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THE
EFFECTIVENESS OF COGNITIVE-BEHAVIORAL TREATMENT FOR ANXIETY DISORDERS
By Monica A. Frank, Ph.D.
After
experiencing severe heart palpitations and shortness of breath while driving,
Diane rushed to the emergency room of the nearest hospital. Extensive tests
showed no physical abnormalities or problems. She was told she had a panic
attack and was given an anti-anxiety medication. As a result of the
panic attack, she quit driving by herself because she became fearful of having
another panic attack and losing control while driving. Whenever she would
attempt to drive by herself, she would have a panic attack. Her family
physician explained to her that Panic Disorder was a chemical imbalance and that
medication helps to regulate the chemicals in the brain. An anti-depressant
was prescribed in addition to the anti-anxiety medication. Diane found that she
began to feel less anxious with the medications, but that she was still avoiding
the driving due to her fear of having a panic attack. Additionally, she became
concerned about needing to be on the medication for a long time and wondered if
any other treatment could help.
The fear of
making mistakes ruled George's life. Everything he did, he checked over and
over again to make sure he didn't make a mistake. Sometimes the need to be
perfect became so overwhelming that he procrastinated on particularly difficult
tasks. This time-consuming checking caused him considerable problems at work
because he couldn't complete his assignments in a timely fashion. He went to
see a therapist who helped him to understand the history of his fear of making
mistakes and how it related to the criticism he received throughout childhood.
However, he still was fearful of making mistakes and on the verge of losing his
job. He finally quit therapy in frustration.
What do these two
cases have in common? They are both anxiety disorders and they did not receive
the treatment of choice for anxiety disorders: cognitive-behavioral treatment.
The treatment they received may have been beneficial to a degree, but it did not
address all aspects of the disorder.
Fortunately,
there is a wealth of research evidence supporting cognitive-behavioral treatment
as the most effective treatment for the anxiety disorders, particularly Panic
Disorder. However, unfortunately, due to the information explosion and the
amount of research conducted every day, many health professionals are inundated
with information and unable to be knowledgeable in all areas. Therefore, it is
important for the mental health consumer to understand the issues, ask
questions, and obtain the necessary treatment.
One of the basic
issues that is often misunderstood is: how can a non-medical treatment be
effective when research has shown that a chemical imbalance is involved with the
anxiety disorders? To address this issue, I will first describe
cognitive-behavioral treatment, present the research evidence indicating its
efficacy, and discuss the distinction between a behavioral disorder and
behavioral treatment.
What is
Cognitive-Behavioral Therapy (CBT)?
CBT is an active, directive treatment approach to teaching the skills
necessary to cope with a disorder of problem. The cognitive portion of therapy
for anxiety disorders involves identifying irrational thinking styles that may
contribute to the anxiety. For instance, a very common thinking style for
someone with Panic Disorder is the belief that he or she is trapped in a
situation. This belief of being trapped contributes to the feelings of panic.
Another common
thinking style for those with anxiety disorders is perfectionism, the belief
that one should not make mistakes. Such a belief causes a great deal of
pressure leading to more anxiety. Cognitive therapy helps the individual to
identify these thinking styles and then to challenge the thoughts with rational
coping statements such as "I don't have to be perfect. Everyone makes
mistakes."
The behavioral
portion of therapy involves techniques to address the problem behavior. For
instance, the individual may be taught different relaxation techniques to reduce
the physical symptoms to anxiety. If the individual is avoiding anxiety
provoking situations, behavioral therapy might involve a gradual introduction to
those situations with assistance from the therapist. The behavioral techniques
are too numerous to describe in this article, but basically they involve doing
some activity to address the problem.
How Effective is CBT?
In an article reviewing the various treatments for Panic Disorder with
Agoraphobia (PDA), Drs. Michelson and Marchione concluded that CBT is the
treatment of choice for PDA. This conclusion was based on comparisons of CBT
and medication treatments. The review of approximately 150 research studies
showed that 87% of people with PDA improved with only a 10% relapse rate for CBT
as compared to a 60% improvement rate with a 35% relapse rate for
anti-depressants and a 60% improvement rate with a 90% relapse rate for
anti-anxiety medications. CBT for Panic Disorder
without Agoraphobia has an improvement rate of 90% with a 5% relapse rate.*
The research
findings for Panic Disorder is important for all the anxiety disorders as Panic
Disorder is often used in research as the model for other anxiety disorders.
Although the effectiveness rates for the other anxiety disorders may not be the
same, research is clearly showing the importance of CBT for all the anxiety
disorders.
However, don't
draw the conclusion that medication is an inappropriate treatment. Medication
is an excellent adjunct to CBT. For many people, it allows control more quickly
so that it is easier to focus on the techniques used in CBT.
What is the Difference
Between a Behavioral Disorder and Behavioral Therapy?
Many people get
the terms "behavioral disorder" and "behavioral therapy" confused because they
both have the word "behavior" as a component. However, they are two very
different terms. Behavioral disorder refers to disorders that are due to a
malfunction in the individual's behavior, usually implying that the problem is
under the individual's control. Examples may include behaviors such as lying,
stealing, etc. Anxiety disorders are NOT behavioral disorders. They are mental
disorders that have a physiological basis, probably genetic, resulting in a
chemical imbalance.
Behavioral
treatment refers to a treatment method that focuses on behavior or activities
that help control a disorder. Just because a disorder can be treated
behaviorally doesn't mean that the disorder is "all in your head."
For instance, in
the treatment of diabetes, the behavioral techniques of stress management can
aid in the control of blood sugar. Does that mean that diabetes if not a
disease? Of course not. Or, we know that some people can have dental work done
using hypnosis, another behavioral technique, rather than chemical
pain-killers. Does that mean that pain is a figment of our imaginations? Of
course not.
Behavioral
therapy has many different uses that include pain management, blood pressure
control, aid with irritable bowel syndrome, and the treatment of the mental
disorders.
How does CBT work if
anxiety disorders are chemical imbalances?
The answer to this question is fairly straight-forward: everything we do
is chemically based. Our brain sends messages to the different parts of our
body through chemicals. For us to walk, talk, think, or engage in any behavior,
chemicals are released to convey the message.
We have certain
kinds of control over the release of some chemicals. For instance, you may be
aware that when you exercise endorphins are released that reduce pain, improve
mood, and enhance sleep. Endorphins are a chemical released by the brain and
exercise is a behavioral technique. Thus, when you exercise you are controlling
the release of a chemical that helps you feel better.
Other behavior
techniques also impact the chemical balance in a healthy way. It is not clear
yet the exact mode of this process; however, research shows that behavioral
therapy changes the chemistry of the brain. Recently, research using a PET scan
pre- and post-behavioral therapy for Obsessive-Compulsive Disorder showed
significant changes in the brain.** A PET scan shows the areas of the brain
with various colors depicting areas of activity which is related to brain
chemistry. Thus, this research shows that behavioral therapy changes the
chemistry of the brain.
In summary, CBT
is a natural means of changing the brain chemistry in order to control the
symptoms related to anxiety disorders.
References
*Michelson, L.K. &
Marchione, K. (1991). Behavioral, Cognitive, and Pharmacological Treatments of
PDA: Critique and Synthesis. Journal of Consulting and Clinical Psychology,
59, 100-114.
**Baxter, L.R., et.al.
(1992). Caudate Glucose Metabolic Rate Changes with both Drug and Behavior
Therapy for OCD. Archives of General Psychiatry, 49, 681-689.
See also:
Making Attributions for a Healthier Attitude
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2000 by www.excelatlife.com.
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