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
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
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?
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
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
How does CBT work if anxiety disorders are
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
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
*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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