PONE-D-19-17020

Stress regulation and executive functioning in women treated for anxiety with art therapy

PLOS ONE

Dear Mrs Abbing,

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

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Reviewer #1: Partly

Reviewer #2: Partly

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

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Reviewer #1: The manuscript entitled ‘Stress regulation and executive functioning in women treated for anxiety with art therapy’ with the aim to examine the to explore possible working mechanisms of anxiety reduction in women with anxiety disorders, treated with art therapy (AT).

Comments

There numerous typographical errors due to the software where some figures with dots were presented as comma.

Materials and methods

Page 4, typo AAT.

Location of the study to be stated. The language version of all questionnaires/inventories to be clearly stated.

Page 5, the randomization method to group the subjects to be clearly stated.

Page 5, (TIST) to be placed after Trier Social Stress Test.

Sample size calculation for the study to be stated. Alternatively, power of study based on the sample size in this study could be discussed.

Page 6 rmssd to be written in capital form RMMSD. NS to be written as Nervous System.

Statistical analysis

The word stress induction or stress or stress task to be standardized where applicable.

The 7 Evaluation expectations to be replaced with the word hypothesis. The write up of the hypothesis could be further improved.

For the hypothesis 1-5, the word ‘Test moment’ to be rephrased/replaced to reflect the time. The word 'versus' or 'vs' to be standardized. pre vs post test to be added for all test moment. Likewise for AT vs WL to be consistently highlighted for the group.

Page 9 Paragraph 1 Line 3, is the cut off 0.05 for the significant level only apply for hypothesis 3 or for all analysis? If for all analysis, this has to be placed at the last section of the statistical analysis.

The sample size is small for regression analysis.

Results

Page 10 Paragraph 3 Line 9, for 'was trend significant (p=0.068), what was the cut off for the significant level in this study?

The presentation of p value using dot or 0. to be standardized throughout the manuscript e.g Page 10 paragraph 4 Line 3.

For Table 1, 2 and 3, statistical test to be denoted in the table footnote.

Discussion

The write up on the limitations could be further improved.

The referencing style in the text and references list did not conform to the journal format.

Reviewer #2: The authors describe a study on working mechanisms and predictor of art therapy outcomes among patients with anxiety disorder. This study is very valuable to this field, since there are only few RCTs on this therapy while in clinical practice art therapy is highly appreciated by clients. Nevertheless, I have several concerns on the theoretical framework, methodology, and the way conclusions are drawn. These concerns lead to my advice to major revisions before accepting this paper.

• Framework

I was confused by the descriptions on self-regulation and how this is linked to emotion and more specific anxiety. The authors mention first that emotions are part of a larger self-regulation system and next that self-regulation consist of three components (stress, cognitive, and social regulation). How does this match? What about emotion regulation? And how is this framework related to anxiety disorders? And more importantly, how will art therapy address self-regulation and from that reduce anxiety symptoms? The authors mention a bit in the conclusion on this, however this is very limited and I would expect this kind of information in the introduction. Therefore, I think that both the introduction and the conclusion could be improved by considering these interrelations in more detail.

In relation to the first comment, I was wondering on the operationalization of self-regulation. The authors used the Brief-A and three tasks of the ANT. The tasks of the ANT are cognitive tasks on aspects of executive functioning. The Brief-A is seen as a behavioral and self-reported measure on executive functioning. How does this align with the framework on self-regulation and its components? Is an emotional aspect represented in these tests? Why was no questionnaire introduced on emotion regulation?

• Methodology

Page 8: Information on reliability and validity of the LWASQ is lacking.

The authors based the analyses on the associating factors on improvements within the experimental group. In order to interpret these analyses, it would be helpful to get information on the within group effects.

Table 1 does not include any information on the statistical parameters. For the interpretation, it would be helpful to receive this information. I would expect a similar table as Table 2 and 3.

Page 13: Why were the outliers removed from the ANT tasks, while other outliers were not removed?

• Interpretation

Since there were a lot of statistical tests with only few participants, I would expect a more careful, nuanced and critical interpretation of the results. In particular, regarding the interpretation of the analyses on the associating factors. As far as I can see, these consists this of only 22 participants. Within this regard, it could be seen as a pilot to get more insight in the working mechanisms and associating factors. Regarding the interpretation of the results, see also my comments on the framework. In addition, I would expect more information on future research: what kind of hypotheses? I think there are many ideas that could be elaborated on. And how should we align RCT to case study design?

• Other comments

Introduction: the authors mention that HRV decrease with cardiac comorbidities. Was this examined in this population? And could it have any effect?

Introduction, page 4, ‘present study’: ‘…improvements is stress…’ change in ‘…improvements in stress…’

Methods, page 5: ‘…with AM and…’ needs to be ‘AT’?

Methods, page 5: what’s the difference in this study between research assistants and outcome assessors?

Methods, statistical analysis, page 8: The terminology ‘baseline HRV’ and ‘baseline HR’ is confusing, since baseline refers also to pre-test. Alternative: ‘resting HRV/HR’

Results, Page 9: HRV/HR data from eleven participant could not be used. This was due to a distorted signal or to refusal. How many were due to refusal?

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Reviewer #1: No

Reviewer #2: No

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Anxiety reduction through art therapy in women. Exploring stress regulation and executive functioning as underlying neurocognitive mechanisms.

PONE-D-19-17020R1

Dear Dr. Abbing,

We are pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it complies with all outstanding technical requirements.

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With kind regards,

Jim van Os

Academic Editor

PLOS ONE

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