Accepted Manuscript

Title: Music Therapy in Generalized Anxiety Disorder

Author: Enrique Octavio Flores Gutiérrez Vı́ctor Andrés

Terán Camarena

PII: S0197-4556(15)00006-4
DOI: http://dx.doi.org/doi:10.1016/j.aip.2015.02.003
Reference: AIP 1308

To appear in: The Arts in Psychotherapy

Received date: 14-11-2014

Revised date: 14-1-2015
Accepted date: 20-2-2015

Please cite this article as: <doi>http://dx.doi.org/10.1016/j.aip.2015.02.003</doi>

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MUSIC THERAPY IN GENERALIZED ANXIETY DISORDER

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Enrique Octavio Flores Gutiérrez* and Víctor Andrés Terán Camarena**

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*MD, PhD. Researcher in Medical Sciences, Instituto Nacional de Psiquiatría Ramón de la

Fuente Muñiz, Sub-direction of Clinical Research.
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E-mail: florese@imp.edu.mx Tel. 52 55 41605381. Present Address: Calzada México

Xochimilco No. 101, Col. San Lorenzo Huipulco, Del. Tlalpan, México, D.F. C.P. 14370.

** B.A. in Psychology, B.A. in Concert Guitar and Music Therapist. Instituto Nacional de
Psiquiatría Ramón de la Fuente Muñiz, Sub-direction of Clinical Research.
E-mail: victor.teran@gmail.com Tel. 52 55 5514906791. Permanent Address: Xochicalco
No. 309-2, Col. Narvarte, Del. Benito Juárez, México D.F., C.P. 03020.

**Corresponding author

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Highlights

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1. We propose Music therapy as a novel approach in clinical psychiatry for Generalized
Anxiety Disorder.

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2. We describe a Music Therapy group model for patients with Generalized Anxiety
Disorder.

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3. Music Therapy with pharmacotherapy treatment reduce anxiety levels in Generalized
Anxiety Disorder according with Beck Anxiety Inventory .

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4. Music Therapy with pharmacotherapy treatment reduce depression levels in Generalized
Anxiety Disorder according with Beck Depression Inventory.

5. Music Therapy achieve significant improvement in patients with Generalized Anxiety

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Disorder.
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ABSTRACT
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This study proposes music therapy as a novel approach in clinical psychiatry for

generalized anxiety disorder, which is one of the most common and incapacitating

disorders. In this study, we present the results of a pilot intervention with patients under

clinical control and receiving pharmacotherapy. Music therapy was used to decrease the

symptomatology of this disorder following a structured protocol. The pilot study group

consisted of seven patients with no comorbidities. The patients were characterized by

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Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria

and diagnosticated by psychiatrists at “XXXX”. The researchers programmed 12 x 2 hour

sessions for this group of patients. A pre-test/post-test design using the Beck Inventories of

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Anxiety and Depression was elaborated. The Wilcoxon statistical test for related groups in

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global scores demonstrated a significant reduction after the intervention. The results

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demonstrate that music therapy was effective in reducing anxiety and depression levels in

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GAD patients. Additional studies are required to corroborate these pilot data.

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Keywords: Music Therapy; Generalized Anxiety Disorder; Psychiatry; Psychotherapy
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1. INTRODUCTION

The cross-cultural study conducted by the World Health Organization (WHO) in 14

countries demonstrates that a substantial proportion, that is, approximately 24% of all

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patients in primary care settings, have a mental disorder. Furthermore, anxiety is one of the

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three most common diagnoses in these settings (Goldberg & Lecrubier, 1995). The results

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of Mexico’s 2001 National Psychiatric Epidemiology Survey (Medina-Mora et al., 2003)

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reveals that the most frequent disorders are of the anxiety type (14.3% at some moment in a

person’s lifetime) and that metropolitan areas have the highest prevalence (3.4%) of such

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disorders. Anxiety disorders (AD) are appearing at earlier ages, with an estimated mean of

15 years as reported in the bulletin of the WHO (2000). Of the different types of AD (i.e.,
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specific phobias, social phobia, post-traumatic stress disorder, agoraphobia, panic disorder),

generalized anxiety disorder (GAD) exhibits the highest incidence (7.9%) according to the
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results of a study published by the WHO (2000) of more than 25,000 patients who were
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assessed using the CIE-10 criteria . GAD in patients is associated with substantial
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reductions in quality of life and deteriorated functionality. The National Comorbidity

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Survey administered in the United States found that GAD is always associated with a

significant degree of deterioration (Hoge et al., 2004).

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With respect to the treatment of anxiety, in 2008, the World Federation of Societies

of Biological Psychiatry (WFSBP) Guidelines included pharmacological treatment

recommendations based on the quality of evidence for efficacy and risk/benefit assessment

of GAD (Bandelow et al., 2008). The strongest evidence of clinical efficacy in the

treatment of GAD was found for SSRIs – citalopram, paroxetine, sertraline; SNRIs –

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venlafaxine, duloxetine; the calcium channel modulator – pregabalin; and a second

generation antipsychotic (SGA) – quetiapine (Bandelow et al., 2008; Allgulander, 2010).

In addition, many authors, citing strong evidence, have recommended the

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benzodiazepines - alprazolam and diazepam - for treatment-resistant cases (Lanouette &

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Stein, 2010). These guidelines specify that in treatment-refractory GAD patients,

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augmentation of SSRI treatment with risperidone or olanzapine (SGAs) may be used

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(Bandelow et al., 2008; Allgulander, 2010).

Another report indicates that the psychosocial first-line treatments such as cognitive

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behavioral therapy (CBT), short-term psychodynamic psychotherapy, and relaxation

therapies such as mindfulness and meditation-based cognitive therapy are efficacious even
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in treatment-resistant cases, both on their own and when combined with medication

(Lanouette & Stein, 2010).

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However, though many treatments exist, both pharmacological and non-

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pharmacological evidence suggests that at least 50% of patients with GAD remain
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symptomatic despite first-line treatments (Hoge et al., 2004; Ravindran & Stein, 2009).
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Therefore, it is important to propose and explore new ways to improve the treatment

of this disorder, and accordingly, music therapy is proposed as one such possible non-
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pharmacological treatment.

Music therapy (MT), broadly speaking, can be defined as the use of music for

therapeutic ends, which is the focus of this pilot study. There are reports that music can

induce favorable effects in individuals with different pathologies (Juslin, 2003; Loomba et

al., 2012). For example, previous publications have demonstrated the effectiveness of

music in temporarily relieving symptoms common among patients with medical problems

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such as asthma and cancer (Sliwka et al., 2012; Pothoulaki et al., 2012). It has also been

used as an anxiolytic-like stimulus in treating osteoarthritis (Ottaviani et al., 2012), in

reducing pre-operative anxiety (Ni et al., 2012) and in assisting ventilation patients (Davis

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& Jones, 2012). Beyond the aforementioned applications, music has also been reported as

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an aid in the treatment and rehabilitation of some psychiatric conditions, including

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schizophrenia, sleep disorders, and prevalent problems, such as depressive disorder

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(Mössler et al., 2011; Chang et al., 2012; Erkkilä et al., 2011). In the same way, it has been

used to reduce anxiety and agitation in patients with dementia (Sung et al., 2012).

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It is necessary to note that there is a difference between playing music in a clinical

place to achieve a specific effect and the use of MT in that MT is a form of psychotherapy
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with an epistemological context, and as such, it requires a therapist be trained in specific

psycho-music techniques.
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There are several types of MT, each associated with specific psychological
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tendencies. In this pilot study, humanist MT of Mexico, which is based on Gestalt

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psychology (Muñoz, 2008), was applied with some variations as this is the direction in
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which the researchers have been prepared.

The use of MT for the treatment the GAD could confer the following advantages:
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1. The capacity to induce deeper states of abstraction and concentration. 2. An improved

ability to evoke positive or convenient memories that make possible cognitive recuperation

in a new way. 3. The creation of controlled situations that simulate problematic experiences

from daily life and the ability to initiate a new perspective on how to approach them.

The present pilot study used a group MT design and was conducted in the applied

psychophysiology area of clinical services at the “XXXX” in Mexico City. Among the

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most common reasons for inter-consultations regarding AD are poor responses to

pharmacotherapy, prolonged treatment times, pregnant women on drug suspension and

exacerbations and/or relapses. This specific department of clinical services usually receives

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GAD patients seeking psychotherapy, and the usual treatment in such instances is CBT due

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to its short-term effectiveness and its optimization of human resources. In the “XXXX”,

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CBT is frequently administered in the form of group therapy. It was this approach that led

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us to adapt methods of MT for the optimization of human resources and the short-term

treatment therapies such as CBT.

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The aim of this pilot study was to explore whether the application of MT can reduce

anxiety levels in patients with GAD, as measured using the Beck Anxiety Inventory, and
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whether this treatment can reduce depression levels in patients with GAD, as measured

using the Beck Depression Inventory. We determine that it is important to evaluate

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depression symptoms at the beginning and the end of the intervention as GAD is often
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found in association with varying degrees of depression (Hoge et al., 2004; Maser et al.,
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1990). Accordingly, the BDI was administered even though the inclusion criteria for this
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study stated that patients with GAD had to be free of comorbidities.

Two questions drove this study. 1. Does the application of MT group sessions
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significantly reduce anxiety levels in patients with GAD? 2. Does the application of MT

group sessions significantly reduce depression levels in patients with GAD?

2. METHODS

The recruitment process began with a detailed evaluation of medical records of

eligible patients (elaborated by psychiatrists of “XXXX”) who were channeled to the

applied psychophysiology area due to persistent symptoms despite pharmacological

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treatment for a minimum of one year. The following inclusion criteria were applied GAD

patients without comorbidities as diagnosed by psychiatrists using the Diagnostic and

Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) norms; subjects currently

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undergoing pharmacotherapy; subjects are part of the psychiatric outpatient control group;

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subjects are free of medical illness; subjects exhibit healthy auditory and locomotor

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systems. Initially, 10 patients who were between the ages of 25 and 45 years were invited to

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participate. Interviews were then held in which subjects reported, on a musical-therapeutic

sheet, the musical history of their families including sound-musical influences in different

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stages of development and current musical habits. This procedure was designed to explore

whether they presented alterations such as musicogenic epilepsy, amusia probable, trauma
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associated to some type of music, or other music-related problems. Furthermore, this

information was considered in determining the music that was to be used during the
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sessions. Before agreeing to join the group, all patients received detailed information, from
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the researchers, about the features of MT and their rights during treatment. By accepting,
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patients gave informed consent. The study was approved by the ethics committee of clinical
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services in accordance with the Declaration of Helsinki. While all patients initially accepted

the invitation, 3 subjects left the group after the second session. Thus, the final pilot group
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was comprised of 7 people, 3 men and 4 women, who remained until the end of the

treatment period, which totaled 12 sessions.

The therapist who led the music therapy intervention was certified as an Individual

Professional Member by the World Federation of Music Therapy (WFMT) and by the

Mexican Institute of Humanist Music Therapy (Instituto Mexicano de Musicoterapia

Humanista, IMMH).

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2.1 Music Therapy

The treatment process was conducted in two modalities - receptive and active MT.

The receptive application used prerecorded music or was executed by the music therapist,

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without the active involvement of the patient in the psychotherapeutic process of the

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musical creation. The active application engaged both the music therapist and the patient in

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the creation of music. For example, they may have used their voices, bodies and/or musical

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instruments during the session (Muñoz, 2008). Our MT treatment, as in CBT, included

breathing exercises, tension-relaxation techniques, psycho-education, and exercises for

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handling irrational thoughts and patterns of erroneous behaviors (Dobson & Dozois, 2010).

By incorporating all of these aspects, we developed and administered MT-based exercises.

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The MT treatment consisted of 12 two-hour structured sessions that were held once a week

on Thursdays, over a period of three months.

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The 12 therapy sessions were structured according to a methodological curve

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(Figure 1) and based on the procedures of humanist music therapy (HMT) (Muñoz, 2008),
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as described herein. This curve, which was used to program each group session and all
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treatment sessions consists of seven steps. The step include 1) Identification of the theme

(T) - In this step the problem is identified, the course to be followed is plotted, and the
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appropriate tool/s is/are confirmed, such as recorded music, active engagement of voice,

body, musical instruments, materials, etc.); 2) Preparation (P) – This step involves

preparing the patients emotionally and physically before engaging them in the therapeutic

experience; 3) Exploration (E): In this step, the patients explore, identify and report their

experiences, with no modifications; 4) Contact (C) - This step involves facilitating the

commencement of the connection with the memories and emotions patients are

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experiencing; 5) Intensification (I) – This step involves the intensity of the patient’s contact

with memories and the expression of emotions; 6) Resolution (R) – This step serves as the

conclusion of the connection with the memories and is confirmed by the expressed

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emotions. This step begins the preparation for finalizing the therapeutic experience; and 7)

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Processing (Ps): This step represents the end of the curve, and as such, it involves

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facilitating the connection and/or therapeutic association with the patient’s life (using

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verbal or written techniques, drawings, sculptures, among others). It also allows the patient

to process the end of the group therapy.

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To exemplify the use of the methodological curve, we briefly explain its use in the

overall design of the 12 sessions (Table 1) as well as the development of one of the sessions
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(Table 2).

Regarding the overall design, the first 2 sessions were devoted to the 1st step of the
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methodology, (T). Both sessions were designed to identify the main theme. For example,
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we presented to the group an introduction to each of the treatment themes and a description
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of AD, while receptive MT exercises focused on stimulating in each patient the

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identification of their specific problematic symptom.

Session 3 focused on the 2nd step of the methodology, (P). In this session, we
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prepared the patients emotionally and physically through the use of emotional expression

exercises with active MT, thus providing patients a management tool for their symptoms.

Sessions 4, 5 and 6 were structured around the 3rd step of the methodology, (E). In

this phase of the treatment, patients explored their own problems through the use of

receptive and active MT exercises focused on the exploration of their life history. They

then engaged cognitive processes as they explained their emotions and physiology.

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Sessions 7, 8 and 9 were designed according to the 4th and 5th steps of the methodology,

(C) and (I). In this phase of the treatment, the psychotherapeutic intensity increases as we

facilitated patients as they began to connect with the memories associated with their

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problems and identify the relationships they have with their emotional and behavioral

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processes. We used exercises focused on their emotional exploration and expression,

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principally with the use of active MT during this respective processing.

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Sessions 10 and 11 were prepared according to the 6th step of the methodology, (R).

This stage began by preparing the patient for the conclusion of treatment by using active

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MT exercises related to the expression of emotions, such as joy and affection, and

addressing issues, such as self-esteem and assertiveness (Dobson & Dozois, 2010), as these
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tools to address anxiety were important for achieving this goal.

Finally, session 12 was designed according to the 7th step of the methodology, (P).
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In this session, verbal and creative processing of the general therapeutic experience was
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facilitated by presenting conclusions and summarizing the resources gained during the
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course of the treatment.

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The use of the methodological curve in one session is presented in table 2.

2.2 Evaluation instruments

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The Beck Anxiety Inventory (BAI) was used to measure the anxiety levels that

patients manifested at two moments - the pre- and post-treatment phases of the 12 sessions.

Similarly, the Beck Depression Inventory (BDI) was applied to estimate levels of

depression. The BAI and BDI are self-administered scales that are among the most

frequently used in the last decade to assess anxiety and depression symptomatology.

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We administered standard versions of the BAI to the Mexican population (α =0.83). The

original version contained 21 questions, each scored using a 4-point scale (Robles et al.,

2001). The scores for symptom severity range from 0 to 63, with 63 representing maximum

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severity (Beltrán et al., 2012). According to Robles (2001), scale scores with respect to the

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severity of anxiety are as follows: 0 to 21 denotes low anxiety; 22 to 35 denotes moderate

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anxiety; 35 and above denotes severe anxiety.

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The BDI is one of the scales most often employed worldwide to measure the

severity of depression symptoms (Jurado et al., 1998). The BDI, as standardized by Jurado

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et al. (1998) for the Mexican population (α =0.87), is a self-reporting form with 21 items

and four response options. The scale scores, following Jurado et al. (1998), establish the
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following ranges of depression severity: 0 to 9 denotes minimal depression; 10 to 16

denotes mild depression; 17 to 29 denotes moderate depression; and 30 and above denotes
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severe depression; and 63 represents maximum severity.

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3. RESULTS
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The results obtained on the BAI, which was applied before and after treatment with
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MT, indicate that while the mean on the pre-test was 24.8,the score on the post-test had

decreased significantly, to just 8.2 (Figure 2). Similarly, the results on the BDI, which was
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administered before and after treatment with MT, show that the mean on the pre-test was

14.5 and that the score on the post-test had decreased significantly, to just 6.2 (Figure 3).

3.1 Statistical analysis

The study required an analysis of the results of the BAI and BDI scores. After mean

scores were calculated using the data for each inventory, they were subjected to a Wilcoxon

statistical test for related groups.

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Statistics show that the difference between the pre-test and post-test results on the

BAI is significant (Z= -2.201, p˂.028) (Figure 2). The difference between the pre-test and

post-test results on the BDI is also significant (Z= -2.023, p˂.043) (Figure 3). Elaboration

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of the non-parametric statistics was conducted using the Wilcoxon test for repeat measures

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with the IBM SPSS Statistics program, version 21.

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4. DISCUSSION

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The aim of this pilot study was achieved in that the application of MT was effective

in significantly reducing the scores on the BAI and the BDI in patients diagnosed with

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GAD who are also under pharmacological treatment. However, although these results are

promising, the results could possibly be more robust if future studies address the different
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threats to external validity, for example, with the inclusion of a control group.

Earlier studies of intervention using music had reported that active MT could reduce
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anxiety symptomatology. For example, Sung et al. (2012) used percussion instruments with
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familiar music and Park et al. (2012) used oriental medicinal music therapy to reduce
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anxiety symptomatology. In our study, we use active MT in patients with GAD as well as
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passive MT. However, a possible explanation of the positive effect of several active MT

sessions is that when we use the intense movement of the body in creative form, we are
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promoting the release of physical and psychological tension. Furthermore, chronic stress is

relieved as the sympathetic autonomic nervous system is regulated in the adrenal medulla,

which reduces the circulation of adrenaline and noradrenaline, thus benefitting the

cardiovascular system, among others. Additionally, the hormonal regulation of the

hypothalamic-pituitary-adrenal cortex axis decreases the circulating stress hormones such

as cortisol, which benefits, among others, the immune system. The aforementioned are

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among the changes and beneficial effects in a complex physiological and immunological

cascade, which, for most patients, can reduce somatic symptoms of anxiety such as

tachycardia and high blood pressure, hypersensitivity to pain, gastrointestinal disorders,

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sleep disturbances, among others. As well, brain and mental functions, such as memory,

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attention, and the functioning of the affective system, are also, in most of cases, enhanced.

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Understanding that music enhances the exploration of memories associated with

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problems related to life history, we used passive MT passive exercises to encourage and

promote the expression of memories and emotions as processing these memories and

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emotions in the resolution step can facilitate cognitive changes and modify the irrational

thoughts and beliefs. Such cognitive benefits may promote the individual’s ability to
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manage conflict, which is perhaps what Dobson referred to as cognitive restructuring in

CBT (Dobson & Dozois, 2010).

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As mentioned in some relevant studies regarding the treatment of mental disorders

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such as TAG, it is important to facilitate a process that promotes empathy, self-esteem, and
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positive thoughts and feelings (Eslinger, 1998; Maddux, 2014; Hansson et al., 2014). The
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methodological curve and work program proposed in this research emphasizes the

importance of the space that patients require to use verbalization as a means of

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exteriorization and processing. That is, the patients need to put what they have learned into

perspective by reconsidering their personal histories and conflicts. This entails a conscious

effort to identify what led them to seek treatment in the first place, what they have learned

about themselves and their personality, and how their experiences have developed over the

course of therapy (Ursano et al., 2004), all of which occurs as part of the dynamics

associated with growth and respect. As a result of the MT program, during their final verbal

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processing, patients recognized that the psychotherapeutic process helped them to develop

empathy, security, self-esteem and alternative tools to use in situations of anxiety or stress,

thus allowing them to assertively manage conflict. This, in turn, may well lead to reduced

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levels of anxiety.

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As GAD is so often found in association with varying degrees of depression (Hoge

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et al., 2004; Maser et al., 1990), we determined it was important to assess the patients’

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levels of depression. Regarding the results of the BDI, the pre-test scale showed that most

participants exhibited mild indexes of depression. However, the post-test measures

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determined there were significant reductions in depression indexes (Z= -2.023, p˂.043). In

fact, in some cases, subjects’ scores on the post-test indicated that they were “free” of
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depression. One individual who was assessed on the pre-test as severely depressed showed

a marked reduction in depression on the post-BDI assessment, with a score indicating a

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depression index of mild”. In light of these data, we suggest that MT as a means to manage
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depression be further investigated.

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It is important to emphasize that although this is a pilot study, this study has certain
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limitations, which may become threats to external validity, for example: A greater number

of participants is desirable, so it is recommended that future studies select a representative

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sample of patients with GAD. Furthermore, there was no control group to provide

comparative evidence from other experimental conditions for this music-therapeutic

process, such as treating GAD’s patients with drugs only or treating a group exclusively

with CBT. If so, we also suggest randomization, a factor that would eliminate a threat to

external validity. In the same way, considering testing the heterogeneity between different

treatment groups would reduce the differences in demographic and clinical variables. The

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use of only two instruments to measure anxiety levels (Beck Inventories) also limits the

evidence that could strengthen the results. For example, the use of distinct measuring

instruments would extend the evidence of the effects of treatment response. Moreover, the

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possible use of blind procedures can prevent and control the variable introduced by the

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researcher. Finally, it would have been beneficial to conduct a follow up of the effects of

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this treatment. Therefore, we consider important to take into account this limitations and

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recommendations in order to future replications can define and generalize more clearly the

scope of MT in GAD.

5. CONCLUSIONS
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It appears that MT was an effective psychotherapeutic treatment in the psychiatric

care of patients with GAD. The results of this pilot study demonstrate that MT was
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effective in reducing anxiety and depression levels in GAD patients, though it is necessary
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to conduct additional evaluations that consider the limitations of this study before
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considering this as a therapeutic option. However, the significant results of the application
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of MT in these cases of GAD encourage and allow us to affirm that MT could function as

an effective adjuvant in treating GAD.

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Figure 1. Methodological curve of HMT. This figure presents the 7-step sequence of the

humanist music therapy process. This sequence is adhered to by the humanist musical
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therapist in both the individual and group studies to lead the patient through a process that

is adjusted to his/her personal experiences and to discover the key moments that will allow
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the individual to express these experiences

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Figure 2. Comparison of total averages on pre- and post-tests for anxiety. This figure

indicates the total pre-test and post-test anxiety averages. The ordinate axes show the scale
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scores on the BAI. Adhering to Robles, R. (2001), the severity ranges with respect to
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anxiety are 0 to 21 denotes low anxiety; 22 to 35 denotes moderate anxiety; 35 and above
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denotes severe anxiety. The asterisk (*) indicates that the difference between the pre-test

and post-test results, using the Wilcoxon statistic on the BAI, is significant (Z= -2.201,
p

p˂.028).
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Figure 3. Comparison of total averages on pre- and post-tests scores for depression.

This figure shows the total pre-test and post-test depression averages. The ordinates axis
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shows the scale scores on the BDI. With respect to Jurado, S. (1998), the severity ranges for
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depression are 0 to 9, which denotes minimal depression; 10 to 16, which denotes mild

depression; 17 to 29, which denotes moderate depression; and 30 and above, which denotes
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severe depression. The asterisk (*) indicates that the difference between the pre-test and the
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post-test results using the Wilcoxon statistic on the BDI is significant (Z= -2.023, p˂.043).
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