7.5: Anxiety Disorders - Treatment

Learning Objectives

• Describe treatment options for generalized anxiety disorder.
• Describe treatment options for specific phobia.
• Describe treatment options for agoraphobia.
• Describe treatment options for social anxiety disorder.
• Describe treatment options for panic disorder.

Generalized Anxiety Disorder

7.5.1.1. Psychopharmacology. Benzodiazepines, a class of sedative-hypnotic drugs that will be discussed in more detail in the substance abuse module, originally replaced barbiturates as the leading anti-anxiety medication due to their less addictive nature, yet equally effective ability to calm individuals at low dosages. Unfortunately, as more research was done on benzodiazepines, serious side effects, as well as physical dependence of benzodiazepines at large dosages, has routinely been documented (NIMH, 2013). Due to these negative effects, selective serotonin-reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are generally considered to be first-line medication options for those with generalized anxiety disorder. Findings indicate a 30-50% positive response rate to these psychopharmacological interventions (Reinhold & Rickels, 2015). Unfortunately, none of these medications continue to provide any benefit once they are stopped; therefore, other effective treatment options such as CBT, relaxation training, and biofeedback are often encouraged before the use of pharmacological interventions.

7.5.1.2. Rational-Emotive therapy. Albert Ellis developed rational emotive therapy in the mid-1950s as one of the first forms of cognitive-behavioral therapy. Ellis proposed that individuals were not aware of the effect their negative thoughts had on their behaviors and various relationships, and thus, established a treatment to address these thoughts and provide relief to those suffering from anxiety and depression. The goal of rational emotive therapy is to identify irrational, self-defeating assumptions, challenge the rationality of those assumptions, and to replace them with new, more productive thoughts and feelings. By identifying and replacing these assumptions, the individual will experience relief of generalized anxiety disorder symptoms (Ellis, 2014).

7.5.1.3. Cognitive Behavioral Therapy (CBT). CBT is discussed in detail in the Mood Disorder Module; however, it is also among the most effective treatment options for a variety of anxiety disorders, including generalized anxiety disorder. Findings suggest 60 percent of individuals report a significant reduction/elimination in anxious thoughts one-year post treatment (Hanrahan, Field, Jones, & Davy, 2013). The fundamental goal of CBT is a combination of cognitive and behavioral strategies aimed to identify and restructure maladaptive thoughts while also providing opportunities to utilize these more effective thought patterns through exposure-based experiences. Through repetition, the individual will be able to identify and replace anxious thoughts outside of therapy sessions, ultimately reducing their overall anxiety levels (Borkovec, & Ruscio, 2001).

7.5.1.4. Biofeedback. Biofeedback provides a visual representation of a patient’s physiological arousal. To achieve this feedback, a patient is connected to a computer that provides continuous information on their physiological states. There are several ways a patient can connect to the computer. Among the most common is electromyography (EMG). EMG measures the amount of muscle activity currently experienced by the individual. An electrode is placed on a patient’s skin just above a major muscle group, usually the forearm or the forehead. Other common areas of measurement are electroencephalography (EEG), which measures the neurofeedback or brain activity; heart rate variability (HRV), which measures autonomic activity such as heart rate or blood pressure; and galvanic skin response (GSR) which measures sweat.

Once the patient is connected to the biofeedback machine, the clinician can walk the patient through a series of relaxation scripts or techniques as the computer simultaneously measures the changes in muscle tension. The theory behind biofeedback is that in providing a patient with a visual representation of changes in their physiological state, they become more skilled at voluntarily reducing their physiological arousal, and thus, their overall sense of anxiety or stress. While research has identified only a modest effect of biofeedback on anxiety levels, patients do report a positive experience with the treatment due to the visual feedback of their physiological arousal (Brambrink, 2004).

Specific Phobias

7.5.2.1. Exposure treatments. While there are many treatment options for specific phobias, research routinely supports the behavioral techniques as the most effective treatment strategies. Seeing as the behavioral theory suggests phobias develop via respondent conditioning, the treatment approach revolves around breaking the maladaptive association between the object and fear. This is generally accomplished through exposure treatments. As the name implies, the individual is exposed to their feared stimuli. This can be done in several different approaches: systematic desensitization, flooding, and modeling.

Systematic desensitization is an exposure technique that utilizes relaxation strategies to help calm the individual as they are presented with the fearful object. The notion behind this technique is that both fear and relaxation cannot exist at the same time; therefore, the individual learns how to replace their fearful reaction with a calm, relaxing reaction.

To begin, the patient, with assistance from the clinician, will identify a fear hierarchy, or a list of feared objects/situations ordered from least fearful to most fearful. After teaching several different types of relaxation techniques, the clinician will present items from the fear hierarchy, starting from the least fearful object/subject, while the patient practices using the learned relaxation techniques. The presentation of the feared object/situation can be in person—in vivo exposure—or it can be imagined—imaginal exposure. Imaginal exposure tends to be less intensive than in vivo exposure; however, it is less effective than in vivo exposure in eliminating the phobia. Depending on the phobia, in vivo exposure may not be an option, such as with a fear of a tornado. Once the patient can effectively employ relaxation techniques to reduce their anxiety to a manageable level, the clinician will slowly move up the fear hierarchy until the individual does not experience excessive fear of all objects on the list.

Flooding is another exposure technique in which the clinician does not utilize a fear hierarchy, but rather repeatedly exposes the individual to their most feared object or situation. Similar to systematic desensitization, flooding can be done in either in vivo or imaginal exposure. Clearly, this technique is more intensive than systematic or gradual exposure to feared objects. Because of this, patients are at a greater likelihood of dropping out of treatment, thus not successfully overcoming their phobias.

Modeling is another common technique used to treat phobias (Kelly, Barker, Field, Wilson, & Reynolds, 2010). In this technique, the clinician approaches the feared object/subject while the patient observes. As the name implies, the clinician models appropriate behaviors when exposed to the feared stimulus, showing that the phobia is irrational. After modeling several times, the clinician encourages the patient to confront the feared stimulus with the clinician, and then ultimately, without the clinician.

Agoraphobia

Similar to the treatment approaches for specific phobias, exposure-based techniques are among the most effective treatment options for individuals with agoraphobia. However, unlike the high success rate in specific phobias, exposure treatment for agoraphobia has been less effective in providing complete relief from the disorder. The success rate may be impacted by the high comorbidity rate of agoraphobia and panic disorder. Because of the additional presentation of panic symptoms, exposure treatments alone are not the most effective in eliminating symptoms as residual panic symptoms often remain (Craske & Barlow, 2014). Therefore, the best treatment approach for those with agoraphobia and panic disorder is a combination of exposure and CBT techniques (see panic disorder treatment).

For individuals with agoraphobia without panic symptoms, the use of group therapy in combination with individual exposure therapy has been identified as a successful treatment option. The group therapy format allows the individual to engage in exposure-based field trips to various community locations, while also maintaining a sense of support and security from a group of individuals whom they know. Research indicates that this type of treatment provides improvement for nearly 60 to 80 percent of patients with agoraphobia; however, there is a relatively high rate of partial relapse, suggesting that long-term treatment or booster sessions should continue for several years at minimum (Craske & Barlow, 2014).

Social Anxiety Disorder

7.5.4.1. Exposure. A hallmark treatment approach for all anxiety disorders is exposure. Specific to social anxiety disorder, the individual is encouraged to engage in social situations where they are likely to experience increased anxiety. Initially, the clinician will role-play various social situations with the patient so they can practice social interactions in a safe, controlled environment (Rodebaugh, Holaway, & Heimberg, 2004). As the patient becomes habituated to the interaction with the clinician, the clinician and patient may venture outside of the treatment room and engage in social situations with random strangers at various locations such as fast-food restaurants, local stores, libraries, etc. The patient is encouraged to continue with these exposures outside of treatment to help reduce anxiety related to social situations.

7.5.4.2. Social skills training. This treatment is specific to social anxiety disorder as it focuses on the patient’s skill deficits or inadequate social interactions that contribute to their negative social experiences and anxiety. During a session, the clinician may use a combination of skills such as modeling, corrective feedback, and positive reinforcement to provide feedback and encouragement to the patient regarding their behavioral interactions (Rodebaugh, Holaway, & Heimberg, 2004). By incorporating the clinician’s feedback into their social repertoire, the patient can engage in positive social behaviors outside of the treatment room and improve their overall social interactions while reducing ongoing social anxiety.

7.5.4.3. Cognitive restructuring. While exposure and social skills training are suitable treatment options, research routinely supports the need to incorporate cognitive restructuring as an additive component in treatment to provide substantial symptom reduction. Like cognitive restructuring previously discussed in the Mood Disorder module, the clinician will work with the therapist to identify negative, automatic thoughts that contribute to the distress in social situations. The clinician can then help the patient establish new, positive thoughts to replace these negative thoughts. Research indicates that implementing cognitive restructuring techniques before, during, and after exposure sessions enhances the overall effects of treatment of social anxiety disorder (Heimberg & Becker, 2002).

Panic Disorder

7.5.5.1. Cognitive Behavioral Therapy(CBT). CBT is the most effective treatment option for individuals with panic disorder as the focus is on correcting misinterpretations of bodily sensations (Craske & Barlow, 2014). Nearly 80 percent of people with panic disorder report complete remission of symptoms after mastering the following five components of CBT for panic disorder (Craske & Barlow, 2014).

Psychoeducation. Treatment begins by educating the patient on the nature of panic disorder, the underlying causes of panic disorder, as well as the mechanisms that maintain the disorder such as the physical, cognitive, and behavioral response systems (Craske & Barlow, 2014). This part of treatment is fundamental in correcting any myths or misconceptions about panic symptoms, as they often contribute to the exacerbation of panic symptoms.

Self-monitoring. Self-monitoring, or the act of self-observation, is essential to the CBT treatment process for panic disorder. In this part of treatment, the individual is taught to identify the physiological cues immediately leading up to and during a panic attack. Then, the patient is encouraged to recognize and document the thoughts and behaviors associated with these physiological symptoms. By bringing awareness to the symptoms, as well as the relationship between physical arousal and cognitive-behavioral responses, the patient learns the fundamental processes with which they can manage their panic symptoms (Craske & Barlow, 2014).

Relaxation training. Similar to that in exposure-based treatment for phobias, prior to engaging in exposure training, the individual must learn relaxation techniques to apply during onset of panic attacks. Though breathing training was once included as the relaxation training technique of choice for panic disorder more recent research has failed to support this technique as effective in the use of panic disorder due to the high incidence of hyperventilation during panic attacks (Schmidt et al., 2000). Findings suggest that breathing retraining is more commonly misused as a safety behavior or means for avoiding physical symptoms as opposed to an effective physiological response to stress (Craske & Barlow, 2014).

Progressive muscle relaxation. To replace the breathing retraining, Craske & Barlow (2014) suggest progressive muscle relaxation (PMR). In PMR, the patient learns to tense and relax various large muscle groups throughout the body. The patient is encouraged to start at either the head or the feet, and gradually work their way through the entire body, holding the tension for roughly 10 seconds before relaxing. The theory behind PMR is that in tensing the muscles for a prolonged period, the individual exhausts those muscles, forcing them (and eventually) the entire body to engage in relaxation (McCallie, Blum, & Hood, 2006).

Cognitive restructuring. Cognitive restructuring, or the ability to recognize cognitive errors and replace them with alternate, more appropriate thoughts, is likely the most powerful part of CBT treatment for panic disorder, aside from the exposure part. As noted previously, cognitive restructuring involves identifying the role of thoughts in generating and maintaining emotions. The clinician encourages the patient to view these thoughts as “hypotheses” as opposed to fact, which allows the beliefs to be questioned and challenged. This is where the detailed recordings produced by self-monitoring are helpful. By discussing what the patient has recorded for the relationship between physiological arousal and thoughts/behaviors, the clinician can help the patient restructure the maladaptive thought processes to more positive thought processes, which in return, helps to reduce fear and anxiety.

Exposure. As discussed in detail in the specific phobia section, the patient is next encouraged to engage in a variety of exposure techniques such as in vivo exposure and interoceptive exposure, while also incorporating the cognitive restructuring and relaxation techniques previously learned to reduce and eliminate ongoing distress. Interoceptive exposure involves inducing panic-specific symptoms to the individual repeatedly for a prolonged period, so that maladaptive thoughts about the sensations can be disconfirmed and conditional anxiety responses are extinguished (Craske & Barlow, 2014). Some examples of these exposure techniques include spinning a patient repeatedly in a chair to induce dizziness and breathing in a paper bag to cause hyperventilation. These treatment approaches can be presented gradually; however, the patient must endure the physiological sensations for at least 30 seconds to 1 minute to ensure adequate time for applying cognitive strategies to misappraisal of cognitive symptoms (Craske & Barlow, 2014).

Interoceptive exposure is continued both in and outside of treatment until panic symptoms remit. Over time, the habituation of fear within an exposure session ultimately leads to habituation across treatment and long-term remission of panic symptoms (Foa & McNally, 1996). Occasionally, panic symptoms will return in individuals who report complete remission of panic disorder. Follow-up booster sessions reviewing the steps above are generally effective in eliminating symptoms again.

7.5.5.2. Pharmacological interventions. According to Craske & Barlow (2014), nearly half of patients with panic disorder present to psychotherapy already on medication, likely prescribed by their primary care physician. Some researchers argue that anti-anxiety medications impede the progress of CBT treatment as the individual is not able to fully experience the physiological sensations during exposure sessions, thus limiting their ability to modify maladaptive thoughts and maintaining the panic symptoms. Results from large clinical trials suggest no advantage during or immediately after treatment of combining CBT and medication (Craske & Barlow, 2014). Additionally, when the medication was discontinued post-treatment, the CBT+ medication groups fared worse than the CBT treatment-only groups, thus supporting the theory that immersion in interoceptive exposure is limited due to the use of medication. Therefore, it is suggested that medications be reserved for those who do not respond to CBT therapy alone (Kampman, Keijers, Hoogduin & Hendriks, 2002).

Key Takeaways

You should have learned the following in this section:

• Treatment options for generalized anxiety disorder include benzodiazepines, rational-emotive therapy, CBT, and biofeedback.
• Treatment options for specific phobias include exposure treatments such as systematic desensitization, flooding, and modeling.
• Treatment options for agoraphobia include exposure and CBT techniques.
• Treatment options for social anxiety disorder include exposure treatment, social skills training, and cognitive restructuring.
• Treatment options for panic disorder include CBT, psychoeducation, self-monitoring, relaxation training, cognitive restructuring, exposure, and pharmacological interventions.

Review Questions

1. Discuss the types of exposure treatments for individuals with anxiety disorders? Which are most effective? What have been some concerns with exposure treatment?
2. What is biofeedback? How is biofeedback used to treat anxiety related disorders?
3. What are the concerns with using pharmacological interventions in the treatment of anxiety disorders? Is there a time when it is helpful to use this treatment method?

Module Recap

Module 7, the first module of Unit 3, covered the topic of anxiety disorders. This discussion included generalized anxiety disorder, specific phobias, agoraphobia, social anxiety disorder, and panic disorder. As with other modules in this book, we discussed the clinical presentation, epidemiology, comorbidity, and etiology of the anxiety disorders. Treatment options included biological, psychological, and sociocultural options. In Module 8, we will discuss somatic symptom and related disorders.