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THE EFFECTIVENESS OF COGNITIVE-BEHAVIORAL TREATMENT FOR ANXIETY DISORDERS
by Monica A. Frank, Ph.D.

"The review of approximately 150 research studies showed that 87% of people with Panic Disorder with Agoraphobia 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."
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 can be an important 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.




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