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Cognitive behavioral therapy in anxiety disorders: Current state of the evidence

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A plethora of studies have examined the efficacy and effectiveness of cognitive-behavioral therapy (CBT) for adult anxiety disorders. In recent years, several meta-analyses have been conducted to quantitatively review the evidence of CBT for anxiety disorders, each using different inclusion criteria for studies, such as use of control conditions or type of study environment. This review aims to summarize and to discuss the current state of the evidence regarding CBT treatment for panic disorder, generalized anxiety disorder, social anxiety disorder, obsessive-compulsive disorder, and post-traumatic stress disorder. Overall, CBT demonstrates both efficacy in randomized controlled trials and effectiveness in naturalistic settings in the treatment of adult anxiety disorders. However, due to methodological issues, the magnitude of effect is currently difficult to estimate. In conclusion, CBT appears to be both efficacious and effective in the treatment of anxiety disorders, but more high-quality studies are needed to better estimate the magnitude of the effect.
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Introduction
nxiety disorders are characterized by excessive
fear and subsequent avoidance, typically in response to
a specified object or situation and in the absence of true
danger. Anxiety disorders have a high prevalence, with
a 12-month rate of about 18% and lifetime rates of
about 29%.
1,2
Cognitive behavioral therapy (CBT) is
considered the gold standard in the psychotherapeutic
treatment of anxiety disorders and several meta-analy-
ses and reviews of these meta-analytic findings regard-
ing the efficacy and effectiveness of CBT have been pub-
lished in recent years.
3-9
CBT is defined as:
An amalgam of behavioral and cognitive interventions
guided by principles of applied science. The behavioral inter-
ventions aim to decrease maladaptive behaviors and
increase adaptive ones by modifying their antecedents and
consequences and by behavioral practices that result in new
learning. The cognitive interventions aim to modify mal-
adaptive cognitions, self-statements or beliefs. The hallmark
features of CBT are problem-focused intervention strategies
that are derived from learning theory [as well as] cognitive
theory principles.
8,10
While it is beyond the scope of this article to review spe-
cific treatment components of CBT, they generally
include various combinations of the following: psychoe-
Clinical research
A
Cognitive behavioral therapy in anxiety
disorders: current state of the evidence
Christian Otte, MD
Keywords:
cognitive-behavioral therapy; psychotherapy; meta-analysis; anxiety
disorder; panic disorder; generalized anxiety disorder; obsessive-compulsive disor-
der; acute stress disorder; post-traumatic stress disorder
Author affiliations: Department of Psychiatry, University Medical Center
Hamburg-Eppendorf, Hamburg, Germany
Address for correspondence: Christian Otte, MD, University Hospital
Hamburg-Eppendorf, Dept of Psychiatry and Psychotherapy, Martinistrasse 52,
20246 Hamburg, Germany
(e-mail: christian.otte@charite.de)
A plethora of studies have examined the efficacy and effec-
tiveness of cognitive-behavioral therapy (CBT) for adult
anxiety disorders. In recent years, several meta-analyses
have been conducted to quantitatively review the evidence
of CBT for anxiety disorders, each using different inclusion
criteria for studies, such as use of control conditions or type
of study environment. This review aims to summarize and
to discuss the current state of the evidence regarding CBT
treatment for panic disorder, generalized anxiety disorder,
social anxiety disorder, obsessive-compulsive disorder, and
post-traumatic stress disorder. Overall, CBT demonstrates
both efficacy in randomized controlled trials and effec-
tiveness in naturalistic settings in the treatment of adult
anxiety disorders. However, due to methodological issues,
the magnitude of effect is currently difficult to estimate.
In conclusion, CBT appears to be both efficacious and effec-
tive in the treatment of anxiety disorders, but more high-
quality studies are needed to better estimate the magni-
tude of the effect.
© 2011, LLS SAS
Dialogues Clin Neurosci.
2011;13:413-421.
413
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Clinical research
ducation about the nature of fear and anxiety, self-mon-
itoring of symptoms, somatic exercises, cognitive restruc-
turing (eg, logical empiricism and disconfirmation),
imaginal and in vivo exposure to feared stimuli while
weaning from safety signals, and relapse prevention.
8
Depending on the specific anxiety disorder, these CBT
techniques are weighted differentially during therapy.
A plethora of studies have examined the efficacy of
CBT for adult anxiety disorders. Furthermore, several
meta-analyses have been conducted to quantitatively
review the evidence of CBT for anxiety disorders.
4,6,9,11
In
meta-analysis, treatment efficacy is quantified in terms
of an effect size. An effect size indicates the magnitude
of an observed effect in a standard unit of measurement.
However, it is important to realize that different types
of effect sizes can be used to appraise the available evi-
dence. For instance, effect sizes are sometimes catego-
rized as “controlled” versus “uncontrolled.
4
A con-
trolled effect size expresses the magnitude of a specific
treatment effect as compared with alternative treat-
ments or control conditions. Most often, it is calculated
by subtracting the post-treatment mean of the control
group from the post-treatment mean of the treatment
group divided by the pooled standard deviation. This
effect size is called Cohen’s d.
12
An uncontrolled effect
size expresses the magnitude of improvement within a
group from pretreatment to post-treatment. It is calcu-
lated by subtracting a group’s post-treatment mean from
its pretreatment mean divided by the pooled standard
deviation. Uncontrolled effect sizes are less preferable
than controlled effect sizes, since they are susceptible to
threats to internal validity.
4
Meta-analytic reviews of CBT studies in anxiety disor-
ders have generally found large effect sizes for the
majority of treatment studies. Accordingly, recent
reviews that summarized the results of these numerous
meta-analyses of CBT treatment in anxiety disorders
concluded that CBT is highly effective.
3,4,13
However, these existing meta-analyses are not without
limitations. In particular, most meta-analyses of CBT for
anxiety disorders have included studies that vary greatly
with respect to control procedures, which range from
waitlist, alternative treatments, and placebo interventions
that were evaluated with or without randomization while
some studies did not include any control groups.
However, it is important to determine how including a
control condition and their specific nature impacts the
efficacy results of CBT in anxiety disorders. Furthermore,
one important question is how results derived from
research studies in mostly well-controlled research
designs (efficacy) generalize to real-world settings in nat-
uralistic surroundings (effectiveness).
Therefore, this review will particularly focus on two
recent meta-analyses by Hofmann
6
and by Stewart
11
regarding CBT treatment for panic disorder, generalized
anxiety disorder, social anxiety disorder, obsessive-com-
pulsive disorder, and post-traumatic stress disorder.
The first meta-analysis
6
limited the included studies to
randomized placebo-controlled trials, the gold standard
in clinical outcome research. For example, the Federal
Drug Administration (FDA) in the United States and the
European Medicines Agency (EMA) require successful
randomized placebo-controlled double-blind trials in
order to approve a new medication. Pharmacotherapy
trials typically administer a sugar pill to individuals in the
placebo condition. Instead of including a pill placebo, a
number of psychotherapy trials have employed psycho-
logical placebo conditions to control for nonspecific fac-
tors. To be included in the meta-analysis,
6
the psycholog-
ical placebo had to involve interventions to control for
nonspecific factors (eg, regular contact with a therapist,
reasonable rationale for the intervention, discussions of
the psychological problem). Although it is almost impos-
sible to protect the blind in placebo-controlled psy-
chotherapy trials, the randomized placebo-controlled
design is still the most rigorous and conservative test of
the effects of an active treatment. This approach assesses
the overall efficacy of CBT in anxiety disorders under
well-controlled research conditions. Overall, 27 studies
met inclusion criteria: n=7 for social anxiety disorder, n=6
for post-traumatic stress disorder, n=5 for panic disorder,
n=4 for acute stress disorder, n=3 for obsessive-compul-
sive disorder, and n=2 for generalized anxiety disorder.
As a controlled effect size, Hedges’ g was calculated,
which is a variation of Cohen’s d taking into account
small sample sizes.
In contrast to well-controlled efficacy studies in research
settings, effectiveness studies examine how efficacious
interventions are transferred into naturalistic real-world
settings. Research treatments might not work equally
well in clinical practice settings because of greater dis-
ease severity, or more comorbid conditions in patients in
general practice compared with patients in research set-
tings. Another variable that might impact the outcome
in naturalistic settings is the treatments themselves and
the clinicians who provide them. Treatment protocols in
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randomized controlled trials are manualized and strictly
monitored with an emphasis on treatment integrity.
However, therapy manuals are less likely to be used in
clinical practice. Furthermore, practitioners typically do
not have access to the level of intensive training, moni-
toring, and supervision available to therapists in research
settings. Clinicians in research settings are more likely to
be expert in the administration of particular treatments
and are motivated through adherence measures to stay
consistent with the protocol. In summary, treatments
delivered in naturalistic settings may not be as rigorous
in terms of content or quality, and this may limit how
well results of controlled research trials can generalize
to actual clinical practice. Therefore, it is important to
empirically examine how well findings from research
studies (efficacy) translate into real-world settings (effec-
tiveness). Thus, in the second meta-analysis,
11
56 effec-
tiveness studies were included to assess how CBT treat-
ment works in less well-controlled real-life settings. CBT
was defined broadly and included any treatment with
cognitive, behavioral (eg, exposure), or a combination of
components. In sum, a total of 56 studies were included
in these analyses: 17 for panic disorder; 11 each for social
anxiety disorder, OCD, and GAD; and 6 for PTSD. No
study assessed effectiveness in acute stress disorder.
We will present and contrast the meta-analytically derived
controlled and uncontrolled effect sizes reflecting the effi-
cacy and effectiveness results for each anxiety disorder.
Results
Panic disorder
Panic attacks are defined as sudden spells of unidenti-
fied feelings consisting of at least four out of 13 symp-
toms such as palpitations, chest pains, sweating, shortness
Figure 1. Average effect size estimates and corresponding 95% confidence intervals of the acute treatment efficacy of cognitive-behavioral ther-
apy as compared with placebo on the various anxiety disorders for the primary continuous anxiety measure (dark blue bars) and depres-
sion measures (light blue bars)
Adapted from ref 6: Hofmann SG, Smits JA. Cognitive-behavioral therapy for adult anxiety disorders: a meta-analysis of randomized placebo-controlled tri-
als. J Clin Psychiatry. 2008;69:621-632. Copyright © Physicians’ Postgraduate Press, 2008
Effect size (Hedges’ g)
Acute stress dis.
Obsessive-compulsive dis.
Post-traumatic stress dis.
Social anxiety dis.
Generalized anxiety dis.
Panic disorder
0.0 0.5 1.0 1.5 2.0 2.5
Depression
Anxiety
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of breath, feelings of choking, trembling, nausea, dizzi-
ness, paresthesias, chills or hot flushes, depersonalization
or derealization, and fear of dying or losing control. In
order to make a diagnosis of panic disorder, additional
criteria are that these attacks at least once have been
unexpected, followed by at least 1 month of fearful
expectation or concern about the consequences of an
attack. Panic disorder is frequently followed (or accom-
panied) by agoraphobia, which is defined as follows: (i)
fear of being in places or situations from which escape
might be difficult or help might not be available; (ii)
these situations are avoided or endured with marked dis-
tress or the patient needs a companion.
CBT for panic disorder typically involves education
about the nature and physiology of the panic response,
cognitive therapy techniques designed to modify cata-
strophic misinterpretations of panic symptoms and their
consequences, and graduated exposure to panic-related
body sensations (ie, interoceptive exposure) and avoided
situations.
Efficacy
Five studies examined the efficacy of CBT in panic dis-
order in a randomized placebo-controlled design.
6
The
effect size was 0.35 (95% CI 0.04-0.65), indicating a small
to medium effect (Figure 1). How important it is to take
into account the type of effect size when appraising the
magnitude of effect can be seen from a different meta-
analysis that calculated uncontrolled pre- to post-treat-
ment effect sizes.
9
That meta-analysis reported an effect
size of 1.53 for CBT in panic disorder.
Effectiveness
Several studies examined the effectiveness of CBT in
panic disorder.
11
The calculated uncontrolled pre- to post-
treatment effect size was 1.01 (95% CI 0.77-1.25) for
panic attacks and 0.83 (95% CI 0.60-1.06) for avoidance.
Generalized anxiety disorder
Generalized anxiety disorder is marked by excessive and
uncontrollable worry. It is believed to be maintained by
cognitive (attention and judgment) biases toward threat-
relevant stimuli and the use of worry (and associated
tension) and overly cautious behaviors as a means to
avoid catastrophic images and associated autonomic
arousal.
8
CBT of generalized anxiety disorder involves
cognitive therapy to address worry and cognitive biases
and relaxation to address tension, as well as imaginal
exposure to catastrophic images and exposure to stress-
ful situations while response preventing overly cautious
behaviors.
Efficacy
The controlled effect size for CBT in generalized anxiety
disorder was 0.51 (95% CI 0.05-0.97), indicating a medium
effect (Figure 1) although only two studies using a ran-
domized controlled design to examine CBT treatment in
patients with generalized anxiety disorder were available.
Nevertheless, these results were recently corroborated by
a Cochrane meta-analysis examining psychological treat-
ments of generalized anxiety disorder.
14
Based on thirteen
studies, the authors concluded that psychological therapies,
all using a CBT approach, were more effective than treat-
ment as usual or wait list control in achieving clinical
response at post-treatment (RR 0.64, 95%CI 0.55-0.74).
However, those studies examining CBT against support-
ive therapy (nondirective therapy and attention-placebo
conditions) did not find a significant difference in clinical
response between CBT and supportive therapy at post-
treatment (RR 0.86, 95%CI 0.70 to 1.06).
Again, the meta-analysis calculating uncontrolled pre-
to post-treatment effect sizes found much a larger over-
all effect size of 1.80.
9
Effectiveness
In eleven effectiveness studies, the pre- to post treatment
effect size for CBT in generalized anxiety disorder was
0.92 (95% CI 0.77-1.07).
Social anxiety disorder
Social anxiety disorder (or social phobia) is characterized
by marked fear of performance, excessive fear of scrutiny,
and fear of acting in a way that may be embarrassing.
Most patients are oversensitive to the assumed opinion
of others and have a low self-esteem, although they feel
their fears are exaggerated and out of proportion. Going
through the feared situations, or even anticipating them,
most people suffer from physical symptoms like sweat-
ing, trembling, or blushing, and these symptoms can
become a trigger on their own to worry about social con-
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sequences. CBT for social phobia typically emphasizes
cognitive restructuring and in vivo exposure to feared
social situations. Patients are instructed in identifying and
challenging their beliefs about their social competence
and the probability of experiencing negative social eval-
uation and consequences. In vivo exposures provide
opportunities to confront feared and avoided social
encounters and to practice social skills.
Efficacy
In seven randomized placebo-controlled treatment stud-
ies, the effect of CBT in social anxiety disorder was 0.62
(95% CI 0.39-0.86, Figure 1) indicating a medium effect.
In a separate meta-analysis, the uncontrolled pre- to
post-treatment acute treatment effect size was 1.27.
9
Effectiveness
In eleven effectiveness studies, the uncontrolled pre- to
post-treatment effect size was 1.04 (95% 0.79-1.29).
5
Post-traumatic stress disorder
The DSM-IV definition for post-traumatic stress disor-
der (PTSD) contains criteria for: (i) the traumatic expe-
rience; (ii) re-experiencing; (iii) avoidance of associated
stimuli and numbing; and (iv) increased arousal. CBT
for PTSD typically includes three components: (i) psy-
choeducation about the nature of fear, anxiety, and
PTSD; (ii) controlled, prolonged exposure to stimuli
related to the traumatic event; and (iii) cognitive
restructuring, processing, or challenging of maladaptive
beliefs/appraisals.
Efficacy
In six randomized placebo-controlled efficacy trials of
CBT in PTSD, the controlled effect size was 0.62 (95%
CI 0.28-0.96), indicating a medium effect. A recent
Cochrane analysis of psychological treatment in PTSD
15
supported these findings and found that trauma-focused
CBT was more effective than treatment as usual or wait
Figure 2. Average odds ratios of acute treatment response to cognitive-behavioral therapy as compared with placebo. *, P<0.05; **, P<0.01
Adapted from ref 6: Hofmann SG, Smits JA. Cognitive-behavioral therapy for adult anxiety disorders: a meta-analysis of randomized placebo-controlled tri-
als. J Clin Psychiatry. 2008;69:621-632. Copyright © Physicians’ Postgraduate Press, 2008
Odds ratio
*
**
**
**
**
Acute stress dis.
Obsessive-compulsive dis.
Post-traumatic stress dis.
Social anxiety dis.
Generalized anxiety dis.
Panic disorder
0 2 4 6 8 10 12 14
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list control. The uncontrolled effect size derived from a
separate meta-analysis was 1.86.
9
Effectiveness
Six studies examined the effectiveness of CBT in the
treatment of PTSD
5
and found an uncontrolled pre- to
post-treatment effect size of 2.59 (95% CI 2.06-3.13).
Acute stress disorder
Acute stress disorder is an anxiety disorder character-
ized by a cluster of dissociative and anxiety symptoms
that occur within a month of a traumatic stressor. Acute
stress disorder may be diagnosed in patients who (i)
lived through or witnessed a traumatic event to which
they (ii) responded with intense fear, horror, or help-
lessness, and are (iii) currently experiencing three or
more of the following dissociative symptoms: psychic
numbing, being dazed or less aware of surroundings,
derealization, depersonalization, or dissociative amne-
sia.
Efficacy
In four randomized placebo-controlled efficacy trials of
CBT in acute stress disorder, the controlled effect size
was 1.31 (95% CI 0.93-1.69) indicating a large effect.
Consistent with these results, a recent Cochrane meta-
analysis concluded that there was evidence that individ-
ual trauma-focused CBT was effective for individuals
with acute traumatic stress symptoms compared with
both waiting list and supportive counseling interven-
tions.
16
Effectiveness
No effectiveness data were available/included in the
meta-analysis of CBT treatment in acute stress disorder.
5
Obsessive-compulsive disorder
Obsessive-compulsive disorder (OCD) is defined as the
presence of recurrent obsessions (persistent thoughts,
impulses, or images) or compulsions (repetitive behav-
ior or thought patterns induced in an attempt to prevent
anxiety) that are excessively time-consuming (taking
more than an hour a day) or cause marked distress or
significant impairment. The subject recognizes that these
patterns are excessive. Components of CBT in the treat-
ment of OCD include exposure and response prevention
as well as cognitive interventions.
3
Efficacy
Three studies examined CBT treatment in OCD in a
randomized placebo-controlled design. The controlled
effect size was 1.37 (95% CI 0.64-2.20) indicating a large
effect, in fact the largest effect size for CBT in any of the
anxiety disorders (Figure 1). However, the 95% confi-
dence interval was large due to the small numbers of
included studies (n=3). Interestingly, the uncontrolled
pre- to post-treatment effect size of 1.50 that was calcu-
lated in a separate meta-analysis
9
was only marginally
larger than the controlled effect size.
These results were corroborated by a Cochrane analysis
of eight studies, all of which compared cognitive and/or
behavioral treatments versus treatment as usual control
groups.
17
These studies demonstrated that patients
receiving any variant of cognitive behavioral treatment
exhibited significantly fewer symptoms post-treatment
than those receiving treatment as usual.
Effectiveness
Consistent with the acute efficacy effects of CBT in OCD,
eleven effectiveness studies found an uncontrolled effect
size of 1.32 (95% CI 1.19-1.45) in real-world settings.
5
Summary
According to recent meta-analyses examining CBT in
anxiety disorders in randomized placebo-controlled tri-
als
6
and in naturalistic real-life settings,
5
both the efficacy
and effectiveness of CBT for anxiety in adults appears
to be well established. These favorable effects of CBT
are further corroborated by several Cochrane analyses
of psychological treatments for several anxiety disor-
ders.
14-16
The controlled effect sizes from 27 randomized placebo-
controlled trials involving 1496 patients ranged from 0.35
in panic disorder (small effect) to 1.37 in obsessive-com-
pulsive disorder (large effect) indicating that CBT com-
pared favorably to placebo conditions in all anxiety dis-
orders. In post-hoc comparisons, the only significant
difference among the different anxiety disorders regard-
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ing the efficacy of CBT was between panic disorder and
obsessive-compulsive disorder. Furthermore, the effect
size for ASD was significantly greater relative to those
observed for all other anxiety disorders except OCD.
However, these results should be interpreted with cau-
tion given the small numbers of included studies for each
anxiety disorder (n of studies ranging from 2 to 7 for
each specific disorder).
Although this meta-analysis circumvented many method-
ological problems of other meta-analyses of psychother-
apy studies by including only randomized, placebo-con-
trolled trials, there still remained methodological issues
that need to be taken into account when appraising these
results. As indicated by the authors, a concerning issue is
the lack of intention-to-treat (ITT) analyses in most stud-
ies included. An ITT analysis is based on the initial treat-
ment intent, not on the treatment eventually administered.
ITT analysis is intended to avoid various misleading arti-
facts that can arise in intervention research. For example,
if people who have a more refractory or serious problem
tend to drop out at a higher rate, even a completely inef-
fective treatment may appear to be providing benefits if
one merely compares the condition before and after the
treatment for only those who finish the treatment (ignor-
ing those who were enrolled originally, but have since been
excluded or dropped out). For the purposes of ITT analy-
sis, everyone who begins the treatment is considered to be
part of the trial, whether he or she finishes it or not. This is
different from the completer or per-protocol analysis,
which only includes those patients finishing the trial. Thus,
the ITT analysis is a much more conservative measure and
is generally used in pharmacotherapy studies.
Not surprisingly therefore, in the meta-analysis of ran-
domized, placebo-controlled trials, pooled analyses using
data from ITT samples yielded much smaller effect sizes
than those derived from completer samples. In the com-
pleter sample, the overall Hedges’ g for anxiety disorder
severity was 0.73 (95% CI: 0.56–0.90 and the pooled
odds ratio for treatment response was 4.06 (95% CI:
2.78–5.92). However, in ITT analyses that were only pro-
vided for the minority of included studies, the Hedges’ g
for anxiety disorder severity was 0.33 (95% CI: 0.11–
0.54), and the odds ratio for treatment response was 1.84
(95% CI: 1.17–2.91). The authors of the meta-analysis
6
concluded the following:
Given the status of CBT as the gold-standard psychosocial
intervention for treating anxiety disorders, it is very surpris-
ing and concerning that after more than 20 years of CBT
treatment research, we were only able to identify 6 high-
quality randomized placebo controlled CBT trials that pro-
vided ITT analyses for continuous measures and only 8 tri-
als for ITT response rate analyses. In our opinion, this is an
unacceptable situation that will have to change for psy-
chosocial intervention to become a viable alternative to
pharmacotherapy in the medical community.
In 56 effectiveness studies of CBT in anxiety disorders in
naturalistic real-life settings, the (uncontrolled) effect
sizes ranged from 0.92 in generalized anxiety disorder to
2.59 in post-traumatic stress disorder. It is important to
keep in mind that these uncontrolled pre- to post-treat-
ment effect sizes cannot be readily compared with the
controlled effect sizes. Nevertheless, these effect sizes
seem to indicate that CBT also works in real-world set-
tings in the treatment of anxiety disorders. Again, in that
meta-analysis only 4 out of 56 included reports of inten-
tion-to-treat data, prohibiting a meaningful ITT-analysis.
Newer therapies for anxiety disorders include mindfulness-
based therapies. These therapies propose different
approaches for dealing with anxiety-related cognition,
including cognitive defusion (eg, distancing from the con-
tent of fear-based thinking) and mindfulness and accep-
tance, and are more contextually based. They are sometime
called the “third wave” of CBT. A recent meta-analysis
found that mindfulness-based therapy in patients with anx-
iety disorders was associated with a large effect size
(Hedges’ g) of 0.97 (95% CI: 0.72-1.22) for improving anx-
iety.
18
Thus, mindfulness-based therapy is a promising new
approach in the treatment of anxiety disorders.
Furthermore, pharmacological augmentation strategies
designed to enhance the learning that occurs with CBT
approaches for anxiety disorders may hold particular
promise. For example, recent studies demonstrated that
glucocorticoids administered 1 hour prior to therapy
sessions enhance extinction-based psychotherapy in
anxiety disorders.
19,20
Furthermore, d-cycloserine, a drug
used in the treatment of tuberculosis, has been shown
to enhance fear extinction in several preclinical studies
21
but also in clinical trials in patients with different anxi-
ety disorders.
22
Thus, combining exposure therapy with
pharmacological agents holds significant promise for
improving the efficacy of CBT.
Conclusion
Despite some weaknesses of the original studies, the quan-
titative literature review of randomized placebo-controlled
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trials and of trials in naturalistic treatment settings pro-
vides strong support for both the efficacy and effectiveness
of CBT as an acute intervention for adult anxiety disor-
ders. At the same time, the results also suggest that there
is still considerable room for further improvement of study
and analysis methods. Thus, the exact magnitude of effect
is currently difficult to estimate. Nevertheless, the meta-
analyses confirm that CBT is by far the most consistently
empirically supported psychotherapeutic option in the
treatment of anxiety disorders. Thus, CBT can be recom-
mended as a gold standard in the psychotherapeutic treat-
ment of patients with anxiety disorders.
420
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La terapia cognitivo conductual en los
trastornos ansiosos: situación actual de la
evidencia
Existen numerosos estudios que han examinado la
eficacia y efectividad de la terapia cognitivo con-
ductual (TCC) para los trastornos ansiosos del
adulto. En los últimos años se han efectuado varios
meta-análisis para revisar cuantitativamente la evi-
dencia de la TCC para los trastornos ansiosos, los
que han empleado diferentes criterios de inclusión
para los estudios, como el uso de condiciones con-
trol o el tipo de ambiente del estudio. El objetivo
de esta revisión es resumir y discutir la situación
actual de la evidencia en relación con el trata-
miento de la TCC para el trastorno de pánico, el
trastorno de ansiedad generalizada, el trastorno de
ansiedad social, el trastorno obsesivo compulsivo y
el trastorno por estrés postraumático. La TCC ha
demostrado globalmente eficacia en ensayos con-
trolados randomizados y efectividad en estudios
naturalísticos en el tratamiento de los trastornos
ansiosos del adulto. Sin embargo, debido a aspec-
tos metodológicos, la magnitud del efecto actual-
mente resulta difícil de estimar. En conclusión, la
TCC aparece como un tratamiento eficaz y efectivo
para los trastornos ansiosos, pero se requiere de
más estudios de alta calidad para una mejor esti-
mación de la magnitud del efecto.
Thérapie cognitivo-comportementale des
troubles anxieux : état actuel des
connaissances
Une pléthore d’études a examiné l’efficacité de la
thérapie cognitivo-comportementale (TCC) dans les
troubles anxieux de l’adulte. Ces dernières années,
plusieurs métaanalyses ont été menées pour exa-
miner quantitativement la preuve de l’efficacité des
TCC dans les troubles anxieux, chacune utilisant des
critères d’inclusion différents pour les études,
comme l’utilisation des conditions de contrôle ou le
type d’environnement de l’étude. Cet article a pour
but de résumer et analyser l’état actuel des connais-
sances sur la TCC des troubles paniques, des
troubles anxieux généralisés, des troubles anxieux
sociaux, des troubles obsessionnels compulsifs et de
l’état de stress post-traumatique. Globalement, la
TCC démontre une efficacité à la fois dans les
études contrôlées randomisées ainsi qu’en condi-
tions naturelles dans le traitement des troubles
anxieux de l’adulte. Cependant, l’amplitude de l’ef-
fet est actuellement difficile à évaluer du fait de
problèmes méthodologiques. Pour conclure, la TCC
semble être efficiente et efficace pour traiter les
troubles anxieux, mais il faut des études de
meilleure qualité afin de mieux estimer l’impor-
tance de son effet.
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No. 4
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2011
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... Many anxiety treatments exist, including anti-anxiety medications (selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, benzodiazepines) [9][10][11][12], cognitive strategies, behavioural approaches (cognitive behavioural therapy, exposure, relaxation), mindfulness and acceptance-based approaches [13][14][15]. However, response rates to antianxiety medication can be poor, many patients also can have negative side effects such as sexual dysfunction and it is difficult to predict reliably which patients will respond well and which will have a limited treatment response [10]. ...
... Although cognitive behavioural therapy has proven to be effective in treating anxiety [14,15], limited accessibility to treatment remains a challenge [13]. Additionally, the active anxiety treating component of cognitive behavioural therapy requires patients to face their fears without use of emotion modulation strategies [13]. ...
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... Some challenges of exposure therapies are related to the need to expose patients to what they fear most. This can be one of the reasons why many patients either avoid treatment in the first place, fail to complete the whole treatment, or experience relapse over time (Bouton, 2002;Craske et al., 2006;Hermans et al., 2006;Phelps et al., 2010;Davis, 2011;Otte, 2011;Schiller & Phelps, 2011;Milad et al., 2014;Grillon et al., 2019). Drug-based treatments are used as alternatives to exposure-based therapies, or may be used in conjunction with them, and involve the use of anxiolytic or antidepressants drugs (Bandelow et al., 2017;Gomez et al., 2018). ...
... Exposure therapies work in many cases, but not in all (Bouton, 2002;Craske et al., 2006;Hermans et al., 2006;Phelps et al., 2010;Davis, 2011;Otte, 2011;Schiller and Phelps, 2011;Milad et al., 2014;Grillon et al., 2019). Two main lines of thought on how to address this problem have so far dominated the field of fearlearning research and treatment. ...
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... It is estimated that up to one quarter of the North American population experiences an anxiety or related disorder in their lifetime (Somers et al., 2006). Anxiety can be effectively treated through psychological interventions, such as cognitive-behavioural therapy (Otte, 2011). However, only a small minority of people with anxiety seek treatment Olivia A. Merritt oliviamerritt@outlook.com 1 including decisions about anxiety and related disorders (e.g. ...
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... The findings in our study suggest the possibility of early introduction of behavioural and cognitive strategies as well as cognitive behavioural therapy (CBT) as soon as the catatonia has settled may be of some benefit in helping patients to manage the strong negative emotive experiences of catatonia. This is based on the current evidence of CBT for symptoms of anxiety, and it remains the psychologic treatment of choice for the majority of anxiety disorders [32][33][34][35][36]. This would also mean that instead of waiting until full remission of catatonia, which is the current practice, one would need to involve the psychology team in the multidisciplinary team management of the patient with catatonia earlier on. ...
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Background Catatonia is a severe psychomotor disorder that presents as abnormality of movement which may also be excessive or severely slowed. It often inhibits communication when protracted or severe. In this study we investigated the emotive and cognitive experience of patients with catatonia during a prevalence study in an acute mental health unit from August 2020 to September 2021. The value of this study is the addition of the inner and often unexplored cognitive and emotive experience of patients in the description of the catatonic state, which lends an additional dimension to complement the medical and psychopathological descriptors that have been the focus of most studies on catatonia. Methods Ethical approval was received from the Nelson Mandela University Human Research Committee and convenience sampling was undertaken to recruit participants admitted into an acute mental health unit with catatonia, four to eight weeks after discharge, following admission. The BFCSI and BFCRS and a pre-designed data collection sheet were used to assess n = 241 participants, and collect data on descriptions of thoughts, feelings, and behaviours they experienced during the catatonic episode. Results Forty-four (18.3%) of the total 241 participants who were assessed had catatonia. Thirty (68.2%) of the 44 participants with catatonia provided data on their experience of catatonia. Twenty-three were males (76.7% of 30) and seven were females (23.3% of 30). All were within the age range of 17 to 65 years. The dominant themes of thoughts, feelings, and behaviors described centered around yearning for or missing loved ones, heightened fear, intense anxiety, negative affect, aggression, obedience, and withdrawal. Conclusions The common themes that emerged from this study were overwhelming anxiety, fear, and depression. These were found to occur frequently in patients with catatonia when describing their psychological experience. These experiences may possibly relate to the flight, fight, freeze and fawn response, as described in prior studies on the subjective experience of catatonia. Trial registration : Not applicable.
... Stress management techniques are already recommended as part of occupational therapy interventions for adults with ADHD in the United Kingdom (Adamou et al., 2021). Stress management interventions such as mindfulness-based stress reduction training or cognitive behavioural therapy have been found to effectively reduce stress and improve wellbeing in individuals suffering from depression or anxiety (Carpenter et al., 2018;Chi et al., 2018;Otte, 2011), however, to date, little is known about the efficacy of such techniques for preventing the development of internalising problems as secondary to ADHD symptoms. ...
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... Antidepressants are effective treatments for depression and anxiety disorders and are widely used treatments [6,7], but there are significant problems with adherence: some studies estimate over 70% of people prescribed antidepressants do not adhere to treatment [8]. Psychological therapies, such as cognitive behavioural therapy (CBT), have been shown to be effective in reducing symptoms of CMDs, with acute phase effects similar, and long-term effects potentially superior, when compared to pharmacotherapy [9,10]. Furthermore, patients often express a preference for these therapies over medication [11]. ...
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Objective The study aimed to ascertain the comparative efficacy of these two forms on reducing anxiety scores of scales in patients with a generalized anxiety disorder (GAD) by examining the available evidence for face-to-face cognitive behavior therapy (CBT) and internet-based cognitive behavior therapy (ICBT). Moreover, this study attempted to determine whether ICBT can obtain similar benefits as CBT for GAD patients during coronavirus disease 2019 (COVID-19) due to the quarantine policy and the requirement of social distance.Methods This meta-analysis was registered with the International Prospective Register of Systematic Reviews (PROSPERO) according to the guidelines in the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement (registration number CRD42021241938). Therefore, a meta-analysis of randomized controlled trials (RCTs) examining CBT or ICBT was conducted in this study to treat GAD patients diagnosed with DMS-IV. The researchers searched PubMed, MEDLINE, Embase, PsycINFO, and the Cochrane Database of Systematic Reviews for relevant studies published from 2000 to July 5, 2022. Evidence from RCTs was synthesized by Review Manager 5.4 as mean difference (MD) for change in scores of scales through a random-effects meta-analysis.ResultsA total of 26 trials representing 1,687 participants were pooled. The results demonstrated that ICBT and CBT were very close in the effect size of treating GAD (MD = −2.35 vs. MD = −2.79). Moreover, they still exhibited a similar response (MD = −3.45 vs. MD = −2.91) after studies with active control were removed.Conclusion Regarding the treatment of GAD, ICBT can achieve a similar therapeutic effect as CBT and could be CBT's candidate substitute, especially in the COVID-19 pandemic era, since the internet plays a crucial role in handling social space constraints.Systematic Review Registrationhttps://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=241938, identifier CRD42021241938.
Chapter
Significant progress has been made in the expansion of our understanding of the biological basis of anxiety disorders. Preclinical research examining the biological basis of fear learning, emotional memory regulation, and the expression of fear in animal models has, in conjunction with clinical research in patients with anxiety disorders, promoted the development of a biologically based understanding of the pathophysiology of fear-related anxiety disorders and suggested points of clinical intervention that may yield novel treatments for these disorders. This chapter will review the historical classification, clinical manifestations, psychobiology, and treatment of anxiety disorders, with an emphasis on fear-related anxiety disorders and posttraumatic stress disorder.
Article
Cognitive behavioural therapy (CBT) is an active, problem-focused, and time-sensitive approach to treatment that aims to reduce emotional distress and increase adaptive behaviour in patients with a host of mental health and adjustment problems. Cognitive behavioural therapists deliver interventions in a strategic manner, such that interventions emerge from the customized case formulation of the patient’s clinical presentation, are delivered in a collaborative manner with the patient, are designed to move patients forward and directly towards meeting their treatment goals, It has been shown to be effective for a wide variety of mental health disorders, including anxiety disorders, Attention deficit/hyperactivity disorders (ADHD), obsessive-compulsive disorder (OCD), insomnia, avoidant/restrictive food intake disorder (ARFID), social anxiety, autism, depression in children and adolescents. CBT has also been associated with improvements in quality of life in all the mental health disorders. CBT is typically conceptualized as a short-term, skills-focused treatment aimed at altering maladaptive emotional responses by changing the patient’s thoughts, behaviours, or both. It is the combination of one’s thoughts, feelings and behaviours. Cognitive therapy focuses on changing cognitions, which is proposed to change emotions and behaviours. Subsequently, the terms cognitive therapy, behavioural therapy, and cognitive-behavioural therapy have emerged. For the purposes of parsimony and to facilitate discussion of this diverse set of treatments, in this article we group the cognitive and behavioural therapies under the umbrella term “CBT” while acknowledging that the relative emphasis of cognitive vs behavioural techniques differs across treatment programs.
Preprint
Full-text available
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This review summarizes the current meta-analysis literature on treatment outcomes of CBT for a wide range of psychiatric disorders. A search of the literature resulted in a total of 16 methodologically rigorous meta-analyses. Our review focuses on effect sizes that contrast outcomes for CBT with outcomes for various control groups for each disorder, which provides an overview of the effectiveness of cognitive therapy as quantified by meta-analysis. Large effect sizes were found for CBT for unipolar depression, generalized anxiety disorder, panic disorder with or without agoraphobia, social phobia, posttraumatic stress disorder, and childhood depressive and anxiety disorders. Effect sizes for CBT of marital distress, anger, childhood somatic disorders, and chronic pain were in the moderate range. CBT was somewhat superior to antidepressants in the treatment of adult depression. CBT was equally effective as behavior therapy in the treatment of adult depression and obsessive-compulsive disorder. Large uncontrolled effect sizes were found for bulimia nervosa and schizophrenia. The 16 meta-analyses we reviewed support the efficacy of CBT for many disorders. While limitations of the meta-analytic approach need to be considered in interpreting the results of this review, our findings are consistent with other review methodologies that also provide support for the efficacy CBT.
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Behavioral exposure therapy of anxiety disorders is believed to rely on fear extinction. Because preclinical studies have shown that glucocorticoids can promote extinction processes, we aimed at investigating whether the administration of these hormones might be useful in enhancing exposure therapy. In a randomized, double-blind, placebo-controlled study, 40 patients with specific phobia for heights were treated with three sessions of exposure therapy using virtual reality exposure to heights. Cortisol (20 mg) or placebo was administered orally 1 h before each of the treatment sessions. Subjects returned for a posttreatment assessment 3-5 d after the last treatment session and for a follow-up assessment after 1 mo. Adding cortisol to exposure therapy resulted in a significantly greater reduction in fear of heights as measured with the acrophobia questionnaire (AQ) both at posttreatment and at follow-up, compared with placebo. Furthermore, subjects receiving cortisol showed a significantly greater reduction in acute anxiety during virtual exposure to a phobic situation at posttreatment and a significantly smaller exposure-induced increase in skin conductance level at follow-up. The present findings indicate that the administration of cortisol can enhance extinction-based psychotherapy.
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Animal models of anxiety attempt to represent some aspect of the etiology, symptomatology, or treatment of human anxiety disorders, in order to facilitate their scientific study. Within this context, animal models of anxiolytic drug action can be viewed as treatment models relevant to the pharmacological control of human anxiety. A major purpose of these models is to identify novel anxiolytic compounds and to study the mechanisms whereby these compounds produce their anxiolytic effects. After a critical analysis of "face," "construct," and "predictive" validity, the biological context in which animal models of anxiety are to be evaluated is specified. We then review the models in terms of their general pharmacological profiles, with particular attention to their sensitivity to 5-HTIA agonists and antidepressant compounds. Although there are important exceptions, most of these models are sensitive to one or perhaps two classes of anxiolytic compounds, limiting their pharmacological generality somewhat, but allowing in depth analysis of individual mechanisms of anxiolytic drug action (e.g., GABAA agonism). We end with a discussion of possible sources of variability between models in response to 5-HTIA agonists and antidepressant drugs.
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This chapter presents an overview of the descriptive epidemiology of anxiety disorders based on recently completed surveys of the general population. The overall prevalence of anxiety disorders is shown to be quite high, but with considerable variation from the most prevalent (specific phobias) to the least prevalent (agoraphobia without a history of panic disorder) disorders. Age-of-onset (AOO) of anxiety disorders is typically in childhood or adolescence and the course is often chronic-recurrent. Anxiety disorders are highly comorbid with each other and with other mental disorders. Because of their early AOO, they are often the temporally primary disorders in comorbid profiles, raising the question whether early interventions to treat anxiety disorders might have a positive effect on the onset, persistence, or severity of secondary disorders such as mood and substance use disorders. This possibility has not yet been extensively explored but warrants further study given the high societal costs of anxiety disorders.
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This chapter reviews the results of community epidemiological surveys concerning the descriptive epidemiology of anxiety disorders, with a focus on lifetime prevalence, age-of-onset, persistence, and comorbidity. Anxiety disorders are found to be very common despite current DSM and ICD criteria underestimating many clinically significant cases. Anxiety disorders often have early age-of-onset and high comorbidity. They typically are temporally primary to the disorders with which they are comorbid. Young people with anxiety disorders seldom receive treatment prior to the onset of secondary conditions. The chapter closes with a discussion of the importance of long-term studies to determine whether early treatment of primary anxiety disorders would influence the subsequent onset and course of secondary disorders.
Article
Errors in Byline, Author Affiliations, and Acknowledgment. In the Original Article titled “Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication,” published in the June issue of the ARCHIVES (2005;62:593-602), an author’s name was inadvertently omitted from the byline and author affiliations footnote on page 592, and another author’s affiliation was listed incorrectly. The byline should have appeared as follows: “Ronald C. Kessler, PhD; Patricia Berglund, MBA; Olga Demler, MA, MS; Robert Jin, MA; Kathleen R. Merikangas, PhD; Ellen E. Walters, MS.” The author affiliations footnote should have appeared as follows: “Author Affiliations: Department of Health Care Policy, Harvard Medical School, Boston, Mass (Dr Kessler; Mss Demler and Walters; and Mr Jin); Institute for Social Research, University of Michigan, Ann Arbor (Ms Berglund); and Section on Developmental Genetic Epidemiology, National Institute of Mental Health, Rockville, Md (Dr Merikangas).” On page 601, the first sentence of the acknowledgment should have appeared as follows: “The authors appreciate the helpful comments of William Eaton, PhD, and Michael Von Korff, ScD.” Online versions of this article on the Archives of General Psychiatry Web site were corrected on June 10, 2005.
Article
Current neurophysiological and psychological accounts view exposure therapy as the clinical analog of extinction learning that results in persistent modifications of the fear memory involved in the pathogenesis, symptomatology, and maintenance of anxiety disorders. Evidence from studies in animals and humans indicate that glucocorticoids have the potential to facilitate the processes that underlie extinction learning during exposure therapy. Particularly, glucocorticoids can restrict retrieval of previous aversive learning episodes and enhance consolidation of memory traces relating to non-fearful responding in feared situations. Thus, glucocorticoid treatment especially in combination with exposure therapy might be a promising approach to optimize treatment of anxiety disorders. This review examines the processes involved in aversive conditioning, fear learning and fear extinction, and how glucocorticoids might enhance restructuring of fear memories during therapy.
Article
There has long been interest in combining pharmacotherapy with psychotherapy, including cognitive behavioral therapy (CBT). More recently, basic research on fear extinction has led to interest in augmentation of CBT with the N-methyl Daspartate (NMDA) glutamate receptor partial agonist D-cycloserine (DCS) for anxiety disorders. In this article, the literature on clinical trials that have combined pharmacotherapy and CBT is briefly reviewed, focusing particularly on the anxiety disorders. The literature on CBT and DCS is then systematically reviewed. A series of randomized placebo-controlled trials on panic disorder, obsessive-compulsive disorder, social anxiety disorder, and specific phobia suggest that low dose DCS before therapy sessions may be more effective compared with CBT alone in certain anxiety disorders. The strong translational foundation of this work is compelling, and the positive preliminary data gathered so far encourage further work. Issues for future research include delineating optimal dosing, and demonstrating effectiveness in real-world settings.
Article
Numerous clinical trials have supported the efficacy of cognitive behavioral therapy (CBT) for the treatment of anxiety disorders. Accordingly, CBT has been formally recognized as an empirically supported treatment for anxiety-related conditions. This article reviews the evidence supporting the efficacy of CBT for anxiety disorders. Specifically, contemporary meta-analytic studies on the treatment of anxiety disorders are reviewed and the efficacy of CBT is examined. Although the specific components of CBT differ depending on the study design and the anxiety disorder treated, meta-analyses suggest that CBT procedures (particularly exposure-based approaches) are highly efficacious. CBT generally outperforms wait-list and placebo controls. Thus, CBT provides incremental efficacy above and beyond nonspecific factors. For some anxiety disorders, CBT also tends to outperform other psychosocial treatment modalities. The implications of available meta-analytic findings in further delineating the efficacy and dissemination of CBT for anxiety disorders are discussed.