The goal of cognitive-behavioral therapy (CBT) is to regain control of reactions to stress and stimuli, thus reducing the feeling of helplessness that often accompanies anxiety disorders. CBT works on the principle that the thoughts that produce and maintain anxiety can be recognized and altered using various techniques, thereby changing the behavioral response and eliminating the anxiety reaction.
A number of CBT approaches have been designed to treat both the general symptoms of anxiety and specific disorders. In one 2000 study of panic disorder patients, either CBT or a tricyclic antidepressant alone or in combination was as effective as short-term and maintenance therapy. After discontinuing treatment, however, CBT alone offered the best chance for a persistent response. Other studies have also reported similar benefits. CBT alone may be as effective as medications for children with OCD. Cognitive-behavioral therapy may even help people with post-traumatic stress disorder. CBT used in group therapy for children with PTSD may be especially helpful.
Treatments are equally effective in men and women. Anxiety disorders are chronic, however, and recurrence is common. Some studies indicate, in fact, that between 30% and 82% of people with panic disorder and phobias have a recurrence of attacks at an average of nine months even after successful short-term therapy. (Women are at much higher risk for recurrence of panic attacks than men.) Medications, then, are also generally recommended for most patients. There may be exceptions.
Basic Cognitive Therapy Techniques. Treatment usually takes about 12 to 20 weeks. The essential goal of cognitive therapy is to understand the realities of an anxiety-provoking situation and to respond to reality with new actions based on reasonable expectations.
First, the patient must learn how to recognize anxious reactions and thoughts as they occur. One way of accomplishing this is by keeping a daily diary that reports the occurrences of anxiety attacks and any thoughts and events associated with them. An OCD patient, for instance, may record repetitive thoughts.
These entrenched and automatic reactions and thoughts must be challenged and understood. Again, using the OCD example, one approach is to record and play back the words of the repetitive thoughts, over exposing the patient to the thoughts and reducing their effect.
Patients are usually given behavioral homework assignments to help them change their behavior. For example, a person with generalized social phobia may be asked to buy an item and then return it the next day, !!observing as he or she does so the unrealistic fears and thoughts triggered by such an event.!!
As the patient continues with self-observation, he or she begins to perceive the false assumptions that underlie the anxiety. For example, OCD patients may learn to recognize that their heightened sense of responsibility for preventing harm in non-threatening situations is not necessary or even useful.
At that point, the patient can begin substituting new ways of coping with the feared objects and situations.
Systematic Desensitization. Systematic desensitization is a specific technique that breaks the link between the anxiety-provoking stimulus and the anxiety response; this treatment requires the patient to gradually confront the object of fear. There are three main elements to the process:
A list composed by the patient that prioritizes anxiety-inducing situations by degree of fear.
The desensitization procedure itself, confronting each item on the list, starting with the least stressful.
This treatment is especially effective for simple phobias, social phobias, agoraphobia, and post-traumatic stress syndrome.
Exposure and Response Treatment. Exposure treatment purposefully generates anxiety by exposing the patient repeatedly to the feared object or situation, either literally or using imagination and visualization. It uses the most fearful stimulus first. (This differs from the desensitization process because it does not involve relaxation or a gradual approach to the source of anxiety.)
Exposure treatments are usually either known as flooding or graduated exposure:
Flooding exposes the person to the anxiety-producing stimulus for as long as one to two hours.
Graduated exposure gives the patient a greater degree of control over the length and frequency of exposures.
In both cases the patient experiences the anxiety over and over until the stimulating event eventually loses its effect. Combining exposure with standard cognitive therapy may be particularly beneficial. This approach has helped certain patients in most anxiety disorder categories. In one study, it even helped prevent PTSD from developing in motor-vehicle accident survivors with acute stress disorder. (The results of this study, however, are not necessarily applicable to other trauma sufferers, such as rape victims.)
Modeling Treatment. Phobias can often be treated successfully with modeling treatment:
The therapy typically uses an actor who approaches an anxiety-producing object or engages in a fear-provoking activity that is similar to the patient’s specific problem. Either a live or video-taped situation may be used, although the live model is considered to be more effective.
The patient observes this event and tries to learn how to behave in a comparable manner.
Eventually, so-called “virtual reality” may prove to be a very useful modeling tool. This technology employs computer-generated images and special headgear to realistically simulate a natural environment and allow interaction with it. In one case, a psychologist used virtual reality to cure a woman of arachnophobia (fear of spiders). More research is needed.
Relaxation Techniques and Breathing Retraining. As part of many of the CBT approaches, patients are taught techniques to reduce the physical effects of anxiety. For example, many people with anxiety disorders experience hyperventilation, rapid, tense breathing that expels too much carbon dioxide, resulting in chest pain, dizziness, tingling of the mouth and fingers, muscle cramps, and even fainting. Hyperventilation is one of the primary physical manifestations of panic disorders. By practicing measured, controlled breathing at the onset of a panic attack, patients may be able to prevent full attacks. Relaxation methods, such as learning how to gradually relax all the muscles, may also be helpful.
Other Forms of Psychotherapy
Other forms of psychotherapy, commonly called “talk” therapies, deal more with childhood roots of anxiety and usually, although not always, require longer treatments. They include interpersonal therapy, supportive psychotherapy, attention intervention, and psychoanalysis. All work is done during the sessions. Some experts believe that such therapies might be more useful for generalized anxiety, which may require more sustained work to process and recover from early traumas and fears.
A surgical technique called cingulotomy involves interrupting the cingulate gyrus, a bundle of nerve fibers in the front of the brain. It is sometimes used as a last resort for patients with severe OCD. A recent variation of this procedure using magnetic resonance imaging (MRI) to guide the surgeon is resulting in long-term improvement in about one-quarter to one-third of OCD patients in whom it is performed. The procedure is generally safe with few serious complications and does not affect intellect or memory.