Literature, Review

Running head: NURSING 410 LITERATURE REVIEW 1

The Impact of Art Therapies on Posttraumatic Stress Disorder (PTSD)

Frida Elonge

Stratford University, Falls Church

Research and Evidence-Based Nursing Practice (NSG 410)

March 2, 2019

NURSING 410 LITERATURE REVIEW 2

The Impact of Art Therapies on Posttraumatic Stress Disorder (PTSD)

Introduction

After experiencing or witnessing a trauma, some individuals are left with an anxiety

disorder, one of which is posttraumatic stress disorder (PTSD). “With the return of soldiers

serving in wars and the increasing violence in the society, PTSD is becoming a more prevalent

and impairing condition” (Stuart, 2013, p. 224). As a society, it is imperative that every option

that can help this group of people regain control of their lives be found. The purpose of this

literature review is to evaluate five research articles that focus on evaluating the impact of art

therapies like music and drawing as an adjunctive treatment with pharmacological therapy in the

treatment of PTSD. Data bases that were searched include ProQuest Central, CINAHL with full

text, and Nursing and Allied Health Database within LIRN Core Collection using the keywords

music therapy, posttraumatic stress disorder, and art therapies and the filtering criteria included

peer reviewed articles, full texts, and articles published between 2014 and 2019.

Clinical question

At the Northern Virginia Mental Health Institute (NVMHI) in adult patients with posttraumatic

stress disorder (PTSD), how effective are complementary therapies as an adjunctive treatment

with standard therapy in controlling symptoms of PTSD compared to standard therapy only in a

one-year period? There are numerous articles with theoretical and empirical evidence to suggest

that individuals with trauma exposure and posttraumatic stress disorder (PTSD) may derive

benefits from complementary therapies as an adjunctive treatment. This literature review will

evaluate five studies including the type and size of sample, reliability and validity of instruments,

methodology, consistency of data collection and procedures, appropriate data analysis, and

identification of limitations.

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Background

The first article titled “Music-instruction intervention for treatment of post-traumatic

stress disorder: A randomized pilot study” by Pezzin, Larson, Lorber, McGinley, & Dillingham is

a prospective delayed-entry randomized pilot trial, done to “examine the feasibility and potential

effectiveness of an active, music-instruction intervention in improving psychological health and

social functioning among Veterans suffering from moderate to severe PTSD” (Pezzin et al.,

2018). Of the 68 subjects, 25 did not meet the inclusion criteria while 3 dropped out of the study

leaving 40 subjects who were part of the study. The veterans were randomized into either the

immediate entry (25 subjects) or the delayed entry (15 subjects) arm in a 2:1 ratio to maximize

the number of subjects immediately available to receive the intervention (Pezzin et al., 2018)

which lasted for a six-week period and the wait time for those in the delayed entry group was

four weeks. The study utilized the PTSD Checklist civilian (PCLC) which is a self-report scale

with 17 items corresponding to the DSM-IV symptoms of PTSD (Pezzin et al., 2018). “The

PCLC has been shown to have good reliability and convergent validity” (Pezzin et al., 2018).

The researchers did a pre and post intervention structured survey. The results showed significant

improvement in PTSD and “support the hypothesis that Guitars for Vets is an effective adjuvant

therapy for emotional expression that decreases psychiatric symptoms in Veterans with moderate

to severe PTSD” (Pezzin et al., 2018). Some limitations identified include the very small sample

size, the fact that results were gotten through self-reporting, and the sample was overwhelmingly

male limiting the ability for generalization of results.

The second article, “Music therapy versus treatment as usual for refugees diagnosed with

posttraumatic stress disorder (PTSD): study protocol for a randomized controlled trial” by Beck,

Lund, Søgaard, Simonsen, Tellier, Cordtz, and Moe is a randomized pilot study done to “test the

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efficacy of Trauma-focused Music and Imagery (TMI) compared to verbal psychotherapy” (Beck

et al., 2018). The study consisted of 70 participants randomized into an experimental and a

standard treatment group that lasted for a period of 4-6 months. The researchers used various

scales such as the Harvard Trauma Questionnaire (HTQ) to measure outcomes. The HTQ has an

acceptable reliability in different languages (Beck et al., 2018). Recruitment for the study took

place over a 1.5-2-year period in three different clinics with 250-300 patients examined a year to

select the sample of 70. The results show that “music can enhance the connection between

prefrontal areas and amygdala/ hippocampus and thereby calm down hypervigilance and enhance

reflectivity and cognitive processing of emotions” (Beck et al., 2018) in patients with PTSD. The

limitations identified include the time period was too short as the recommended time frame for

maximum outcome is between 1-2 years compared to the 4-6 months the study lasted. Also, the

stress of the realities in the participants home countries like current bombings and death of loved

ones makes it hard to “construct a social and psychological space suitable for healing past

trauma” (Beck et al., 2018).

The third article titled “Military-Tailored Yoga for Veterans with Post-traumatic Stress

Disorder” by Cushing, Braun, Alden & Katz is a pilot study done to “assess the impact of yoga to

decrease PTSD symptoms in post-9/11veterans when used as an adjunctive therapy to the usual

care of psychotherapy and pharmacological treatments” (Cushing, Braun, Alden & Katz, 2018).

The study consisted of 18 veterans who completed the pre- and post-intervention self-report

questionnaires while the intervention lasted for a 10-week period. Participants were asked to

attend at least five sessions in seven consecutive weeks once a week. The researchers used the

PTSD Check List Military (PCL-M) as a measure of the outcome. “The PCL-M has been shown

to have high internal consistency (0.96–0.98) and good convergent validity (0.62–0.90

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depending on the comparator instrument) (Cushing et al., 2018). The participants were asked to

complete 4 different questionnaires within a week of consent and were then entered into the

intervention program. Follow-up data were collected within a week of the participant finishing

his/her fifth weekly session in seven consecutive weeks (Cushing et al., 2018). Data analysis was

done using the Shapiro-Wilk test. The results “demonstrated decreased PTSD symptomatology in

all three-symptom clusters represented by the PCL-M (i.e., hyperarousal, re-experiencing, and

numbness/avoidance)” (Cushing et al., 2018). The results were both clinically and statistically

significant. Some identified limitations include a small sample size, lack of a control group and

lack of a long-term post-intervention follow-up (Cushing et al., 2018).

The fourth article titled, “Feasibility, qualitative findings and satisfaction of a brief Tai

Chi mind–body programme for veterans with post-traumatic stress symptoms” by Niles, Polizzi,

Ples Kaiser, Ledoux & Wand is an observation and qualitative study done to “examine feasibility,

qualitative feedback and satisfaction associated with a 4-session introduction to Tai Chi for

veterans with post-traumatic stress symptoms” (Niles, Polizzi, Ples Kaiser, Ledoux, & Wand,

2016). The study consisted of 17 veterans with posttraumatic stress disorder in two cohorts

consisting of up to nine veterans each participated in a four-session Tai Chi protocol designed to

provide a brief introduction to Tai Chi exercise (Niles et al., 2016). At the end of the final Tai Chi

sessions, satisfaction questionnaires were completed to provide feedback to investigators. The

cohorts were run sequentially thus feedback from the first cohort was used to modify the study

protocol for the second cohort. After the final session, an audiotaped focused-group interview

was done with participants as well as individual interviews to provide additional feedback in

privacy. Descriptive and summary statistics were used to examine recruitment, participant

characteristics, adherence and satisfaction (Niles et al., 2016). It was found that “Tai Chi appears

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to be feasible and safe for veterans with symptoms of post-traumatic stress disorder (PTSD),

helped with several symptoms, such as intrusive symptoms, concentration difficulties and

physiological arousal, and several participants spoke of feeling unusually focused during the Tai

Chi sessions and feeling calmed during and after sessions” (Niles et al., 2016). Limitations of

this study include small sample size, study did not use a diagnostic measure, possibility of a

selection bias, and results not being generalizable because some participants still complained of

symptoms of PTSD after the intervention.

The fifth article titled, “Breathing Biofeedback as an Adjunct to Exposure in Cognitive

Behavioral Therapy Hastens the Reduction of PTSD Symptoms: A Pilot Study” by Rosaura

Polak, Witteveen, Denys, and Olff is a randomized study done to “ investigate the feasibility of

breathing biofeedback when it is implemented as a direct adjunct to the exposure element

within CBT sessions and to examine whether this leads to a significant pre to post treatment

decrease of PTSD symptoms” (Rosaura Polak, Witteveen, Denys, & Olff, 2015). The study was

made up of 8 participants “randomized to either the control condition in which they received

treatment with Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) or to the biofeedback

condition in which exposure similar to the regular TF-CBT group was combined with breathing

biofeedback” (Rosaura Polak et al., 2015). The researchers used the RespiFit biofeedback device

to measure the breathing frequency per minute. The device was already preprogrammed with the

breathing frequency and it provided immediate feedback by way of a beep sound to the

participants once their breathing wasn’t in line with the pre-programmed pace. The Impact of

Event Scale-Revised (IES-R) was used to measure the main outcome. The IES-R scale is good

for reliability and validity because “the IES-R is a 22-item self-re-port measure (with five

point Likert scales, 0–4) that assesses subjective distress caused by traumatic events and is

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known as a solid measure of posttraumatic symptoms that is used often in clinical as well as

research settings” (Rosaura Polak et al., 2015). For consistency of data collection and

procedures, “The IES-R was assessed at baseline (i.e., pre-treatment), at each weekly session and

at follow-up (i.e., 1-week post-treatment)” (Rosaura Polak et al., 2015). A variety of tools were

used for data analysis including the “non-parametric Mann–Whitney U-test for continuous

variables. Fisher’s exact tests for small samples were used to assess ordinal variables” (Rosaura

Polak et al., 2015) amongst others. The results show that “breathing biofeedback addition exerted

an additional effect through a clinically (though borderline statistically) significant faster

decrease of PTSD symptoms compared to treatment as usual (TF-CBT)” (Rosaura Polak et al.,

2015). The main limitation identified was the small sample size hence results should be

interpreted with caution.

Conclusion.

Of all the article reviewed above, similarities between them include the fact that they are

all pilot studies hence very small sample sizes. This was a common theme for limitations

identified by the researchers of all the articles. Secondly, the articles are all focused on

complementary and adjunctive therapies to standard PTSD treatment therapies. The final

similarity is the fact that all the articles showed a promise for relieving symptoms of PTSD. The

main difference between these articles is the fact that they all looked at various complementary

therapies as an adjunct to different standard therapies for PTSD.

Strengths of these articles are that a majority of them were randomized controlled studies

which means the results were trustworthy. On the other hand, weaknesses include the fact that

some of the studies had no control group and the type of study was not mention by the

researchers leaving the reader to guess as they read along.

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Overall, I think there is promise to these studies. These pilot studies have opened the door

to a whole new possibility of treatment for PTSD. Furthermore, these interventions are cost-

effective which makes it easy for everyone to participate. It also takes into account the fact that

some people who are worried about the stigma associated with mental health can still be treated

with these complementary therapies without having to worry about any stigma. Finally, these

studies highlighted areas of limitations which should help guide other future studies to prevent

same error and limitation.

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References

Beck, B. D., Lund, S. T., Søgaard, U., Simonsen, E., Tellier, T. C., Cordtz, T. O., … Moe, T.

(2018). Music therapy versus treatment as usual for refugees diagnosed with

posttraumatic stress disorder (PTSD): study protocol for a randomized controlled trial.

Trials, 19(1), 301. https://doi.org/10.1186/s13063-018-2662-z

Cushing, Robin E,M.P.A.S., DrP.H., Braun, K. L., DrP.H., Alden, S. W., C.I.A.Y.T., & Katz, Alan

R,M.D., M.P.H. (2018). Military-tailored yoga for veterans with post-traumatic stress

disorder. Military Medicine, 183(5), E223-E231.

doi:http://dx.doi.org/10.1093/milmed/usx071

Niles, B. L., Mori, D. L., Polizzi, C. P., Pless Kaiser, A., Ledoux, A. M., & Wang, C. (2016).

Feasibility, qualitative findings and satisfaction of a brief tai chi mind-body programme

for veterans with post-traumatic stress symptoms. BMJ Open, 6(11)

doi:http://dx.doi.org/10.1136/bmjopen-2016-012464

Pezzin, L. E., Larson, E. R., Lorber, W., McGinley, E. L., & Dillingham, T. R. (2018). Music-

instruction intervention for treatment of post-traumatic stress disorder: A randomized

pilot study. BMC Psychology, 6 doi: http://dx.doi.org.prx-

stratford.lirn.net/10.1186/s40359-018-0274-8

Rosaura Polak, A., Witteveen, A. B., Denys, D., & Olff, M. (2015). Breathing biofeedback as an

adjunct to exposure in cognitive behavioral therapy hastens the reduction of PTSD

symptoms: A pilot study. Applied Psychophysiology and Biofeedback, 40(1), 25-31.

doi:http://dx.doi.org/10.1007/s10484-015-9268-y.

Stuart, G. W. (2013). Principles and practice of Psychiatric nursing (10th ed.). St. Louis, MO:

Elsevier.