LWASQ, MANSA, DERS, BRIEF) and takes about 40 minutes. All participants who
completed the therapy are then asked whether they want to participate in an
open interview of up to 1 hour. For participants in the treatment group, there
is a time investment of 10 to 12 therapiesessions of 45-60 minutes..

For participants in the control group (waiting list), there is also the
possibility, after three months, to follow the therapy. Again, this is a time
investment of 10 to 12 AT sessions each lasting 45-60 minutes.

Benefit for the participants is that they participate in a non-verbal treatment
aimed at reducing anxiety. The effect of the treatment could be that the
participant will need more information or guidance. If this is the case, the
participant is referred to the own treatment coordinator (general practioner or
other).
Physiological parameters (stressresponsivity) are measured with Biopac
equipment, in which patches are stuck on the skin and fingers. It is a
non-invasive measurement. Evoking stress while physiology protocol could have
negative consequences for the participant. When stress levels do not return to
baseline at the end of the measurement, the caretaker of the participant will
be contacted.