Cognitive Behavioral Therapy for Anxiety
Cognitive Behavioral Therapy for Anxiety
- Michelle L. Moulds, Michelle L. MouldsSchool of Psychology, UNSW Sydney
- Jessica R. GrishamJessica R. GrishamSchool of Psychology, UNSW Sydney
- and Bronwyn M. GrahamBronwyn M. GrahamSchool of Psychology, UNSW Sydney
Cognitive behavioral therapy (CBT) is an evidence-based, structured, goal-oriented, time-limited intervention for psychological disorders. CBT integrates behavioral and cognitive principles and therapeutic strategies; practitioners and clients work collaboratively to identify patterns of behaving and thinking that contribute to the persistence of symptoms, with the goal of replacing them with more adaptive alternatives. In the treatment of anxiety problems, the primary focus of CBT is on reducing avoidance of feared stimuli (e.g., spiders) or situations (e.g., public speaking) and modifying biases in thinking (e.g., the tendency to interpret benign situations as threatening). At its broadest, CBT is an umbrella term; it describes a range of interventions targeting cognitive and behavioral processes—ranging from early, traditional CBT protocols to more recently developed approaches (e.g., mindfulness-based cognitive therapy). CBT protocols have been developed for the full range of anxiety disorders, and a strong evidence base supports their efficacy.
- Clinical Psychology: Disorders and Therapies
The Emergence and Development of Cognitive Behavioral Therapy for Anxiety
Early forms of exposure therapy, the predominant behavioral treatment for anxiety disorders, originated in the 1950s and 1960s when psychologists applied the theories of behaviorism to understand the development and maintenance of clinical problems (Rachman, 2015). Behaviorism assumes that all behavior is a product of one’s learning history, the key mechanisms of which are Pavlovian conditioning (i.e., the association between cues and outcomes) and reinforcement contingencies (i.e., the association between behavioral responses and reward or punishment). In a behaviorist model (e.g., Mineka & Zinbarg, 2006), anxiety disorders reflect learned patterns of maladaptive behavior, wherein excessive avoidance of nonthreatening cues and situations arises due to the prior association of these cues and situations with negative events. Avoidance of feared cues and situations leads to an immediate reduction in anxiety (i.e., a reward), which reinforces the use of avoidance when such cues and situations are encountered in the future. Therapeutic behavioral techniques such as exposure (see table 1, “behavioral strategies”) were developed in order to modify these problematic patterns of behavior.
By the end of the 1970s, behavior therapy had become the treatment of choice for many conditions, including anxiety disorders. However, discontent with the behavioral approach had begun to emerge, fueled by the perceived “mechanistic notions” underlying its implementation (Hawton et al., 1989, p. 9). This prompted the suggestion that cognitive factors may play a key role in the persistence of psychopathology, particularly in individuals who did not respond to behavioral interventions. Such thinking coincided with the publication of Beck’s cognitive theory and therapy of depression (Beck et al., 1979). Cognitive theory assigns a key role to cognitions (negative automatic thoughts and dysfunctional schema) in the persistence of depression; accordingly, the goal of cognitive therapy is to help clients identify and challenge unhelpful patterns of thinking and replace them with more adaptive, balanced alternatives.
This resulted in the emergence of theoretical models of clinical disorders informed by the principles of both behavioral and cognitive approaches and, in turn, the development of cognitive behavioral therapy (CBT) for anxiety, integrating cognitive and behavioral strategies. Randomized controlled trials have established a strong evidence base confirming the effectiveness of CBT as a treatment for anxiety. This article discusses the content and application of CBT for anxiety disorders, limiting the focus to anxiety disorders as identified in fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013)—namely separation anxiety disorder, selective mutism, specific phobia, social anxiety disorder, panic disorder, agoraphobia, and generalized anxiety disorder.
Cognitive Behavioral Therapy for Anxiety: Standard Components and Structure
Cognitive Behavioral Therapy (CBT) is a short-term, structured psychological treatment. It is collaborative: The clinician and client adopt a problem-solving approach and work together throughout the course of assessment and treatment. Although CBT inevitably varies in focus depending on the disorder being treated, the structure, approach, delivery, and core components are relatively consistent across CBT packages for different anxiety problems. At the outset, the clinician conducts a detailed assessment of the client’s presenting problem, its course, and its development. This information provides the basis of a collaboratively derived formulation, with an emphasis on the case-specific cognitive and behavioral maintenance factors, which in turn become the targets of treatment. Psychoeducation is an important component of the initial treatment session(s). The clinician shares information with the client about the nature and function of anxiety and provides a rationale for targeting the cognitive and behavioral processes identified in their individualized case formulation that contribute to the persistence of their symptoms.
Treatment is composed of both behavioral (e.g., graded exposure) and cognitive (e.g., thought challenging) strategies. Despite such a distinction between these two types of therapeutic strategies, it is widely recognized that CBT techniques involve both cognitive and behavioral elements, and thus facilitate both cognitive and behavioral change (e.g., behavioral experiments). Therapeutic strategies are initially completed during therapy sessions, with repetition outside of sessions (homework tasks). Self-monitoring is a key part of CBT and includes clients keeping a daily record of their symptoms (e.g., anxiety levels and cognitions), as well as homework tasks, which form an important focus of therapy sessions. Relapse prevention is a focus of final sessions, and it involves identifying high-risk situations with the potential to trigger or exacerbate anxiety in the future. A course of CBT may end with booster sessions, tapered off over time (e.g., moving from weekly to monthly sessions). See table 1 for a summary of key treatment components.
Table 1. Summary of Key Components and Structure of CBT for Anxiety
Detailed assessment of current anxiety symptoms (e.g., nature, severity, impact on functioning) and their development, course, and history; goal is to arrive at a collaborative formulation
Collaboratively developed working hypothesis regarding how anxiety developed (e.g., vulnerability factors, precipitants) and is maintained (cognitive, behavioral processes)
Information about the nature and function of anxiety and the fight-or-flight response; education about the CBT model and approach; rationale for targeting maintaining factors using CBT techniques (e.g., reducing avoidance via exposure, addressing unhelpful interpretations via cognitive challenging)
Graded, prolonged exposure to fear-eliciting stimuli (including feared objects, contexts, physical states) with the goal of violating expectancies about feared outcomes
Identification of unhelpful patterns of thinking (e.g., catastrophizing), cognitive biases (e.g., overestimation of threat), and processes of thinking (e.g., worry); teaching clients to generate alternative interpretations via cognitive challenging, behavioral experiments
Review of CBT strategies; anticipation of future high-risk situations and formulation of plan to implement strategies to prevent/manage anxiety symptoms
Additional sessions following cessation of course of CBT; spaced (e.g., monthly), taper off over time
Research in nonhuman animals illustrated that fear responses to a conditioned cue that was previously paired with a negative outcome can decrease and eventually cease to occur if the cue is presented repeatedly without the negative outcome—a process termed “fear extinction” (Bouton et al., 2020). Research on conditioned fear extinction led to the development of exposure therapy. In its earliest iteration, known as systematic desensitization (Wolpe, 1961), clients imagined feared cues while engaging in relaxation strategies, whereas in later iterations, known as in vivo exposure, real cues and situations were confronted. Exposure therapy is the dominant behavioral strategy employed in CBT for anxiety. The cues and situations targeted in exposure therapy span physical objects, cognitions, and physical sensations; may be real or imagined (“imaginal exposure”); and are tailored to the individual, informed by their specific diagnosis and self-reported focus of fear (Craske, Treanor et al., 2014). For example, exposure therapy for specific phobia may involve interacting with phobic-relevant objects and scenarios (e.g., spiders in arachnophobia, and small rooms and elevators in claustrophobia). Exposure therapy for social anxiety disorder may involve engaging in social interactions or public performance scenarios (e.g., public speaking). Exposure therapy for panic disorder comprises two components—entering situations in which the potential occurrence of a panic attack is feared (e.g., a crowded shopping center) and interoceptive exposure, in which somatic sensations that typically accompany panic attacks are deliberately elicited. Interoceptive exposure includes tasks such as breathing through a straw (to induce shallow breathing), spinning (to induce dizziness), and physical exercise (to induce sweating, elevated heart rate, and shortness of breath). Exposure therapy for generalized anxiety disorder involves exposure to discrete, preselected topics of worry itself.
Irrespective of its precise focus, exposure therapy across different anxiety presentations is characterized by common procedural elements:
Exposure is graded. A hierarchy of feared cues/situations is constructed, arranged according to how likely the feared outcome is believed to occur (i.e., least to most likely), which typically corresponds to those that elicit low to high degrees of fear. Traditional views on exposure therapy posit that exposure commences on a low step of the hierarchy and progresses upward, such that the starting point and each successive step elicits a level of fear that is challenging but not unmanageable. Later views suggest that there is utility in progressing through the exposure hierarchy randomly, in order to maximize variability (see point 3). However, only few clinical studies have directly compared the two approaches, and they have produced equivocal outcomes (Knowles & Olatunji, 2019).
Exposure is prolonged. The feared cue or situation is confronted without escape. Some protocols dictate that exposure to a given cue or situation should continue until anxiety reduces to a predetermined level (e.g., a 50% reduction in subjective fear) (Foa & Kozak, 1986). However, there is little correlation between the amount of within-exposure reduction in fear and long-term symptom remission, suggesting that acute anxiety reduction during exposure therapy may not be an informative indicator of long-term exposure success (Craske, Treanor et al., 2014). This led Craske, Treanor et al. (2014) to suggest that exposure should continue for a predetermined duration, which enables the expectancy of the feared outcome to be violated, with the exposure task being repeated as necessary until expectancies are reduced to a predetermined level. Somewhat relatedly, others suggest that cognitive change (i.e., changes in the degree of belief that a catastrophic outcome will occur; Davis et al., 2012) and fear tolerance (Abramowitz, 2013) may be more useful indicators of when a sufficient duration of exposure to a given cue or situation has been reached.
Exposure is varied and extends beyond therapy. The various steps on the exposure hierarchy are practiced in different contexts (i.e., in different environments), with multiple variations (e.g., using different stimuli, durations, and circumstances), and as part of the individual’s daily life (i.e., the individual engages in exposure outside of the designated therapy sessions), the goal being to maximize the generalization of inhibitory learning (Craske, Treanor et al., 2014).
What are the mechanisms of change promoted by exposure therapy? A key element is the prevention of avoidance, which enables anxiety responses to the feared stimulus to habituate (Foa & Kozak, 1986) and disrupts the avoidance–reward contingencies that promote future avoidance. Most critically, however, prolonged exposure without avoidance enables new inhibitory learning about the feared cue or situation to occur (e.g., it is safe) that contradicts prior beliefs (e.g., the cue/situation will cause a catastrophic event) (Craske, Treanor et al., 2014). This new inhibitory learning reduces the anxiety felt when subsequently encountering the cue/situation, which decreases motivation to avoid it. For these reasons, it is critical that exposure therapy is conducted without the aid of safety behaviors—that is, behaviors designed to prevent the occurrence of the feared catastrophic outcome and thus are logically linked to the individual’s specific fears (Blakey & Abramowitz, 2019). For example, a person with social anxiety disorder may rehearse conversation topics before embarking on an exposure task involving a social interaction in order to avoid running out of things to say. Safety behaviors are subtle forms of avoidance because they prevent new learning about the feared cue/situation even when the cue/situation is not being overtly avoided. In the social anxiety disorder example, if the conversation runs smoothly, the person will likely attribute this to the use of the safety behavior rather than interpret it as evidence of their capacity to carry on a conversation.
Although the precise contents of what is learned during exposure therapy may differ (e.g., the stimulus is safe or anxiety is tolerable), it is widely agreed that exposure therapy does not erase the original feared association between the cue/stimulus and the feared outcome (Craske, Treanor et al., 2014). Rather, a new inhibitory association is formed (e.g., the cue is safe) that coexists with the old association. Studies in nonhuman animals have shown that a range of conditions provoke the retrieval of the feared association instead of the safety association, including stress, changes in environment, and the passage of time, which mimic the conditions under which relapse is often observed in clinical populations (Bouton et al., 2020). The emphasis on continual practice of exposure in a wide range of contexts is designed to boost the frequency with which the inhibitory association is retrieved to prevent relapse. Several other strategies developed from fear extinction paradigms are also proposed to augment inhibitory learning and expectancy violation during exposure therapy, such as simultaneous presentation of multiple feared cues and use of retrieval cues, some of which have shown promise in clinical trials (Craske, Treanor et al., 2014).
Other behavioral strategies are designed to directly counteract the physiological components of anxiety (e.g., hypertension and hyperventilation), with the goal of helping clients manage anxiety symptoms. Jacobsen (1964) developed progressive muscle relaxation (PMR) as a stand-alone treatment to counteract “nervous excitement” in cases of neuroses or hypertension. PMR involves tensing and then releasing discrete muscle groups, a skill that is practiced extensively (~50 sessions of 30–60 min duration). Öst (1987) later developed applied relaxation, which extended PMR by teaching the individual to identify early warning signs of anxiety and then counteract them using rapid relaxation strategies as a coping skill to manage daily stressors. Breathing retraining, typically utilized in panic disorder, is the process of counteracting hyperventilation (especially during panic attacks) via slow, diaphragmatic breathing. Underlying the rationale for relaxation and breathing strategies is the assumption that the different facets of anxiety are connected and mutually interact; deactivating one component (i.e., physiological tension) should thus reduce activation of other components (feelings and thoughts) (Conrad & Roth, 2007). These strategies have been administered as stand-alone treatments or as one component of a CBT package. In some cases, relaxation/breathing strategies have been integrated with exposure therapy. For example, Wolpe (1961) theorized that conditioned cues could be retrained to be associated with inhibitory responses if individuals were instructed to utilize relaxation techniques in the presence of feared cues, as part of systematic desensitization. However, anxiety management techniques (e.g., breathing retraining) are frequently omitted from CBT packages on the basis that they may inadvertently function as safety behaviors and prevent disconfirmation of anxious individuals’ beliefs (e.g., “I didn’t pass out because I controlled my breathing—but I may not be so lucky next time”; see Craske et al., 1997; Salkovskis, 1991).
In the context of depression, Beck proposed that dysfunctional patterns of thinking and negative thought content were not merely symptoms of the disorder but also play a key role in depression onset and maintenance. This account prompted the development of cognitive conceptualizations of anxiety (e.g., Beck et al., 1985), along with cognitive models of individual anxiety disorders (e.g., panic disorder [Clark, 1986] and social phobia [Clark & Wells, 1995]). Central to cognitive accounts is the notion that biases in processing influence the way in which an individual attends to, appraises, and makes attributions about their environment and their responses to it (e.g., emotional and physiological), which in turn fuels anxiety. The biases in processing or “cognitive errors” characteristic of anxious individuals include the tendency to overestimate the likelihood of danger and a propensity to interpret relatively benign situations and cues as threatening. For example, for an individual with panic disorder, the experience of being short of breath may indicate an impending heart attack; for a socially anxious individual, seeing another person glancing at their watch while they are speaking likely signals boredom with the conversation. Irrespective of the specific fear or disorder, the central tenet of cognitive conceptualizations is that anxiety is not a consequence of the feared cue per se; rather, anxiety is a consequence of the biased way in which the individual interprets the feared cue.
The primary goal of traditional cognitive therapy is to teach anxious individuals to identify the unhelpful content and patterns of thinking that maintain and exacerbate their anxiety and to encourage them to generate and adopt alternative, more balanced interpretations. The first step is to develop an awareness of unhelpful cognitions, which may be elicited during the course of discussion in treatment sessions, and also recorded in daily life between sessions using monitoring forms. This process facilitates understanding of the cognitive model—that is, that cues → appraisals → anxiety. Next, the clinician encourages the client to begin to notice whether their thinking is characterized by unhelpful patterns or habits, such as the tendency to engage in dichotomous thinking, emotional reasoning, and catastrophizing. As the anxious individual develops an awareness of the content and patterns of their thinking, the next step is for them to begin to question their thoughts. One approach is for the clinician to verbally challenge the content of thoughts with curious questions (e.g., “What is the evidence for the thought?” “Is there another way you could look at this situation?” and “How would thinking that make you feel?”). The process of cognitive challenging introduces the idea that situations can potentially be interpreted in multiple ways (with distinct emotional consequences), and it encourages the client to adopt more helpful interpretations as a means by which to reduce their anxiety. Over time, the goal is for clients to become their own clinicians, challenging unhelpful thoughts when they occur in everyday life. Another approach is to devise and carry out in vivo behavioral experiments to test the validity of an anxious individual’s interpretations, beliefs, or predictions (Bennett-Levy et al., 2004). That is, the client and clinician collaborate to devise a real-world experiment to gather evidence and empirically test a client’s specific hypothesis (e.g., their prediction about what might happen if they confront a fear-eliciting situation), as well as realistically appraise the consequences if their predictions are indeed confirmed.
Clark (1999) proposed that anxious individuals’ tendency to overestimate the dangerousness of fear-eliciting situations is maintained by key cognitive processes, including safety-seeking behaviors, emotional reasoning, and spontaneous imagery. Based on cognitive accounts (e.g., Clark & Wells, 1995), Clark and colleagues developed effective cognitive therapy packages for a number of anxiety disorders (e.g., panic and social anxiety) which seek to identify, target, and reverse key cognitive maintenance factors. Although these interventions include exposure to fear cues (e.g., situations and bodily sensations), it is notable that the theoretical rationale underpinning exposure tasks is cognitive rather than behavioral. That is, exposure is conceptualized as a means by which to shift clients’ perceptions of the dangerousness of feared cues rather than to facilitate habituation to the anxiety they elicit.
Efficacy of Cognitive Behavioral Therapy for Anxiety
A recent meta-analysis of randomized controlled trials indicated that cognitive behavior therapy (CBT) produces superior outcomes 1–6 months post-treatment compared to a range of comparison groups (including care as usual, relaxation or tension only, psychoeducation, pill placebo, and supportive therapy), with small effect sizes for panic disorder and generalized anxiety disorder, medium effect sizes for social anxiety disorder, and medium to large effect sizes for specific phobia (van Dis et al., 2020). At 12 months post-treatment, CBT remained superior to comparison groups for generalized anxiety disorder (small effect size) and social anxiety disorder (medium effect size), but not for panic disorder (effect size for specific phobia could not be calculated because only one study included a 12-month assessment). In a recent summary of meta-analytic evidence, Penninx et al. (2021) noted that CBT effect sizes are large compared to wait-list control conditions and small to moderate when either treatment as usual or pill placebo are controls.
Although it is evident that CBT is an efficacious treatment across different subtypes of anxiety, it is less clear which aspects of CBT are primarily responsible for driving its effects and whether it is necessary to administer all the elements of the CBT package to achieve optimal outcomes. Addressing these gaps is crucial both to increase CBT’s efficiency and to identify how the magnitude and persistence of its efficacy can be improved. Some studies have indicated that different components of CBT are equivalently effective when compared separately. For example, a meta-analysis (Montero-Marin et al., 2018) found no evidence for superiority of CBT (composed primarily of exposure and/or cognitive restructuring techniques) over pure relaxation techniques for specific phobias, social anxiety disorder, or generalized anxiety disorder, whereas CBT showed a small advantage over relaxation for panic disorder only at the 1-year follow-up and not immediately post-treatment. However, others have indicated that different components have different levels of efficacy. For example, a network meta-analysis of CBT-based treatments for panic disorder indicated that a combination of cognitive restructuring and interoceptive exposure yielded better outcomes than a combination of in vivo or virtual reality exposure, breathing retraining, and muscle relaxation (Pompoli et al., 2018).
Related Approaches: Mindfulness- and Acceptance-Based Interventions
Interest in mindfulness and acceptance-based interventions for anxiety and other psychological disorders has grown exponentially during the past two decades. The most prominent of these approaches are acceptance and commitment therapy (ACT; Hayes et al., 2012) and mindfulness-based cognitive therapy (Segal et al., 2002). Because these therapies emerged under the cognitive–behavioral umbrella and have similar philosophical underpinnings, they are sometimes referred to as the “third wave” of CBT (Hayes, 2004). Both mindfulness- and acceptance-based approaches aim to facilitate present-centered awareness, encouraging individuals to relate to their experience with acceptance instead of avoidance, control, or suppression (Hayes, 2004; Williams, 2010). When applied to anxiety disorders, the primary aim of these approaches is to reduce distress by observing symptoms and thoughts without overly identifying with them or reacting to them (Roemer et al., 2008). Although these approaches differ from traditional CBT with respect to specific components of their rationale and therapeutic strategies, some researchers have questioned whether they are an extension of CBT rather than qualitatively novel therapies (Arch & Craske, 2008; Hofmann & Asmundson, 2008).
Meta-analyses have found moderate to large effect sizes for mindfulness- and acceptance-based therapy on anxiety symptoms (e.g., Fumero et al., 2020; Vøllestad et al., 2012). In addition, randomized clinical trials comparing ACT to more established forms of CBT generally have found comparable outcomes for generalized anxiety disorder (Hayes-Skelton et al., 2013; Hoge et al., 2013), social anxiety disorder (Craske, Niles et al., 2014; Goldin et al., 2016; Kocovski et al., 2013; but see Herbert et al., 2018), and mixed anxiety disorders (Arch et al., 2012). Despite this preliminary support for third-wave approaches, researchers have commented on the need for larger scale, more methodologically rigorous trials of both ACT (e.g., Swain et al., 2013) and mindfulness (e.g., Davidson & Kaszniak, 2015; Kuyken et al., 2016).
Transdiagnostic Treatments for Anxiety Disorders
Transdiagnostic treatment approaches to mood and anxiety disorders have rapidly gained momentum among practitioners as an antidote to the proliferation of diagnosis-specific treatments. Transdiagnostic treatments address shared etiological factors among psychological disorders with a single set of therapeutic principles (Harvey et al., 2004). The rationale for this approach hinges on the identification of common factors within mood and anxiety disorders (Barlow et al., 2016), which manifest as high rates of comorbidity among these disorders (Brown et al., 2001). Further evidence in support of these shared underlying factors for anxiety and mood disorders has come from both affective neuroscience research (e.g., Etkin & Wagner, 2007) and structural equation modeling studies (e.g., Watson, 2005). Transdiagnostic therapy has substantial practical and economic benefits, including increased efficiency of treatment and ease of implementation. A clinician treating a patient with multiple comorbidities can conceptualize common mechanisms across presenting issues and apply a transdiagnostic approach rather than selecting a single disorder protocol.
A prominent transdiagnostic approach for anxiety and mood disorders is the Unified Protocol (UP; Barlow & Farchione, 2017). The UP addresses emotion dysregulation in five main or core cognitive–behavioral modules (Ellard et al., 2010), which can be supported by three additional complementary modules. The main UP modules are emotion awareness training, cognitive reappraisal, emotion-driven behaviors and emotional avoidance, awareness and tolerance of physical sensations, and interoceptive and situational exposures. The overarching theme of the UP is to challenge the view that negative emotional experiences are aversive and in need of reduction and to learn to react differently to negative emotions (Barlow & Farchione, 2017). More recent versions of the UP also emphasize reducing avoidance of positive emotions and greater approach to positive emotional experiences (Farchione et al., 2012). Norton and colleagues have developed a similar transdiagnostic approach to target either anxiety and depression (McEvoy & Nathan, 2007) or heterogeneous anxiety disorders (Norton & Phillipp, 2008).
There have been several meta-analyses and reviews of transdiagnostic approaches (Carlucci et al., 2021; McEvoy et al., 2009; Newby et al., 2015; Norton & Phillipp, 2008; Reinholt & Krogh, 2014). Overall, these reviews conclude that transdiagnostic treatments lead to improvements in the severity of comorbid anxiety disorders and anxiety symptoms and generally outperform control conditions. Effect sizes for symptoms are similar to those of disorder-specific treatments (Hofmann & Smits, 2008), and there are also moderate to large effects on measures of temperamental affectivity (Farchione et al., 2012). These findings are encouraging and will likely lead to further research to address remaining gaps, including long-term follow-up evaluation and additional randomized controlled trials comparing UP and other transdiagnostic treatments to traditional single-disorder CBT (Carlucci et al., 2021; Newby et al., 2015).
New Directions in Cognitive Behavior Therapy for Anxiety
The Intersection of Biology and Cognitive Behavior Therapy Effectiveness
The prospect that CBT effectiveness can be improved by leveraging insights on the biological mechanisms of fear regulation has gained momentum during the past two decades. Advances in neuroscience methods have enabled the key neurocircuitry and molecular signaling cascades underlying conditioned fear extinction, the basis of exposure therapy, to be precisely mapped in rodents and then tested in humans using functional magnetic resonance imaging (Graham & Milad, 2011). Because there is striking cross-species similarity between the mechanisms of fear extinction in rodents and humans, novel means of augmenting fear extinction can be trialed and refined in rodents before translating these interventions in human clinical trials.
One approach to improving CBT outcomes that has been extensively investigated is the use of pharmacological adjuncts that augment the biological mechanisms of CBT. A prototypical example is d-cycloserine (DCS; targeting the glutamate system), which was initially shown to augment fear extinction in rats and has since been found to enhance exposure therapy and CBT outcomes in humans across a broad range of anxiety disorders, albeit with small effect sizes (Mataix-Cols et al., 2017). A recent meta-analysis of DCS studies indicated that optimizing the delivery of DCS (via a sufficient number of doses delivered at the correct time relative to each exposure session) may increase its effectiveness as an adjunct considerably (Rosenfield et al., 2019). Irrespective, research on DCS has seeded a wealth of literature examining other pharmacological adjuncts to extinction in rodents, targeting the glutamate, endocannabinoid, and neuropeptide systems, that have shown promise in human clinical trials (Sartori & Singewald, 2019).
A different approach to improving CBT outcomes is to harness its delivery to optimal natural biological states, such as periods of elevated endogenous hormones that moderate fear extinction. For example, studies in rats and humans have established that fear extinction is modulated by the stress hormone cortisol, which is elevated in the morning and declines throughout the day (Merz et al., 2018). Accordingly, it has been found that exposure therapy for spider phobia leads to better long-term reduction in symptoms when it is delivered in the morning, coincident with elevated cortisol, versus the evening, coincident with reduced cortisol (Lass-Hennemann & Michael, 2014). As another example, in rats and women, fluctuations in the sex hormone estradiol over the menstrual cycle modulate fear extinction, whereby fear extinction during periods of elevated estradiol (e.g., ovulation and the second half of the cycle) leads to more long-term reduction in fear compared to when it is delivered during reduced estradiol (e.g., the beginning of the cycle/menstruation) (Li & Graham, 2017). Accordingly, women who have elevated estradiol levels at the time of exposure therapy for spider phobia show better long-term reduction in symptoms relative to those with lower estradiol levels (Graham et al., 2018). Moreover, women using hormonal contraception, which chronically suppresses ovarian estradiol production, show poorer long-term gains from exposure therapy for spider phobia relative to women with natural menstrual cycles (Graham et al., 2018; Raeder et al., 2019). Leveraging predictable fluctuations in natural biological states provides a simple and safe alternative to pharmacological manipulation of these states, and it can be implemented by psychologists independently.
Ultra-Brief Cognitive Behavior Therapy for Anxiety
The recognition that CBT is time-intensive and typically associated with high out-of-pocket costs for clients has led an impetus to develop more efficient “brief” CBT protocols, without compromising efficacy. Brief CBT for anxiety typically comprises a single longer duration (e.g., 3-hour) session, or several sessions of shorter duration, with the total number of sessions being considerably less than a standard course of CBT. Brief CBT follows the same principles as standard CBT, but it focuses exclusively on strategies that are thought to be most potent in creating cognitive and behavioral change (Hazlett-Stevens & Craske, 2002). Thus, the primary strategies in brief CBT are exposure therapy and behavioral experiments, which enlist direct experiential evidence to promote such change.
The efficacy of brief CBT has been most extensively assessed in specific phobia, in the form of one session treatment (OST), pioneered by Öst (1989). OST delivers graded exposure to phobic-relevant stimuli and situations in an intensive session over a maximum duration of 3 hours. One focus is on the reduction in anxiety experienced in response to increasingly challenging interactions with the phobic stimulus, as per standard exposure therapy. The other focus is on psychoeducation and cognitive restructuring. The client is encouraged to verbalize predictions about the feared outcomes prior to each successive step and to subsequently compare these predictions to the observed outcomes, akin to a series of behavioral experiments. Using this approach, Öst (1989) reported that 90% of patients exhibited clinically significant improvement that was maintained 4 years later, with a mean treatment duration of only 2.1 hours.
The remaining literature on brief CBT has primarily focused on panic disorder, which typically requires 12–15 sessions of standard CBT. Otto et al. (2012) showed that very large pre- to post-treatment reductions in panic symptoms were achieved with as few as 5 weekly sessions, followed by 2 booster sessions over the next 3 months (6½ hours of treatment in total). Likewise, 9 hours of intensive treatment over 2 days led to large, clinically significant reductions in panic symptoms (Deacon & Abramowitz, 2006). Although such outcomes are promising, most studies have not compared the efficacy of brief CBT relative to standard CBT in head-to-head trials, but the few that have compared these approaches have reported equivalence of outcomes (e.g., Marchand et al., 2009; Öst et al., 1992). Moreover, although data are lacking regarding the utility of brief CBT for conditions such as social anxiety disorder and generalized anxiety disorder, a recent meta-analysis examined the dose–response function of standard CBT administered in outpatient settings for a range of anxiety disorders, among which these two disorders were highly represented. This analysis indicated that 5 sessions were required for reliable change, and 9 sessions were required for clinically significant change (Levy et al., 2020), suggesting that brief forms of CBT may be feasible across a range of conditions.
Imagery-Based Approaches to Anxiety
Preliminary evidence that integrating imagery-based techniques into traditional CBT may achieve a deeper level of therapeutic change fueled a surge in this area of research (Thoma & McKay, 2014). Although imagery-based techniques, including imaginal exposure and guided imagery, have been incorporated into cognitive behavioral approaches to anxiety since the 1970s, imagery rescripting (ImRs) has the strongest evidence, with the largest number of randomized controlled trials (Pile et al., 2021). ImRs was originally developed to treat trauma-related psychopathology (including post-traumatic stress disorder) but was later found to reduce symptoms associated with aversive memories in other emotional disorders (Morina et al., 2017).
During ImRs, a client retrieves a distressing memory and uses imagery to emotionally reactivate the memory. The client is then encouraged to modify the imagery in a way that better addresses their emotional needs (Arntz, 2012; Holmes et al., 2007). The mechanisms of this approach continue to be investigated, but a leading hypothesis posits that ImRs facilitates a change in the meaning of an event and its associated images, which reduces memory-related negative emotional responses (Arntz, 2012). In addition to traditional ImRs approaches that change the meaning of an image, simple techniques that focus on altering perceptual aspects or generating positive images might also be beneficial (e.g., Slofstra et al., 2016).
A meta-analysis of 19 trials of ImRs across a range of disorders concluded that ImRs was largely effective in decreasing psychological symptoms associated with aversive memories from pre- to post-treatment and at follow-up (Morina et al., 2017). With respect to anxiety disorders, there is preliminary evidence that ImRs is effective as either a stand-alone treatment or an adjunctive technique for social anxiety disorder (e.g., McEvoy et al., 2022; Nilsson et al., 2012; Wild et al., 2008) and specific phobia (Hunt & Fenton, 2007). Although these initial findings are promising, there are many potential avenues for additional research on ImRs. Well-powered, rigorous studies are needed to examine the efficacy of ImRs compared to established treatments for other disorders, identify the necessary and sufficient elements of ImRs, clarify mechanisms of change, and determine the optimal dose and mode of delivery (Strachan et al., 2020).
Internet-Delivered Cognitive Behavioral Therapy for Anxiety
Another new frontier in the treatment of anxiety disorders is the integration of technology into traditional therapy approaches. Technology-based innovations include stand-alone, automated or minimally guided online programs (internet-delivered CBT [iCBT]), as well as the use of technology in conjunction with traditional CBT. iCBT has emerged as an effective method of increasing dissemination of CBT by overcoming geographic and economic barriers (Andrews et al., 2018; Carpenter et al., 2018). Numerous meta-analyses support the efficacy of self- or minimally guided iCBT in treating anxiety disorders, with moderate to large effects for generalized anxiety disorder, panic disorder, and social anxiety disorder (Andersson et al., 2019; Andrews et al., 2018; Carlbring et al., 2018; Guo et al., 2021; Pauley et al., 2021; Stech et al., 2020; Wootton, 2016). The typical effects of iCBT on psychological symptoms appear to be similar to those of face-to-face CBT (Carlbring et al., 2018), with large within-group effects on core symptoms for social anxiety disorder and panic disorder (Andersson et al., 2019; Andrews et al., 2018; Hedman et al., 2012). Several meta-analyses found that iCBT that incorporated therapist guidance generated larger effect sizes and higher completion rates compared to unguided programs in treating anxiety disorders (Andersson & Cuijpers, 2009; Cuijpers et al., 2009; Palmqvist et al., 2007; Spek et al., 2007); however, a recent meta-analysis found no difference in outcomes between guided and unguided interventions (Polak et al., 2021).
Effectiveness studies have extended beyond randomized controlled trials to examine iCBT in routine care contexts. They have generally shown similar improvements in anxiety symptoms, although completion rates tend to be lower (e.g., Hobbs et al., 2017; Newby et al., 2020; Niles et al., 2021). Some researchers have also begun to examine the most essential components of iCBT for anxiety disorders. Stech et al. (2021) found initial evidence that iCBT for panic disorder focusing only on exposure is as efficacious and acceptable to clients as more established multicomponent iCBT.
Despite these promising results, implementation research is needed regarding the effectiveness of iCBT in a range of health care settings that differ in terms of client populations, clinician training, and the mode of delivery (Titov et al., 2018). Moreover, several iCBT studies have reported that approximately 40% of participants continue to report symptoms in the clinical range following treatment, suggesting ample room for improvement (e.g., Allen et al., 2016; van Ballegooijen et al., 2014). Other researchers have raised concerns about iCBT adherence (Gilbody et al., 2015), relatively high attrition rates (Penate & Fumero, 2016), and the lack of randomized controlled trials directly comparing internet- and face-to-face CBT (e.g., Andersson et al., 2014; O’Kearney et al., 2019), as well as the need for more studies on the longer term effects of iCBT (Andersson et al., 2018).
Enhancing Cognitive Behavioral Therapy Using Technology
In addition to the self-help protocols of iCBT, recent studies have investigated the use of technology as an adjunct approach to enhance outcomes for traditional CBT for anxiety disorders. Technology may be used to support a clinical intervention, provide an alternative way to connect with the clinician, or deliver didactic material (Cooper et al., 2021). Adjunctive use of technology includes virtual reality, videoconferencing, mobile devices or smartphone apps, audio/visual recordings, and wearable devices. Therapists might use videocalls to conduct exposure exercises with clients in relevant contexts (e.g., home or work; Goetter et al., 2013) or use virtual reality to conduct items on an exposure hierarchy when in vivo exposure is not feasible (Lindner et al., 2019; Rothbaum et al., 2006). They may assign out-of-session work through a mobile app and improve therapy engagement through reminders, skill-building tasks, and gamification (Pramana et al., 2018; Silk et al., 2020). Nascent research on these adjunctive uses of technology suggests that they may broaden treatment access and improve compliance and engagement; however, additional empirical support is needed (Cooper et al, 2021).
Across cognitive behavioral therapy (CBT) models of anxiety disorders, avoidance behavior and biased cognitive processing are consistently implicated in disorder maintenance; accordingly, they represent key treatment targets of CBT approaches. Although there is some variability in focus and delivery, exposure and cognitive therapy represent the fundamental components of CBT interventions. Recent developments in the field include considerations of the influence of biological factors on treatment outcomes, innovations in treatment delivery (e.g., iCBT and ultra-brief CBT), and the incorporation of novel components (e.g., imagery rescripting). Although CBT is currently well supported by evidence from randomized controlled trials, going forward, efforts to extend and enhance the efficacy of established protocols should be a research priority.
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