International Journal of Play Therapy

The effectiveness of Sandplay Therapy in treating Generalized Anxiety Disorder

patients with childhood trauma using a Magnetic Resonance Spectroscopy to examine
choline level in Dorsolateral Prefrontal Cortex and Centrum Semiovale.
--Manuscript Draft--

Manuscript Number: PLA-2021-0268

Full Title: The effectiveness of Sandplay Therapy in treating Generalized Anxiety Disorder
patients with childhood trauma using a Magnetic Resonance Spectroscopy to examine
choline level in Dorsolateral Prefrontal Cortex and Centrum Semiovale.

Abstract: Generalized Anxiety Disorder (GAD) is a chronic psychological disorder that involves
brain function and physiological disorders. Sandplay Therapy (SPT) has been shown
to be successful in treating GAD symptoms, but few studies have been performed to
investigate the efficacy of SPT in the treatment of GAD patients with childhood trauma
(CT) in the Dorsolateral Prefrontal Cortex (DLPFC) and Centrum Semiovale (CSO)
using neuroimaging. This study would investigate the efficacy of SPT in treating GAD
symptoms (using HAM-A and GAD-7 as a clinical indicator of anxiety) and
improvements in choline levels in DLPFC and CSO (using Magnetic Resonance
Spectroscopy (MRS)). Participants in this study are GAD patients with CT (n=7) and
healthy control (n=2), age 21-40 years old. Participants will have one hour of 30 SPT
sessions and pre-post neuroimaging measurements using MRS. Early Trauma
Inventory Self Report-Short Form (ETISR-SF) was used to monitor early childhood
trauma. The pre-post test design and the compared mean as a statistical analysis were
used in this study. The findings showed an improvement in symptoms of anxiety and
an increase in choline levels in DLPFCs and CSOs, which showed that the choline
trend moved toward a healthy range. This research concludes that SPT is effective in
treating not only symptoms of GAD with CT but also in enhancing the metabolite in the
brain. These results are preliminary due to the small sample size that the limitation will
be addressed and further analysis will also be required.

Article Type: Article

Keywords: Generalized Anxiety Disorder, Sandplay Therapy, Choline, Dorsolateral Prefrontal

Cortex, Centrum semiovale

Corresponding Author: Mariana Foo, Ph.D

Perhati Counseling and Care Center
Jakarta, DKI Jakarta INDONESIA

Corresponding Author E-Mail: mariana@perhati-indonesia.com;anafoo2010@gmail.com

Corresponding Author Secondary

Information:

Corresponding Author's Institution: Perhati Counseling and Care Center

Other Authors: Anggun Pratiwi

Corresponding Author's Secondary

Institution:

First Author: Mariana Foo, Ph.D

Order of Authors Secondary Information:

Manuscript Region of Origin: INDONESIA

Suggested Reviewers:

Opposed Reviewers:

Order of Authors: Mariana Foo, Ph.D

Anggun Pratiwi

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Cover Letter

Dr. Mariana Foo,

Perhati Clinical Research Center
Jl. Pluit Selatan Raya No. 60,
RT.21/RW.6, Pluit, Jakarta Utara
DKI Jakarta 14450
+62 818-912-088
mariana@perhati-indonesia.com

Dr. Franc Hudspeth

Editor
International Journal of Play Therapy

January 2, 2021

Dear Dr. Hudspeth:

I am pleased to submit an original research article entitled “The effectiveness of Sandplay Therapy in treating
Generalized Anxiety Disorder patients with childhood trauma using a Magnetic Resonance Spectroscopy to examine
choline level in Dorsolateral Prefrontal Cortex and Centrum Semiovale by Foo, Pratiwi, for consideration for
publication in the International Journal of Play Therapy. This manuscript marks our study using control group to
examine the possible effect of sandplay therapy on the brain, especially Dorsolateral Prefrontal Cortex and Centrum
Semiovale region.

In this manuscript, we show that sandplay therapy is an effective psychotherapy that has a capacity to help
generalized anxiety disorder (GAD) patients with childhood trauma (CT) to regulate their emotion which can be
assessed through clinical assessments and neuroimaging procedures, namely the proton magnetic resonance
spectroscopy (MRS). The clinically significant improvement in this study was in line with previous researches that
used clinical assessments and neuroimaging study. The use of choline level in determining improvement in
dorsolateral prefrontal cortex and centrum semiovale in GAD patient with CT is an interpretation that need further
confirmation. In the manuscript, we have set a theoretical dynamic in the manuscript for how sandplay therapy can
accomplish this effect on the brain.

We believe that this manuscript is appropriate for publication by the International Journal of Play Therapy because it
pinpoints the current issue in sandplay therapy, a form of play therapy.

This manuscript has not been published and is not under consideration for publication elsewhere. We have no
conflicts of interest to disclose.

Thank you for your consideration!

Sincerely,

Dr. Mariana Foo,

Director
Perhati Cinical Research Center
Title page with All Author Information

The effectiveness of Sandplay Therapy in treating Generalized Anxiety Disorder patients

with childhood trauma using a Magnetic Resonance Spectroscopy to examine choline level

in Dorsolateral Prefrontal Cortex and Centrum Semiovale

Mariana Foo1, Anggun Pratiwi2

Perhati - Clinical Research Center, Jakarta, Indonesia

Corresponding e-mail : mariana@perhati-indonesia.com

Masked Manuscript without Author Information

The effectiveness of Sandplay Therapy in treating Generalized Anxiety Disorder

patients with childhood trauma using a Magnetic Resonance Spectroscopy to

examine choline level in Dorsolateral Prefrontal Cortex and Centrum Semiovale

Abstract

Generalized Anxiety Disorder (GAD) is a chronic psychological disorder that involves

brain function and physiological disorders. Sandplay Therapy (SPT) has been shown to

be successful in treating GAD symptoms, but few studies have been performed to

investigate the efficacy of SPT in the treatment of GAD patients with childhood trauma

(CT) in the Dorsolateral Prefrontal Cortex (DLPFC) and Centrum Semiovale (CSO)

using neuroimaging. This study would investigate the efficacy of SPT in treating GAD

symptoms (using HAM-A and GAD-7 as a clinical indicator of anxiety) and

improvements in choline levels in DLPFC and CSO (using Magnetic Resonance

Spectroscopy (MRS)). Participants in this study are GAD patients with CT (n=7) and

healthy control (n=2), age 21-40 years old. Participants will have one hour of 30 SPT

sessions and pre-post neuroimaging measurements using MRS. Early Trauma

Inventory Self Report-Short Form (ETISR-SF) was used to monitor early childhood

trauma. The pre-post test design and the compared mean as a statistical analysis were

used in this study. The findings showed an improvement in symptoms of anxiety and

an increase in choline levels in DLPFCs and CSOs, which showed that the choline trend

moved toward a healthy range. This research concludes that SPT is effective in treating

not only symptoms of GAD with CT but also in enhancing the metabolite in the brain.

These results are preliminary due to the small sample size that the limitation will be

addressed and further analysis will also be required.

Keywords: Generalized Anxiety Disorder, Sandplay Therapy, Choline, Dorsolateral

 2

Prefrontal Cortex, Centrum semiovale

Introduction

Generalized Anxiety Disorder (GAD) is a chronic psychiatric disorder that

affects the brain functional response and metabolic abnormalities (Price et al., 2011;

Ball et al., 2013; Moon et al., 2014; Mathew et al., 2004, 2008). Major symptoms as

characterized by DSM-V are psychiatric distress such as pervasive and uncontrollable

worry, emotional dysregulation, frustration, somatic complaints, and some studies

showed cognitive impairment (American Psychiatric Association, 2013). Studies have

found that many GAD patients are treated later and are reported to be associated with

other psychiatric comorbidities such as depression, panic disorder, PTSD, or other

psychological disorders when they come to professional help (Hirschfeld, 2001; Noyes,

R. Jr., 2001). Several factors can cause GAD such as childhood trauma (CT)

experiences and stressful life events (Liao et al., 2015; Sue Morton, 2020). CT criteria

include exposure to a stressful incident or a sequence of chronic traumatic events,

physical assault, mental abuse, and sexual abuse (Bremmer et al., 2007). Many studies

also show that CT greatly determines a person's brain development in later life and

mental health problems or psychopathology problems (De Bellis, 2001; Anda et al.,

2006; Brietzke et al., 2012; Bremner, 2006; Kascakova et al., 2020).

How childhood trauma turns into GAD requires a comprehensive explanation.

In general, it can be explained that childhood trauma can cause developmental

alterations in the brain, such as cortical or subcortical disorders and brain chemical

responses that affect hyperactivity in the limbic system (Liao et al., 2015; De Bellis et

al., 2014). The hyperactivity in limbic regions will cause the person to have consistent

arousal, to experience distress, distraction, and obstructions, or to continuously feel

 3

threatened or worried that something will happen. This condition then induces an

increase in cortisol output which creates a metabolic disturbance in the brain. High

levels of cortisol induced by the perception of trauma may activate brain anxiety and

dysregulation. This condition is well described as the top-down emotional

dysregulation as encountered by GAD patients such as attention deficit, maladaptive

evaluation of events, and hyperactivity (Patriquin & Matthew, 2017; Qiao, Li, Cao,

Wang, Sun & Xu, 2017). Long-term dysregulation experiments have demonstrated

that the synaptic function in the brain changes and also creates a biological stress system

during their lives (Liao et al., 2015; De Bellis et al., 2014; Martin et. al., 2009).

The region of the brain that brings concern is DLPFC which is found to be

related to GAD patients with early-life stress. The neuroimaging study revealed an

improvement in neuronal viability of the right Dorsolateral Prefrontal Cortex (DLPFC)

in GAD patients without early-life stress but decreased in GAD patients with early-life

trauma as assessed by proton MRS (Mathew et al., 2004). Studies showed that early

life stress or trauma impaired the severity of GAD as well as diminished brain neuronal

viability (Mathew et al., 2004). DLPFC is a cortex region in the brain that correlates

with social responses and cognitive performance, including concentration and working

memory (Mathew et al., 2016). In the brain, it plays a control role that has reciprocal

ties to limbic structures such as the amygdala, hippocampus, and prefrontal which are

structural changes in DLPFC that are reported to be associated with PTSD and has an

important role in psychological recovery from a severely traumatic event in humans

(Lyoo et al., 2011). In the top-down study and management of affection mechanisms

that influence the affection process, studies have shown that DLPFC also plays an

important role in improving the understanding of affection and modulating the

motivational response (Grisaru et al., 2001; Spielberg et al., 2008; De Raedt et al., 2010;
 4

Leyman et al., 2011; Banks et al., 2007; Goldin et al., 2008; Notzon et al., 2017; Wager

et al., 2008; Zwanzger et al., 2014). It is also involved in working memory processes,

executive functions such as shifting focus and inhibiting inappropriate responses,

controlling impulses, emotional emotions, and self-awareness (Craig, 2002; Critchley

et al., 2004; Moon et al., 2015).

Another study found that GAD was associated with a low level of Cho to N-

Acetylaspartate (NAA) in DLPFC that is strongly linked to the incidence of symptoms

and cognitive impairment and DLPFC concentrations of choline (Cho) were negatively

correlated with psychiatric evaluations using Hamilton Anxiety Rating Scale (HAM-

A) and Generalized Anxiety Disorder Scale 7 (GAD-7). Low levels of Cho/NAA in

DLPFC patients were found in GAD patients in another recent study, and this was

negatively associated with anxiety severity (Moon et al., 2015). The latest

neuroimaging experiments using fMRI have shown that hypoactivation in DLPFC in

GAD patients is correlated with emotional dysregulation and deficit in attentional

function throughout negative emotion regulation (Price et al., 2011; Ball et al., 2013).

H-MRSI studied made by Coplan et al., (2006) showed elevations of N-acetyl-

aspartate/creatine (NAA/CR) in the right dorsolateral prefrontal cortex (DLPFC) in

patients with a generalized anxiety disorder (GAD) in comparison to healthy

volunteers. It hypothesis that in compliance with the results of gray matter, GAD

patients will either experience elevated NAA in CSO relative to stable controls or

instead show decreases in choline concentrations.

In the brain, choline accelerates the synthesis and release of acetylcholine, a

protein that carries signals between brain cells and is important for memory and many

other brain functions such as memory and mood (Amenta et al., 2008; Sarter et al.,

2005). Choline is metabolized to form acetylcholine, a neurotransmitter that is mostly

 5

used by nerves regulating the breathing, heart rate, and skeletal muscles that is a critical

metabolite that can be used as an indicator of acetylcholine levels in the brain (Mathew

et al., 2015). Therefore, its effect on acetylcholine and dopaminergic activity, which

has a crucial position in neurotransmitter function (Geurts et al., 2004). Choline also

plays a crucial role in the control of gene expression, sleep disruption therapy, and

creatine acceleration. Choline dysfunction can result in cognitive impairments,

including memory deficits and poor concentration (Moon et al., 2015).

Besides DLPFC, centrum semiovale (CSO) white matter is brought to concern

because it impacts membrane MRSI metabolite concentrations and forms the nucleus

of the cerebral hemisphere's central white matter (Coplan et al., 2006). CSO is the

central region of white matter located below the cerebral cortex made up of axons and

some dysfunction in this region was found related to mild traumatic brain injury (Boyd,

2014). A study reported that CT could inhibit the myelination in axons which was

associated with white matter in the brain (De Bellis & Zisk, 2014). While the GAD-

related CSO analysis was still uncommon and unclear, a study found that the choline

metabolite in CSO decreased in GAD patients without early trauma relative to healthy

volunteers, and GAD with early trauma had higher CSO choline than GAD subjects

without early trauma (Coplan et al., 2006, 2012). The study also shows that decreases

in the amounts of choline and cr metabolites, which are inversely correlated with the

symptoms of GAD.

The most common treatments for trauma and GAD are pharmacotherapy and

psychotherapy (Bandelow et al., 2017). Commonly used psychotherapy such as

cognitive-behavioral therapy (CBT); family therapy; psychodynamic; eye movement

desensitization and reprocessing (EMDR), narrative therapy, exposure therapy,

psychoeducation, and supportive therapy (Gillies et al., 2016; Bandelow et al., 2013;
 6

Crits-Christoph et al., 2004). In addition to the commonly used psychotherapy, this

study will highlight one of Jung's psychodynamic approaches namely the Jungian

Sandplay therapy (SPT). SPT is a Jungian psychodynamic approach used to treat

several mental health problems in children and adults efficiently (Roesler, 2018) which

is a psychotherapy modality that has been proven to be effective in treating anxiety

symptoms (Jang & Kim, 2012; Lee & Kowen, 2016; Foo et al., 2017; Foo et al., 2020).

There are some important aspects of SPT that have the potential to be effective

in the treatment of GAD with CT. SPT is considered as non-verbal and non-

interpretative therapy which can access areas that cannot be accessed by a verbal

approach. This approach becomes important because people with GAD or trauma

frequently have trouble communicating themselves, and the anxiety problems they have

encountered often occur from intrapsychic disputes that emerge from the region below

their level of consciousness and without a clear cause (Portman, 2009). These issues

could be overcome because the non-verbal and non-interpretive aspect of the SPT offers

a deep focused, multisensory, safe, and clear access for GAD patients with CT to

articulate themselves (Weinrib, 2004; Kalff,2003). The other aspect of SPT is the play

method which creates a free exploration and creates an imaginative world as an

expression of their feelings in the sand and promotes the development of plasticity in

the brain (Steward et al., 2016; Perry & Szalavitz, 2006; Siviy, 2018; Baarendse, et al.,

2013). Freedle (2017) suggests that playing in the sand tray has helped highly distressed

people to relieve their conditioned fear response, as well as to encourage neural

integration and well-being. Moreover, SPT has the capability to process a bottom-up

and top-down in processing anxiety and trauma (Yeh et al, 2015; Allen, 2018). The

bottom-up and top-down processes are achieved by enhancing the sensory system and

the emotional right brain through sand media and 3D miniature stimulants used in the
 7

treatment. Through these media, the unconscious conflict that is induced from fear and

painful memory or trauma was brought into attention. At the conscious level on top-

down process, the client is working out their dilemma without feeling judged by the

therapist. The genuine therapist closely observes the process and records verbal and

non-verbal cues to ensure the well-being of the client, and provides the patient a

corrective emotional experience (Carey, 2006; Homeyer & Sweeney, 2011; Turner,

2005).

Various sandplay therapy studies have been performed in treating anxiety

symptoms and GAD, but limited studies have been conducted to examine

improvements and change in the brain's neural pathways. Akimoto, Furukawa, and Ito

(2018) used NIRS to study the cortical brain system involved in SPT (near-infrared

spectroscopy). The single-case research showed that in both hemispheres, SPT caused

several associations between multiple brain regions. A complex pairing of the

prefrontal and temporal regions (fronto temporal network) showed the most noteworthy

result, showing how sandplay enables the recovery and reprocessing of memories with

an optimum amount of cognitive power. Another study by Foo et al. (2020) showed an

improvement in the NAA/Cr ratio in the thalamus following sandplay therapy (SPT),

and randomized clinical trials confirmed that SPT was successful in substantially

decreasing GAD symptoms (Foo et al., 2017). However, SPT has not been performed

on GAD patients with childhood trauma to examine choline in DLPFC and choline

CSO. This study will also examine how SPT not only effectively improves anxiety

symptoms but also affects the increase in choline presented by DLPFC and CSO in

white matter.
 8

Method

Participants

This study used experimental pre-post design and used compared means in

statistical analysis. Participants were recruited by ads consisting of 6 females (aged 21-

40) years and 1 male (aged 40 years) who met the participation criterion, diagnosed

GAD with early childhood abuse based on the DSM-V criteria, and no medications or

substances used in this sample. The procedure has been clarified and informed consent

has been granted before further procedures. SPT care was completed at the Perhati

Clinic in North Jakarta, Indonesia.

Participants underwent a psychological interview and self-report using the Early

Trauma Inventory Self Report-Short Form (ETISR-SF) to monitor early childhood

trauma. All participants met the criteria of early trauma including general trauma,

physical assault, mental abuse, and sexual abuse. The total score ETISR-SF of each

participant ≥ 4 (M=12.5). Clinical assessment using the Hamilton Anxiety Rating Scale

(HAM-A) and Generalized Anxiety Disorder Scale 7 (GAD-7) was conducted to

evaluate the level of anxiety encountered before therapy and MRS testing. Pre-

assessment was conducted before therapy with SPT and MRS. The post-assessment

was carried out after 30 sessions of therapy with SPT and MRS. Healthy control MRS’s

measurement was taken twice. The first taken was at the beginning and the second after

210 days of waiting.

 9

Table 1.
Demography and Clinical Assessment (intake)
Gender Age ETISR-SF HAM-A GAD-7
a Female 21 12 33.67 19.67
b Female 23 13 39.33 19
c Female 23 15 30.67 18
d Female 35 11 29.33 18.67
e Male 35 19 43.30 18.67
f Female 40 14 37.00 13
g Female 40 4 42.33 17

Procedure

Participants filled admission forms and interviewed before the evaluation of 3

psychologies before the therapy session. After a psychological assessment has been

conducted, participants will be given one hour of the session at each meeting.

MRS

MRS is a non-invasive method used to measure the metabolite assessment by

measuring the peak intensities of such metabolites to evaluate a wide variety of brain

processes (Trześniak, et. al, 2008). Subjects were tested using an MRS scanner GE 1.5

T Signa HDxt Optima Variant scanner with a multi-volume MRS proton imaging

sequence. These scans were carried out using a T2-weighted axial imaging plan. Both

pre-and post-treatment MRS measurements were done by a qualified and autonomous

radiologist at Bethsaida Hospital, Tangerang. The object of the study was not to be

revealed to the radiologist. The results of the scan were obtained before and after each

step, followed by choline measurements within the region of interest (ROI) on both the

left and the right CSO and DLPFC.

Clinical Assessment

Hamilton-Anxiety Rating Scale (HAM-A) (Hamilton, 1959) is a 14-item

psychological appraisal scale commonly used in clinical trials for the assessment of
 10

anxiety severity. The fourteen elements assessed are anxiety, stress, terror, insomnia,

intellectual, depressive mood, somatic (muscular and sensory), cardiovascular,

pulmonary, gastrointestinal, genitourinary, autonomic, and behavioral symptoms. Each

item is graded on a scale from 0 (not present) to 4 (severe) where the optimal HAM-A

score range is: mild anxiety for 8-14, moderate anxiety for 15-23, and severe ≥ 24. The

Cutoff score of 24 or higher was used as the GAD criterion (Matza et al, 2010).

Generalized Anxiety Disorder-7 Scale (GAD-7) (Spitzer et al., 2006) is a 7-item

self-report assessment of anxiety symptoms (following DSM-IV criteria) seriousness

and frequency over the past 2 weeks. Objects are scored from 0 (not at all) to 3 on a 4-

point Likert scale (nearly every day). Cut-off score >9 was used as the GAD criterion

(Plummer et al., 2016). During the study, three professional psychologists qualified in

the use of HAM-A dan GAD-7 using a blind appraisal approach were assessed.

Childhood Trauma

Childhood trauma analyzed using the Early Trauma Inventory-Self Assessment

Short Form (ETISR-SF) consists of 27 items that measure four forms of early childhood

trauma incidents, including general trauma (11 items), physical assault (5 items),

mental abuse (5 items), and sexual abuse (5 items) (6 items). Each of the things replied

yes (coded as 1) or no (coded as 0) (Bremmer et al, 2007). The cut-off score of the

ETISR-SF > 4.
 11

Result

Table 2.
Clinical Assessment and MRS Before and After Treatment
GAD with CT Healthy
Measurement T1 T2 T1 T2
HAM-A 36.52 14.95 2.7 3
GAD-7 17.71 7.80 2 1
Choline
Right DLPFC 1,413.14 7,663.14 5,480 35,480
Left DLPFC 1,288.43 8,172.57 4,628 27,672
Right CSO 2,826.57 15,363.71 8,448 44,142
Left CSO 2,342.14 16,762.43 44,779 33,951

Clinical Assessment

Results of clinical trials revealed reduced signs of anxiety. The results (figure

1) of the HAM-A (T1=36.52; T2=14.95) and GAD-7 (T1=17.71; T2=7.80)

measurements showed that from the first evaluation, the average score of the individual

had declined in the therapeutic range for anxiety. At the endpoint of the analysis, the

average score dropped below the therapeutic cut-off to the standard range.

Figure 1.
Clinical assessment for GAD
 12

MRS

Dorsolateral Prefrontal Cortex (DLPFC)

The result of MRS (figure 2 and figure 3) showed a significant increase in

choline levels in the right (T1=1413.14; T2= 7663.14) and left hemispheres

(T1=1,288.43; T2=8,172.57) of DLPFC in GAD participants with CT after SPT

treatment. All participants' choline levels were out of the healthy range before treatment

and moved into the healthy control range after treatment.

Figure 2. Figure 3.

Centrum Semiovale (CSO)

The results of MRS (figure 4 and figure 5) showed elevated choline levels in

the right (T1= 2,826.57; T2=15,363.71) and the left (T1=2,342.14; T2=16,762.43)

hemisphere of CSO in GAD participants with CT after SPOT treatment. All

participants' choline levels were out of the healthy range before treatment and choline

levels in the right hemisphere of the CSO were moved into the healthy control range

(8,448 - 44,142). The choline levels in the left hemisphere of CSO seem to move to

the healthy control range but not yet reach into the healthy control range.
 13

Figure 4. Figure 5.

Discussion

The results of this study indicate that choline levels in the left and right

hemisphere of GAD participants with CT in DLPFC and CSO after SPT treatment were

improved. This result is also reflected in the visible improvement of the symptoms of

anxiety which has decreased and can be seen from the clinical assessments (HAM-A

and GAD-7). The findings are consistent with the results of the study by Moon et al

(2015) and the previous study of Foo et al., (2017, 2020). This improvement implies a

possibility that SPT will be affected in the treatment of GAD with CT. This can be

explained because the sandplay therapy approach offers a safe and protected space

(Kalff, 2003), and bottom-up and top-down processes provide experiences that allow

GAD patients with CT to become more emotionally regulated. Thus, the mechanism of

cognition also increases with improved self-regulation as the cognition process also

gets better along with better self-regulation.

Although the results of this study indicate that there is an improvement in

choline levels, these results still require further study with a larger number of subjects

to provide a clearer understanding of the metabolite analysis in the brain. Both CSO

and DLPFC on healthy control showed a wide range, these probably related to the small

size samples, therefore a large number of subjects were needed for the future study.
 14

The findings of this study suggest that SPT is modality helps the participants

with CT dealing with the anxiety symptoms and increases the levels of choline levels

in both hemispheres of DLPFC and CSO. However, the results of the choline level in

the left CSO of participants GAD with CT have not reached the healthy control range

as expected. This may be related to a small size of healthy controls. A balanced number

of healthy control subjects were suggested to give a better result. Moreover, this study

further shows that SPT can be used as an alternative not only for treating GAD patients

but also with childhood trauma. Another speculative reason can be due to the

complexity in the brain related to lateralization and the possibility of a gap level of CT

for each different participant. Therefore, it would be good if the CT levels of the

subjects were not so different in future experiments.

Although the findings of choline in CSO that reflect white matter in the brain

tend to have increased, experiments with a higher number of participants are highly

needed and other areas of white matter in the brain may be impaired by the complexities

of childhood trauma that effects later develop into GAD. Besides, white matter is an

important region that is still rarely studied but seems to have an important role in

childhood trauma especially a study-related to myelination in the brain.

 15

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