The Arts in Psychotherapy 45 (2015) 64–68

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The Arts in Psychotherapy

Effectiveness of dance/movement therapy on affect and psychotic

symptoms in patients with schizophrenia
Hye-Jin Lee, Ph.D. a , Seung-Ho Jang, M.D. b , Sang-Yeol Lee, M.D., Ph.D. b,∗ ,
Kyu-Sic Hwang, M.A. b
a
Department of Public Health, Wonkwang University Graduate School, Iksan, Republic of Korea
b
Department of Psychiatry, School of Medicine & Hospital, Wonkwang University, Republic of Korea

a r t i c l e i n f o a b s t r a c t

Article history: Schizophrenia is a debilitating and pervasive mental illness involving a range of cognitive, behavioral,
Available online 17 July 2015 and emotional dysfunctions alongside impaired occupation or social functioning. Previous studies have
suggested that dance/movement therapy (DMT) could be useful for the treatment and management of the
Keywords: symptoms of schizophrenia. This study investigated the effects of DMT on affect and psychotic symptoms
Dance/movement therapy in patients with schizophrenia. The DMT group (n = 18) received both DMT and medical treatment over 12
Schizophrenia
weeks, and the control group (n = 20) received only medical treatment. The DMT group showed a signifi-
Anger
cant decrease of state anger and depression compared to the control group after treatment (for state anger,
Depression
Anxiety
F (1, (1, 36) = 2.26, p < .05; for depression F (1, (1, 36) = 5.92, p < .01), and attained a significant increase of
anger control compared to the control group after treatment (F (1, (1, 36) = 5.11, p < .01). For psychotic
symptoms the DMT group showed a significant decrease of negative psychotic symptoms compared to
the control group after treatment (F (1, (1, 36) = 5.12, p < .01). DMT is therefore presented as a treatment
program that can reduce negative affect with anger control, and improve negative psychotic symptoms.
© 2015 Elsevier Ltd. All rights reserved.

Introduction and sometimes medical, views include the belief that schizophrenia
is a chronic and debilitating condition from which individuals have
Schizophrenia is a debilitating and pervasive mental illness little chance of recovering (Angermeyer, Matschinger, & Corrigan,
involving a range of cognitive, behavioral, and emotional dys- 2004). This conceptualization can be threatening and distressing to
functions with impaired occupation or social functioning (Villa & those given the diagnosis, and is likely to contribute to the high level
Pai, 2013). The core symptoms for schizophrenia diagnosis should of depression experienced by many patients with schizophrenia
be followed by one of delusions, hallucinations, and disorganized (Bosanac & Castle, 2013).
speech. Unlike neurotic mental disorders, schizophrenia tends to Schizophrenic psychopathology is multidimensional and het-
go chronically along with one’s life, and its genetic factors cannot erogeneous (Mossaheb et al., 2014). Factor analytic studies
be ignored on the level of his or her family medical history (Janicak, have often shown positive, negative, and disorganization factors
Marder, Tandon, & Goldman, 2014). The psychopathology has sub- (Cichocki, Cechnicki, & Polczyk, 2012). Positive symptoms include
stantial impact on the quality of life and social and occupational delusions and hallucinations, and negative ones include affective
function. Thus schizophrenia creates a considerable socioeconomic flattening, alogia, avolition, anhedonia, and asociality. While psy-
burden (Zeidler, Slawik, Fleischmann, & Greiner, 2012). chopharmacotics are effective in improving positive symptoms,
Schizophrenia is a highly stigmatizing disorder and many their effectiveness on negative symptoms is limited (Van Os &
individuals with this diagnosis feel devalued and discriminated Kapur, 2009).
(Dickerson, Sommerville, Origoni, Ringel, & Parente, 2002). Societal, Anger and its expression are especially important consid-
erations for patients with schizophrenia as they often show
aggressive behaviors that can result in harm to themselves and
others. Schizophrenic patients’ aggressive behaviors are linked
∗ Corresponding author at: Department of Psychiatry, School of Medicine & Hos-
to the underlying psychopathology of thought and perception
pital, Wonkwang University, 895 Muwangro, Iksan 570-711, Jeollabukdo, Republic
disorders and to the lack of anxiety and impulse control that
of Korea. Tel.: +82 63 859 1044; fax: +82 63 857 1043.
E-mail address: psysangyeol@hanmail.net (S.-Y. Lee). impairs their ability to withhold minor complaints. Thus, diagnosis,

http://dx.doi.org/10.1016/j.aip.2015.07.003
0197-4556/© 2015 Elsevier Ltd. All rights reserved.
 H.-J. Lee et al. / The Arts in Psychotherapy 45 (2015) 64–68 65

symptom identification, and noting their progression may help Table 1

Demographic and clinical characteristics of subjects.
predict these aggressive behaviors. Anderson’s model (Lindsay
& Anderson, 2000) suggests that aggressive behaviors are trig- DMT group Control group
gered by aggressive cognition, affect, and arousal. According to (n = 18) (n = 20)
this model, anger that influences violent behaviors can be cat- Gender
egorized as either situational or dispositional anger; and anger Male 8 10
expression can be categorized into “anger out,” which involves dis- Female 10 10
Age (M ± SD) 41.5 ± 10.5 41.8 ± 11.1
playing aggressive language or behaviors toward another person
Education year (M ± SD) 10.3 ± 2.4 11.0 ± 2.1
or object, and “anger in,” which involves repressing or containing Marital status
anger. The concept of “anger control” was added later to explain Unmarried 11 12
individual differences in patients’ efforts and their will to control Married 3 3
Divorced 3 4
anger expression (Speilberger, Reheiser, & Sydeman, 1995).
Other 1 1
Besides medical treatments for schizophrenia, psychosocial Onset age of illness (M ± SD) 21.3 ± 3.4 20.5 ± 4.7
rehabilitation therapies, such as dance/movement therapy (DMT), Duration of current illness 8.9 ± 4.2 8.4 ± 5.8
were found to be effective. “Dance therapy” was introduced by (M ± SD)
Chase as a supplementary treatment method (Chace, 1953). Cur- Subtype of schizophrenia
Paranoid type 12 13
rently, “movement therapy” is combined with sports therapy
Undifferentiated 5 5
and is utilized in the field of psychiatry. DMT utilizes physi- Others 1 2
cal activities and sensory stimulation to help restore patients’ N of types of medication taken
ego integrity through creative movements. DMT can effectively M (SD) 4.5 (1.3) 4.5 (1.3)
Range 2–10 2–10
enhance interpersonal relationships and communication skills,
N (%) of subjects on medication with clozapine
control anger and aggressiveness, and prevent social regression - Has taken clozapine 5 (27.7) 6 (30)
(Mutri, 2002). Furthermore, adequate physical activity and regu- - Has not taken clozapine 13 (72.3) 14 (70)
lar movements can improve cardiopulmonary functions, enhance N (%) of subjects on medication during trial
physical strength and joint flexibility, strengthen the body’s Typical antipsychotic 5 (27.7) 7 (35)
Clozapine 2 (11.1) 2 (10)
homeostasis and immune functions, and lower sensitivity to anxi-
Quetiapine 1 (5.5) 2 (10)
ety and depression. Olanzapine 2 (11.1) 3 (15)
With the results of previous studies, we hypothesize that DMT Risperidone 8 (44.6) 6 (30)
can have an positive effect on affect and psychotic symptoms in DMT = dance/movement therapy.
patients with schizophrenia compared to the control group receiv-
ing only medical treatment. This study investigated the effects of
DMT on anger, expression of anger, depression, anxiety, and posi- of the study. The DMT intervention comprised 12 weekly 60-min
tive and negative symptoms in hospitalized schizophrenic patients. sessions. In the initial stage (Sessions 1–4), self-awareness was
developed; in the intermediate stage (Sessions 5–8) interpersonal
Methods relationships were facilitated; and in the final stage (Sessions 9–11),
relationships between the individual and group were formed, with
Design Session 12 serving to conclude the intervention and conduct post-
tests. The treatment process is explained in Table 2. A total of 18
The current study involved pre- and post-tests. The participants patients with schizophrenia received both the DMT and medical
received sufficient explanations regarding the study and were edu- treatment, and 20 patients with schizophrenia received only med-
cated on the overall DMT process. The DMT and control groups ical treatment as a control group. A researcher who had completed
were comparable in socio-demographical and clinical characteris- DMT professional courses at Wonkwang University in 2010 and has
tics (Table 1). previously conducted DMT sessions conducted the intervention.
Before the study, participants were provided detailed explanations
Participants regarding study purposes and procedures, based on which they
signed research participation agreements indicating consent. Par-
Participants were recruited through the Wonkwang University ticipants were randomly assigned to the DMT or control group
hospital. The psychiatric diagnosis was confirmed by a licensed by flipping a coin. Because this study focuses on improving affect
psychiatrist based on Diagnostic and Statistical Manual of Mental and psychotic symptoms in patients with schizophrenia, the scales
Disorders-5 (American Psychiatric Association, 2013). We obtained related with depression, anxiety, anger, and psychotic symptoms
written informed consent from all participants after explaining to were used in this study.
them the aims and procedures of the study. Study inclusion psychi-
atric criterion was schizophrenia. Exclusion criteria in the current Measurements
study were comorbidity with other psychopathologies – such as
depression, bipolar disorder, and drug addiction – and current/past In order to measure the effect of the DMT program, the clinical
medical history for various neurological disorders, such as brain rating scales used included STAXI, BDI, STAI, and PANSS. Partici-
damage or dementia. Patients with IQ scores lower than 70 and pants were also asked to complete the program evaluation form at
those deemed incapable of filling out a survey on their own were the end of the last session.
excluded. To eliminate the influence of dosage change of antipsy-
chotic drugs administered to patients, the experimental and control State-trait anger expression inventory (STAXI)
groups maintained their drug dosages during the study period.
The STAXI provides a self-reported measure of the experience
Procedure and expression of anger in 44 items (Speilberger, 1988). Individuals
answered on a 4-point Likert scale (“Not at all” to “Almost always”)
A 60-min DMT session was held once a week for 12 consecutive to assess either the intensity of their angry feelings or the frequency
weeks. DMT was explained to participants before the beginning in which anger is experienced, expressed, or controlled.
66 H.-J. Lee et al. / The Arts in Psychotherapy 45 (2015) 64–68

Table 2
Stage-wise goals and curriculum of the DMT intervention.

Session Pre-session 1–4 5–8 9–11 12

Stage Initial stage (the Intermediate stage (the Final stage (improving
“self-awareness” stage) “other-awareness” stage) sociality)
Activity goal Figuring oneself out Forming relationships Forming relationships
between oneself and others between oneself and the
Forming rapport
group Conclusion and
with participants
- Bodily self-awareness - Expressing emotions - Doing the cha-cha-cha conducting the
and conducting
(forming self-esteem, using tools (personal needs with everyone (forming post-test
the pre-test
relieving nervousness) and emotional relationships and
understanding; tools: stabilizing emotions
Program
cloth, ball, nearby objects, among groups)
curriculum
etc.)
• Becoming aware of • Motioning 5 beautiful • Dancing the
anatomy words cha-cha-cha with everyone
• Passing tools (ball, • Motioning 5 sad words • Clapping along the
cloth) to become physically cha-cha-cha
aware
• Motioning together in - Reflecting on activities
two groups (relaxing the muscles;
developing group trust, a
sense of unity, and a sense
of achievement)
- Eye contact - Expressing emotions with • Sounding beats and
(self-acceptance, music (refining emotions, rhythms
understanding affect) forming trust; tools: cloth,
ball, nearby objects, etc.)
• Developing self-esteem • Expressing emotion • Creating a work of art
through eye contact with bright music using 7 movements
• Developing self-esteem • Expressing emotions • Presenting the work
using tools (cloth, tape) with sad music
- Recognizing the body of
another (emotional
stability between oneself
and the other person)
• Mirroring, repeating
after beats

DMT = dance/movement therapy.

Beck depression inventory (BDI) The scale constitutes 30 items including seven positive symptom
sub-scale items, seven negative symptom sub-scale items, 16
The BDI is a 21-item questionnaire designed to assess the degree general psychopathology symptom items, and three depres-
of depressive symptoms present over a 1-week period (Beck, Ward, sion/anxiety symptoms items. The patient is rated from 1 to 7 on
Mendelson, Mock, & Erbaugh, 1961). Each of the 21 items corre- 30 different symptoms based on the interview from primary care
sponding to a symptom of depression is summed to give a single hospital workers. These seven points represent increasing levels of
score. There is a four-point scale for each item ranging from 0 to psychopathology (from 1 = “absent” to 7 = “extreme”).
3. Total score of 0–13 is considered minimal range, 14–19 is mild,
20–28 is moderate, and 29–63 is severe. We used the Korean ver-
sion of the BDI (Sung et al., 2008). Statistical analysis

State-trait anxiety inventory (STAI) Paired t-tests were used to analyze and compare scores on
before and after DMT. Two-way repeated measures of ANOVAs
The STAI is a commonly used measure of trait and state anx- were also used to analyze the differences between variables over
iety (Speilberger, Gorsuch, & Lushene, 1970). It has 20 items for time, at the two evaluation periods for each group. The level of sig-
assessing trait anxiety and 20 for state anxiety. State anxiety items nificance was set at p = .05. The statistical package for social sciences
include: “I am tense; I am worried” and “I feel calm; I feel secure.” (SPSS version 19.0) was used for all analyses.
Trait anxiety items include: “I worry too much over something that
really doesn’t matter” and “I am content; I am a steady person.”
All items are rated on a 4-point scale (e.g., from “Almost never” to Results
“Almost always”). Higher scores indicate greater anxiety. The state
anxiety inventory (SAI) assesses how one feels in particular situa- Demographic and clinical characteristics of subjects
tions at particular times, reflecting the anxiety one feels in specific
situations. The trait anxiety inventory (TAI) defines how one feels Table 1 shows the baseline demographic data in our subject
in general. groups. The average age of the DMT (n = 18) was 41.5 years (±10.5)
and 56% of the sample (n = 10) were women. No significant differ-
Positive and negative symptom scale ences were found in age or gender ratio between the groups. There
was also no significant difference in education levels between the
The PANSS, a semi-structured interview schedule, was adopted groups. A subtype of schizophrenia were paranoid type 67% (n = 12),
to assess psychotic symptoms (Kay, Fiszbein, & Olper, 1987). undifferentiated type 28% (n = 5) and residual type 5% (n = 1).
 H.-J. Lee et al. / The Arts in Psychotherapy 45 (2015) 64–68 67

Table 3
Results of comparison for mean difference scores at 12 weeks of DMT for anger and anger expression.

D.V. Group Pre Post Group Time Group × time

M ± SD M ± SD F F F

Type of anger
DMT 14.33 ± 5.3 11.31 ± 4.5*
State anger 1.187 4.245** 2.264*
CON 13.36 ± 5.4 11.81 ± 4.4
DMT 16.51 ± 3.5 17.56 ± 4.3
Trait anger 0.565 2.354 0.985
CON 17.87 ± 3.7 18.58 ± 5.3

Anger expression
DMT 12.89 ± 5.3 14.23 ± 6.5*
Anger in 0.461 3.434* 1.272
CON 13.68 ± 5.5 14.16 ± 5.1
DMT 12.90 ± 4.3 12.33 ± 5.3
Anger out 1.565 2.434 1.212
CON 13.45 ± 4.8 14.56 ± 6.1
DMT 16.76 ± 7.1 20.45 ± 6.8* **
Anger control 2.562 8.434 5.105**
CON 16.34 ± 6.9 15.25 ± 7.2

D.V. = dependent variable; DMT = dance/movement therapy; CON: control group.

*
p < .05.
**
p < .01.

Table 4
Results of comparison for mean difference scores at 12 weeks of DMT for depression and anxiety.

D.V. Group Pre Post Group Time Group × time

M ± SD M ± SD F F F

BDI DMT 21.63 ± 4.4 16.25 ± 3.5**

2.011 9.398*** 5.922**
CON 20.66 ± 4.9 21.11 ± 4.9
State anxiety DMT 58.30 ± 7.2 56.71 ± 7.8
1.565 1.142 1.785
CON 59.61 ± 8.5 60.71 ± 9.6
Trait anxiety DMT 58.22 ± 8.3 54.25 ± 7.1
0.998 2.434 1.872
CON 57.92 ± 8.4 56.7 ± 8.9

D.V. = dependent variable; DMT = dance and movement therapy; CON = control group; BDI = beck depression inventory.
**
p < .01.
***
p < .001.

Results of comparison for mean difference scores at 12 weeks of 1.09 points, but was not significant. For anger control, the DMT
DMT for anger and anger expression group’s score increased significantly by 1.34 points (p < .05); while
the control group’s score increased by 0.48, but was not significant.
Regarding changes in the experimental and control groups at The ANOVA results showed that overall and group-wise changes
the pre- and post-test, situational anger decreased significantly by in anger control over time were statistically significant (p < .001;
3.02 points in the experimental group (p < .05); while the control Table 3).
group’s score decreased by 1.55 points, showing no significant dif-
ference. The results of the ANOVA on overall changes in situational Results of comparison for mean difference scores at 12 weeks of
anger over time were significant (p < .01). However, there were no DMT for depression and anxiety
significant differences in overall or group-wise changes in dispo-
sitional anger over time. The results of the ANOVA on changes in Depression significantly increased by 5.38 points for the exper-
anger expression showed that overall temporal “anger in” changes imental group (p < .01); however, the increase of 0.45 points in
were statistically significant (p < .05), but those by group were the control group was not significant. The results of the ANOVA
not significant over time. For “anger out,” no significant tempo- indicated that overall (p < .001) and group-wise (p < .01) tempo-
ral differences were observed for overall and group-wise scores. ral changes in depression were statistically significant. However,
The experimental group’s anger control significantly increased by overall and group-wise situational and dispositional anxiety did
3.69 points (p < .05); while the control group’s score decreased by not differ significantly over time (Table 4).

Table 5
Results of comparison for mean difference scores at 12 weeks of DMT for positive and negative symptoms of schizophrenia.

D.V. Group Pre Post Group Time Group × time

M ± SD M ± SD F F F

DMT 20.87 ± 7.3 21.86 ± 5.6

PANSS-P 1.517 2.641 1.352
CON 22.64 ± 9.1 24.16 ± 6.4
DMT 25.36 ± 5.3 20.42 ± 5.9**
PANSS-N 4.565** 11.511*** 5.185**
CON 26.45 ± 5.4 28.95 ± 8.7

D.V. = dependent variable; DMT = dance and movement therapy; CON = control group; PANSS = positive and negative syndrome scale; P = positive symptoms; N = negative
symptoms.
**
p < .01.
***
p < .001.
68 H.-J. Lee et al. / The Arts in Psychotherapy 45 (2015) 64–68

Results of comparison for mean difference scores at 12 weeks of studies, the current study examines the effects of DMT on patients’
DMT for positive and negative symptoms of schizophrenia anger and proposes measures for preventing aggressive tendencies
in schizophrenic patients. Future studies should verify the effects
Overall and group-wise changes in positive symptoms for each of DMT on larger samples and explore its effectiveness in treating
group were not significant over time. However, with regard to nega- other disorders.
tive symptoms, the experimental group demonstrated a significant
decrease of 4.94 points (p < .01); while the control group showed Conclusion
an increase of 2.50 points that was not significant. The results of
the ANOVA on overall (p < .001) and group-wise (p < .01) changes in This study investigated the effectiveness of DMT on affect and
negative symptoms were significant over time (Table 5). psychotic symptoms in patients with schizophrenia. The DMT
group showed significantly improved effects on depression, state
Discussion anger, anger control, and negative symptoms. Although this study
has a limitation like a small sample size, it is expected to be an
This study was conducted to examine the effect of DMT on anger, alternative treatment program to be able to cure patients with
expression of anger, depression, anxiety, and positive and negative schizophrenia. Future study with larger sample size would be help-
symptoms in hospitalized schizophrenic patients. ful to generalize DMT for patients with schizophrenia.
Anger status of hospitalized schizophrenic patients was signifi-
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