Pandemic has been affecting all of us negatively. But if you are among 600 Million people who suffer from anxiety in general, these days must be extra difficult for you. I have always been interested in Psychology and finally, last fall semester, during my master class, I was able ti study Cognitive Psychology in depth. In my final literature review paper, I dig deep into what anxiety is, what are the causes for it, whether it is hereditary or not and what the best treatment method is. Turns out that CBT (Cognitive Behavioral Therapy) seems like the most effective treatment method although it faces its own challenges as well. Maybe this time my blog post is in a different format, a little harder to read or follow, but please trust me. I wouldn’t have shared it if I didn’t believe that people would benefit from it. I certainly did!
Cognitive Behavioral Therapy’s Success in Treating Anxiety
University of Massachusetts Boston
COGNITIVE BEHAVIORAL THERAPY’S SUCCESS IN TREATING ANXIETY
According to the World Health Organization (WHO), 1 in 13 globally suffers from anxiety. The WHO reports that anxiety disorders are the most common mental disorders worldwide with specific phobia, major depressive disorder and social phobia being the most common anxiety disorders (Baxter et al., 2013). As far as the treatment methods are concerned, Cognitive-Behavioral Therapy (CBT) has been proven to be the most effective treatment method in treating anxiety disorders.
This literature review will discuss the methodology of Cognitive Behavioral Therapy in treating anxiety disorders and its success. Moreover, herein it will be discussed what has been working and what needs improvement in practicing CBT. This study will conclude with suggestions for future research.
In the US alone, about 40 million adults are suffering from clinical levels of anxiety (Freeman & Freeman, 2012, p.2). The word ‘anxiety’ originates from the ancient Greek word ‘angh’ meaning ‘to press tight’, ‘to strangle’ or ‘to be weighed down with grief’. It also means ‘load’ ‘burden’ or ‘trouble’ (Freeman & Freeman, 2012, p.2). There have been many attempts to define ‘anxiety’ but none of them are truly complete yet. However, we have to be able to define the problem, as well as the causes to it, so that we can propose treatment methods.
The DSM (The Diagnostic and Statistical Manual of Mental Disorders), which is compiled by the American Psychiatric Association, gives below definition (Freeman & Freeman, 2012, p.11):
‘The apprehensive anticipation of future danger or misfortune accompanied by an unpleasant feeling or somatic feelings of tension. The focus of anticipated danger may be internal or external.’
As any other emotion, anxiety occurs normally and regularly. It can be observed in all human beings from different cultural or ethnic backgrounds as well as in many animal species (Wiedemann, 2015, p.560). According to DSM, there are 5 anxiety disorders: panic attacks and panic disorder, phobias, social phobia, and generalized anxiety disorder. PTSD and OCD, of which the anxiety remains as a relevant dimension, are no longer considered among the anxiety disorders (Wiedemann, 2015, p.560).
Many people with anxiety wonders why they are feeling the way they do. According to Wiedemann (2015, p.805), anxiety has complex roots including genetic, biological, social and psychological events and influences. The most significant factors affecting anxiety are listed as genetic and biological disposition, acute stressors and traumatic experiences that challenge the person to adapt to both new changes and the developmental and environmental impacts on the individual.
There have been 4 main perspectives proposed to explain the origins of anxiety since the end of the 19th century: psychoanalytic, behavioral, cognitive and neurobiological (Freeman & Freeman, 2012, p.14).
In Psychoanalytic approach, Freud claims ‘At the root of every neurotic anxiety is the fear of an external danger.’ He introduced the term “Anxiety Neurosis” (Angstneurose) which must be distinguished from other forms of nervous illnesses (Freeman & Freeman, 2012, p.15).
In Behavioral Approach, anxiety is a learned response. John Broadus Watson and his followers explain our behavior in one simple sentence: We learn it. Watson and Rosalie Rayner introduced the term ‘conditioning’ which is a process of learning to fear an innocuous random object or situation after associating it with another event which is frightening. Watson and Rayner suggest that all fears are learned in our childhood as a result of conditioning nature (Freeman & Freeman, 2012, p.19). CBT has its insight from this approach unhelpful thoughts, feelings, and behaviors are learned. Therefore, they can be unlearned with a help of a therapist (Freeman & Freeman, 2012, p.22).
In Cognitive Approach, appraisal or interpretation of a situation creates anxiety and this doesn’t always take place as a conscious process, it usually shows itself as an ‘intuition’. According to this approach, if the thinking process can be changed, so can emotions. Ingrained preconceptions, ideas or habitual thought processes, or as Aaron T. Beck defines as ‘schematic beliefs’, affect our lives negatively by causing us to adapt ‘safety behaviors’ which aims to avoid the occurrence of whatever we fear of (Freeman & Freeman, 2012, pp.22-26).
In Neurobiological Approach, It has been claimed that the two components of the amygdala in our brain, central nucleus of the amygdala and the bed nucleus of the stria terminalis indicate a high degree of connectivity and they play a key role in producing negative emotions such as fear or anxiety once stimulated by an environmental or conditioned stimuli (Johansen et al., 2011). Thus, amygdala is involved in appraisal of emotional meaning. However, it is more complex than that since there is an interplay of multiple regions of brain such as frontal lobes, the hippocampus and insula which creates awareness for internal feelings and the neurochemicals such as Corticotropin-releasing hormone (CRH releases stress hormones when amygdala detects danger) and Gamma aminobutyric acid (GABA calms us down when we are anxious) (Freeman & Freeman, 2012, p.32). Besides all, the monoamine transmitters, serotonin and noradrenalin and neuropeptides such as CRF play a significant role in regulating anxiety and fear (Kent et al., 1998 & Sullivan et al., 1999). Therefore, this approach suggests that people with anxiety disorder might have: an overactive amygdala and/or insufficiently active frontal lobes and/or a hippocampus which cannot locate exactly what factors in an incident on the basis of past experience signal danger, causing an unnecessary anxious reaction.
Nature or Nurture?
Heritability of anxiety has been studied extensively and yet there are so many questions remained unanswered. Researchers indicate that, with a 20%-40% probability, anxiety disorders are moderately heritable. This affirms that 40% of the differences in levels or neuroticism across the population are likely to have genetic roots although we don’t know which genes are responsible for it. The most prominent theory is the ‘polygenic theory’ in which many different genes are in play in generation and maintenance of anxiety (Freeman & Freeman, 2012, p.37). In addition, neurogenesis, genetic and epigenetic factors may have the power to regulate proliferation, survival and integration of cells into the hippocampus. This is particularly important since hippocampus is in charge of information processing of fearful events (Kheirbek et al., 2012).
If we consider the fact that genetics’ contribution to anxiety is 40%, then it leaves 60% to the environmental factors. The main environmental factors that researchers thought of were: 1, Traumatic or other upsetting events; 2. Parenting and attachment styles during childhood and adolescence years (Freeman & Freeman, 2012, pp.38-44). Under acute and chronic stress, an imbalance of neural circuitries creates changes in the amygdala and prefrontal cortex due to their structural plasticity. In short term, the effects maybe adaptive. However, despite the fact that dangerous situation no longer exists if the changes in neural circuitries persist, anxiety disorder may form (McEwen et al., 2012). Besides abusive and neglecting parents, the overprotective and controlling ones also might contribute to their children’s future anxiety problems. As far as the attachment styles are concerned, psychologists discovered that babies who displayed anxious/resistant attachment with separation anxiety and stranger anxiety combined, are more likely to develop anxiety problems (Freeman & Freeman, 2012, pp.41-43).
In treating the anxiety disorders, the best results have been received with the application of CBT. Researchers believe the reason why it works as the best solution is that CBT aims to question the accuracy of beliefs and anxiety occurs when a person ‘believes’ a situation or object is threatening. In this paper, CBT process and benefits in treating anxiety will be discussed in great detail.
Although with CBT, the gains are much greater and they last longer and CBT has no side effects, medication is still considered as another form of treatment. SSRIs, which increase the amount of serotonin in the brain, Benzodiazepines, which produce a sense of relaxation, and Beta-blockers which quickly prevent many of the anxiety symptoms are among the most commonly prescribed ones to treat anxiety symptoms. Although they are helpful in short term, without therapy they don’t provide a long-lasting solution (Freeman & Freeman, 2012, pp.111-117).
Cognitive Behavioral Therapy (CBT)
Originally developed by Aaron Beck to treat depression, Cognitive Behavioral Therapy is a complex and rich treatment model that aims to identify and assess negative thoughts, feelings and resulting unhelpful behaviors (Freeman & Freeman, 2012, p.117). CBT not only does work in a wide range of psychological disorders, especially in treating anxiety, but also is considered as an evidence-based approach to psychotherapy (Wenzel et al., 2016, p.6). The main idea of CBT is that fear is a result of an interpretation process. People are in fear not because there is a threatening situation right now, because they believe it will happen in the future. CBT includes testing this interpretation by exposing oneself to the situations that they fear, without using any safety behaviors that the person adopted. This way, CBT proves that the beliefs are misplaced (Freeman & Freeman, 2012, p.118).
A standard CBT session structure is described as follows, by Wenzel et al. (2016, p.44): “1. A brief mood check; 2. Bridge from the previous session; 3. Agenda setting; 4. Discussion of the agenda items including the review of previous homework; 5. Development of new homework; 6. Final summary and feedback.” Although this is a typical structure, depending on the client needs, the order can be changed by the therapist. All these steps play a crucial role, however, there is a great importance of homework in CBT. The ‘Homework’ term refers to the work the clients do in between sessions to practice what they already discussed in session in a real-life experience (Wenzel et. al, 2016, p.51). As in education, the more attentive and complete assignment one submits, the more benefit they gain in CBT. Most clients consider homework as the key to their treatment and they openly express its necessity in their healing process (Wenzel et. al, 2016, p.51). Kazantzis et. al (2010) claims in their meta-analysis of 46 studies that 62% of clients show improvement when their therapy included homework whereas the success rate went down to 38% in clients who chose therapy without homework. The client’s failure to do the homework also plays a critically important role as this way the therapists can analyze what caused them to fail in terms of their environmental and interpersonal variables.
Therapists follow behavioral strategies during CBT in order to help their clients to change their ways in their daily lives. These behaviors might include but not limited to increasing their engagement with rewarding activities, overcoming their avoidance behavior for the activities that feel overwhelming for them, or helping them adopt healthy behaviors so that they can focus on their self-care better (Wenzel et. al, 2016, p.54). There are two main strategies that CBT therapists use: Behavioral Activation includes the most effective set of methodologies to treat depression. It aims to help clients reengage in activities which will rebuild their confidence and sense of accomplishment. This will also give them the feeling of satisfaction and pleasure (Wenzel et. al, 2016, p.55). The second strategy, Exposure is the main component in CBT while treating anxiety, Obsessive-compulsive-related, and trauma- and stressor- related disorders (Olatunji, Cisler, & Deacon, 2010). Basically, Exposure is a well-structured, well-ordered, prolonged contact with the stimuli or the situations that the client fears (Wenzel et. al, 2016, p.62). One important recent advancement in exposure strategy is that the effectiveness of it is maximized when the therapists make the ‘fear tolerance’ their focus, instead of ‘fear reduction’ (Craske et al., 2014). Learning the coping skills for uncertainty and risk is necessary not only for clients who have anxiety problems but also for all human beings.
Difficulties in CBT
Despite the fact that CBT works wonders for many psychological disorders, there is comparatively only a tiny fraction of clients who suffer from anxiety receive the treatment. For example, in comparison to 34% of clients who receive some sort of therapy and medication for their phobias, there is only 11% who receives CBT. Another example is while 15% people with generalized anxiety disorder take some kind of medication and therapy, only 3% is treated with CBT (66% doesn’t even seek treatment) (Freeman & Freeman, 2012, p.114). The reason has been explained as there are not being enough well-trained CBT practitioners yet.
Another problem CBT is facing is that there is still a considerably high number of clients who fail to complete the treatment. Therapists face problems such as resistance, poor or non-existent homework performance and dropouts. There are also issues such as clients who rejects the therapy all together or those who suffer from relapses or residual symptoms (Federici et al., 2010, p.11).
There are many factors which can lead to negative treatment outcome. One of them is Client-Related Factors; If the client holds positive opinions about their symptoms, they will tend to resist treatment more. Also, clients who don’t have high hopes about getting better, who disagree with the treatment structure won’t go very far in healing process. Therapist Related Factors include poor alliance which is associated with no or little warmth towards the clients (Foa, Steketee, Grayson & Doppelt, 1983), lack of confidence (Hedley, Thornes, Larsen & Friis, 2006), lack of therapist skill, poorly timed interventions, not setting therapeutic goals, setting unrealistic expectations, etc. (Federici et al., 2010, p.13). According to Hadley & Strupp (1976), the negative results received in treatments often are because of therapist related factors. Among the Diagnosis Related Factors, there are the situations when the severity of the disorder is really high and the comorbid situations such as comorbid mood disorders, substance use, autism, and intellectual limitations affect the treatment outcome negatively (Anderson & Morris, 2006; Chambless, Tran, & Glass, 1997). About the intelligence level, it has been proven that the higher the fluid intelligence, the greater improvement the clients will show for depression and anxiety (Double day, King & Papageorgiou, 2002).
There have been many studies suggesting different approaches to solve the problems CBT is currently facing. In this paper, in order not to lose focus, only few of them will be mentioned.
Integrating SMAD (Self-wound Model for Anxiety Disorders) with CBT: Wolfe (2005, 2006) suggests that self-wounds are products of the interplay between traumatic life experiences and both cognitive and emotional coping strategies that the patient created for themselves. In other words, the clients’ anxious symptoms are due to the unconscious fear they feel towards the exposure of painful, intolerable views of themselves. The latter one manifests itself as the fear of a disaster about to happen to them physically and/or psychologically (Alladin, 2015, p.2). Alladin (2013b, 2014b) has integrated hypnotherapy into Wolfe’s integrative psychotherapy for anxiety disorders and that created Cognitive Hypnotherapy (CH), which is essentially the combination of CBT with hypnotherapy. In this approach, what is different from mainstream CBT methodology is: First, hypnotherapy that is used to uncover and heal self-wounds. Second is a third-wave addition to the therapy: the promotion of mindfulness, gratitude and acceptance (Alladin, 2014a; Wolde & Sigl, 1998).
Promotion of Positive Emotions Approach: Taylor et al. (2017) proves that during CBT therapy, by focusing on positive traits instead of negative emotions, the anxiety symptoms during and after treatment can be reduced significantly. Mention of positive traits had regulatory and calming physiological effects on patients during stressful thought-challenging exercises. Additionally, distress tolerance is proven to allow clients to engage in treatment fully and a previous study has already shown the positive correlation between people’s emotional and physical distress, and positive emotions (Simons & Gaher, 2005). The neuroscientific study by Yoshimura et al. (2017) demonstrated that MPFC-ACC had increased connectivity causing depression during self-referential judgment of negative words of emotions and increased connectivity after CBT. They proposed that CBT might be suppressing this MPFC-ACC coupling, diminishing depression. If we make the connection with Simons & Gaher’s (2005) study, we can claim that there might be an interaction between positive emotional words and the MPFC-ACC connectivity decreasing, which needs to be studied further.
Although CBT is still considered as the most successful therapy for anxiety disorders, there needs to be more work done in terms of future research to make CBT more efficient. The effects of Motivational Interviewing (MI), which helps with treatment resistance (Miller & Rollnik, 2002), the positive influence of ‘Acceptance and mindfulness-based interventions’ in CBT practice (Federici et al., 2010, p.21), the ways in which the positive emotions affect the distress tolerance, the answer to the question: ‘Is fear tolerance or dear reduction better?’, the limitations of SMAD or CH and the functional connectivity in brain from pretreatment to post treatment need to be studied further.
Treating anxiety can be challenging as there are many variations of this disorder, each of which might require different treatment strategies. Until this day, Cognitive Behavioral Therapy has kept its fame as being the most fruitful treatment method in treating anxiety. However, the research indicated that despite the high demand for CBT trained therapists, there aren’t enough of them in the field. In addition, new approaches that are mentioned in this paper need to be considered, further studied and implemented in order to prevent the failure of the treatment due to incidents such as ambivalence, drop outs, re-lapses and residual symptoms. Once these factors are carefully considered and necessary steps are taken, the future of CBT in treating anxiety will definitely be brighter.
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